Making a Health Insurance Claim

Different health insurance companies have slightly different ways in which they deal with claims so it is important to find out ahead of time how your company deals with claims.

A lot will depend on the type of health cover policy that you have: whether its a moratorium or fully underwritten policy. The most important advice is unless you are prepared to be out of pocket do not agree to any treatment or consultation that has not been agreed by your insurance company.

1. Visit your GP
This should alsways be your first port of call. If your GP agrees that you need to be refered for treatment or further investigation then you need to inform them that you are making an insurance claim and give them the details of the company that you are with.

In order to make a claim you will need details of your condition and probable diagnosis and the treatment that has been suggested. You will need the details of the consultant/hospital that you would like to have treatment with.

2. Contact your medical insurance company
Some companies provide an online claims method as well as a telephone number for you to ring.

You will be asked about the details of your condition and in some cases you will be informed that the insuerer will need to contact your GP to get more details about your health status. When you sign a private health insurance policy you must make sure that you have answered everything truthfully - any differences in what you have said and what the GP reveals about your records may invalidate your claim at this stage.

3 Confirmation of claim
You health insurance company will confirm whether you are covered for treatment/consultation under your policy. Companies vary in the length of time that they take to do this. Pruhealth issue an authorisation code which you need in order to have your bills paid efficiently.

4 Make an appointment
Once your medical insurance company have agreed to pay for a claim you can book an appointment to begin treatment. You will need to take your insurance details with you when you go.

5 Paying the Bill
Companies vary in how bills are settled. In most cases bills are sent directly to health insurance companies who then settle up with the health care providers. In some cases you pay the bill and your insurance company pays you back. With some policies, for example with Freedom Healthnet Ltd, the rules are very different. Freedom pay you the cash and then you pay the health provider directly.

Complaining About Health Insurance

If you have a complaint related to your health insurance then you do have redress, initially with the medical insurance company and if you are not satisfied, with the Financial Ombudsman Service (FOS).

1) Your first port of call is your health insurance provider. They will have a complaints procedure which you will have to follow. Ask to be sent a copy of the complaints procedure. This will give you a timescale by which they agree to deal with your complaint. Without following this you have no standing with the Financial Ombudsman.

2) Decide what you want to achieve from your complaint and make sure that you communicate this with the insurer.

3) Write to your insurance company explaining in as much detail as possible the nature of your complaint. Include all your details as well as copies of any documents that are relevant to the complaint. If you keep to written communication then you will have a copy of everything that has transpired. Its easy to forget what has been said in telephone conversations. IF you do have telephone contact take down the date, name of the person you spoke to and details of your conversation.

4) You should receive a reply within their agreed time scale. If not write again.

5) IF you are not pleased with a company's response then you can ask for a letter of deadlock. With this you can appeal to the Financial Ombudsman service which looks at each case impartially and decides whether applicants have a case. They can rule insurance companies to pay out up to £100,000 per case. Their website is: financial-ombudsman.org.uk

The Advantages of Health Insurance

The statistics show that the NHS is improving its targets all the time so what are the advantages of having medical health insurance?

Get seen quickly
Hospital waiting lists are down to 18 weeks but this is still too long. If you have private health insurance you can be seen very quickly. This is reassuring and means you are tackling your health problems quickly abd therefore improving your chances of good health. It also cuts down on the stress of having to wait for important diagnosis and treatments.

Choice
With private health insurance you have much greater choice about which consultant you see and which hospital you go to. Different medical insurance companies offer a range of different hospital networks.

Cleanliness
Survey's conducted this year cited the poor NHS standards of cleanliness as the main reason that people would consider taking out private health insurance. Concerns over superbugs such as c.difficile and MRSA are particularly important and the private health sector is perceived as having much higher standards of cleanliness.

Comfortable Surroundings
Many private hospitals offer very pleasant and comfortable surroundings. Usually patients have a room to themselves with a television and they are provided with good quality meals.

Staying with Children
Most medical insurance policies cover a parent staying overnight in hospital with their children of 12 or under. For many people with children this gives great peace of mind.

Budgeting
Paying monthly premiums for health insurance enables people to budget their money better. For people who want private health care, medical insurance helps to spread the cost and mainly avoids large, unexpected medical bills.

Bupa Talks Swine Flu

After a decline in cases of swine flu over the summer months health professionals are preparing for a possible increase and severity of the virus over the autumn and winter months. Bupa UK Health Insurance assistant medical director Dr Rebecca Small spoke to Health Insurance and Protection Magazine about what Bupa are doing about about Swine Flu.

