Is Cataract Surgery Covered by Insurance?

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Medically Reviewed by Dr. Aman Priya Khanna
Written by Hexahealth Care Team, last updated on 29 September 2023| min read
Is Cataract Surgery Covered by Insurance?

Quick Summary

  • Cataracts are a common eye condition that can cause vision impairment and even blindness. Cataract surgery is a common procedure to remove the eye's cloudy lens and replace it with an artificial one.
  • The cost of cataract surgery can be a significant barrier for many people who need it. Fortunately, many health insurance plans cover cataract surgery, making it more accessible to those who need it.
  • Depending on your insurance plan, there may be certain criteria you need to meet before the procedure is covered, such as demonstrating a certain level of vision impairment. Additionally, the type of surgery you choose and your specific insurance plan can also impact the cost and coverage.

Cataracts can be debilitating, causing vision impairment and even blindness in some cases. Cataract surgery is a common procedure to remove the eye's cloudy lens and replace it with an artificial one. However, the cost of cataract surgery can be a significant barrier for many people who need it. Fortunately, many health insurance plans cover cataract surgery, making it more accessible to those who need it.

Cataract surgery covered by insurance is an important topic to discuss, as navigating the different options and requirements can be confusing. Depending on your insurance plan, there may be certain criteria you need to meet before the procedure is covered, such as demonstrating a certain level of vision impairment. Additionally, the type of surgery you choose and your specific insurance plan can also impact the cost and coverage. Understanding the ins and outs of insurance coverage for cataract surgery can make all the difference in accessing the care you need.

Need for Cataract Surgery Insurance

Cataract is a common vision problem among older adults, affecting millions worldwide. While cataract surgery is generally considered safe and effective, it can be expensive without insurance. Below mentioned are some reasons for having cataract surgery insurance.

  1. Cataract surgery can be expensive without insurance coverage. Cataract surgery costs include pre-operative tests, surgeon's fees, anaesthesia, operating room fees, post-operative medication, and follow-up appointments. 
  2. Insurance for eye operation can provide financial protection and help patients access the necessary care.
  3. Many insurance plans, including Medicare, provide coverage for cataract surgery, but it's important to check the specifics of each policy to understand the details of the coverage.
  4. Insurance coverage for cataract surgery can help patients avoid delaying or forgoing necessary treatment due to financial concerns.
  5. Insurance coverage can help ensure patients receive timely and appropriate care for their cataracts.

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Financing Options Available for a Cataract Surgery

Cataract surgery may be expensive for people with limited financial resources. Hence, in such cases, to get cataract surgery done, the patient or the patient's family may go for various payment options, such as cataract surgery covered by insurance. There are several financing options available for cataract surgery. Some of the financial options available for cataract surgery include the following, 

Cataract surgery covered by health insurance

  1. Health insurance can provide financial assistance during medical emergencies, including coverage for cataract surgery in India.
  2. Medical insurance can cover hospitalisation costs, provide tax benefits, offer affordable premiums, and allow cashless treatment at partner hospitals.
  3. Additionally, medical insurance can offer access to second opinions from renowned doctors, and individuals can compare and find the best health insurance plans online.

Cataract surgery by EMI 

  1. EMI is a fixed monthly payment someone pays to the person or organisation they borrowed money from. The payment includes both the money borrowed (principal) and the interest charged.
  2. The borrower can repay the entire loan by paying the same amount every month for a few years.
  3. EMI options for cataract surgery can make this procedure more accessible and affordable for patients who cannot afford to pay for the surgery upfront.
  4. Patients can choose a repayment plan that fits their budget and financial situation, making it easier to manage the cost of the procedure over time.
  5. Additionally, EMI options may be interest-free or come with low-interest rates, reducing the overall cost of the procedure.

Cataract surgery on medical loan

  1. A medical loan is a type of personal loan available to people who need money to pay for medical emergencies.
  2. This loan can be used to cover various expenses, including hospital bills, surgery expenses, prescription costs, chemotherapy, and any other medical-related expenses. A medical loan can be obtained for cataract surgery. 

Factors Affecting Cataract Surgery Insurance

Regarding cataract surgery covered by insurance, several factors can affect the extent and level of coverage a patient receives. These factors can include:

  1. Age
    1. Age is crucial in determining health insurance premiums. Younger individuals pay lower premiums as they are less likely to require medical coverage.
    2. As one age, the likelihood of hospitalisation and medical expenses increases, resulting in higher premiums. Some insurance providers have an age limit for purchasing new policies as assessing risk factors and medical expenses with advancing age becomes difficult.
    3. Hence age is an essential factor affecting cataract surgery covered by insurance. 
  2. Medical History
    1. Individuals with pre-existing medical conditions such as high blood pressure or diabetes may experience long-term effects on their health, which can result in higher medical bills and hospital charges.
    2. The severity of their condition, as evaluated by a doctor, will determine the amount of the premium they must pay for their health insurance.
  3. The insured sum
    1. The amount of money chosen for the healt her premium, but it will provide more coverage for medical expenses. Choosing an SI that suits the patient's needs and budget is essential.
  4. Occupation
    1. Occupation is a significant factor in determining the health condition and the cost of the health insurance premium.
    2. For example, suppose a person has a high-stress job or works in a hazardous environment.
    3. In that case, they may be charged a higher premium due to the increased likelihood of developing significant medical issues. 
  5. Lifestyle
    1. Another potential factor that may affect cataract surgery health insurance coverage is the patient's lifestyle.
    2. Habits such as smoking and consuming tobacco may affect the insurance premium, as these activities may increase the likelihood of developing cancer and other severe conditions. 

