Self referral health insurance

jcrennie

I was wondering if anyone ccould help me here with the underwriting of my private healthcare policy that I have through work. When joining the the scheme it is subject to a two year moritairum with the wording on the renewal certificate

"no benefit is payable before XXX for medical conditions exisiting or forseeable at the date of enrolement or the reccurence of past medical conditions"

I have as mole which I would quite like to get checked out (will be done via the NHS if not), this mole changed colour (dark to light) in 2020, seemingly to fade. However recently I noticed the mole begin to change shape and size and feel slightly inflamatory. When trying to self refer through AXA to see a specialist, the underwriters have said because the mole changed colour previously, they won't treat under private until the mortaorium period is over. I knew there was a two year moritory period on pre-exisiting conditions, but it was news to me, the policy was underwritten about this other fact. I can accept this is maybe an mistake on my behalf being too open with the claims handler, however the company policy states:

"The moratorium policy means pre-exisiting conditions will not be covered for the first two years of membership".

I believe the two year moritarium period is built in by my employer (and I get the reasons why). My claim is based on new symptoms appearing and not a pre-exisiting condition that I have been seeking treatment for. I get the word "pre-exisiting" is vague and they will state this as symptoms, but I have always interpreted that as pre-diagnosed conditions based on the company policy and seemingly as a corporate member, there is no clear guidance anywhere what constitues what a "pre-existing conditon is".

Just wondering if anyone knows if this is worth fighting and complaining about?

DullGreyGuy

You say when your potential medical condition could be considered to have started but you dont mention when the policy started?

Sounds like the fact that the mole never returned back to normal that they are considering it one continuous condition and I am assuming your policy incepted after 2020. These are often the challenges of ongoing undiagnosed things because without knowing what it is/was makes it hard to know if future things are the same or different.

There are 4 options when coporates buy PMI for their staff when it comes to pre-existing conditions. moratoriums is one of the middle ground options.

jcrennie

DullGreyGuy said:

You say when your potential medical condition could be considered to have started but you dont mention when the policy started?

Sounds like the fact that the mole never returned back to normal that they are considering it one continuous condition and I am assuming your policy incepted after 2020. These are often the challenges of ongoing undiagnosed things because without knowing what it is/was makes it hard to know if future things are the same or different.

There are 4 options when coporates buy PMI for their staff when it comes to pre-existing conditions. moratoriums is one of the middle ground options.

It started June 2022 when I was eligible to qualify based on my job banding. 

The definition of “pre-existing condition” is very vague. My challenge is the symptoms are different now, but the claims adviser says this doesn’t matter. I’ll challenge the findings, was just wondering what the best way to do this is via technicalities.

DullGreyGuy

Without getting medical opinion it'll be difficult to really say if the two things are linked or not and/or if the fact it never returned to normal should be considered as a continuous symptom or not. Your complaint to them will naturally argue it wasnt 

I'm guessing you work for a fairly large company? It can be worth speaking to your employers too, companies with large numbers of insured staff often arent buying standard insurance as consumers would understand it and often fund some or all of the claims so will at times instruct the insurer to deal with a claim, go above policy limits etc (more often for more senior staff though)

jcrennie

DullGreyGuy said:

Without getting medical opinion it'll be difficult to really say if the two things are linked or not and/or if the fact it never returned to normal should be considered as a continuous symptom or not. Your complaint to them will naturally argue it wasnt 

I'm guessing you work for a fairly large company? It can be worth speaking to your employers too, companies with large numbers of insured staff often arent buying standard insurance as consumers would understand it and often fund some or all of the claims so will at times instruct the insurer to deal with a claim, go above policy limits etc (more often for more senior staff though)

I believe with this policy, AXA just administer the Trust that the company funds. I’d already told AXA I’d go to my employer, but they wanted it to go through their internal system of complaints. 

My complaint is what you have essentially said- it’s just how I word it aligned to the policy to give it the best possible chance of succeeding.

DullGreyGuy

You can do the two at the same time, they arent mutually exclusive. 

jcrennie

DullGreyGuy said:

You can do the two at the same time, they arent mutually exclusive. 

Thanks, so I’ve made a complaint but can take up to 8 weeks. I’ll speak to my company too, but again, I suspect that will take weeks.

other options I see:

1) I had another mole I wanted checked over, but that got lost in the heat, when the first one was claimed
2) say I made an error and looked over photos that discolouring happened X amount of time ago
3) make a new self referral claim for a completely different mole in a few days/weeks

obviously understand there are some morals/ethics involved in the above & suspect they would get flagged up but there’s genuinely no medical evidence anywhere. 

sheramber

https://www.skincancer.org/blog/amelanotic-melanoma-it-doesnt-look-like-other-melanomas/#:~:text=Physicians refer to these as,or essentially clear and colorless.

For example, certain melanomas may have no color at all. Physicians refer to these as “amelanotic” melanomas, because they are conspicuously missing melanin, the dark pigment that gives most moles and melanomas their color. These unpigmented melanomas may be pinkish-looking, reddish, purple, normal skin color or essentially clear and colorless.