Health Insurance Underwriting Methods and Chronic Conditions. Everything you need to know about new, pre-existing and chronic conditions

Transcription

1 Heath Insurance Underwriting Methods and Chronic Conditions Everything you need to know about new, pre-existing and chronic conditions

2 Contents Section Introduction 3 A choice of underwriting methods 4 Frequenty asked questions 6 How we dea with chronic conditions 8 Your rights as a patient 12 How we use your persona detais 13 Pease note Saga Heath Insurance poicies are underwritten by AXA PPP heathcare Limited. Any reference to we, us, or our in this document means AXA PPP heathcare Limited. This document shoud be read aongside your Poicy Summary. In each section of this eafet we have underined certain important terms and provided more detaied definitions in boxes beow. 2

3 Introduction When you are considering heath insurance, it s important to understand a the options avaiabe to you. This eafet provides detais of your cover options for new, pre-existing and chronic conditions. You can find more information in the Poicy Book, which is avaiabe on request, if you do not aready have a copy. Aternativey, you can find copies of a our Poicy Books onine at saga.co.uk/heath-insurance/poicy-documents. Underwriting our poicies We offer a choice of three types of underwriting method: 1) Moratorium 2) Fu Medica Underwriting 3) Continued Persona Medica Excusions As is the case with heath insurance poicies from other providers, your choice of underwriting method wi determine the eve of cover you have for medica conditions. Depending on which option you choose, we may be abe to cover you for pre-existing medica conditions as we as new ones. Pre-existing medica conditions any disease, iness or injury for which: you have received medication, advice or treatment; or you have experienced symptoms; before taking out the poicy. It is unikey that we wi be abe to cover pre-existing chronic conditions, as these generay require reguar or periodic treatment, medication or medica advice (see page 8 for more information on chronic conditions). 3

4 A choice of underwriting methods Moratorium With this option, we wi provide cover for new medica conditions that arise after the poicy begins. However, we wi excude any pre-existing conditions you had during the three years immediatey before your poicy started and, in some cases, other specified conditions. We wi excude any specified conditions from your cover for at east two years after you join if: you were aready aware that you had diabetes when you joined, or you were aready aware that you had raised bood pressure (hypertension) when you joined (see Cover for pre-existing hypertension opposite), or you were aready being investigated, monitored or treated as a resut of a PSA (Prostate Specific Antigen) test to do with the prostate when you joined. The specified conditions we wi not cover are isted in the tabe beow. We wi not cover treatment for these specified conditions whatever the cause, even if they are not reated to the pre-existing condition or they deveop after you join. Pre-existing conditions If you: Specified conditions We wi not pay for treatment of: Have been diagnosed with diabetes Diabetes Ischaemic heart disease Cataract Diabetic retinopathy Diabetic rena disease Arteria disease Stroke Have had treatment for raised bood pressure (hypertension) in the three years before you joined Have been under investigation, had treatment or undergone monitoring as a resut of a Prostate Specific Antigen (PSA) test in the three years before you joined Raised bood pressure (hypertension) Ischaemic heart disease Stroke Hypertensive rena faiure Any disorder of the prostate It is possibe that we wi be abe to cover these conditions under your poicy once you have hed your poicy for two years. At this point, you can contact us to caim for treatment of pre-existing conditions as ong as you have had a troube-free period of two consecutive years for the condition. Troube-free We define troube-free as when, in reation to the medica condition, you have not: had any medica opinion from a medica practitioner incuding GPs or speciaists; taken any medication (incuding over the counter drugs) or foowed a specia diet; had any medica treatment; or visited a practitioner, therapist, physiotherapist, homeopath, acupuncturist, optician or dentist. 4

