Orthopaedic surgeries are commonly performed on areas such as the knee, spine, hip, shoulder, ankle, wrist, and elbow. Some of the most frequently conducted orthopaedic procedures include:
If you’re diagnosed with an orthopaedic condition and advised to undergo surgery, the expenses can be quite significant. Orthopaedic surgeries are typically costly and can severely impact your savings. For instance, a joint replacement surgery can cost several lakhs, and additional expenses such as MRIs, X-rays, and frequent specialist consultations can add to the financial burden.
Is orthopaedic surgery covered by health insurance?
Yes, many health insurance plans in India offer coverage for orthopaedic surgeries. Most standard health insurance policies include hospitalization-related expenses such as:
Operation theatre charges
Surgical appliances and implants
Doctor’s and anaesthetist’s fees
Room rent and nursing charges
Costs of pre- and post-surgical care
In addition, several plans also cover pre-hospitalization and post-hospitalization costs, which may include diagnostic tests and physiotherapy sessions.
If your orthopaedic procedure falls under day care treatment (i.e., it doesn't require 24-hour hospitalization), you can still claim coverage—provided your policy includes day care benefits. Many modern health plans offer this feature, so it’s important to review your policy or speak with your insurer.
Keep in mind that the extent of coverage—whether partial or full—will depend on your individual policy terms and conditions. To avoid surprises, it's advisable to confirm coverage details with your insurance provider as soon as the surgery is recommended.
Benefits of health insurance for orthopedic procedures
Health insurance for orthopedic procedures comes with several advantages, ensuring that patients can access the required treatments without bearing a heavy financial burden.
1. Financial support:
Orthopedic surgeries can be costly. Health insurance ensures that you don’t have to pay the full amount out of pocket.
2. Access to quality care:
With insurance, you gain access to a network of reputable hospitals and surgeons specialising in orthopedic treatments.
3. Coverage for pre- and post-surgery care:
Many insurance plans cover not only the surgery but also pre-operative consultations and post-operative rehabilitation, which are crucial for recovery.
4. Cashless treatment:
Most insurance policies provide a cashless treatment option at network hospitals, allowing you to receive medical care without upfront payments.
5. Comprehensive coverage:
In addition to surgery, some policies also cover diagnostic tests, medications, and follow-up visits, ensuring a holistic approach to your orthopedic care.
What are the waiting periods for orthopaedic surgery under health insurance?
While most health insurance plans in India do cover orthopaedic surgeries, it’s important to note that some procedures come with a waiting period. Treatments such as joint replacement surgery or those related to arthritis are typically covered only after a waiting period of 1 to 2 years. This means you won’t be able to file a claim for these specific surgeries until the waiting period mentioned in your policy is completed. However, this restriction usually does not apply to day care procedures, which are often covered without any waiting period.
Another key factor is the timing of your diagnosis. If you were diagnosed with an orthopaedic condition before purchasing the policy, your insurer will classify it as a pre-existing condition. Most health insurance plans cover pre-existing conditions only after a 2 to 4-year waiting period. Therefore, if your orthopaedic issue was pre-existing, you will have to wait out this period before being eligible to claim expenses related to surgery.
How to choose the right health insurance plan for orthopedic surgery?
Selecting the right health insurance plan for orthopedic surgery requires careful consideration. Here are some tips to help you choose the most suitable option:
Evaluate your needs:
Start by assessing your health condition and the likelihood of requiring orthopedic surgery in the future. If you have a pre-existing condition, such as arthritis or a history of bone injuries, you may want a plan that covers these treatments.
Check for comprehensive coverage:
Ensure that the insurance plan covers all aspects of orthopedic treatment, including hospital stays, surgeries, rehabilitation, and follow-up visits.
Network hospitals:
Choose an insurance provider that has a wide network of hospitals known for their orthopedic departments. Cashless treatment is often available only at these network hospitals.
Pre-existing condition coverage:
Some policies may not cover pre-existing conditions, or they may impose a waiting period. Make sure to understand these terms before choosing a plan.
Examine the claim process:
Opt for an insurance provider with a straightforward claim settlement process to avoid complications during a medical emergency.
Consider premiums and co-payments:
While comprehensive coverage is important, ensure that the premiums are affordable and that co-payment options are clearly defined.