Medical Aid for Gastric Bypass

medical aid for gastric bypass

Gastric bypass is a surgical weight loss procedure used to treat morbidly obese people. It reduces the capacity of the stomach and, in so doing, limits the intake of food to small amounts at a time.

A patient who undergoes a gastric bypass procedure is fully anaesthetised for up to three hours, and specialised skills are required to complete the surgery. Accordingly, the associated medical costs for the surgery alone can be anywhere in the region from R100 000 to R150 000!

Until quite recently, scheme members undergoing a gastric bypass had to cover the costs themselves. Medical aids in South Africa deemed the procedure an elective surgery, and consequently excluded the treatment altogether.

Medical aid schemes that cover gastric bypass

More recently, medical aid schemes such as Discovery Health, Medshield, Momentum Health and Bonitas have included benefits for gastric bypass, also known as bariatric surgery, on some or all of their plans.

One of the motivating factors is that people suffering from obesity have a greater risk of developing chronic conditions such as high blood pressure, type 2 diabetes, high cholesterol, heart disease, lower back pain and asthma.

By treating obesity with gastric bypass surgery, a scheme may help prevent the onset of these life threatening conditions.

Bariatric surgery clinical entry criteria

As with all expensive procedures, there are clear guidelines as to who is eligible for bariatric surgery benefits. Bonitas, for instance, provides the following clinical entry criteria for gastric bypass procedures:

  • aged 18 years or older
  • a body mass index (BMI) equal to or greater than 40 or a BMI of 35 to 40 with associated health problems
  • a minimum of six months of organised weight reducing attempts at a specialised weight reduction centre
  • assessed sufficiently fit for surgery.

Medical motivation and pre-authorisation

Even if you meet the clinical criteria that a medical aid scheme outlines for a gastric bypass procedure, you’ll have to get written motivation from the attending doctor as to why the procedure is medically necessary. Pre-authorisation is also required.

Once you've met all a scheme’s criteria, you’ll be eligible for the major medical benefits as outlined in your plan or option. You’ll enjoy complete or partial cover for the costs relating to the hospital, theatre, blood tests, surgeon and anaesthetist.

No cover for post-op constructive surgery

In addition to the surgery, you’ll have to follow a proper eating plan for the rest of your life, and take essential supplements to boost your nutritional intake.

The type and level of plan you have subscribed to will determine whether there's cover for a nutritionist, dietician and NAPPI-coded nutritional supplements.

Most medical aid schemes will not cover the costs of post-operative plastic and constructive surgery, such as excess skin removal.