Health Insurance Explained - Abi

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HEALTHINSURANCEEXPLAINEDabi.org.uk@BritishInsurers

ContentsPrivate Medical Insurance4Cash Plans9Further Information213abi.org.uk

IntroductionThe National Health Service (NHS) is the cornerstone of the UKhealthcare system, with the majority of services accessible free atthe point of use. Yet, with pressures on the NHS to meet healthcaredemands of an ageing population and with increasingly stretchedresources, there is a role for health insurance to complement theseservices.Health insurance is designed to work alongside, not to replace, all theservices offered by the NHS and customers can continue to use theNHS. This guide outlines some of the reasons you might choose privatehealthcare and how insurance can help you to access and fund this.Health insurance can help you to take care of your everyday wellbeing,aids a speedy diagnosis and recovery through reduced waiting times,and helps to pay for some or all of the treatment that you need. Thereare different health insurance products to meet your needs, with anumber of market providers to choose from.This guide aims to help you understand more about what your healthinsurance options are, why people buy it and how it works, so that youcan make an informed choice when you buy a policy. In this guide,we outline the two main forms that private health insurance can take,Private Medical Insurance and Cash Plans.Before choosing health insurance you should: Consider your health requirements Compare the benefits provided by each insurer Compare the costs covered@BritishInsurers3

Private MedicalInsurance4abi.org.uk

What is PrivateMedical Insurance?Private Medical Insurance (PMI) isdesigned to cover the cost of privatemedical treatment for ‘acute conditions’that start after your policy begins.Cover usually includes:PMI is available at a range of different levels ofcover at various premiums designed to meet theneeds of different customers. For example, youcan have choices around the types of treatmentcovered, what level of cover will apply to thosetreatments, the location where your treatment isprovided and the contribution you might be willingto make to the treatment cost (called ‘the excess’). The costs of seeing a consultant The cost of hospital admission Diagnostic tests, such as MRI and CT scans Surgery Hospital accommodation and nursing care Cancer drugs - some polices will includedrugs that are not available on the NHSCover may also include: Outpatient consultations Mental health treatment options Complimentary therapies Physiotherapy and chiropody@BritishInsurers5

Why buy PrivateMedical Insurance?PMI can complement the services of the NHSby providing cover for the cost of promptaccess to private treatment, and access tocancer drugs and services not alwaysavailable on the NHS.Timely access to healthcare: Prompt referral to a consultant Quick admission to a private hospital Treatment at a time to suit youChoice of healthcare: Direct care by a consultant Advanced treatment options, such asaccess to some cancer drugs that are notavailable on the NHSHigh-quality private clinic and hospitalaccommodation: Privacy of an en suite room Home amenities, such as TV Comfort and cleanliness6PMI is designed to cover the cost of privatemedical treatment for 'acute conditions'which start after your policy begins. Anacute condition is a disease, illness orinjury that is likely to respond quickly to thetreatment that aims to return you to thestate of health you were in immediatelybefore suffering the disease, illness orinjury, or which leads to your full recovery.Your insurer will typically not cover ‘chronicconditions’. These are diseases, illnesses orinjuries that have one or more of thefollowing characteristics: needs long-termmonitoring, control or relief of symptoms,requires rehabilitation, continues indefinitely,and has no known cure or is likely to comeback.You will normally not be covered forany illnesses you are currently sufferingfrom, or have already had. However, youmay be able to get cover for some preexisting medical conditions by paying asupplementary premium, or if you meetcertain criteria.abi.org.uk

Understanding the coverTo make sure that you understand what you are covered for andthe limits that will apply if you make a claim, read the policy termsand conditions. If you have any questions, you should contact theinsurer who can talk you through the cover available to you.When choosing PMI, you might wantto know: Are there monetary limits on the policy– how much of the cost of a treatment,or course of treatments, would you becovered for? How does an excess work – will it beapplied per claim or per policy year? What cover is there for cancer – whattreatments are covered and for whichstages of the disease?There can be limits on cover for cancer drugtreatments which you may want to ask theinsurer about. A drug treatment that yourinsurer has covered might not be available onthe NHS when your insurance cover ends. Yourinsurer will contact you as you approach theend of cover about the options available to youso you can discuss it with your specialist.These options could include: Return to the NHS and receive thetreatment there, if available Return to the NHS and receive alternativetreatment Pay for the treatment privately on a self-paybasis@BritishInsurers7

