Is Catarct Surgery Covered Under Health Insurance

A health insurance policy typically covers cataract surgery. However, this is only if your policy is active and you have completed the required waiting period. Each eye has a sub-limit, which means your total claim depends on your insurance policy. Premium lenses and bills above the cap may need partial payment from you. Confirm your plan's exact terms in the policy schedule.

Cataract surgery replaces a clouded natural lens with a clear artificial one. The WHO (World Health Organisation) calls cataract the leading cause of blindness worldwide, with more than 94 million people affected. Cost adds another worry. In 2022-23, household out-of-pocket spending in India made up 43.4% of total health expenditure, which comes to 3.82 crore in total. A common, treatable procedure shouldn’t eat into your savings, and checking your cover before surgery helps prevent that. This blog explains whether health insurance covers cataract surgery, when doctors recommend it, and how to claim.

Is Cataract Surgery Covered Under Health Insurance?

It depends on the specific health insurance policy. Cataract surgery is typically covered as a day-care procedure after the waiting period specified in your policy document has been completed. The policy pays up to the per-eye sub-limit stated. 

Usual inclusions:

• Pre-surgery examination and diagnostic tests.
• Surgeon and operation theatre charges.
• The intraocular lens, within the cap.
• Post-surgery care and follow-up visits.

However, the cover is not unlimited here. Every policy sets a limit per eye. Knowing these gaps is important, as they help you prepare ahead. 

What Does Health Insurance Not Cover for Cataract Surgery?

Coverage stops at the limits that your policy sets. Four areas commonly sit outside the payout.

• Any cost above the cataract sub-limit, which may apply per eye.
• The additional cost of a premium lens, such as a multifocal or toric lens, if your policy covers only a standard lens.
• Surgery carried out during the applicable waiting period.
• Treatment for a pre-existing cataract that was not disclosed when buying the policy, subject to the policy’s terms and applicable waiting period.

These exclusions are policy-specific, which is why it's important to carefully read your health insurance document. Planning for them early keeps surprises away.

When Is Cataract Surgery Recommended?

Surgery may be necessary when the cataract starts interfering with your daily activities and is advised by your eye doctor.

According to the World Health Organisation, there are about 1 in 2 people across the globe who require cataract surgery but do not have access to it. There are some obstacles that make this happen. These include high costs and lack of awareness.

Based on the NICE (National Institute for Health and Care Excellence) guideline NG77, you should get a consultation after you discuss these points: 

• How the cataract affects your vision and quality of life.
• Whether one or both eyes are affected.
• The risks and benefits of surgery.
• The likely impact of delaying it.
• Your own preference.

NICE also advises that visual acuity shouldn’t limit access to surgery, since it can miss glare and loss of color vision. Trouble with reading, night driving, and glare all count as symptoms.

This matters for claims. Your doctor's prescription acts as evidence that this test or procedure was necessary, which is why it’s important to carefully save your prescriptions.

What Is the Average Cataract Surgery Cost in India?

The amount required for undergoing cataract surgery in India differs significantly. The typical surgeries can cost anywhere between ₹30,000 and ₹50,000 per eye, and some high-end lenses could cost more. The above amounts are only indicative in nature.

For reference, as per the Ministry of Statistics & Programme Implementation:

• Average expenditure of OOP costs for each hospitalisation case, excluding childbirth, was ₹34,064.
• Median OOP expenditure was ₹11,285.

Niva Bupa health insurance policies state the per-eye cap in the policy schedule, so you can compare it with your expected bill.

Cataract Surgery: Coverage and Cost at a Glance

These prices are indicative only and can vary a lot based on the city, hospital, procedure, and insurance company. This is why you should always check the real price at the hospital and based on what your insurance covers.

Which IOL Options Does Health Insurance Cover?

The intraocular lens (IOL) replaces the eye’s clouded natural lens during cataract surgery. Health insurance may cover the IOL as part of cataract surgery expenses. However, this is subject to the policy’s cataract sub-limit. Coverage of the lens type varies by insurer and policy.

• Monofocal: The standard lens, providing clear vision at one chosen focal distance, usually distance vision. It is the lens type most commonly covered, usually within the applicable cap. 
• Toric: Corrects astigmatism in addition to replacing the clouded lens.
• Multifocals (trifocals included): Lenses designed for clear vision at multiple distances with reduced reliance on glasses.

