CXL paid for WPA medical insurance

[Anne Klepacz]

Am I missing something here? Aren't clinical trials always on the NHS? So why would a private insurer be involved in paying anything???
Anne

[gr1ffiths]

Hi... how annoying !

But they've really (in my opinion) shot themselves in the foot with that letter. I cannot believe that the provider has put in writing that they would fund treatment based on a participation in a clinical trial. Nowhere in any PMI policy's T's and C's would it ever say words to the effect that "sometimes we'll take the view that a procedure is experimental and we won't pay but if it's part of a clinical trial we might change our view and pay for it then". And they cannot simply rely on NICE guidance anyway as a proxy for their decisioning process; they absolutely have to be guided by what is currently Customary and Expected in clinical practice and -- especially -- by your consultant's Best Advice to you (and them). It seems that the provider has cherry-picked certain facts and ignored others.

You can never guarantee, but I think the Ombudsman would be interested in how that is complying with easy to understand and consistent product terms -- or is treating customers fairly.

I think an appeal to the Ombudsman stands a fair chance of succeeding. I've got a template which is pretty much ready to go for this. Do let me know if you'd like me to take this forward.

Best wishes

Chris

Hi Chris

Your template and help would be much appreciated.... I cannot believe that BUPA know these forums exist and they should know that we all discuss certain things with each other, the fact that they have paid for the treatment ("in Error") and even partially funded Sushila's sons treatment says to me that they should cover every patient rather than hand picking cases.

Is this letter classed as a letter of deadlock or is it worth speaking to Alistair on the phone and explaining the situation. I am more than happy to go the ombudsman or even speak to the surgeon and ask if he'll do a clinical trial just to see what BUPA's response to this would be.

If they did pay for a clinical trial, would they impose any conditions do you think??

Your help is much appreciated Chris, Many Thanks

[longhoc]

No, you're not missing anything Anne, you're quite right. It was a truly bizarre statement for a Private Medical Insurer to make -- offering to somehow subsidise a clinical trial by means of a policy benefit paid to the holder... It defies common sense even to a non-expert in the fields of insurance or medical practice. If you know retail/general insurance regulations and contract law, it really is a LOL. Except that it's gr1ffiths who's being given the run-around.

[longhoc]

Hi gr1ffiths

No problem at all.

Their letter is sufficient to indicate a deadlock.

As for this whole "clinical trial" nonsense, as Anne and I have just mentioned below, it is a complete red herring. My suggestion is don't even go there. It's a waste of both your and your consultant's time to even consider trying to sort things out that way.

What wouldn't hurt is to contact the provider concerned, thank them for their letter and advise that you'll be pursuing the matter via the Financial Ombudsman Service. They may take the opportunity to "settle on the steps of the courthouse". But then again they probably won't. I'll prepare the template and PM you with the file (I think I've got enough to go on, you should just need to print and sign). Will be in touch asap.

Best wishes

Chris

[gr1ffiths]

Hi gr1ffiths

No problem at all.

Their letter is sufficient to indicate a deadlock.

As for this whole "clinical trial" nonsense, as Anne and I have just mentioned below, it is a complete red herring. My suggestion is don't even go there. It's a waste of both your and your consultant's time to even consider trying to sort things out that way.

What wouldn't hurt is to contact the provider concerned, thank them for their letter and advise that you'll be pursuing the matter via the Financial Ombudsman Service. They may take the opportunity to "settle on the steps of the courthouse". But then again they probably won't. I'll prepare the template and PM you with the file (I think I've got enough to go on, you should just need to print and sign). Will be in touch asap.

Best wishes

Chris

That's excellent Chris

I will phone tomorrow and thank them. If there is anymore information needed from me then please ask.

