Can a High BMI Lead to Rejection of Health Insurance Claims?

Does BMI Influence Health Insurance Eligibility?

Health issues are an inevitable part of life. BMI is a basic screening tool to gauge your weight for your height. Being a predictor of body fat percentage, high BMI levels not only influence the rejection of health insurance claims but also determine the rate of premiums and coverage options.

However, before delving deep into answering the question, it is important to know that a high BMI does not automatically lead to the rejection of health insurance claims. Various factors, such as pre-existing conditions and policy conditions, impact the claim approval and rejection process.

Also read  BMI Chart Explained

Impact of BMI on Health Insurance Claims

The rejection of health insurance claims depending on high BMI hardly happens. However, there are certain circumstances where it can be true:  

● Policy Limitations or Exclusion Clauses:

Many health insurance policies come with a set of exclusion clauses. These limitations are based on coverage for certain conditions. Most conditions are closely linked to obesity, such as weight-related surgeries, bariatric procedures, or treatment for obesity-related diseases.

If an individual with a high BMI seeks any obesity-related treatment, then the insurer has the right to refuse the claim if the same is mentioned in the specifics of the policy.

As per IRDAI, if a policyholder has a BMI of 35 along with other comorbid conditions such as coronary heart disease, uncontrolled Type-2 diabetes, severe sleep apnea, and obesity-related cardiomyopathy, then they will be eligible for coverage. However, this coverage will only be granted after less invasive weight loss methods have proven ineffective.

● Non-Disclosure or Misrepresentation:

If a policyholder has a high BMI and is unable to provide relevant health information when applying for coverage, in cases of weight-related health issues or a recent diagnosis related to obesity, the insurer can reject the claim.

Health insurance policies typically require accurate disclosures of health status. Non-disclosure of information or misinterpretation creates space for denial. This is applicable even if the condition is not at all related to obesity.   

Also read How to Find BMI

● Claim Approval for Obesity-Related Conditions:

If a policyholder files a claim for an obesity-related medical condition, the insurer will investigate the individual’s BMI to determine the relevance of the claim. While it is illegal to reject the claim outright because a person has a high BMI, insurance companies will scrutinise the claim mindfully. This will allow them to find grounds for disease aggravation due to the individual’s weight. In such cases, insurers might delay or reduce coverage depending on the policy details.  

Also read  BMI Formula Explained

Legal and Ethical Considerations

There are several countries around the globe that have introduced anti-discrimination laws to prevent insurers from rejecting claims based solely on weight status or BMI.

For example, in the United States, the Affordable Care Act prevents insurers from denying coverage due to pre-existing conditions or using BMI as a basis for discrimination.

Similarly, the European Union has protections against weight-based discrimination in health insurance. The level of enforcement can vary by country.

Though India does not have a law that exactly mirrors the Affordable Care Act in the U.S., as per Article 21 of the Constitution of India, every Indian citizen has a right to receive healthcare services.

Despite these protections, there is still an ongoing debate about whether it is ethical for insurers to use BMI as a determinant of premiums or eligibility. Many argue that BMI is not a perfect measure of health. It can also penalise individuals who are healthy despite having a high BMI, like athletes.

There is also another concern that BMI-influenced premiums affect policyholders from lower socio-economic backgrounds. It also pessimistically impacts those who have limited access to healthcare resources.

A high BMI can impact health insurance premiums. However, it is generally not a reason for the rejection of health insurance claims, especially in India, where anti-discrimination protections apply.

Also Read:

→ Can Athletes with High Muscle Mass have a Misleading BMI

→ Do BMI Calculators for Women Consider Age and Hormonal Factors

→ Is BMI Considered a Pre-existing Condition in Health Insurance

→ Does Childhood BMI Affect Adult Health Risks

→ Does Menopause Affect BMI Calculations for Women