Health insurance is very particular in its purpose – and is fine for curable, short-term health problems, and for allowing policyholders to bypass the NHS queues and get straight through to the consultants to receive quality care in a much faster time. However, there are many other treatments and situations which do not fall within the scope of the policy.
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Before you read on, we should advise you that every policy is different and you really need to read your own documents to get the full picture. However, this article will give you some very good pointers on what to look out for.
Chronic conditions
If you fall ill and it turns out that the illness can be cured in the short-term, it's called ‘acute' and you're covered. If, however, your problem is incurable or, even with treatment, it will last for a long time, then it will be classed as ‘chronic' and your policy will not cover you.
It's the line between ‘acute' and ‘chronic' that causes conflict between insurer and policyholders. Diabetes and asthma for example are chronic – they are not curable and they stay with you for the rest of your life. Some types of cancer cannot be so easily classified. The doctors may decide that the cancer is curable, but then the illness could worsen and the diagnosis could be changed to incurable. This means that while the illness is considered curable, then you can make the most of your cover, but if the diagnosis changes to incurable, your cover will be lost. Insurance companies reserve the right to reclassify an illness from acute to chronic during treatment.
Long-term treatment
Long-term treatment is a definite no-no. But check your policy documents first to see their definition of “long-term”. It may be that the insurer will pay for 10 months, so if it's a 12 month treatment, you will need to pay for the final 2 months yourself.
Preventative medicine
Health insurance covers the treatment and cure of conditions, it cannot be used to pay for preventative treatment.
What counts as being preventative is another grey area. For example, the drug Herceptin is used in the early stages of breast cancer, and research shows that Herceptin can reduce the chance of the cancer returning by 50% for women who have an aggressive form of the cancer called ‘HER2'. Some insurance companies call it preventative, some call it treatment:
Norwich Union, WPA, BUPA and Standard Life Healthcare will pay;
Legal and General and Axa PPP will not.
Drugs that have not yet been approved
Two of the main benefits of health insurance are quicker treatment and access to the latest treatments and drugs – but there's another spanner in the works.
The Institute for Health and Clinical Excellence has to approve a drug before it can be used in the NHS in England and Wales. If it hasn't been approved, the insurer will probably not allow its use. It's not even necessarily that the drug has not been tested as safe to use, it's actually an administration issue relating to whether the benefits of the drug outweigh the financial costs of using it in the NHS. As a result, extended delays are occurring in drug approval, to the detriment of the people who need them.
The Financial Ombudsman has found a compromise – basically that if the insurance won't cover ‘experimental treatments', then it should provide cover to the cost of the approved conventional treatment, and the policyholder can make up the difference if the experimental treatment costs more.
Pre-existing conditions
Any condition or illness that occurred before the beginning of your policy is called a ‘pre-existing condition'. You cannot make a claim on a pre-existing condition.
This is why the medical questionnaire is so lengthy and detailed when you apply – they need to see a full picture of your current and past health so they can provide you with an accurate quote. Insurers will often write to your GP for specific details of your medical history, or request you to attend a medical examination.
The subject of pre-existing conditions is another contentious one. Say you broke your wrist playing hockey a few years ago. It seemed to heal but now you are suffering again because it turns out that you have a torn cartilage. If you make a claim for the operation, the insurer could argue that the condition pre-existed the policy, and you would either have to pay for the treatment, or join the NHS queue.
Some insurance companies provide some respite on this issue, by writing a moratorium provision into your policy. This means that as long as you have not suffered from the condition for two years, and the first incidence arose in the last 5 years, then you will be covered. Time frames vary and not all insurers provide moratorium provision, so check your policy.
The condition or illness is not covered
Like car insurance, health insurance works as an annual contract and every year, they are at liberty to change your premium and the terms of your cover.
The worst case, but entirely possible, scenario to arise in this case is to be told that the illness that you are receiving treatment for, is no longer covered by your policy. This could happen if your policy comes up for renewal during the treatment. You would have to pay for the rest of the treatment if this did occur.
As medical research advances, there are far more conditions that are now considered treatable. As a result, the line between chronic and acute conditions is always moving. There are a number of effects from this. Firstly, because more conditions are being classified as acute, more claims are being made. New treatments are also becoming increasingly expensive, Herceptin for example.
The net result is that the insurers are getting hit where they hurt the most – in the pocket. They have to pay out more, so they pass that straight onto the customer, which means higher premiums for you, especially at renewal time. They also take the opportunity to adjust their definitions and exclusions to lessen the risk of you making a claim, so take particular care to read your renewal notice in full before you sign up for another year.
So if you're thinking about getting Health Insurance, do your research first, and remember that the goalposts are always changing. If you have health insurance and you are in need of treatment, give your insurer a call first to make sure that you are covered, otherwise it's you that will be footing the bill.
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