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Bupa problem - outpatient allowance exceeded

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My wife has private medical cover through work, provided by Bupa through PMI Health Group.

She recently got 2 referrals from her NHS GP for 2 separate issues. She got appointments on the same day to see specialists at a local private hospital. One of the consultants decided that some tests were required, so these were done.

Now Bupa is refusing to cover the costs of all of these, as the outpatient allowance has been exceeded - despite having authorised all the procedures at the time.

She has obtained recordings of the phone calls (both between her and PMI, and PMI and Bupa) to authorise the procedures. It all seemed quite disconnected - there are a couple of mentions of the amount left in her outpatient allowance, and that it would be sufficient to cover the costs, but they didn't take into account the fact that other procedures had also been authorised at the same time.

They are refusing to budge on this - they are saying that it was my wife's responsibility to know how much was left in her outpatient allowance, to find out the cost of each procedure and ensure that there was enough to cover everything. Unfortunately she was under the impression that if they authorised a procedure, they were accepting liability to pay for it.

Any advice? Should she just pay up?
Let's settle this like gentlemen: armed with heavy sticks
On a rotating plate, with spikes like Flash Gordon
And you're Peter Duncan; I gave you fair warning

Comments

  • vaio
    vaio Posts: 12,287 Forumite
    Part of the Furniture 10,000 Posts Combo Breaker
    As always, if she feels she is being treated unfairly then complain to the insurer and refer to the FOS if still not satisfied
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