IRDAI Finally Approves Bariatric and Metabolic Surgery Under Insurance Claims from October 1, 2019

IRDA understands you are one step closer to selecting a surgery for your growing obesity. The insurance regulatory authority has taken this important step in your transformation path and one not to be taken lightly. 

In order to enhance the health insurance coverage that is granted at the time of issuing a policy it is considered important to rationalise the exclusions that were prevalent in the health insurance policy contracts issued by all Insurance companies. To enable the individuals who are suffering with obesity get the health insurance coverage, it is essential to let the Insurance companies accept such health risks.

IRDA is aware that the health insurance industry in India is keeping pace with the advancements in technologies that are taking place in the healthcare industry. In order to have a holistic and structured approach in devising appropriate guidelines, IRDAI, constituted a Working Group to review the practices and make appropriate recommendations. 

One of the important suggestion from this Working Group is listed in Chapter III, point “F” of this circular. This explains, while every insurance company may want to enhance the availability of health insurance coverage to bariatric patients, the insurance policy contracts may allow for expenses related to the surgical treatment of obesity that does met the below conditions:

1. Surgery conducted is upon the advice of a Doctor
2. The surgery/procedure conducted is supported by clinical protocols
3. The member is 18 years of age or older and
4. Body Mass Index (BMI):
   1. greater than or equal to 40 or
   2. greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight loss:
      1. Obesity-related cardiomyopathy
      2. Coronary heart disease
      3. Severe Sleep Apnea
      4. Uncontrolled Type2 Diabetes

These provisions will be applicable in all health insurance products (Other than Personal Accident, Domestic and Overseas Travel Policies) (both Individual and Group). All existing health insurance products that are not in compliance with these Guidelines will not be offered and promoted from 01stOctober, 2020 onwards.

Source: https://www.irdai.gov.in/ADMINCMS/cms/Search_Results.aspx (Chapter III, point “F”)

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