Nasty surprise - private medical consultation / tests have exceeded Bupa policy limit

dizzie

Wutang wrote: »

Clearly not an expert - if you get told you have comprehensive cover, would you then think all was covered in full? Answer this and then look at Bupa's fee guidelines.

......and if you can find Bupa's fee guidelines, you are a miracle worker.

That's a very valid point Wutang. I'd like to add to this...

For most health insurance policies - this is how it works:

1. You usually have an annual Excess - just like every other type of insurance. Clearly you need to pay this before your insurer will consider reimbursing anything else.

2. You have an annual Outpatient allowance. This is the category into which they usually place consultations, outpatient therapies (e.g. physio) and sometimes (depending on insurer), diagnostic tests (although some policies make separate provision for this). As far as consultations go, with the exception perhaps of AXA PPP, there is not usually a limit on what the doctor can charge - most initial consultations in my experience are between £150 to £200. But you need to be careful - annual outpatient allowances can be VERY low. For example, we only have a £500 allowance each year. That's something that you (or your employer) decides when they arrange the policy.

You have to remember that your doctor or the hospital don't know what your outpatient allowance is because that is between you and your insurer. Also, if for example you've been having a course of physio elsewhere before you decide to see a doctor, then your annual outpatient allowance will have already been eroded.

In summary, it is very common to exceed your annual outpatient allowance and be left to pick up the excess costs.

2. The second component is "Procedure Costs" e.g. a surgical procedure or injection etc. Now here is where Wutang is EXACTLY right. Insurers publish fee schedules to set a cap on what they'll pay for each procedure. Most companies have changed the rates little (if at all) since 1992. Consultants aren't obliged to stay within these rates (unless they've entered a contract to do so with the insurer) and many don't! (after all, would you accept a 20 year pay freeze?). All insurers set different reimbursement levels and you should be able to check whether they'll be any shortfalls by asking your consultant for the procedure code and the cost. I think that consultants and hospitals should advertise their fees more prominently - but if they don't, then you must not be afraid or embarrassed to ask.

Wutang points out that you (the patient) won't find a BUPA fee schedule published anywhere and again he is RIGHT (although you will find that other insurers (e.g. AXA PPP, Cigna, Pru Health, WPA etc) make this information publicly available on the web. So why are BUPA so secretive about this information? Well it may interest you to know that after holding procedure fee reimbursements static for the past 20 or so years, they are now slashing them - some reimbursement levels have already gone down by 45-70%...and clinicians are being given very little notice of these cuts (e.g. between one and three weeks!).

BUPA now pay significantly less than other insurers...although you and I won't find that fact reflected in our annual premiums (which of course seem to rise in leaps and bounds every year).

I would recommend that patients be more savvy....
establish what all of the costs are - then speak to your insurer. Put the onus on them to tell you whether they'll reimburse these in full! They should be able to tell you if you'll have anything to pay. Take and record the name of the BUPA adviser you spoke to, along with the date and time (in case there is any back-pedalling later on!)

Sadly, whilst consultants have tried to contain what they charge for procedure fees over the past 20 years (to try to protect patients from significant shortfalls given the relatively static reimbursement levels over that time), they have raised consultation fees. After all, the cost of living and professional costs e.g. indemnity insurance etc have increased massively over this timescale! Remember also, that doctors do not generally charge in the same way as solicitors - i.e. your consultation fees don't just include the time your are in the consulting room - there is often a fair amount of additional work for them (and their secretary) in writing letters back to referring clinicians, chasing up results and liaising with their colleagues on patient care...

Increased consultation costs however does mean that your limited outpatient allowance doesn't go far...and this is precisely why the insurance industry use the model they do - to limit their own liabilities for what they pay out and place more of the financial onus on you the patient.

Hope that helps answer your question. P.S. We have an ongoing claim with BUPA at the moment, but once that is finished, we'll be changing insurer. Clearly, we'll have to stomach the "pre-existing condition" clause with another company...but BUPA are bringing in all sorts of nasty surprises such as OPEN REFERRALS where your GP won't be able to decide who the best person for you to see is....instead, BUPA will give you a limited choice of consultants based upon who they can get the cheapest!

dizzie

"I therefore advised the cardiologist of that sub-limit and enquired how much everything would cost, to which he assured me that the sub-limit would not be breached."

Laurat...further to my previous post - out of interest, what did BUPA say the sub-limits were? (i.e. what did you tell the cardiologist?)...and what did he say the exact costs of everything would be?

This might help us to establish who is at fault. I am wondering if your cardiologist really had all of the facts about your policy to hand - he may have simply been referring to the fact that he charged within the BUPA fee guidelines (for procedures) that apply to every policy.

