Authors:

• Dr. Sujeet Rajan, Director, Breath First Foundation, Mumbai
• Dr. Shayana Ganesh, Chief Medical Officer, Medshield Medical Scheme, South Africa
• Upasana Kharb, Lead- Partnerships, ResMed India
• Dr. Sibasish Dey, Head -Medical Affairs, ResMed India

Obstructive Sleep Apnea (OSA) is a chronic sleep related breathing disorder with complete or partial blockage of the upper airway during sleep. These interruptions during sleep, impact oxygen flow to the lungs (and subsequent delivery to vital organs), degrades sleep quality and overall health. Symptoms of OSA include loud snoring, insomnia, fatigue, dry mouth/sore throat, short-term memory losses, difficulty in concentration, morning headaches, and even depression.

While obesity or sedentary habits can increase risk, many people with OSA are neither overweight nor unhealthy and are affected by OSA due to anatomical (narrow upper airways) and physiological factors.

Globally, OSA affects around 1 billion people worldwide, which equals to approximately 20% of the total adult population. India ranks 4th worldwide with approximately 52 million Indians having OSA, as per a 2019 global prevalence study¹. A 2024 AIIMS meta-analysis highlight that around 104 million Indians are affected with OSA of whom 47 million patients have moderate to severe OSA². However, a majority of them remain clinically undiagnosed (80%)³ and untreated, primarily due to lack of awareness of the disorder, stigma and access to care.

OSA also significantly impacts women, especially during pregnancy and menopause, often presenting with atypical symptoms. In a study it was found prevalence increases with age—24% in women aged 20–44, 56% in those 45–54, and 75% in the 55–70 age group⁴. In children, OSA often due to enlarged tonsils or adenoids can lead to behavioural problems or poor academic performance and is often mistaken for ADHD⁵.

There is substantial evidence that suggest OSA has high association with co-morbid conditions like type 2 diabetes mellitus³ (52%), drug resistant hypertension³ (83%), heart failure⁶ (76%), stroke⁷ (63%), coronary artery disease⁸ (57%), atrial fibrillation⁹ (49%), depression¹⁰ (45%) and morbid obesity¹¹ (70%). A recent Lancet study reinforces that untreated OSA is a major but modifiable risk factor for both all-cause and cardiovascular-related death, highlighting the importance of consistent CPAP use¹².

Recognising this, the Research Society for Study of Diabetes, India (RSSDI) and American Heart Association (AHA), recommends screening, diagnosis, and treatment of OSA in patients with T2DM at initial stages¹³, resistant/poorly controlled hypertension, pulmonary hypertension, and recurrent atrial fibrillation¹⁴ and in patients with an ischemic stroke¹⁵ respectively.

To guide Indian clinical practice, the Indian Initiative on Obstructive Sleep Apnea (INOSA) guidelines was published in 2014 under the auspices of Ministry of health and family welfare, Government of India. This initiative provides comprehensive guidelines for the diagnosis, risk assessment, and management of OSA in India’s healthcare system¹⁶.

Beyond clinical impacts, untreated Obstructive Sleep Apnea (OSA) imposes a considerable economic burden. In the United States, it contributes to an estimated $86.9 billion in lost productivity, $15.9 billion due to road traffic accidents, and 1,400 preventable deaths annually. Individuals with untreated OSA also incur nearly twice the healthcare costs compared to those without the condition¹⁷. European data echoes this burden, where annual per-patient costs range from €236 to €28,267 depending on disease severity, with Italy alone experiencing national losses between €10.7 and €32 billion¹⁸. These figures show that delayed OSA diagnosis and treatment harm health and place a costly burden on health systems and economies.

Insurance Coverage for Sleep Apnea: India vs Global Models

Despite the rising burden of Obstructive Sleep Apnea (OSA), coverage under Indian health insurance remains limited. Patients often pay out-of-pocket for diagnosis and treatment. while insurers end up covering costly complications like stroke, heart disease, and hypertension—without addressing OSA as the root cause. The absence of standardized protocols and low awareness among payers and providers are key barriers to designing suitable insurance products.

Some insurers are taking early steps.  by extending coverage that includes coverage for sleep apnea and insomnia, along with sleep studies .  Some plans further includes CPAP/Bilevels device support post-hospitalization, with defined waiting periods for broader access. There are also policies that also  covers costs related to buying or renting CPAP equipment under its Durable Medical Equipment benefit.

Several countries have established robust frameworks that recognize the long-term health and economic burden of OSA.

• United States: Most insurers, including Medicare, cover sleep studies, PAP devices, and resupplies. Telemonitoring-enabled devices have improved adherence, enabling outcome-based reimbursement.
• France: Offers tiered reimbursement favoring connected CPAP devices, encouraging compliance and data-driven follow-up care.
• United Kingdom: The NHS now covers even mild OSA cases, emphasizing connected CPAP use and linking treatment to improved cardiovascular and daytime outcomes
• South Africa: Blends traditional insurance with wellness-linked models:
  1. CPAP is typically covered under high-tier plans with referrals and pre-authorizations.
  2. Disease Risk Management (DRM) programs offer structured care post-diagnosis.
  3. Wellness-linked platforms use gamified tools, rent-to-own CPAP models, and rewards for adherence.
  4. Partnerships among insurers, device companies (e.g., ResMed), and medical associations help reduce long-term complications.
  5. A central Risk Equalization Fund pools resources across insurers to make expensive therapies more accessible is now being adapted to devices.

Key Recommendations for India

To integrate sleep apnea into mainstream health insurance, the following steps are critical:

• Recognize OSA as a chronic NCD or lifestyle-linked condition within insurance and wellness frameworks.
• To standardize OSA coverage, prioritizing high-risk medical conditions.
• Subsidize diagnostics and CPAP devices as part of expert-guided treatment plans
• Include sleep health in preventive care; make Type 3 sleep studies part of annual checkups for high-risk groups.
• Create an industry-led data repository to build insurer confidence through evidence on claims, comorbidities, and outcome
• Design targeted insurance models for seniors, women, and high-net-worth Individuals to address lifestyle-linked OSA risks
• Integrate OSA into chronic disease management programs to improve outcomes and reduce costs.