CXL paid for WPA medical insurance

[dalbeath]

Hi Dalbeath, I am also going to take this up with the financial Ombudsman. Would you mind telling me what I need to do to do this since you have already entered thius process.
Many Thanks,
Sushila

Hurrah for going to the ombudsman and taking a stand. What do you have to do ???? Talk to the very lovely Longhoc and hope he is nice enough to do it for you. Seriously though, it's thanks to Longhoc that I made the claim and if more people stand up to the insurance companies it is the only way we will get anywhere.

[sushila]

Hi All,
I have been doing a bit of research on the internat and found this very interesting news update on this site the http://www.rcophth.ac.uk/news.asp?itemi ... Title=News
Particularly like the reference to "prevention of sight loss" which we are all trying to aim for!

Public Health Outcomes Framework - College Statement
24/01/2012

The Royal College of Ophthalmologists is pleased to announce that “Preventable sight loss” has been included as a public health indicator in the Public health outcomes framework for England, 2013-2016, published by the department of health on the 23rd of January 2012. It is included as item 12 under domain 4 which covers healthcare public health and preventing premature mortality. Together with UK vision strategy, the RNIB, the College of optometrists and the Optical federation, the Royal College of Ophthalmologists contributed, through interactions with appropriate government officials, in pressing home the importance of such an indicator. Data on total and partial sight loss related to glaucoma, diabetic retinopathy and age related macular degeneration, collected through the certification of visual impairment, will form the basis of this indicator.

We have collectively maintained that sight plays a crucial role in determining the quality of life of individuals of all ages irrespective of any other ailment they may concurrently suffer from. We are therefore delighted that, for the first time, an eye health indicator has been included in the assessment of public health. We can now hope and expect that this indicator will focus attention and resources on prevention of sight loss thus improving the nation’s health and quality of life. "[/i]

[longhoc]

Hi again Sushila

Have sent you a PM as I'll need a couple of pieces of information in order to complete the complaint template to the Financial Ombudsman Service (your address, policy number etc.) so to protect your confidentiality it's best not to post those on a public website ! Let me know if you've not got the message. Once we've completed the last two or three fields in the form, it's good to go.

One thing though, we have to give the PMI provider 8 weeks to resolve the complaint. If this amount of time hasn't elapsed yet, could you contact them and ask for their final written answer (often known as a "Letter of Deadlock") ? Basically their confirmation that they can't / won't do any more.

Yes, you're quote from the rcopth is very pertinent. There's lots of worthy talk about how everyone wants the best possible outcomes for patients with sight problems, the professionals such as the members of the College of Optometrists and the Royal College of Ophthalmologists definitely desire that for us, but probe a little deeper and pretty soon you come up against the (not so-) small matter of cold hard cash. Be it in the public or private arena, it's never that far away. Lynn White and I exchanged posts on this sort of subject in another thread. The slightly depressing conclusion I came to was that we who have Keratoconus (or are looking after a family member who has it) will have to drag the vested interests sometimes kicking and screaming along the path of improving access to new treatments. Otherwise, we'll end up with an ossified set of treatment options, stuck somewhere in a time warp circa 1992.

Which is why I get a little tug at the heart when some brave people are prepared to plug away at a system which stacks the deck so far out of our favour.

Okay, sermon over (for today )

As I said, respond to the PM I sent you and we can take this one to the Ombudsman.

(everyone, please give three cheers for Sushila !)

Chris

[sushila]

Hi All, Horrahh!! I got a call from BUPA today after I chased them for my Letter of deadlocK, saying that they would partially pay for the treatment.(see response below).I was told
that I was given the wrong decision on the phone yesterday !!

"To Mrs Mangabhai
Thank you for speaking to me today.

To confirm we will contribute a total of £1209 for the intended procedure (C5130)

Broken down this is:
£208 for the consultant fee
£125 for the anaesthetist fee
£876 for the hospital fee

We have based these figures on what our Medical Director believes to be the closest eligible procedure. This is C5122 Chelation of cornea/photo therapeutic keratectomy.

