Private Medical Insurers not paying out, but who is at fault?

Private Medical Insurers not paying out, but who is at fault? 1

Photo credit: www.cheapestinsuranceuk.com

It could be a case of mistaken austerity, but increasingly, private medical insurers are seeming to land their customers with additional bills for operations that should be fully covered under the terms and conditions of their policies. Take the case of Panorama reporter Tom Mangold, he has paid for private medical insurance for over 30 years so when he recently developed cataracts, he was pretty confident he’d get the surgery he needed when he wanted it and from his choice of surgeon. This was all the case, however, his insurer – AXA PPP informed him that although there was no problem with him having the operation, he would have to stump up an extra £600 per eye on top of the insurance premium he’d already paid for the cover. And this is on top of AXA PPP increasing his premiums by 8% this year. In another case, Gareth Brocklebank was told he needed surgery on a prolapsed disk, AXA PPP agreed to pay in full. However he decided not to go ahead with the operation as the pain had subsided so it was postponed. Then, a year later the pain returned and it was decided the operation should go ahead. But in that time AXA PPP’s position on the matter had changed.

Gareth said: “A week before the operation, I had a phone call from AXA PPP telling me that there was going to be an £800 shortfall in the surgeons fees. They said it was because they’d capped my surgeon’s fees between the last surgery that was supposed to happen and this year…I’ve never missed a payment and this is the only major claim I’ve made with them. And I feel they’ve pulled the rug out from underneath me and I’ve been left with hundreds of pounds left to pay.” Jacqui Wigg had also developed cataracts and her GP referred her to an experienced surgeon who charged £1200 per eye. She said: “I expected to have at least a fairly major contribution towards that but I was told that there would be a 75% shortfall and I would only get £289 per eye.” Jacqui was given alternative options by her insurer but she felt that as over the years she had spent tens of thousands of pounds on medical insurance, she deserved and expected the best.

So why are medical insurers reducing what they’re prepared to pay? Could it be that doctors and consultants are over-charging? Some consultants think not. Professor David Gartry, the consultant ophthalmic surgeon who performed Tom Mangold’s surgery, says: “We haven’t put our fees up for nearly 20 years. We’ve all adhered to the guidelines as set by BUPA in 1992. By making this decision they’ve effectively given surgeons a massive pay cut. Those who have signed up to the new contract are recouping by charging more for extras.”

However, representatives for private medical insurance companies are disagreeing, saying that it is the fault of the doctors and consultants who are charging exorbitant costs for simple procedures. In a statement from AXA PPP, they that they pay around 97% of the fees submitted to them. And that it is only where consultants have ‘chosen to inflate their fees to such an extent that it would be detrimental to the long term benefit of our members if we were to pay them unchallenged’ that there may be a shortfall. Whilst a spokesperson for Bupa said: Our members can choose from over 10,000 highly qualified, experienced private consultants whose fees are covered in full by Bupa. We offered Mrs Wigg the choice to have her operation with all the costs paid by us. Mrs Wigg decided to have her cataract surgery carried out by Richard Packard, with the full understanding, in advance, that he would send her an additional bill. Richard Packard charged £1,200 for cataract surgery, the most common operation performed in the UK and a procedure that normally takes only 15-20 minutes. Many other experienced consultants are happy to undertake this routine operation for our standard fee level, which is considerably higher than the NHS consultant rate for this surgery. Bupa has not seen any evidence that Mr Packard’s outcomes for cataract surgery are better than those of any other cataract surgeon, and we can therefore see no justification for the fees he has sought to charge Bupa, equivalent to an hourly rate of £3,600 for a routine operation.”

So are the doctors and consultants charging excessive fees or not? In some cases this could be so, but as the Association of British Insurers advises, there is a lot of competition within the private medical insurance market with insurers offering a range of affordable options and varying levels of cover for customers to choose from.

At the end of the day, consultants can and do set their own fees but customers are free to choose who is their preferred consultant. They should, however, be aware of any costs which may fall outside the scope of their insurance policy.

Source: BBC Watchdog

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