C-section coverage with Aviva

[ghislaine]

I'm hoping someone who's been through this can share her wisdom with me....

I have a gynaecological condition that means I need to have a c-section. In my last pregnancy, my health insurance (Groupama) agreed to cover me. But as I then lost my baby at 14 weeks, I never inquired into the details of what exactly they were prepared to cover. Fast forward a year, and I'm pregnant again but with a new insurance co. When we changed companies to Aviva - (well, my husband's work changed coverage) he range them to say we were TTC and the previous co had covered a section.

So earlier this week, I saw my gynaecologist and as in her words, a VB is "extremely inadvisable", she is writing a letter to Aviva about my need for a section. She's sending the letter to me first, just in case she inadvertently says anything that doesn't help my case. I also have another letter from my first gynae (she's not seeing patients at the moment) who is world expert in my condition, from my first pregnancy.

Does anyone who's had a c-section covered with Aviva have any advice about the process, how difficult it was to get coverage, and also how extensive their coverage is? I'm aware, now being 14 weeks, that I've left it very late to start booking with non-Portland consultants. We can afford some top-up but not a huge amount.

[BagofHolly]

As far as I know it depends on the coverage of your individual policy. I had my first ELCS covered by Aviva and they were brilliant, really helpful. The indication was placenta previa, but chatting informally afterwards, I discovered that malpresentation is also indication for cs and that's how a lot of insurance claims are coded, but essentially it's down to the consultant's opinion. In your shoes I'd pick a private consultant, go along and then get them to write to Aviva, as they'll be familiar with how it all works. Aviva only agreed cover quite late and it was knelt for the cs and post natal stuff, not ante natal but I was happy with that as I was under my local foetal medicine centre and then transferred.
Hope that helps! Good luck!

[BagofHolly]

BTW my second cs was begrudgingly covered by Axa PPP to whom my company had changed their policy, and they were utterly, utterly awful. Just saying. I like to get a dig in about them whenever I can.

[ghislaine]

Thanks Holly.

We have their Solutions Plus policy, and when we transferred, they seemed amenable in principle to a c-section. I only want private op and post-natal, not the whole package.

But when I became pregnant and wanted coverage to see my gynae they refused and advised me to keep on using my (teratogenic!) cream and said that was my only option and if I didn't want to use it, I'd just have to suffer. Saw gynae anyway who said absolutely not to use it and prescribed something much more mild (although this has meant my condition has gone haywire). So I'm expecting a battle, and want to be well-armed!

[ghislaine]

Bumping this with an update...

So Aviva agreed to cover me for my c-section. My real issue is with the degree of coverage (same old story).

Basically my annoyance with them is that while they will pay for one pre and one post-op consultation and pay contribute towards operation itself, they will not cover me for any consultant post-operative care while I'm in the hospital. Although the shortfall to us is not great (about £800) I'm still ticked off that they think is somehow ok. I rang and asked what would happen if there were problems arising afterwards - was I supposed to discharge myself and go to the NHS down the road? Their response was that I would have to ring up and negotiate separate cover for that at the time. Yes, of course I will have the presence of mind to do this. Unsurprisingly also they will only pay a 1/4 of the anaesthetist's fees.

I have have had two gynaecological operations privately and have never been covered for the operation alone. Each time consultant post-operative care was included, plus anaethetist's fees in full.

My current thought is to challenge their interpretation of "cover" as my policy document definitely says "cover" not "contribution". It also seems to me to be clinically negligent to agree to cover a medically necessary operation but not the after care. Or I suppose I could write and ask who they will secure for me to do the operation at the rates they provide cover at (don't really want to do this as I'm going to stick with my NHS consultant and I don't want to change at the last minute). Has anyone had any success with either of these strategies and how far did you have to go?

[BagofHolly]

Scuse brevity.,,

I was incensed by Axa ppp's appalling stance on c section and their assertion that they provided cover when actually it was only a contribution - this is CID they INSIST that the going rate fir a c section is £300! Have you ever heard nonsense like it? I was going crackers about it and threatened to go to the insurance ombudsman, but my husband's firm's policy is an odd one in so far as they themselves underwrite the costs abs axa ppp simply manage the administration. This meant that the ombudsman wouldn't consider our case as ultimately Axa ppp could say that they recommended the cover for c section should be £300 but ultimately it was down to the trustees of the policy to decide what would or wouldn't be paid.

In the end my husband's company very kindly underwrote the entire bill and paid everything in full. Thank goodness!

[QTPie]

Hi

I had similar joy with bupa (well I couldn't get the section - for breech - pre-authorised in time, despite 3 weeks notice, then it took 4 months of constant phone calls and nagging to get about £3k out of them towards my £15k costs ). Although I appreciate that prenatal care isn't covered, very little else seemed to be either! Not even one night of hospital accommodation.

