Postby longhoc » Mon 16 Jan 2012 1:41 pm
Hi Sushila
Many thanks for letting us know what the insurer said for your son's treatment.
The NICE comments used as justification for declining your claim are a bit of a mis-step by your insurer -- NICE guidance should not be used by insurers in claims handling (their decisions are their own, and NICE does not have any official role in the insurance policy decisions process). This is especially true of crosslinking where NICE hasn't made any judgement on the safety and effectiveness of crosslinking, it is asking for more data when the procedure is performed on the NHS. In other words, if consultants perform crosslinking on the NHS, the must submit the results to a clinical trial to enable NICE to make a more informed decision on the procedure. So NICE's statement confers absolutely nothing about the procedure's status as "experimental" or being "unproven". It merely asks for more data when it is done on the NHS.
While it looks like a straight decline from the insurer, it is actually a lot more constructive than some of the previous responses I've seen from insurance providers in the recent past. This is because they have offered to enter into a dialogue with the consultant. While they don't spell it out, I read into this that they are willing to accept new information on the current clinical practice in the treatment of Keratoconus and are amenable to being convinced that crosslinking might now be best practice for an initial treatment.
Are you able to contact your son's consultant and ask him if he would be willing to discuss the matter with BUPA ? If he is, then that would be very helpful to your case. If you speak to him or his office, there's two key points that it would be useful for him to be able to comment on:
1) That he would perform the crosslinking treatment "with curative intent" (the form of words is very important -- it has a specific meaning in the insurance contract you have with BUPA so it's a good idea to note down this phrase and quote it exactly). It means that when he does the crosslinking, it is his professional opinion that it stands a good chance of actually fixing the problem for good -- or for a reasonably long period of time, say 10 years+
and
2) That he considers that crosslinking is now "customary and expected" (again, the form of words needs to be exactly as I've written). This invites the consultant to opine that he would perform crosslinking for any and all patients in your son's position and that his clinical decisioning is supported by what he would consider an acceptable level of evidence.
The consultant might not be happy to speak to the insurer on the phone, which is open to all sorts of misinterpretations. If he is okay to put in writing something which confirms points 1) and 2) above, then you can simply send that back to your insurer and ask them to reconsider based on the information you've sent them.
Does what I've put above give you enough confidence to go to the consultant and ask him if he is willing to provide a statement to that effect ?
Do let me know if anything not clear !
Best wishes,
Chris
(PS, I've deleted a small amount of your original post just to protect your anonymity, hope that's okay)
