Cataract surgery claim rejected or cut?

Why cataract surgery claims get rejected or cut

• “Waiting period not completed”: many policies put cataract on their specific-disease list, often with a 24-month wait.
• A per-eye sub-limit: many policies cap what they pay for cataract surgery per eye. The cap must be written in your policy.
• The lens: when a premium lens (multifocal or toric) costs more than the sub-limit allows, the difference is often not paid.
• “Less than 24 hours in hospital”, even though cataract surgery is a standard day care procedure.
• “Reasonable and customary” cuts: the insurer pays less by comparing your bill with network-hospital package rates or an internal guideline, even when the policy has no cataract cap.
• Laser-assisted (femto) cataract surgery paid only at the rate for standard surgery, or the laser charge cut as a consumable.

Rules that apply

• Waiting period: many policies put cataract surgery on the specific-disease list, often for 24 months. The cap is 36 months of continuous cover, ported years count, and it never applies after an accident.
• Under 24 hours in hospital: check your policy’s day care list. If cataract surgery is on it, a short stay is no reason to reject.

What decided these disputes

In 45 published Insurance Ombudsman awards on cataract surgery claims that we reviewed, the policyholder got paid in full or in part in 89% of cases. Past awards don’t predict any one case.

• Whether the policy itself carried a cataract cap often decided the outcome. Where it didn’t, cuts based on network package rates or internal guidelines were usually reversed.
• An insurer relying on “reasonable and customary” charges was generally expected to show comparable rates from similar hospitals. A deduction without that evidence rarely stood.
• Where a cataract sub-limit was clearly written in the policy or the signed proposal form, it was generally applied as written.
• Whether a cap added at renewal or migration had been communicated to the policyholder often mattered.

Documents to keep ready

• The biometry (A-scan) report showing the lens power
• The IOL invoice or the lens sticker from the operation notes
• The ophthalmologist’s advice recommending surgery
• Whether one or both eyes were operated, and on which dates
• The discharge summary, the itemised final bill and the rejection or settlement letter

How to challenge the decision

Write to the insurer’s Grievance Redressal Officer, who must reply within 14 days. If that fails, use Bima Bharosa or go to the Insurance Ombudsman within one year. The guides below have the letter format and the steps.

Questions people ask

Is cataract surgery covered by health insurance?

Usually, yes, as a day care procedure. Many policies have a waiting period for it, often 24 months, and some cap the amount paid per eye. Check the specific-disease list and sub-limits in your policy wording.

Why did the insurer pay less than my cataract bill?

The usual reason is a per-eye sub-limit, or a premium lens costing more than the policy allows. Ask for the claim settlement sheet, which should show each deduction with the policy clause behind it.

Are eye drops and check-ups before and after cataract surgery covered?

Many policies pay pre and post-hospitalisation expenses, such as tests, eye drops and follow-up visits, for the number of days stated in the policy. Check whether your cataract sub-limit covers only the hospital bill or the whole treatment.

Can I claim again when the second eye is operated on?

Usually, yes. Each eye is a separate operation and a separate claim. If your policy has a per-eye sub-limit, it applies to each eye.