IRDAI Offers Relief to Patients, Includes Bariatric Cover Under Health Insurance

Published On Nov 04, 2019 12:00 AM By Sakshi Aggarwal

As per the IRDAI’s (Insurance Regulatory and Development Authority of India) latest guidelines, bariatric or weight loss surgery will be included under health insurance cover with effect from 1st October 2019, offering some relief to morbidly obese people suffering from the disease. The inclusion will help lakhs of patients in India who cannot afford the treatment, that is spread 8-38% in rural areas and 15-30% in urban areas. As per the experts, “Barring a few, the surgery was not covered by many insurance firms as it was considered a cosmetic procedure rather than a life-saving treatment.”

But the gastroenterology surgeons do not want the insurers to add a lot of riders/extra clauses to save themselves from covering it. They also demand more clarity on the move.

Previously, the insurance regulatory authority regularized the list of exclusions in health insurance policies standardizing them for the insurers. The surgical treatment of obesity can only be excluded, as per those regulations, when-

a doctor has not advised the surgery, or
the patient is younger than 18 years, or
BMI of the patient is lesser than 40 or 35, or
the surgery has been conducted without clinical protocols.

The Secretary of the Obesity Surgery Society of India and Head of the Bariatric Surgery Department of Gem Hospital, Dr. Praveen Raj confirms that all the insurers in India will have to offer weight loss surgery cover to customers purchasing policies after 1st October 2019. For the existing policyholders, the benefit shall be added after 1st October 2020.

Dr. Raj shares, “Many insurance policies would mention any bariatric surgery as one of the exclusions or quote an archaic 1970 clause that calls weight loss surgery as a cosmetic procedure to get away from covering it. Now, it must be covered with the conditions mentioned in the guideline.”

As a matter of fact, cover for bariatric surgery has been provided by the Tamil Nadu Comprehensive Health Insurance Scheme since 2017 after they identified it as a life-saving treatment.

Dr. V G Mohan Prasath of VGM Hospitals shares, “Sometimes, a surgery or an endoscopic procedure is the only long-term weight loss solution for morbidly obese. A significant weight loss sometimes solves all other issues like heart problems, diabetes etc.”

Insurance agents share that they have not yet seen any insurer modify their policy wordings as per the new guidelines. An insurance broker who runs Link insurance shares, “United India Insurance has always covered bariatric surgery as long as the doctor certifies it to be a life-saving procedure, links it to a life-threatening ailment in the discharge summary. If there is a change in base condition, we have not been notified yet.”

The doctors are still unclear on the policy cover and want clarity on doubts like how much cost of the surgery will be covered under the insurance policy, whether it will ask for co-payment from the policyholders or not, or will it increase the premium amount for added benefits, if given, etc. However, health insurance premium varies on the basis of age and sum insured opted for. But, the doctors will only be satisfied when their doubts will be cleared.