 P.M.I. Buying Guide
Please seek Independent Advice from us regarding Private Medical Insurance as
this product type is very complex.
Take a look at this guide
before you decide.
(information taken from
Association of British Insurers Website November 2004)
What is
Private Medical Insurance?
Private medical insurance is
designed to cover the costs of private medical treatment for curable short term
illness or injury (commonly known as acute conditions).
Most people buy this type of
insurance to gain the reassurance of knowing that treatment is available
promptly, if you or a member of your family become ill or are injured, (if
family all insured within a plan).
Some illnesses and treatments
will not be covered by a private medical insurance policy and these are common
to most schemes. It is also important to remember that this insurance is not
designed to replace all of the services offered by the NHS. Some, such as
accident and emergency, are beyond the scope of most private hospitals.
How do I
choose the right cover?
When looking at cover, it is
useful to know that treatment is categorised in the following way :
In-patient This is
when you go into hospital for private treatment or investigations and stay for
one or more nights.
Day-patient
This is
sometimes referred to as day-care, or day-case. It is when you go into hospital
for private treatment or investigations but do not need to stay in hospital
overnight.
Out-patient
This is
when you receive treatment or investigations or consultations which do not need
you to stay in hospital either as an in-patient or day-patient.
There is a large variety of
schemes available, from low-cost schemes, offering limited cover, to those which
offer wide-ranging cover and benefits. Most schemes offer cover for in-patient
and day-patient care, but not always out-patient..
What am I
covered for? What does my
cover not include?
Remember, private medical
insurance is designed to cover treatment for curable, short-term illness or
injury (commonly known as acute conditions). Some illnesses and treatments are
never covered and these are common to most schemes.
Usually included :
Cover for treatment of
short-term, acute, medical conditions
In-patient tests
Surgery
Hospital accommodation and
nursing
Sometimes included :
Out-patient tests
Out-patient consultations with
a specialist
Overseas cover
Cash payment for treatment
received as an NHS inpatient
Travel insurance built into
plan.
Usually not included :
Conditions you had before
taking out the insurance (commonly known as pre-existing conditions)
GP services
Cover for long term illnesses
which cannot be cured (usually referred to as chronic conditions)
Accident and emergency
admission
There are other conditions or
treatments normally outside of your cover including drug abuse, self-inflicted
injuries, out-patient drugs and dressings, HIV/AIDS, infertility, normal
pregnancy, cosmetic surgery, gender reassignment (also known as sex change),
preventative treatment, kidney dialysis, mobility aids, experimental treatment,
experimental drugs, organ transplant, war risks, injuries arising from dangerous
hobbies (often called 'hazardous pursuits').
What will
affect my premium?
Whichever scheme you choose, it
is likely that your premiums will rise above the rate of general inflation.
This is because of factors which affect how healthcare is provided in all
western economies.
Each year more people claim on
their insurance cover for private medical treatment. A hip replacement costs
around £6,000.00 and is a common procedure, particularly for older patients.
The number and sophistication
of treatments to improve quality of life is increasing steadily.
Your Choice
of cover will affect what you pay :
Paying an excess (paying the
first part of a claim yourself).
Choosing to receive treatment
at a specified hospital.
Receiving treatment under the
NHS when it is available within 6 to 12 weeks.
Paying for part of your
treatment (first out-patient consultation with a specialist).
Choosing a different grade of
hospital accommodation.
Will I need
to provide details of my health?
Insurance Companies may accept
your application for cover in one of two ways :
Medical History Declaration (Full Medical Underwriting—FMU)
You are asked to fill in a
form, giving details of your medical history. If necessary, the insurance
company may write to your doctor for more information. It is essential that you
give all the information you are asked for in full. If you don’t, you may find
that your insurance company questions claims that you make in the future.
If you are not sure whether or
not to mention something, it is best to do so. If you have a medical condition
which is likely to come back, the insurance company will issue a policy, but
that condition (and any related to it) will probably not be covered, either
indefinitely, or for a set period of time.
Moratorium :
This is when you are asked to
fill in a form, but you are not asked to give details of your medical history.
Instead, the insurance company does not cover any medical condition which
existed in the last (usually) five years.
These conditions may
automatically become eligible for cover, but only when you do not have symptoms,
or receive treatment, medication, tests and advice ( from your GP or a
specialist ) for that condition for a continuous period of ( usually ) two
years, after your policy has started.
There are some conditions, for
example chronic conditions, that will probably never be eligible for this
delayed cover because you will always need regular or occasional treatment,
medication, tests or advice for them. You should not delay getting medical
advice or treatment, simply to get cover.
