Does Health Insurance Cover Robotic Surgery?

Robotic surgery is a type of surgery performed with the help of tiny tools attached to a robotic arm. It allows surgeons to perform complex surgical procedures with better precision, control, and flexibility as compared to traditional techniques. Under this surgery, the surgeon directs the movement of the robot while sitting at the computer

Mostly, robotic surgery is required for brain surgery, heart replacement surgery and cancer of vital organs amongst other conditions. However, robotic surgery is an expensive procedure in India. Usually, the cost of robotic surgery ranges from Rs 1.4 lakh to Rs 11 lakh depending on the type of surgery and the city where the surgery will take place.

For example, the cost of cardiothoracic robotic surgery is more than an abdominal robotic surgery. Similarly, robotic surgery costs more in metropolitan cities like Delhi than in tier 2 cities like Varanasi. As a result, robotic surgery is difficult to afford for most people in India.

Is Robotic Surgery Covered by Health Insurance Plans in India?

Yes. Health insurance plans in India cover the cost of robotic surgery. As per the guidelines issued by the Insurance Regulatory & Development Authority of India (IRDAI) in 2019, all health insurance companies have to mandatorily provide coverage for robotic surgeries. As a result, every insurance company covers robotic surgery costs in at least one of their plans under modern treatment.

The coverage for a robotic surgery includes the cost of hospitalization, surgery fees, doctor’s fees, nursing charges, ICU charges, etc. The plan also covers the pre-hospitalization and post-hospitalization expenses associated with the surgery. Some insurance companies may also cover the cost of the ambulance services used to transport the patient to the hospital.

Conditions Applicable Under Health Insurance Plans for Robotic Surgery Coverage

Robotic surgeries are covered under health insurance only if the surgery has been advised by a qualified surgeon trained in the technique. Without the recommendation of a qualified surgeon, insurance companies will deny the claim. Moreover, if the surgeon recommending robotic surgery is not trained in the technique required to perform the surgery, the claim will get rejected.

Besides, the coverage for robotic surgeries may be subject to sub-limits. This means that the insurance company will cover the cost of robotic surgery as per the pre-specified limit. The remaining expenses will have to be paid by the policyholder. For example, if robotic surgery comes with a sub-limit of 1% of the sum insured and the sum insured if Rs 10 lakh, the policy will cover surgery costs of up to Rs 1 lakh only.

Health Insurance Waiting Period for Robotic Surgery

Robotic surgeries are not covered under health insurance plans from day 1. Instead, policyholders need to wait out a pre-defined waiting period to avail coverage for robotic surgery. The waiting period may vary as per the disease or medical condition that requires a robotic surgery. For example, if robotic surgery is required for knee replacement surgery, a waiting period of 2-3 years may apply.

But in case the insured was diagnosed with a medical condition requiring a robotic surgery before purchasing the policy, the waiting period for pre-existing diseases will apply. This is because the said disease or medical condition will be considered pre-existing in this case. Usually, pre-existing diseases are covered by health insurance plans after a waiting period of 2 to 4 years.

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