5 If you choose the Moratorium underwriting method, you ony need to provide basic information about yoursef and anyone ese on your poicy. Important note: Pease do not deay seeking medica advice and treatment for a pre-existing medica condition during the first two poicy years simpy to obtain cover. Fu Medica Underwriting This option is simiar to Moratorium in that we provide cover for new medica conditions that arise after the poicy begins. However, when it comes to excusions for pre-existing and specified conditions, we wi base these on the answers you provide in response to our fu medica history assessment. The benefit of this option is that we wi state, in writing, which medica conditions we wi excude. As with the Moratorium option, we may ater cover a pre-existing medica condition if you ask us to review the excusion and we agree to remove it. Important note: If necessary, we may ask your doctor for any further information required to hep us determine which medica conditions we shoud excude from your poicy. Continued Persona Medica Excusions This option is ony avaiabe if you aready have cover with another insurer, subject to your medica history over the previous 12 months. If you wish to retain any medica underwriting appied by your previous insurer, pages 6 and 7 of this eafet do not appy. Pease ca one of our speciaist advisers on for more detais. Cover for pre-existing hypertension A our underwriting methods can provide cover for eigibe treatment of pre-existing hypertension, subject to the terms of your poicy. If you do choose such cover, you wi aso be abe to caim for eigibe treatment of any conditions reated to hypertension that arise after your poicy starts. Pease note: Treatment of a other medica conditions wi be subject to the rues appicabe to the underwriting method you choose. 5

6 Frequenty asked questions Q. Wi my choice of underwriting method affect my premium? A. Choosing between Moratorium and Fu Medica Underwriting wi not affect your premium. However, if you choose Continued Persona Medica Excusions, your premium may increase. Moratorium is the most popuar underwriting method as it is the most straightforward option to take out cover. However, the Fu Medica Underwriting method makes it easier to understand, as you decare your medica history up-front and we then make you aware of any excusions at the start of your cover. Q. What if I suspect I am suffering from a condition (for exampe, I have abdomina pain) but have not seen a doctor about it, nor received any firm diagnosis before my cover starts. Wi I be covered if I need to have any investigations or treatment for the condition once my poicy has started? A. You woud not be covered with either Moratorium or Fu Medica Underwriting for any treatment you woud have to have because of the abdomina pain. This is because symptoms were evident when you took out the poicy making it a pre-existing condition. Q. I had an operation on my right knee recenty. Wi I be covered for any further treatment to it after my poicy starts? A. During your first two years of continuous cover with us you woud not be covered for any further treatment reating to your knee operation, or the condition for which it was performed. After that time, provided you have been troube-free (see definition on page 4) for a consecutive two-year period in reation to your knee probem, you woud be covered for any further eigibe treatment. Pease note: If you have chosen the Fu Medica Underwriting method and asked us to review your excusion, you woud need to contact us to request that review of terms before we coud offer any cover for the knee condition. Q. Some time after my cover starts, I go to my doctor for a routine visit. A heart condition is diagnosed that must have started to deveop before my poicy started. What is the position? A. You woud be covered provided there were no symptoms evident at the time your poicy commenced, and it is not a specified condition (shown in the tabe on page 4) or a pre-existing condition. 6

7 Q. How do reguar check-ups affect my cover? A. It depends what the check-ups are for. For exampe: 1) If you have a medica condition before your poicy starts and your doctor, or speciaist, recommends that you continue to have check-ups for that medica condition, then we wi not cover the cost of private treatment received for that medica condition for a period of two years from the time your poicy started. If the medica condition is one of those shown in the tabe on page 4, you woud not be covered for it either. Cover wi ony be avaiabe once you have been discharged from care and have no further treatment, medication or advice for a continuous period of two years. 2) In the same situation, if you choose to continue having check-ups for your own peace of mind even though you have been discharged from care, we wi cover you for the condition (but not the routine check-ups) if you are troube-free for a continuous period of two years from your ast appointment prior to discharge. 3) If you have genera check-ups simpy to maintain good heath, and not for any particuar medica condition, we ignore them when appying the restrictions for treatment of pre-existing conditions. Pease note: We do not pay for check-ups in any of the circumstances described above. 7

