A weight loss surgery may cost several thousand dollars. Can medical insurance cover the cost of bariatric surgery?
Those who have been through the process know that getting a physician's approval for weight loss surgery (i.e., bariatric surgery) can be challenging. Because of the risk of complications and the rare chance of death, doctors generally only give the nod for the surgery for:
- Men who are about 100 pounds overweight with a body mass index (BMI) of 40 or more
- Women who are about 80 pounds overweight with a BMI of 40 or more or
- Men and women with a BMI between 35 and 39.9 and a serious health problem connected to their obesity.
Even if a person meets these candidacy requirements, they must have tried to lose weight by all other means possible, and often must undergo a psychological evaluation and receive nutrition counseling.
Once these hurdles have been overcome, there's the question of how you will pay for the costs associated with such a surgery. The medical cost of weight loss surgery can cost anywhere from $20,000 to $25,000, according to the Weight Control Information Network (WIN). The question on many people's minds is, "Will my insurance cover the cost of weight loss surgery?"
Unfortunately, the answer to that question is "It depends." Medical insurance coverage for weight loss surgery varies from provider to provider and even from state to state, the WIN notes. In general, your chance of having the procedure covered by your insurance depends on whether the procedure is proven to your insurance company to be:
- Medically necessary
- Specifically to correct an obesity-related illness (e.g., diabetes, severe sleep apnea, heart disease)
- Included in a list of covered weight loss surgery procedures
Examining Your Policy
To find out if your weight loss surgery is covered, the Obesity Action Coalition (OAC) recommends first reading your insurance policy carefully. If your health insurance is paid for by your employer, request a copy of the policy. If your medical insurance plan is self-insured by your employer, request a copy of your Summary Program Description (SPD).
These policies aren't always the easiest to understand, so you may want to familiarize yourself with medical insurance terminology and call the consumer services division of the department of insurance in your state to ask any questions you may have about insurance (that's their job).
You can also contact your insurance provider or benefits manager to get your questions answered, requesting that they send you a copy of the SPD with the portions relating to weight loss management highlighted, the OAC notes.
What to Look for
What you want to look for in these documents are any exclusions for morbid obesity management, the OAC explains. If you find that there is an exclusion for weight loss management, or specifically weight loss surgery, don't be discouraged. You can still contact your employer and ask them to add the benefit.
The OAC provides a sample letter you can use in your case to get the exclusion removed. You will also want to look for weight loss management inclusions, and carefully read the specifications necessary to have the procedure covered. Many times, the policy will only list medical coverage for certain types of weight loss surgery, limiting you to the types of bariatric surgery you can have.
What Your Insurance Might Require for Approval
Before the insurance plan agrees to cover your weight loss surgery it may require the following:
- Documentation of your past attempts to lose weight
- Documentation from your physician
- Weight/age requirements
- Using a specific medical provider
- Weight loss prior to surgery
After examining your policy, you may arrive at the conclusion that a weight loss procedure is fully or partially paid for by your insurance. On the other hand, you might also learn after getting a denial of coverage in writing that weight loss surgery is simply not covered by your insurance and that your employer is unwilling to add such coverage.
If this is the case, consider alternate means of paying for the procedure, such as through loans or financing plans with your physician. After all, it's hard to put a price on your life and health.
This is a guest post by Susan Wells. Susan is from Insurance Quotes (link deactivated by request), she writes on topics including health/car/life insurance, mortgage, real estate.