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

Updated On Sep 05, 2023

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. 

Benefits of Including Bariatric Cover

  • Advantages for the Patients:
    • Improved access to bariatric treatment, addressing obesity-related health concerns.
    • Enhanced overall well-being and quality of life for individuals struggling with obesity.
  • Reduced Out-of-Pocket Expenses:
    • Decreased the financial burden on policyholders due to coverage of bariatric procedures.
    • Relief from large medical bills, ensuring more affordable healthcare for policyholders.

This decision by IRDAI marks a pivotal shift in health insurance dynamics, benefitting both patients and the healthcare system. It makes it easier to access vital bariatric treatments, previously inaccessible to many due to financial constraints. The inclusion of bariatric coverage effectively addresses the rising obesity epidemic and its associated health risks. Moreover, it sets a model for insurance companies to adopt a more comprehensive and compassionate approach, potentially leading to broader coverage for other specialised treatments in the future. Ultimately, this move reflects a positive side towards a more inclusive and patient-centric healthcare landscape.

Understanding Bariatric Surgery

  • Bariatric surgery is a specialised medical procedure designed to treat obesity and its associated health complications. Its primary purpose is to help individuals achieve significant weight loss, thereby improving their overall health and reducing the risk of obesity-related diseases. This surgical intervention involves altering the digestive system to limit food intake, leading to weight reduction.
  • In recent years, the prevalence of obesity has reached alarming levels, contributing to various health issues such as diabetes, heart disease, and joint problems. This global health concern has prompted a critical need for effective interventions. Bariatric surgery has emerged as a key solution to address this crisis. It offers a comprehensive approach to weight loss that often proves more successful than traditional methods like diet and exercise alone.
  • The effectiveness of bariatric surgery lies in its ability to deliver substantial and sustainable weight loss, which in turn reduces obesity-related health problems. By altering the gastrointestinal anatomy, these procedures lead to reduced calorie intake and improved metabolism. Patients often experience significant improvements in blood sugar, cholesterol, and blood pressure, resulting in a marked reduction in the risk of chronic diseases.
  • Including bariatric surgery in health insurance coverage recognises its healing value in fighting the obesity epidemic and its associated health complications. This inclusion not only enhances individuals' access to life-changing treatment but also acknowledges the evolving medical landscape's emphasis on comprehensive and proactive healthcare strategies.

Steps for Availing Bariatric Cover in Health Insurance

To start the process:

  • Consultation with a Medical Professional: Seek advice from a medical practitioner to determine if bariatric surgery is a suitable option for your condition.
  • Policy Review: A thorough review of your health insurance policy to understand the coverage for bariatric procedures.

Documenting the procedures to be done:

  • Medical Documentation: Gather medical records that establish the necessity of bariatric surgery for your health condition.
  • Consultation Reports: Obtain detailed consultation reports from healthcare providers explaining the procedure's medical rationale.
  • Pre-authorisation: Contact your insurance provider to obtain pre-authorisation for the surgery. This ensures that the procedure will be covered under your policy.

Meeting the medical requirements:

  • Medical Necessity: Ensure the bariatric surgery is regarded medically necessary as per your policy terms. Some policies might require specific BMI or health condition criteria.
  • In-Network Providers: Opt for healthcare facilities and surgeons that are part of your insurance network to streamline the claims process.
  • Procedure Approval: Once pre-authorisation is received and medical criteria are met, the insurance provider will approve the procedure.

Navigating the claim process:

  • Clear Communication: Maintain open communication with your healthcare provider and insurance company to ensure a smooth process.
  • Document Everything: Keep copies of all documents submitted and received throughout the process for reference.
  • Claim Submission: Submit all required documents, including pre-authorisation papers, medical records, and consultation reports, to the insurance company for claim processing.
  • Follow-Up: Regularly follow up with the insurance company to track the progress of your claim and address any potential issues.

Conclusion

The inclusion of bariatric cover within health insurance marks a progressive shift. This decision addresses the pressing concern of obesity-related health issues and reflects a commitment to entire healthcare. By providing better treatment access and reducing financial burdens, this move emphasises a more inclusive and compassionate approach. It sets an official action for healthcare that values comprehensive well-being, ultimately offering relief and hope to patients seeking effective solutions.

FAQs

Q. What is the latest development by IRDAI regarding health insurance coverage? 
A. IRDAI has included bariatric or weight loss surgery under health insurance coverage since October 1, 2019. This move aims to provide relief to individuals suffering from morbid obesity and offer access to treatment that was previously not covered by many insurance firms.

Q. Why was bariatric surgery excluded from many insurance policies in the past? 
A. Previously, bariatric surgery was often considered a cosmetic procedure rather than a life-saving treatment. This perception led to its exclusion from many insurance policies.

Q. What are the conditions that need to be met for bariatric surgery coverage to be excluded?
A. As per the regulations set by IRDAI, bariatric surgery can only be excluded if a doctor has not advised the surgery, the patient is younger than 18 years, the patient's BMI is below 40 or 35, or if the surgery has been conducted without following clinical protocols.

Q. When will the inclusion of bariatric surgery coverage come into effect for policyholders? 
A. Insurance providers are mandated to offer bariatric surgery coverage for customers purchasing the policies after October 1, 2019. The coverage will apply for existing policyholders after October 1, 2020.

Q. Are there any concerns from medical professionals about this inclusion? 
A. Yes, some medical professionals are seeking more clarity on the coverage. They are uncertain about factors such as the extent of coverage, the possibility of co-payment, and potential premium increases due to added benefits. They are awaiting clarification to address these doubts effectively.

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