8 How we dea with chronic conditions There are certain things your poicy wi be unabe to cover. For exampe, chronic (ong-term) conditions. However, we wi cover the treatment of acute exacerbations or compications (fare-ups) necessary to bring the condition back to its controed state or ead to a fu recovery. Chronic conditions A disease, iness or injury that has one or more of the foowing characteristics: It needs ongoing or ong-term monitoring through consutations, examinations, check-ups, and/or tests It needs ongoing or ong-term contro or reief of symptoms It requires your rehabiitation, or for you to be speciay trained to cope with it It continues indefinitey It has no known cure It comes back or is ikey to come back. If your iness or medica condition requires recurring consutations over a ong period, checks on your medication, ong-term therapy or treatment to ease symptoms, your condition may be defined as a chronic condition. If you have been receiving ongoing or continuing treatment, or treatment that is intended to manage your condition or keep your symptoms in check, we wi review your treatment to assess whether it remains eigibe. What does this mean in practice? In ine with other heath insurance poicies, our pans are designed to cover caims for expenses incurred due to unexpected events, and we do not continue to pay for treatment of medica conditions that wi continue indefinitey or keep recurring. With your permission, we may contact your speciaist or GP who knows your particuar circumstances to confirm the diagnosis of your condition and detais of the treatment you are currenty receiving, and to give us a future prognosis for the condition. If our information indicates that you have a chronic condition, we wi write to inform you that we wi stop paying benefit for the continuing or recurrent treatment of the condition. What if your condition gets worse? There are certain chronic conditions, such as Crohn s disease, that require management of recurrent episodes during which the symptoms of the condition worsen. Because of the ongoing or continuing nature of the condition, we wi write to te you when there is no further benefit avaiabe for the treatment of that medica condition. 8

9 Exampes of chronic conditions The foowing are exampes of chronic conditions and how they are usuay deat with. In a the foowing exampes we may need to write to you or your doctor to obtain further information, as expained opposite. Important note: Certain pans have specific restrictions to benefits such as out-patient treatment, treatment that coud have been received on the NHS within four weeks and other specific excusions covered in your poicy terms. The cover for cancer aso varies by pan, with some pans offering ower eves of cover than those described in this document. The exampes beow are designed to show our genera poicy on chronic conditions and how we woud dea with them for a customer on a mid-range pan, e.g. Saga HeathPan Saver Pus. Pease read your Poicy Book carefuy to estabish what cover you have, as a the other terms (incuding any imits) of your poicy wi continue to appy to your cover. Exampe 1 Angina and heart disease Aan has been covered with Saga for many years. He deveops chest pain and his GP gives him an open referra to a speciaist. After caing us to pre-authorise this referra he has a number of investigations and is diagnosed as suffering from angina. Aan is paced on medication to contro his symptoms. We woud pay for the initia consutation and tests to diagnose the condition and further consutations with the speciaist to aow the medication to bring the condition under contro. At this point we woud advise Aan that further reguar review consutations to monitor the condition woud not be covered, but we woud aow one further consutation for Aan to discuss aternative arrangements shoud he wish to do so. Two years ater, Aan s chest pain recurs more severey and his speciaist recommends that he has a heart bypass operation. We woud confirm to Aan that we wi cover that operation as it wi stabiise his condition and substantiay reieve his acute symptoms. We woud then expain to Aan that, athough his poicy woud not normay cover reguar check-ups, in this particuar circumstance we woud aow for a further ten years of annua postoperative check-ups with the speciaist to ensure that his condition remains stabiised. This benefit woud ony be avaiabe on poicies with out-patient cover and whie the poicy remains in force. Exampe 2 Asthma Eve has been covered with Saga for five years when she deveops breathing difficuties. Her GP gives her an open referra to a speciaist. After caing us to pre-authorise her consutation and initia treatment she has a number of tests. These revea that Eve has asthma. Her speciaist puts her on medication and recommends a foow-up consutation in three months to see if her condition has improved. At this consutation Eve states that her breathing has been much better, so the speciaist suggests she has check-ups every four months. We woud agree to cover Eve s initia tests and consutation to estabish the diagnosis and aso the subsequent consutation to see if there was an improvement. However, we woud then advise Eve that she is not covered for reguar check-ups. Eighteen months ater, Eve has a bad asthma attack. We woud agree to cover the cost of hospita treatment unti her condition has been stabiised. We woud aso pay for one further consutation foowing discharge from hospita. 9