I can't really beleive it! All I can say to everyone who is takinh their case to BUPA that hopfully you will get a speedy resolution.Go straight to customer relations ,they should have all the details on this case now "

Good luck everyone! I will keep you all posted as to how things progress with my sons treatment.
Have a good weekend!

[sushila]

Sorry,just wanted to add, thank you Chris for your contant support and encouragement. Couldn't have done it without you XXXX

[gr1ffiths]

Hi All, Horrahh!! I got a call from BUPA today after I chased them for my Letter of deadlocK, saying that they would partially pay for the treatment.(see response below).I was told
that I was given the wrong decision on the phone yesterday !!

"To Mrs Mangabhai
Thank you for speaking to me today.

To confirm we will contribute a total of £1209 for the intended procedure (C5130)

Broken down this is:
£208 for the consultant fee
£125 for the anaesthetist fee
£876 for the hospital fee

We have based these figures on what our Medical Director believes to be the closest eligible procedure. This is C5122 Chelation of cornea/photo therapeutic keratectomy.

I can't really beleive it! All I can say to everyone who is takinh their case to BUPA that hopfully you will get a speedy resolution.Go straight to customer relations ,they should have all the details on this case now "

Good luck everyone! I will keep you all posted as to how things progress with my sons treatment.
Have a good weekend!

That's great news!!

Though should we settle for part payment?? or continue to fight for full cover?? Does anyone know the cost of the procedure. I think my consultant said that it was £1500 per eye but I don't know whether that covered the Hospital Fee part?

Congratulations Sushila!!

[longhoc]

Hi gr1ffiths

Cost for the crosslinking procedure does vary, £1,500 is at the top end, I've seen figures in the range of £1,100 to £1,600. A lot depends on whether the clinic is including follow-ups in the initial cost or not and as you rightly say any hospital fees which may be levied on top. Sometimes you need to pay separately for the riboflavin and the local aesthetic if needed etc. Drugs may well be a separate claim but that isn't usually where the difficulties lie as these are standard items.

Ah... the vexed question of whether to accept a compromise agreement that allows the insurer to make a distinction between overtly funding the crosslinking or to dodge the question and make what is usually termed a goodwill settlement by offering a nearest-equivalent procedure of comparable value and accepting claim for that but allowing crosslinking to be performed.

My recommendations to anyone in this situation is to accept the insurer's compromise agreement unless the shortfall is material. There's a complex explanation behind that, I really want to explain it in more detail, will post again on that subject when I've a bit more time !

Cheers

Chris

[sushila]

Hi Chris,
Below is another email from BUPA. Altough I accept that any extra cost needs to be payed by me,I feel that the next line refering to non payment should any complications arise(which I pray won't) is unfair. Surely any medical procedure arries an element of risk. They are paying based on the cost of the nearest equivalent pro cedure that BUPA has approved, which must carry some element of risk.Shurely they would need to pay for complication should they arise. I have asked for further explanation of "Experimental" and were in the T&C of the policy this is refrenced to.
My other concern is say in the future there is a need for further treatment, would BUPA have a right to refuse it on this ground .

Would live to hear your thoughts on this.
thanks,
Sushila

Sent: Fri Feb 03 16:47:13 2012
Subject: FW: Keratoconus forum
I should have explained this earlier.

I must advise that any costs above this amount will need to be paid for by you.

As we are making a contribution towards the treatment under our Experimental rule, we will not contribute any further, should any complications arise.

Again, please contact Alistair if you have any queries.

Kind regards

Leisha

[longhoc]

Hi Sushila

Well, I said in my quick reply earlier this was heading into complex areas and this one is typical of the sorts of quagmire you can get into. One of the foundations of insurance, going back centuries (insurance law and contracts are very well settled and there's not much new that comes up, just variations on old problems) is that the benefit an insurance policy provides can never -- ever -- put one in a more advantageous position after the claim than you would have been before. So if your car is in an accident, you get it repaired but you don't get a new car. Or if your house is a small 2-bed bungalow in an acre of land and it burns down, you don't get to build a new 4-bed house with a higher value even if the rebuild costs are the same (you can take the insurers settlement money and use it build a bigger new house, but you can't claim for 6 months of accommodation while it goes through planning).