Dr Small said that they were taking measures to limit the spread of swine flu:

'We have introduced more rigorous office cleaning regimes, implemented hygiene measures including provision of alcohol gel for staff for hand-washing, published advice and helplines for staff on what to do if they suspect they have flu and issued specific protocols for managers.'

There have been many queries about what kind of cover can be expected from private health insurance companies when it comes to swine flu claims. Usually health insurance policies only cover people for non-emergency treatment of acute conditions.

Most cases of Swine flu are very mild and those that are affected are usually people who have underlying health conditions. This complicates matters as medical insurance companies will normally only cover conditions which are 'new'. If the complications of swine flu are brought about by underlying conditions this will surely muddy the waters when it comes to an medical insurance claim.

According to Bupa, swine flu is covered by them. Dr Small said:

'Those with Bupa health insurance can be reassured that they are covered for inpatient and outpatient treatment of swine flu by a consultant so long as they are referred by their GP.'

Individual or Company Health Insurance?

Many employers offer private health insurance as part of your remuneration package. Is it better to take up this offer or to have your own individual health insurance?

Most people in the UK who have health insurance have it through their employer and overall if you can get health cover through work it is usually the best option. There are three main differences between company and individual health insurance:

1) It will be cheaper. You will normally not have to pay anything towards the premium although it is a taxable benefit. Companies can normally negotiate much lower rates for their employees than can be obtained by individuals and this will keep down the taxable amount that you have to pay.

2) A company scheme will be less strict about exclusions. Because policies have to be underwritten en masse there are differences between the policies when it comes to pre-existing conditions. Company policies tend not to exclude these whereas individuals policies certainly do. Chronic conditions are normally excluded on company schemes however in the same way as they are on individual policies.

3) Company health insurance normally covers partners and children of the employee too which is not automatically the case with individual private medical insurance. You would normally have to pay a lot more to include a partner although with some companies children can be included for free.

Problems
Problems arise when people leave their jobs and want to keep some form of health insurance. Most people find that the premiums that they have to pay are much higher than they expected. If you are moving within the same insurance company it may be possible to negotiate better rates and its always worth asking as you never know what could be offered to you.

7) No Claims Discount

No claims discount enables people who do not make claims on their health insurance to pay smaller premiums. For each year that you do not make a claim you are rewarded by lower premiums.

It is a controversial area and many private health insurance companies are opposed to it on ethical grounds. The argument is that it may stop people claiming when they need to for fear of loosing their no claims discount.

Another argument against no claims discount policies is that the information provided about possible premium savings are misleading. Often no claims discount policies are more expensive at the zero rating than their counterparts policies that do not offer no claims discounts. It is important to check this out. Additionally if you do make a claim you may have to pay a surcharge and your monthly premium may shoot up and be higher than when you first took out the policy.

AXA PPP Healthcare and Standard Life Healthcare offer no claims discount policies.

All Standard Life Policies have a no claims discount and do not offer their policies without this option. AXA PPP Healthcare's policies give you the option of a no claims discount policy or not.

Standard Life
Standard Life claim that you can get up to a 50% reduction on all their policies with your no claims discount. If you do need to make a claim you do back two years per claim and can then build your no claims discount back up from there. They give you a starter discount of 35% when you take up one of their policies.

With Standard Life some things do not affect your no claims discount.

'such as if you receive cash for staying in an NHS hospital, claim on the travel or add-on element of a policy, make calls to the GP Advice Line, or use any other free service provided under Healthy Rewards.'

The discounts are as follows:

Level 0 - 0% discount
Level 1 - 10% discount
Level 2 - 20% discount
Level 3 - 25% discount
Level 4 -30% discount
Level 5 - 35% discount
Level 6 - 40% discount
Level 7 - 45% discount
Level 8 - 50% discount


AXA PPP Healthcare
AXA PPP offer no claims discount policies and their discounts vary slightly from Standard Life:

Level 0 - 0% discount
Level 1 - 10% discount
Level 2 - 20% discount
Level 3 - 27.5% discount
Level 4 -35% discount
Level 5 - 40% discount
Level 6 - 45% discount
Level 7 - 50% discount

If you make one or more claims with this company you go down by three discount levels and claims for the same medical condition are treated as one as long as they are within 180 days of each other.

In Standard Life's literature they say that it might be better for their customers to pay for small bills themselves rather than go through the insurance and loose the no claims bonus. They iterate:

'However, your first consideration should always be ensuring that you receive the treatment you need.'

