CXL paid for WPA medical insurance

[sushila]

Hi All,
I am still battling with BUPA. The latest is that they are saying to me that they will ONLY fund this if it is part of a clinical trial.
May I please check with the people who have had funding approved if they did form part of a clinical trial.
I would really appreciate some feedback on this.I will not give up this fight.Am really frustrated!!

kind regards,
Sushila

Below is an email I sent them FOR ATTENTION OF THE AUTHORISING TEAM
This is the letter from my consultant.
Diagnosis
Progressive bilateral keratoconus
When XXXXXXXX was seen at Moorfields on 10/11/11 it was clear from serial Pentacam corneal
topography scans that his keratoconus had progressed between 10/11/11 and 1/7/10. Until recently when we
were able to perform it on the NHS at Moorfields it was the practice of myself and several of my colleagues
to offer patients in this situation corneal cross linking. This would be performed on one eye at a time. The
treatment is done to prevent further progression of the keratoconus and if performed correctly in an early
~ ~ - - eas&-weuld-be-extremely-likely-te-prevent-f~gressien.-W--ithoytcross linkingtreatmenUt.isJike1ythat
Mr XXXXXXXXX's keratoconus will progress further. Without PCT approval I have no other treatment that I
can offer him to arrest the progression of his condition.

I Also added these extra points from me
1) The expert advice from the consultant is that this is the only treatment that he is able to offer, and that he would be performing the Crosslinking treatment with curative intent, which, in his professional opinion, stands a good chance of actually preventing further progression.

2) Until recently, when he was able to perform it on NHS, it was customary for his colleagues and himself to offer this to patients in Dipesh’s situation. In the consultants opinion, he would perform Crosslinking for any and all patients in my son's position, and that his clinical decision is supported by what he would consider an acceptable level of evidence. He considers that Crosslinking is now customary and expected.

3) Crosslinking is on the CCSD list of accepted procedures.

4) Since both the consultant (who is BUPA authorised) and the CCSD scheme participants (which includes BUPA) recognise Crosslinking as a viable procedure, I am at a loss to understand how you can reject our claim. Further, the NICE position, from my understanding, is that Crosslinking is NOT classed as experimental, although NICE are encouraging clinicians to submit results of the procedure to get a better idea of the indications and contra indications. This is not the same as “experimental” as defined in the insurance policy T&C.

5) Kerataconus is progressive and in my view any further delay by BUPA in authorising this treatment is exacerbating the condition. I am expecting BUPA to please resolve this matter without delay because time is of the essence.

[dalbeath]

I know this is no help to you but I have been battling with Pru Health now since last June. I've had my CXL done and paid for it myself but have been locked in deadlock with Pru since the end of the year and am now pursuing the matter with the Financial Ombudsman.

These insurance companies really are gits. Ironically the CXL was for my right eye. But I now need a graft in my left eye and they agreed to fund that in 24 hours with only a couple of questions to my consultant. Yet they refuse to consult the consultant about the CXL which is about half the cost

[sushila]

Thanks for your feedback.Please do carry on.I am intending to carry on the battle as well.It is really frustrating to think that they will fund a procedure which costs more in the long term and also by that stage the condition of your eye has got to a stage when it can't be saved. I was also wondering if there was some way of getting NICE to review their stand on the procedure since the Insurance companies are hiding behind the NICE guidelines.
If anyone has any ideas please let me know. Right now BUPA are messing with a very annoyed(but very worried) Mum and I am ready for a battle!!

[longhoc]

Hi Sushila

All I can say is, blimey, well done, it takes a lot out of you to challenge what I consider to be a totally unfair decision. It's hard enough when you're trying to provide all the support you can for your son. And trying to do this as too, well, you could do without it.

The letter from the consultant is the clincher. It states exactly what is needed to help your case. By pointing out that the NHS did used to provide crosslinking until funding halted any new treatments being made this is pretty much an open-and-shut case that it is not some unproven, experimental treatment we're talking about here, but something that a specialist thinks will improve a patient's condition. It makes clear that this would be done tomorrow for you son if the NHS had the money to do it. Frankly, if a private medical insurance policy isn't there to step in when a simple question of funding slows down the speed when you can be treated on the NHS, what is it there for ?!

The "we will pay only if the treatment is part of a trial" is a complete fob off. While it is okay (sort-of) for NICE to specify that NHS patient results must be collated and fed into a trial as condition for funding this is completely irrelevant for an insurer ! They don't care about crosslinking, the patient or the clinical research (they're not being callous, it is simply irrelevant to the matter of should this policy pay out a benefit or not).

Okay, ignore my ranting (just makes me a bit peeved when someone gets given the run-around).

