Policy Exclusions

Policy Exclusions

male's hands writing on paperPolicy exclusions
The first step in reviewing your policy is to determine if your policy has an exclusion. Exclusions are medical services that are not covered by an individual’s insurance policy.

Example of Language for a Policy Exclusion: 

"Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including morbid obesity, or for the purpose of weight reduction, regardless of the existence of co-morbid conditions."

If your policy has an exclusion, you should contact your employer or your insurance provider and encourage them to add the benefit. Often times exclusions are a challenging case to plead, however, many people have been successful in encouraging their employer to add a benefit. Read this sample letter to help when contacting your employer to address exclusions. Learn more about the insurance appeal process if you face coverage denial from your plan.
 
Policy Inclusions
If your policy has an inclusion, this means that your policy covers bariatric surgery, under certain specifications.

Example of Language for a Policy Inclusion: 

"The plan will cover the surgical treatment of obesity if the patient is morbidly obese and if the surgery is performed by a practice certified by the Surgical Review Corporation (SRC)."

If your policy covers bariatric surgery, you’ll want to find out the requirements and make sure that you meet all requirements before moving forward.
 
Expenses Not Covered
If you don’t have a direct inclusion or exclusion, your policy could have some general exclusion language in one part of the plan, but specifically allow the surgery in another. Be sure to read your policy carefully to make sure you understand what is covered and what isn’t covered.

For instance, oftentimes policies have a section that lists “Expenses Not Covered.” While this section may seem to have exclusions, it also will provide language where there’s a covered benefit.

Here’s some sample language for “Expenses Not Covered:”

"The medical plan doesn’t cover the following expenses:

  • Any services or supplies not specifically listed under covered expenses.
  • Treatment or surgery for obesity, weight reduction or weight control unless the patient is severely obese and suffers from a related medical condition. Pre-treatment approval is necessary. The only procedures currently allowed are Vertical Banded Gastroplasty and Gastric Bypass (GBP)/Gastric Bypass with Roux-en-Y.
  • Severe/morbid obesity is defined as having a Body Mass Index (BMI) of 40 or greater or a BMI of 35 or greater with related medical conditions. Related medical conditions include, but will not be limited to: arthritis, diabetes, hypertension, liver and gallbladder disease, and cardiovascular disease.
  • Treatment or surgery to reverse any procedures performed to treat obesity, weight reduction or weight control unless medically necessary."

 
Covered Expenses
Other language to consider is listed as “Covered Expenses.” This language directly lists what’s a covered benefit and also provides more specifics about coverage specifics.

Here is sample language for “Covered Expenses:”

  • “Treatment or surgery for obesity weight reduction or weight control if the patient is severely obese and suffers from a related medical condition. Severe obesity is defined as having a Body Mass Index (BMI) of 40 or greater or a BMI of 35 or greater with related medical conditions. Related medical conditions include, but will not be limited to: arthritis, diabetes, hypertension, liver and gallbladder disease, and cardiovascular disease. The only procedures currently allowed are Laparoscopic Adjustable Gastric Banding (LAGB) and Gastric Bypass/Gastric Bypass with Roux-en-Y.
  • Medically necessary treatment or surgery to reverse procedures performed to treat obesity, weight reduction or weight control."

It’s important to take your time and read your policy carefully. Sometimes the wording may appear confusing or misleading. If you’re having a hard time reading your policy, the best thing to do is to contact your insurance provider or benefits manager and discuss your plan in more detail.

Learn more about your insurance and insurance pre-approval.


This content is adapted from The OAC (Obesity Action Coalition) Insurance Guide.