Is Knee Replacement Surgery Covered by Health Insurance?

Knees are important for a person to run, walk, or even sit. Without our knees, we probably won't be able to do any of the basic mobility functions, let alone any adventure activities. However, knees can be troublesome for a lot of us, especially during old age. And knee replacement surgery happens to be an excellent cure for knee-related issues. Concerns regarding knees have been on a rise. According to the Times of India, over 2.5 lakh individuals undergo knee replacement surgery in India ^[1]. And the cost of knee replacement surgery can be anywhere between Rs. 50,000 to Rs. 2 Lakh. So, shouldn’t we all be protected against an issue so prevalent? This article expounds on how a health insurance plan with a knee replacement surgery cover will prove to be beneficial:

What is Knee Replacement Surgery?

Our knee joints can cause serious problems during old age if we ignore minor, yet important aspects of life during our young age. These factors include obesity, a sedentary lifestyle, stress, etc. Osteoarthritis, knee injury, long-lasting knee pain, etc. are a few reasons why an orthopaedic surgeon recommends knee replacement surgery (also known as Arthroplasty). It involves the replacement of the damaged bone and cartilage with an artificial joint and prosthesis. While partial knee replacement focuses only on the affected area, total knee replacement surgery replaces the entire knee with a prosthesis.

When Do You Need Knee Replacement Surgery?

Knee replacement surgery may be necessary when knee pain and stiffness become debilitating and significantly affect your daily activities. Typically, it’s recommended when conservative treatments, like physical therapy, medications, and lifestyle changes, fail to provide relief. Common conditions that may require surgery include severe osteoarthritis, rheumatoid arthritis, or knee injuries causing extensive damage to the joint. If pain persists despite non-invasive treatments and mobility is impaired—making tasks like walking, climbing stairs, or even standing difficult—surgery could be considered. Ultimately, the decision is based on the severity of symptoms and how much they hinder quality of life.

What is a Knee Replacement Surgery Cover?

A knee replacement surgery cover offers compensation against expenses involved in undergoing Arthroplasty. Since Athroplasty’s definition was unclear, insurers rejected claims raised against knee replacement surgery. However, that is not the case anymore. Most leading insurance companies cover the cost of knee replacement surgeries as per their terms and conditions. Insurance companies generally reimburse 50% of the cost on old health insurance policies. Hence, it is recommended that you peruse your policy document to get maximum coverage against such medical treatments. Also Read: What are the Common Causes of Knee Pain

Why Do You Need Health Insurance for Knee Replacement Surgeries?

Knee pain can get intolerable at times. During such cases, doctors advise knee replacement surgery. However, these medical procedures can cost a fortune, compelling us to live with the pain as long as we can. However, with a health insurance plan, you can undergo the surgery without worrying about finances. Hence, when buying a health insurance plan, ascertain that it compensates for knee replacement surgeries. Here are the two most important benefits of a comprehensive health insurance plan:

1. Cashless treatment

With a comprehensive health insurance plan, you do not have to worry about arranging cash for high-ticket treatments. Your insurer will settle your medical bills directly with the hospital. However, you will have to schedule your surgery in advance for a seamless experience. *

2. Coverage for medical treatment

The right health insurance plan will provide coverage for your pre-hospitalisation and post-discharge expenses as well. These include consultation charges, follow-ups, medical tests, etc. It will also cover in-patient hospitalisation expenses. Health insurance plans also offer coverage against a day care surgery. * Also Read: Types of Health Insurance

Is Knee Replacement Covered by Insurance?

Yes, knee replacement surgery is usually covered by health insurance if it is medically necessary. Most health insurance plans, including private and employer-provided policies, cover the procedure when it's required due to conditions like arthritis or injury. Coverage specifics, such as whether it includes partial or total knee replacement, may vary by insurer and policy. It’s important to check for pre-authorization requirements, waiting periods, and exclusions in your policy. Additionally, some plans may also cover rehabilitation and post-surgery care. Always confirm with your insurer for full details on your coverage.

Things to consider before choosing health insurance for knee replacement surgery

While health insurance is essential for everyone, you must consider certain factors before choosing a health insurance plan. And they are:

1. Waiting period

If you are buying health insurance to undergo knee replacement surgery, check the waiting period. Since insurers have just started to look at this surgery with a positive perspective, they could have a waiting period of 2 to 4 years. Opt for a plan with the shortest waiting period. *

2. Coverage limit

A lot of insurers offer only 50% coverage against Arthroplasty. Do thorough research and for a plan that offers maximum benefits. Note: You might have to opt for health insurance with OPD cover to avail coverage during further follow-ups and health check-ups. *

Conclusion

Until a decade back, health insurance companies considered this surgery to be a cosmetic procedure. However, they have now understood the need for knee replacement surgery. Not undergoing this procedure means living with excruciating pain whether you are walking or resting. So, now that insurance providers have included knee replacement surgery under comprehensive health insurance, ensure that you are covered against medical emergencies. Along with Arthroplasty, it covers you against multiple other medical treatments such as cataracts, dengue, diabetes, COVID-19, etc.  However, make the most of health insurance premium calculators to make sure that you get the right insurance plan for the best deal.

FAQs

Q1. What is the average cost of knee replacement surgery?

The cost of knee replacement surgery can vary significantly depending on factors such as location, type of surgery (partial or total), and the hospital chosen. On average, the cost ranges from ₹1.5 to ₹3.5 lakhs in India, but it may be higher in private hospitals or for advanced prosthetics. It’s important to check with your insurance provider to see what is covered under your policy.

Q2. Is knee replacement surgery high-risk?

While knee replacement surgery is generally considered safe, like any surgery, it carries some risks, including infection, blood clots, and anesthesia complications. However, with advancements in medical technology and skilled surgeons, the risk of complications is low, and most patients experience significant improvement in mobility and pain relief.

Q3. What is the ideal age for knee replacement surgery?

The ideal age for knee replacement surgery is typically between 60 and 75 years. However, the decision depends on the individual's health, lifestyle, and the severity of the knee condition. Younger patients may undergo the procedure if they experience severe pain or reduced function, but their orthopedic surgeon may suggest alternatives if possible.

Q4. Which type of knee replacement is best?

The best type of knee replacement depends on the patient’s condition. Total knee replacement (TKR) is most common and suitable for those with extensive joint damage. Partial knee replacement (PKR) may be an option for patients with damage in only one part of the knee. Your surgeon will determine the best option based on your specific needs.

Q5. What are the consequences of delaying knee replacement surgery?

Delaying knee replacement surgery can lead to worsening pain, reduced mobility, and joint deformity. Over time, the affected knee may suffer further damage, leading to a more complex and costly procedure. Delaying treatment may also result in muscle weakness and a diminished quality of life. It is best to consult an orthopedic surgeon to evaluate your condition and consider timely surgery. * Standard T&C Apply Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.