Coverage of the cost of surgery in Health Insurance

What is surgical intervention/procedure?

Surgical interventions are the operative procedures performed in a hospital or day care centre by a competent medical professional to treat an illness, injury, to provide relief from suffering and prolong life.

Most of the Health Insurance policies in India are indemnity-based, which means the insurance company will reimburse the expenditure incurred on treatment up to the Sum Insured. By choosing a Health Insurance cover, a policyholder is covered for hospitalisation expenses through Medical or Surgical management, Day care procedures, ICU charges, doctor consultation fee, medicines, etc. and is also incentivised for active participation in wellness activities by way of discount in Premium. 

Surgery works best for some of the medical conditions due to advanced technologies in healthcare and is, therefore, an effective option for patients. But having access to quality treatment is of paramount importance. While considering the rising medical and surgery costs, it is wise to buy a Health Insurance policy that offers adequate coverage for the same.

Note that you can ask the hospitals and healthcare providers to provide a rough cost estimate for the medically necessary treatment and surgery before undergoing them. Policy documents list the expenses that are covered and excluded in the policy for a surgical procedure.

Let us take a look at how your Health Insurance plan covers the cost of surgery. Most Health Insurance companies cover surgery costs if your claim is admissible as per the terms and conditions of the Health Insurance policy. The surgery should be medically necessary and advised by your medical practitioner.

Costs of surgeries in Health Insurance cover

Some surgeries involve extensive procedures, which cost more and lead to a huge financial burden. It is advisable to check if your Health Insurance plan covers these expenses before undergoing such surgeries. Some of the insurance plans either do not cover advanced surgeries or restrict the indemnity for such procedures. If surgery costs are to be claimed, one has to go for higher Sum Insured options to ensure adequate protection.

Expenses incurred for surgery include pre- and post-operative tests, operation theatre costs, surgeon fees, cost of implants, anaesthesia, intravenous medication, medical equipment, room charges and in-patient care as well.

Does your Health Insurance cover the surgery expenses?

Surgeries are done to save your life.

Yet, there is a specific waiting period after which your insurance company will be able to cover the expenses incurred for the treatment of the specified ailments. For example, under Star Comprehensive Insurance plan, expenses incurred on hospitalisation for Bariatric surgery on the advice of the doctor are covered after a waiting period of 36 months (from the first commencement of the policy) and subject to certain limits mentioned in the policy document. Similarly, coverage for surgery expenses of Knee Replacement diagnosed post-policy inception is provided after a waiting period of 2 years. But if the same has been a pre-existing condition, the waiting period may vary from 3 years to 4 years. So securing your family at the earliest, including the elders, in a good Health Insurance plan is very important.

The in-patient hospitalisation expenses incurred for organ harvesting and transplantation are covered based on the policy terms and conditions. In addition, a cash benefit up to the limits mentioned for each completed day of hospitalisation for a maximum of 7 days is payable. For more details, you can refer to the policy clause.

Day care procedures covered by Health Insurance

Day care treatment/procedure means medical treatment and/or surgical procedure, which is, undertaken under General or Local Anesthesia in a hospital/Day care centre in less than 24 hours because of technological advancement, and which would have otherwise required hospitalisation of more than 24 hours.

Know about the Exclusions in surgeries

‘Exclusions’ are those medical expenses or diseases/conditions which are not covered by the insurance company. They are of two types – Time-bound Exclusions (excluded for a specific period of time) and Permanent Exclusions. It is always important to note the Exclusions are mentioned in the policy document of your Health Insurance plan. The exclusions (not covered items) include cosmetic surgery, plastic surgery, infertility treatments, etc. If a claim is registered by a customer for such surgery expenses, it may result in rejection. 

Key takeaways

A comprehensive Health Insurance plan is the need of the hour to keep oneself away from worries about health, wellness and finances. Adequate coverage for treatments/surgeries and Day care procedures in Health Insurance will make you financially stable. With rising medical inflation and operation costs, it is always wise to have a Health Insurance plan with an adequate Sum Insured to cover your surgery and treatment costs.