What is condition management & why medical insurers use it?

Most medical insurance companies house within their claims departments a condition management team. This team is usually responsible for dealing with the most complex, long running and expensive cases. Don’t be surprised if you get passed on to this team if you receive a serious diagnosis or your claim has been going on for a long time. It’s standard procedure at most insurance companies, but can still be unsettling for policyholders who don’t understand the claims process.

Major national insurers such as Aviva and Bupa have a number of condition management departments that specialise in cancer, cardiovascular, psychiatric and gastrointestinal claims. If you’re suffering from one of these conditions then you’ll generally benefit from a higher standard of customer care, shorter waiting times and a more personal touch.

So what do condition management teams actually do?

  • Arrange cover – As with any other claim, if you claim is being handled by a claims management team, they can put cover in place for you to have any necessary treatment. They will often want to manage your claim for closely than usual as the treatments you are having have been taking place over a long period of time or are highly expensive. This means you’re more likely to just be given cover for the next treatment you need rather than a package of cover for a few months.

  • Closer monitoring of claims – Your insurer can keep a closer eye on your claim if they decide to give it to a specialist claims management team. You will generally be given your own adviser who will deal specifically with your case. They can do all the necessary leg work for you such as dealing with specialists and calculating fees. Plus you’ll have a named point of contact and even be given a direct line to someone who knows your case. This can be especially reassuring when you’re going through a traumatic or stressful illness.

  • Decide when a condition in chronic – Often it’s the responsibility of the claims management team to decide whether the condition is becoming chronic. If this is the case your insurer will inform you in advance that they are ceasing cover and the reasons for this.

Why do medical insurers use it?

  • Understanding – Complex claims are easier to understand if one person deals with them in their entirety. This means claims assessors aren’t going over the same ground every time they answer your call and can make effective decisions more quickly.

  • Cost – If one person is monitoring a claim it can be given increased scrutiny and declared ‘chronic’ at the appropriate point. This saves the insurer money from paying out for rehabilitative and routine treatments that do not fall within the scope of the policy.

  • Customer service – If your claim is handled by a dedicated team they are more aware of the nature of your condition, can offer increased advice and support and generally provide a higher standard of customer service.

  • Specialised claims – Some claims require specialised knowledge, for example cardiovascular and cancer claims. These teams often are staffed by medically trained staff who can make speedy decisions surrounding your condition without the wait of referring it on to a higher authority.

What kind of claims are condition managed?

  • Long term claims – If a claim is long running such as a back problem that has persisted despite several surgeries, it may be referred to a condition management team.

  • Cancer claims – Once you’ve received a diagnosis you’ll usually be passed to the oncology team who can help give you the support and advice you need throughout your claim.

  • Cardiovascular claims – Cardiac claims often involve very complex and expensive surgery which your insurer is keen to monitor.

  • Gastrointestinal claims – Many ongoing gastrointestinal conditions such as Crohns disease are complex and prone to flare ups. They benefit from claims management as they may last throughout an individuals lifetime so need close monitoring.

  • Psychiatric claims – For mental health claims the psychiatric team often have an appropriate background and training in counselling.

Do I need to worry if my claim is being condition managed?

No – It’s actually a good thing, it means you’ll be getting a more efficient and personal service from your insurer. You’ll have your own point of contact who’ll be familiar with your case and able to offer you expertise and advice when you need it. Trained condition management specialists can offer patients valuable support, and point you in the right direction of charities and local support groups that can help you come to terms with your new diagnosis.

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