I thought that it was crap - and the bad handling of the claim - I told them so and left bupa. I didn't pursue the unfairness of the coverage (through an ombudsman etc): by that time the whole matter had taken up far too much time, hassle and stress. Although honestly I think that is their ploy - if we string it out long enough, make it as difficult to claim as possible, then they will give up.

I did ask bupa for a copy of their C Section policy - what is covered at which hospital (apparently it differs!) - but they couldn't produce one! I did get sent other random policy documents instead.... I am very suspicious of this - does seem to allow them to make it up as they go along.

BagsofHolly, I am pretty sure that AXA PPP nolonger cover C Sections (for medical reasons) at all on new policies. I am now with them (personal policy). This doesn't affect you (since you are an existing policy holder), but maybe a sign on things to come for all companies? AXA PPP were still the best policy for me (despite no C Section coverage): I have just accepted that any further C Sections will be completely self funded...

OP, tell us if you have any luck pursuing this? However, expect no luck with the insurer (you will have to appeal to some form of ombudsman) and expect a vey long, drawn out, frustrating battle :(

(this whole issue seriously shook my confidence in heth insurance, but we still have it incase of major problems...)

QT

[ajmama]

QT I know its too late for you now but I have just put in a claim for a second section with BUPA and have been staggered at how brilliant they have been. I was not expecting anything but they have agreed to pay up without a hitch. They now have a dedicated team who deal with sections it has been painless. I was with QBE for my first and they were another story!

[ghislaine]

What I particularly didn't like was the "you posh cow at the Portland, you can afford it" vibe I got. The woman kept saying that "this is a very expensive hospital" and "we don't pay for luxuries" er, like post-operative care...?

On the other hand, they have agreed to pay all hospital fees for five days which is a not insignificant sum but it is a bit baffling what they do and don't cover eg visit from post-natal physio, yes, but visit from breastfeeding midwife = luxury.

[QTPie]

ajama, yes, they had a "dedicated C Section" team when I had my problems.... didn't help at all.... (it was January 2010).

I was incredibly pro-active - both before and after the op - chasing pre-authorisation and then the claim. I may have been unlucky and I have a feeling that my Consultant's secretary didn't help... Once the operation happens, the claim is pretty much out of the "dedicated C Section" team's hands and you are back into the normal system (chasing the claim). I escalated, many times, to managers etc and still no-one seemed to take ownership and move it along.

I still don't know if all of the people were so truly incompetent (and certainly not interested in "championing" a claim to get it ressolved) or being obstructive. Left a very bad taste in my mouth (we had been with Bupa for 13 years, 6 of those as individual/private members). Felt like a 3rd rate citizen who was being continually fobbed off...

[ajmama]

I cant speak for Aviva but Bupa will pay for the hospital fees and up to 4 days at the Portland plus about £500 towards consultants fees. They will not pay for things like Nursery Care which I think is fair enough. My final bill has gone down from £17,000 to around £9000 which is a hell of a saving. Bupa also seem to have a relationship with the Portland which I dont know if other companies do. Hang in there Ghislane, my consultant has been very helpful as well, do you have a consultant yet? If not, you do need to get a move on as they do get booked up plus they are used to dealing with Insurance Companies and can help.

[BagofHolly]

Ajmama, why only £500 towards the actual cost of the operation?? If you had to go and have your leg off they'd pay the entire cost, not give you a bung towards it! Who (the hell) will do a c section for £500? No one in the UK!

[ghislaine]

Aviva are the same - £540 for the c-section. I completely agree Holly, and for what other procedure would they only make a contribution towards the anaesthesia? I think the leather strap I'm supposed to bite down on must have fallen out of the envelope.

On the one hand I think I'm quite lucky as they will also pay for one pre and one post op consultation, and my consultant does this as a package for £2000. Before I spoke to Aviva I spoke to his very sympathetic secretary and she said that they would bill Aviva for the consultation fees in a way that was more favourable to me than if I was self-funding, so about £600-£700 for the consultations. This would mean that Aviva would pay about £1200 of the £2000. The rest presumably is to cover the post-operative care but again, what other operation would you get only nursing care?????

For anyone else who's with Aviva, they agreed to pay:

5 nights at the Portland (or any private wing of an NHS hospital - I am just going to the Portland because it's the only place my NHS consultant practices at privately) and all hospital fees. This includes nursing care, drugs, meals.
First baby check when in theatre.

Of course when you ring the Portland, their accounts dept tells you all sorts of things that they say are covered on an Aviva package which Aviva then says are not.

