Private medical insurance claims

Common claims issues

• Pre-existing medical conditions (PEMC)

  A PEMC is a physical or mental health condition that the customer had before they took out the policy. Claims are usually declined because the customer had symptoms of, or was receiving treatment for, the condition before they took out the policy.

  When we’re looking at whether it’s fair for you to decline the claim we’ll usually consider:

  • when the policy was taken out
  • when the customer started experiencing symptoms
  • dates of any medical appointments
  • the policy terms and conditions, and whether there’s a moratorium clause [anchor link to moratorium underwriting on PMI overview page]
  • copies of medical records

  Read more in our case studies. 

  PEMCs and misrepresentation

  In cases where the customer complains that you’ve turned down their claim because of non-disclosure or mis-representation, we’ll try to establish if the customer:

  • provided accurate information
  • took reasonable care

  We’ll do this by looking at:

  • details of the questions and answers from the medical screening and sale of the policy
  • the customer’s relevant medical records
  • the underwriting criteria (if the insurer is saying they wouldn’t have covered the customer if they’d declared the condition or symptoms)

• Acute and chronic conditions

  PMI policies usually cover acute conditions, but not chronic conditions.

  If you decline a claim on the basis that the customer has a chronic condition, you need to show the condition is chronic rather than acute.

  Acute conditions

  • tend to happen suddenly and unexpectedly like a. heart attack or malignant (cancerous) tumour
  • need short term treatment or surgery
  • are curable
  • usually lead to a full recovery after treatment
  • can become a chronic condition if treatments aren’t effective or the condition deteriorates

  Chronic conditions

  • long term condition like asthma and epilepsy
  • usually need ongoing monitoring or treatment
  • can be managed with treatment but not cured
  • can sometimes cause acute symptoms which may be covered by a PMI policy

  Acute conditions can become chronic. If this happens and you decide to withdraw cover, we’d expect you to tell your customer quickly and with empathy. We’d also expect you to be able to justify your decision to do this through medical evidence or opinion.

  Read more in our case studies. 

• Experimental or unproven treatment

  Most PMI policies will not pay for treatment or procedures which are experimental or unproven based on established medical practice. This may be because the drugs aren’t licenced or because the particular procedure isn’t approved by the National Institute for Health and Care Excellence (NICE) 

  We’ll consider the policy terms and conditions taking into account that:

  • this is a constantly evolving area as drugs or treatments which are ‘experimental’ might become standard practice over time
  • medication is often prescribed by medical practitioners for use outside the terms of the licence when it’s considered medically appropriate
  • some insurers may cover experimental treatments as a gesture of goodwill

  We’ll weigh up all the evidence and decide whether you’ve acted fairly.

  Read more in our case studies. 

• Emergency treatment

  Most policies won’t cover emergency treatment, admission to hospital in an emergency or urgent admission following an unplanned outpatient appointment.

  When deciding whether treatment was urgent or an emergency, we’ll take into account the overall circumstances, including any medical evidence that’s available.

  We’ll look at whether the customer:

  • went to hospital on the advice of a medical professional
  • travelled to hospital by NHS or private ambulance
  • contacted you (and what they said)
  • was admitted to hospital
  • had treatment
  • was given a diagnosis

  Read more in our case studies. 

• Pregnancy and childbirth

  Most PMI policies don’t cover medical expenses for routine procedures during pregnancy or childbirth.

  Some policies will cover the treatment of an acute condition which may happen during pregnancy like:

  • ectopic pregnancy
  • stillbirth
  • post-partum haemorrhage
  • retained placental membrane

  We often see complaints about insurers refusing to cover caesarean sections, even if the customer has been advised to have a caesarean by their doctor or consultant.

  Some insurers agree to cover caesarean sections in limited circumstances – for example, where there is clear medical evidence that there is a specific risk to the mother’s life.

  Other insurers may not agree to cover the cost of a planned caesarean section, but may agree to cover the cost of an emergency caesarean if the need arises during the course of a natural birth.

  We’ll also consider the information or advice the customer was given about their policy at the point of sale. If the terms weren’t made clear to the customer and there could be a valid mis-sale complaint.

  Read more in our case studies. 

• Preventative treatment

  Preventative treatment may include surgery, tests or investigations. The customer will usually be in good health but concerned about the risk of illness. We don’t usually consider it unreasonable for you to apply this exclusion to a policy, as long as it’s applied reasonably.

  Occasionally, treatment of an acute condition can also be preventative. In these cases we’ll need to weigh up the medical evidence to decide what’s fair. 

  Read more in our case studies. 

• Cosmetic treatments

  Private medical insurance policies usually exclude cosmetic treatment like nose or breast reconstruction. But if evidence suggests the treatment is required on medical grounds to cure or relieve the symptoms of a medical condition, we may tell you to meet the claim.

  ‘My insurer wouldn’t pay for my breast reduction surgery because they said it was a cosmetic treatment’.

• Delays

  A customer may sometimes complain that you haven’t processed their claim quickly enough. In these cases, we’ll establish a timeline including key dates including when a claim was submitted and dates when you asked for information.

  We appreciate that you’ll often need to ask for information from third parties like hospitals and the customer’s GP. It’s not your fault if you need to wait for information, but we would expect you to chase at regular intervals.

  ‘It took my insurer four months to settle my medical insurance claim’.

• Choice of consultant or hospital

  Sometimes a customer is unhappy because they can’t use their choice of consultant, or go to the hospital they want to use.

  Private medical insurers usually have a list of ‘recognised’ [anchor link to ‘recognised consultants below] consultants and hospitals whose fees your prepared to meet up to the policy benefit limits. For hospitals, this usually means you've entered into a contract with the hospital to agree on the level of charges you’ll have to pay.

  In some cases, we might ask you to meet the full fees of the specialist or hospital even if the fees are higher than you’d  normally pay.

  We’d look at all the circumstances to decide what’s fair and reasonable including:

  • how far the customer would need to travel to see the a recognised consultant or to attend a hospital on your list
  • the customer’s state of health
  • how reasonable is it to ask the customer to travel
  • how regularly the customer will need to attend the hospital or receive treatment

  'My insurer wanted me to use a private hospital 40 miles from my house, even though there was a hospital only six miles away’.

  Generally, we think an insurer has the right to decide who they ‘recognise’ to treat their policyholders.

• Dental treatments

  Some private medical insurance policies include dental or oral treatment as an additional benefit. But the following treatments aren’t usually covered:

  • routine treatment and fillings
  • dental inspections and dental hygiene
  • dentures, crowns and bridges
  • cosmetic dentistry
  • jaw shrinkage
  • gum disease
  • implants

  If a customer has a stand-alone dental plan or a ‘cash plan’, they might be entitled to claim the cost of some treatment up to the maximum policy benefit.