| In the UK around 7 million people spend around | | | | NHS in England and Wales. Until that body has |
| £3 billion a year on medical insurance. One | | | | approved the drug your insurer is unlikely to pay |
| in seven policies are taken out by individuals with | | | | for its use. The problem is that the Institute's |
| the balance being put in place by their employers. | | | | brief is to perform a cost/benefit analysis to |
| The problem is that Medical Insurance is complex | | | | ensure that the financial benefits to the nation |
| and few policyholders take the time to really | | | | from using the drug, outweigh the costs of using |
| study the details of their cover. As a result, many | | | | it in the NHS. A difficult brief and it has placed the |
| misunderstand what will be covered. If you | | | | Institute under scrutiny for the extended delays in |
| expect medical insurance to pay every health | | | | drug approval. |
| claim, you're mistaken. | | | | The compromise hit on by the Financial |
| Medical Insurance is designed to provide protection | | | | Ombudsman is that if your medical policy won't |
| for curable, short-term health problems and allow | | | | pay for the use of experimental treatments, then |
| policyholders to jump the NHS queues to see | | | | it should meet the cost of an approved |
| consultants, be diagnosed, receive surgery or be | | | | conventional treatment with the policyholder |
| treated. That sounds fine, but before you buy | | | | footing the bill for the balance if the experimental |
| you need to appreciate the treatments and | | | | treatment is more expensive. |
| situations that fall outside the scope of the cover. | | | | Sorry - it's a pre-existing condition |
| But first a word of warning. This article does not | | | | The basic principle is that if you are already |
| relate to any specific policy and the terms and | | | | suffering from a condition when you start a |
| conditions issued by individual insurers do vary. So | | | | policy, then that condition "pre-exists" the policy |
| please ensure you also check your policy | | | | and any claims for its treatment are invalid. |
| documents. After reading this article, you'll know | | | | For this reason, insurance companies insist you |
| what to look out for! | | | | complete an exhaustive questionnaire before they |
| Sorry - it's a chronic condition | | | | agree to insure you. After all they need a clear |
| If a condition can be cured and is not a long-term | | | | picture of your medical condition before they |
| problem, your insurance company will classify it as | | | | quote. For many applications, the insurer will, with |
| acute and should meet the cost. If your problem | | | | your approval, also write to your GP for specific |
| is incurable or it's a problem that, despite | | | | details of your medical history. They like to have |
| appropriate treatment, will be with you for a long | | | | a complete picture. |
| time, then your insurance company will classify it | | | | So lets say some years ago you twisted your |
| as chronic - and no, you won't be covered. | | | | knee playing tennis. It appeared to recover but |
| But deciding whether a condition is acute or | | | | now it turns out that you have a torn cruciate |
| chronic is fraught with problems. It's rarely a black | | | | ligament and it needs to be operated on. Your |
| and white decision and this can lead to a major | | | | medical insurance company could argue that the |
| area of conflict between policyholder and insurer. | | | | ligament damage was a pre-existing condition and |
| It's clear that asthma and diabetes are chronic | | | | you have to pay for the operation. |
| conditions as you're almost certain to suffer from | | | | Some insurers try to accommodate these grey |
| them for the rest of your life. So those | | | | areas with a moratorium provision within your |
| categories of illness are not covered. | | | | policy. These provisions typically say that so long |
| Problems arise when Doctors initially consider a | | | | as you have been symptom free for two years |
| patients' condition to be curable, but the condition | | | | relating to any condition you've suffered from |
| later deteriorates and the medical team changes | | | | within the last 5 years, they will pay for |
| its' mind, it's now become incurable. This can | | | | subsequent treatment. Not all policies have these |
| sometimes happen, especially in the treatment of | | | | moratorium provisions and the time periods do |
| certain types of cancer. | | | | vary between insurers. You should carefully read |
| In these circumstances, the condition is initially | | | | your policy. |
| defined as acute and is therefore insured, but | | | | Sorry - its not covered |
| deteriorates and becomes chronic - and outside | | | | Medical Insurance is an annual contract - just like |
| the terms of cover. This is possible as insurers | | | | your car insurance. So when it comes to renewal, |
| retain the right to reclassify a condition from | | | | your insurer is at liberty to review not only your |
| acute to chronic during treatment. | | | | premium but also change the conditions on which |
| Sorry - it's too long term | | | | your cover is provided. |
| The insurance company will not pay out for long | | | | Therefore, if your policy comes up for renewal |
| term treatment. But you need to check your | | | | mid way through a course of treatment, it's |
| policy documents to see how they define | | | | possible to find that your new policy no longer |
| "long-term". You can find the situation where a | | | | covers that particular treatment. This means that |
| course of drugs extends for say 12 months, but | | | | you will have to foot the bill for the balance of |
| the insurer will only pay for ten months. | | | | the treatment. |
| Sorry - it's preventative | | | | Furthermore, with ongoing advances in medical |
| Your insurance is designed to pay for the | | | | research, more and more conditions are becoming |
| treatment and cure of conditions when they arise. | | | | treatable. This progress has the effect of shifting |
| It is not designed to pay for treatments that are | | | | back the dividing line between chronic and acute |
| used to prevent an illness. | | | | conditions. |
| Again, the problem of definition arises. Sometimes | | | | This hits the insurers' pocket in two ways. With |
| it is arguable whether a treatment is preventative | | | | more conditions being reclassified as acute, the |
| or a cure. Take the drug Herceptin for example. | | | | number of claims is increasing. And there's also a |
| This drug can be used in the early stages of | | | | trend for new treatments to cost more - |
| breast cancer. Research shows that Herceptin can | | | | Herceptin being a good example. The net result is |
| halve the incidence of cancer returning for women | | | | that the insurers are finding themselves having to |
| who have a particularly virulent form of the | | | | pay out far more. This is inevitably passed back |
| cancer known as HER2. In this situation, is | | | | to you through increased renewal premiums. And |
| Herceptin offering a cure or is it a preventative? | | | | in an attempt to reduce their risk exposure, |
| Insurance companies are split on the debate. | | | | insurers have a tendency to adjust their |
| Norwich Union, WPA, BUPA and Standard Life | | | | definitions and exclusions. This means that you |
| Healthcare will pay for Herceptin for HER2 | | | | must read your renewal notice closely before you |
| patients whereas Legal and General and Axa PPP | | | | decide to renew. |
| will not. | | | | So if you're tempted to buy Medical Insurance, be |
| Sorry - the drug is not approved | | | | aware that everything is not always black and |
| Two of the main attractions for taking out | | | | white. If you've got insurance and need |
| medical insurance are: to jump the queues at the | | | | treatment, you're well advised to contact your |
| NHS, and to get the latest treatments and drugs. | | | | insurer without delay and get them to confirm |
| But there's a rider. | | | | that they will meet the cost of your proposed |
| The Institute for Health and Clinical Excellence | | | | treatment. |
| exists to approve the use of new drugs by the | | | | |