If the rules get changed -- like what happened when a group of women in Europe (Holland maybe, I can't recall) successfully challenged the long-standing practice of insurers to offer different rates and benefits to men and women (it was something to do with annuity rates if I remember correctly -- women get less income per year given the same capital sum because they live longer) then you end up with all sorts of unanticipated consequences. For instance, now, women drivers have to pay the same premium as male drivers because the insurer can no longer price to risk on gender grounds. So what was great for Dutch women pensioners is a bit rubbish for British women drivers.

What we have to do is compare the situation for someone getting crosslinking paid for under a PMI policy compared with someone walking in off the street and coughing up for the procedure on a pay-as-you-go cash basis. With crosslinking, although the procedure is now increasingly the default offer for patients with progressive Keratoconus who are either contact lens intolerant or progressing at a rate which indicates a graft is likely to be a necessity and it has a good safety and effectiveness record this is all based on a (relatively) small numbers of patients because of Keratoconus' rarity. There are, with the current state of clinical knowledge, some "known unknowns". The reason we have a case for this procedure not being experimental or unproven is that there aren't really any "unknown unknowns" any more. But there are some data items which need fine tuning -- around corneal thickness, corneal steepness and patient age as contra indicators mainly.

If I'm a pay-as-I-go patient, I have to stump up for the initial procedure obviously. If I choose to do this, but later there are complications directly as a result of the procedure then of course I have to pay to sort those out too -- there's no one else who could step in. If an insurer agrees to pay for the procedure, it would go against that fundamental principle of what insurance is and what it does and does not do if suddenly patients could claim for treating complications because the insurer can -- rightly -- say that no-one really knows what the fat-tail risks ("known unknowns") are exactly. It will only be the passage of time -- and greater numbers of patients receiving crosslinking treatment -- that will finally give an as-good-as-we're-ever-going-to-get understanding of the sorts of low incidence and perhaps very long term complications that any procedure has. Because the sort of risk transfer (of treating complications) from the patient to the insurer isn't available to the pay-as-they-go patient (there's no-one else to transfer the risk to), you'd end up putting the insured patient who has made a claim in a better position for same given event than an uninsured patient. It's not equitable to expect to lay off an as-yet unquantifiable risk for a consequential loss onto an insurance provider just because you're able to make a claim on the original event -- that luxury isn't available to a comparable pay-as-you-go patient. And insurers have the right to refuse cover where they can realistically make a case that they aren't in a position to quantify the risk and so be able to set a fair premium price.

Sorry if that all seems complicated. It's because it is ! But hopefully the principle at stake is clear (ish).

I should point out that there's nothing in any of this that would prevent a civil action against the clinic for malpractice. That would be outside of any insurance considerations. Also, the insurer would, if push came to shove, have to prove that the crosslinking itself caused the complication. That would not be easy. Let's say acute hydrops occurred shortly after the procedure was carried out. Keratoconus does on some occasions lead to acute hydrops. Crosslinking has not been shown to increase the risk of a hydrops incident. Treatment of the hydrops would still be covered under the PMI policy unless the insurer could show otherwise.

Apologies, I wish I could make this all much more straightforward. While I'm the first to be critical of unreasonable insurers acting perversely, on this point I think they're right.

Of course, what would be ideal is if this whole notion of "experimental" could be dismissed. My personal opinion is that there's now more than enough data to quantify the contra indications for crosslinking and the risks. But in order to bring a successful complaint to the Ombudsman, that would need proper clinical opinion. While I know my stuff on insurance law and contracts, I'd be the first to admit it's just my hunches on the medical side of things here.

It was a canny move by the insurer to offer a compromise agreement based on "nearest alternative procedure". It deftly avoids getting into a "should this benefit be paid or not ?" question and turns it into a "are all the <1% risks fully known for this procedure ?" one. The answer to the first question is and was always in my opinion a definite "yes". The answer to the second one is, alas, "no".

There's more where this came from, on different themes, I'll save that for when you've all regained the will to live...

Kind regards

Chris

[sushila]

Thanks Chris,
I kind of understand where I stand but it all seems very complicated . I am going to accept BUPAS offer and hope for the best.
Take Care,
Sushila