Medical Insurance Long Term (chronic) Conditions Explained

Transcription

1 Medical Insurance Long Term (chronic) Conditions Explained October 2013 FS wpa.org.uk EMS IS

2 Introduction This leaflet explains how we manage claims for our policyholders whose medical condition becomes long term (chronic). Private medical insurance gives cover for short term treatment of acute medical conditions which start after you have taken out your policy and which can be cured. Your policy does not cover treatment for chronic medical conditions that keep on coming back or need long term monitoring and management to suppress their effects. Examples include: diabetes, glaucoma, Alzheimer s disease, macular degeneration, ulcerative colitis, Crohn s disease, MS, rheumatoid and juvenile arthritis. Policy terms that would normally apply to long term conditions do not apply to cancer. Please refer to the section of your Guide on cancer. 1

3 What is a long term (chronic) medical condition? A long term (chronic) medical condition is commonly recognised as a disease, illness, or injury that has one or more of the following characteristics: it needs ongoing or long term monitoring through consultations, examinations, check-ups, and/or tests; it needs ongoing or long term control or relief of symptoms; it requires your rehabilitation or for you to be specially trained to cope with it; it continues indefinitely; it has no known cure; it comes back or is likely to come back. What does this mean in practice? If your illness or medical condition requires recurring consultations over a long period (normally more than a year), checks on your medication or long term therapy or treatment to ease symptoms, your condition may have become long term. If you are having therapy, such as osteopathy, physiotherapy or chiropractic treatment, we would normally consider treatment that has continued for more than 6 months to be long term, hence chronic. It may not always be clear when you first have investigations and/or treatment for your symptoms that your condition could be defined as long term. Whilst we will cover the costs of reaching the diagnosis, it is important that as soon as a diagnosis is made you contact us so that our medical team can determine whether your condition might be defined as long term and at what stage no further benefit would be available to cover the costs of continuing management or treatment. We would always allow you time to make alternative arrangements once your medical condition has been defined as long term. The fact that we may have paid for treatment for that condition in the past does not necessarily mean that we will continue to pay for it in the future. If your treatment has been ongoing for some time (usually more than 6 months) then you should inform us so that we can review your condition to establish whether your condition falls within the long term definition. What happens next? First, we will write to you and explain why we think your condition may be classified as long term. If there is insufficient medical information or if you disagree with our decision, we will ask you to contact your specialist or GP who knows your particular circumstances to ask for their clinical view. Your doctor s reply will be personally reviewed by our Chief Medical Officer if there is any doubt as to the decision that should be made. If it is decided that your condition should now be defined as long term we will let you know, and give you time to make other arrangements for your continued treatment, such as asking your doctor to transfer you to NHS care. We will always take note of your particular circumstances and look at your case on an individual basis. 2

4 If we establish that your condition is not currently long term we may need to review it again, after a period of time. In this event we will advise you and your specialist when we will need an update on your condition. What if my condition gets worse? If your condition flares up again after a period of remission, you may be suffering an acute exacerbation. If you have an acute flare up of your condition this may be eligible, within the terms of your policy, on re-referral by your GP. For an ongoing condition which requires monitoring and management on a long term basis, we would consider an acute flare up to be a development of severe new, or life-threatening, symptoms not previously experienced, that can only be investigated/treated by a specialist; or existing symptoms flaring up to the extent that an acute surgical intervention is needed. This would not include investigations such as endoscopies that are primarily diagnostic or treatment for relief of symptoms consequent to a long term illness, e.g. pain relief injections. Targeted Therapies (Advanced Therapeutics) for long term conditions Targeted Therapies are sometimes called Advanced Therapeutics which include cancer growth inhibitors and monoclonal antibodies. Certain Targeted Therapies are now being used for long term conditions ranging from macular degeneration, to Crohn s disease and Rheumatoid arthritis. If your specialist considers that you may respond to a short term course of a Targeted Therapy, such as Lucentis, Xolair or Remicade (Infliximab) you must obtain pre-authorisation from us. A short term course of a Targeted Therapy might be funded to allow your specialist to ascertain whether the treatment will be effective and can stabilise your condition. Benefit for these Targeted Therapies is only available if you obtain authorisation from WPA and your specialist confirms that they are not readily available to you as an NHS patient and then, generally, for a period not exceeding 3 months. Drug treatments that we define as Targeted Therapies can be found on our website wpa.org.uk/tt. We constantly review and update this information as and when new agents become available. It is important to highlight that some of these may become approved by the National Institute for Clinical Excellence (NICE) for use in the NHS and at this point would fall outside the terms of the policy. Please note that some large company funded schemes for their employees and dependants have different benefits and if you belong to one of these bespoke plans this will not necessarily apply to you. If you are in any doubt please check with us. Examples of long term medical conditions In all of the following examples we would write to you and your doctor as we have explained previously. All benefit is provided within the limits of the policy. 3