However, what you need to know is that insurance policies are a minefield. There are so many different ways that companies can tailor individual or company scheme policies - i.e. some won't pay for initial consultation, but will pay for treatment beyond this...some only pay for costs associated with any inpatient treatment etc. Some categorise components of care (e.g. therapies, consultations, tests and investigations, procedures) differently and besides setting limits as to what they will pay for individual tests or treatments - they then set different limits and caps on the maximum total annual allowance of these....I hope I am illustrating just how non-straightforward all of this is!

Given this, it is your insurer who is the expert on how your policy is designed - not the hospital or the doctor. So you really need to press your insurer about what will be reimbursed and get the information from THEM - not the hospital or doctor.

Ideally (and I know it is a pain in the behind) but if you want to be absolutely sure, then the way you need to do it is this:

1. Remember that the doctor is independent from the hospital, which means that both usually bill the insurer for their individual fees:

2. So, get a quote from your consultant about his fees and details of what you need to have done (including procedure codes where relevant)

3. Then speak to the hospital about any of their fees associated with tests or procedures.

...try to get this in writing if possible.

4. Then go armed with all of this information to your insurer and let them decide - based on the individual terms of your policy what will and will not be covered, and how much you will need to pay. Always, always take the name of the insurer's adviser who gives you this information.

Then, if there is a problem you have all of the parties information to hand and can then properly identify anyone at fault for any misinformation.

Wutang_2

ACG wrote: »

If they had said "you have comprehensive cover, we will cover everything" then yes i would be complaining to Bupa - but that isnt the case.

As i said im no expert and im more than open to be shown im wrong, but i dont feel "comprehensive cover" justifies being covered for anything and everything.

So, what does comprehensive cover mean to you when you are purchasing medical insurance?

With most insurers, comprehensive medical insurance means unlimited.

Bupa have comprehensive packages (eg Bupacare) which states "outpatient specialist consultations - in full"....do you think that leads the customer to believe that Bupa will pay for all the costs of the specialist consultations in full? YES or NO?

Wutang_2

starrystarry wrote: »

Perhaps so but that doesn't make this Bupa's fault. The policy has a limit, they pointed this out to the OP. It's the hospital's fault the limit was exceeded.

Perhaps nothing. Read the original post.

Wutang_2

dizzie wrote: »

I would recommend that patients be more savvy....
establish what all of the costs are - then speak to your insurer. Put the onus on them to tell you whether they'll reimburse these in full! They should be able to tell you if you'll have anything to pay. Take and record the name of the BUPA adviser you spoke to, along with the date and time (in case there is any back-pedalling later on!)

Sadly, whilst consultants have tried to contain what they charge for procedure fees over the past 20 years (to try to protect patients from significant shortfalls given the relatively static reimbursement levels over that time), they have raised consultation fees. After all, the cost of living and professional costs e.g. indemnity insurance etc have increased massively over this timescale! Remember also, that doctors do not generally charge in the same way as solicitors - i.e. your consultation fees don't just include the time your are in the consulting room - there is often a fair amount of additional work for them (and their secretary) in writing letters back to referring clinicians, chasing up results and liaising with their colleagues on patient care...

Increased consultation costs however does mean that your limited outpatient allowance doesn't go far...and this is precisely why the insurance industry use the model they do - to limit their own liabilities for what they pay out and place more of the financial onus on you the patient.

Hope that helps answer your question. P.S. We have an ongoing claim with BUPA at the moment, but once that is finished, we'll be changing insurer. Clearly, we'll have to stomach the "pre-existing condition" clause with another company...but BUPA are bringing in all sorts of nasty surprises such as OPEN REFERRALS where your GP won't be able to decide who the best person for you to see is....instead, BUPA will give you a limited choice of consultants based upon who they can get the cheapest!

Firstly, whilst agreeing, I would recommend everyone out there to stop falling for the name BUPA. Its a name, they spend a lot on marketing and very little on claims.

With regards to your worry of moving and stomaching the pre-existing condition fears, there will be options out there with better insurers - who will also have NO fee guidelines.

ACG

Wutang wrote: »

So, what does comprehensive cover mean to you when you are purchasing medical insurance?

To me it means it would cover the vast majority of things - its near impossible to cover everything.


With most insurers, comprehensive medical insurance means unlimited. - Were not talking about most insurers, were talking about Bupa.

Bupa have comprehensive packages (eg Bupacare) which states "outpatient specialist consultations - in full"....do you think that leads the customer to believe that Bupa will pay for all the costs of the specialist consultations in full? YES or NO?

Yes.

