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Is Cleft Lip Repair Covered by Health Insurance?

Cleft lip repair surgery is covered by health insurance for patients of all age groups. Whether a child is born with a cleft lip or an adult has this deformity due to an accident, injury, or burn, they can get ample coverage with insurance. Talk to our experts to learn all about the terms and conditions of the insurance policy.

Cleft lip repair surgery is covered by health insurance for patients of all age groups. Whether a child is born with a cleft ... Read More

Cleft Lip Treatment Insurance Claim

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Why is Cleft Lip Repair Covered by Insurance?

Though cleft lip repair surgery comes under cosmetic and plastic surgery, its expenses are payable by all health insurance policies. This is because the surgery is reconstructive, not purely cosmetic. The surgery is recommended for a patient to restore the function of the mouth, lips, and palate.

The doctor certifies that the surgery is medically necessary for the patient. Only then the insurance company agrees to pay the treatment expenses.

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How to get Cleft Lip Repair Covered by under Insurance?

1 Intimation

Fill up the pre-auth form at the network hospital for cashless approval. Fill up the pre-auth form at the network hospital for cashless approval

2 Approval/Rejection

Fill up the pre-auth form at the network hospital for cashless approval. Fill up the pre-auth form at the network hospital for cashless approval

3 Hospitalisation

Hospitalisation can be done on the basis of pre-auth approvalHospitalisation can be done on the basis of pre-auth approval

4 Claim Settlement

At the time of discharge, we settle the claim directly with hospitalAt the time of discharge, we settle the claim directly with hospital

1 Hospitalization At Non Network Hospital

You need to pay the bills initially and preserve the original invoices

2 Register A Claim

Post hospital discharge send us all your invoices and treatment documents

3 Verification

We verify your claim related invoices and treatment documents

4 Claim Settlement

We send the approved claim amount to your bank account

Benefits of Health Insurance Plan

Most patients with cleft lip and palate often require multiple surgeries over the next few years to regain the complete function of the organs. Having a health insurance plan for the children will allow the patients to cover the expenses of all of these medically necessary procedures. The policy will have the following benefits-

Hospitalization Benefits- The insurance will cover major expenses incurred at the hospital, including room rent, ICU charges, doctor’s fees, OT charges, nursing fees, medicine costs, ambulance costs, etc. You can claim the entire sum insured for a treatment.
Cashless & Reimbursement Clause- With insurance, you get a cashless payment option at the network hospitals and a reimbursement option at the non-network hospitals. Through both options, you can get coverage for over 600 surgeries with a guaranteed benefit amount.
Refill Sum Insured Amount- Avail the benefit of refilling the sum insured and reinstating it when exhausted. In most plans, a 100% refill/reload of the sum insured is offered to the patients, especially in case of accidents and unrelated illnesses.
Complimentary Health Checkups- Through insurance, you can avail of annual health checkups for comprehensive health evaluation. It covers check ups for heart health, organ functions, metabolism rate, and other symptoms to keep track of your health.
Additional Coverage- Every policyholder can opt for add-ons to get additional, optional coverage over the base policy at an additional low premium price. It will provide extra protection for critical illness, personal accident, maternity cover, room rent, hospital cash, and much more.
Tax Benefits- Under Section 80D of the Income Tax Act 1961, the child’s parents can enjoy tax benefits towards the health insurance policy. The benefit can be availed for personal, family, and parental health insurance policies.

All Major Insurances Accepted

Expenses Covered by Health Insurance

Each policy has standard inclusions and exclusions regarding the expenses that can be covered. The expenses that are covered include-

In-patient hospitalization
Pre & post hospitalization
Annual health check-ups
Hospitalization bills
Cost of implants if any
Daycare treatments
ICU & OT charges
Room rent
Doctor, nurses, & anesthetist fee
Diagnostic benefits
Organ donor expenses
Second opinion

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FAQs Related to Cleft Lip Insurance Coverage

Is it possible to reduce or remove the waiting period?

You can request your insurance provider to levy off or reduce the waiting period. But the decision is entirely up to the insurers. This usually can be done for higher premiums. You should talk to your respective insurance provider regarding this.

What is a waiting period in health insurance plans?

The waiting period refers to the amount of time you need to wait before filing a claim for a specific treatment. For instance, if there is a 2-year waiting period for cataract surgery, you won’t be able to get coverage for the treatment until the 2 years are complete.

When can my claim get rejected?

The insurance company may deny your claim if you claim the insurance against a treatment whose waiting period is not over or for an illness that is not covered by the policy. The insurer also has the right to reject the claim if the documents are falsified.

What is the difference between cashless claims and reimbursement claims?

In the cashless claim, the medical expenses of the treatment are paid by the insurance company directly to the hospital at the time of your discharge. In a reimbursement claim, the patient pays for the medical expenses during the discharge and later files a claim to get the reimbursement.

Which documents are required for insurance claims?

To file a claim request, a patient needs to submit the following documents- Health Card/ E-Card Duly filled claim form Medical certificate/form signed by the doctor Payment Summary All bills and receipts Prescriptions cash memos Investigation reports

How to Get Cashless Claim for Cleft Lip Repair?

The cashless claim service is offered to patients for all treatments, including cleft lip repair. However, this service can be availed only when the patient decides to get treatment at a network hospital that is empaneled by the insurance company.

To get a cashless claim for cleft lip repair surgery, follow the steps below-

Choose a hospital from the insurance network and schedule the surgery.
Fulfill the treatment-related formalities and inform the TPA (third-party administrator) at the hospital regarding the surgery.
Fill out the cashless claim form and submit the required medical documents to the TPA.
The TPA coordinates with the insurance company on the patient’s behalf and provides a summary of the hospital bills.
The insurance company validates the documents and provides approval for the claim request.

As soon as the claim is approved, the patient also receives confirmation through an email or text message. And the hospital bills are settled by the insurance company directly. If the insurance claim is denied due to some reason, the patient can file a reimbursement claim request.

Undergo Cleft Lip Repair Surgery With or Without Insurance At Pristyn Care

Around 80% of the population in India doesn’t have health insurance coverage. And Pristyn Care aims to make the treatment accessible for everyone irrespective of the coverage. We accept all health insurance policies and also offer flexible payment options to allow patients to choose a convenient mode of payment.

We also offer services that reduce the patient’s expenses to some extent-