Mumbai: A diagnosis of Multiple Sclerosis can be life-altering, but for many patients in India, the financial burden that follows can be equally overwhelming. A recent patient account has brought attention to a critical gap in India’s health insurance system — the limited coverage available for pre-existing conditions.

In 2019, the patient was hospitalised for five days following diagnosis and received a bill of Rs 2 lakh. At the time, corporate health insurance covered 90 per cent of the cost, offering temporary relief. However, that sense of security proved short-lived.

Within a year, as the illness progressed and mobility issues increased, the patient had to leave their job — and with it, the corporate insurance cover that had been a financial safety net.

Pre-existing conditions limit access to coverage

The case underscores a fundamental challenge in India’s insurance landscape. Health insurance policies are typically designed to be purchased before the onset of illness. Once a disease is diagnosed, it is classified as a pre-existing condition, often leading to exclusions, restrictions or long waiting periods.

Even relatively common conditions, such as thyroid disorders, can attract waiting periods of up to three years before claims are permitted. For more complex and lifelong diseases like multiple sclerosis, the barriers are significantly higher, often resulting in complete exclusion from coverage.

In this instance, despite being part of a family insurance plan since 2004 with continuous premium payments, the patient’s request to increase the sum insured after diagnosis was denied. The insurer cited the condition as pre-existing, leaving no flexibility to enhance coverage when it was most needed.

High treatment costs add to financial strain

The cost of managing multiple sclerosis is substantial. The patient relies on Ocrevus (ocrelizumab), a disease-modifying therapy that costs approximately Rs 2.81 lakh per infusion. Including hospital and associated expenses, each treatment cycle amounts to nearly Rs 3.5 lakh.

With the therapy administered every six months, the annual cost rises to around Rs 7 lakh. This figure is nearly twice the average annual income of a middle-class household in urban India, highlighting the financial strain faced by patients without adequate insurance support.

Such high recurring costs make long-term disease management difficult, particularly for those who are unable to maintain stable employment due to health conditions.

Awareness gaps contribute to delayed planning

The issue is not limited to policy design but extends to awareness and financial planning. Health insurance remains a topic that is rarely discussed openly in many Indian households. As a result, individuals often fail to secure comprehensive coverage before illness strikes.

Many professionals rely solely on employer-provided insurance, assuming it will suffice. However, as this case demonstrates, losing employment due to illness can simultaneously result in the loss of insurance, compounding the financial impact.

The patient reflects that awareness about health insurance often comes too late — after a diagnosis, when options become severely limited. The lack of early education and public discourse around insurance planning contributes to this gap.

Limited policy reforms and advocacy efforts

There have been some attempts to address these challenges. The Multiple Sclerosis Society of India launched the #InsureMyMS campaign in 2024, advocating for more inclusive insurance policies for individuals living with multiple sclerosis.

Additionally, certain insurance products for persons with disabilities have been proposed, offering coverage of up to Rs 5 lakh. However, these policies often come with high premiums, waiting periods of up to two years for pre-existing conditions and strict eligibility requirements, including benchmark disability certification.

For many patients with multiple sclerosis — a condition that can have invisible symptoms — meeting these criteria can be difficult, limiting access to even these specialised policies.

Need for systemic reform in insurance sector

Experts argue that the current system places disproportionate emphasis on timing rather than need. Insurance, in principle, is meant to protect individuals against uncertainty. In practice, however, it tends to benefit those who secure coverage before any health issues arise.

This creates a gap where individuals who develop chronic illnesses without prior insurance are left with limited or no financial protection. The situation calls for stronger regulatory intervention to ensure that insurance products are more inclusive and responsive to real-world needs.

Conclusion

The experience of this multiple sclerosis patient highlights a broader systemic issue within India’s health insurance framework. While personal financial planning is important, the lack of awareness and limited policy flexibility leave many vulnerable when illness strikes unexpectedly.

Bridging this gap will require a combination of better public awareness, policy innovation and regulatory support. A system designed to provide financial security must evolve to ensure that access to healthcare does not depend solely on timing, but on genuine need.