BMI and Coverage for Obesity-Related Heart Surgeries

Vote: 1

BMI plays an important role in determining if your health insurance will cover heart surgeries due to obesity. The reason why the BMI becomes an important factor may be because insurance companies take note of this before issuing insurance plans, as obesity is associated with problems such as hypertension, heart disease, and heart failure. However, coverage would still depend on various factors.


Why BMI Matters in Health Insurance Assessment?


The body mass index (BMI) test is widely used to determine whether an individual is underweight, at a healthy weight, overweight, or obese. The insurance companies could employ this method to assess the general health risks of insured individuals.


Individuals who have a higher level of BMI may be more susceptible to heart problems. Therefore, insurers can do any of the following:



  • Require further medical examinations.

  • Impose waiting periods for some conditions.

  • Raise the insurance premium in certain situations.

  • Examine pre-existing health issues very thoroughly.


Ultimately, this will come down to what the insurer’s underwriting criteria are.


Are Obesity-Related Heart Surgeries Usually Covered?


Several health insurance plans can cover heart surgeries due to obesity if they are deemed medically necessary and covered by the health insurance plan.


The heart surgeries may include:



  • Coronary artery bypass grafting (CABG)

  • Angioplasty

  • Valve replacement

  • Heart failure surgery


But normally, the health insurer will verify the pre-existence of the illness prior to the purchase of the policy. If the illness falls under pre-existing conditions, then coverage will come after the waiting period.


When May Claims Become Complicated?


There could be certain cases that result in extra attention being given to the claim during its evaluation. Such cases can be the following:



  • Failure to mention obesity and/or any diseases connected with it at the time of purchasing a policy

  • Diabetes, hypertension, or sleep apnoea

  • Need for surgery immediately after purchasing a policy

  • A policy that includes exclusion due to treatments for obesity management


Some insurance companies can distinguish between obesity treatment per se and heart problems as a result of being overweight.


Thus, bariatric surgery aimed at weight loss could be considered separately from a medically required cardiac surgery.


Documents Generally Required During Claims


For obesity-related heart surgery claims, insurers may ask for:



  • Doctor’s consultation records

  • Diagnostic reports

  • BMI and medical history records

  • Hospital admission documents

  • Surgery recommendation from the treating specialist

  • Discharge summary and bills


Offering accurate and complete medical information when purchasing an insurance policy may be helpful in minimising potential future disputes.


Things to Check in Your Health Insurance Policy


All health insurance plans do not categorically provide for the coverage of diseases arising out of obesity. Some plans might even have an exclusion clause related to obesity. Before selecting any plan, it will be prudent to verify the following:



  • Waiting period in case of pre-existing illnesses

  • Coverage of heart surgeries

  • Exclusions related to obesity

  • The co-pay provision in the insurance policy

  • The medical underwriting process of the insurance company


The coverage and claim status depend on your insurance policy and medical underwriting.