I have developed obesity due to Type 2 diabetes and a sedentary lifestyle. It is now posing significant risks to my health. My doctor has recommended bariatric surgery as a medical necessity to improve my health. I have been covered under a medical insurance policy for seven years. However, I have been informed that bariatric surgery is often considered cosmetic and is excluded from the insurance coverage. However, in my case, it is not cosmetic but a health-critical procedure. Could you clarify whether this surgery would be covered under my health insurance policy?
– Name withheld on request
Under the Insurance Regulatory and Development Authority guidelines specified in circular IRDAI/HLT/REG/CIR/117/09/2019, bariatric surgery, while generally excluded from health insurance coverage, can be payable if specific conditions are met. In your case, since the underlying cause is uncontrolled Type 2 diabetes, the surgery may qualify for coverage, provided it adheres to the outlined criteria.
First and foremost, the surgery must be conducted on the advice of a licensed doctor. It is essential that the medical necessity of the procedure is documented in detail, with the doctor explaining why bariatric surgery is a critical part of the treatment plan. Additionally, the surgery must be supported by clinical protocols, ensuring that the procedure follows established medical guidelines recognized by national or international bodies.
The patient’s age is another consideration, as the individual must be 18 years or older at the time of the surgery. Beyond age, the patient’s Body Mass Index (BMI) plays a crucial role in determining eligibility. If the patient’s BMI is 40 or higher, the surgery is automatically eligible for coverage if all other requirements are met. However, if the BMI is between 35 and 39.9, the surgery may still be covered if the patient has severe co-morbidities such as obesity-related cardiomyopathy, coronary heart disease, severe sleep apnea, or uncontrolled Type 2 diabetes. In such cases, it must also be shown that less invasive weight-loss methods have been attempted and have failed.
Given the details provided, if the surgery is being recommended as a treatment for uncontrolled Type 2 diabetes, and if the patient’s BMI is either 40 or higher or between 35 and 39.9 with co-morbidities, it is likely that the claim will be payable. However, it is critical to ensure that all required medical documentation is in place. This includes the doctor’s recommendation, clinical justifications, and evidence that less invasive methods of weight loss were unsuccessful.
If you meet all stipulated conditions and submit the proper documentation, your claim for bariatric surgery under your health insurance plan should be payable.
Shilpa Arora is co-founder and COO at Insurance Samadhan.
