Does Health Insurance Cover Orthopaedic Surgery?

Orthopaedic health conditions have become quite common in India. They are no longer limited to just elderly people but are increasingly diagnosed amongst younger people due to their sedentary lifestyle. The work from home regime adopted during the COVID-19 pandemic has only worsened the lifestyle of the people. Although minor orthopaedic conditions can be treated through medication, exercises and physiotherapy, severe cases may require orthopaedic surgery.

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    What is Orthopaedic Surgery?

    Orthopaedic surgery is a type of medical surgery performed on the musculoskeletal system of the body in case of an acute injury or trauma or other medical conditions. It is conducted to treat orthopaedic conditions arising out of congenital & acquired disorders, chronic arthritis and acute injuries to the bones, ligaments, tendons and associated soft tissues.

    Orthopaedic surgeries can either be performed traditionally by open surgery or through arthroscopy. In case of open surgery, you may be required to get admitted to a hospital for a couple of days. However, arthroscopy is conducted as a day care procedure that requires hospitalization of less than 24 hours and allows you to go home on the same day.

    Most Common Types of Orthopaedic Surgeries

    Orthopaedic surgeries are mostly performed on the knee, spine, hip, shoulder, ankle, wrist and elbow. Some of the most common orthopaedic surgical procedures are as follows:

    • Joint arthroscopy
    • Joint replacement surgery
    • Bone fracture repair
    • Soft tissue repair
    • Osteotomy
    • Spine fusion
    • Arthroplasty
    • Fusion of bones
    • Debridement
    • Revision joint surgery

    In case you are suffering from an orthopaedic health condition and are required to undergo orthopaedic surgery, it may cost you dearly. This is because orthopaedic surgeries are costly and can reduce your savings substantially. For example, joint replacement surgery can cost you a couple of lakh rupees. Moreover, diagnostic tests like MRI, X-RAY are also expensive and frequent visits to the orthopaedic can also dig a hole in your pocket.

    This brings us to the question of whether health insurance plans cover orthopaedic surgery or not. Let’s find out the answer.

    Is Orthopaedic Surgery Covered by Health Insurance?

    Yes. Several health insurance plans in India provides coverage for orthopaedic surgeries. Almost all health plans cover hospitalization costs that include various expenses, such as operation theatre charges, cost of surgical appliances, doctor’s fee, room rent, nursing charges, anaesthetist’s fee, cost of surgical implants, etc. A lot of health plans will also cover your pre-hospitalization and post-hospitalization expenses, including the cost of physiotherapy.

    Even if your orthopaedic surgery is a day care procedure, you can get your insurance provider to cover its cost if you have a health insurance plan with day care treatment cover. Several health plans provide coverage for day care procedures. All you need to do is to check whether your policy covers day care procedures or not.

    Health insurance plans may either cover the cost of an orthopaedic surgery partially or completely. However, the extent of coverage depends entirely on the terms and conditions of your health insurance policy. Therefore, it is better to check with your insurance provider as soon as the surgery is scheduled to understand if the surgery cost will be covered and to what extent.

    Waiting Periods for Orthopaedic Surgery under Health Insurance

    Although most health insurance plans in India will provide coverage for orthopaedic surgery, some of the procedures may be covered after a waiting period. Insurance companies cover orthopaedic procedures like joint replacement surgery and arthritis after a waiting period of 1 to 2 years. This means you cannot raise a claim for specific orthopaedic surgeries listed under your policy unless your waiting period is over. However, this does not apply to day care procedures as they don’t come with any waiting period.

    Another important thing to note is the time when you were diagnosed with an orthopaedic condition. If you were diagnosed with the condition before buying the health policy, your insurance company will consider it as a pre-existing disease. Most health plans cover pre-existing diseases after a waiting period of 2 to 4 years. Hence, if you had a pre-existing orthopaedic condition, you will be unable to raise a claim for orthopaedic surgery until it gets over.

    In a Nutshell

    Orthopaedic conditions can have severe implications if they are not treated at the right time. You may require orthopaedic surgery to treat certain orthopaedic conditions. The only way to protect your hard-earned savings from orthopaedic surgery is to buy a health insurance policy that covers open orthopaedic surgeries as well as day care procedures. Make sure to check the terms and conditions of your policy before raising a claim.

    Written By: PolicyBazaar - Updated: 12 October 2021

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