What surgeries are covered by health insurance?

The word ‘surgery’ can easily cause worry and stress. Worry about the procedure, the pain, the recovery period, and the costs involved. Those who have health insurance may be in a better position to meet the expenses. However, it is essential to understand the surgery-related coverage provided by different health insurance plans.

Let’s understand all about surgeries and health insurance coverage.

Surgery cover varies from insurer to insurance

Health insurance policies differ from each other vastly. To know the types of surgery expenses included in a policy would require knowing the clauses mentioned in the policy. 

Here’s what a policyholder can do: ask your doctor/surgeon/hospital to share a detailed plan of what surgeries would be required. You could even get a rough estimate of the cost of the surgeries. Next, read your health insurance policy document clauses section. Policy documents list costs that are covered and excluded in the plan. This should give you basic information about the surgery costs covered by your insurer. For clarifying doubts and concerns, it is best to contact your insurance agent or the health insurance company representative.

Also Read: How Health Insurance Works

Day Care Procedures and Surgery

Surgeries are of various kinds. Some may require hospitalization of a few days to a long duration, while some may be completed within a few hours and not require hospitalization. This is where daycare procedures coverage for surgeries comes in. 

Top Surgeries that covered under Health Insurance Plans in India

Here’s a list of some of the covered day care procedures in health insurance including surgeries that are covered by different insurance plans as mentioned below:- 

• Certain surgeries related to the ear – stapedotomy, surgeries of the auditory ossicles, and reconstruction of the middle ear, among others.
• Certain surgeries are related to the nose – sinus, nasal concha, foreign body removal, among others.
• Surgical treatments for eyes – cataract, corneal incision, eyelid incision, removal of foreign body, among others.
• Neurological surgery
• Oncology
• Chemotherapy

Top Surgeries that are not covered under Health Insurance Plans in India

Alongside, let’s also look at surgeries and procedures that are not included in health insurance plans.

• Cosmetic surgeries
• Dental surgeries
• Non-essential surgeries
• Experimental surgeries

Non-essential or experimental surgeries

Most health insurance plans that provide coverage for daycare procedures would cover surgeries. However, this may vary depending on the policy clauses. Medical technology is advancing fast, but po may take time to catch up. Certain new technology-based surgeries may not be included or mentioned in the health insurance policy and hence, there are chances of such treatments not being covered.

Some surgeries can require extensive procedures, pre and post the actual operation. Without extensive insurance coverage for surgery, these surgeries and procedures can create a huge financial burden. It is important to understand whether or not your health insurance plan covers these costs. Medical treatment costs are on the rise. Hi-tech medical procedures cost lakhs and it is important to keep the cost factor in mind when buying the insurance policy. It is better to have a high sum insured if surgery costs are to be claimed. Experts advise that a sum insured of Rs 10 lakh to Rs 25 lakh is a good start in case surgeries are required.

Know more about surgeries that are covered by health insurance plans with this infographic.

List of additional costs of surgery apart from general costs

There are some additional costs of surgery as well. Take a look at some of the additional costs of surgery apart from general costs:

• Pre-Operative and Post-Operative Tests: Various tests are conducted to check the patient’s condition before and after the surgery. Diagnostics, bloodwork, x-rays, check-ups, etc. incur a significant amount of expenses in a surgery. 
• OT Cost: The Operation Theatre, where the surgery or procedure is conducted, has separate costs on a procedure or per-hour basis. The expenses for the OT varies from one medical facility to other.
• Surgeon and Attendant’s Fee: The fees for surgeons, co-surgeons and any other doctors or nurses required in the procedure, although applied separately to the bill, is one of the primary costs of surgery.
• Medication: Costs occurred due to medication such as intravenous medication, anesthesia, etc. as required and prescribed by the doctor. These are a significant portion of the total expenses incurred in a surgery or a procedure.
• Medical Equipment: Medical equipment like braces, wheelchairs, crutches required are also required by the patient after the surgery which further incur some additional costs.
• Recovery Room and Inpatient Care: There is a stipulated recovery time after the surgery and inpatient care is required for the patient, depending on the condition of the patient after the surgery. These inpatient care expenses are also added to the surgery costs.

Important practices to avail coverage for surgery from health insurance

• Remember and consider the waiting period to avail insurance coverage for surgery. You cannot buy a new health insurance plan today and go into surgery the next day thinking that the insurer will pay the claims. Typically, health insurance policies have a waiting period. The insurer would pay claims only after the waiting period is over.

