Knee Replacement Surgeries Are Covered By Insurance: Know The Fine Print

Knee replacement that is medically necessary, like any other illness requiring hospitalisation, is fully covered under standard health insurance and is not an exclusion, subject to waiting periods or pre-existing conditions as may be applicable. 

It actually depends on the specifics of your policy. Most comprehensive health insurance policies now include knee replacement surgery, although the level of coverage varies. “For example, while the surgery itself may be covered, fees such as room rent over the sublimit, advanced implants, or post-operative physiotherapy may not be fully reimbursed, so you may still incur some out-of-pocket costs. It's always wise to go through the policy inclusions and sub-limits carefully,” says Sarita Joshi, product head, health and life Insurance, Probus, an insurance broker. 

Be Aware Of Waiting Periods 

Knee replacement is a planned medical procedure. It is not something that develops suddenly but over a course of time. Therefore, there can be a tendency for some people to take insurance after knowing that they are candidates for knee replacement in the future. “To discourage such moral hazard cases, there may be waiting periods applicable. However, if the onset of osteoarthritis or such conditions are discovered after waiting periods are over under the policy, then coverage is not a problem,” says Hari Radhakrishnan, expert, Insurance Brokers Association of India (IBAI). 

Typically, knee replacement falls under joint replacement surgeries, which usually come with a waiting period of anywhere between two to four years, depending on the insurer. As for exclusions, pre-existing conditions not declared during policy purchase, cosmetic procedures, or surgeries advised but not considered medically necessary by the insurer could lead to rejections. So, reading the fine print and communicating with your insurer ahead of time is critical. 

Robotic Surgery Likely To Be Covered, But With Conditions 

“Coverage for modern treatments like robotic surgery needs to be provided as per the Insurance Regulatory and Development Authority (Irda) guidelines. However, there can be limits applicable, such as 50 per cent of the sum insured or 50 per cent of the billed amount, etc. Some insurers provide 100 per cent limits also,” says Radhakrishnan. One must check the applicability of such limits carefully before opting for modern treatments.

In fact, while most insurers cover standard knee replacements, there is still some ambiguity surrounding robotic or computer-assisted surgeries. “They may be covered by certain insurers, but only if they are deemed medically required and not experimental. It is advisable to consult your insurance provider in advance,” says Joshi.