Robotic surgery can cost several lakhs of rupees, but having a health insurance policy with a high sum insured does not necessarily mean the insurer will pay the entire hospital bill. Even when robotic surgery is covered, procedure-specific sub-limits, waiting periods, room rent restrictions and non-payable expenses can reduce the final claim amount.
So, before opting for robotic surgery, policyholders need to look beyond the total sum insured and understand exactly what their policy covers.
Is robotic surgery covered under health insurance?
Robotic surgery is covered under Indian health insurance policies when it is medically necessary and the underlying illness or procedure is covered, but the extent of payment depends on the policy’s terms, applicable sub-limits and other conditions.
IRDAI’s 2019 health regulations require insurers to cover robotic treatments, so every insurer offers it, but with different sub-limits and policy conditions. This was reinforced in IRDAI’s 2024 Master Circular. But covered is not the same as fully paid.
According to Akash Parwal, CEO & Co-Founder at Square Insurance, in practice, a claim is payable when:
The surgery is medically necessary and prescribed by a qualified doctor. Insurers look for clinical justification.
The underlying condition has cleared its waiting period. For example, knee replacement for degenerative osteoarthritis usually carries a waiting period. Only accidents are covered from day one, and 2–3 years is typical for pre-existing or listed conditions.
Robotic surgery sub-limits: How much will your health insurer pay?
One of the most important conditions to check is whether your health insurance policy places a separate sub-limit on robotic surgery.
Even when a procedure is covered, insurers may restrict the payout through a fixed monetary cap, a percentage of the sum insured or a limit linked to the coverage amount.
“For example, some policy wordings may cap robotic surgery at ₹1 lakh for specified procedures, while others may limit coverage to 25% of the sum insured. Certain plans may offer coverage of up to 50% of the sum insured, subject to a maximum of ₹5 lakh,” says Ankita Srivastava, General Manager, THIP Insure.
According to Parwal, insurers generally apply robotic surgery sub-limits in three ways:
- Fixed rupee cap. Niva Bupa Health+ limits robotic surgeries to ₹1 lakh, with carve-outs for radical prostatectomy, cardiac surgery, partial nephrectomy and malignancies. ReAssure also has a ₹1 lakh sub-limit on a few robotic surgeries.
- Tiered by sum insured. Star Family Health Optima pays ₹3 lakh on a ₹10 lakh cover and ₹4 lakh on ₹15 lakh.
- Percentage of sum insured. Star Health Gain caps robotic surgery at ₹2.5 lakh on a ₹5 lakh cover, which is 50%. Some plans are reported to use 10% of sum insured, which means ₹1 lakh on a ₹10 lakh cover.
