Health Insurance That Covers Bariatric Surgery
Imagine this: you’ve been on countless diets and tried every workout plan, yet your weight remains the same. 😞
In such cases, obesity can lead to serious issues like diabetes, heart disease, and joint pain. Hence, doctors may suggest undergoing bariatric surgery (weight-loss surgery). But here’s the big question: will your health insurance cover it?
The good news is that many insurance providers in India now offer coverage for bariatric surgery, but there are conditions and fine print you need to know. In this article, you will learn what types of bariatric surgery are, why they are important, and when you are eligible for them.
What is Bariatric Surgery?
In simple words, weight-loss techniques involving surgery are called Bariatric Surgery. These operations aim to alter the digestive system to help with weight loss. It is a safe process that can assist patients in losing weight and eliminating extra pounds.
While some operations may limit the quantity of nutrients your body can absorb, others may limit the amount of food you consume. These procedures are usually only recommended when diet and exercise have not produced the desired effects.
People who are obese and have major weight-related health problems, such as cardiovascular disease, type-2 diabetes, high blood pressure, etc., are advised to have this operation.
Does Health Insurance Cover Bariatric Surgery?
Yes, bariatric surgery is now covered by health insurance, provided you meet the standard criteria. According to the 2019 Insurance Regulatory and Development Authority of India, most health insurance companies cover bariatric surgery.
To guarantee coverage, reviewing the terms and conditions of the insurance that covers bariatric surgery is advisable. Bariatric surgery is only covered by health insurance policies if a patient satisfies specific requirements.
Criteria for Availing Coverage for Bariatric Surgery Under Health Insurance
- You have to be at least 18 years of age.
- The patient's body mass index (BMI) needs to be 40 or over.
- A patient is eligible for insurance coverage if their BMI falls between 35 and 40 and they have concomitant conditions like diabetes, stroke, or heart disease.
- A trained physician must recommend the operation, which must be medically essential.
- The patient must present pertinent test results and the physician's prescription.
Why Having Health Insurance for Bariatric Surgery is Important?
Obesity has become a significant global health concern, leading to an increased prevalence of various chronic diseases. Excess body fat is strongly associated with heightened risks of conditions such as type 2 diabetes, heart disease, certain cancers, and stroke.
Given such serious health conditions, here is why having health insurance for bariatric surgery is important:
Bariatric surgery can be expensive, with costs often exceeding lakhs of rupees. Health insurance coverage makes these life-changing procedures financially accessible to a broader population.
Insurance coverage for bariatric surgery promotes proactive health management, enabling individuals to address obesity before it leads to more severe health issues.
While the initial cost of bariatric surgery is significant, it often leads to reduced long-term healthcare expenses by mitigating obesity-related conditions.
Types of Bariatric Surgery Covered in Health Insurance
Bariatric surgery, commonly referred to as weight loss surgery, encompasses various types that are designed to help individuals struggling with obesity achieve weight loss. Health insurance companies offer coverage for such specific types of bariatric surgeries, which include:
Note: Insurance coverage for these procedures varies from policy to policy. Read your policy document before purchasing a health insurance policy to confirm coverage for Bariatric surgery.
Exclusions Under Health Insurance That Covers Bariatric Surgery
While many health insurance plans now cover bariatric surgery, there are several exclusions and limitations that policyholders should be aware of. Here are some common exclusions:
Claims cannot be made during a plan's initial waiting period, which may last about 30 days. If obesity or related conditions are classified as pre-existing diseases, the policy might impose a waiting period of 1-3 years before covering the surgery.
If the surgery is performed purely for aesthetic reasons and not due to medical necessity (e.g., no severe obesity-related health risks), it is usually not covered by a health insurance plan.
Certain drugs and conditions like binge eating disorder, severe depression, or anxiety-related overeating may contribute to obesity. In such cases, some insurers might not cover bariatric surgery.
What is the Cost of Bariatric Surgery in India?
Bariatric surgery in India is expected to cost between 1 lakh and 5 lakhs(1). The cost varies depending on several factors, such as:
- The medical condition
- The city of operation
- The hospital chosen
- Post-surgery complications
- Age of patient
If someone has a medical problem that could arise before or after the surgery for connected or unrelated reasons, it could increase the cost of the surgery. Therefore, seeking insurance for weight loss surgery is a good idea before dealing with such medical concerns.
Does Bariatric Surgery Insurance Have a Waiting Period?
Yes, bariatric surgery has a waiting period for health insurance. It is typically 2 years, depending on your insurer and policy terms. During this time, any expenses related to bariatric surgery are not covered.
Additionally, bariatric surgery is usually covered only if it is medically necessary, such as in cases of severe obesity, with related health complications like diabetes or hypertension. It’s important to review your policy details to understand the exact waiting period and eligibility criteria for bariatric surgery coverage.
Who Should Get Health Insurance That Covers Bariatric Surgery?
Bariatric surgery is not for everyone struggling with weight issues; it is a medical intervention designed for individuals with severe obesity who have been unable to achieve sustainable weight loss through diet, exercise or other medical treatments.
