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You are not covered by my health insurance

You are not covered by my health insurance

Around £3 billion is spent annually in the UK on medical insurance, covering around 7 million people. Only around one in seven policies are purchased by individuals themselves; the rest are provided by their companies. The problem is that most people who purchase medical insurance don't take the time to learn all the ins and outs of their coverage. Thus, many people have the wrong idea about the scope of the discussion. Do not assume that your health insurance will cover any and all medical expenses.

Those who have medical insurance can bypass the lengthy wait times patients in the United Kingdom's National Health Service (NHS) face to visit a specialist, get a diagnosis, or undergo surgery. That's great and all, but there are treatments and circumstances not included in the policy that you should be aware of before making a purchase.

First, though, a word of caution. Individual insurance policies have their own terms and conditions, which are not addressed in this article. Please also double-check the terms of your insurance policies. You'll be prepared now that you've read this post.


Unfortunately, it's long-term and incurable

Your insurance company should cover the expense of an acute condition if it is treatable and not expected to last a long time. If your issue is considered chronic by your insurance company—meaning it will persist despite reasonable treatment efforts—then you will not be eligible for benefits.

However, it might be difficult to determine if an illness is acute or chronic. It's not always clear-cut, and that might be a source of tension between the policyholder and the insurer.

If you have asthma or diabetes, you will almost certainly deal with these problems for the rest of your life. Consequently, we cannot cover those types of illnesses.

When doctors initially think a patient's illness is treatable, but then it worsens and they realize it's now incurable, complications occur. This is a possible outcome of cancer treatment, especially for specific forms of the disease.

Acute conditions are covered under insurance policies until they progress to chronic ones, at which point they are no longer covered. Insurers can change the status of a condition from acute to chronic as treatment progresses, making this option available.

Sorry, but that would take too long.
Long-term care is not covered by the insurance policy. Yet, you should review your coverage details to learn how "long-term" is defined. There may be cases where a patient needs medication for, say, 12 months, but the insurance company will only cover 10 of those months.

I'm afraid this is preventative.
The purpose of health insurance is to cover the costs associated with diagnosing and treating an illness or injury. Preventative care procedures are not covered by this plan.

The issue of definition comes up once more. It can be difficult to tell whether a treatment is truly preventative or curative. As an example, consider the medicine Herceptin. When administered early, this medication has shown promise in the treatment of breast cancer. Herceptin has been shown to significantly reduce cancer recurrence in women with the HER2 subtype of the disease. Is Herceptin a treatment or a preventative in this case?

The insurance industry is divided on the issue. In contrast to Legal & General and Axa PPP, Norwich Union, WPA, BUPA, and Standard Life Healthcare will cover Herceptin for HER2 patients.

Sorry, this medication is not yet legal.
The ability to bypass lengthy NHS wait times and access cutting-edge medical care are two major selling points for private health insurance. However, there is a catch.

The NHS in England and Wales relies on the Institute for Health and Clinical Excellence to vet and sanction the introduction of any new medications. Your insurance company probably won't cover the cost of the drug until that committee gives its stamp of approval. To make sure that the financial benefits to the nation from using the drug surpass the expenses of using it in the NHS, the Institute has been tasked with conducting a cost-benefit study. The Institute has been under scrutiny for very long delays in drug approval, and this is a difficult brief.

The Financial Ombudsman Service came up with a compromise wherein insurance companies would pay for the cost of an approved conventional treatment if the experimental treatment was more expensive, but the policyholder would be responsible for the difference.

A pre-existing condition, unfortunately

The underlying idea is that if you have an illness that "pre-exists" the coverage, then any claims you make to treat that illness will be denied.

That's why prospective policyholders have to fill out a long questionnaire before their insurance is approved. They will need detailed information about your health situation in order to provide an accurate estimate. With your permission, many insurance companies will also contact your primary care physician in order to collect additional information for your application. They prefer to have all the pieces in place.

Let's say you twisted your knee while playing tennis some years ago. Despite initial signs of improvement, a ruptured cruciate ligament has been discovered, necessitating surgery. The ligament damage can be considered a pre-existing condition by your health insurance carrier, meaning you'll have to foot the bill for surgery out of pocket.

Some insurance companies try to cover these ambiguities with a "moratorium" clause in your policy. These clauses often state that they will continue to cover therapy for any ailment you have had during the last 5 years as long as you have been symptom-free for the previous 2 years. These moratorium clauses are not included in all plans, and their duration varies widely depending on the insurer. You need to read your policy thoroughly.

Nope, that's not included

Like vehicle insurance, health insurance is purchased on an annual basis. Your insurer has the right to reconsider your premium and the terms under which coverage is provided at the time of renewal.

This means that you may discover that your new policy does not cover a certain treatment if you are in the middle of a course of treatment and your coverage renews. That leaves you responsible for paying for the rest of the treatment out of pocket.

More illnesses are also being treated as medical research continues to make strides in this direction. The boundary between chronic and acute diseases is being redrawn as a result of these advancements.

There are two ways in which this costs insurers money. The number of claims is growing as a result of the expanding list of diseases now considered "acute." Newer medicines, including Herceptin, tend to be more expensive than older ones. As a result, insurance companies are spending significantly more money on claims than they had anticipated. Renewal premium increases are the inevitable result of this. In addition, insurers frequently revise their definitions and exclusions in an effort to lower their risk exposure. This means that you should carefully examine your renewal notice before making a decision.

Be mindful of the gray areas if you're considering purchasing health insurance. If you have insurance and are in need of medical care, you should contact your provider as soon as possible to verify that they will pay for the procedure.

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