Aviva won't pay for:

Routine monitoring of baby (they will pay for SCBU, NICU etc if you advise them of the delivery date the week before)
Pre-discharge and hearing checks for baby
Nursery fees (although the Portland thinks they do!)
Breastfeeding midwife help (ditto)
Ante-natal care (fair enough, I am more than happy with my NHS care).

Interestingly the Portland seem to have dropped their fee for husbands/partners staying overnight which brings the bill down a bit.

All in all, I expect to pay around £2000-£3000 all up, which is a lot better than if I paid myself but I am still annoyed! I am sure there is an element of sexism and lifestyle choice-ism behind their funding decisions. Grrr.

[ajmama]

I know what you are saying Bags but I am happy to have the insurance payout that I am having. I was going to the Portland anyway and this payout is a bonus.

[BagofHolly]

I think it's fortunate that you're in the position to make up the difference, but I think it's disgraceful that these companies take their policyholders' money but then fail to indemnify against these expenses. Either they offer cover or they don't, and if they don't, they should at least be open about this instead of offering to pay a CONTRIBUTION towards the cost. That simply isn't what cover means! Aarrgh!

[whostolemyname]

This is very eye opening. Im surprised insurance companys do cover it to be honest. For most ops i can see why - you get to jump a waiting list! But for a medically indicated c-section, what is the benefit? Is it that you get a known consultant do the actually operation?

[ghislaine]

I think they cover it (if they chose to - some companies won't cover c-sections at all) on the basis that it is a "complication of pregnancy/childbirth" so you have to have some reason (eg breech, placenta previa) why a c-section is recommended over a VB.

For me, the benefits of being able to go private are:

• guaranteed a particular consultant who knows my history (indeed, a consultant in the first place rather than a registrar or SHO)
  
• guaranteed private ensuite room
  
• husband can stay overnight with me. This is very important to us, we want to be able to both stay with our baby when he's born rather than have my husband be sent off and me left on the ward
  
• 1:1 or close nursing/midwife care.
  
• pain relief and food when you want/need it.

[Chynah]

If you medically need a CS the NHS will give you one free and you can always get the private room etc afterwards at a fraction of the cost.

[BagofHolly]

There were no private rooms available at all at any of the local hospitals near me. They are often used for isolation cases or stillbirth, and unless they have dedicated private facilities are almost impossible to book in advance anyway. And even if you have a "private" NHS room it doesn't mean you get extra midwifery/nursing support, or any other facilities you'd expect to find on the post natal ward of a private unit. There's no comparison sadly.

[BagofHolly]

And just to add, as this is a thread about cs on insurance, you have to medically need one to get your insurer to pay for it.

[ghislaine]

I hear what you're saying Chynah and I do have an NHS CS agreed just in case it doesn't go to plan. But just as my NHS section will be "free" ie pre-paid through taxes, I expect my private one to be free as well as I pre-paid for it through my premiums.

My NHS hospital also has a policy of not allowing women with CS to have private rooms and has a 24 hour discharge policy so what I get for my money isn't really comparable.

[whostolemyname]

Thanks for your post ghislaine, just to clarify i wasn't suggesting you shouldn't, I think we all do what we think will be best for us and our families, I was just interested in what the benefits are just because I was surprised insurance covers it. I hope you get it sorted, it does seem the insurers want to get out of paying the appropriate amount.

[ghislaine]

No worries

[BagofHolly]

Whostolemyname I think that, IMO the real difference is in the level of (extraordinary) aftercare - private room, medics at the push of a button, roomservice, nursery for the baby if you need a sleep, extra bed for your partner etc. But you also get to meet and choose your surgeon who is unlikely to be anyone junior.

[ChocolateBiscuitCake]

I have an appointment at 36 weeks to see If I can have an ELCS at the C&W. It is DC3 and have had two previous large babies, failed epidurals, spinals, vontouse...however after DC2 I was immobile for 6 months as am hypermobile and must have done some damage during labour. This baby is measuring large for dates and I am being monitored.

As I will have 3 children under 3.5, I would like to ensure a safe delivery for the baby and try to minimise any further damage to my pelvis.

I am insured under Aviva Solutions Plus policy and wondered what their criteria for 'cover/contribution' is to an ELCS.

Anyone any ideas or experiences, please?

[helenlouisey]

Hiya, I'm not sure about aviva but the BUPA policy I have only covers medically necessary c- sections, so your consultant would have to agree this was the case, and even then they didnt cover everything, only part of the consultants fees and anaesthetist fees, but they did cover the hospital fees, accommodation and drugs while I was in hospital. They also covered a follow up appointment with consultant and also some expensive blood test as consultant thought I had a blood clotting disorder.

I think only way you're going to find out is call them up and ask if they cover any medically required c-sections and the process for getting the procedure approved.

Best of luck