Is a PET-CT Scan Covered by — Health Insurance in India?

It depends on how the scan is ordered. Most standard policies cover PET-CT when it is part of a hospital admission, treating it as a diagnostic test ordered for an admitted patient. The same scan ordered in the outpatient department — even for the same diagnosis — is often excluded. Whether you have an OPD rider, a day-care clause that applies, or a policy that explicitly includes advanced diagnostics determines the answer for your specific plan. Reading your policy's Exclusions section, not the brochure, is the only reliable way to check.

Yes, for most policies. Pre-authorisation is a formal confirmation from your insurer that the scan is covered under your plan, obtained before the procedure takes place. Without it, the insurer can reject the claim even if the scan would otherwise have been covered. Call the pre-authorisation helpline printed on your insurance card as soon as your doctor orders the scan — not on the morning of the appointment. Keep a record of your reference number and the name of the person who confirmed it.

The most common reasons are: the scan was ordered as an outpatient test and the policy excludes outpatient diagnostics; pre-authorisation was not obtained before the scan; the imaging centre is not on the insurer's empanelled network; the clinical indication does not match the covered conditions listed in the policy; or the documentation submitted with the claim was incomplete. Ask your insurer for the specific rejection reason in writing, because each of these has a different remedy, and a generic rejection letter is not enough to know which applies to you.

Yes, for approved cancer indications — but only at empanelled hospitals and only up to the scheme's reimbursement ceiling. The treating hospital must be listed as an Aarogyasri network hospital, and the indication for the scan must match those specified by the scheme. Not every cancer diagnosis is on the approved list. Ask the hospital's Aarogyasri or EHS desk before you book, as they can check your eligibility against the current approved procedure list. PET-CT at CION is coordinated through partner imaging centres, and eligibility will depend on whether those centres are on the scheme panel.

You have the right to appeal. Ask your insurer for the rejection reason in writing, then submit a formal grievance with supporting documents — your oncologist's referral, the clinical indication, and the policy clause you believe covers the scan. If the insurer does not resolve it within the timeframe IRDAI specifies, you can escalate to the Insurance Ombudsman in your region, which is a free process. IRDAI's Bima Bharosa portal also accepts complaints if the insurer's internal grievance process does not resolve your case.

Yes, for cashless claims. Cashless coverage — where the insurer settles directly with the centre and you pay nothing at the time — applies only at centres that are part of your insurer's network. At a non-network centre, you pay the full cost at the time of the scan and submit a reimbursement claim afterwards. Reimbursement takes longer to process and may be paid at a rate lower than what you actually paid. Confirm with your insurer which centres in your city are on their panel before booking, so you are not managing a reimbursement process on top of your treatment.