Reply to them with this statment:

"Thank-you for your response. I believe your imposition of a condition on policyholders that they can only receive the treatment needed by my son as part of a NICE-sponsored trial is unreasonable. This is because it is irrelevant as to whether a policy holder can receive a benefit under the policy held if the procedure indicated by a specialist should be performed as part of a clinical trial. This stipulation in the NICE guidance is merely to allow NICE to require consultants providing NHS treatment to gather data for the purposes of managing an NHS fact-finding exercise. NHS fact-finding is not a concern of a private medical insurance provider such as yourselves. Having read my policy document, I can find no reference in any of the Terms and Conditions to claims for treatments being dependent on the participation in a clinical trial. If you are certain of this point, perhaps you could indicate which section of the policy document's Terms and Conditions it appears in ?

If you are unable to demonstrate this criteria applies to my policy's Terms and Conditions as notified by yourselves, please could you kindly reconsider your decision.

Also, I think I should advise you that the treatment we are discussing here is currently being performed by other NHS hospitals who are not so funding constrained as the one my son attended. It is a classic case of a "postcode lottery". Your company's marketing activity stresses the advantages of holding the product I purchased to counter this very same situation, yet you appear to be negating the advantage you claim to offer people considering purchasing your policies. To me, this amounts to mis-selling.

If you do not provide clarity on which policy term is in force here stipulating that particular treatments must be participating in a clinical trial and take into account my information on the treatment currently being performed elsewhere within the NHS, yet wish to continue to maintain the stance you have indicated regarding my claim, please could you issue a Letter of Deadlock confirming that you have failed to resolve my complaint to our mutual satisfaction. I will then proceed to pursue the matter further through the Financial Ombudsman Service.

Thanks and regards,

<your name here>"

Fingers crossed.

Best wishes, and again, huge plaudits for getting this far.

Chris

[sushila]

Hi Chris,
Thanks you so much for your encouragement and the fanasticaly compiled letter for me to send to BUPA. I am also thinking of approaching Watchdog about this because I really feel that nobody sould have to go through all this when they have taken out a medical insurance policy to cover them for instances when a medical procedure is recommended as the ONLY option by a consultant and the NHS won't cover it because of funding issues. What do you think ? Do you think I should do this ? I would really appreciate your views.
Thanks and once again really appreciate your help !

[longhoc]

Hi Sushila

Generally going outside the industry's own route for trying to resolve disputes makes things more complicated for all parties (because the insurers feel they have to defend their positions in public rather than being pragmatic and sorting things out in private between the company and the policy holder). And from what I've been told about shows such as Watchdog, they prefer to take things up when an obvious injustice has failed to be put right by the regulator. That makes for a better story for them. If all else fails, try that, but I think it might be best to give the insurer chance to look at this again (and then we can ask the regulator to look at it if the insurer insists on being stubborn).

Unfortunately due to the poor economy (and some complex structural changes leading to insurers facing increasing difficulty supplementing their income from investing the cash they receive from premium payments -- I won't bore you !) the pressure is on insurers profitability. This translates to an increasingly "take no prisoners" approach to settling claims. Not all insurers are alike. I just hope that the risk of reputational damage stops things getting too bad. But more and more I'm hearing horror stories from motor, home and travel claims, not just health...

Do please let me know what the next move they make is.

Best wishes

Chris

[Bupa]

Hi Sushila,

Sorry to hear you've been having problems. So that I can help you, please could you email me the details at customerservice@bupa.com with your full name and membership number.

Thanks,
Ruth

[gr1ffiths]

So I have finally had my appointment and discussed CXL with my consultant. I asked him whether BUPA had ever paid out a claim for CXL and he said that they and other insurers have part paid in the past, he also said that he'd be happy to write a letter to BUPA if I decided I wanted the treatment.

So... A phone call to BUPA is needed tomorrow and let the fight begin!!!!

Great forum guys!!!

[dalbeath]

My consultant, Mr Srinivasen from Ayr, Told me 3 weeks ago that he had just done a CXL that was paid for by BUPA. He said that knowing the problems I had been having with Pru he was expecting a battle but they paid without any hassle. So keep going, we are slowly getting to their conscience and they are realising that their actions are unfair!

BUPA now posting on forum - great . Welcome to the discussion!

Should have also added that I can not take the credit for going to Ombudsman - it is all down to the support and help I get from the very lovely Longhoc - Thank you Chris, you are a super star

[longhoc]

Many thanks dalbeath -- but honestly, it's down to those determined individuals who are willing to be test cases when treatments move into the mainstream and prompt the need for a review by the Private Medical Insurers (PMIs) to make sure they are reflecting current clinical practices in their claims handling processes.

And, it must be said, to those enlightened PMIs themselves who are willing to keep an open mind and look at the individual's cases to make sure their customers are treated fairly.

Cheers all

Chris