Private Health Insurance - Best Practice

[cardamomginger]

Hi,

Hope that someone might know the answer to this:

Are Private Health Insurance companies permitted to cap the payments they will make towards consultation and treatment fees after a patient has embarked upon a course of treatment with a particular consultant?

I started a course of consultation, investigation and treatment in February 2011 and my insurers agreed to meet all costs in full. They did not state at any time that this might change and a cap might be put in place in the future. Fast forward to March 2012 and a limit has been put on the payments they are willing to make, leaving me with a shortfall. My consultant has not increased his charges and the introduction of the limit does not coincide with the renewal of my policy.

The consultant's practice manager believes that health insurers are not permitted to place a limit on payments once a patient has started treatment, but she can't point me in the direction of any document that says this. I'm ploughing though the FSA and ABI websites with not much success. The Financial Ombudsman cannot advise, as this would compromise their impartiality.

Will be really grateful if anyone can help!

I think it depends on the terms of both your origional policy and the letter agreeing to treatment.

Are you paying the hospital, or are they paying the hospital directly? If they pay the hospital directly the hospital may absorb the cost. The hospital I worked for did this, BUPA would only pay a set amount for a pacemaker implant and not pay above that.

I spent an interesting morning explaining that an ICD is not a pacemaker and does cost considerably more.

Regardless of what you find in your T and C - talk to the hospital finance department, if it is only a small amout, they may waiver it, you are more valuable to them if you pay 90% of the fee than going elsewhere and them getting 0.

I'll have another read through the policy. I never had a letter from the insurers (AXA) agreeing - just statements after each invoice for treatment informing me that the amounts had been paid in full.

Hospital fees continue to be met in full (outpatient investigations, day case treatment and inpatient surgery), it's just my consultant's fees for consultation, investigation and surgery that they have imposed a limit on.

Thank you for replying!

OP* What jumps out here is- were the limits already in place but you didn't know about them when you began treatment?

There is a difference between the insurers saying they will " meet all costs" and yet these will still be within the limits of your out patient allowance.

You should have been told- at the time, vernbally, and in writing beforehand, which limits there were.

Both DH and I have an out patient limit of £900 after which we have to top up- and indeed have, often- when the fees/investigations exceed this within the year.

Ameila - this is not an excess on the policy, nor is it that I have reached the limit of my cover for certain types of treatment. The cap on fees is, as I understand it, specific to my consultant, not specific to my policy. So it would apply to all his patients who are covered by AXA. At the time that I began my treatment, there was no cap.

Have heard back from the Association of British Insurers, who can't help me. I'll read through the T's & C's of my policy again and insist that AXA point to exactly where it is in these T's & C's that it states they can do what they have done. Still waiting to her back from the Financial Services Authority.

I find it very odd that thre in no limit on your out patient limit.

I don't want to be pedantic but I think you should double check. I've never ever heard of l imits per consultant. We have had private cover for 25 years and although the provider has changed- it's a company scheme so they shop around- the basic elements of a limit have always existed.

Have you asked WHY there is this cap? Are you possibly confusing it with payments for on going chronic care which they will not provide, once your acute condition has been assessed and treated?

We have a policy through my husband's company which has no limits on inpatient treatment or outpatient consultations, diagnostic tests or treatment. There are limits for physio that is not provided within a hospital setting (be that inpatient or outpatient) and I think there are limits on things like acupuncture - we are entitled to a certain number of sessions per year. Things like outpatient medication is not covered - but I don't think that's ever covered. There are also limits on things like hospice care and possibly some elements of cancer care (not read this) - but that's standard across insurers and across policies.

It is quite common to impose a limit on a consultant's fees. I've had in the past for anaesthetist's charges, and in this bout of ill health the 2 consultants I sought second and third opinions from charged in the region of £300 per consultation and AXA only met I think it was £175 of the fee, leaving a shortfall that I had to meet (I was informed of this when I made the appointments - so I have no problem with this.). This is because for each clinical speciality the company has calculated 'average' fees that a consultant should charge for a consultation or for a certain procedure. (Quite how these averages are calculated and whether they take into consideration things like sub-specialty training and seniority, that should entitle a consultant to charge a higher than average fee, because of their greater experience, is open to debate!) Where a consultant decides to charge more than this 'average' amount, the insurer may still decide to meet the total fee. They may ask the consultant to reduce their fees, to bring them more in line with the 'average'. Or, as in the case I have, they may decide to place a limit on the amount they will pay, leaving the insured patient with a shortfall. This is nothing to do with the policy the patient has - I have confirmed this with AXA. It is to do with the consultant and the fee scale the consultant has. Of course, if a patient also had an excess on their policy, or exceeded the limits of their cover, again there would be a shortfall to make up. But that is not the situation here.

