Private medical insurance policies are only designed to cover acute conditions, meaning if the illness you are suffering from is deemed chronic your insurer is entitled to cease your cover. The main reason for this is the excessive cost, as chronic conditions cannot be cured and only maintained over the course of a patients lifetime.
If your insurer deems your condition as chronic then it’s likely your condition is of long term duration. Sometimes you have to face the facts and accept that your condition is chronic, and your policy isn’t designed to cover this. However, there are situations where your insurer is wrong to deny you further cover and where it’s worth fighting their decision.
Signs your condition isn’t chronic:
Treatment will remedy the problem – Chronic conditions are essentially incurable, so if there’s a treatment on the market that will return you to your previous state of health, you’ve got a good argument that your condition isn’t chronic. However, this doesn’t include pain relief treatments, although these will resolve the problem for a while, the remedy they provide isn’t permanent.
Acute phase – If you’re going through an acute phase of a chronic condition then this is something your insurer should cover. Even though your condition is long term, often people have flare ups where it is worse than usual. For example, asthma is a long term chronic condition that can only be maintained, but if you need hospitalisation after an asthma attack your insurer should cover this.
Medical opinion to the contrary – If your specialists believe your condition isn’t chronic then this is something your insurer will take into consideration. A letter or phone call from your specialist will often do the trick.
All medical insurance policies come with some kind of exclusion. This could be an express term of the policy which states you are excluded from making a claim for a specific condition, or a general exclusion that applies to all policies. If your insurer tells you your condition is excluded from cover it can be frustrating. Sometimes there is nothing you can do as this is a central part of the policy you signed up for, but if you feel you’ve been wronged there a number of ways to fight your insurers decision.
Exclusions on your policy:
Fully medically underwritten policies – These policies are assessed against your previous medical conditions, and if your insurer feels its likely you’ll need to claim for something you’ve suffered from previously this will be expressly excluded from your cover. For example, if you broke your left leg in the past and exclusion could be “any injuries involving your left leg”.
Moratorium policies – These policies come with a 2 year time limit from when the policy is taken out, so the conditions excluded from cover will vary depend on the time that you claim. If you’ve not gone for 2 years without symptoms from the start of the policy, then the condition will be excluded.
General policy exclusions – All policies are subject to general exclusions, for example cosmetic treatments are excluded including bariatric surgery. This is common for all policies regardless of your level of underwriting.
What can you do about exclusions?
Fully medically underwritten policies – On these policies you can often review your exclusions after a set period of time and get them removed from your policy. Your insurer doesn’t generally broadcast this, but many conditions can be reviewed. For clarification contact your insurers underwriting department.
Related conditions/symptoms – If you’ve got an express exclusion on your policy you could find conditions related to this exclusion being unjustifiably excluded. Claims assessors aren’t medically trained and sometimes mistakes are made when they feel that a condition or symptom is related to an excluded one. If you disagree with your claims assessors decision don’t be afraid to ask to speak to their supervisor. Don’t be afraid to provide medical evidence to the contrary to prove your point.
It’s important to not be afraid of challenging your insurer. Sometimes they get it wrong just like the rest of us, and if you disagree with their decision it’s well within your rights to take it further. A complaint can lead to a fresh pair of eyes looking over your claim, who will often spot something that has been missed. However, also remember that your claim is often denied for the right reasons. Private medical insurance isn’t designed to cover excluded or chronic conditions, so unless you’re able to prove your illness doesn’t fit in these categories your denial is likely to be maintained.
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