Cover for routine consultations for long-term problems: Yes/No?

Private medical insurance is designed to cover acute conditions, but sometimes an acute condition develops into a long term problem.

So what happens then?

This is best illustrated by using an example, so lets imagine you fell over and slipped a disc in your back. Your back was fine before but now you’re in a lot of pain and require surgery to re-attach the disc. This would be covered under your medical insurance, as it’s clearly a new problem that would be regarded as acute. Once you’ve had the surgery your consultant refers you to a physiotherapist and asks you to return in 6 weeks time for a follow up consultation. Your policy should also cover you for this.

When you go back to your consultant for your post-op assessment you’re still suffering from a lot of pain. Your specialist examines you, sends you for some scans and finds the disc in your back is starting to degenerate. There’s no procedure your specialist can perform for you, but it’s something you can help maintain and keep at bay by regular physiotherapy. At this point when you phone your insurance company to advise them of this, they will explain to you that the condition is likely to be turning chronic. They will usually cover you for another check up as a gesture of goodwill, but after that you will be no longer covered for this condition unless you go through another acute stage i.e your disc slipping again.

This leaves you in the position where you need further physiotherapy and annual or bi-annual check up’s with your specialist, but your insurer won’t cover you. If you’re fortunate enough to take out cover for routine consultations and maintenance now you’ll be able to use it. This additional cover will finance a block of physiotherapy sessions for you (usually 10 over the policy year) and cover for your routine consultations with the specialist.

What are ‘chronic’ conditions?

For details regarding the nature and scope of chronic conditions see Chronic conditions which require regular monitoring and maintenance include back problems, heart defects and diabetes. Regular physiotherapy, scans or blood tests can ensure these conditions are kept stable over a long period of time, but they won’t provide a cure.

What are ‘routine’ consultations?

Routine consultations are meetings with your specialist at fixed intervals throughout the year. They are used for monitoring an existing condition. They could include an examination by your specialist, discussion regarding your medication and any new medical treatments that are becoming available. They are designed to ensure your condition is maintained at a safe level, and if anything is going wrong that it can be spotted in a timely fashion so your specialist has time to act to correct it.

Advantages of taking out routine benefit

  • Enables you to stay in the private sector without having to go back to the NHS for routine consultations.

  • Gives you the peace of mind that you won’t have to foot the bill for any expensive private consultations.

  • There’s less chance of your claim being denied, which can be stressful. It’s easy to misunderstand the distinction between acute and chronic conditions and think you’re covered when in fact you’re not.

The downsides of taking out routine benefit

  • Like all additional options, routine benefit has a limit attached to it. This is usually £1000 and although it might sound a lot, in terms of medical costs it won’t actually get you a great deal for your money. Due to the cost of specialists fees it will only cover 3-4 consultations a year.

  • There’s no cover for any kind of treatment for chronic conditions, only maintenance. However its worth noting that if you do suffer from an acute phase of the condition, where it becomes unusually severe, your insurer could cover treatment for this. Unfortunately there are no hard and fast rules as to whether a condition is seen as acute or chronic, this is ultimately at the discretion of your insurer.

  • Normally young healthy people suffer from acute conditions which rarely become chronic. This could mean you end up paying more money for something that doesn’t benefit you.

Like all the additional extras you can include on your policy, you need to think about your own personal circumstances and whether you’d use a routine benefit on your policy. Sometimes peace of mind is worth a slightly higher premium, but if you’re struggling to make your repayments already, it makes sense to leave it off and go with a no frills approach. Remember you can always add and remove ‘extras’ at the end of your policy year.

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