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In common with all other private medical insurance policies, the cover provided Universal Provident's products relates primarily to acute medical conditions, with only limited cover applying to chronic medical conditions. The following notes are intended to clarify the cover provided for chronic conditions.
What is a chronic condition?
A chronic condition is defined in our policy document as:
A disease, illness or injury which has one or more of the following characteristics:
- It needs ongoing or long-term monitoring through consultations, examinations, check-ups and/or tests;
- It needs ongoing or long-term control or relief of symptoms;
- It requires your rehabilitation or for you to be specially trained to cope with it;
- It continues indefinitely;
- It has no known cure;
- It comes back or is likely to come back.
Our approach to such conditions is depends on whether or not the condition existed at the time you took out your policy (i.e. whether or not it is a pre-existing condition).
If it is a pre-existing condition then it will fall to be dealt with under one of the acceptance methods described (see Pre-existing Medical Conditions). It should be borne in mind that, if cover is arranged under a moratorium, the very nature of such conditions means that it is unlikely that a person will ever go for a two year period without any advice or treatment relating to a chronic condition and therefore cover will never apply. If cover is arranged on a fully underwritten basis it is likely that a specific exclusion will be applied in respect of the condition.
If a chronic condition develops after the start of a policy, cover is provided under the policy, but is restricted to the initial period of treatment up to stabilisation of the condition and then for any subsequent acute flare-ups of the condition, again until stabilisation (see below for further information in this respect).
What does this mean in practice?
If you have a medical condition that has developed since taking out your policy we will pay for any eligible treatment required to stabilise the condition. In deciding whether or not a condition is chronic we will seek whatever medical opinion is deemed appropriate. Once a condition has been declared to be chronic, no further cover will be available under the policy for the on-going management and monitoring of the condition. Should there be a worsening of the condition, the policy will provide cover to stabilise the condition once more.
If the chronic condition is pre-existing, in normal circumstances no cover will be available under the policy either for management/monitoring of the condition or even for acute flare-ups. However, under a moratorium policy, if you have gone two years without advice or treatment, cover may be available for acute flare-ups of a chronic condition.
What if your condition gets worse?
No cover is provided under the policy for on-going monitoring or management of a chronic condition. However, if there is a sudden deterioration in your condition (we refer to this as an acute flare-up), cover will apply under the policy (assuming that the condition is not pre-existing), but only for the treatment necessary to stabilise the condition once more. Once the condition has been re-stabilised there will again be no cover for the on-going monitoring and management of the condition. Each time there is a flare-up of the condition, cover will apply until stabilised.
Examples of chronic conditions
Below are some examples of circumstances involving chronic conditions, which we hope will explain the situation under our policies and clarify any issues you may have. Please note that in all cases, if cover was arranged under our former InCare or Group InCare plan, no cover would apply to outpatient treatment other than chemotherapy or radiotherapy. If cover was arranged under NHS Plus or Group NHS Plus then no cover would apply to either daypatient or outpatient treatment. Please also note that for all products, limitations in the amount of benefit payable for certain treatments may apply.
Example 1 - angina and heart disease
Alan has been with Universal Provident for many years. He develops chest pain and is referred by his GP to a specialist. He has a number of investigations and is diagnosed as suffering from angina. Alan is placed on medication to control his symptoms.
We would pay for the consultation with the specialist and all of the diagnostic tests. However once the condition has been diagnosed as angina we would inform Alan that this is a chronic condition and that as such we would be unable pay for the on-going medication (this would be deemed to be the management of a chronic condition - please refer to the policy definition of "treatment").
Two years later, Alan's chest pain recurs more severely and his specialist recommends that he has a heart by-pass operation.
This situation is an acute flare-up of the underlying chronic condition and as such is covered by the policy. However, once the operation has been successfully completed and the condition has been stabilised, cover would no longer apply to the management and monitoring of the condition.
Example 2 - cancer
Beverley has been with Universal Provident for five years when she is diagnosed with breast cancer. Following discussion with her specialist she decides to have the breast removed followed by breast reconstruction. Her specialist also recommends a course of radiotherapy and chemotherapy. In addition she is to have hormone therapy tablets for several years. Will her insurance cover this treatment plan and are there any limits to the cover?
Provided that Beverley's policy includes Module A1 we would cover the cost of the removal and reconstruction together with the radiotherapy and chemotherapy in full, within her chosen hospital scale. Hormone therapy will be payable for a maximum of 12 months following the breast reconstruction.