10 Exampe 3 Cancer Beverey has been a Saga poicyhoder for five years when she is diagnosed with breast cancer. Foowing discussion with her speciaist she decides to have the breast removed, foowed by breast reconstruction. Her speciaist aso recommends a course of radiotherapy and chemotherapy. In addition she is to have hormone therapy tabets for severa years. Wi her insurance cover this treatment pan and are there any imits to the cover? We woud pay for the breast to be removed and for the first reconstruction to restore appearance. In addition we woud aso pay for the course of radiotherapy and icensed chemotherapy aimed at curing or bringing the condition into remission. Hormone therapy tabets (such as Tamoxifen) are out-patient drugs and, in ine with other out-patient drugs, are not covered by our poicies. Cara has previousy had breast cancer which was treated by umpectomy, radiotherapy and chemotherapy under her existing poicy. She now has a recurrence in her other breast and has decided to have a mastectomy, radiotherapy and chemotherapy. Wi her insurance cover this and are there any imits to the cover? We woud pay for treating the recurrence as described above. Monica, who was previousy treated for breast cancer under her existing Saga poicy, has a recurrence which has unfortunatey spread to other parts of the body. Her speciaist has recommended the foowing treatment pan: A six month course of six cyces of chemotherapy, aimed at destroying cancer ces. Monthy infusions of a drug to hep protect the bones against pain and fracture. This infusion is to be given for as ong as it is working (hopefuy years). Weeky infusions of a drug to suppress the growth of the cancer. These infusions are to be given for as ong as they are working (hopefuy years). Wi her insurance cover this treatment pan and are there any imits to the cover? We woud pay for the course of icensed chemotherapy aimed at curing or bringing the condition into remission. We woud pay for the icensed drugs (e.g. Herceptin) to suppress the growth of the cancer. Treatments that are given for proonged periods woud not normay be covered but, in the case of cancer, we make an exception. Thus the use of such drugs wi be covered for a period of time as described in your poicy document, or for the period of the drug s icence if this is shorter. Sharon woud ike to be admitted to a hospice for care aimed soey at reieving symptoms. Wi her insurance cover this and are there any imits to the cover? Hospice care is provided by the NHS and charitabe institutions at no cost to the patient, therefore we woud not cover this. However, if you seect our Extended Cancer Cover option, a donation to the hospice of 100 per night, up to 2,000, is avaiabe. 10

11 Exampe 4 Diabetes Deirdre has been covered with Saga for two years when she deveops symptoms that indicate she may have diabetes. Her GP gives her an open referra to a speciaist. After caing us to pre-authorise this referra Deirdre has her consutations and tests which confirm her diagnosis. She then starts on ora medication to contro the diabetes. After severa months of reguar consutations and some adjustments made to her medication regime, the speciaist confirms the condition is now we controed and expains that he woud ike to see her every four months to review the condition. We woud expain that we cannot continue to provide benefit for the review consutations, but woud agree to provide benefit for one more consutation to aow Deirdre the opportunity to discuss aternative arrangements for foow up. One year ater, Deirdre s diabetes becomes unstabe and her GP arranges for her to go into hospita for treatment. We woud provide benefit for this admission and for a short period after her discharge. Exampe 5 Hip pain Bob has been covered with Saga for three years when he deveops hip pain. His GP refers him to an osteopath who treats him every other day for two weeks, before recommending that he return once a month for additiona treatment to prevent a recurrence of his origina symptoms. We woud expain that the monthy visits are not covered by Bob s poicy but that, if he shoud have further probems or if his condition shoud worsen to the point where a hip repacement is needed, this woud be covered if his GP gave him a referra to a speciaist and he caed us to pre-authorise treatment. Pease note: Ony certain poicies cover compementary therapies such as osteopathy and you shoud check your Poicy Book to see if this is the case. 11

