You may not be aware that your health insurance policy covers Lasik surgery for correction of refractive errors. If your specs number is higher than +7 or -7 (what doctors refer to as a refractive error above 7 diopters), you may be eligible for Lasik surgery coverage under your health insurance. However, most people are not aware of this because it is mentioned under the exclusion clause of the policy.
All health insurance policies in India have standard exclusions as mandated and defined by IRDAI (Insurance Regulatory and Development Authority of India). IRDAI has defined 18 standard exclusions that must be part of every health insurance policy , and exclusion no. 15 is related to refractive error, wordings of which is as follows:
“Refractive Error: Code- Excl15 — Expenses related to the treatment for correction of eyesight due to refractive error less than 7.5 dioptres.”
IRDAI Guidelines on Standardization of Exclusions in Health Insurance Contracts (IRDAI/HLT/REG/CIR/177/09/2019)
This means refractive errors of more than 7.5D are covered under health insurance policies. However, this is often less known because it’s mentioned under the “Exclusion” section of the policy, which people usually skip reading. So, if your glasses’ number exceeds 7.5D, you can get the condition treated with Lasik surgery.
But insurance companies are generally conservative when it comes to paying such claims. You need to be very careful and well-prepared while filing a Lasik surgery claim.
Points to Consider Before Going for Lasik Surgery
Only New Refractive Errors Are Covered:
Health insurance covers only those refractive errors which develop after the purchase of a health insurance policy.If you had the condition before buying your policy and didn’t declare it, then it will be treated as a pre-existing condition and won’t be covered.
Pre-existing Conditions Can Be Covered — After Waiting Period:
If you declared a pre-existing eye condition that requires Lasik surgery, it may be covered after the waiting period for pre-existing diseases is over, as per the terms of your policy.
Corporate Health Insurance Plans May Have Better Coverage:
If you are covered under a corporate health insurance plan, check the specific terms related to Lasik surgery. Many corporate policies cover even pre-existing Lasik conditions without a waiting period and without the 7.5D limit.
Check Waiting Period for Refractive Errors (Lasik Surgery):
Some policies have a specific waiting period even for refractive errors that arise later. For example, National Insurance Parivar Mediclaim Policy has a 2-year waiting period. So, if you develop the condition after buying the policy, you still need to wait 2 years before you can undergo Lasik surgery.
Medical Necessity Is Crucial:
Insurance doesn’t cover procedures done for cosmetic or convenience reasons. Lasik surgery must be medically necessary—which means you should have tried conventional treatments (like glasses or contact lenses) and not seen improvement. Only then does Lasik become justified as a treatment. So, ensure it’s documented that other methods have failed, making Lasik necessary.
Get Proper Diagnostic Reports Before Surgery:
Once you’ve met the criteria and are ready for surgery, make sure your hospital performs proper diagnostic tests:
Refractive Testing Report: Preferably machine-generated rather than manual, as it carries more weight and authenticity.
Corneal Topography, Pachymetry, etc.: These tests check corneal thickness and are essential pre-surgery diagnostics. They serve as proof that the surgery is medically advised and carried out properly.
Lasik Machine Report (Ablation Report): When Lasik is performed, the machine generates an ablation or treatment report. It records the surgery’s parameters and confirms that Lasik was done.
These diagnostic reports help the insurer verify the authenticity and necessity of the treatment.
Share All Reports and documents with the Insurance Company:
Submit all pre- and post-surgery diagnostic reports along with your claim. Insurance companies scrutinize Lasik claims closely because there are many fraudulent or unnecessary claims. Proper documentation will establish the genuineness of your claim and speed up the approval process.
If your claim is genuine and the hospital provides the required documents, it is usually settled without much hassle. However, never attempt to manipulate or game the system, as it can not only lead to claim rejection but also cancellation of your policy..
