CXL paid for WPA medical insurance

[gr1ffiths]

Well I have just had a second response to my complaint. Are they just stalling for time or what??

Very frustrating waiting for so long!!

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[sushila]

Hi,
I totally feel for you but don't give up. As I said in my last posting BUPA eventually paid .They paid £1309 and we covered the rest.
The procedure cost £2000 and he had it done at Moorfield 3 weeks ago. My son has recovered really fast after his procedure and was back at uni within days.
What was the reason for refusal? If you are with BUPA let me know because I went all the way to the top and I can't beleive that they are still refusing to pay for this treatment.
Good luck!
Sushila

[sushila]

Below is the reply I received from BUPA.I really hope it helps you. Maybe you should ask to speak to Alistair who was the the Customer Relations Manager who is totally aware of my case.I do wish you good luck !! ...don't give up.
Take care,
Sushila

Hi,

Thank you for taking time to speak me and my colleague Leisha regarding your son's treatment. In line with our complaint escalation process, your concerns have been passed to me so I may ensure we have been fair and reasonable in our dealings with you, and to advise you of our final decision.

I understand your consultant, Mr Mark Wilkins, has recommended Dipesh has Corneal Collagen Cross-linking with Riboflavin for Keratoconus. I can confirm we will be able to contribute towards this treatment up to the equivalent of the standard conventional treatment costs.

We will contribute a total of £1209; this will be £208 for the consultant's fee, £125 for the anaesthetist fee and £876 towards the hospital costs. Any costs that exceed these amounts will need to be paid by you. 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.

This treatment has not yet been approved by the National Institute of Clinical Excellence (NICE) and is only suggested under the guidance and supervision of a clinical trial. NICE have issued guidance to indicate the treatment is quite new, therefore there is not a lot of information yet about how well it works, its safety and which patients will benefit most from it.

To clarify, we are making a contribution towards this treatment as it is not eligible for normal benefit. This treatment is considered 'experimental' and therefore we will apply these rules of the policy that can be found in your policy guide. We do not cover any complication of experimental treatment so should these arise, you will need to discuss alternative funding with Mr Wilkins. I have enclosed a copy of these rules for easy reference. Please read these and if you have any questions, contact us before your son has his treatment.


In relation to your query regarding procedure codes, the Clinical Classification and Schedule Development Group are an independent body. Their role is to establish and maintain a common standard of procedure codes, reflecting current medical practice within the independent healthcare sector. Even though there is an established code for this procedure, you are still subject to the terms and conditions of your insurance policy.

I am sorry you have had to give so much time and energy to getting a resolution from us. As Leisha explained this was a big decision for to make as a business that will affect many members and as I am sure you will appreciate, it was not a decision that could be made lightly.

I wish you and your son all the best and I hope he gets the desired outcome from this procedure.

Yours sincerely



Alistair Hunter
Customer Relations Manager

...;....--¬

--¬

Enc. 'Your complaint and the Ombudsman'

. Lines are open 8.00am - 5.30pm Monday to Friday
Calls may be recorded and monitored t If you have speech or hearing difficulties you can call our textphone number 0845 6066863. Lines are open 8.00am - 5.00pm Monday to Friday

We believe that our customers are always treated fairly, and we take the time to investigate all customer complaints fully before reaching a decision.

If on this occasion you feel that Bupa has not dealt with your complaint in this way, and you would like it to be investigated further, you have 6 months to escalate your complaint to the Financial Ombudsman Service (FOS). For your reference I have enclosed a leaflet on FOS and how to escalate your complaint to them.

[gr1ffiths]

Hi,
I totally feel for you but don't give up. As I said in my last posting BUPA eventually paid .They paid £1309 and we covered the rest.
The procedure cost £2000 and he had it done at Moorfield 3 weeks ago. My son has recovered really fast after his procedure and was back at uni within days.
What was the reason for refusal? If you are with BUPA let me know because I went all the way to the top and I can't beleive that they are still refusing to pay for this treatment.
Good luck!
Sushila

Hi

I am with BUPA, they originally refused over the phone, so a letter of complaint was sent, They replied saying they would resolve the complaint within 15 working days.... on the 16 working day I received the letter saying they had not resolved my complaint and it will take a further 21 working days. They haven't even given a refusal of payment for treatment in writing yet. I can't believe that it takes over a month of working days to make a decision.

Does anyone think I should ring up and demand a letter of deadlock and then take it further??

Glad your son has had a positive outcome was the £2000 per eye or for both??

[longhoc]

Hi, no, annoying though it is, best to wait. It's actually a good sign that they are requesting more time, it does show they are taking the matter seriously. You could if you want ask for a letter of deadlock, but the regulator may take the view that the provider had not acted unreasonably in requesting it and was entitled to a bit more time.

Of course, it is enough to make you hacked off... the longer they say they need, the more hacked off you get. If you can force yourself to take the moral high ground and wait, it is the right course of action in my humble opinion.

