Chronic Conditions Explained

 

In common with other annual insurance policies, medical insurance is designed to cover claims for expenses incurred as a result of unexpected events. Therefore, it is important to understand when buying medical insurance that policies are designed to cover treatment of medical conditions that respond quickly to treatment, referred to by us as “acute conditions”. Medical insurance is not intended to cover you against the cost of recurrent, continuing or long-term treatment of chronic medical conditions since these treatments become a series of predictable, rather than unexpected, events.

 

This page is designed to help you understand more about what insurers mean by chronic condition and provide practical examples of when they will or will not cover treatment of those conditions.

 


 

What is a chronic condition?

 

A chronic condition is a disease, illness or injury that has one or more of the following characteristics:

 

 

Healthcare policies cover the cost of treatment for acute conditions. That is, treatment which aims to return you to the state of health you were in before suffering the condition, or which leads to your full recovery. This includes short-term medical intervention to treat unexpected complications or exacerbations of a chronic condition.

 

If your illness or medical condition requires recurring consultations over a long period, checks on your medication, long term therapy or treatment to ease symptoms, your condition may fall within the definition of a chronic condition. If you have been receiving ongoing or continuing treatment or treatment that is intended to manage your condition or keep your symptoms in check, your treatment will be reviewed to assess whether it remains eligible for benefit.

 


 

What does this mean in practice?

 

For pre-authorised claims, you will be informed if the insurers think your condition is now a chronic condition under their rules.

 

They may then (with your permission) contact your specialist or GP who knows your particular circumstances. Insurers may ask them for confirmation of the diagnosis of your condition and details of the treatment you are currently receiving and to obtain a future prognosis for the condition.

 

Medical insurance policies are designed to cover claims for expenses incurred as a result of unexpected events and insurers do not go on paying for recurring or continuing treatment of medical conditions that will continue indefinitely or that keep recurring. Should the information they have indicate that you have a chronic condition insurers would usually write to tell you they will stop paying benefit for the continuing or recurrent treatment of the chronic condition.

 


 

What if your condition gets worse?

 

Insurers will pay for the treatment of acute exacerbations or complications (flare ups) in order to bring the condition quickly back to its controlled state (for instance in-patient treatment needed to re-stabilise a chronic condition such as diabetes). There are certain other chronic conditions such as Crohns disease which because of their nature, require management of recurrent episodes during which the symptoms of the condition worsen. Because of the ongoing or continuing nature of such conditions, we will write to tell you when there is no further benefit available for the treatment of that medical condition.

 


 

 

Examples of chronic conditions

 

The following are examples of chronic conditions and how insurers usually deal with them. In all of the following examples we or the insurers may need to write to you or your doctor to obtain further information as explained above.

 

Important note – certain plans have specific restrictions to benefits such as out-patient treatment, for treatment that could have been received on the NHS within six weeks and other specific exclusions covered in the policy terms.

 

The cover for cancer also varies by product with some products having higher levels of cover than those described in this document while others have lower or no cover for cancer.

 

The examples below are designed to show general policies on chronic conditions and how insurers would deal with them for a customer on a mid-range policy. Therefore, the examples may not necessarily be applicable for all insurers or types of policies. Please read your handbook carefully to establish what cover you have as all the other terms of your policy (including any limits) will continue to apply to your cover.

 

Example 1 – Angina and Heart Disease

Alan has held a healthcare insurance policy for many years. He develops chest pains and is referred by his GP to a specialist. He has a number of investigations and is diagnosed as suffering from Angina. Alan is placed on medication to control his symptoms.

Insurers would pay for the initial consultation and tests to diagnose the condition and further consultations with the specialist to allow the medication to bring the condition under control. At this point the insurers would advise Alan that further regular review consultations to monitor the condition would not be covered, but they would allow one further consultation to allow Alan to discuss alternative arrangements should he wish to do so.

