Private medical insurance

Private medical policies typically cover conditions that are “acute” and exclude those that are “chronic”. This exclusion catches a wide range of common conditions including asthma, diabetes and arthritis. Furthermore, in some cases an insurer will reclassify a condition from acute to chronic during treatment. The consequence is that no further medical expenses are paid. Typically such action will be taken where it has become clear that there will be no cure: further treatment will simply be aimed at alleviating the symptoms of the condition.

The FOS has expressed in Ombudsman News 1 two concerns about such an approach:

  • The news that payments are to cease can be extremely distressing for the patient and the patient's family. Apart from raising the question of how further treatment can be funded, it is effectively a statement that the insurer does not believe the patient will recover. In some cases, the patient's own medical advisers may take a different view. Even if they agree, they may not yet have communicated their opinions to the patient. Considerable sensitivity is therefore required.
  • The sometimes fine distinction between “acute” and “chronic” conditions is not helpful to the image of insurers. In fact, the FOS may not support insurers who cease to pay benefits for a critically ill patient where:
    • earlier treatment has been funded;
    • general medical opinion would recommend further payment;
    • the patient's own medical advisers demonstrate that further treatment may stabilise the condition so that the patient can lead a more or less normal life.