They do offer no claims protection for a further fee to some customers however even with this your discount level will still drop by one level should you need to make a claim and the protection will be removed should you make claims in two consecutive years out of three.

Standard Life also allow you to reinburse them the money you have paid for a claim in order to preserve your no claims bonus as long as you do it within 30 days of the policy renewal date.

6) Excess

When you make a health insurance claim the 'excess' refers to the amount you have to pay upfront yourself before the insurance company will pay out. Paying more or less excess will affect the amount you pay for your monthly health insurance premium and paying extra is one way in which people can keep down the costs of their health cover. Each provider offers a different range of options when it comes to paying an excess. Some companies offer policies where you do not have to pay any excess at all.

Why do you have to pay an excess?
Firstly, excesses do help to keep your health insurance premium down. It means that you have to pay something if you need to make a claim but overall when you are not making a claim your premiums are reduced. The more excess you pay the cheaper your insurance will be.

Having an excess also stops people making claims small claims for things that could easily be cleared up by the NHS. This helps the insurance company to keep costs down. This is one reason why some people are against excesses as they feel that it might stop people seeking medical attention when they need it particularly as small health issues could be an indicator of something more serious.

How much excess will I have to pay?
Excesses normally start at £100 but the amounts vary from provider to provider. Most range from £100-£500. Some companies offer policies with no excess.

Some providers offer a one level excess. Freedom Healthnet for example, who offer one of the cheapest health insurance policies on the market, ask for a £100 excess on each claim.

Some companies offer very large excesses. Sometimes these medical insurance policies pay unlimited amounts for treatments costs and care should you become ill. The monthly premiums are then kept very low.

How much less will I have to pay for my premiums?
The discounts offered vary from company to company. Below is a selection of quotes from various health insurers for a 40 year old man who is in good health and has a healthy lifestyle.

Bupa's Select Heart and Cancer Care
This policy has several excess options available: £100, £150, £200, £250, £500, £1,000 or £2,000. Bupa do not give online quotes for their health insurance plans.

PruHealth: Comprehensive Plan
0 excess: £71.16
£100 excess: £68.47
£250 excess: £64.45
£500 excess: £60.43
£1000 excess: £53.38


AXA PPP: Comprehensive Cover
£100 excess: £48.06
£200 excess: £44.08
£500 excess: £40.52


XS Health
This provider offers large excess contributions which significantly lower your monthly premiums.

£1,500 excess: 19.08
£3,000 excess: £11.71
£5,000 excess: £7.21

With this company once your treatment costs have exceeded your limit WPA will cover the cost in full for all eligible treatment for a further 12 months. This kind of policy is usually only recommended to healthy individuals who are not expecting to make any claims.

The most important thing to consider is whether you would be able to pay for a large excess should you become ill. If not, then you are better off budgeting with higher monthly premiums. If you have savings that you can dip into the higher excess policies may be for you but if you will struggle to pay the excess then this is not the right type of policy for you.

MP's Attitudes to Private Health Insurance

The private health sector and the NHS have been sitting along side each other ever since the inception of the NHS in 1945. Some are not keen that people should be able to pay for private treatment if they can afford it but others are keen to move the NHS towards privatisation. Most people lie somewhere in the middle.

On the whole the British are proud of the NHS which gives free treatment to every UK citizen at the point of use. A new poll by health insurance provider BMI Healthcare reveals that conservative MP's are more supportive of the private health sector than other parties.

The BMI poll showed that two thirds of MP's backed tax relief on private medical insurance. In contrast only 1% of the labour MP's wanted this option.

The conservatives have been criticised for wanting to turn their back on the NHS despite Mr Cameron's insistence that they are 'the partly of the NHS.'

Allastair Darling, Chancellor of the Exchequer, said that the introduction of tax relief on private health insurance would harm the NHS:

'Tax breaks for private health care would take money away from the health service and undo the real progress we have made with the NHS over the last 12 years.'

'After a torrid two weeks, David Cameron can no longer hide the two faces of his party on the NHS – this poll shows where the heart of the Tory party lies.'

Adrian Fawcett, chief executive of General Healthcare Group (which owns BMI Healthcare), said:

'The results help progress what, in the run-up to an election, is an important debate about the future of health provision in the UK. I do not believe there are many in the private healthcare sector that would support a switch to the US model. The UK already has a growing partnership between the public and the private healthcare sectors and we are pleased that so many MPs take a pragmatic view about how such a partnership can be further developed and how it can be used to meet the health needs of an increasingly ageing population.

