Unfortunately, you do not have health insurance

Unfortunately, you do not have health insurance

About 7 million Britons shell out about £3 billion annually for health insurance. Individuals purchase one out of every seven insurance plans, while companies provide the other six. The issue is that medical insurance is complicated, and many policyholders don't read their policies well. This leads many to believe that we will not be discussing certain topics. Your expectation that health insurance will cover every medical expense is unrealistic.

If you have medical insurance, you can avoid waiting in line at the NHS for appointments with specialists, diagnoses, surgeries, and other treatments for minor, treatable illnesses. That makes sense, but you should know what treatments and scenarios are not covered before you buy. 

To start, though, a cautionary tale. Because different insurance companies issue different policies with different terms and conditions, this article is not applicable to any particular policy. Thus, it is imperative that you double-check your policy documentation. You will be prepared after reading this post! 

Apologies; it's a long-term health issue.

Your health insurance should cover the expense if the issue is treatable and won't persist for a long time. Your insurance company may label your condition as chronic, meaning they will not cover it if it is either incurable or expected to persist for an extended period of time even after receiving proper treatment.

However, there are several obstacles to overcome when trying to determine if a health issue is acute or chronic. Decisions are rarely black-and-white, and this is where policyholders and insurers often find themselves at odds.

Because they are lifelong diseases, asthma and diabetes clearly qualify as chronic ailments. That means those kinds of diseases aren't going to be covered.

The situation becomes problematic when doctors think a patient's illness is treatable at first, but then their opinion changes since the patient's health worsens and it's now incurable. This is a real possibility, particularly in the context of cancer treatment.

When this happens, the ailment is insured since it is considered acute at first, but as it worsens, it becomes chronic and no longer qualifies. This is feasible because insurance companies maintain the option to designate a condition as chronic rather than acute while treatment is ongoing.

Apologies, but it's really lengthy.

Treatment that lasts a lengthy time will not be covered by the insurer. To find out what "long-term" means in your policy documents, though, you should consult them. There are cases where an insurance company will only cover a portion of the cost, even though the medication course is longer than expected (say, 12 months).

Apologies; it's for our safety.

The purpose of your insurance is to cover the costs of diagnosing and treating medical issues as they occur. Its intended usage is not to cover preventative healthcare services.

The issue of definition comes up once more. At times, the question of whether a treatment serves to cure or prevent something can be debated. Consider the medicine Herceptin. When breast cancer is still in its early stages, this medication can be used. Studies have shown that women with HER2 cancer, which is highly aggressive, can reduce their risk of cancer recurrence by half by using Herceptin. Is Herceptin providing a treatment or a means of prevention in this case?

Within the insurance industry, opinions vary on the matter. While Axa PPP and Legal & General will not cover the cost of Herceptin for HER2 patients, Standard Life Healthcare, Norwich Union, BUPA, and WPA will.

The medicine has not been approved, I'm afraid. 

The ability to avoid waiting in line at the National Health Service (NHS) and access to cutting-edge medical care are two major draws for people to purchase health insurance. However, there is a catch.

Approval of novel pharmaceuticals for use by the National Health Service (NHS) in England and Wales is a function of the Institute for Health and Clinical Excellence. Your insurance will probably not cover the cost of the medication until that organization has given its approval. The issue is that the Institute is supposed to conduct a cost-benefit analysis to make sure the drug is worth more to the country than it costs to use it in the NHS. Quite a challenging brief, and it has certainly put the Institute in the spotlight over the lengthy medication clearance delays.

In a middle ground, the Financial Ombudsman proposed that, in cases where medical insurance refuses to cover experimental treatments, it should cover the cost of an approved conventional treatment, and if the experimental treatment is more expensive, the policyholder should be responsible for paying the difference.

Apologies, but it's already a medical condition.

An individual's pre-existing conditions are considered to have "pre-existed" the policy, and any subsequent claims for treatment of such conditions are void, according to this fundamental concept.

This is why, before agreeing to insure you, insurance firms will make you fill out a long questionnaire. They can't provide an accurate price until they have a thorough understanding of your medical history. With your permission, the insurance company will also contact your primary care physician to request detailed information about your medical history for many applications. They prefer a comprehensive view.

So, imagine you hurt your knee playing tennis a few years ago. It seemed to get better, but now we know it's a damaged cruciate ligament that requires surgery. The insurance company may try to get you to pay for the surgery by claiming that the injured ligaments were a pre-existing condition.

A moratorium provision may be an attempt by some insurers to smooth over these ambiguities. As a general rule, these clauses state that they will cover any further treatment you may need once you've gone two years without symptoms of any ailment you've had in the last five. These moratorium protections are not present in all policies, and the durations do differ among insurers. Take the time to read your policy thoroughly.

It is not covered, I'm afraid. 

Like auto insurance, medical insurance is a yearly contract. Therefore, your insurer has the right to assess both your premium and the terms of your coverage when it is time to renew.

Thus, it is conceivable to discover that your new policy does not cover that specific treatment if your policy renews in the middle of a course of treatment. What this implies is that the remaining cost of the treatment will be entirely on you.

In addition, more and more diseases are becoming treatable as a result of persistent improvements in medical practice. As a result of these advancements, the boundary between acute and chronic illnesses is moving backward.

There are two ways this affects the insurer's bottom line. More and more diseases are being classified as acute, which is leading to an increase in the number of claims. Herceptin is only one illustration of how the rising expense of new medicines is becoming the norm. The end effect is that insurance companies are having to pay out significantly more money. Renewal premium increases are an inevitable consequence of this. Insurers often change their definitions and exclusions to try to lower their risk exposure. Because of this, before you renew, make sure you read the renewal notice thoroughly.

Knowing this, keep in mind that there are many gray areas when considering purchasing medical insurance. If you have health insurance and are in need of medical care, you should not hesitate to contact your provider to verify that they will cover the expense of your treatment.