Bariatric and metabolic surgeries are fully covered by medical insurance w.e.f. 1st October 2020. Prior to this, most insurance companies had excluded obesity related treatment from insurance coverage. However through an *order dated 27th September 2019, Insurance Regulatory and Development Authority(IRDA) has mandated that bariatric surgery will be covered by all health insurance policies, subject to meeting following criterion –
BMI >= 40 without co-morbidities, or
BMI >= 35 with any of the following –
- Obesity-related cardiomyopathy
- Coronary heart disease
- Severe Sleep Apnea
- Uncontrolled Type 2 Diabetes
However, most insurance companies are likely to deny coverage for persons with individual policies under pre-existing disease clause. This clause does not usually apply if –
- policy is held for a minimum of 4 consecutive years
- person is covered under a corporate
- family floater policy
It is not surprising that most hospitals and even insurance functionaries are not fully conversant with bariatric related medical insurance.
Insurance Coverage Procedure
Once the person has decided to undergo surgery, our team provides a medical necessity letter justifying the surgery based on symptoms, test reports etc, for health related reasons or as a life-saving procedure. Usually the cashless claims are sent 7-10 days prior to hospitalisation. Within 24 hours of raising a claim, most insurance companies confirm the coverage. Most of the times initial approval is of less(25%-30%) amount, however, in most cases the final amount is significantly higher.
What if Cashless Claim is Denied
Initial denial of cashless request does not mean a denial of insurance coverage. Person can still raise a claim for reimbursement of treatment expenses and in most circumstances insurance companies reimburse the entire amount.
Persistent Denial Despite a Valid Claim
There are various government mandated platforms for seeking corrective actions. All insurance companies have a grievance officer** to resolve most issues. If the issue remains unresolved then the matter can be taken up by the Ombudsmen and most issues are resolved at this level. However, consumer redressal forums or civil courts can be approached if the issue is not resolved to person’s satisfaction.