The premium IOLs may be expensive, and the excess amount beyond the sub-limit in the cataract insurance plan per eye will be the out-of-pocket cost. There are also factors relating to vision and lifestyle that influence the choice of a lens, so it’s important to talk to your ophthalmologist. Also review your insurance policy for the sub-limit on the cataract per eye and the exclusions of premium IOLs.

What Pre-Surgery Eye Tests Are Covered?

Pre-surgery eye tests are usually covered as part of the insured treatment when the claim is eligible. The assessment verifies the diagnosis and helps your surgeon plan the procedure. The pre-operative assessment normally involves:

• Full eye examination. 
• Biometry, which is a measurement of the eye to calculate the IOL power. 
• Reports to be kept, because they will prove the decision as well as the claim.

Eligibility depends on your waiting period and sub-limit.

How Do You Claim for Cataract Surgery?

You can claim through cashless treatment at a network health eco-system or through reimbursement. Both routes need proper documents.

If you have a Niva Bupa health insurance plan, both routes are available to you, subject to the terms in your policy document.

How Does Cashless Cataract Treatment Work?

A network health eco-system sends a pre-authorisation request to the insurer, and the insurer responds within set timelines.

1. Choose a network health eco-system and show your health card.
2. The hospital submits the pre-authorisation request.
3. Under IRDAI rules, the insurer must decide pre-authorisation within 1 hour. 
4. The insurer must also decide final discharge authorisation within 3 hours and bears any delay beyond that.

For example, you have a Niva Bupa health insurance plan, have completed your waiting period, and your doctor has recommended surgery for your left eye. If you book your surgery through a Niva Bupa network health eco-system, then you'll have to show your health card at the desk. After this, the hospital will send your pre-authorisation request to us.  

If your bill is ₹52,000 because you choose a toric lens, and your policy per-eye sub-limit is ₹40,000, then Niva Bupa pays ₹40,000 directly to the hospital, and you pay the remaining ₹12,000 yourself. (These figures are illustrative. Your own sub-limit is mentioned in your policy schedule).

How Does Reimbursement Work?

You pay the hospital first, then submit documents to the insurer.

• Discharge summary
• Surgeon's bill
• IOL sticker or invoice
• Payment receipts

If you prefer a hospital outside the Niva Bupa network for your cataract surgery, then you'll pay the full bill at the time of discharge, collect the documents, and submit them to Niva Bupa. Your claim will then be assessed against the same per-eye sub-limit, and any amount above it stays with you.

Insurers must settle or reject reimbursement claims within 15 days. Make sure you keep the original and copies of every document and ensure that everything you submit is error-free.

Final Note

Cataract surgery is generally covered under health insurance when your policy is active and the applicable waiting period has been served. Make sure you verify the waiting period for the timing of your claim, check the per-eye sublimit to determine how much is covered by your insurer, and verify the type of lens that you will be using with the hospital.

In case you have a Niva Bupa health insurance plan, verify the exact cataract coverage in your plan document and seek a quote from the hospital. Just a quick phone call to us can simplify things for you.

Frequently Asked Questions

1. Is cataract surgery covered under Niva Bupa?

Yes, depending on the terms of your insurance plan. Cataracts are usually classified as a scheduled procedure, which is covered upon expiration of the waiting period, subject to a sub-limit per eye and supporting documentation. You may verify the limit for your plan.

2. What is the average cataract surgery cost in India?

This varies. The reported range per eye usually falls between ₹30,000 and ₹50,000. This is a general estimate and not an exact figure. The cost details should be verified with the hospital and the terms of the health insurance cover.

3. Are premium IOLs (toric or multifocal) covered?

The charge for the artificial lens is usually included in the surgical fee, although there is a limit on how much can be charged based on the sublimit per eye. In case of a more expensive toric or multifocal lens, the extra charges will need to come from your own pocket.

4. Is there a waiting period for cataract surgery?

Indeed, cataracts can be regarded as a specific or progressive ailment with a waiting period. In accordance with IRDAI guidelines, the maximum waiting period for a specific ailment cannot be more than 36 months. However, in the case of surgery caused by an accident, there is no need for a specific ailment waiting period.

5. Is cataract surgery covered if an accident causes it?

Yes. In cases where there is direct causality between a trauma and cataract surgery, then the waiting period related to the particular disease may not be applicable to the claim and should be handled under the accident/eergency clause of the policy. Make sure you keep the accident and treatment record.