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National Health Insurance and Cataract Surgery Coverage

By Juhi Walia
30 August 2022, 5:33 PM

More than 60% of all blindness in India is caused by cataract, or the clouding of the internal eye lenses. The probability of developing a cataract is significantly higher as you age – the prevalence of cataract-related blindness in the seventy-plus age group is estimated to be four times that of other younger age groups. For senior citizens, most of whom have no regular source of income, finding the resources for cataract surgery necessary, is, therefore a challenge. The question therefore arises, is the cost of surgery and treatment covered by health insurance? The answer is a resounding YES! Many general insurance companies, such as National Insurance Company Limited, offer the same.

National Young India Mediclaim Policy and National Mediclaim Plus Policy offered by National Insurance Company Limited, the oldest General Insurance Company in India, also provide cataract surgery coverage. 

Cataract Surgery Coverage Under National Health Insurance Schemes

Cataract surgery coverage under National Health Insurance Policies is likely to be subject to fulfillment of the waiting period as specified in the policy document. These policies will likely have a waiting period of two years. If the cataract has been classified as a pre-existing disease condition, the waiting period could increase up to four years. There could also be a cap on the cost of surgery depending on the type of scheme you have opted for and the premium you have paid. The coverage will also depend on the extent of a defect in your eyes. Only when the refractive error of the eye exceeds 7.5 dioptres will you get cataract coverage under National health insurance. Again, if the policy you have purchased mandates a co-payment, you will have to pay some percentage of the total cost from your own pocket. You will need to check your policy document to understand this. Alternatively, check this out by contacting your health insurance company.

Does National Health Insurance Come with a Sub-limit for Cataract Coverage?

Yes, National health insurance comes with a sub-limit for cataract coverage. A sub-limit means the extent to which the coverage you will get for a specified illness or treatment. Here’s how National health insurance applies sub-limits on cataract coverage across policies.

National Health Insurance PlansSum Insured (In INR)Sub-limit
National Young India Mediclaim Policy3, 5 and 10 lakhUp to 10% of the sum insured, up to INR 50,000 per eye per year
National Mediclaim Plus Policy

Plan A - 2-10 lakh

Plan B - 15/20/25 lakh

Plan C - 30/40/50 Lakh

Plan A - Up to 15% of the sum insured or INR 60,000, whichever is less, for each eye

Plan B - Up to INR 80,000 for each eye

Plan C - INR 1 lakh for each eye

Understanding Cataract

A cataract is said to occur when the naturally clear lenses in your eyes become cloudy. This makes it difficult to see. It is associated with ageing and usually begins in the forties, when the normal protein in the eye lenses begins breaking down. Though this is easily treatable through a relatively safe and simple procedure, this often goes untreated, even though the procedure does not require hospitalisation. Due to the lack of awareness regarding the simple nature of treatment and the cost factor, the number of blind people in India is over one crore. Most of them could overcome their blindness with a simple cataract operation.

During cataract surgery, the surgeon will replace the cloudy natural lens with an artificial lens. This relatively simple and safe procedure could vastly improve the quality of your life. However, to increase the success of your surgery, you will need to follow some basic precautions for a week or so after the surgery, as advised by your doctor. Usually, such precautions include avoiding strong light, keeping your eye away from heat (yes, no cooking!), no water on the eyes, avoiding any activity that may stress your eye muscles - such as lifting heavy weights or exercising, and no reading.

So, if you are suffering from blurry vision, it is advisable to visit an ophthalmologist and find the reason for this blurriness. If you are diagnosed as having a developing or developed cataract and are advised surgery, you do have the option to have the costs covered under National health insurance plans.

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1. How much coverage does National health insurance provide for cataract surgery?

The coverage for cataract surgery depends on the type of National health insurance policy you opt for. Some policies specify a sub-limit, which limits your coverage to an extent. Do check the National health insurance policy document for cataract surgery coverage. If the policy has a sub-limit, knowing that beforehand will only help you plan effectively the amount not covered. It will thus ensure no last-minute hassle arranging the sum.

2. What is meant by “waiting period for cataract surgery?

This is the period between the start of the policy and the time before you can get covered for cataract surgery. Assuming you don’t have this before buying a policy. In that case, the waiting period would be two years. However, if you have it before, be ready to serve a waiting period of up to four years.

3. What is the co-pay option for cataract surgery?

A co-pay option is when your policy requires you to pay a percentage of your claim while the insurer pays the rest. This may vary from 10% to 30%, depending on the health insurance provider. Taking this option could drive down your premium by as much as 10% and is usually opted for by the healthy young-aged population who do not anticipate any major hospitalisation, but have opted for medical cover just as a precautionary measure.

4. I have been advised to have cataract surgery, but the waiting period specified by my health insurance policy has not been completed. How risky is it for me to postpone the cataract surgery?

The development of a cataract is usually a slow process, so unless the cataract is very advanced and causing near blindness, you could consider waiting as such waiting poses no added risk to your eye. However, you may consider the impact on your everyday life: does it interfere with your independence, does it prevent you from doing tasks essential to your everyday living - such as driving and cooking or reading? As always, do discuss the possible postponement of the surgery with your doctor and your family members.

5. Why are there such huge differences in the cost of a cataract surgery offered by different service providers?

While the cost of most surgeries depend on the fees of the surgeon/s performing the operation and the standard of the nursing home or hospital in which the surgery is performed, in the case of cataract,  the type of lens you opt for impacts the price. On average, the price range of the lens could vary from INR 3000-75,000. While some basic lenses will require you to wear spectacles after the surgery, some lenses are designed to offer freedom from the same. Some are locally made and some are imported. This, therefore, accounts for the huge difference in price.

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