Insurance World

Private medical insurance policies can be very particular about what they do and don’t cover. For example, if you are insured with Bupa, then you will only be covered for experimental medical treatment if it is part of a bona fide medical trial or study. And Norwich Union Healthcare stipulate that treatment is only covered if it is considered to standard practice in the UK.

So what happens if your doctor recommends that the best course of action would be to have a newer type of treatment, rather than a long established standard procedure? For the sake of your health, you will probably be wanting to take your doctor’s recommendation. However, many private medical insurance policies simply do not allow for this.

The issue has come to light as a number of people have been recommended experimental treatment, only to find that the insurer will not cover it. These people complained to the Financial Ombudsman Service (FOS) who, in some cases, rules against the insurers. One of the treatments that has emerged as something that should be paid for is a new form of varicose vein surgery. Standard practice in the USA for the last five years, insurers in the UK were refusing to pay out until the FOS made their decision.

A type of larynx surgery which is performed by laser is also now to be insured, as is bladder surgery carried out by keyhole rather than through an open wound, and a new type of spinal treatment which means vastly reduced side effects.

However, the FOS has only been able to overturn insurer’s decisions on policies in which experimental treatments are not specifically stated in the policy as being excluded. The Ombudsman can’t do anything about those policies that do specifically exclude experimental treatments.

The FOS has pointed out that just because they have ruled against the insurers, it doesn’t mean they are endorsing specific types of treatment. They also said: “If the policyholder has been advised by his or her treating physician that, in their particular circumstances, they should have a newer treatment instead of an established procedure, our general view would be that it could be unfair for the firm to turn down the claim entirely.”

As a result of these recent rulings, insurers may well reconsider how they deal with experimental treatments in their policies. Insurers say that they act in the best interests of their customers, and if they are asked to fund something that they consider to be against the best interests of the patient, then they will reject the claim. However, one insurer, WPA, has admitted that if the customer’s doctor does recommend a particular course of experimental treatment, and there is a very good reason why that treatment is better than any other, then they will pay out. Norwich Union Healthcare has already said that they will be reviewing their policies in the light of the FOS’ rulings. As for Bupa, it has expressed concern that customers will be claiming for procedures or drugs that have not been fully tested in the UK.

At the moment, it’s a case of ‘watch this space’. If you are thinking about getting private medical insurance, then keep this issue in mind when you choose your policy. It would be very frustrating to be recommended a treatment, and then find that you are not insured for it. Remember to check out the Internet first for the cheapest policies, most private medical insurance policies offer a lot of advice and information on which policy is best suited to you, which can be very useful with all the choice out there.

A Preferred Provider Organization, or a PPO, is health care organized by a particular insurance company. Medical professionals, hospitals, and clinics are contracted by the insurance company to work with the PPO system. The PPO decides the managed medical care guidelines and the fee schedule and the medical professionals, hospitals, and clinics that are contracted by the PPO agree to these terms.

A PPO is similar to a health maintenance organization (HMO) in that it offers a network of health care professionals available to the insured person; however, a PPO is more flexible than an HMO in that a PPO also offers the option of seeing an out-of-network health care professional. Many times people would rather visit their family doctor, or a doctor that is highly recommended, than a doctor in the PPO network with whom they may not be familiar. Yet, PPO networks usually represent a high number of medical professionals, doctors, and clinics over a large geographic area, so finding an agreeable doctor might not be that difficult.

The insurance offered by a PPO usually covers a high percentage of the cost to see a health care professional in the PPO network, and the insured person will pay a co-payment at the time of the doctor, hospital, or clinic visit. Fees for out-of-network health care professionals are often higher than fees for seeing a health care professional in the PPO network. PPOs want to encourage the insured person to visit a doctor within the network, but it is obviously not required. PPOs also require the insured person to pay a yearly out-of-pocket fee before medical bills will be covered.

Other advantages to a PPO are the fact that its premium is less expensive than that of an individual health insurance plan and the fact that PPO networks usually have a plan that will offer prescription drugs at much lower costs. A PPO will also cover more medical services than an individual health insurance plan.