If your insurance company
offers a 'moratorium', they will give you printed information explaining how
their particular moratorium works.
Will my cover be
effected if I am disabled?
Insurance
companies will not refuse to cover you because you are disabled. As with
other pre-existing conditions, your insurance company may exclude cover for
treatment arising directly from your disability. However, it must be
reasonable and fair for them to do this.
If you
sigh a 'medical declaration', you must reveal all relevant information about
your disability. If your policy automatically does not cover pre-existing
conditions, then an existing medical condition causing disability, or arising
from it, will not be covered. If you would like more information, call the
Association of British Insurers on 0207 600 3333 and ask for the information
sheet 'Insurance for disabled people'.
How
do I make a claim?
Apart
from emergency admissions to NHS hospitals, all medical treatment has to start
with a referral by your GP to an appropriate specialist.
You :
Before you receive any treatment privately, you should call your insurance
company to check that you are covered for the treatment that you will receive.
In fact, some insurance companies insist that you do this.
Your GP
and your specialist will probably need to fill in and sign your claim form.
Your GP may charge a small fee which will not be covered by your insurance.
Your
specialist may recommend tests, admission to hospital as an in-patient, or a
day-case treatment.
Most
hospitals and some specialists have their bills paid directly by the insurance
company. Others will send the bills to you.
Your
Insurance Company:
Your insurance company will give you all the guidance you need, confirm what
your cover includes and, if necessary, send you a claim form.
Stay in
contact with your insurance company, who will confirm that any treatment you
plan to receive is within your cover.
Your
insurance company will tell you how they pay claims. Remember, if you have
chosen to pay an excess, you will still have to make that payment.
How is private medical insurance controlled?
Industry
Code of Practice :
Providing advice regarding
private medical insurance comes under the Association of British Insurers Code
of Practise covering selling general insurance and other guidelines which cover
private medical insurance. The code and other guidelines cover training,
face-to-face and phone selling, as well as standards of documents and handling
complaints.
Your
application form :
Your application form is the
basis for the contract with the insurance company. Always fill it in fully and
accurately. If you don’t, your insurance company may refuse to pay your claim
and could even cancel your policy.
Absolute
confidentiality :
By law all insurance companies
have to treat personal information, especially medical details, with absolute
confidentiality. Totally anonymous statistical information is sometimes given
to outside organisations carrying out research.
A formal
procedure for handling complaints :
Most insurance companies have
their own complaints procedures in place, so if you have a problem with any part
of your cover, speak to your insurance company first. If you are not satisfied
with the way in which your complaint is handled, you can contact either the
Insurance Ombudsman Bureau, or the Personal Insurance Arbitration Service
(depending on which one your insurance company uses). These services are free
of charge to you.
Your
checklist :
You agree to give the insurance
company all the information they need.
You agree to pay regular
monthly or yearly premiums as long as you want cover.
The cost of your premiums may
increase once a year when you renew your cover.
If your insurance company plans
on making changes and improvements to a scheme, all customers will be told
before they renew.
If you change insurance
companies, you may not be covered for conditions or treatments that your
existing policy covers.
Cooling-off
period
Once you have received your
policy, read it carefully :
Read your policy document
carefully, you must keep to its terms and conditions. However, if you did not
receive all the policy documents before you decided to buy the policy, you will
be given a cooling-off period, of around two to four weeks, in which you can
make sure the policy is right for you.
If you decide not to go ahead
you will usually receive a full refund of premiums you have already paid, unless
you have made a claim.
If you want to cancel your
policy after the cooling-off period, your insurance company does not have to
refund your premiums, even those you have paid up front.
Useful
Addresses :
If your insurance company
cannot sort out your complaint, the following organisations will tell you how to
go about taking the matter further (your insurance company’s literature will
tell you which one to contact ). Their decisions are binding on the insurance
company, but do not affect your right to take legal action if you want to do so.
The
Financial Ombudsman Service
South Quay Plaza
183 Marsh Wall
London
E14 9SR
Telephone : 0845 600 6666
The
Personal Insurance Arbitration Scheme
12 Bloomsbury Square
London
WC1A 2LP
Telephone : 0207 4217444
For general information on
insurance and, more specifically private medical insurance, you can contact :
The
Association of British Insurers
51 Gresham Street
London
EC2V 7HQ
Telephone : 0207 600 3333
Web : www.abi.org
| 
R.J.
Nash
Consultancy Ltd
