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Does health insurance cover Orthopaedic Surgery?

Team AckoJun 4, 2024

Orthopaedic surgery, a specialised field within the medical domain, addresses musculoskeletal conditions ranging from fractures and joint injuries to degenerative diseases like arthritis. As a crucial component of healthcare, orthopaedic procedures aim to restore mobility, alleviate pain, and improve patients' quality of life. However, the financial aspect of such treatments often raises concerns, prompting individuals to seek the protective cover of insurance.

But does-health-insurance-cover-orthopaedic-surgery? Well, read ahead to find out!

Orthopaedic surgery encompasses various treatments, including outpatient department (OPD) procedures, which cater to less severe cases such as minor fractures, tendon injuries, and sprains. The OPD treatment offers timely interventions, allowing patients to resume their daily activities swiftly. Additionally, orthopaedic insurance plans extend coverage to a comprehensive list of critical illnesses, ensuring financial assistance during unforeseen medical emergencies.

Navigating the intersection of orthopaedic surgery and insurance requires a nuanced understanding of treatment options, associated costs, and coverage limitations. By securing adequate insurance, individuals can mitigate the financial burden associated with orthopaedic interventions, facilitating timely access to quality healthcare and promoting overall well-being.

Does

Contents

What is Orthopaedic Surgery?
Types of Orthopaedic Surgeries
Orthopaedic Surgery Cost in India
Does your health insurance policy cover Orthopaedic Surgery?
- Coverage for Orthopaedic Surgery
- Waiting period for Orthopaedic Surgery
Limitations and Exclusions in Health Insurance Policies
Tips for Maximising Insurance Benefits for Orthopaedic Surgery
To wrap up
Frequently asked questions

What is Orthopaedic Surgery?

Orthopaedic Surgery, is a medical procedure for individuals suffering from bodily deformities. These could result from disease, injury or genetic causes. Orthopaedic treatment is usually administered to the musculoskeletal system of the human body. This system includes bones, ligaments, tendons, cartilage and connective tissue. The two commonly suggested Orthopaedic treatments are open surgery and arthroscopy. In the case of open surgery, treatment may require being admitted to a hospital for a few days. However, in the case of arthroscopy, it is usually a day care procedure that spans less than 24 hours. Thus, you may not require to be admitted.

Types of Orthopaedic Surgeries

Orthopaedic treatments cater to deformities occurring in the musculoskeletal system of the body. This could include surgeries performed on the shoulder, hip, spine, ankle, wrist, knee, elbow, etc. Based on these regions, below are some of the treatments commonly prescribed.

Shoulder Replacement Surgery

Anterior Cruciate Ligament (ACL) Reconstruction Surgery

Shoulder Arthroscopy

Knee Replacement Surgery

Spinal Surgeries

Osteotomy

Bone fracture repair

Soft tissue repair

Hip Replacement Surgery

Knee Arthroscopy

Joint arthroscopy

Trigger Finger Release

Ankle Repair

Debridement

Orthopaedic Surgery Cost in India

Orthopaedic treatments can be expensive in India due to the extensive procedures that it may require. To help you get a better idea below are some examples of common Orthopaedic treatments prescribed and their respective costs.

Raj is a 23 year-old footballer and suffered a knee injury while playing football. So, he had to undergo a Knee Replacement Surgery that cost him around Rs. 2 lakhs.

Sivaraman is a 70 year-old. He unfortunately lost balance and slipped while bathing. He had to undergo a Hip Replacement Surgery that cost him around Rs. 3 lakhs.

Does your health insurance policy cover Orthopaedic Surgery?

Orthopaedic treatment, especially open surgery, can be an expensive affair in India. The costs may not only include the treatment itself, but also related costs (like hospitalisation, medical tests, doctor’s fee, etc). Also, some treatments may require hospitalisation for more than a day. Such treatments could cost considerably more than a day care procedure.

Most Orthopaedic treatments are usually non-invasive. However, in severe instances, surgery may be required. Thus making the cost of availing medical care sky-high. Fortunately, Orthopaedic Surgery is considered a common medical procedure in India. Hence, it is usually covered under health insurance policies. However, this may differ from policy to policy.

Coverage for Orthopaedic Surgery

As mentioned above, health insurance policies usually cover Orthopaedic procedures. Also, in most cases, the treatment cost as well as all the pre and post-hospitalisation costs are covered too. At times, Orthopaedic treatment may require inserting surgical implants in the places of deformity. This too is usually covered under most health insurance policies.

Note that the coverage offered by a health insurance policy is usually subject to the sum insured limit. For example, if the sum insured of a plan is Rs. 5 lakhs, you will receive coverage for your treatment only up to Rs. 5 lakhs. Further expenses may have to be borne by you. Refer to the policy wordings of a health insurance plan to find out its exact sum insured.

