Bariatric
surgery: Will your insurer pay?
Opinion is divided on
whether the surgery is cosmetic in nature or not. Most insurers say it is
Vivina Vishwanathan
Bariatric surgery, which is
commonly referred to as weight loss surgery, is a treatment that most insurers
do not cover because insurance experts, insurers and doctors differ on the
surgery’s classification. Many lifestyle surgeries have become a norm rather
than an exception. Here is an overview of bariatric surgery’s significance in
insurance. Heavy weight “The term bariatric surgery was derived from the word
‘baros’, which means weight loss. The surgery is now known to normalize
intestinal hormones and metabolism function. It also normalizes body balance,
weight regulation, sugar and insulin regulation as well as metabolic syndrome.
Hence, it is now known as metabolic and bariatric surgery. There are two
types—restrictive (restricts food intake) and malabsorptive (absorbs fat),”
said Dr Shashank Shah, head of department for metabolic and bariatric surgery,
Fortis Hospital and S.L. Raheja Hospital, Mumbai, and president of Obesity and
Metabolic Surgery Society of India (OSSI). In India, the number of bariatric
surgeries has seen a steady increase—from about 3,500 in 2011 to over 10,000 in
2013, according to Metabolic Surgery Foundation of India. Such a surgery normally
costs between Rs.1 lakh and Rs.5 lakh. Bariatric surgery is one of the ways to
tackle diseases whose root cause is obesity. Obesity is calculated based on a
person’s body mass index (BMI), which is a weight-height ratio. In India, a
person with a BMI of over 32.5 is considered morbidly obese. According to
bariatric surgeons, 11% of India’s population is either overweight or obese.
“Obesity leads to many medical conditions such as diabetes, high blood
pressure, lack of sexual desire, metabolic linkage to thyroid—all these lead to
cardiovascular diseases,” said Dr Jayashree Todkar, bariatric surgeon and
director of bariatric department of Dr L.H. Hiranandani Hospital, Mumbai,
adding that among Indians, diabetes is the most common disease caused by obesity.
Grey area Many Indians may be opting for bariatric surgery—Todkar, for
instance, has treated over 10,000 obese patients since 2004, of whom 1,800
underwent this surgery—but insurance for it is a grey area. Firstly, there is a
conflict in opinion on how to view bariatric surgery—cosmetic or non-cosmetic.
“The government has said that obesity is a disease and bariatric surgery is a
non-cosmetic surgery,” said Dr. Ramen Goel, senior metabolic and bariatric
surgeon, Hinduja Healthcare at Khar, Mumbai. The central government’s health
scheme has been offering reimbursement to patients for bariatric surgery since
November 2013. On 21 August, the Medical Council of India stated in a letter
that “bariatric surgery is gastrointestinal non-cosmetic surgery under the
rubric of surgical gastroenterology and not plastic surgery”. However,
insurance experts don’t agree. They say that insurers consider it as cosmetic
surgery. “Chances of getting an insurance claim approved are very low. If you
take a look at the bariatric surgery cases in India, almost 95% of them are
cosmetic in nature. So, generally, insurers refuse to accept a claim for such a
surgery,” said Kapil Mehta, managing director, SecureNow Insurance Broker Pvt.
Ltd. Another reason why the surgery is usually not covered is that many
insurers exclude any surgery related to obesity. Obesity is not covered; the
only exception is if the situation is life threatening. “There was one
gentleman who came to me five years ago. He weighed 120 kg and needed a
surgery. Since the insurer denied him mediclaim on the grounds that it was for
weight loss, he could not undergo the surgery. Five years later, he was back,
but now he weighed 180 kg, had full grown diabetes and a breathing problem.
This time, he got corporate insurance. Why should the patient wait for the
disease to worsen when it can be cured at an earlier stage?” said Todkar. There
are a few insurers that provide cover. “We provide cover for bariatric surgery
if it is done for medical purposes. We do a thorough due diligence and if
proved that it is not for cosmetic reasons, we cover the surgery,” said Sanjay
Datta, chief-underwriting and claims, ICICI Lombard General Insurance Co. Ltd.
In the past 2-3 years, insurers have been providing cover, but under certain clauses.
Shalini Jadhav, a 32-year-old homemaker in Mumbai has insurance cover for
bariatric surgery. At 89.6 kg and BMI of 39.5, she was suffering from back
pain, lethargy, tiredness and breathlessness while walking and climbing. “I had
vitamin B12 and D3 deficiency, dyslipidemia, hyperinsulinemia, low calcium
level and fatty liver. I was suggested metabolic and bariatric surgery and
underwent the surgery in February this year. My insurer covered it,” said
Jadhav. The insurance company was ICICI Prudential Life Insurance Co. Ltd, and
it considered Jadhav’s surgery to be done in a life threatening situation. Last
year, claims from four of Todkar’s patients were accepted. However, she points
out that there have been instances where despite a genuine case for surgery,
insurers rejected the claims. “Generally, no insurer provides a cover for
bariatric surgery, as it’s treated as a cosmetic surgery,” said Yashish Dahiya,
chief executive officer and co-founder, PolicyBazaar.com. “There are a couple
of companies, including Cigna TTK and New India Assurance, that might cover the
surgery, but the coverage would be taken into consideration only if it’s a life
threatening situation. This, too, only if the insured member is healthy and
doesn’t have a high BMI during the proposal of the policy,” he added. So, it is
also your responsibility to prove that the surgery was done for a medical
condition to get a claim. “Normally, if the surgery is done for medical
purposes and is prescribed by the doctor, then you can get mediclaim for the
surgery. Insurers will have to abide by it. However, if the sole purpose of the
surgery is weight loss, then you can’t get a claim,” said Rahul Aggarwal, chief
executive officer, Optima Insurance Brokers Pvt. Ltd. What should you do If you
specifically need this cover, your options are limited as only a few companies
offer it. Check for specifications before buying the health insurance policy.
Also, if you indeed need a bariatric surgery, check with the insurer before
agreeing to it.
Read more at: http://www.livemint.com/Money/dHhqdKqE3aVH6oBTV3hjFJ/Only-a-few-insurers-cover-bariatric-surgery.html?utm_source=copy
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