How Does Insurance Support Orthopaedic Care?

Vote: 100

From broken bones, torn ligaments, to serious arthritis and spine ailments, orthopaedic diseases and conditions affect lakhs of Indians each year. Not only are treatments medically complicated, but they're equally costly. Whether it's for a broken ankle or a joint replacement surgery, health insurance is a key component that ensures access to orthopaedic care and makes it affordable.


What is Orthopaedic Care?


There are at least 2.5 lakh knee replacement surgeries done every year in India, and orthopaedic treatments are some of the most commonly covered health insurance procedures. Costs range from ₹50,000 for a simple arthroscopy to ₹3.5 lakh or more for complex joint replacement surgery, making insurance cover essential.


Health Insurance for Orthopaedic Care


Let's take a closer look at how insurance helps with orthopaedic care at each phase of treatment:



  • Emergency Fracture and Trauma Cover


Coverage is in effect for accidental injuries (including bone fracture, dislocation and ligament tear) from day 1 of the policy. This includes hospitalisation, surgery, surgical implants (plates and screws), and necessary follow-up care.



  • Planned Orthopaedic Surgeries


Most surgical procedures, such as knee replacement, hip replacement, shoulder replacement, and spine fusion, are included in comprehensive plans. With these surgeries, there is usually a waiting period of 1-2 years before the claim can be made under the policy.



  • Diagnostic Tests


Both pre-hospitalisation investigations (including X-rays, MRIs, CT scans, bone density tests and orthopaedic consultations) and appropriate investigations and consultation following hospital admission are covered for 30 to 60 days before admission, depending on the insurer.



  • Surgical Implants and Prosthetics


Artificial joints, bone cement, titanium rods and other implants used during orthopaedic surgery are covered by most health plans, although some policies have a sub-limit on implant costs.



  • Arthroscopy as a Day-Care Procedure


Most of the plans will charge for arthroscopic surgeries, which do not require the patient to be admitted to a hospital for 24 hours. Day-care benefits do not have a waiting period and are not covered.



  • Physiotherapy and Rehabilitation


A lot of plans offer physiotherapy after surgery as part of the post-hospitalization benefit (usually 60-90 days after your surgery). Wellness benefit packages may also cover OPD physiotherapy sessions for some premium packages.


Common Exclusions in Orthopaedic Insurance Coverage



  • Orthopaedic cosmetic, or aesthetic surgery not indicated for medical conditions.



  • Experimental treatments and surgeries are not recognised by the Medical Council of India.



  • Treatment in the Outpatient Department and Physiotherapy (excluding OPD rider if added to policy).



  • Orthopaedic conditions resulting from drug abuse and/or self-inflicted injuries.



  • Except for accidental injuries, surgeries during the first 30 days of the waiting period.



  • Many policies place a hard cap on reimbursement of implants regardless of actual expenses.


Final Thought


Orthopaedic care is both physically and financially demanding. From acute sports injuries to elective joint replacement surgery, a suitable insurance policy will allow you to access prompt and exceptional treatment for your injury without impacting your savings. Purchase early and select a plan that covers the implants, physiotherapy and day-care procedures comprehensively.