Health policies: cover and exclusions

Read about what cover you can get from your health insurance and when you can get it.

The reason most people like private medical insurance is that it frequently speeds up your care. For ‘popular’ scans and treatments it could be much, much quicker, bringing the wait down from six months to a few weeks.

However, you do need to be aware of what your cover will pay for. And when you're covered!

It doesn’t work like car insurance

You see, health insurance is different from car insurance.

With car insurance, when you have an accident, you are covered for that accident even after your policy has expired. If you crash, let’s say, one week before the policy ends, your insurer will still pay out until everything that you were covered for has been put right.

However, with many medical-insurance policies, if you have an accident or illness that is covered by the policy, as soon as it expires you are no longer covered for any further procedures or consultations. Usually the only way to continue your cover is to renew your policy with the same insurer. Of course, the cost of renewal may have gone up as a result of your age and your recent claim.

So you need to be clear about when your policy will cover you.

Cover

Now let's move on to what your policy will cover.

Basic cover will often include in-patient (meaning you’re staying overnight at the hospital) and day-patient accommodation, diagnostic tests, operating-theatre charges, drugs, dressings, nursing care and specialists’ fees (which should include surgeons, anaesthetists and physicians). Ensure the insurer has access to a decent-sized list of hospitals that it can use for your treatment.

As for out-patient cover (meaning you’re receiving treatment in a hospital but not staying overnight), you might want cover for surgical procedures, radiotherapy and chemotherapy for cancers, and expensive scans (such as MRI and CAT). It might be a good idea to see whether you can get specialist consultations and diagnostic tests.

Furthermore, you may be interested in such things as alternative therapies and physiotherapy, psychiatric cover, treatment at home, cover for a few pregnancy complications and some oral surgery procedures. If your policy covers your children, you might want other benefits, such as accommodation for you or your partner if your child is in hospital.

Look at the amount of cover you’re getting in each section of the policy. Is it sufficient for you? Also, what excess are you being asked to pay? Could you afford it?

Exclusions

In general, most private medical insurance plans do not cover the following:

• Normal pregnancy, drug abuse, infertility, GP fees, any medical prescriptions, normal dentistry, alcohol abuse, self-inflicted injuries, AIDS, chronic long-term illnesses such as diabetes or asthma, cosmetic surgery or regular renal dialysis.

• Medical conditions suffered prior to joining a new plan are known as pre-existing conditions. All plans exclude pre-existing conditions either permanently or for a given period of time.

I’ve also found no policies where you’re allowed to claim on it to prevent conditions occurring (e.g. vaccinations). Also, they won’t test you to see if you have a condition when you have no symptoms. Plus, such things as warts on the skin are often excluded, even from comprehensive policies, as well as the cost of fitting external prosthesis.

Cancer exclusions

Cancer is a big worry for a lot of people, so I shall use this as an example of the sorts of loopholes you might expect to find, whatever your illness.

The small print in insurance policies, especially under the heading of ‘chronic conditions’ can often exclude treatments for cancer or even cut the treatments short.

Steve Clements of Mercer (a ‘health and benefits service’ for businesses) recently pointed out that yet more long-term treatments are arriving that will prolong life and ease symptoms, rather than cure. He wants medical insurers to clarify whether these will be covered.

I wouldn’t count on it though. Mercer conducted a survey of medical insurers which found that the majority did not cover ‘palliative care’ (relieving or soothing symptoms for a terminal illness, such as cancer.) A key phrase I took from one broker's website is: ‘Private Medical Insurance provides cover for acute, treatable medical conditions.’

Also, as I look at a leading provider’s ‘comprehensive’ policy booklet, it says the policy will cover you ‘until the treatment becomes long-term’.

I’m perhaps deviating from my remit as a financial writer here, but I believe that one of the better insurances against dying from cancer is to check yourself regularly. A large percentage of our cancers occur in breasts and testes. A nurse recently told me that I should check myself every two weeks. It may seem excessive, but a few seconds of my time once a fortnight, preferably in a private room, is well worth it. On the financial side, spending an hour reading the small print is worth it, too (not necessarily in a private room).

This is an updated version of an older Lovemoney article.