Insurance in Case of Major Surgery

A major surgery, much like serious illnesses, can significantly disrupt one's life. Prolonged recovery, inability to return to work, and more can make financial support essential. While there are various options like income loss insurance or critical illness insurance, this article focuses specifically on insurance for major surgery.

What is Insurance for Major Surgery?

Insurance for major surgery is a type of policy that provides financial support in the event of a costly surgical procedure. This type of insurance can cover various costs, such as hospitalization fees, medical fees, rehabilitation costs, and other expenses related to the treatment process. Such policies are particularly important for individuals who want to protect themselves and their families from unforeseen expenses that could significantly strain the household budget. Insurance for major surgery offers peace of mind, allowing one to focus on recovery rather than worrying about the financial aspects of treatment.

Definition of Major Surgery According to Insurance Companies

Contrary to what one might think, it is not easy to find a definition of major surgery in the terms and conditions of various insurance companies, as much depends on how this type of benefit is named. It is often included in serious illness or renamed as surgical operation.

Sample Description from the General Terms of Group Insurance by Generali:

• Surgical operation: An invasive surgical procedure, performed under general, regional, or local anesthesia by an authorized doctor with a surgical specialty, necessary from a medical point of view to restore the proper function of the diseased organ or system, aimed at removing the disease focus. Procedures carried out for diagnostic purposes (biopsy, tissue sampling, exploratory surgery), minor surgical procedures not requiring hospitalization, and non-medically necessary procedures are not considered surgeries under these terms. It only includes cases listed and described in the Catalog of Surgical Operations, which is Appendix No. 2 to these terms and conditions.

As seen in the last sentence, virtually every insurer has its own catalog of surgical operations/major surgeries according to which the payout will be made.

Sample List of Major Surgeries

A sample list of major surgeries that may be covered by insurance in case of major surgery includes:

• Heart surgeries:
  • Coronary artery bypass graft (CABG)
  • Heart valve replacement or repair
• Organ transplants:
  • Liver transplant
  • Kidney transplant
  • Heart transplant
• Neurological surgeries:
  • Brain tumor removal
  • Craniotomy
• Oncological surgeries:
  • Mastectomy (breast removal)
  • Prostatectomy (prostate removal)
  • Removal of stomach, intestine, lung tumors
• Orthopedic surgeries:
  • Hip or knee replacement
  • Spinal scoliosis surgery
• Gastrointestinal surgeries:
  • Gallbladder removal
  • Liver and pancreas surgeries
• Transplant surgeries:
  • Bone marrow transplant
  • Corneal transplant

These surgeries are typically complex, require specialized medical care, and involve a long recovery period, highlighting the importance of having appropriate insurance. Of course, the list of surgeries or their level of advancement depends on the terms and conditions, so I always recommend a thorough analysis of the surgery catalogs.

When Insurance Does NOT Apply?

Insurance for major surgery does not always cover all cases. There are situations where the policy may not apply. Here are some typical exclusions:

• Chronic and pre-existing conditions:
  • If the surgery results from a disease diagnosed before purchasing the policy, the insurer may refuse to pay the benefit.
• Neglect and risky behaviors:t
  • The policy may not cover surgeries resulting from neglect of health, such as lack of regular check-ups, or from actions knowingly taken that endanger health, e.g., extreme sports without proper precautions.
• Self-harm and suicide attempts:
  • Insurance usually does not cover the costs of surgeries related to self-harm or suicide attempts.
• Illegal activities:
  • Surgeries resulting from participation in illegal activities, such as fights, may be excluded from insurance coverage.
• Experimental and unrecognized treatments:
  • The insurer may refuse to cover the costs of surgery if the medical procedure is experimental or unrecognized by the relevant medical authorities.
• Cosmetic and non-medically necessary surgeries:
  • Surgeries performed for cosmetic reasons rather than medical necessity are typically not covered by the policy.
• Non-compliance with policy terms:
  • Failure to adhere to the procedures specified in the policy, such as the need for prior insurer approval for the surgery, may result in refusal to pay the benefit.

Understanding these exclusions is key to understanding the scope of protection offered by the insurance policy. It is important to read the insurance agreement terms carefully and consult with an insurance advisor to fully understand the scope of protection.

Individual Insurance vs. Group Insurance

"I have surgery covered by my company’s group policy, why would I need additional insurance?" - I often hear this, so I decided to describe the differences between benefits from two different policies.

Individual Insurance

An individual policy can be precisely tailored to the specific needs of the insured. There is an option to choose the scope of coverage, the sum insured, and additional extensions. The insured has full control over their policy, allowing for flexibility in modifying its terms if necessary. The cost of individual insurance can be higher than group insurance, as the premium is calculated based on individual risk factors. The insured independently concludes the contract and pays the premiums, which may involve a more detailed application process and risk assessment.

Group Insurance

Group insurance is usually offered by employers as part of a benefits package for employees. Group insurance may have limited ability to adapt to individual needs, as conditions are collectively set for the entire group. The cost of group insurance is typically lower, as the risk is spread across a larger number of people, which can lead to lower premiums. In the case of a group policy, the employer often covers part of the insurance costs, further reducing the financial burden on the employee. The application process is usually simplified, and the risk assessment may be less stringent compared to individual insurance.

In summary, the choice between individual and group insurance depends on the individual needs and preferences of the insured. Those who value flexibility and the ability to tailor the policy to their own needs may prefer individual insurance, while those looking for a more economical and less complicated option may lean towards group insurance.

Not Just Surgeries - Comprehensive Life Insurance

Life insurance is one of the foundations of financial security, but it is also worth considering other aspects that can protect against various risks. Here are a few key elements to include in a comprehensive insurance policy:

• Health insurance:
  • Covers treatment costs, doctor visits, diagnostic tests, medications, and rehabilitation. This is particularly important to ensure quick access to high-quality medical care without having to wait in long queues.
• Accident insurance (NNW):
  • Protects in case of permanent health damage, temporary inability to work, or death due to an accident. It may also cover treatment and rehabilitation costs after an accident.
• Critical illness insurance:
  • Provides a payout in case of diagnosis of a serious illness, such as cancer, heart attack, or stroke. These funds can be used for treatment, care, and to cover daily expenses when the insured person is unable to work.
• Income protection insurance:
  • Guarantees the payment of a specified percentage of income in the event of loss of the ability to work due to illness or accident. This is important security for individuals who cannot afford to lose regular income.
• Property and casualty insurance:
  • Covers the protection of the house, apartment, and valuable items against destruction, damage, or theft. The policy may cover damages caused by fire, flooding, burglary, and other random events.
• Liability insurance (OC):
  • Protects against claims of third parties for damages caused by the insured or members of their family. It may cover damages to property, health, or life of other people.
• Travel insurance:
  • Provides protection during trips abroad, covering treatment costs, possible medical evacuation, loss of luggage, or trip cancellation. This is crucial protection for frequent travelers.

When choosing comprehensive insurance, it is important to pay attention to individual needs and the risks to which we are most exposed. If you want to know more about life insurance, visit my blog or contact me, and I will be happy to tell you about all the possibilities.

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