Types of policyINDIVIDUAL POLICYIf you are applying for an individual policy,you will need to provide some information tothe insurer. You must answer all questions asfully and accurately as you can, to the bestof your knowledge and belief. Insurers willonly ask you for information that is relevantto the cover you are applying for. There aretwo mains methods that insurers use tounderwrite your application for PMI cover.These are:FULL MEDICAL UNDERWRITINGAll PMI companies will offer the option of fullmedical underwriting where you will be askedto give details of your medical history. With yourconsent, the insurer may write to your doctorfor more information, but they do not do so inevery case. You must give all the informationyou are asked for. If you are unsure whether tomention something, it is best to do so. If youdo not, your insurer may reduce your claim orrefuse to pay and cancel your policy.If you have a medical condition that is likelyto come back, the insurer will issue a policy,but that medical condition (and any related toit) might not be covered.MORATORIUM UNDERWRITINGSome insurance providers may offer PMIpolicies that use moratorium underwriting.This means you do not need to tell theinsurer about your medical history when youapply for the policy. If you claim, however,your insurer might ask for medical notesthat are needed to decide if your claim canbe covered, as the insurer will not covertreatment for any medical condition thatyou have received treatment for, takenmedication for, asked advice on or hadsymptoms of which predates the startingdate of the policy. In other words, you will notbe covered for any condition that existed inthe past few years (usually, this is in the lastfive years but the period of time may vary).8Each moratorium works slightly differentlyso you may want to check with the insureror read your policy documents so you canunderstand what this means for you.GROUP POLICYYour employer may offer you access to agroup PMI scheme, which typically doesnot ask employees to declare their medicalhistory. The scheme is underwritten basedon the average age of the workforce, thelocation of the company and other nonpersonal factors. A basic group PMI schemewill only cover some treatments such ashospital admission and tests. More extensiveschemes could provide additional cover.Check with your employer to see what coveris available to you as it may be funded as anemployee benefit or the employer might helpto facilitate you accessing individual cover.Making aClaimAlthough policies can differ, medicaltreatment usually has to start with areferral by your GP for specialist treatment.Before you arrange any private treatment,you should call your insurer to check thatyou are covered for the treatment.Stay in touch with your insurer at eachstage of your treatment so they canconfirm your cover. It is likely thattreatments for some illnesses, includingpre-existing conditions (conditions fromwhich you are already suffering, or havealready had before your policy started) willnot be covered by an individual privatemedical insurance policy.abi.org.uk

Cash Plans@BritishInsurers9

What is a Cash Plan?A Cash Plan is an insurance policy that canhelp to cover the cost of everyday healthcare,such as visits to the dentist, opticians orphysiotherapy, by reimbursing you for someor all of the cost of routine and /or unforeseenhealthcare costs.Different Cash Plans cover differentaspects of everyday healthcare,including:Cash Plans are available for a monthlypremium and are an affordable, simple andaccessible way of helping you to manage thecost of everyday healthcare. Chiropody Optician sight tests and prescriptionglasses or contact lenses Physiotherapy Hospital surgery (limited to specificpolicies and certain types of surgery) NHS prescription charges Dental check-ups and treatment10abi.org.uk

