Insurance in bariatrics

Dr Ramen Goel, Director, Center of Bariatric & Metabolic Surgery, Wockhardt Hospitals bats for the inclusion of bariatric surgery under insurance coverage. He explains that contrary to popular belief it is more than just a cosmetic procedure and often is a life-saving surgery

Insurance for bariatric surgeries has been a controversial subject in our country for almost 20 years. Routinely almost all insurance companies (private or public) had been declining claims and pleas for payments (cashless or reimbursement) citing various reasons.

These refusals arise from a perception that obesity is a self inflicted problem and these self indulging individuals have no right to insurance largesse. Mostly reasons cited for rejection includes exclusion of obesity and related treatment in policy document and/ or bariatric surgery is a cosmetic procedure. None of these arbitrary pronouncements can withstand evidence-based scientific and legal scrutiny.

Is obesity the outcome of self-indulgence?

This populist perception exists even amongst few medico-professionals, even though enough scientific data exists to contrary. Let’s examine this basic issue in detail:

• World Health Organization (WHO) has declared obesity as a disease many years back.
• If indulgence is the only factor for weight gain how to justify large number of slim people eating larger portions while most of obese keep restricting their food intake and still not lose weight.
• Studies have shown that 92 per cent of overweight and 98 per cent of morbidly obese are likely to regain weight within three years of a serious weight loss attempt.
• Increasing role of intestinal hormones and gut bacteria is recognised as obesity-causing factors.
• Once we accept that obesity is an illness, it is easier to accept that obese person is not the cause but a victim of a disease over which he/ she has no control.

Obesity treatment in exclusion list of insurance policy

Once bariatric surgery gained acceptance, insurance companies started including obesity treatment in the exclusion list to avoid insurance claims. This was done without any scientific basis and long-term impact assessment on health of denied insured persons.

To provide legal status to exclusion list, these insurance companies got an amendment approved by the regulator. Though the regulator went through the drill of public hearing, not many responses were elicited. This was expected as, on one side lobby of well organised corporates was well represented, while on the other side individual insured persons remained poorly organised and unrepresented.

That policy exclusion is not the final word and has been established in various forums worldwide. The burden of proof, scientific and otherwise, should lie at the doorstep of insured companies and not an individual with limited options.

It is a situation where governments have risen to occasion ahead of private sector, whether it is Blue Shied in the US, NHS in the UK or even CGHS in India, which offers free bariatric surgery to its citizen or employees. (The central government’s health scheme has been offering reimbursement to patients for bariatric surgery since November 2013. In August 2014, 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.”) One can presume that insurance companies are united by financial interest and not the societal requirements.

A cosmetic surgery

An untruth spoken a thousand time cannot change the reality. Bariatric surgery is now accepted worldwide as treatment of multiple diseases like diabetes, high BP, sleep apnoea, obesity, PCOD etc.

The cosmetic reason for claim refusal is obviously a figment of imagination without any scientific/ medical background. The argument to refuse insurance cover include:

• Surgery does not involve any skin level manipulation. Bariatric surgery involves stomach/ intestinal re-routing with resultant hormonal/gut bacterial levels.
• Bariatric surgery is neither done by plastic/ cosmetic surgeons. This is done by gastrointestinal surgeons with entirely different qualifications.
• It is not considered a cosmetic surgery by insurance companies in any other country.

Even though most of the patients, due to better health and enhanced fitness levels may look better, that cannot be the reason to deny a life saving surgery to millions looking forward to better health.