Does your health insurance policy cover robotic surgery?

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Medical technology keeps getting better with lower error rates ensuring precision and control over the conventional methods. For example, diabetic patients no longer need to visit hospitals, as now they can easily monitor their health remotely through wearable devices. One of the significant leaps has been made in robot-assisted surgeries that help doctors in performing complex procedures with more precision and control than traditional techniques.

Robotic surgeries hold significant promise in healthcare for surgeries needing a high degree of accuracy. “Robotic surgery has specific indications and is usually a planned procedure. Robotic surgery does not mean surgery by robots by remote access. A robotic interface is used during a surgical procedure for precision e.g. tissue removal around the brain or large blood vessel,” said Bhaskar Nerurkar, head- health claims, Bajaj Allianz General Insurance. But patients going for robotic surgery generally have one question on their mind- does my health insurance policy cover robotic surgery?

Do all insurers cover robotic surgery?

As per the health regulations issued by the Insurance Regulatory and Development Authority of India (IRDAI) in 2019, all insurers are mandated to cover robotic treatments. Hence, all insurers offer it but with different sub-limits and policy conditions defined in the product.

“Robotic surgeries are common in oncology and general surgery. The claims are not very frequent since this is done only at higher centers of excellence and demands extensive training. Also, the procedure being costly, only insured members with a high sum insured opt for it. People with a lower band of insurance may opt for traditional techniques if there is an option. Generally, robotic surgeries form less than 0.02% of total claims,” said Shreeraj Deshpande, chief operating officer, Future Generali India Insurance.

“Around 3-4 % of overall claims may have utilisation of robotics in surgery as per indication,” added Nerurkar.

Fine print

You need to read the terms and conditions of your policy carefully before opting for the surgery. For example, certain indications like Osteoarthritis can have a waiting period. “Admissibility of robotic surgery depends upon the indication/ disease/ ailment for which the surgery is being carried out. For example, robotics can be used for joint replacement surgery like total knee replacement. However, if the indication for such knee replacement surgery is degenerative conditions like osteoarthritis, it generally has a waiting period in a policy,” Nerurkar added.

Moreover, your doctor should explicitly mention the need for robotic surgery in the prognosis for the claim to go off without a hitch. “Robotic surgeries generally qualify for reimbursement if advised by a qualified medical practitioner trained in the technique. However, insurers do verify the need for the surgery and whether the same is guided by standard international treatment protocols. Robotic surgeries are usually advised in specific circumstances where the surgical technique demands precision and expertise. Thus, although there are no specific exclusions, insurers would verify the clinical necessity of the procedure,” Deshpande further said.

What to do?

If a policyholder is going for robotic surgery, one must check beforehand the reasons for the surgery and applicable waiting periods for the smooth settlement of a claim. Moreover, check sub-limits, co-pay, or any other cost-sharing conditions applicable to the policy.