Health Insurance - It's Important To Know What's Not Insured!

Around 7 million people in the UK are covered by healthinsurance, the majority being covered through their employers.The problem is that few have really studied their policydocuments and many misunderstand what is covered. And perhapsjust as important, what isn't. If you expect health insurance topay all your health costs, you're mistaken. Health insurance is designed to provide protection for curable,short-term health problems and allow policyholders to jump theNHS queues to see consultants, be diagnosed, receive surgery orbe treated. That sounds fine, but before you buy you need toappreciate the treatments and situations that fall outside thescope of the cover. But first a word of warning. This article does not relate to anyspecific policy and the terms and conditions issued byindividual insurers do vary. So please ensure you also checkyour policy documents. After reading this article, you'll knowwhat to look out for! Sorry - it's a chronic condition If a condition can be cured and is not a long-term problem, yourinsurance company will classify it as acute and should meet thecost. If your problem is incurable or it's a problem that,despite appropriate treatment, will be with you for a long time,then your insurance company will classify it as chronic - andno, you won't be covered. But drawing a firm line between what is acute and what ischronic is fraught with problems, and leads to the biggest areaof conflict between insurer and policyholder. Everyone agrees that diabetes and asthma are chronic conditionsas you're likely to suffer from them for the rest of your life.So those sorts of condition are not covered. Problems arise when the medical team initially considers apatients' illness to be curable, but the condition subsequentlydeteriorates and the doctors change their mind, it's now becomeincurable. This can happen especially in the treatment of sometypes of cancer. In these circumstances, the condition is initially defined asacute and is therefore insured, but deteriorates and becomeschronic - and outside the terms of cover. This is possible asinsurers retain the right to reclassify a condition from acuteto chronic during treatment. Sorry - it's too long term The insurance company will not payout for long term treatment. But you need to check your policydocuments to see how they define "long-term". You can find thesituation where a course of drugs extends for say 12 months, butthe insurer will only pay for ten months. Sorry - it's preventative Your insurance is designed to pay forthe treatment and cure of conditions when they arise. It is notdesigned to pay for treatments that are used to prevent anillness. Again, the problem of definition arises. Sometimes it isarguable whether a treatment is preventative or a cure. Take thedrug Herceptin for example. This drug can be used in the earlystages of breast cancer. Research shows that Herceptin can halvethe incidence of cancer returning for women who have aparticularly virulent form of the cancer known as HER2. In thissituation, is Herceptin offering a cure or is it a preventative? Insurance companies are split on the debate. Norwich Union, WPA,BUPA and Standard Life Healthcare will pay for Herceptin forHER2 patients whereas Legal and General and Axa PPP will not. Sorry - the drug is not approved Two of the main attractions fortaking out health insurance are: to jump the queues at the NHS,and to get the latest treatments and drugs. But there's a rider. Unless the drug has been approved for use by the NHS in Englandand Wales, by the Institute for Health and Clinical Excellence,your insurer is unlikely to approve its use. The problem is thatthe Institute's brief is not simply to decide whether a drugworks, but to carry out a cost/benefit analysis to ensure thatthe benefits to the nation outweigh the financial costs of usingit in the NHS. Not an easy brief - and one that has placed theInstitute under scrutiny for the extended delays in drugapproval. The compromise hit on by the Financial Ombudsman is that if ahealth policy won't pay for the use of experimental treatments,then it should meet the cost of an approved conventionaltreatment with the policyholder footing the bill for the balanceif the experimental treatment is more expensive. Sorry - it's a pre-existing condition The basic principle is that if you are already suffering from acondition when you start a policy, then that condition"pre-exists" the policy and any claims for its treatment areinvalid. For this reason, insurance companies insist you complete anexhaustive questionnaire before they agree to insure you. Afterall they need a clear picture of your medical condition beforethey quote. For many applications, the insurer will, with yourapproval, also write to your GP for specific details of yourmedical history. They like to have a complete picture. So lets say some years ago you injured your knee playingfootball. It appeared to recover but now it turns out that youhave a torn cartilage and need an operation. The insurer couldargue that this is a pre-existing condition and you have to payfor its' treatment. Some insurers try to accommodate these grey areas with amoratorium provision within your policy. These provisionstypically say that so long as you have been symptom free for twoyears relating to any condition you've suffered from within thelast 5 years, then they will pay for subsequent treatment. Notall policies have these moratorium provisions and the timeperiods do vary between insurers. You should carefully read yourpolicy. Sorry - its not covered Health Insurance is an annual contract - just like your carinsurance. So when it comes to renewal, your insurer is atliberty to review not only your premium but also change theconditions on which your cover is provided. Therefore, if your policy comes up for renewal mid way through acourse of treatment, it's possible to find that your new policyno longer covers that particular treatment. This means that youwill have to foot the bill for the balance of the treatment. Furthermore, with ongoing advances in medical research, more andmore conditions are becoming treatable. This progress has theeffect of shifting back the dividing line between chronic andacute conditions. This hits the insurers' pocket in two ways. With more conditionsbeing reclassified as acute, the number of claims is increasing.And there's also a trend for new treatments to cost more -Herceptin being a good example. The net result is that theinsurers are finding themselves having to pay out far more. Thisis inevitably passed back to you through increased renewalpremiums. And in an attempt to reduce their risk exposure,insurers have a tendency to adjust their definitions andexclusions. This means that you must read your renewal noticeclosely before you decide to renew. So when you are considering Health Insurance, be aware thateverything is not always black and white. And if you've gotinsurance and need treatment, always contact your insurerwithout delay and get them to confirm that your treatment isindeed covered