Is Orthopaedic Surgery Covered Under Health Insurance?

Are you worried about how to cover the cost of an upcoming orthopaedic surgery? If you are in search of health insurance to meet such costs, you are not alone. Orthopaedic surgeries, including replacement of joints or repairing of fractures, are costly, thus making the insurance plan a relieving factor. But, 

Does health insurance cover orthopaedic surgery? 

This blog will give you the answers!

Here, we'll explore if health insurance plans cover orthopaedic surgeries, what exclusions one has to keep in mind while choosing health insurance to cover orthopaedic surgery costs and much more!

Let's get started!

What is Orthopaedic Surgery?

Orthopaedic surgery concentrates on correcting problems associated with the musculoskeletal system – the bones, joints, ligaments, tendons and muscles. These surgeries address a wide range of chronic diseases, such as arthritis and even congenital disabilities. 

These are done using arthroscopy, a surgery that is usually carried out at a daycare or traditional open surgery that will most likely require a few overnight stays at the hospital. 

Types of Orthopaedic Surgeries

There are numerous kinds of orthopaedic operations, which are designed for different purposes.

• Bone Fracture Repair: Bone Fracture Repair is carried out when bones have developed some brittleness. These are common due to accidents, most especially while driving and playing.
• Joint Replacement Surgery: Often done in the case of older people with extreme pain because of arthritis or worn-out joints.
• Osteotomy: This surgery reshapes the bones or joints which have been deformed back to their appropriate shapes and positioning.

Other procedures may include soft tissue repair, spine fusion, arthroplasty, bone fusion, debridement, and joint revision surgery due to complications from previous operations. 

Understanding these options can help you choose which treatment path is most suitable for you.

Does Your Health Insurance Policy Cover Orthopaedic Surgery?

When it comes to orthopaedic surgery, the first question most people ask themselves is whether their health insurance policy will cover the procedure. Usually, the answer depends on your insurance coverage. Most insurance providers cover hospitalisation expenses for orthopaedic procedures. However, it is also very important to consider the pre- and post-treatment costs.

Coverage for Orthopaedic Surgery

Most insurers include coverage for surgical appliances, implant costs, doctors' fees, and room rent. In addition, since the majority of orthopaedic surgeries are accompanied by physiotherapy treatment, it would be wise to select a plan that also includes these expenses for treatment after surgery.

In health insurance, coverage is not limited to inpatient surgery but also daycare procedures such as arthroscopy. Nonetheless, the extent of coverage differs greatly across policies, thereby making it important to understand the specific terms before committing to a plan.

Conditions for Coverage of Orthopaedic Surgeries

Another aspect that needs attention is the duration of waiting periods for the coverage of orthopaedic surgeries. The waiting period, in most cases, depends on the specific type of orthopaedic condition. 

In accidental cases where surgical procedures are required, the expenses are usually covered immediately. However, some procedures may have waiting periods from one year to two years. Pre-existing conditions especially increase the complexity of the situation; if they are covered, they often come with a waiting period of four years or more.

Best Health Insurance Plans for Orthopaedic Surgeries

Here is a list of top health insurance plans in 2024: 

Exclusions in Health Insurance for Orthopaedic Surgery

When dealing with health insurance coverage for orthopaedic surgery, it is important to familiarise yourself with some coverage exclusions likely to be encountered. Key exclusions include the following:

• Pre-existing Conditions: Most plans tend to have provisions denying coverage for any orthopaedic injuries sustained before the commencement of the policy. If an injury or illness has been sustained previously, check whether it has been included in the policy.
• Experimental or Cosmetic Procedures: Some orthopaedic surgical procedures may be defined as experimental or cosmetic and may be excluded. If the procedure is not accepted widely as standard treatment, it is likely your policy will exclude this procedure.
• Elective vs. Medically Necessary: Insurance companies differentiate between elective surgeries (those chosen by the patient) and medically necessary procedures in most cases. Coverage for elective surgeries may be limited or excluded completely.
• Specific Treatments: Some treatments, such as nonmedical procedures or certain medications, may be excluded from your benefits.

Policyholders must read their policy documents properly to avoid unexpected - out-of-pocket costs. Being aware of such exclusions will assist you in choosing your health insurance options regarding your orthopaedic treatment. Talking about health insurance options…

Summary

To sum up, it is important to find a suitable health insurance policy that provides coverage for orthopaedic surgery procedures to avoid financial burdens. It is advisable to select a health insurance plan that includes hospital admits and post-surgery treatment and has the least number of exclusions possible. 

Frequently Asked Questions

Ques 1. Can I get health insurance for orthopaedic surgery?

Ans. Sure, most health plans offer to cover orthopaedic surgeries and also the cost of hospitalisation. However, you need to be cautious about the expenses incurred pre-and-post treatment as this differs from the plans.

Ques 2. What types of orthopaedic surgeries are there?

Ans. Common types include bone fracture repair, joint replacement, and osteotomy. Soft tissue reconstruction and spinal fusion are other examples, but these depend on the condition or injury sustained.

Ques 3. How does the waiting period for coverage work?

Ans. Waiting periods are based on the nature of the orthopaedic condition. Coverage for accidental injuries is usually instant, but some conditions may require a waiting period of 1 to 2 years before coverage takes effect.

Ques 4. Does health insurance have any exclusions for treatment of orthopaedic surgery?

Ans. There are, for example, pre-existing conditions, coverage for experimental surgery and/or procedures and elective surgery restrictions. Understanding these exclusions is crucial to avoid unexpected costs.

Ques 5. Do health plans include physiotherapy post-surgery?

Ans. Most of the health insurance plans available include rehabilitation by physiotherapists for a few weeks after surgery. It is wise to confirm this aspect before choosing any plan to avoid disappointments during the recovery process.

Ques 6. Are daycare procedures such as arthroscopy included?

Ans. Most health insurance policies cover daycare procedures such as arthroscopy. These are normally non-invasive and can be undertaken without staying in the hospital overnight.