Medical Insurance Companies for Cataract Surgery Coverage

Several medical insurance companies provide coverage for cataract surgery to ease the financial burden on patients. Some of these include: 

Insurance Name

Plan offered

ICICI Lombard Complete Health Insurance
Star Health Insurance Senior Citizens Red Carpet Policy
SBI General Health Insurance
Apollo Munich Health Insurance Optima Senior
Bajaj Allianz Health-Guard

Hospitals Empanelled under Medical Insurances Companies

When it comes to medical procedures, particularly those that are costly, it's essential to have medical insurance coverage. One way to ensure you can access quality healthcare without worrying about the financial burden is by choosing hospitals empanelled under medical insurance companies. This section will discuss some of the top hospitals empanelled under medical insurance companies, particularly for procedures such as cataract surgery. 

  1. Accura Eye Care, Delhi
  2. Aravind Eye Hospital, Madhurai
  3. Drishti Netralaya, Mumbai
  4. Aaradhya Netralaya, Pune 
  5. Nelivigi Eye Hospital, Bangalore
  6. ECHS Empaneled Network Hospitals 

Ex-Servicemen Contributary Health Scheme (ECHS) is a type of healthcare scheme that is offered to retired armed forces personnel and their family members. The list of some of the ECHS hospitals includes the following, 

  1. Ruby Eye Hospital, Bhubaneshwar
  2. Jagdamba Eye Hospital, Alwar
  3. Nandadeep Eye Hospital, Sangli
  4. Birla Eye Hospital, Nashik
  5. J V R Eye Hospital, Kangra

Ayushman Insurance Coverage for Cataract Surgery

Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a national health insurance scheme launched by the Indian government to provide financial protection to poor and vulnerable families for secondary and tertiary care hospitalisation. The scheme covers over 10 crore poor and vulnerable families in India, making it one of the world's largest health protection schemes. One of the medical procedures covered under this scheme is cataract surgery.

The cataract surgery coverage includes the following:

  1. Pre-operative investigations: The scheme covers the cost of pre-operative investigations such as blood tests, urine tests, and ECG.
  2. Surgical procedure: The scheme covers the cost of cataract surgery, including the surgeon's fee, anaesthetist's fee, and charges for the operation theatre.
  3. Post-operative care: The scheme covers the cost of post-operative care, including medications, dressings, and follow-up consultations.

The scheme covers both phacoemulsification and manual small incision cataract surgery (MSICS). The beneficiaries can choose either of the procedures, depending on their preferences and the doctor's recommendation.

  1. Under the Ayushman Bharat scheme, patients can avail of cataract surgery at empanelled hospitals free of cost. The scheme covers the cost of pre-operative investigations, surgery, post-operative care, and medicine for 10 days after the surgery.
  2. To avail of the benefits of the Ayushman Bharat scheme, patients need to be registered under the scheme. The registration process is simple and can be done through the Ayushman Bharat website, by calling the Ayushman Bharat helpline number, or by visiting a nearby Ayushman Bharat center.
  3. However, it is important to note that not all hospitals are empanelled under the Ayushman Bharat scheme. Patients need to visit an empanelled hospital to avail of the benefits of the scheme. They can check the list of empanelled hospitals on the Ayushman Bharat website or by calling the Ayushman Bharat helpline number.

Claiming Process for Cataract Surgery Insurance

To get the services that are covered by the health insurance policy, a health insurance claim is to be submitted to the insurance company. There are two methods available for claiming health insurance. These include the following, 

  1. Cashless claim
  2. Reimbursement claim

Cashless Claim Process

  1. To get a cashless claim for cataract surgery; the patient must enrol in a network hospital, after which the health insurer will take care of the bill. 
  2. The patient must get approval for the treatment in advance from the insurer. The patient must fill out the necessary forms and share the ID proof and health e-card with the hospital. 
  3. The forms are to be shared with the insurer and third-party administrator. Once done, the patient is to wait for the claim to settle. The cashless claims are to be approved by the insurer beforehand. 
  4. For planned hospitalisation, the insurer must approve the claim before at least 72 hours. In case of an emergency, the claim is to be approved by the insurer within 24 hours.  

