Can Insurance Deny Surgery Because You Smoke?

Health insurance policies are contracts outlining coverage terms. When lifestyle factors like smoking are involved, complexities can arise regarding covered medical services. Understanding these nuances is important for individuals navigating their healthcare benefits.

How Smoking Influences Insurance Coverage

Health insurance companies assess risk to determine policy terms and premiums. Smoking is categorized as a significant health risk due to its strong association with various severe illnesses, including lung cancer, heart disease, and respiratory conditions. This elevated risk translates into higher potential healthcare costs for insurers.

Insurers use actuarial science to calculate premiums based on the likelihood of claims. For smokers, this risk assessment often results in higher premiums or specific surcharges. On average, smokers may pay 15-20% more for health insurance premiums than non-smokers, with some surcharges going up to 50% of the base premium. This increased cost is a way for insurers to offset the higher anticipated medical expenses related to tobacco use.

Health insurance policies define “tobacco use” to include cigarettes, cigars, pipe tobacco, and chewing tobacco. Individuals are often considered smokers if they use these products four or more times a week within the last six months. Even occasional smoking can lead to higher premiums or waiting periods for certain benefits related to smoking-induced conditions.

Factors Affecting Coverage Decisions

An insurance company might deny coverage for surgery if smoking directly impacts the medical necessity or success of the procedure. Insurers determine “medical necessity” based on whether a treatment is necessary to maintain or restore health, or to treat a diagnosed medical problem, and if it meets accepted medical standards. Smoking can complicate this determination, especially for certain elective surgeries.

Smoking significantly increases surgical risks, such as impaired healing, higher infection rates, and decreased lung capacity, which can make anesthesia more hazardous. For procedures requiring successful healing, like certain reconstructive surgeries, bariatric surgery, or spinal fusion, an insurer’s medical review team may flag smoking as a concern. If continued smoking substantially reduces a surgery’s success rate, the insurer may deem the procedure less medically necessary.

Pre-authorization processes play a significant role, requiring approval from the insurer before a non-emergency procedure is performed. During this review, an insurer’s medical team evaluates the patient’s overall health, including smoking status, in relation to the proposed surgery. This can lead to a denial or a requirement for the patient to undergo smoking cessation before approval. While emergency or life-saving surgeries are less likely to be denied solely due to smoking, complications related to tobacco use may still be noted and can affect post-surgical care.

Understanding Regulatory Protections

The Affordable Care Act (ACA) impacts how insurers treat individuals with pre-existing conditions, including those related to smoking. Under the ACA, insurers cannot deny coverage or charge higher premiums due to pre-existing conditions in most individual and small group plans. This means an insurer cannot deny a health insurance policy because an applicant smokes.

However, the ACA does allow for tobacco surcharges on premiums. Insurers can charge tobacco users up to 50% more than non-smokers for the same health plan. This surcharge is applied after premium tax credits are calculated, meaning subsidies do not cover this additional cost. Some states have opted to limit or prohibit these tobacco surcharges, but many states allow the maximum 50% rate.

While the ACA prevents denial of coverage for a plan, it does not prevent denial of a specific service if it is not deemed medically necessary or if specific policy exclusions apply. For employer-sponsored plans, if a tobacco surcharge is implemented, federal rules require offering access to a tobacco cessation program. The surcharge should not apply if the individual enrolls in such a program. The ACA also mandates that most health insurance plans cover tobacco cessation treatments as a preventive service, including counseling and FDA-approved medications.

Steps to Take if Coverage is Denied

If you receive a denial of coverage for surgery where smoking is cited as a reason, reviewing your policy is an important first step. Carefully read the policy document to understand the specific terms, exclusions, and appeal procedures related to smoking or medical necessity. It is important to obtain a clear, written explanation from the insurer detailing the reason for the denial.

You have the right to an internal appeal with the insurance company. This involves asking your insurer to conduct a full review of its decision, usually within 180 days of receiving the denial notice. During this process, gathering supporting medical documentation, such as letters from your doctor explaining the medical necessity of the surgery despite smoking status, can strengthen your case. If the case is urgent, your insurance company must expedite this internal appeal process.

If the internal appeal is unsuccessful, you have the option for an independent external review. This process involves an independent third party, such as a state insurance department or an independent review organization, reviewing your denied claim. External reviews are limited to denials based on medical judgment or medical necessity. Requesting an external review must be done within four months after receiving the final adverse determination from your internal appeal. Patient advocates can assist in navigating this process, helping to gather documentation and communicate with the insurer.