12 Your rights as a patient Before we can assess your appication, we may need to get a medica report from a doctor who has cared for you. The Access to Medica Reports Act (1988) gives you certain ega rights. These are: We need your agreement before we can appy for a medica report from your doctor. You can refuse, but if you do, we wi not be abe to assess your appication. You can ask to see the report before your doctor sends it to us, or for up to six months after it has been sent. If you have ticked the box on the medica history decaration form to indicate that you want to see the report, your doctor can charge a reasonabe fee to cover costs of suppying a copy. If you think any part of the report is incorrect or miseading when you see it, you can ask to have it changed. If your doctor wi not agree to do this, you may attach a statement of your own. Your doctor is not obiged to et you see any part of a report if: Your doctor beieves it coud seriousy harm your physica or menta heath, or that of others. It indicates the doctor s intentions in respect of you. It reveas information about another person, or the identity of someone who has given the doctor information about you (uness that person consents or is a heath professiona invoved in caring for you). We wi write and te you when we have requested the report. If you asked to see the report before your doctor sends it to us, you wi have 21 days to contact your doctor from the date of receipt of our etter. Once you have seen the report, your doctor needs your agreement to send it to us. If you don t arrange to see this report within 21 days, your doctor wi be free to send it to us. 12

13 How we use your persona detais AXA PPP heathcare Data Protection When you buy a poicy, AXA PPP heathcare, as the underwriter of the poicy, wi receive information about you from Saga. This wi incude any necessary medica information, such as medica excusions, needed to set up a poicy record. We wi use this information to manage our business and our reationship with Saga (such as aowing auditing of each other s records), to identify you when you contact us to caim and to hep administer those caims. Your Poicy Book has further information about other detais AXA PPP heathcare wi coect about you, for exampe when you caim, and what we use this for. You can find our fu privacy information on the AXA PPP heathcare website at Saga Data Protection Saga wi keep your persona information securey and use it to provide the highest standard of service in the administration of this poicy and other products that you hod with Saga, for underwriting and pricing purposes and, in certain circumstances, caims mediation and market research and to maintain management information for business anaysis. Saga may share your persona information and your medica data with other Saga Group (Saga pc and its subsidiaries) companies. Saga uses the data they coect from you, incuding sensitive persona data, to contact you and personaise their communication. They aso use it for administrative purposes to provide the service you requested and for preparing quotations. If Saga has obtained your permission to do so, they wi aso contact you by post, teephone, emai or other means to te you about offers, products and services that may be of interest to you. At any time you can opt out of receiving such information, revise the products you woud ike to hear about or change the method they use to communicate with you. You can update these preferences by caing For further information about how the Saga Group uses your persona information, pease visit or contact the Saga Group Data Protection Officer by emai: data.protection@saga.co.uk or post: The Saga Buiding, Enbrook Park, Sandgate, Fokestone, Kent CT20 3SE. 13

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16 Saga Heath Insurance This eafet is aso avaiabe in arge print, audio and Braie. If you require any of these formats pease contact us on If you have a hearing or speech impairment, you can aso contact us by e-maiing dda@saga.co.uk For more detais on our cover, pease ca am 7pm weekdays 9am 1pm Saturdays 10am 2pm Sundays. Saga Services Limited has arranged for its heath insurance to be underwritten by AXA PPP heathcare Limited, Phiips House, Crescent Road, Tunbridge Wes, Kent TN1 2PL. AXA PPP heathcare Limited. Registered Office: 5 Od Broad Street, London EC2N 1AD, United Kingdom. Registered in Engand No AXA PPP heathcare Limited is authorised by the Prudentia Reguation Authority and reguated by the Financia Conduct Authority and the Prudentia Reguation Authority. Saga Services Limited is a whoy owned subsidiary of Saga pc and is registered in Engand and Waes (Company No ). Registered Office: Enbrook Park, Sandgate, Fokestone, Kent CT20 3SE. Authorised and reguated by the Financia Conduct Authority. CSL-HE2518 May 2018 PM/LE/UC/A5/518