Reimbursement Claim Process

  1. A reimbursement claim is a type of claim where the patient is supposed to pay the hospital bills post-treatment. Then, these bills are to be submitted to the insurer along with any other documents, such as medical documents, to get the claim approved. 
  2. To get the reimbursement claim, all the bills and documents will be collected after the treatment. 
  3. Then, the patient is to fill out all the necessary forms and submit the documents along with the bills to the insurer to claim the reimbursement. 

Takeaway

In conclusion, cataract surgery is a common procedure that can significantly improve a patient's vision and quality of life. However, the surgery cost can be a significant burden for many patients, especially those with limited financial resources. This is where medical insurance can play a critical role in providing financial assistance and making the procedure more affordable. One can consider various  financing options available for cataract surgery, such as EMI and medical loans. These options can make the procedure more accessible and affordable for patients who cannot afford to pay for the surgery upfront.

HexaHealth offers a wide range of medical services, including cataract surgery. We understand the importance of insurance coverage for our patients and strive to make the process as hassle-free as possible. Our team of highly qualified professionals is dedicated to assisting patients with their insurance claims, ensuring that they receive the coverage they are entitled to. Whether you need cataract surgery or any other medical service, choose HexaHealth for a stress-free and reliable healthcare experience.

Frequently Asked Questions

Yes, cataract surgery is covered by insurance. The amount of insurance may vary from patient to patient. To file a claim for getting cataract surgery insurance, the patient may have to wait for a period of 2 years.
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Yes, cataract surgery is generally covered by medical insurance plans, including government schemes like Ayushman Bharat and private health insurance plans. The coverage may include the cost of pre-operative investigations, the surgical procedure, and post-operative care, depending on the specific insurance plan.

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Cataract surgery may be covered by Star Health Insurance, depending on the specific policy and the terms and conditions of coverage. To know for sure, it is important to check the policy documents or consult with a representative from Star Health Insurance.

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The insurance companies have full control over the maximum amount that can be claimed for cataract treatment under their health insurance policy. It is important to carefully check the policy's terms and conditions to determine what is covered and what is not.

The cataract claim limit can be determined either by the sum insured or as a percentage of the sum insured. For example, if the limit is set at 10% of the sum insured, the maximum amount that can be claimed for cataract surgery would be Rs. 25,000.

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The cost of a premium for a cataract surgery insurance plan can vary depending on several factors, such as the insurance provider, coverage type, policy features, and individual circumstances.
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There are several companies offering insurance for eye operations. Some of these companies include 

  1. ICICI Lombard
  2. Star Health Insurance
  3. SBI General
  4. Apollo Munich Health Insurance,
  5. Bajaj Allianz
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The coverage for cataract surgery under Cigna insurance can vary depending on the specific plan and policy. In general, many Cigna health insurance plans do cover cataract surgery, but it's important to check the specific terms and conditions of the policy to determine the coverage amount.
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The benefits of a cataract surgery insurance plan are that it offers financial assistance to the patient that can help cover the high costs associated with cataract surgery, such as the surgeon's fees, hospital charges, and post-operative care.

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The cataract claim limit is determined by the insurance provider and may be specified in the policy documents. While many insurance companies do not have any restrictions on cataract claims, some may set a limit. The claim limit for cataract treatment is typically based on the sum assured, with some policies capping coverage at 10% of the sum assured. As an example, if a health insurance policy has a sum assured of five lakhs, the maximum coverage for cataract treatment would be Rs. 50,000.

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The cost of cataract surgery with insurance is about ₹ 20,000 for one eye and may go to ₹ 30,000 or more. In order to claim cataract surgery insurance, a waiting period of 2 years is to be observed.
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The average cost of a cataract surgery in India without insurance is around ₹ 85,000. The starting price of cataract surgery in India is ₹ 30,000, and it may go up to ₹ 1,40,000.
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Yes, there is a waiting period for cataract surgery. In order to claim cataract surgery insurance, a waiting period of 2 years is to be observed.
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Yes, cataract surgery insurance is covered by a group health plan. However, it is advised to check with the insurer about the cataract surgery coverage and read the terms and conditions properly to know more about the coverage limit and the waiting period. 

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Since cataract surgery does not develop overnight after the person buys the insurance, cataract is considered a pre-existing condition. However, no set rules exist to determine which condition is to be considered pre-existing.

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Updated on : 29 September 2023

Disclaimer: The information provided here is for educational and learning purposes only. It doesn't cover every medical condition and might not be relevant to your personal situation. This information isn't medical advice, isn't meant for diagnosing any condition, and shouldn't replace talking to a certified medical or healthcare professional.

Reviewer

Dr. Aman Priya Khanna

Dr. Aman Priya Khanna

MBBS, DNB General Surgery, Fellowship in Minimal Access Surgery, FIAGES

12 Years Experience

Dr Aman Priya Khanna is a well-known General Surgeon, Proctologist and Bariatric Surgeon currently associated with HealthFort Clinic, Health First Multispecialty Clinic in Delhi. He has 12 years of experience in General Surgery and worke...View More

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