Legal Judgements & Successful Insurance Claims

Umbrella opens to include Bariatric surgeries
Umesh Isalkar,TN

A bariatric surgery is no longer considered a cosmetic weight loss procedure but a life-saving intervention for morbidly obese patients battling with medical conditions either caused by or related to obesity.

The wife of a Union government employee became the first person in the city to be reimbursed for a bariatric surgery under the Central Government Health Scheme (CGHS). Besides, a privately employed professional also received a full cashless cover from a public sector insurance company a few days ago. 

Thirty-four-year-old Manisha (name changed) weighed 99 kg at the time of surgery. She had a host of medical conditions like breathlessness even at slightest physical activity, loud snoring, pain in the knees, irregular menstruation, fatty liver disease, mood swings and episodes of depression. Besides, she was battling hormonal imbalances due to which she was unable to conceive. Manisha had attempted non-surgical weight loss programmes in the past but to no avail. She lost 5 kg in a week's time after the surgery. Her mood swings have gone down and her physical activity has increased. "I feel better, lighter and energetic. I have started going on regular walks which was not possible before the surgery," Manisha said.

Initially, Manisha and her husband faced hassles in availing of benefits under the CGHS. "We have a copy of the Union government's recently issued circular with specific guidelines to this effect. We had to get an approval from a government hospital for the surgery, which asked us to carry out some investigations and gave us permission after seeing the reports," Manisha said.

K M Vishwas, additional director of CGHS, confirmed that Manisha's claim approval for benefit under CGHS was indeed the first case of its kind. "The Centre's circular fixes criteria for availing of the benefit under CGHS. The benefit is extended on a case-to-case basis," Vishwas said. The circular was issued in November 2013.

The selection criterion is very stringent and only those with co-morbid conditions like uncontrolled diabetes, hypertension, osteoarthritis or back pain can avail of the benefit. "Those with no associated ailments are not considered for the cover," said another CGHS official.

Forty-two-year-old Anish (name changed), a resident of NIBM Road, was treated for an abdominal tumour in 2009. He weighed 120 kg. Anish continued to put on weight even after the treatment. He approached doctors again in April 2014 and was advised a surgery.

Anish presented with complaints like swollen legs, severe breathlessness even at rest, snoring to extreme extent, sleep apnea, severe backache restricting his physical movements. He was unable to sit properly and walk a few extra steps. On investigations, he was found to be pre-diabetic needing appropriate diet control which was a challenging situation in his case.

Anish's BMI was 62 and was operated  on May 23 and discharged after three days. All his surgical expenses amounting to Rs 3.51 lakh were sanctioned by the New India Assurance Company. "It was a full cashless sanction," he said.

Anish has lost 30 kg in 15 days after the surgery. "I can sit and get up with ease and can walk considerable distance now. I am feeling lighter and more energetic," he said.

A person with a BMI of 30 and above is called obese. And those who have BMI of 40 and above are considered morbidly obese. "But in India, a person having a BMI of 37.5 and above is considered mordbidly obese as Indian population is found at risk of developing complications at the BMI of 37.5 and above. A person with BMI of less than 37 but with a host of other medical conditions can be advised to undergo bariatric surgery," said the surgeon, who treated Manisha and Anish.

 JASBIR KAUR Family Health  Plan TPA Claim -- View Mail

PRADEEP KUMAR HIRAWAT Insurance Claim -- View Mail

1. Bariatric ( Weight-loss Surgery)

Download File 1
Download File 3 : ( Ombudsman Ruling);
Download File 5 : (CGHS Govt of India Approval); Jasbir kaur 1 & 2; Apollo Chennai Cashless; Kerala SG Ombudsman; Vimla;

2. Diabetes Surgery

Download File 2 |
Download File 4 | : Dipankar Biswas Cashless & Insurance Email;



Bariatric operations get insurance shield

TNN | Mar 9, 2014, 03.31AM IST

Bariatric Surgery in Hyderabad title=

Bariatric surgeries were initially recommended for morbidly obese people, but in the last five years they are being offered to diabetic patients who are not obese.

MUMBAI: After years of looking at bariatric surgery as a cosmetic weight-loss procedure, Indianmedical insurance companies seem to have changed their minds. They have begun reimbursing some patients who have undergone bariatric surgery — now classified as a metabolic operation that involves cutting or bypassing parts of the stomach and intestine — to control or even get rid of their diabetes.

K Satishan (name changed), a 62-year-old businessman from Pune who was a diabetic patient for 15 years, got Rs 5 lakh reimbursement from Bajaj Allianz after he and his doctors explained that the surgery was literally his last option. "I was on high doses of insulin and oral medication and yet my sugar levels were four times the normal," he said.

While bariatric surgeries essentially lead to weight loss, a welcome side-effect has been the control of diabetes and hypertension. These surgeries were initially recommended for morbidly obese people, but in the last five years they are being offered to diabetic patients who are not obese. "Satishan was 90-odd kg. His weight wasn't as much a problem as his diabetes and hypertension," said Shashank Shah, a metabolic surgeon from Pune who operated on the businessman.

Another of Shah's patients, Somnath Holkar, got reimbursed from United India Insurance after six months of explanations. "I underwent the operation seven months ago and got the reimbursement last month."

Satishan recalled how he took his blood sugar and pressure readings everyday and showed the three-month chart to the insurance firm. "I don't take any diabetic pills now. The company even interviewed my doctor before agreeing," he said. He was operated in May 2013 and got his reimbursement recently.

Incidentally, the Central Government Health Scheme (CGHS) in December declared it would fund bariatric surgeries for current and former government employees. Ramen Goel, a metabolic surgeon from Mumbai, said if CGHS can fund surgeries for its employees, insurance firms should take the cue.

Sanjay Datta from ICICI Lombard said medical insurance companies have begun reimbursing bariatric and metabolic surgeries on a case-to-case basis.

Metabolic surgery for diabetes is still in trial stage, with many medical associations admitting that long-term studies are needed before accepting surgery as a cure for diabetes. Hence, many patients who have undergone metabolic surgeries in the last five years have got reimbursements only after moving consumer courts.

Doctors hope insurance payoffs will become the trend, especially because India has over 60 million diabetes patients. Shah, who has operated on 800 patients for diabetes, said many of them are now approaching insurance firms. "A patient who is scheduled to undergo surgery in Fortis Hospital in Mulund is awaiting his insurance company's decision," he added.

Medical insurance firms have begun reimbursing some patients who have undergone bariatric surgery to control or even get rid of their diabetes.