Penny* applied for prior approval for a sleeve gastrectomy. Penny’s doctor recommended the surgery to improve her metabolic health, and specifically to reverse Penny’s pre-diabetes and hypertension.
The insurer declined to pay for the surgery, as the policy excluded “Procedures performed for any reason … relating to obesity”. Penny argued that, from a cost benefit analysis, the insurer should pay for the surgery, because it would decrease the chance of future health problems.
While there were other reasons for Penny’s surgery, it was surgery “relating to obesity”. Based on the broad nature of the policy exclusion, the insurer was entitled to decline the claim.
The insurer had not agreed to pay for these claims and the IFSO Scheme was only able to consider whether the insurer had correctly applied the terms of its policy, which it had.
Complaint not upheld.
*Names have been changed .