Do Health Insurance Cover Weight Loss or Bariatric Surgery?

Q: A health insurance company will not cover bariatric surgical procedures in the following cases:

1. Surgery is done due to cosmetic/aesthetic reasons 2. Pre-existing conditions related to claims 3. Claim during the initial waiting period of 30 days for the health insurance policy will be rejected. 4. Obesity due to Drugs Psychiatric and eating disorders Untreated hormonal imbalance

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Dieting and exercise can be challenging for people who are overweight and have a higher BMI. There are cases of obesity where doctors recommend bariatric surgery to avoid any health issues in the future.

Bariatric surgery is a surgical procedure that helps lose weight by making changes to the digestive system. It is a good option for those patients who meet the medical criteria and for whom, diet and workout are not effective.

Does Health Insurance Cover Bariatric Surgery?

In health insurance policies bariatric surgery was a standard exclusion. However, after the 2019 Guidelines of the Insurance Regulatory and Development Authority of India (IRDAI), bariatric or weight loss surgery is included in Health Insurance policies.

However, expenses related to bariatric surgery for obesity will be included when the following conditions are fulfilled:

The doctor advises the surgery
The insured patient must be at least 18 years old
Body Mass Index (BMI) must be:

Greater than or equal to 40 or
Greater than or equal to 35 with any of the following co-morbidities:

Sleep Apnea
Type 2 Diabetes (uncontrolled)
Coronary heart disease
Obesity-related cardiomyopathy

Point to be Noted:

A health insurance company will not cover bariatric surgical procedures in the following cases:

Surgery is done due to cosmetic/aesthetic reasons
Pre-existing conditions related to claims
Claim during the initial waiting period of 30 days for the health insurance policy will be rejected.
Obesity due to

Drugs
Psychiatric and eating disorders
Untreated hormonal imbalance

Read How Insurance Samadhan Resolved an Insurance Claim Rejection Case Related to Bariatric Surgery

Manoj’s wife was suffering from Morbid Obesity with Obstructive Sleep Apnoea and bilateral knee pain for a long time. Her treating doctor advised her to lose weight. She tried a lot and reduced some weight. However, she gained it again. Her BMI came out to be more than 40. Her doctor recommended bariatric surgery that would help her lose weight. She was admitted to the hospital and had her surgery.

Also Read: Why Maintaining Accurate Records is Essential to Expedite the Insurance Claim?

Manoj informed about the surgery to TPA. He submitted the claim form along with the necessary documents for reimbursement. However, her claim was rejected by TPA stating that the surgery is not covered under the terms and conditions of the policy.

The couple became worried as the expenses were quite high. Manoj tried multiple times to explain his case to the TPA but failed to get reimbursed. Then he approached Insurance Samadhan. We investigated the case and found it to be genuine. We guided him and helped him get his reimbursement.

If you have any problem related to your insurance, you can approach Insurance Samadhan. We have resolved 14,500+ insurance-related complaints. Contact us to get samadhan for your insurance-related issues, we’ll be happy to help you.