Joe Biden Diagnosed With Prostate Cancer: What Indian Men Should Know About Insurance Coverage, Costs

When the news of former U.S. President Joe Biden undergoing treatment for prostate cancer broke out, the conversation around this disease, which is often under-discussed, saw a sudden spike across the globe. The severity and cost burden of this disease is still lost on many people. In India, prostate cancer affected 37,948 men in India in 2022, accounting for about 3 per cent of the 14 lakh new cancer cases reported that year (WHO data).

While prostate cancer tends to progress more slowly than some other malignancies, the financial burden associated with its treatment can escalate quickly. Robotic surgeries, hormone therapies, and cycles of radiation can stretch well into lakhs of rupees. And this is where your health insurance policy either becomes your shield or leaves critical gaps.

Do standard health insurance plans cover prostate cancer treatment?

Broadly speaking, yes. Most comprehensive health insurance policies in India do cover prostate cancer treatments, provided the disease is not pre-existing at the time of buying the policy. This means if you are diagnosed or show signs like elevated PSA (Prostate Specific Antigen) levels or biopsy-confirmed malignancy before purchasing a plan, the cancer would be tagged as a pre-existing condition. Once that label sticks, you are typically looking at a waiting period of up to three years before coverage kicks in.

Srinivasan Gopalan, MD and CEO of Galaxy Health Insurance, explains: "Most comprehensive policies cover prostate cancer from the 31st day of policy inception if it's not pre-existing. However, benign prostate conditions do have a two-year waiting period. So disclosure at the time of policy purchase becomes crucial."

Early-Stage or Advanced: Will it make a difference in coverage?

Interestingly, health insurers do not usually discriminate between early-stage and advanced or metastatic prostate cancer in their coverage terms. That might come as a surprise given that high-grade prostate cancers (often marked by a Gleason score of 9 or 10) tend to need more aggressive, and expensive, treatments.

But the nuance lies in the details. While the basic coverage exists across stages, some insurers cap the amount payable for certain high-cost procedures, especially those falling under "modern treatments" like robotic-assisted surgery. So, while there's coverage, it may not always be enough without top-up plans or riders.

Says Gopalan, "The coverage does not vary for different stages of prostate cancer. Modern treatments are used in advanced /metastatic diseases. Some health insurance policies have a sub-limit for such modern treatments."

However, he adds, "Treatment modalities, including modern treatment, and cost vary for high-grade and low-grade cancers, for which coverage is given as per policy terms and conditions."

What about the tests and screenings?

Prostate cancer is not usually caught in its earliest form unless men undergo screenings like PSA tests or MRIs. It is often triggered by a doctor's suspicion rather than part of a routine check-up.

Says Priya Deshmukh, Head, Health Products, Operations & Services, ICICI Lombard, "Typically, prostate cancer related screenings are not a part of the preventive health check-ups. However, some policies may offer coverage for these tests if they are deemed medically necessary by a healthcare provider."

This means that if the tests are prescribed due to clinical suspicion, say, persistent urinary symptoms or abnormal digital rectal exams, some insurers will foot the bill. "Insurers cover outpatient diagnostics like PSA tests and MRIs if they are medically indicated by a practitioner," Deshmukh adds.

The real cost of treatment and what to watch out for

Robotic prostatectomy alone can cost upwards of Rs 3 to 5 lakh in private hospitals. Add to that radiation cycles, chemotherapy, long-term hormone therapy, and even post-treatment monitoring, and the expenses quickly balloon. Some policies, especially those with disease-specific sub limits or caps on modern treatments, may not stretch enough to cover the full bill.

Some plans do include long-term hormone therapy under active treatment, and also cover advanced procedures like robotic-assisted surgeries, but only when they are not considered experimental. Says Deshmukh, "Policyholders should note that treatments classified as experimental, or taken outside of recommended protocols, may be excluded."

To put simply, if you undergo any treatments which are termed outside standard protocols, or those not cleared by the medical board, the cost may not be reimbursed by your insurer.

Another thing men should be aware of is the duration of coverage after hospitalisation. Prostate cancer treatments often span several months or even years. Policies with extended pre- and post-hospitalisation coverage (say, 90 to 180 days) offer a safety net for associated medical expenses that occur outside of inpatient care.

Should you plan ahead?

Deshmukh says that men, especially those above the age of 45, should start evaluating their health insurance with an eye on prostate and other age-linked cancers. While one might not expect to need robotic surgery in their 50s, that's precisely why getting insured earlier while in good health matters.

Flexibility in sum insured, the inclusion of top-up covers, and the absence of disease-specific sub-limits are important factors to weigh. Since a base policy may not be enough, one can consider booster plans that offer up to Rs 1 crore in coverage. This is especially relevant given how treatment costs can spiral beyond expectations amid rising medical inflation.