PEC 101. (c) PT&A HEALTH September,

Transcription

1 PEC 101 (c) PT&A HEALTH September,

2 Why do we need to be concerned about PECs? The legislation (and contracts) concerned with general insurance requires people to disclose if there are any circumstances that may affect the risk associated with the insurance duty of disclosure. Private Health Insurance does not have this protection it has its own legislation dealing with pre-existing conditions that affords the funds and their members protection for the first 12 months after a member joins or upgrades cover. (c) PT&A HEALTH September,

3 The Pre-Existing Condition Rule Where is the information and authority? PRIVATE HEALTH INSURANCE ACT 2007 (Supersedes the Pre-Existing Ailment provisions in the National Health Act, 1953) PRE-EXISTING AILMENTS BEST PRACTICE GUIDELINES (Commonwealth Circular HBF 736 / PH 470) (c) PT&A HEALTH September,

4 Where are the provisions in the Act Section Meaning of pre-existing condition (1) A person insured under an insurance policy has a pre-existing condition if: (a) The person has an ailment, illness or condition, and (b) in the opinion of a medical practitioner appointed by the insurer that issued the policy, the signs and symptoms of that ailment, illness or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the policy. (c) PT&A HEALTH September,

5 EXCLUSIONS from PECs NOTE: Section 75-1 Waiting period requirements (1)(b) disallows the 12 month PEC waiting period from being applied to: psychiatric care rehabilitation palliative care ONLY the general 2 month waiting period can be applied - so if that has been waived there is no waiting period applicable! (c) PT&A HEALTH September,

6 We now need to define the terms in the Act. Ailment, illness or condition are NOT DEFINED in the Act so how do we define them? We are not lawyers but the Acts Interpretation Act indicates that: We must have regard to the desirability of being able to rely on the ordinary meaning of the word or provision and we must take into account the context of the word or provision within the Act and the purpose or object underlying the Act and the need to avoid prolonging legal or other proceedings if there is no compensating advantage in doing so. (c) PT&A HEALTH September,

7 Ailment, illness or condition Ailment: any bodily disorder or chronic disease or minor illness. Illness: unhealthy condition of body or mind or a sickness. Condition: state of health, appearance, fitness, etc. Covers things that are not actual sicknesses or illnesses (c) PT&A HEALTH September,

8 SYMPTOMS and SIGNS SYMPTOM: Something subjectively noticed or reported by the patient. At some time in the relevant 6 months. e.g. sore throat, painful wrist, abdominal pain, vomiting, etc. SIGN: Something related to an ailment illness or condition that is noted by the medical practitioner either in questioning (history), examination or in the results of various tests. Symptoms and signs can overlap and that is why the legislation says symptoms OR signs. It does not matter which it is. (c) PT&A HEALTH September,

9 Symptoms/signs/risk factors The symptoms or signs MUST be relevant to the ailment illness or condition in question!!! RISK FACTORS!!! e.g. pure family history of bowel cancer resulting in a colonoscopy in the first 12 months of membership. Pure risk factors with no other symptoms or signs cannot be used to form an opinion that a matter is a PEC!! The consolation in the above example is that if a bowel cancer is picked up early it is far better for the patient and is usually far less expensive for the fund. (c) PT&A HEALTH September,

10 If the patient has not seen a medical practitioner in the relevant 6 months As a medical practitioner I can form the opinion that: in my medical opinion if the patient had been examined at the time of joining the fund, symptoms or signs would have been evident but I have to be able to justify that as a medical opinion to the Ombudsman or the Courts if necessary. The guidelines indicate that I cannot form the opinion that a matter is a PEC based on the patient having to have exhaustive or complicated tests such as coronary angiograms, surgical procedures, etc., at the time of joining the fund. (c) PT&A HEALTH September,

11 Chronic or known problems It is sometimes possible for signs to have been present for more than 6 months with no symptoms or further signs being present during that 6 months. In some of these cases the problem can still be PEC. Example: A patient had gallstones diagnosed by imaging a year before joining and then had no symptoms and no further tests during the 6 months prior to joining. Three months after joining the patient had a cholecystectomy to remove the gallstones. (c) PT&A HEALTH September,

12 Chronic or known problems The medical opinion was that the gallstones were a PEC because: Even though there were no symptoms during the 6 months prior to joining and no investigations were undertaken during that time it is clear that the existing imaging record showed the gallstones were present (a clear sign!) and gallstones do not disappear of their own accord (and indeed they didn t the gall bladder had to be removed after joining). (c) PT&A HEALTH September,

13 Increasing challenges to PEC opinions The number of PEC opinions being challenged is increasing significantly. Therefore we all have to be careful that proper legal process (as detailed in the legislation) is followed to ensure fairness and to minimise the risk of possible litigation. NOW let us move on to look at some examples that demonstrate how the process works and how difficult it can be. (c) PT&A HEALTH September,

14 Case Presentation Number 1 Genetic Markers (c) PT&A HEALTH September,

15 Predictive Genetic Testing Research unlocking the genetic code contained in every human cell began in An international collaboration - The Human Genome Project - produced a working draft in 2000, and a final DNA map in Medical applications for this new knowledge began to emerge in the 1990 s, and we have now seen the proliferation of the predictive medical services industry. (c) PT&A HEALTH September,

16 Predictive Genetic Testing Genetic Test Kits are becoming increasingly available. The US experience has been that regulation is challenging! The reality is that most of the available test kits have reached the market without FDA approval. (c) PT&A HEALTH September,

17 Predictive Genetic Testing At this time, no genetic test can predict with 100% certainty that a person will develop cancer they can only indicate an increased risk. Breast Cancer 1 and Breast Cancer 2 (BRCA1 and BRCA2) gene mutations are associated with a significant increase in lifetime risk for a patient developing breast and/or ovarian cancer. (c) PT&A HEALTH September,

18 Predictive Genetic Testing A woman who carries a BRCA1 or BRCA2 gene mutation has a 30-60% lifetime risk of developing breast cancer, and a 20% lifetime risk of developing ovarian cancer although she may remain free of both of these cancers. Not surprisingly, some women elect to have preemptive surgery to reduce their risk, before they develop any signs or symptoms of any cancer. Is a known genetic predisposition only a risk factor, or can it be a condition as well? (c) PT&A HEALTH September,

19 RECAP of Case Number 1 Dawn had genetic testing performed 15 months prior to joining the fund the test showed that she had the BRCA2 variant gene. This puts her at significant risk of developing breast and ovarian cancer. A hysterectomy and a possible bilateral mastectomy were advised. 12 months after receiving the test result Dawn went onto the public surgical waiting list. Dawn joined the fund 1 month after this. (c) PT&A HEALTH September,

20 DISCUSSION on CASE NUMBER 1 Does Dawn have an ailment, illness or condition? Is the positive test a symptom, a sign or a risk factor? Does Dawn have a pre-existing Condition? (c) PT&A HEALTH September,

21 CASE PRESENTATION NUMBER 2 and DISCUSSION (c) PT&A HEALTH September,

22 END (c) PT&A HEALTH September,