Why buy a Cash Plan?The costs of everyday healthcare, such asdental check-ups, a visit to the opticiansor buying prescription medicines, are everincreasing and can all add up. A Cash Planis designed to help you meet these costs, sothat you do not have to worry about payingfor treatment when health issues arise.There are many benefits to taking outa Cash Plan, such as: Help to budget for everyday health careexpenses Low monthly premium Choice to cover the whole family foradded peace of mind Choice of the healthcare practitionerthat you want to see , plus there is noneed for a GP referral Cover for pre-existing medicalconditions Access to a range of benefits such asmedical helplines and 24/7 GP access@BritishInsurersDifferent Cash Plans have enhanced levelsof cover for different treatments so you canchoose the right cover that suits your needsto make the most of your Cash Plan. Forinstance, musculoskeletal problems affectmany of us at some time of our lives, so ifyou want to ensure that you are preparedshould this affect you, then you could choosea Cash Plan that offers you more cover forphysiotherapy, osteopathy or chiropractictreatment. If you go for annual dental checkups and regular hygienist visits, you couldchoose a Cash Plan that offers you moredental cover on an annual basis or choose adental cash plan which is specific to dentalcare and maintenance only.The majority of plans will also cover preexisting conditions but make sure that youcheck this before you buy the policy.Cash Plans typically do not reimburse youfor treatments such as cosmetic surgery,laser eye surgery, professional sports injuriesand non-prescription medicines or glasses.Remember to check the terms and conditionsof your policy to see which treatment yourCash Plan will reimburse you for.11

How can I get a policy?When you buy insurance, you will be askedto fill in an application. This may be online,over the telephone or by completing a paperapplication form. Once your application hasbeen accepted you will be told when coverwill start. It is important to take reasonablecare to answer the insurer’s questions as fullyand as accurately as you can.If you are unsure whether something isimportant, it is best to tell your insurer. If youdo not, your insurer may reduce your claim orrefuse to pay and cancel your policy.Types of policyINDIVIDUAL POLICYGROUP POLICYWhen you buy an individual policy you mayalso have the option to cover your partnerand/or your children under the same policy.Assess the healthcare needs of your familybefore shopping around for a Cash Plan assome policies may offer separate allowancesfor children or have a shared overall familyallowance.Your employer may offer group Cash Plansallowing you to claim money back on manyeveryday health expenses. If you join youremployer Cash Plan scheme you may notneed to fill in an application. Check with youremployer if they have a healthcare plan andfind out what it covers you for. You may beable to include cover for your family under anemployer Cash Plan scheme.Making a ClaimWhen you receive treatment you pay the costof that service upfront and then you sendyour insurer the receipts, showing the costsyou have incurred. If the costs are covered,12the insurer will reimburse you directly withina few days for either a part of that cost or thefull cost, depending on how much cover yourparticular Cash Plan provides.abi.org.uk

Further Information@BritishInsurers13

Which insurersoffer cover?There are many providers whooffer health insurance products.You can contact insurers directlyor use an adviser to find theproduct that best suits your needs.SWITCHING INSURANCEPROVIDERIf you are thinking about switching insuranceprovider, there are a number of things youneed to consider: It is best to consider switching providerwhen your current policy reaches itsrenewal date, otherwise you may incur a feefor switching provider before the insurancecontract has come to an end. You should compare the benefits, policyterms and cover limits from differentproviders carefully, so that you get the coverthat is right for you. Some insurers might not cover illnesses orinjuries you have had in the recent past orany condition that you suffer from now, evenif these are covered by your current insurer.14abi.org.uk

ComplaintsIf you are unhappy with the way you havebeen treated by an insurer when taking out aninsurance policy or when making a claim, youcan make a complaint directly to the insurer.If you are still not comfortable with theinsurer’s response, you can take yourcomplaint to the Financial OmbudsmanService (FOS), an independent bodywhich aims to settle complaints betweenconsumers and businesses providingfinancial services. More details on the FOScan be found atwww.financial-ombudsman.org.uk.ConfidentialityIn line with the Data Protection Act 1998, allinsurers treat personal sensitive informationconfidentially, including medical details.When you are asked for information, you will@BritishInsurersbe told what it will be used for, who it maybe given to and in what circumstances. Youcan ask to see any information an insurerhas about you.15

January 2017For more informationAssociation of British InsurersOne America Square17 CrosswallLondon EC3N 2LB020 7600 333316abi.org.uk@BritishInsurersabi.org.uk

Health insurance is designed to work alongside, not to replace, all the services offered by the NHS and customers can continue to use the . Consider your health requirements Compare the benefits provided by each insurer Compare the costs covered. 4 abi.org.uk. Private Medical Insurance @BritishInsurers 5.

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