Many Thanks

Leighton

[sushila]

Hi ,
I am completely stunned by the response from BUPA .I had a similar refusal lettwer from them stating that they would fund the procedure if it was a clinical terial BUT not otherwise.
As I said before,they changed their mind at the final hour and partially funded it once I said I was going to take this case to the Ombudsman. My sons procedure was NOT part of a clinical trial and Alistair most definately knows this. They are NOT treating everyone the same. I did think that after all the fuss I made BUPA would have some sort of a policy for dealing with these cases in a consistant and fair manner. I am truely disappointed with them !

Please let me know if you need any evidence for your case to the Ombudsman.I am really annoyed at the way BUPA is treating you.Don't give up.Good luck!

Thanks,
Sushila

[gr1ffiths]

Hi ,
I am completely stunned by the response from BUPA .I had a similar refusal lettwer from them stating that they would fund the procedure if it was a clinical terial BUT not otherwise.
As I said before,they changed their mind at the final hour and partially funded it once I said I was going to take this case to the Ombudsman. My sons procedure was NOT part of a clinical trial and Alistair most definately knows this. They are NOT treating everyone the same. I did think that after all the fuss I made BUPA would have some sort of a policy for dealing with these cases in a consistant and fair manner. I am truely disappointed with them !

Please let me know if you need any evidence for your case to the Ombudsman.I am really annoyed at the way BUPA is treating you.Don't give up.Good luck!

Thanks,
Sushila

Many thanks, Chris has sorted me out with the complaints form.

Fingers crossed

[sushila]

Good morning all, A year and half ago I win my battle with Bupa who eventually partially funded my sons X linking procedure which he had done in Feb 2012 and his left aye has been stable since than.(...thanks to the excellent advice and guidance from Longhoc). Unfortunately he now needs this done to his right eye. My company have movedc the insurance provider from BUPA to Cigna and when I called Cigna yesterday ,they said they don't fund this procedure because it is nt NICE approved. However, they have aked me to provide a letter from my consultant which I will do soon and I will let you know how I get on with this case.

To anyone who is fighting with BUPA , I would say don't give up! it was at the very last moment when I asked them to provide writen documentation as to why they were refusing which I said I would take to the Ombudsman that they called me and said they would partially fund the procedure.Also ,several people have won their case with Bupa and I just don't understand how they can get away with refusing on grounds of "efficacy of treatmemt not been proven".How can they justify paying some and not the others.

This whole thing is so frustrating that these insurance companies want you to go blind first and they will than fund a corneal transplant but not fund something that will halt the progression of this condition.
Good luck everyone!!!

[sushila]

Hi All,
Guess what,Cigna have refused to pay for my sons treatment. Would really appreciate some advice on what I should do next.Should I ask them to take it further up as a complaint or should I request a "letter of deadlock"?

Many Thanks,
Sushila


Our consultants letter to Cigna said-:
"Serial Pentacam scans taken on the NHS show progression of his right ectasia and this is confirmed by the above changes in his right spectacle refraction, particularly his increase in astigmatism. I therefore recommend that he undergo right corneal cross-linking to prevent further progression. This would mean that he would be able to wear far less complex spectacles or contact lenses and would also remove any risk of him progressing towards him needing a corneal transplant"

Cigna's Response
"Our medical advisors have deemed that corneal cross-linking meet a direct exclusion or your health plan . This exclusion reads :
4.2 e Treatments that are not evidence based treatment.
The definition for evidence based treatment reads:
16.18 'Evidence based treatment - treatment which has be researched, reviewed and recognised by:

The National Institute for Health and Clinical Excellence or

CIGNA's Medical Advisory Panel or

Another source recognised by CIGNA Life INSURANCE Company of Europe S.A.N.V., UK Branch.

Unfortunately therefore your health plan is unable to support this treatment.

I know this decision is disappointing, but I hope I have clarified Cigna's position"

[sushila]

Dear Longhoc,

I would really appreciate your views on if I have a legitimate case to fight with Cigna with regards to the exclusion poily they are quoting . Do you think I have a chance of winning this one?

Kind Regards,
Sushila