Private medical insurers must explain the full impact of the exclusion of chronic conditions to policyholders or be forced to pay claims, the insurance ombudsman has said.
Principal ombudsman (insurance) Tony Boorman said if the impact of chronic exclusion is not fully explained before private medical insurance (PMI) is purchased, the Ombudsmen are unlikely to support restrictions of cover that rely heavily on the insurer’s interpretation of this exclusion.
He believes the exclusion of chronic cases is a significant term in policies, and one which makes the scope of cover far more limited than potential customers often realise.
He says clear explanations are essential as insurers do not cover the cost of many common conditions, nor would they provide cover if acute conditions deteriorated.
The ombudsman has also questioned the benefit to the PMI industry’s image of refusing to fund further treatment after a policyholder’s condition has deteriorated.
Using the example of heart problems or cancer treatment, Boorman said that telling someone that their condition is now considered to be chronic “is tantamount to saying that in the insurer’s view the patient will not recover”. He said that this could be extremely distressing to the policyholder.
He questioned the appropriateness of using the chronic exclusion in cases where the insurer had previously funded treatment of the condition, and when medical opinion recommended further treatment and doctors could demonstrate that further treatment had hope of stabilising the condition to allow a more or less normal life.
Boorman said that insurers should liaise closely with the patient and medical team about the nature and availability of cover for further treatment in the future.
Boorman said his office had been asked to adjudicate a steady stream of cases recently when insurers had deemed a medical condition to have become chronic.
Boorman said the definitions of the terms acute and chronic currently varied widely between insurers and medical definitions were often of little help to potential customers.
He said: “More needs to be done by insurers to clarify the acute/chronic distinction and to explain to policyholders the significance of the exclusion of chronic conditions.”