So, hang on in there...



Cheers

Chris

[gr1ffiths]

Hi, no, annoying though it is, best to wait. It's actually a good sign that they are requesting more time, it does show they are taking the matter seriously. You could if you want ask for a letter of deadlock, but the regulator may take the view that the provider had not acted unreasonably in requesting it and was entitled to a bit more time.

Of course, it is enough to make you hacked off... the longer they say they need, the more hacked off you get. If you can force yourself to take the moral high ground and wait, it is the right course of action in my humble opinion.

So, hang on in there...



Cheers

Chris

Thanks Chris, Will await the outcome and hope it's positive!!

[sushila]

Good Morning! I have been thinking about your case last night.It is interesting that they haven't given the usual "NICE guideline" excuse again.What I find really frustrating is if they have authorised treatment for one case,are they not obliged to do the same for another?When I was having my "discussions" with them,I did query this issue with them and several different people said that the previous cases "may" have been authorised in "ERROR" . Well I know that my case WAS NOT in error. I had 3 refusal and the decision was turned at the 11th hour to a partial payment when I chased up my letter deadlock.I was told that the person I spoke to on the previous day who told me that the procedure had been turned down "had made a mistake". I really can't beleive that BUPA is giving people the same run around.Surely this should be part of their policy now so that anyone phoning in for an authorisation code is given the option of partial payment with the clause that any further complications etc that may occur as a result of treatment would not be covered by BUPA ..I know that in every email or phone convesation I had with Bupa ,I stresssed the fact that the progressive nature of the condition was a concern and Time was of an essence (see my last email to them below) .I do with you luck and hope that they won't take the 21days to reach a decision

Thanks you very much for your call today. I really appreciate it.

I do understand that my son’s case is currently being looked at by the medical director in BUPA but I am really hoping for a speedy resolution of this since I do believe that it does not require a massively time consuming and extensive investigation by BUPA due to the fact that I have supplied so much information already regarding this. As per the consultants letter, (who is BUPA authorised) this procedure is the only option he can offer my son to arrest the progression of his condition.

As I have said below, the progressive nature of my son’s condition is of a huge concern to me and therefore I really would appreciate a quick response. If there is any further information that you might need, please do not hesitate to contact me.

Hope to hear from you soon.

Regards,
Sushila

[gr1ffiths]

Good Morning! I have been thinking about your case last night.It is interesting that they haven't given the usual "NICE guideline" excuse again.What I find really frustrating is if they have authorised treatment for one case,are they not obliged to do the same for another?When I was having my "discussions" with them,I did query this issue with them and several different people said that the previous cases "may" have been authorised in "ERROR" . Well I know that my case WAS NOT in error. I had 3 refusal and the decision was turned at the 11th hour to a partial payment when I chased up my letter deadlock.I was told that the person I spoke to on the previous day who told me that the procedure had been turned down "had made a mistake". I really can't beleive that BUPA is giving people the same run around.Surely this should be part of their policy now so that anyone phoning in for an authorisation code is given the option of partial payment with the clause that any further complications etc that may occur as a result of treatment would not be covered by BUPA ..I know that in every email or phone convesation I had with Bupa ,I stresssed the fact that the progressive nature of the condition was a concern and Time was of an essence (see my last email to them below) .I do with you luck and hope that they won't take the 21days to reach a decision

Thanks you very much for your call today. I really appreciate it.

I do understand that my son’s case is currently being looked at by the medical director in BUPA but I am really hoping for a speedy resolution of this since I do believe that it does not require a massively time consuming and extensive investigation by BUPA due to the fact that I have supplied so much information already regarding this. As per the consultants letter, (who is BUPA authorised) this procedure is the only option he can offer my son to arrest the progression of his condition.

As I have said below, the progressive nature of my son’s condition is of a huge concern to me and therefore I really would appreciate a quick response. If there is any further information that you might need, please do not hesitate to contact me.

Hope to hear from you soon.

Regards,
Sushila

You are so right Sushila, BUPA actually said to me on the phone that they have made "errors" in the past authorising the procedures. they then quoted NICE guidelines etc etc. I will wait the 21 days and see what they have to offer, if they keep messing me around then I will have to escalate my complaint higher if possible. Fingers crossed for the outcome.

Thank you so much for your reply.

Leighton

[gr1ffiths]

Well the dreaded letter has arrived....

It goes something like this..

"Thank you for your complaint blah blah blah however it is not authorised by NICE and we don't cover this procedure as per exclusion 16 in the membership booklet"

but they did say "If Dr Anderson would like to enter you into a clinical trial, we would be happy to reconsider our position" and "if you don't like the decision then complain to the Financial Ombudsman"

copy of the letter in the link below

Please, any suggestion for taking this further as in previous posts they have contributed towards the cost etc. and by the sounds of it Sushila had dealings with "Alistair Hunter" who has written my letter.

Many Thanks

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[longhoc]

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