Insurteer covering full codts of op?

Enigmaman

As an adjunct to my post last week. I wonder what others' experience is of health insurance companies covering/not covering the cost of ops?

I find it concerning that Vitality are talking about "getting clearance first" before adding to the agreed basket of treatment. What is I am out cold? Even if not, would I have to phone from my hospital bed? What if it is when they are closed?

y strategy is to try to get as much as possible added ahead of the op but of course, the unforeseen is the unforeseen.   They do say I can "probably" get it added retrospectively if the consultant says it was necessary but "the probably" is not what I want to hear.

Dont need this extra stress on top of the operation.  

DullGreyGuy

Enigmaman said:

I find it concerning that Vitality are talking about "getting clearance first" before adding to the agreed basket of treatment. What is I am out cold? Even if not, would I have to phone from my hospital bed? What if it is when they are closed?

y strategy is to try to get as much as possible added ahead of the op but of course, the unforeseen is the unforeseen.   They do say I can "probably" get it added retrospectively if the consultant says it was necessary but "the probably" is not what I want to hear.  

UK PMI doesn't deal with emergency medicine so if you are knocked off your motorbike into a fence and have to go straight into surgery to deal with the fence post that is sticking out your chest then that will all be done by the NHS... you wont be phoning the insurers from the back of the ambulance. 

Once you're stable you potentially can transfer to the private hospital/wing and follow up surgeries done under your PMI.

We use Bupa but most insurers work in similar ways, you advise the insurer you need to make claim, for most conditions this will require a referral from a GP but for some things you can self refer. After that the consultant and the insurer talk to each other so if your consultant says you need to extend your hospital stay by two weeks they advise your insurers and they say yay or nay.

Realistically if you are under the knife and something goes wrong they will deal with it, they wont step out to call your insurers whilst your skull is open on the operating table. Realistically the only two scenarios are either the Dr does something totally inappropriate/unnecessary in which case there is a reasonable challenge from everyone as to why anyone should pay them for it or the issue that arrises is directly linked to a pre-existing condition exclusion on the policy. 

I'm not a medical expert and struggle a little to think of a scenario it could happen in but I am sure there must be some. I've never heard of it happening so have no idea how the costs would be covered.

Part of the reason for the pre-approval is exactly to avoid these kinds of problems. If the doc says its A and the insurer agrees the procedure but when they get in they discover they were wrong and its B but B is excluded from your insurance then the procedure is still covered as it was preauthorised. 

Enigmaman

Thanks for this.  I was aware emergency admissions are not covered but unsure as to how it works with retrospectively adding any unexpected tests etc, e.g. an extra CT scan if needed.

However, from what I gather, the consultant needs to support any additions to the pre-agreed treatment basket.

I guess he's familiar with the MO for private ops.

TELLIT01

Of course the insurer will want the opinion of the consultant/doctor before approving any treatment.  The claimant can't simply say they are going to have a CT scan, or any other treatment, without medical evidence that it's necessary.

DullGreyGuy

Enigmaman said:
unsure as to how it works with retrospectively adding any unexpected tests etc, e.g. an extra CT scan if needed.

Under what circumstances would you need a CT scan whilst you are still on the operating table?

Enigmaman

I'm not just talking about what happens on the operatibg table! I mean any and every aspect of treatment from beginning to end of the stay.

TELLIT01

Enigmaman said:

I'm not just talking about what happens on the operatibg table! I mean any and every aspect of treatment from beginning to end of the stay.

Before any procedure was agreed to there would be discussion between the insurers and the medical professionals.  If additional treatment was required the insurer may allow the medics to add it and then inform them if it's very urgent.  If it's something which needs to be done but is not urgent/life threatening it would probably need to be given the OK by the insurer before the procedure is carried out.

Enigmaman

Sounds like I potentially might need to stay in longer if it's eg a Sunday. Jeez.

DullGreyGuy

Enigmaman said:

I'm not just talking about what happens on the operatibg table! I mean any and every aspect of treatment from beginning to end of the stay.

But you have to be realistic... there are only certain circumstances where an emergency happens that may be associated with something not connected with the original approval of a material cost -v- say an operation. 

In out largest claim an initial 1 week in/day patient care was approved it quickly became apparent that wasn't going to be close to sufficient and so the consultant spoke to the insurer and they signed off another 3 weeks care. I was in a somewhat similar place to you at the time and didn't understand the policy and so when the Doc said it I phoned the insurer thinking I had to deal with the extension. 

Their answer was that it was unlikely to be approved however it was dependent on the medical evidence from the consultant. In reality not only was it approved but was so the next extension. I wasn't told anything about it until about 2 months after when I got a statement saying how much they'd paid on the claim.

These are organisations that are used to dealing with each other and undoubtably have side agreements... I dont believe Bupa were paying £1.200 per day (excluding meds and doctors) for just staying in a basic hospital setting especially as the list place of the clinic was £900. They claimed they paid £50,500 just for the room... I've worked with large corporations that do on the surface pay over the odds but then get massive rebates at year end based on total volumes.