Elective Surgeries and Treatments Cover in Health Insurance

Inclusive within elective surgeries are all non-essential surgical procedures performed for reasons other than medical necessity. This includes cosmetic surgery procedures like facelifts, breast implants, liposuction, and breast reduction, which are aimed at subjectively enhancing a patient's physical appearance.

In this write-up, we will learn more about elective treatments in general.

Which Treatments are Considered Medically Necessary?

The term ‘medically necessary’ refers to services or supplies required to diagnose or treat a medical condition, adhering to accepted medical practice standards. In the healthcare insurance industry, it denotes the coverage provided by a health plan, with each health insurance company establishing its own criteria for determining medically necessary services.

These services typically consist of the following -

• Diagnosis, treatment, cure, or alleviation of a health condition, illness, injury, or disease
• Essential and appropriate for the diagnosis, treatment, cure, or alleviation of a health condition, illness, injury, or disease
• Consistent with the generally accepted medical standards within the community
• Not primarily for the convenience of the insured, the insured's family, or the healthcare provider

Types of Elective Surgeries

Elective surgeries can be categorised in two ways. The first category comprises medically necessary elective surgeries, which are recommended when all other treatments have proven ineffective. For instance, individuals suffering from knee arthritis, who have exhausted options such as injections, medications, or therapy, may opt for a knee replacement to enhance their quality of life.

In cases where a specific body part fails to function properly, elective surgeries can be scheduled to address the issue. Medical insurance often provides coverage for some or all of the costs associated with these surgeries, although it is crucial to obtain pre-approval and adhere to all medical management guidelines.

The second type of elective surgery involves procedures that are not medically necessary. These are chosen based on personal preference rather than medical needs. A classic example is a face lift, as the face functions adequately without surgical intervention, making the procedure non-essential from a medical perspective.

Typically, most health insurance plans don’t cover such surgeries, although there are exceptions like reconstructive surgery after a mastectomy. It is advisable to contact your insurance company before scheduling any procedure to determine coverage and potential costs.

Understanding the Difference between Elective and Medically Necessary Treatments through Examples

Go through the following examples for further clarity on the differences between elective and medically necessary procedures -

• Elective and Medically Necessary: Suppose you are dealing with severe knee arthritis and have tried various treatments such as joint injections and non-steroidal anti-inflammatory drugs. You've even made efforts to lose weight. Unfortunately, you face difficulties while navigating your front porch stairs.

According to your orthopaedic surgeon, a knee replacement is necessary. You decide to schedule the surgery for next September, as you anticipate your grandchildren's visit during the summer, and you want to avoid recovering during that time!

The surgery here is considered necessary medically as it is important for your knees to function normally. However, it is also elective because you have the option to delay it until September, have it earlier, or choose not to undergo the procedure at all and endure the pain. This surgery is typically covered by most health insurance plans.

• Non-Elective and Medically Essential: In the next example, assume that you sustain a wound to your neck during an accident, resulting in significant blood loss and difficulty maintaining your airway. Emergency responders rush you by helicopter to the trauma centre, where you undergo surgery immediately.

This surgery is unquestionably not elective, as refusing it would have quickly led to a fatal outcome. The situation demanded immediate intervention — postponing the surgery was not an option. The procedure was medically necessary to control the bleeding, secure your airway, and repair the damage caused by the gunshot wounSeod.

• Elective But Not Medically Necessary: Let’s say you've noticed signs of ageing and feel dissatisfied with your appearance. After trying Botox and dermal fillers with unsatisfactory results, a plastic surgeon recommends a full facelift to achieve your desired effect. You choose to schedule the facelift for next month.

The facelift falls under the category of elective procedures, as it is not required for your facial functions to operate properly. You can still close and open your eyelids correctly, eat without difficulty, and breathe normally. The decision to have the facelift is entirely up to you, and most health plans would not cover it, as it is not medically necessary. The cost is likely to be your responsibility.

How to Use Your Health Insurance Plan Smartly?

To make the most of your health insurance plan, it is important to look into the following aspects -

• Check if your plan requires pre-approval for the elective procedure. If the plan does affirm this, your doctor would be required to inform your insurance provider that the procedure is medically necessary before you actually undergo the surgery.
• Make sure that your procedure takes place within a network hospital. There are chances that your insurance company might not pay for benefits if you get treated out of the network.

How to Get a Cover for Elective Treatment?

Discovering that your health insurance does not cover the expenses of your surgery can be a stressful situation. This may be due to the surgery not being deemed 'necessary' or because your insurance provider does not include such coverage. Whatever the case, you could find yourself solely responsible for covering the entire cost of the procedure here.

If that's the case, there are several avenues that you can explore -

• Opt for the Best Deal: In case your health insurance doesn't cover the surgery, it's essential to research and examine various doctors and healthcare practitioners within your network who perform the procedure. Prices for the same service often differ among clinics, hospitals, and surgeons. Conduct thorough research to select a facility that offers the most affordable option.
• Numerous hospitals and surgeons extend payment plans to patients who cannot afford to pay their medical expenses upfront. A payment plan is a formal agreement between the patient and the medical institution, enabling the patient to make monthly payments over an agreed period to cover the full cost of their bill.
• If your current insurance policy doesn't provide coverage for your surgical costs, you always have the option to explore alternative healthcare plans that offer more comprehensive coverage. For instance, if you're married and your employer insurance plan doesn't cover your surgery but your spouse's insurance does, switching plans can save you money.

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To know more about elective treatment, read the following frequently asked questions section.

Frequently Asked Questions

Q1. What are some examples of elective treatments?

Ans: Some elective treatments include simple cosmetic procedures such as the removal of a mole or a wart. However, there can also be surgeries for more serious conditions like hernia surgery, removal of kidney stones or appendix, and more.

Q2. What is the basic difference between elective and non-elective treatments?

Ans: An elective surgery is usually planned well in advance and, at times, can be postponed. A non-elective (or emergency) surgery, on the other hand, has to be performed instantly as usually a life-threatening or critical health condition is involved in such cases.