About 7 million people in the UK have health insurance, and most of them get it through their jobs. The problem is that few people have really read their policies, and many people have the wrong idea about what is covered. And what isn't might be just as important. If you think your health insurance will pay for everything, you're wrong.
Health insurance is meant to cover short-term, treatable health problems and let policyholders skip the NHS lines to see a doctor, get a diagnosis, have surgery, or get treated. That sounds good, but before you buy, you need to know what kinds of treatments and situations aren't covered.
But first, let me warn you. This article is not about a specific policy, and the terms and conditions that each insurance company gives out are different. So, please check your policy documents as well. You'll know what to look for after reading this article.
Sorry, it's a long-term problem.
If you have a condition that can be fixed and doesn't last for a long time, your insurance company will call it "acute" and pay for it. If your problem can't be fixed or will last for a long time even with the right treatment, your insurance company will call it "chronic," and no, you won't be covered.
But it's hard to draw a clear line between what's short-term and what's long-term, and this is where insurers and policyholders fight the most.
Diabetes and asthma are both considered chronic conditions because you are likely to have them for the rest of your life. So conditions like these are not covered.
When the medical team at first thinks a patient's illness can be treated, but then the illness gets worse and the doctors change their minds and say it can't be treated, this is a problem. This can happen when some kinds of cancer are being treated.
In this case, the condition is first seen as acute and is therefore covered, but then it gets worse and becomes chronic, which is not covered. This is possible because insurers can change a condition from "acute" to "chronic" while it is being treated.
Sorry, but that's too long.
Long-term care is not covered by the insurance company. But you should look at your policy documents to see how "long-term" is defined. There are times when a drug course lasts, say, 12 months, but the insurance company will only pay for 10 months.
Sorry, but it's a precaution.
Your insurance is meant to pay for medical care and cures when they are needed. It is not meant to pay for treatments that keep someone from getting sick.
Again, there is a problem with defining. Sometimes it's hard to say whether a treatment is a cure or a way to keep from getting sick. Think about the drug Herceptin. In the early stages of breast cancer, this drug can be used. Research shows that Herceptin can cut in half the chance of cancer coming back in women with HER2 cancer, which is one of the most dangerous types. In this case, does Herceptin treat the cancer or stop it from getting worse?
On this issue, insurance companies have different opinions. Legal and General and Axa PPP will not pay for Herceptin for people with HER2, but Norwich Union, WPA, BUPA, and Standard Life Healthcare will.
Sorry, but the drug is not okay.
Two of the best reasons to get health insurance are to avoid waiting in line at the NHS and to get the newest treatments and medicines. There's a catch, though.
If the drug hasn't been approved by the Institute for Health and Clinical Excellence for use by the NHS in England and Wales, your insurance company isn't likely to let you use it. The problem is that the Institute's job isn't just to decide if a drug works or not. It also has to do a cost-benefit analysis to make sure that the benefits to the country outweigh the costs of using the drug in the NHS. Not an easy task, and because of it, the Institute has come under fire for the long delays in drug approval.
The Financial Ombudsman came up with a compromise: if a health policy won't pay for experimental treatments, it should cover the cost of an approved conventional treatment. If the experimental treatment costs more, the policyholder should pay the difference.
Sorry, but it was already there.
The basic idea is that if you already have a condition when you buy a policy, that condition "pre-exists" the policy and you can't make a claim for treatment.
Because of this, insurance companies make you fill out a long questionnaire before they will agree to cover you. After all, they need to know a lot about your health before they can give you a quote. For many applications, the insurance company will also write to your doctor, with your permission, to find out more about your health history. People like to see the whole picture.
So, let's say you hurt your knee playing football a few years ago. It looked like it was getting better, but now you have a torn cartilage and need surgery. The insurance company could say that this is a pre-existing condition for which you have to pay.
Some insurers try to cover these grey areas with a clause in your policy called a "moratorium." Most of the time, these rules say that they will pay for treatment as long as you haven't had any symptoms for two years from any condition you've had in the last five years. Not all policies have these moratoriums, and the lengths of time vary from insurer to insurer. You should read your policy with care.
Sorry, we don't cover that.
Health insurance is like car insurance in that you sign a new contract every year. So, when it's time to renew your policy, your insurer can look at not only your premium but also the terms under which your coverage is given.
So, if you have to renew your policy in the middle of a course of treatment, it's possible that your new policy won't cover that treatment anymore. This means that you will have to pay for the rest of the treatment out of your own pocket.
Also, as medical research keeps getting better, more and more diseases are becoming treatable. Because of this progress, the line between chronic and acute conditions is moving back.
This hurts the insurance companies in two different ways. The number of claims is going up because more conditions are being reclassified as acute. And it's becoming more common for new treatments to cost more, like Herceptin. In the end, this means that the insurance companies have to pay out a lot more money. This will be passed on to you in the form of higher renewal premiums. And insurers often change their definitions and exclusions to reduce the amount of risk they are exposed to. This means you should carefully read your renewal notice before deciding to renew.
So, if you are thinking about Health Insurance, keep in mind that not everything is black and white. And if you have insurance and need treatment, you should always call your insurance company right away to make sure your treatment is covered.
