Is Orthopaedic Surgery Covered Under My Health Policy?

Yes, most health insurance policies in India cover orthopaedic surgery. The coverage during this surgery typically includes hospitalisation, surgeon fees, operating room charges, and implants. However, policyholders must serve a specific waiting period to receive this benefit.

If you are wondering about the relevance of this surgery, a report by The Times of India states that orthopaedic issues in India will rise from 2.5 lakh to 5-6 lakh annually among young adults in the next 5 years. This is why having this surgery coverage in your health insurance is more essential than ever.

What is Orthopaedic Surgery?

Orthopaedic surgery is a medical procedure performed to treat, rehabilitate, and prevent injuries and diseases of the musculoskeletal system, including bones, joints, ligaments, and nerves.

This surgery can be conducted by open surgery or through arthroscopy. If the policyholder requires an open surgery, they must remain hospitalised for at least 24 hours. One of the common types of orthopaedic surgeries includes joint arthroscopy, joint replacement, bone fracture repair, soft tissue repair, and osteotomy.

How is Orthopaedic Surgery Covered in Health Insurance?

• Medical Necessity: You will only get coverage for orthopaedic surgery if it's medically necessary. Therefore, you must keep all necessary medical prescriptions on hand to demonstrate the treatment’s urgency.

• Waiting Period: A waiting period of 12 to 36 months will apply to planned orthopaedic surgery. However, surgeries required for accidental injuries will be covered immediately.

• Cost Limitations:Insurers can impose a sub-limit cap on the sum insured for orthopaedic surgery. In this situation, the policyholder must pay a specified percentage of the treatment out of pocket.

• Modern Treatment Benefits:For orthopaedic surgery, the policyholder can also receive benefits for advanced treatments such as robotic surgery or stem cell therapy for specific bone conditions.

• Coverage for Hospitalisation: Most reputable insurers in India cover hospitalisation costs for orthopaedic surgery. For example, you will get coverage for pre- and post-hospitalisation costs, surgeon fees, hospital room rent, and ambulance charges.

• Day Care Facility:Orthopaedic procedures via arthroscopy, which generally require less than 24 hours of hospitalisation, are also covered in the healthcare plan.

• Pre-authorisation Requirement: If the surgery is planned, the policyholder must obtain prior approval from the insurer to confirm their eligibility.

• Cashless or Reimbursement Treatment Option: To avail a cashless treatment facility for this surgery, the policyholder must be admitted to an insurer's network hospital. Meanwhile, non-network hospitals will have to make an upfront payment for the hospital bill and later receive reimbursement.

Final Words

Orthopaedic treatments can get serious if they are not treated at the right time. Given its rising prevalence among young people, you must ensure your health insurance policy covers orthopaedic conditions. This way, you can protect your hard-earned savings in the event of an unexpected medical emergency that may require this surgery.