Analysis: Chronic conditions

Traditionally PMI covers just acute conditions, but what about other healthcare essentials such as routine monitoring and check-ups for long-term conditions? Emily Borkowska finds out more.

Group private medical insurance (PMI) has traditionally existed to cover the costs of treating employees’ acute – i.e. curable and short-term – medical conditions. But providers have introduced a range of services that have seen the product encompassing some treatments for chronic conditions as well.

Providers have clearly defined benefit rules within their insured contracts that state that chronic or critical illnesses which cannot be cured, such as multiple sclerosis, asthma and diabetes, are not covered. In practice, however, it is not this black and white. If an employee is treated for an acute condition and then needs further monitoring to maintain their health, some insurers will assist them. And if a member is receiving such treatment and the business is switched to an alternative provider, brokers will usually negotiate the continuation of the treatment.

Paul Moulton, sales and client relationship manager at AXA PPP healthcare, says: “In some invasive cancer cases we have paid for follow-up check-ups because in our view it is important that the person checks they are in remission. However, something like arthritis is not curable and so we would not provide cover for this.”

Matthew Judge, technical director at Jelf Employee Benefits, believes insurers should offer a degree of flexibility around long-term conditions.

“Some PMI providers like Aviva offer a benefit that can be tailored to set a financial limit so a person can have some treatment of a chronic condition, say an annual check-up and blood test relating to a high cholesterol condition. This type of flexibility is good, can be controlled and does not increase the risk and cost too much,” he says.

Wayne Jackson, sales and marketing director at Premier Choice Group, agrees: “I think some flexibility would not go a miss here. By this I mean something like a small allowance each year to cover, say, one episode of monitoring. This could help with earlier intervention thereby avoiding a much more serious and more expensive claim at a later date.”

GP referred service

Aviva allows members of its Healthy Solutions policy to choose to cover routine specialist consultations and tests for non-acute conditions. Its GP referred services option on Healthy Solutions is for companies covering between two and 249 employees and covers up to ten physiotherapy, chiropractic, osteopathy and acupuncture sessions; chiropody, podiatry and homeopathy; radiology/pathology; GP minor surgery; and specialists’ fees for consultations and tests for non-acute conditions.

Dr Doug Wright, head of clinical services at Aviva UK Health, says: “Traditionally, PMI puts the policyholder’s care under the control of a specialist rather than a GP. The GP referred services option mirrors NHS practice whereby the GP refers a patient for diagnostic tests prior to a referral to a specialist. It privately funds tests and diagnostics which wouldn’t normally be covered under PMI and it gives employees a more seamless experience in accessing private healthcare.”

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