This is not a situation of ongoing chronic care. I sustained multiple serious birth injuries when I gave birth to DD 21 months ago and I have had to have investigation and treatment from an orthoapaedic surgeon (whose fees are met in full!) as well as from my uro-gynae surgeon. I have just had my second major operation. It's all acute. All designed to get me back up and cartwheeling again .

cardamon you haven't told me anything in your last post that I didn't know already:)- especially the middle paragraph- which I am familiar with.

We have a limit of £900 and somethinglike £300 for complementary treatments which you talk about here.

I still think it is very unusual for a company policy to have no limits to out patient charges, and given your predicament, think your husband or you should check with the insurance company.

One point- have you actually asked them why they have imposed this limit seemingly retrospectively? If you have- what did they say?

whatever- hope you are now better:)

Just to reiterate- your DH if it's his policy- should get an annual statement clearly stating what is provided. You should have a policy booklet. He will need all of this as it's considered a perk and will be liable for tax on it- hence the usual need for limits which he would declare.

I still don't understand what the company has had to say- sorry not being awkward but surely you have spoken to them and been given an explanation- however unfair it may seem?

Maybe my husband's company provides a higher level of cover than your's? Before switching to this policy I was on an individual policy that also had no maximum for most things (aside from acupuncture and physio). That had an excess of £100 per year.

I'm looking at the brochure now and it clearly states there is no annual maximum for inpatient and day patient specialists' fees; inpatient consultations; outpatient surgical procedures; outpatient specialist consultations; outpatient diagnostic tests; outpatient radiotherapy; outpatient scans; hospital at home; ambulance services. Why don't you believe me?!?!???

I'm sorry if my middle paragraph didn't say anything you didn't already know and if it came across as patronising, that's not what I intended. I wrote it in answer to your comment that you had not heard of limits per consultant - it felt helpful (as much for anyone else who reads this thread who might be able to help me) to respond in detail.

(Of course, maybe your policy is better than ours in that yours doesn't limit the amounts paid to consultants for consultations, procedures, etc.... The consultant's practice manager has said that other insurers do meet his charges in full.)

I'm clear about the reasons for the cap on his fees - AXA say my consultant has consistently charged over the 'average' and they are placing a limit on the amount they will pay towards his fees. I've discussed it with them, I've discussed it with his practice manager and it is a decision they have reached on the basis of his charges and their assessment of them, not on the basis of my policy. It applies to every patient of his who wishes to claim under AXA, no matter what their policy stated - I have confirmed this with both AXA and with the practice manager.

BTW - it's not retrospective - it applies to consultations and treatment from end March onwards. My original question was that as these are part of a programme of ongoing treatment that they originally funded in full, are they now, and without warning me of the possibility of this when I started treatment at the beginning of last year, allowed to limit what they will pay.

Thanks for your good wishes. Just wish this wasn't an additional hassle for me .

Oh and as I said in my OP - the Practice Manager believes that they are not entitled to do this to existing patients, but she can't find where it says this.

If they are entitled to do this and they/the consultant are not willing to make an exception as a gesture of good will, then I'll just have to suck it up. But if there is something that indicates they are trying to pull a fast one, I'd like too know!

HMMM. I don't know. Our policy re. inpatient investigations etc gives a list of hospitals and if they are covered. Outpatient investigationst like blood tests and scans come out of the £900 limit and they will not pay for repeated scans etc etc on a condition that has been diagnosed and treated, even if on going monitoring is advised. I am currently having to pay for annual/biannual scans etc that they no longer pay for.

There has always been a limit to out patients and I believe what we have is a reasonable policy- my DH is senior in the company. However, happy to believe what you say!

Based on what you have said here- I think the insurers should have raised this at the start and said that the condultant's fees were relatively high- and that this might be an issue longer term. They would normally say what the limit of the fee was per consultation/investigation.

My consultant has always worked within the limits of scales that insurer has.

I assume you know too that many consultants and hospitals have 2 scales- one for insurance and one for self funding? if you now have to self fund then your consultant may lower the fee anyway.

On another point- I think your dr sounds greedy! If his fees are high and his patients are having to self fund after a while, that is not good practice.

I know - it is a bit of a hmmm, isn't it....

In my consultant's defence, he charges a lot less that the £300 the second and third opinion people charged and he is EXTREMELY senior and very highly specialised. DH is seeing a surgical Prof for something (it's quite busy in our house at the moment!) who charges a lot more than my consultant ad they meet this charge in full. It all seems so arbitrary.....

Useful to know about the different fee scales.... Thanks for that!!