What's in medical records? Why insurers use them?Your rights?

Making a new claim when you’ve got moratorium underwriting on your policy can be an unsettling time for policyholders. While some claims can be approved on the very first call to your insurer, for others more medical information is needed. Your insurer may need to write to your GP with specific questions regarding your medical history, or request that you complete a claim form with the input of your GP. But what is your insurer looking for in your medical history? And what are your legal rights when it comes to your medical records?

Why might your insurer request for more information on your medical history?

  • If you’ve got moratorium underwriting on your policy it can mean some conditions and symptoms are excluded from cover.

  • You will only be covered for medical issues which you had no symptoms, treatment, advice or medication for in the five years prior to your policy, if you have gone for a 2 year clear period without treatment, advice or medication.

  • Your insurer will want to see if there’s anything documented in your medical records which could mean the medical issue you are claiming for isn’t covered.

  • This isn’t because they don’t believe you. It’s hard to remember dates that far back, and easy to forget medical issues you had years ago. Some people get offended when claims assessors ask for a claim form, don’t take it personally, it just means they’re doing their job.

What are your legal rights surrounding your medical records?

  • Your insurance company can’t apply for a medical report about you without your consent. The law surrounding this is governed by the Access to Medical Reports Act 1988.

  • You can request to see the report before it’s sent to your insurer. This means that once it’s been written, you’ll have 21 days to view and approve it. Your GP won’t send the report to your insurer without your consent.

  • If you don’t want to see your report initially, you still have the right to view a copy of it within six months, although you may be charged for the photocopy.

  • If the report contains any aspects that you disagree with, you can ask for it to be amended. If your GP refuses for any reason, then you can ask to include a statement of your objections for your insurer to see.

What happens if you deny your insurer access to your medical information?

Failure to give your insurer access to your medical records could mean they don’t have the information they need to properly assess your claim, which would ultimately mean your claim is denied.

What’s documented in your medical records?

  • Visits to your GP – Including what the problem was and any advice given.
  • Treatments
  • Prescribed medications
  • Details of referrals to specialists
  • Accurate dates of all medical activity

What isn’t included in your medical records?

  • Medications you’ve bought over the counter from a pharmacist without a prescription.
  • Any private physiotherapy, chiropractics, osteopathy or accupuncture you’ve had without going to your GP first.
  • Alternative therapies

What does this mean for claims on a moratorium policy?

  • It’s important to be honest with your insurer and answer any questions they ask, but sometimes saying too much can actually go against you.

  • If you’ve got a moratorium policy and want to qualify for a medical issue you’ve had in the 5 years prior to the policy, then you need to go a 2 year period from the policy start date without medication, treatment or advice.

  • In practice this means if you’ve had symptoms of the problem but not done anything about it, you’d still be covered, although obviously your insurer wouldn’t encourage this.

  • Medication refers to any prescribed or over the counter medicine. However, although your insurer can access your medical records if you give them permission, they’ll not be able to see any over the counter medication such as paracetamol, ibuprofen and indigestion tablets etc.

  • If you mention for example, that you’ve taken medication for back pain such as paracetamol, this could invalidate your claim as it may mean you don;t qualify for that 2 year clar period! Also, as all insurance calls are recorded, it’s also not something that you’re able to go back on later.

What does a denial mean?

  • If your claim is denied it means you’re unable to be funded by your policy for private treatment on the facts your insurer presently has.

  • Your insurer may be open to re-assess the claim if you can provide additional information to prove your claim’s validity, such as a letter from your GP or specialist.

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