Private Health Insurance - Best Practice

[cardamomginger]

Hi,

I have posted this in General Health as well.

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!

As far as I am aware (and I'm a general commercial insurance lawyer, not health) they wouldn't usually be able to unless there is something in the terms and conditions of the insurance which gives them scope to do so - it should be a matter of basic contract. Have you checked your insurance policy to see what it says about limits of payment? For example, look for words like "we will pay reasonable ongoing consultation costs" or something which allows for some discretion from the insurer.

You say that the insurer originally agreed to meet all costs in full - did they say that in writing? If so, it seems to me that you should be covered for all costs provided they relate to the original referal unless there is an argument that you are now being treated for issues which go beyond that.

Thanks. I will check the T's and C's again - and the ABI have said that I should go back to them (AXA) and ask them to specify exactly which clause entitles them to do what they've done.

I have nothing in writing saying that they will cover all fees - only statements issues after each invoice was paid stating that the invoice has been paid in full. When I verbally obtained authorisation for each consultation and procedure, I was told that it was all OK. This contrasts to consultations I had with other specialists (I sought second and third opinions) when they did state there was a limit on the amount they would pay.

The treatment I am receiving now relates to the original problem. And whilst the treatment and surgery, the fees for which I have now run into problems with, had not been booked before the cap was implemented, I informed my insurers that I would require further treatment and surgery, so they were aware of this and noted it on my file before they imposed the cap. Do you think this would make any difference? I suppose part of the argument is whether each consultation and episode of treatment is taken as a discrete and separate incident, or whether the totality of consultations and treatment is seen as a single process. I'd argue the latter, whereas I'm sure they'd argue the former!

It sounds as though all should be considered as relating to the original problem. If they aren't asking you to stump up further excess payments (assuming you had one in the first place - and some policies require a new excess payment to be made each year so check that), that would suggest they consider it all to stem from a single claim too. The fact that they've tried to introduce a cap after being told that further treatment would be made is a little suspicious - again, check the t's and c's for any discretion for the insurer to alter their terms and/or impose a cap. It seems unlikely to me so you are right to press them as to their basis for doing so.

It's not something that is specific to my policy, it's something specific to the consultant. So the same situation of capped fees applies to all patients of his who are claiming through AXA. Don't know whether this has any bearing on it one way or the other?

Really appreciate your input - thank you so much!

That is even more bizarre! So are they saying there wouldn't be the same cap if you used a different consultant? I can see why you are confused! All I can say is keep pressing the insurer to confirm (in writing) the basis on which they claim to be entitled to do this. It sounds very strange. Good luck!

Thanks for your help!