Two years later, Alan’s chest pain recurs more severely and his specialist recommends that he have a heart by-pass operation.

Insurers would confirm to Alan that they will cover that operation as it will stabilise his condition and substantially relieve his acute symptoms. They would then explain to Alan that although his policy would not normally cover regular check-ups, in this particular circumstance they would allow for a further ten years of annual postoperative check-ups with the specialist to ensure that his condition remains stabilised. This benefit would only be available on policies with out-patient cover and while the policy remains in force.

 

Example 2 – Asthma

Eve has been with her healthcare insurers for 5 years when she develops breathing difficulties. Her GP refers her to a specialist who arranges for a number of tests. These reveal that Eve has asthma. Her specialist puts her on medication and recommends a follow-up consultation in three months, to see if her condition has improved. At that consultation Eve states that her breathing has been much better, so the specialist suggests she have check-ups every 4 months.

Her insurers would agree to cover Eve’s initial tests and consultation to establish the diagnosis and also the subsequent consultation to see if there was an improvement. However, they would then advise Eve that regular check-ups are outside the scope of cover.

Eighteen months later, Eve has a bad asthma attack

Her insurers would agree to cover the cost of hospital treatment until her condition has stabilised. They would also pay for one further consultation following discharge from hospital.

 

Example 3 – Cancer

 

Beverley has been with her healthcare for 5 years when she is diagnosed with breast cancer. Following discussion with her specialist she decides to have the breast cancer removed followed by breast reconstruction. Her specialist also recommends a course of radiotherapy and chemotherapy. In addition she is to have hormone therapy tablets for several years. Will her insurance cover this treatment plan and are there any limits to the cover?

Her insurers would pay for the breast to be removed and initial reconstruction to restore appearance. In addition they would also pay for the course of radiotherapy and licensed chemotherapy aimed at bringing the condition into remission or cure. Hormone therapy tablets (such as Tamoxifen) are out-patient drugs and, in line with other out-patient drugs are usually not covered by healthcare policies.

Cara has previously has breast cancer which was previously treated by lumpectomy, radiotherapy and chemotherapy under her existing policy. She now has a recurrence in her other breast and has decided to have a mastectomy, radiotherapy and chemotherapy. Will her insurance cover this and are there any limits to cover?

Her insurers would pay for treating the recurrence as described above for the initial breast cancer.

Monica, who was previously treated for breast cancer under her existing policy, has a recurrence which has unfortunately spread to other parts of her body. Her specialist has recommended the following treatment plan:

 

 

Will her insurance cover this treatment plan and are there any limits to cover?

 

They may also pay for the licensed drugs to suppress the growth of the cancer (e.g. Herceptin). These chemotherapy treatments that are given for prolonged periods would normally fall outside benefits but in the case of cancer insurers may make an exception. Thus the use of such drugs will be covered for a period of time as described in your policy document or for the period of the drug’s licence if this is shorter.

Sharon would like to be admitted to a hospice for care aimed solely at relieving symptoms. Will her insurance cover this and are there any limits to cover?

Hospice care is provided by the NHS and charitable institutions at no cost to the patient and many insurers would not therefore cover this.

 

Example 4 – Diabetes

 

Deidre has been with her healthcare insurer for two years when she develops symptoms that indicate she may have diabetes. Her GP refers to her to an endocrinology specialist who organises a series of investigations to confirm the diagnosis, and she then starts on oral medications to control the diabetes. After several months of regular consultations and some adjustments made to her medication regime, the specialist confirms the condition is now well controlled and the specialist explains he would like to see her every 4 months to review the condition.

Her insurers would explain that they cannot continue to provide benefit for the review consultations but, may agree to provide benefit for one more to allow Deidre the opportunity to discuss alternative arrangements for follow up.

One year later, Deidre’s diabetes becomes unstable and her GP arranges for her to go into hospital for treatment.

Her insurers may provide benefit for this admission and for a short period after her discharge.

 

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