July 21, 2024

Health: Is surgery cost covered by health insurance?


Main highlights:

  • Why do we need a health insurance
  • Things you should know about, the cost and health insurance

Can health insurance cover surgery cost Source: Google Images

Health insurance has become essential for every Indian citizen to acquire due to the country’s skyrocketing health care costs and rising health hazards brought on by a desk-bound lifestyle. But here we will look for the answers to questions like what is covered by health insurance? What takes place if you need surgery? Furthermore, is there a cap on how much the health insurance will pay out for surgery?  All these are always to be kept on mind when you bring health insurance into your payments for medical expenses particularly complex treatments and surgeries.

Depending on the health plan and the procedure, a health plan’s payment amount may change. It will depend on the member’s outstanding deductible and coinsurance balances as well as the surgery’s actual cost. Fortunately, the No Surprises Act now guarantees that most patients will only have to fulfil their in-network cost-sharing requirements, even if out-of-network ancillary providers are engaged in the procedure.

What Does Surgery Cover Under Insurance?

The majority of health insurance plans do, with some restrictions, cover procedures, which is good news. The expenses that are reimbursed must be deemed “medically essential,” which means that they must involve surgery that is either intended to save a patient’s life, improve their health, or prevent an impending sickness. However, “cosmetic” procedures are typically not covered by insurance. For instance, a rhinoplasty or nose operation will be covered if it improves a person’s breathing or reconstructs their face after an injury, but not if it is performed just to alter the appearance of your nose.

How Much Surgery Coverage Does Health Insurance Offer?

This varies significantly and is dependent on numerous variables. Check the terms and conditions of your policy and ask your health insurance provider for clarifications to find out how much of your procedure the insurance provider will cover. To learn an approximate cost for the procedure and make plans accordingly, you can also speak with your doctor and surgeon. Remember that no one can give an exact figure because there can be extra expenses depending on what the physicians find out when performing the surgery.

Things you should know:

Every health plan is unique. You have two tasks to complete in order to best prepare yourself for the financial effects of your surgery: consult with your healthcare professional and review your health insurance plan.

For an estimate of the cost of your treatment as well as the necessary materials, care, and prior planning, ask your surgeon.

Keep in mind that hospitals and other healthcare facilities may struggle to give precise estimations since they are unsure of what to expect once the operation has started. However, the more inquiries you make, the more knowledge you’ll have.

To obtain a general notion of how much you may anticipate paying once everything is said and done, you’ll also want to understand how your cost-sharing is going to operate. Your deductible amount is important to know because it affects the majority of surgical procedures. Additionally, once your deductible has been satisfied, you will typically have to pay coinsurance (a portion of the bill) until you reach your plan’s out-of-pocket maximum.

Can health insurance cover surgery costSource: Google Images

What Additional Costs Are There for Surgery?

Along with its general price, surgery has some specific characteristics, including:

1. Pre-Operative and Post-Operative Tests: Bloodwork, X-rays, and other procedures necessary to assess the patient’s condition prior to and following surgery

2. OT Cost: The Operation Theatre, the room where the surgery is performed, will have separate costs based on the procedure or per hour.

3. Surgeon and Attendant’s Fee: The fees for those assisting the surgeon during the procedure will be applied separately to the bill. They consist of the surgeons, the co-surgeons, and any additional medical personnel needed.

4. Medication: As needed and recommended by the doctor, such as intravenous drugs, anaesthesia, etc.

5. Medical equipment, such as crutches or a brace that the patient needs following surgery.

6. Recovery Room and Inpatient Care: Depending on the patient’s condition, there is a set amount of time after surgery for recovery and care. These will increase the price of the procedure.

Your insurance policy will determine the extent to which these components are covered because every plan has a varied degree of coverage.


In a nutshell, health insurance coverage often cover operations, but there are certain restrictions. When you submit a claim, the insurance company will often only authorise expenses that are deemed “medically necessary.” The specifics of the coverage, however, varies significantly between different insurance. It is best for you to study the policy document and/or get clarification from your insurance company. Online shopping for health insurance is now an option. The technique is also quite easy to follow. You can compare health insurance providers, the plans they offer, their network of cashless medical facility networks, and the premium calculator in just a few simple clicks. Today, even insurance renewals can be completed online.



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