---

However, the OP called and was told otherwise over the phone. I agree if the paperwork the OP holds states they will pay in full and the advisor on the phone said otherwise - its miss leading and if taken to the ombudsman the OP would probably win as she would have something in writing.

Again, i fully hold my hands up...PMI is one contract i know very little about, i wasnt aware of the text in the paperwork you have typed above - so if that is all correct then i can see your point.

dizzie

Wutang - yes, we were stupid enough to pick BUPA based on them being a "Big name brand", I'll admit that in hindsight. It is easy to see how the companies who spend the most on advertising and promotion get the lion's share of the market...yet if we used our common sense, we'd work out that that perhaps the companies who don't spend vast amounts on marketing....are the ones that actually pay out more for patient health care!

I'd like to campaign for more transparency from insurers - particularly BUPA since their fee schedule is kept inaccessible to patients on the web. Now that I know what BUPA are doing, the question is a more balanced one..

"Do I accept that if I move to another insurer, I'll have special terms imposed about pre-existing conditions

....or do I stay with BUPA and accept that if I need anything else....for any other condition or injury that may arise...that I'll end up paying more for all these claims myself anyway?"


...and about that rubbish about BUPA reimbursing outpatient consultations in full...

it really should be added to to say, "subject to the deduction of your annual excess...and provided that you don't exceed your (paltry) annual outpatient allowance"

dizzie

Since BUPA aren't being transparent with their customers, FIPO have felt the need to start to alert patients themselves...

http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&ved=0CHcQFjAD&url=http%3A%2F%2Fwww.aagbi.org%2Fsites%2Fdefault%2Ffiles%2Fimages%2FFIPO%2520-%2520Patient%2520Leaflet%2520-%2520May%25202012%2520%255B2%255D.pdf&ei=JEXTT-P1AYmb8gP3_uWxAw&usg=AFQjCNFkiEvHuqcooxyOUhvYnmgWswwpgg

starrystarry

Wutang wrote: »

Perhaps nothing. Read the original post.

Eh? Perhaps you should read the original post. The OP wasn't asking for opinions about whether Bupa policies are any good or not which is what you seem to have launched into a tirade about.

Whether the policy is good value or not, it is what it is. Bupa warned the OP about the limit, its not their fault its been breached. Even the OP doesn't feel this is Bupa's fault.

dizzie

starrystarry wrote: »

Eh? Perhaps you should read the original post. The OP wasn't asking for opinions about whether Bupa policies are any good or not which is what you seem to have launched into a tirade about.

Whether the policy is good value or not, it is what it is. Bupa warned the OP about the limit, its not their fault its been breached. Even the OP doesn't feel this is Bupa's fault.

Without knowing a little more about the details of exactly what the OP was told by BUPA, the hospital and the doctor - I don't think we can assume that this is a clear cut case. The things I'd really want to know are:

1. How much of the shortfall was BUPA's annually imposed excess?
2. Does your policy pay for an initial consultation.
3. Were all of the components that were to be delivered discussed with BUPA - i.e. the consultation and all of the individual tests required. Were BUPA prepared to consider funding ALL of these, or were there some tests that were excluded from the policy?
4. Did BUPA make it clear whether the consultation and tests were to come out of the same "benefit pot" or were these components to come out of separate pots for the policy.
5. Did BUPA remind you what the collective annual allowance for each of the relevant benefit pots was? e.g. "we allow up to £500 per year in total for tests".
6. Did BUPA make it clear whether they would limit the reimbursement levels of any individual components e.g. what they would be for each individual test e.g. "we will pay up to £120 for Text X, and £75 for Investigation Y"

Do you see why this can be quite complex and why you should never, ever leave it to the hospital or doctor to decide whether your costs are going to be covered?

BUPA would really like someone else to be the bearer of bad news, so they like to leave the ball in another person's court if they can...then if the fees aren't covered in full, you might think it's because the consultant or hospital charges too much. Trouble is, that your doctor or hospital does not have the benefit of all of the terms of your policy and details of any previous claims to hand which may affect pay-out.

It is BUPA that is responsible for setting up the particular terms of your policy and THEY should be the ones analysing the breakdown of fees and giving you full advice on what they are prepared to reimburse.


I would discuss this with BUPA in the first instance. I have had BUPA make mistakes with reimbursement in the past, so it is always worth checking. If BUPA only provided part of the information about reimbursement (e.g. said what they'd pay for some individual tests but neglected to say what maximum they'd be prepared to pay out in total per year for all tests done (or vice versa), then perhaps BUPA are culpable (although they'll probably say that any information that wasn't spelled out to you can be found in the small print of your contract with them!).

Like I said, if the OP is prepared to add more detail about this situation and the precise information she was given, then we will be in a better position to make a judgement.