Which Surgeries are Covered Under Health Insurance in India?

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Health insurance in India covers a wide range of surgeries to help the policyholders manage high medical costs without any financial stress.


It includes minor procedures like cataract surgery and major operations, followed by covering joint replacements and bypass surgery. This is where your healthcare plan will provide surgery coverage, subject to your policy terms and medical necessity.


What Types of Surgeries are Covered Under a Health Insurance Plan?



  1. Emergency Surgeries


Health insurance usually covers emergency procedures, such as accident-related surgeries, without a waiting period. From trauma surgery to urgent operations for fracture repairs, internal bleeding or organ damage, these surgeries are essential in saving a patient’s life.



  1. Planned Surgeries


Most health insurance policies cover the expenses of the policyholder's planned surgeries after a specified waiting period. These procedures generally include hernia repair, cataract surgery, gallbladder removal, and joint replacements. However, the list of these procedures can vary across insurers.



  1. Daycare Procedures


Several procedures, such as cataract removal, dialysis, and minor orthopaedic surgeries, no longer require lengthy hospital stays due to advancements in medical technology. This is when the daycare procedure helps cover treatments that require less than 24 hours.



  1. Modern Treatments


As per the guidelines of the Insurance Regulatory and Development Authority of India (IRDAI), every health insurance provider must cover at least 12 modern treatments under their policy. These procedures include robotic surgery, immunotherapy, stem cell therapy and balloon sinuplasty.


Which Surgeries are Not Covered in a Health Insurance Plan?


While health insurance often includes comprehensive coverage for surgeries, certain procedures are excluded. It includes:



  1. Cosmetic or aesthetic surgeries, such as nose jobs, liposuction or hair transplants.



  1. Surgeries for infertility or assisted reproduction (IVF).



  1. Operations required for self-harm or conditions arising from substance abuse.


Factors That Affect Your Healthcare Coverage for Surgeries



  1. Medical Necessity:Insurers usually cover only surgeries that are medically necessary for the policyholder.



  1. Pre-existing Conditions and Waiting Periods:To get coverage for conditions diagnosed before purchasing insurance, policyholders must wait. It generally lasts 12 to 36 months.



  1. Sub Limit:WhenInsurers impose a sub-limit cap on the sum insured for certain surgeries, policyholders have to pay a specific percentage of the treatment out-of-pocket.For example, if your policy has a sub-limit of 10% on the maximum ₹1,00,000 sum insured, you have to pay ₹10,000 by yourself.



  1. Pre-authorisation: For planned or non-emergency surgeries, you have to get prior approval from your insurer. Additionally, the condition requiring the procedure must be a part of your healthcare plan.


Final Words


Health insurance can significantly reduce the financial stress associated with surgeries. However, this coverage will come with certain limitations, like a waiting period or sub-limits.


This is why you should always verify the details of your health insurance plan and consult your insurer before undergoing any procedure. This way, you can receive quality treatment with a smooth and hassle-free claim process.