• Whether you had to go in for emergency surgery or it was a planned factor in your medical treatment plan, it is essential to inform your insurer on time. In order to claim the expenses from the insurance company, follow the guidelines and rules of the company.

5 Best Health Insurance Plans with Surgery Coverage

If you’re looking to buy a health plan that provides insurance coverage for surgery, here are some health plans that you could consider as mentioned below:-

1. Aditya Birla Activ Diamond Plan
2. Bajaj Allianz Health Guard Plan
3. Star Health Family Health Optima
4. Bharti AXA Senior Citizen Health Insurance
5. HDFC Ergo Health Insurance for Senior Citizens

1. Aditya Birla Activ Diamond Plan

A ccomprehensive general health insurance plan, this plan also offers additional cover for critical illness and reduction of pre-existing diseases waiting period. Its key features are:

• 150% reload of the sum insured, for subsequent claims due to unrelated illness, maximum up to Rs 50 lakh
• Coverage for 586 daycare procedures
• Health Returns worth up to 30% of your premium for staying fit and healthy
• International and domestic medical emergency services
• Coverage for in-patient hospitalization of more than 24 hours because of planned treatment or an emergency
• Pre and post hospitalization expenses covered for 30 and 60 days respectively
• Coverage for domiciliary hospitalization up to a maximum of Rs. 50,000

2. Bajaj Allianz Health Guard Plan

A comprehensive plan, both for individuals and families, it offers coverage for pregnancy as well as a newborn baby. Here are its key features:

• Two variants available: Silver (up to 2 lakh sum insured) and Gold (up to 50 lakh sum insured)
• Ambulance charges are covered with a limit of Rs. 20,000 for a policy year
• Pre and post hospitalization expenses covered for 60 and 90 days respectively
• Entry age: 3 months to 65 years
• Offers lifelong renewability
• Includes comprehensive coverage: pre and post-hospitalization, critical illness, organ donor expenses, AYUSH treatment, maternity and more.
• Health-Guard Family Floater provides coverage for all daycare treatments

3. Star Health Family Health Optima

This super saver family health insurance plan is available for the age group of 18 years to 65 years. It includes members- spouse, dependent children (16 days to 25 years), and parents. Its key features are:

• Sum insured up to Rs 25 lakh
• Coverage for in-patient hospitalization expenses like room charges, nursing expenses, ICU, surgeon’s fee, etc.
• Provides coverage for all daycare treatments that take less than 24 hours
• Coverage for newborn baby
• Air ambulances cover up to 10% of the basic sum insured
• Pre and post hospitalization expenses covered for 60 and 90 days respectively
• Bonus and additional sum insured

4. Bharti AXA Senior Citizen Health Insurance

Health Insurance specially designed to safeguard senior citizens of 65 years and above, is currently one of the most recommended senior citizens’ health insurance plans. Here are its key features.

• Offers additional cover for critical illness
• Cashless hospitalization
• Pre and post hospitalization expenses covered for 60 and 90 days respectively
• Coverage for outpatient emergency treatment for accidents
• 100% restoration benefit for the sum insured is available
• Sum insured ranging from Rs. 5 Lakh to Rs. 1 Crore
• Special dedicated customer care support for senior citizens

5. HDFC Ergo Health Insurance for Senior Citizens

With no age limit, this here is one of the best plans for senior citizens’ healthcare needs. Its key features are:

• Provides coverage for all daycare treatments that take less than 24 hours
• Pre and post hospitalization expenses covered for 30 and 60 days respectively
• Coverage for in-patient hospitalization expenses like room charges, nursing expenses, ICU, surgeon’s fee, etc.
• Coverage for domiciliary hospitalization
• Portability benefits, no claim discount, e-opinion, no maximum entry age, lifelong renewal option
• Ad-on available for enhancing the coverage to cover critical illnesses
• Additional coverage for alternative systems of medicine i.e. AYUSH treatments

Conclusion

Surgery can cause concern, not only about health and wellness but also about finances. Similarly, without coverage for daycare procedures in health insurance, the towering expenses can hinder your financial stability. It is important to be financially prepared for such health needs. Hence health insurance experts often urge policyholders to maintain a high sum insured. With rising medical treatment and operation costs, it is only wise to have an insurance policy that covers surgery and one with a high sum insured.