Cara has previously had breast cancer which was previously treated by lumpectomy, radiotherapy and chemotherapy under her existing policy. She now has a recurrence in her other breast and has decided to have a mastectomy, radiotherapy and chemotherapy. Will her insurance cover this and are there any limits to the cover?
Provided that Cara's policy includes Module A1 we would cover the cost of all of the treatment proposed in full, within her chosen hospital scale.
Monica, who was previously treated for breast cancer under her existing policy, has a recurrence which has unfortunately spread to other parts of the body. Her specialist recommends the following treatment plan:
- A course of six cycles of chemotherapy aimed at destroying cancer cells, to be given over the next six months.
- Monthly infusions of a drug to help protect the bones against pain and fracture. This infusion is to be given for as long as it is working (hopefully years).
- Weekly infusions of a drug to suppress the growth of the cancer. These infusions are to be given for as long as they are working (hopefully years).
Will her insurance cover this treatment and are there any limits to the cover?
Provided that Monica's policy includes Module A1 and that the intent of all treatment given is to cure disease, we could cover the cost of chemotherapy in full, within her chosen hospital scale. With regard to the monthly and weekly infusions, we will only pay for these for a maximum of 12 months.
Sharon would like to be admitted to a hospice for care aimed solely at relieving symptoms. Will her insurance cover this and are there any limits?
Sharon's policy will contain an exclusion of palliative treatment, being treatment that is aimed at managing symptoms and/or improving the quality of life, rather than to cure or alter the disease. As such no cover will be provided for the proposed treatment.
Example 3 - hip pain
Bob has been with Universal Provident for three years when he develops hip pain. His GP refers him to an osteopath who treats him every other day for two weeks and then recommends that he return once a month for additional treatment to prevent a recurrence of his original symptoms.
The initial two weeks treatment would be covered as this is intended to stabilise the underlying condition. However the further monthly treatment would not be covered as this is preventative treatment and is not curing a medical condition.
Example 4 - diabetes
Deidre has been with Universal Provident for two years when she develops symptoms that indicate she may have diabetes. Her GP refers her to an endocrinology specialist who organises a series of investigations to confirm the diagnosis and she then starts on oral medication to control the diabetes. After several months of regular consultations and some adjustments to the medication regime, the specialist confirms the condition is now well controlled and explains he would like to see her every four months to review the condition.
We would cover the cost of the initial consultation with the specialist together with the costs relating to the investigations. The cost of the medication would not be covered as this not only forms part of the management of the chronic condition, but the policy also specifically excludes the cost of outpatient drugs. Similarly we would be unable to consider the cost of the four-monthly check-ups as this forms part of the monitoring of the chronic condition.
One year later, Deidre's diabetes becomes unstable and her GP arranges for her to go into hospital for treatment.
The would be considered an acute flare-up of the underlying chronic condition and as such our policies would pay for the cost of the treatment necessary to stabilise the condition once more. Once stabilised and Deidre is again having four-monthly specialist consultations, the policy cover would no longer apply.
Example 5 - asthma
Eve has been with Universal Provident for five years when she develops breathing difficulties. Her GP refers her to a specialist who arranges a number of tests. These reveal that Eve has asthma. Her specialist puts her on medication and recommends a follow-up consultation in three months to see if her condition has improved. At that consultation Eve states her breathing has been much better, so the specialist suggests she has check-ups every four months.
We would cover the cost of the initial consultation with the specialist together with the costs relating to the investigations. The cost of the medication would not be covered as this not only forms part of the management of the chronic condition, but the policy also specifically excludes the cost of outpatient drugs. The follow up consultation would be covered as this would be deemed to part of the initial treatment. We would be unable to consider the cost of the four-monthly check-ups as this forms part of the monitoring of the chronic condition.
Eighteen months later Eve has a bad asthma attack.
The would be considered an acute flare-up of the underlying chronic condition and as such our policies would pay for the cost of the treatment necessary to stabilise the condition once more. Once stabilised and Eve is again having four-monthly specialist consultations, the policy cover would no longer apply.
If you have any concerns regarding the eligibility of a medical condition under the terms of a Universal Provident policy, please telephone our helpline on 0844 873 0900, who will be pleased to offer you any advice and will be able to discuss matters professionally and in complete confidentiality.