Surgeries Covered in Health Insurance

Explore the range of surgeries covered by health insurance and understand your coverage options.
Explore Plans
Check Health Insurance Plans
Get Quote
3 min
09-October-2024

Health insurance is essential in providing financial support during medical emergencies, particularly when it comes to surgeries. Surgical procedures, whether planned or emergency, can lead to high medical expenses. This is where health insurance steps in, alleviating the financial burden for policyholders. But not every surgery is covered by health insurance. Understanding which surgeries are covered and how to check your policy for coverage is crucial to avoid surprises. This article explores the surgeries covered by insurance and factors affecting surgery coverage.

What surgeries are typically covered in health insurance?

Health insurance policies are designed to cover a wide range of medical treatments, including surgeries. However, the type of surgery and the specifics of your health insurance plan determine whether a particular procedure is covered. Below are some common types of surgeries that are typically covered by health insurance:

1. Emergency surgeries:

Health insurance generally covers emergency surgeries like appendectomies, heart surgeries, or surgeries resulting from accidents. These are considered life-saving procedures and fall under essential healthcare services.

2. Elective surgeries:

Although the term ‘elective’ suggests that these surgeries are optional, many are necessary for improving quality of life. Elective surgeries covered by health insurance often include cataract surgery, gallbladder removal, or hernia repair. These procedures are typically scheduled in advance but still qualify for coverage under many plans.

3. Orthopedic surgeries:

Health insurance often covers joint replacements, fracture repairs, and ligament repairs, especially if they are medically necessary to restore mobility and prevent further health complications.

4. Cancer surgeries:

If you are diagnosed with cancer, many health insurance policies cover surgeries related to tumor removal, biopsies, and other cancer-related operations. Early diagnosis and treatment are often encouraged, and surgical procedures are seen as critical interventions.

5. Maternity-related surgeries:

Health insurance plans that include maternity benefits typically cover cesarean sections (C-sections) and other maternity-related surgeries. Policies that cover pregnancy also often include post-natal surgical care if complications arise.

6. Bariatric surgeries:

For patients with severe obesity-related health issues, bariatric surgeries like gastric bypass or sleeve gastrectomy may be covered by health insurance. This is usually applicable if the surgery is medically necessary to treat obesity-related health conditions such as diabetes or hypertension. Read more about health insurance for obesity.

While these surgeries are generally covered by health insurance, it's vital to check your individual plan for specific coverage details, as not all insurance policies are the same.

How to check if your surgery is covered by health insurance?

Before undergoing any surgery, it is critical to confirm whether your health insurance will cover the procedure. Here are steps you can take to ensure your surgery is covered:

1. Review your policy document:

The first step is to thoroughly review your health insurance policy. Look for sections that specify covered surgeries and medical treatments. Most insurers provide a list of treatments that are included in the policy.

2. Contact your insurance provider:

Reach out to your health insurance company directly for confirmation. You can either call customer service or visit their website to get a comprehensive breakdown of what’s covered. Many insurers also provide online tools or portals where you can check the coverage of specific surgeries.

3. Get pre-authorisation:

For planned surgeries, many insurance companies require pre-authorisation. This means your doctor will need to submit documentation explaining why the surgery is necessary, and the insurer must approve the procedure before it is scheduled. This step can help ensure the surgery will be covered.

4. Check network hospitals:

If your surgery will take place in a hospital, it’s essential to verify whether the hospital and surgeon are part of your insurance network. Surgeries performed outside the network may either not be covered or may result in higher out-of-pocket costs.

5. Consult with your doctor:

Your healthcare provider is often familiar with insurance policies and may help determine whether your surgery is covered. They can provide necessary details to the insurance company about the medical necessity of the surgery.

Explore: List of diseases covered in health insurance

Common exclusions in health insurance surgery coverage

While health insurance covers many surgeries, some exclusions apply. Policies can vary, but here are common surgeries and circumstances typically excluded from coverage:

1. Cosmetic surgeries:

Procedures performed for purely aesthetic reasons, such as facelifts, liposuction, or rhinoplasty, are generally not covered by health insurance unless they are medically necessary due to an accident or congenital issue.

2. Experimental surgeries:

Health insurance does not usually cover experimental or investigational surgeries that are still undergoing clinical trials or are not yet widely accepted in medical practice.

3. Fertility-related surgeries:

Procedures like in-vitro fertilization (IVF), vasectomy reversal, or tubal ligation reversal are often excluded from insurance coverage, as they are considered elective or non-essential.

4. Pre-existing condition surgeries (during the waiting period):

Many insurance policies have a waiting period for surgeries related to pre-existing conditions. If you undergo surgery related to a pre-existing condition before the waiting period is over, it may not be covered.

5. Self-inflicted injuries:

Surgeries required as a result of self-inflicted injuries, including suicide attempts, are commonly excluded from health insurance coverage.

Understanding exclusions is essential to avoid unexpected out-of-pocket expenses. Make sure to review the fine print in your policy and discuss any concerns with your insurer.

Also, read: Exclusions under health insurance

Factors affecting surgery coverage in health insurance

Several factors can influence whether your health insurance will cover surgery and to what extent. Some of these factors include:

1. Medical necessity:

The most critical factor affecting surgery coverage is whether the surgery is medically necessary. Insurers typically cover surgeries deemed essential for saving life, improving health, or preventing further medical complications. Your doctor’s recommendation is key in establishing the necessity of surgery.

2. Pre-existing conditions:

If your surgery is related to a pre-existing condition, it may not be covered until the waiting period is over. Some policies impose waiting periods ranging from two to four years for conditions like diabetes, hypertension, or heart disease.