Also, read; Critical Illness Insurance Policy

Waiting period for Orthopaedic Surgery

The waiting period refers to the period after buying the health insurance plan during which you cannot raise a claim. The waiting period for Orthopaedic Surgery might span from 1 to 2 years. And for individuals suffering from pre-existing conditions, this duration could be a lot longer. However, these terms and conditions may differ from insurer to insurer.

Fortunately, the ACKO Health Insurance Policy comes with a zero waiting period for pre-existing conditions. However, all these conditions have to be disclosed at the time of buying the policy. After that you can raise medical claims from day one itself! So you can focus on recovering, while we deal with the financial implications of availing quality treatment.

Limitations and Exclusions in Health Insurance Policies

Health insurance policies often contain limitations and exclusions concerning coverage for orthopaedic surgery, affecting individuals seeking health insurance for surgery. These restrictions may involve pre-existing conditions clauses, which could exclude coverage for orthopaedic issues predating the policy. Certain orthopaedic procedures might be excluded if considered experimental or cosmetic.

Additionally, coverage limitations might distinguish between elective and medically necessary procedures. Exclusions may extend to specific treatments, such as alternative therapies or certain medications. It's crucial for policyholders to review their documents thoroughly to grasp these aspects. Understanding such provisions can guide individuals in navigating their orthopaedic care and mitigating unexpected out-of-pocket expenses.

Moreover, understanding the meaning of daycare hospitals can help policyholders significantly.

Tips for Maximising Insurance Benefits for Orthopaedic Surgery

Maximising insurance benefits for orthopaedic surgery involves strategic planning and awareness of one's policy provisions, especially regarding covered critical illness and surgical health insurance.

Start by thoroughly reviewing your health insurance policy to understand the extent of coverage for orthopaedic surgery, paying particular attention to benefits related to surgical procedures and critical illnesses.

Check if your orthopaedic surgeon and the hospital are within your insurance provider's network to reduce out-of-pocket costs. Obtain pre-authorization from your insurance provider before scheduling surgery to ensure eligibility for coverage. Understand your policy's deductible and copayment requirements and consider scheduling surgery when these costs are minimised.

Explore supplemental surgical health insurance or critical illness coverage if necessary. Utilise tax-advantaged accounts like Health Savings Accounts (HSAs) or Flexible Spending Accounts (FSAs) to save for surgery expenses. Follow post-operative care instructions to minimise complications and avoid additional expenses. By following these steps, individuals can optimise their insurance benefits and alleviate the financial burden associated with orthopaedic surgery.

To wrap up

Due to sedentary lifestyle choices, conditions requiring Orthopaedic care have become more common. Orthopaedic Surgeries are usually expensive procedures and can cause financial hardship. Fortunately, Comprehensive Health Insurance Policies usually cover such treatments. Nonetheless, make sure to read the wording of health insurance policies thoroughly to find out the exact scope of their coverage.

Frequently asked questions

The following are common questions asked about health insurance coverage for Orthopaedic treatments.

What are the Orthopaedic treatment costs covered under a health insurance policy?

There are usually two types of treatments available for Orthopaedic conditions. Namely, open surgery and arthroscopy. Both these treatments are usually covered under a health insurance policy. Additionally, coverage is also usually offered for pre and post-hospitalisation costs. These coverages may be partially or fully covered under a health insurance policy. That is why it is important to go through the policy wordings of a health insurance policy before buying one.

Is the medical cover offered by a health insurance plan adequate for covering Orthopaedic treatments?

The coverage limit of a health insurance policy is usually equivalent to the sum insured. Also, Orthopaedic procedures are usually expensive. Thus, a lower sum insured may not adequately cover the medical expenses you incur. That is why it is important to select a plan with a reasonably high sum insured. This may also mean paying a higher policy premium as well. Fortunately, ACKO Health Insurance Policy offers a sum insured of Rs. 1 crore.

In the context of Orthopaedic treatment expenses, what are the coverages to look for when buying a health insurance plan?

Orthopaedic treatments are usually expensive. Hence, when buying health insurance it is important to make sure that the sum insured is adequate. Also that the related costs like room rent, ambulance charges, consultation fees, etc, are covered too.

Apart from these, check if the policy covers hospitalisation and day care treatments. Usually, health insurers offer a day care treatment cover on top of a regular health insurance plan. This cover usually covers day care procedures that do not require hospitalisation.

What benefit does a health insurance plan provide for individuals suffering from conditions requiring Orthopaedic treatment?

Health insurance offers financial protection against high medical expenses resulting from Orthopaedic treatments. Not having health insurance may cause you to use up your hard-earned savings. This in turn may cause you a lot of financial and emotional stress. That is why we recommend buying the ACKO Health Insurance Policy to financially protect against such scenarios. Also, it will help you meet rising medical costs resulting from economic inflation.

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Disclaimer: The content on this page is generic and shared only for informational and explanatory purposes. It is based on industry experience and several secondary sources on the internet; and is subject to changes. Please go through the applicable policy wordings for updated ACKO-centric content and before making any insurance-related decisions.