Modern treatment coverage is promised everywhere, so why do claims still go wrong
Walk into any good hospital today, and you’ll notice something. Almost nothing is done the old way anymore. What used to be routine laparoscopic surgery is now done with robotic assistance because it improves precision and speeds up recovery. Cardiac bypasses, orthopaedic procedures, prostate surgeries—hospitals increasingly prefer advanced, minimally invasive techniques whenever they can.
And insurers, for once, aren’t behind. These “modern treatments,” as the industry calls them, are now part of most comprehensive health insurance plans. IRDAI has even notified 12 modern procedures that insurers cannot exclude as long as they are medically required. You’ll see insurers proudly advertising “Modern Treatment Coverage up to Sum Insured” everywhere.
More customers now actively ask for this feature. Hospitals encourage it. Insurers advertise it.
Sounds perfect, right?
Not really. A lot can still go wrong, and that’s what this article is about.
A case study that explains the problem
Let me start with a claim we handled recently. A few months ago, we helped a customer whose mother was admitted with severe chest pain. Tests showed a 90% blockage in her LAD artery. The cardiac surgeon recommended a MICS CABG, a minimally invasive bypass technique that offers faster recovery and fewer complications than the traditional open-chest method. In insurance language, this falls under modern treatment.
The hospital sent a pre-authorisation request for ₹9 lakh, the estimated cost of treatment. The insurer approved ₹99,000.
This is not always a cause for alarm because pre-auth numbers are tentative. But in this case, the approval letter included a clear note: MICS was not part of their tariff list, so they would only pay the rate for a conventional CABG, which typically comes to around ₹4 lakhs.
This is a fairly common issue with modern treatments. Tariff agreements between insurers and hospitals are often based on older, conventional procedures. So the insurer’s position was essentially: we only pay ₹4 lakh for bypass surgeries at this hospital. If they are charging more for a newer technique, that is outside our agreement.
The medical necessity of MICS did not feature in their initial assessment at all.
We escalated the matter with the surgeon’s justification, angiogram findings, and a request asking the insurer to point to any clause that allowed them to restrict payment. After a second review, the insurer reconsidered the tariff and eventually approved about ₹7 lakh after hospital discounts.
Why modern treatment coverage does not guarantee a full claim
This case just goes on to show that modern treatment coverage on paper does not automatically translate to a full claim in practice. The feature exists, the policy mentions it, and IRDAI requires it, but the actual approval depends almost entirely on how the insurer interprets medical necessity.
Even if the policy covers modern treatments, the insurer can deny or restrict the amount if the doctor hasn’t clearly explained why the modern technique was essential. Without strong documentation, the claim becomes very weak during internal medical review.
We recently saw this again. A patient underwent a robotic gallbladder procedure. The hospital requested cashless approval, but the insurer denied it because there was no clear explanation of why a robotic technique was required. We tried again during reimbursement with a more detailed note, but the insurer still rejected it. We’re now pursuing the case with the Ombudsman.
Medical justification is not always black and white
Just because a robotic or minimally invasive option is available does not automatically make it medically necessary. For instance, robotic surgeries cost substantially more because of the equipment, the setup, and the specialised teams involved. Insurers usually approve them for critical conditions like cancer, prostate disorders, and brain-related surgeries, where there is strong medical precedence that added precision genuinely improves outcomes.
But for routine procedures like hernia repair or gallbladder removal, insurers often restrict or deny the robotic technique, arguing that these can be managed safely through conventional or laparoscopic methods.
On the other hand, several other modern treatments, such as intravitreal injections for eye diseases or monoclonal antibody therapy for certain types of cancer, are routinely approved. These have clearer clinical indications and established medical evidence.
And naturally, this creates tension. Treating doctors often push back against insurers’ interpretations, especially when they believe the modern technique is in the patient’s best interest. Insurers, meanwhile, rely on cost considerations and legacy tariff structures. This back-and-forth will continue until there is a stronger regulatory framework for hospitals, too, one that clearly defines when certain modern techniques are considered medically necessary and at what price.
What you can do as a customer
Here are a few practical steps.
1. Check whether the treatment is part of the IRDAI-mandated list
If the treatment is one of the 12 procedures insurers are not allowed to exclude, you can challenge any unreasonable restriction with confidence.
2. Look closely for sublimits
Many policies still place caps on modern treatments. If the sub-limit is ₹5 lakh, for instance, the insurer will not pay a rupee more even if your sum insured is 10 lakh rupees.
3. Ensure strong medical justification is documented
Ask your doctor to clearly explain why the modern technique was necessary. Proper documentation makes a substantial difference during insurer review.
4. Understand elective versus necessary procedures
If the technique is solely elective or based on convenience, you should expect some back-and-forth with the insurer.
5. Consider taking help from an advisor
Having someone who understands the process deeply cuts down delays and helps with escalations. You can book a free call with experts at Ditto or any other advisor you trust.