3. Policy type:

The type of health insurance policy you hold—whether individual, family floater, or group insurance—can also influence coverage. Group insurance plans offered by employers may have more comprehensive coverage compared to individual policies.

4. Sum insured:

The sum insured in your health insurance policy dictates the maximum amount the insurer will cover for surgeries and other treatments. If the cost of the surgery exceeds this limit, you will have to bear the excess costs.

5. Hospital network:

Insurance companies often have tie-ups with specific hospitals known as network hospitals. If your surgery is conducted in a network hospital, you may be eligible for cashless treatment, where the insurer directly pays the hospital. Surgeries performed outside the network may require reimbursement or partial coverage.

6. Co-payment and deductibles:

Many insurance policies include co-payment clauses, where the insured must bear a certain percentage of the treatment costs. Deductibles, or the minimum amount you must pay before insurance kicks in, can also affect your surgery coverage.

Health insurance plays a critical role in covering the costs of surgeries, ensuring that policyholders receive necessary medical treatments without facing severe financial strain. While many types of surgeries, such as emergency, elective, and maternity-related procedures, are covered, it's essential to be aware of potential exclusions like cosmetic and experimental surgeries. Factors such as medical necessity, pre-existing conditions, and policy details can significantly influence whether your surgery is covered. By reviewing your policy, getting pre-authorisation, and checking hospital networks, you can better prepare for any surgical procedure, knowing your health insurance has you covered.

Also Read

Family Health Insurance

Senior Citizen Health Insurance

Parents Health Insurance

Frequently asked questions

What types of surgeries are generally covered by health insurance?
Health insurance typically covers essential surgeries such as emergency procedures, cancer surgeries, orthopedic operations, and maternity-related surgeries like C-sections. These surgeries are considered medically necessary and often improve or save lives.

Are there any common surgeries that are not covered by health insurance?
Health insurance often excludes cosmetic surgeries like facelifts or liposuction, experimental surgeries, and fertility-related procedures like IVF. Surgeries related to self-inflicted injuries may also be excluded from coverage.

How can I find out if my specific surgery is covered under my health insurance plan?
To find out if your surgery is covered, review your policy documents, contact your insurance provider, or consult your doctor. Additionally, getting pre-authorisation from the insurer can confirm coverage.

Show More Show Less

Bajaj Finserv App for all your financial needs and goals

Trusted by 50 million+ customers in India, Bajaj Finserv App is a one-stop solution for all your financial needs and goals.

You can use the Bajaj Finserv App to:

Apply for loans online, such as Instant Personal Loan, Home Loan, Business Loan, Gold Loan, and more.

  • Explore and apply for co-branded credit cards online.
  • Invest in fixed deposits and mutual funds on the app.
  • Choose from multiple insurance for your health, motor and even pocket insurance, from various insurance providers.
  • Pay and manage your bills and recharges using the BBPS platform. Use Bajaj Pay and Bajaj Wallet for quick and simple money transfers and transactions.
  • Apply for Insta EMI Card and get a pre-approved limit on the app. Explore over 1 million products on the app that can be purchased from a partner store on Easy EMIs.
  • Shop from over 100+ brand partners that offer a diverse range of products and services.
  • Use specialised tools like EMI calculators, SIP Calculators
  • Check your credit score, download loan statements, and even get quick customer support—all on the app.
Download the Bajaj Finserv App today and experience the convenience of managing your finances on one app.

Do more with the Bajaj Finserv App!

UPI, Wallet, Loans, Investments, Cards, Shopping and more

GET THE APP

Disclaimer

*T&C Apply - Bajaj Finance Limited (‘BFL’) is a registered corporate agent of third party insurance products of Bajaj Allianz Life Insurance Company Limited, HDFC Life Insurance Company Limited, Future Generali Life Insurance Company Limited, Bajaj Allianz General Insurance Company Limited, SBI General Insurance Company Limited, ACKO General Insurance Limited, ICICI Lombard General Insurance Company Limited, HDFC ERGO General Insurance Company Limited, Tata AIG General Insurance Company Limited, The New India Assurance Company Limited, Cholamandalam MS General Insurance Company Limited, Niva Bupa Health Insurance Company Limited , Aditya Birla Health Insurance Company Limited, Manipal Cigna Health Insurance Company Limited and Care Health Insurance Company Limited under the IRDAI composite CA registration number CA0101. Please note that, BFL does not underwrite the risk or act as an insurer. Your purchase of an insurance product is purely on a voluntary basis after your exercise of an independent due diligence on the suitability, viability of any insurance product. Any decision to purchase insurance product is solely at your own risk and responsibility and BFL shall not be liable for any loss or damage that any person may suffer, whether directly or indirectly. Please refer insurer's website for Policy Wordings. For more details on risk factors, terms and conditions and exclusions please read the product sales brochure carefully before concluding a sale. Tax benefits applicable if any, will be as per the prevailing tax laws. Tax laws are subject to change. Tax laws are subject to change. BFL does NOT provide Tax/Investment advisory services. Please consult your advisors before proceeding to purchase an insurance product. Visitors are hereby informed that their information submitted on the website may also be shared with insurers. BFL is also a distributor of other third party products from Assistance Services providers such as CPP Assistance Services Pvt. Ltd., Bajaj Finserv Health Ltd. etc. All product information such as premium, benefits, exclusions, sum insured, value added services, etc. are authentic and solely based on the information received from the respective insurance company or the respective Assistance service provider company.



Note – While we have made all efforts and taken utmost care in gathering precise information about the products, features, benefits, etc. However, BFL cannot be held liable for any direct or indirect damage/loss. We request our customers to conduct their research about these products and refer to the respective product’s sales brochures before concluding their sale.

Show All Text