Coverage for Surgeries Under Health Insurance

Surgery is a medical procedure and is required as a part of the treatment of various illnesses. Whether planned or emergency, surgeries often incur high medical expenses. Health insurance plays a crucial role in providing much-needed relief against the hefty costs associated with surgeries and eases policyholders’ financial burden. Surgeries under health insurance typically cover the surgery costs, including in-patient hospitalisation, medicines, surgeon fees, etc. However, it's crucial to understand the surgeries that health insurances typically cover and the extent of their coverage to make the most of it. 

In this article, we will explore which surgeries are covered by health insurance and which are exempted and better understand your coverage options.

What Surgery Costs Are Covered By Health Insurance?

Below, we have listed some of the general types of surgeries that are covered by health insurance.

Common Surgeries 

Common types of surgeries often include elective procedures designed to enhance overall well-being and improve quality of life. Many health insurance plans in India offer coverage on a wide range of common surgeries such as:

• Gastrointestinal surgeries, e.g., Gallbladder removal (Cholecystectomy), appendectomy
• Orthopaedic surgeries, e.g., Knee replacement, hip replacement, fracture repair
• ENT surgeries, e.g., Tonsillectomy, sinus surgery, cochlear implant
• Hernia surgeries, e.g., Inguinal hernia repair, umbilical hernia surgery
• Kidney & Urinary surgeries, e.g., Kidney stone removal, prostate surgery

Critical Surgeries 

Critical surgeries refer to life-saving and emergency procedures and are generally covered in health insurance as they fall under essential healthcare. Various critical surgery covers include: 

• Organ transplants, e.g., Kidney transplant, liver transplant, heart transplant
• Cancer surgeries, e.g., Tumor removal, mastectomy (Breast cancer), prostatectomy
• Cardiac surgeries, e.g., Heart bypass, angioplasty, pacemaker implantation
• Neurological surgeries, e.g., Brain tumour removal, spinal cord surgery, epilepsy surgery
• Pulmonary surgeries, e.g., Lung transplant, lobectomy (lung cancer removal)
• Bariatric surgeries, e.g., critical and life-saving obesity-related surgeries

Maternity Surgeries 

Various health insurance plans in India offer maternity benefits and cover the cost of various maternity-related surgeries if complications arise during the pregnancy. Maternity surgeries covered under health insurance include:

• C-Section Delivery
• Ectopic Pregnancy Surgery
• Hysterectomy (Uterus Removal) in case of complications arises
• NICU (Neonatal Intensive Care) in case of premature babies

What Surgery Costs Are Not Covered by Health Insurance?

There are some medical expenses that are exempted from health insurance on account of various reasons. Checkpoints below to know which surgeries are not covered by health insurance:

• Cosmetic & Various Elective Surgeries, such as hair transplants, liposuction, breast augmentation, etc.
• Dental surgeries, such as dental implants, teeth whitening, etc.
• Pre-existing surgeries, such as piles surgery, haemorrhoid surgery, etc.
• Any unproven or experimental surgeries
• Treatment required for self-inflicted injury
• Surgery is required for any drug consumption or addiction
• Treatment for any sexually transmitted diseases such as AIDS, syphilis, etc.
• Treatment outside the country

Quick Steps to Make the Most of Your Surgery Insurance 

While we have listed various surgeries that are covered by health insurance, it is crucial to check with insurance providers and get details on the coverage of the specific surgery. Here, we have listed steps that you can take to make sure your surgery is included in the plan:

Step 1: Review your policy documents

Go through the documents provided by your insurer and look for a section that covers inclusions and exclusions. Make sure your specified surgery covers medical procedures or requires any additional costs.

Pro Tip: Look for terms like pre-existing conditions, waiting period, and any specified exclusions.

Step 2: Contact the customer care or your agent 

Get in touch with the customer helpline of the health insurance provider or your agent and provide details and give details on the surgery to know its coverage. 

Pro Tip: Make sure to ask about reimbursement limits, clauses related to co-payments, or any prior authorisation is needed. 

Step 3: Check the network of hospitals

The insurance providers in India have a network of hospitals where you can get cashless treatment. Checking if the hospital comes under the network gets you hassle-free treatment. Otherwise, you have to pay the medical expenses first and later claim for reimbursement. 

Pro Tip: For non-network hospitals, make sure you understand the reimbursement network, the documents required, and timeline of the process. 

Step 4: Post-Surgery Expenses 

Some health insurance policies cover just the surgery costs, while others extend coverage for post-surgery expenses and follow-ups, medicines, etc. Check if your policy covers post-surgery expenses and plan accordingly. 

A Surgery Insurance Can Save You if You Plan Wisely

Health insurance is a lifesaver in case of diseases and critical illnesses and can be effectively used to alleviate financial burdens if you understand your policy thoroughly, plan wisely, and choose the most extensive insurance coverage. Health insurance from prominent insurance providers in India, such as Niva Bupa, not only covers your surgery costs but extends coverage to diagnostic tests, medication charges, doctor consultations, and ambulance charges, among others. 

Our well-curated health insurance policy is not just another plan but a safety net that extensively covers your medical expenses in emergencies as well as planned surgeries. So, take your first step towards a financially secure future with peace of mind with our plans.

Frequently Asked Questions (FAQs)

1. What medical expenses during surgery are covered under health insurance plans?

   Health insurance covers a wide range of expenses depending on the plan chosen. It generally includes surgery costs, diagnostic tests, surgeons' fees, ICU charges, medical equipment, medication charges, etc. 

2. Which surgeries are not covered under the health insurance plans?

   Health insurance plans do not cover cosmetic surgeries, experimental surgeries, self-inflicted injuries, and pre-existing condition surgeries. You can check with your insurance providers if a specified surgery is included in your plan. 

3. How to check if your surgery is covered by health insurance?

   Go through policy documents, contact your agent, check the waiting period clause, get prior authorisation, and check the insurer's network of hospitals before undergoing a surgery to avoid any unexpected expenses.