BUPA private health insurance query

Sam10000

This seems like a simple query, but I can't seem to find the answer no matter how much I search here or elsewhere.

My wife is having a lot of problems with her health insurance with BUPA (via a company program). They seem to be declining things (mental health care) orally and not putting anything in writing, which makes it hard to challenge. And when they do call my wife to tell her things are declined, she gets extremely distressed and cannot take it all in.

My question is: what is the appropriate way to deal with health insurance refusals (which are based on their flawed interpretation of the treatment proposed with regards the policy exclusions)? I know we can go to the Financial Ombudsman after eight weeks, but I'm hoping there's some form of established procedure to handle things internally - preferably in writing. Can anyone advise?

Many thanks.

Quentin

You must deal with their complaints procedure first.

Then if you are unhappy with the reply or they ignore you for 8 weeks you can escalate to the FOS

Sam10000

Thanks. Any suggestions as to their decisions not being given in writing?

Last question - eight weeks is a very long time for medical treatment, and not doubt the FOS will take a long time too... Is it advisable to pay for the treatment now (we can afford it) and hope it will be repaid if we can successfully challenge, or do insurers only work on advance approvals? Sorry, I'm not from the UK.

lisyloo

Is it a group policy? or an individual one?
If the former then she might want to raise it with her employers HR department.


If they are declining things verbally then she should get name, time and date for future complaints and also so that recordings can be replayed if necessary.
If she can't deal with it then could she allow someone (maybe yourself) to deal with it on her behalf (most companies allow this provided she gives her pemission).

and hope it will be repaid if we can successfully challenge

I think that would be quite a big risk.
The have all sort of rules, limits, pre-agreed arrangements with certain hospitals/consultants that you'd likely fall foul of.


I have a few comfortably off relatives who pay for tests (often not too expensive but long waiting lists) and if they are diagnosed with something then go via the NHS having jumped the queue.
Could you consider doing that?


I do sympathise though. The entire point is that it's meant to be stress-free and quick.
Does she have a booklet from them that she could check for their decisions?
I would ask them for paragrpah/page numbers when they decline.

Sam10000

Thanks, that's really helpful.

It is a group policy, so we will try the HR route.

Part of the problem is that the treatment she has been approved for - levothyroxine for bipolar disorder - is borderline experimental (but they approved it, although they excluded other treatment - rTMS - that he wanted to undertake in parallel), which basically only this one London doctor does, albeit with considerable success. He needs to monitor the treatment via regular ECG and blood tests (which he has to carry out personally, rather than any other provider, for regulatory reasons), which they are excluding from cover on the basis that it is considered 'monitoring'. However, it is extremely dangerous to continue his treatment without monitoring, so he has refused to take it any further, which of course puts my wife at more risk because she's not getting any treatment.

I'll ask them about the option of us paying for the 'monitoring' while we continue to challenge their cover of it (and the other things they've refused), given the circumstances (i.e. this doctor insists on doing it himself in order to continue with the treatment).

Thanks again to you both.

Sam10000

I should clarify - although I'm not sure anyone will be able to assist with the specific policy wording - the exclusion they seem to be relying on is:

Exclusion 25 Screening, monitoring and preventive treatment
We do not pay for:
o health checks or health screening. By health screening we mean where you may not be aware you are at risk of, or are affected by a disease or its complications but are asked questions or have tests to find out if you are and which may lead to you needing further tests or treatment
o routine tests, or monitoring of medical conditions, including:
routine antenatal care or screening for and monitoring of medical conditions of the mother or foetus during pregnancy routine checks or monitoring of chronic conditions such as diabetes mellitus or hypertension
o tests or procedures which, in our reasonable opinion based on established clinical and medical practice, are carried out for screening or monitoring purposes, such as endoscopies when no symptoms are present
o preventive treatment, procedures or medical services. Exception: If you are being treated for cancer, have strong direct family history of cancer and your consultant has advised that you receive a genetically based test to evaluate future risk of developing further cancers, we will pay for this test as well as the recommended prophylactic surgery when it is recommended by your consultant and is eligible under your benefits. You must have our written confirmation before you have tests, procedures or treatment and we will need full clinical details from your consultant before we can give our confirmation.

lisyloo

My gut feeling is that they have it sewn up with their small print but if it's a group your company may be able to throw their weight behind it.


I do know of a case where there was an issue with cancer treatment and the employer (several hundred individuals) got involved and the treatment was provided in the end and I think it was BUPA.