Expenses Covered by Medical Insurance
Here is a breakdown of the expenses that are usually covered by health insurance-
- Hospitalization expense which includes admission fees, bed charges, room rent, medical consumables, ICU charges, OT charges, nursing fee, etc.
- Pre and post-surgery hospitalization expenses, such as pre-surgery consultation and follow-ups.
- Ambulance cost is also covered in the policy, usually up to Rs. 2,000.
- Cost of medicines given to the patient during the stay.
- Surgeon’s fees, anesthetist’s fees, and anesthesia costs.
- Cost of standard intraocular lens, i.e., monofocal lens.
- Second opinion from another doctor.
Insurance policies are offered to people so that they can get optimal care without worrying about expenses. However, there are some exclusions in the insurance plans which people are usually not aware of.
Expenses Not Covered by Medical Insurance
Please keep in mind that the following expenses or mediclaim limit for cataract operation are not covered by health insurance under any circumstance-
You’ll have to bear the cost of these on your own.
Standard Clause of Medical Insurance for Cataract Surgery
There are several clauses mentioned in insurance policies that can limit the amount of sum insured that can be claimed for cataract surgery or even exclude them from getting any coverage.
Waiting Period
Most health insurance policies come with a waiting period of 2 years for cataract surgery coverage. This means that the patient has to wait for at least 2 years before he/she can file a claim. This clause is added to the policy to ensure that the policyholders don’t purchase the policy only to cover the expense of the cataract operation.
In corporate insurance policies, there may not be a waiting period clause in the insurance policy. To clearly understand the terms and conditions, it will be best to talk to the healthcare providers.
Claim Limit
Insurance providers also put a cataract surgery insurance claim limit on the amount of the policyholders for cataract surgery. Any additional expense that is incurred during or after the treatment over the specific sub-limit must be borne by the patient.
The good thing is that the limit on claim amount is usually not the same across policies. So, while purchasing a health insurance policy, make sure that you go through the terms and conditions carefully and ensure that you can avail the full sum insured amount for most surgical treatments, including cataract surgery.
Cataract Surgery Insurance Claim Process
Thanks to modern technologies, cataract surgery is performed on a daycare basis. Thus, insurance policies cover the treatment under daycare procedures. This means that the patient doesn’t need to be hospitalized for 24 hours to get a claim.
The insurance companies offer two options to make a claim for cataract surgery- cashless and reimbursement and the process for each are slightly different.
Cashless Claim
To get a cashless claim from the insurance company, you are obliged to choose a network hospital to undergo cataract surgery.
Step 1- Inform the insurance provider at least 3 days before the procedure and fill out the cashless form. The hospital’s TPA team will coordinate with the insurance company to get the claim beforehand.
Step 2- The insurance company will send you an email or message or both to confirm that your claim request is approved.
If your claim amount is lesser than requested, you can always submit a second claim request to ask for more coverage for the procedure.
Reimbursement Claim
Step 1- Choose a hospital and schedule your surgery. Let the insurance company know that you’ll be undergoing surgery. You can also choose to inform the insurance provider within 2 days of admission.
Note- It will be best to inform the company earlier to avoid issues with the paperwork and claim process.
Step 2- Get the reimbursement form online or from your insurance agent. Fill the form and submit all paperwork, including discharge summary, pre and post-surgery evaluations, and other bills.
Step 3- As soon as the documents are submitted, the insurance company will validate them and reimburse the total amount of surgery at the earliest.
You will also get notified if your claim is denied. It should also be noted that there is a specified duration within which a patient can get a reimbursement claim. Typically, this duration is 30 days after surgery. This period may vary depending on the insurance plan.
Contact Pristyn Care to Undergo Cataract Surgery With/Without Insurance
If you have been diagnosed with cataracts and need to undergo surgery, you can always contact Pristyn Care. We offer best-in-class services for cataract patients. We also provide assistance to the patients to get the maximum amount of claim against the treatment.
As more than 80% of Indians don’t have an insurance policy, they can’t avail the benefits of health coverage. Thus, Pristyn Care provides affordable medical care along with services that reduce the expense of treatment at the patient’s end. The services include-
- Free initial consultations
- Free transport service on the day of surgery
- Multiple follow-up consultations without additional fees
- Flexible payment options, including cash, credit cards, and health insurance
- No-Cost EMI service to divide the treatment cost in easy installments
You can give us a call to learn more about our services.