'The NHS delivers strong core health services but the patient experience, the clinical outcomes and the timeliness of treatment can undoubtedly be further improved, if the private sector is encouraged to work more closely with the NHS to deliver reduced waiting times and improved value for money.

'In my view, the private sector is not advocating a root and branch reconstruction of health provision in this country, rather measures to widen patient choice and improve patient services and outcomes as part of a closer public-private partnership.'

5) Moratorium & Full Medical Underwriting

Health insurance companies are like bookies. They have to work out the odds of people becoming unwell in order to charge them appropriate premiums. This is known as underwriting.

There are two ways that medical insurance companies assess you in order to provide you with health cover. Moratorium underwriting or full medical underwriting. Each has advantages and disadvantages.

Some companies offer both types of underwriting and others only offer one or the other.

Full Medical Underwriting
This involves companies taking a full medical history (Medical History Declaration) and lifestyle profile of you right from the start. In some cases your GP may be contacted to clarify issues that may be unclear. This is always done with your consent.

Advantages
-What you will and will not be covered for will be very clear. There will be no surprises should you become ill
-If you do become ill clearing your treatment will be speedy as all your information has already been collected by the insurer
-Companies that use full medical underwriting often have health reward schemes which enable you to reduce your premiums by performing certain health enhancing activities.

Disadvantages
-This type of policy tends to be more expensive
-You have to fill out long forms at the beginning and getting cover may be delayed whilst everything is checked out
-You are responsible for full disclosure when you take out this type of policy. If you have omitted anything you may not be covered. And it may be difficult to prove that the insurance company was at fault.

Moratorium Underwriting
This type of underwriting means that initially you only have to give out brief information about your health and lifestyle.

Under this type of policy you are not covered for any condition that you have, up to five years prior to taking out the policy until you have been on the policy for two consecutive years. After this time, if you have not had a recurrence of the condition or its symptoms you will be covered.

Advantages
-You can get health insurance very quickly with this type of health insurance. You won't have to fill out long medical forms and your application will be quick as the underwriting is not done until you actually make a claim.
-Premiums tend to be cheaper
-Once your period of moratorium is up you will be covered for everything as long as its in the policy document.

Disadvantages
-Treatment can be delayed if the insurance company needs to check out details of your medical history with the GP.
-Because this type of policy does not investigate your medical history thoroughly you could be surprised and disappointed to find that you are not covered when you go to make a claim.
-People could be put off seeking medical advice if they are trying to eek out their time until their two year, symptom free, window is up. This is potentially catastrophic.

8) Rewards for Healthy Behaviour

Rewarding customers for healthy behaviour is a fairly new idea in the health insurance world but one that is very attractive to customers. It offers a win-win combination - you pay less in premiums and help yourself stay in better health.

PruHealth: Vitality
PruHealth was the first health insurance company to introduce the idea of rewards for healthy behaviour. In their Vitality scheme policyholders are rewarded with lower premiums if they take part in a list of activities that promote a healthier lifestyle.



With PruHealth you join at the Bronze level and the more Vitality Points you earn the more chance that you can increase your status to Silver, Gold or even Platinum. Over and above your renewal premium discounts you are also eligible for discounts in several of their partner businesses including: Eurostar, Mark Warner holidays, Champneys Health Spas and Cineworld.

Below is a list of only a few of the activities which enable you to work towards lowering your premium. The activities fall into one of categories: education, screening, not smoking, exercise and nutrition.

• Flu vaccination
• Regular check-ups for child/baby Children
• Completed vaccinations Children for children
• Mammogram for women over 45
• Maintaining blood pressure over six month period
• Improving blood pressure over six month period
• Maintaining fitness rating over six month period
• Workout – Gym session
• Fitness assessment A
• Being a non-smoker
• Quit smoking with Allen Carr
• Maintaining target BMI band over six
• Creating a healthy meal plan online

For each activity that you do PruHealth rewards you with points which are then added together at the end of the year.


Aviva: My Health Counts

In recent months Aviva have also introduced their own version of healthy behaviour rewards which can help you to get a 15% discount of your next years insurance premium. They have launched My Health Counts with is a health management service that encourages you to take steps towards good health.

You take an online test on Health Trackers. It checks for Any improvements that you make over the course of the year are rewarded with points that add up to reduce your premiums. You are assessed in the following areas: Weight/BMI, Fitness, Smoking, Alcohol, Blood Pressure, Cholesterol, Heart Disease. These are used to asses your Q Score.

Your Q Score is a statistical measurement which assess your health risks in comparison with other people your own age.