Planning robotic surgery? Your health insurer may pay only 50% of the hospital bill: Know what to check

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.

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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.

The following examples illustrate how robotic surgery limits can vary across health insurance plans.

Insurer	Plan	Robotic sub-limit	Conditions/notes
Aditya Birla	Activ One Max	No sub-limit reported	No disease-wise sub-limits
Care	Supreme	No sub-limit reported	Listed among plans without sub-limits
HDFC Ergo / ICICI Lombard	Health Click / Health Pro	Reported at 10% of SI	Older aggregator source; unverified
HDFC Ergo	Optima Secure	No separate sub-limit	Modern treatments up to sum insured
Niva Bupa	ReAssure	₹1L on a few robotic surgeries	Otherwise, modern treatments covered up to SI
Star Health	Family Health Optima	₹3L (₹10L SI); ₹4L (₹15L SI)	Disease-wise sub-limit under modern treatments
Star Health	Gain	₹2.5L at ₹5L SI (50%)	1% daily room-rent limit can trigger proportionate deductions

Source: Square Insurance

These examples show why policyholders should not compare health insurance plans only on the basis of their overall sum insured. Two policies offering Rs 10 lakh cover may have very different robotic surgery limits.

Also read: No health insurance but a personal medical fund: How good is this idea?

Why can the hospital bill and final claim settlement differ?

A robotic surgery claim may be approved, but the amount paid by the insurer can still be lower than the hospital bill.

This is because the final payout depends not only on the sum insured but also on procedure-specific sub-limits, eligible medical expenses and other policy conditions.

“For instance, someone may have a ₹10 lakh policy and undergo robotic surgery worth ₹5 lakh. If the insurer has put a ₹3 lakh cap on that procedure, the patient will have to pay the remaining amount,” says Sarita Joshi, the Head of Life & Health Insurance, Probus.

The final payout can also be affected by expenses that the policy does not cover, such as certain robotic instruments, disposable components and other consumables.

There is another aspect policyholders should be aware of. If the insurer considers the robotic approach an optional upgrade rather than a medically necessary part of the procedure, it may pay only what it considers reasonable for the covered treatment, explains Parwal.

This means that even when the underlying surgery is covered, the choice of surgical technique and the associated expenses can affect how much the insurer reimburses.

What should policyholders check before undergoing robotic surgery?

A high sum insured does not necessarily mean that every treatment expense will be covered in full. Before going ahead with robotic surgery, policyholders should check the modern treatment section of their policy and see whether a separate limit applies to the procedure.

“It is also worth checking how the insurer treats robotic instruments, disposable components and other consumables, as some of these expenses may not be payable. Room rent limits and co-payment clauses deserve attention too, since they can affect the final claim amount,” says Joshi.

If you are planning to undergo robotic surgery, speak to your insurer before going ahead. It is better to know what the policy will pay for and what you may have to manage from your own pocket than to be caught off guard when the final bill arrives.