5 Example 1 Back Pain John has been with WPA for 2 years when he presents with lower back pain and numbness that has spread into his leg. He undergoes a series of tests and investigations and is diagnosed with sciatica due to a slipped disc. He is initially treated with physiotherapy and oral pain relief medication. This does not relieve the pain and symptoms so John is referred for pain relief injections. This provides John with short term relief but after a few weeks, his symptoms return. He therefore has pain relief injections repeated on a regular basis. Will John s policy provide benefit for this treatment on an ongoing basis? WPA policies are designed to cover, elective, short term, specialist care, provided with curative intent, in the reasonable expectation that it will restore you to the same or possibly even better health than you enjoyed before treatment. We would therefore fund the initial investigations and tests to diagnose the condition, a short term course of physiotherapy and 3 initial pain relief injections. After 3 injections, we would seek a treatment plan. John s specialist forwards a medical report which confirms that his condition is responding to the pain relief injections and as John is reluctant to undergo alternative treatment, he recommends that he should continue with physiotherapy and further pain relief injections should the pain increase. Are there any limits? Yes, as the treatment plan falls within the long term ruling due to it being preventative and solely to relieve symptoms and control pain. Notification will be sent to both John and his specialist to advise that benefit falls outside the scope of the policy and that alternative arrangements will need to be sought if he wishes to continue treatment on a private basis. Will John s policy cover a flare up? John s policy will only provide cover if he developed severe new, or life-threatening symptoms not previously experienced, that can only be investigated/treated by a specialist; or existing symptoms flaring up to the extent that an acute surgical intervention is needed. John develops severe new symptoms including numbness, paralysis of one leg and incontinence. This suggests severe nerve compression and John requires surgery. Will John s policy provide benefit for a private admission for surgery when the original claim has been ruled chronic? Yes, John s policy would cover a private admission for surgery as this would be deemed as an acute surgical intervention that is required to cure his condition. Benefit for the admission and a short term course of physiotherapy as part of a rehabilitation programme would be granted but ongoing, long term therapy or pain relief injections would not. 4

6 Example 2 Angina and Heart Disease Alan has been with WPA for many years. He develops chest pain and is referred by his GP to a specialist. He has a number of investigations and is diagnosed as suffering from angina. Alan is placed on medication to control his symptoms. Will Alan s policy provide benefit for ongoing treatment? After getting information from his specialist which confirms that Alan s condition is now stable, WPA explain that they cannot cover the cost of the monitoring and management of Alan s angina on a long term basis. They agree to cover one more consultation with his specialist, to give him the opportunity to make alternative arrangements for continued care. Two years later, Alan s chest pain recurs more severely and his specialist recommends that he has a heart by-pass operation. Will Alan s policy cover this acute flare up? WPA will cover the cost of Alan s surgery and a period of follow-up care. Following this, when he has recovered from surgery, we will explain that WPA cannot continue to provide benefit for the monitoring and management of Alan s condition, but he will be assured that if an acute flare up should occur this would again be covered by his policy. Example 3 Asthma Eve has been with WPA for 5 years when she develops breathing difficulties. Her GP refers her to a specialist who arranges for a number of tests. These reveal that Eve has asthma. Her specialist puts her on medication and recommends a follow-up consultation in 3 months to see if her condition has improved. At that consultation Eve states her breathing has been much better. So the specialist suggests she has check-ups every 4 months. Will Eve s policy provide benefit for ongoing treatment? We explain that we cannot continue to cover the cost of Eve s check-ups, but agree to cover one more consultation with her specialist, to give the opportunity to make alternative arrangements for continued care. 18 months later, Eve has a bad asthma attack resulting in an in-patient admission. Will Eve s policy cover this acute flare up? WPA will cover the cost of the treatment of this acute exacerbation and initial follow-up treatment, until her condition has once again been stabilised. 5

7 Example 4 Diabetes Deidre has been with WPA for 2 years when she develops symptoms that indicate she may have diabetes. Her GP refers her to an endocrinology specialist who organises a series of investigations to confirm the diagnosis, and she then starts on oral medication to control the diabetes. After several months of regular consultations and some adjustments to the medication regime, the specialist confirms the condition is now well controlled and explains he would like to see her every 4 months to review the condition. Will Deidre s policy cover repeat consultations? WPA explain that we cannot continue to cover these review consultations which could be carried out by the GP, but agree to cover 1 more, to give Deidre the opportunity to make alternative arrangements. 1 year later, Deidre s diabetes becomes unstable and life-threatening, her GP arranges for her to go into hospital for treatment. Will Deidre s policy cover this admission? We cover the cost of this admission and for her treatment until her condition has been stabilised again. Example 5 Hip Pain Bob has been with WPA for 3 years when he develops hip pain. His GP refers him to an osteopath who treats him every other day for 2 weeks and then recommends that he return once a month for additional treatment to prevent a recurrence of his original symptoms. Will Bob s policy provide ongoing monthly therapy benefit? We explain that the monthly visits are not covered by his policy on an open ended basis but that if he should have further problems, or if his condition should worsen to the point where a surgical procedure is needed, this would be covered, if his GP refers him to an orthopaedic specialist. We agree to provide benefit for 1 more monthly visit to the osteopath within his therapy benefits to allow Bob time to organise other arrangements. 6

