Under-insured, over-insured, but not properly insured: the structural liability-coverage gap in co-located robotic surgery and telesurgery.

Robotic-assisted and remote surgery distribute a single operative event across multiple independent actors - the operating surgeon, the credentialing healthcare facility or ambulatory surgical center (ASC), the device manufacturer, the technology services platform integrator that remote-enables and orchestrates the surgical procedure, and, in telesurgery, the telecommunications and connectivity service providers. Liability for an adverse outcome is correspondingly distributed among these actors. Yet the insurance that responds is assembled from separately conceived, separately underwritten insurance products - medical professional liability, product liability, facility general liability, and cyber or technology errors-and-omissions coverages - each designed for single-actor, single-domain risk. Reasoning from insurance coverage architecture and tort liability doctrines rather than from a well-constructed, comprehensive claims dataset, this review argues that the existing patchwork leaves co-located robotic surgery simultaneously over-insured (through duplicated premium costs and overlapping liability defense) and under-insured (through inter-insurer apportionment of liability disputes, the cyber-physical bodily-injury gap, other-insurance clauses and anti-stacking of insurance policy limitations and effects, and erosion of liability coverage for defense costs-within-limits) - such that the activity is insured but not properly insured. This gap is one of coverage architecture rather than of coverage limits, and so it is not closed by the conventional risk-financing responses - higher excess or umbrella layers, self-insured retentions, or captive insurance arrangements - because those deepen each actor's own insurance coverage tower without integrating the several towers a single event implicates: the gap lies between the towers, not within any one of them. Telesurgery and teleintervention compound the problem with genuinely novel and emerging legal exposures: cross-jurisdictional professional licensure and choice-of-law uncertainty, connectivity services-provider liability shielded by contractual limitation of liability clauses, and healthcare professionals' standard-of-care ambiguity for remote and AI-assisted actions or inactions. We contend that the field requires a single, outward-facing, multi-domain integrated liability insurance product - one coherent contract with a single coverage trigger and a single accountable risk-bearing counterparty - and that such a product is likely to be both more protective of its insureds and, by eliminating coverage duplication, more economical than the status quo. We frame the implications separately for the surgical, device-manufacturing, platform-integrator, and healthcare facility communities.