Here are the key criteria for individuals who may need bariatric surgery:
A BMI of 40 or higher indicates severe obesity and makes a person an ideal candidate. Surgery may be recommended if the individual also suffers from conditions like diabetes, hypertension, or sleep apnea.
Bariatric surgery can help manage and even reverse several life-threatening conditions, including Type 2 Diabetes, Heart Disease & Hypertension, Sleep Apnea, etc.
Candidates for bariatric surgery must have attempted and failed weight loss programmes, diet and exercise regimens, medications, etc.
What are the Risks of Delaying Bariatric Surgery?
The rising health problem of obesity impacts the majority of Indians. The World Health Organisation (WHO) reports that throughout the past forty years, the number of medical cases of obesity has tripled.
If the obese condition is not managed, one may develop other health problems such as:
- Obesity can result in Type 2 diabetes.
- Being overweight can lead to hypertension.
- Obesity can lead to poor heart health.
- If left untreated, obesity may raise blood pressure.
- Weight gain may raise cholesterol levels.
- Obesity can also result in sleeping problems.
FAQs About Health Insurance That Covers Bariatric Surgery
Will my health insurance cover bariatric surgery?
According to IRDAI, bariatric surgery is covered by health insurance; however, you must meet some criteria and eligibility requirements.
What are the requirements to be eligible for bariatric surgery coverage?
Here are the requirements to be eligible for bariatric surgery:
- You must have a BMI of 40 or more and be at least 18 years old.
- You need to have the results of diagnostic tests and a doctor's prescription stating that surgery is medically essential.
- You can still obtain coverage if you have comorbid conditions like diabetes, stroke, or hypertension and your BMI is between 35 and 40.
How can I find out whether my insurance covers bariatric surgery?
When purchasing health insurance, you must carefully study the policy document's features and limitations. If unsure, consult the agent or insurance provider if your insurer covers bariatric surgery.
Does bariatric surgery have a waiting period?
Yes, most health insurance plans require a 30-day initial waiting time for bariatric surgery, and if you already have a medical condition, you must wait an additional 1-2 years to obtain coverage.
For whom is bariatric surgery necessary?
Patients who have been clinically identified as Class III obese may be candidates for bariatric surgery. There are two situations under which your physician will suggest bariatric surgery:
- You have a body mass index of 40 or more. This amounts to 100 pounds of excess weight.
- You have one or more severe medical conditions, such as hypertension, fatty liver, and cardiovascular disease, and your body mass index is 35 or higher.
If I transfer my health insurance, would I still be covered for bariatric surgery?
Yes, if you switch to a new plan, you will be covered for bariatric surgery. However, this is only possible if the new plan also provides financial assistance for bariatric surgery. If appropriate, the new plan will impose a new waiting period on you.
Does receiving health insurance coverage for bariatric surgeries need any additional payments?
The base plan of certain health insurance policies may not cover bariatric surgeries. Hence, you must opt for it as a slightly higher-cost add-on. Therefore, before purchasing a plan, it is crucial to confirm this with your insurer.
What is the appropriate amount of insurance needed to control bariatric surgery costs?
You could require an amount insured of at least Rs. 5 lakhs because bariatric surgeries might cost anywhere from Rs. 2.5 lakhs to Rs. 5 lakhs. However, you also need to account for the price of any post-surgery assistance you might need, such as dietary counselling from a nutritionist and other fees associated with changing your lifestyle.
What happens to my bariatric surgery benefit if I am porting my health insurer?
If you are porting an existing policy from some other general or health insurance company or if you are adding this cover while renewing your health policy, a fresh waiting period will be applied for bariatric surgery benefit.
Are there any exclusions or limitations for bariatric surgery coverage?
Yes, some plans may exclude certain types of bariatric surgery or have limitations on coverage. For example, some insurers may not cover procedures considered experimental or cosmetic, and some might exclude a certain procedure. Hence, it is always important to read your policy document before purchasing.
Does Digit cover bariatric surgery?
Yes, Digit covers certain bariatric surgeries if the specific eligibility criteria are met. Digit provides bariatric surgery coverage in all policies up to the sum insured. However, it merely depends on the mutual agreement of the insurer and the insuree.
What should I do if my insurance denies coverage for bariatric surgery?
If your insurance denies coverage, you can appeal the decision. This often involves providing additional documentation from your healthcare provider to demonstrate medical necessity. You may also explore other options like financing plans or grants.
Are there additional costs associated with bariatric surgery, even if covered by insurance?
Yes, there may be additional costs such as co-pays, deductibles, and coinsurance. Some services related to the surgery, like nutritional counselling or follow-up care, might also incur extra costs.
What are the documents required for claiming bariatric surgery?
Most insurers require documentation of medical necessity, including a Body Mass Index (BMI), documented obesity-related health conditions and evidence of prior unsuccessful weight loss attempts.
Is Bariatric Surgery the Most Effective Method for Losing Weight?
Unfortunately, bariatric surgery is not the most effective method for losing weight; it depends more on lifestyle. The procedure's effectiveness greatly depends on your dedication to making regular lifestyle adjustments, even though it might be a useful tool.