8 Example 6 Crohn s Disease George has a number of symptoms suggestive of a diagnosis of Crohn s Disease 4 years after he takes out his policy. His GP refers him to a specialist to establish the diagnosis and he is given advice on how he can manage this condition. He is put onto a course of medication. His specialist reviews this after 3 months and George then continues with his medication under the supervision of his GP. Will George have benefit for this? We will cover George s consultation with his specialist and the tests to establish how his medication is working. GP (primary) care is not covered under the policy. 3 months later George becomes ill again and goes back to his specialist who reviews his medication and changes the dosage. George s condition then stabilises once more. Will you cover the consultation? We will cover this review of his condition. This happens again after 6 months, resulting in a hospital admission and a change of drug therapy to use Targeted Therapies. Will you cover the consultation? We will again cover the treatment, but explain that this condition is becoming long term. The Targeted Therapies will only be covered for a 3 month period, After 3 months George s condition again deteriorates and he needs to be reviewed. Does George have benefit for this? We refer this to our Chief Medical Officer. His view is that George s condition now falls within the definition of long term and therefore is outside the scope of his policy. We liaise with George and his specialist and will cover 1 further review to allow time for George s treatment to be transferred to the NHS. In the event that an acute surgical complication arises at some time in the future, then we would cover it and the subsequent care until the condition was again stabilised. 7

9 Example 7 Ulcerative Colitis Freda has been with WPA for 15 years and during that time has made several claims for treatment of her ulcerative colitis. She visits her specialist for a recurrence of moderate to severe ulcerative colitis and he feels that it is appropriate for her to be treated with a drug called Remicade (Infliximab). He advises her that she will be given 3 infusions of this drug and will be assessed to consider the response. He says that if the treatment is effective, she will need to remain on the treatment on a long term basis to maintain the effect. Will Freda s policy cover this on a long term basis? Freda s specialist considers that she will respond to a short term course of a Targeted Therapy (Advanced Therapeutic) drug, in this case Remicade (Infliximab). He has confirmed that she would not readily be able to have this treatment funded by the NHS, so Freda asks us to pre-authorise 3 infusions. We agree because the course is intended to ascertain whether the treatment will be effective and stabilise Freda s condition. We advise her that the limit to the cover is 3 months. After 3 infusions Freda s specialist tells her that he feels she will benefit from further infusions to maintain the remission achieved in a stable state. As he and his patient understand that cover is limited to the initial 3 months course of treatment as the medication is not yet available on the NHS, Freda agrees to fund the drug herself privately and have the infusions as a private patient at home. Will WPA contribute to this? No benefit is available for this as above. Example 8 Macular Degeneration Harry has been with WPA for 20 years when he starts to notice problems with his vision. He visits an ophthalmology specialist who carries out some tests and diagnoses him with wet macular degeneration. His specialist recommends treatment with a drug called Lucentis (Ranibizumab a Targeted Therapy). He tells Harry he will need 3 injections over 12 weeks directly into his eye. His specialist informs him that after the first 3 injections he will be reviewed and if there is a good result, he will need further continued treatment. Will Harry s policy fund the treatment? Harry approaches us to find out if we will fund this treatment. As the drug has now been assessed by NICE and Harry s specialist confirms that he can obtain his treatment (possibly up to 14 injections) on the NHS, we advise him that it will not be covered by his policy. 8

10 Example 9 Glaucoma Sue had been insured with WPA for 9 years when her optician identified possible glaucoma. She was referred to an ophthalmology specialist who conducted investigations and confirmed the diagnosis. He prescribed drops and arranged to see her again every 6 months to monitor her eye pressures. This is sometimes carried out by an optician who will report if the pressures have changed. Some cases of glaucoma are unstable and progressive in which case an ophthalmic surgeon s opinion is necessary. Does Sue s policy provide benefits for this? Sue sees her specialist for 2 further 6 monthly appointments. It then appears that her visits to the specialist are for her glaucoma to be monitored and managed. WPA writes to her specialist for more information and as the specialist confirms that Sue s consultations are now to monitor the condition, WPA explains that they are no longer able to cover these appointments, as they fall outside the policy terms. Sue arranges for her specialist to see her as an NHS patient. 2 years later Sue s eye pressures increase and her specialist explains that she requires surgery to treat her glaucoma. Will Sue s policy provide benefit for the surgery? WPA agree to cover the surgery and 1 post operative check up, as this is considered as an acute surgical event. Her specialist advises she will need to continue to have 6 monthly check-ups. WPA explain these cannot be covered and so Sue s specialist then transfers her back to be treated as an NHS patient for her long term care. 9

11

12 wpa.org.uk Western Provident Association Limited Rivergate House, Blackbrook Park, Taunton, Somerset, TA1 2PE Registered in England No The member state of the insurer is the United Kingdom. WPA is a registered service mark of Western Provident Association Limited. WPA is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and Prudential Regulation Authority. To help protect your interests, and those of the Association, telephone conversations may be recorded for the purpose of ensuring an accurate record of discussions. Western Provident Association Limited 2013 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of Western Provident Association Limited. 10/13611