Chronic Conditions The limits of your cover for treatment of chronic medical conditions Chronic Conditions Explained
In common with other annual insurance policies, medical insuranceis designed to cover claims for expenses incurred as a result ofunexpected events. Therefore, it is important to understand whenbuying medical insurance that policies are designed to cover treatmentof medical conditions that respond quickly to treatment, referred to byus as ‘acute conditions’. Medical insurance is not intended to coveryou against the cost of recurrent, continuing or long-term treatment ofchronic medical conditions since these treatments become a series ofpredictable, rather than unexpected, events.
This leaflet is designed to help you understand more about what wemean by a chronic condition and provide practical examples of whenwe will or will not cover treatment of those conditions. What is a chronic condition? A chronic condition is a disease, illness, or injury that has one or more of the following characteristics:
• it needs ongoing or long-term monitoring through consultations, examinations, check-
• it needs ongoing or long-term control or relief of symptoms• it requires your rehabilitation or for you to be specially trained to cope with it• it continues indefinitely• it has no known cure• it comes back or is likely to come back.
At AXA PPP healthcare we cover the cost of treatment for acute conditions. That is,treatment which aims to return you to the state of health you were in before sufferingthe condition, or which leads to your full recovery. This includes short-term medicalintervention to treat unexpected complications or exacerbations of a chronic condition.
If your illness or medical condition requires recurring consultations over a long period,checks on your medication, long term therapy or treatment to ease symptoms, yourcondition may fall within the definition of a chronic condition. If you have been receivingongoing or continuing treatment or treatment that is intended to manage your condition orkeep your symptoms in check, we will review your treatment to assess whether it remainseligible for benefit. What does this mean in practice? For pre-authorised claims, we will tell you if we think your condition is now a chronic condition under our rules.
We may then (with your permission) contact your specialist or GP who knows yourparticular circumstances. We may ask them for confirmation of the diagnosis of yourcondition and details of the treatment you are currently receiving and to give us a futureprognosis for the condition.
In line with other medical insurance policies, our plans are designed to cover claims forexpenses incurred as a result of unexpected events and we do not go on paying forrecurring or continuing treatment of medical conditions that will continue indefinitely or thatkeep recurring. Should the information we have indicate that you have a chronic conditionwe will write to tell you we will stop paying benefit for the continuing or recurrent treatmentof the chronic condition. What if your condition gets worse? We will pay for the treatment of acute exacerbations or complications (flare-ups) in order to bring the condition quickly back to its controlled state (for instance in-patient treatment needed to re-stabilise a chronic condition such as diabetes). There are certain other chronic conditions such as Crohn’s disease which because of their nature, require management of recurrent episodes during which the symptoms of the condition worsen. Because of the ongoing or continuing nature of such conditions, we will write to tell you when there is no further benefit available for the treatment of that medical condition. Examples of chronic conditions The following are examples of chronic conditions and how we usually deal with them. In all of the following examples we may need to write to you or your doctor to obtain further information, as explained above. Important note – certain plans have specific restrictions to benefits such as out-patient treatment, for treatment that could have been received on the NHS within six weeks and other specific exclusions covered in the customer’s policy terms. The cover for cancer also varies by product with some products having higher levels of cover than those described in this document while others have lower or no cover for cancer. The examples overleaf are designed to show our general policy on chronic conditions and how we would deal with them for a customer on a mid-range policy. Therefore, the examples may not necessarily be applicable for all types of policy. Please read your handbook carefully to establish what cover you have as all the other terms of your policy (including any limits) will continue to apply to your cover. Example 1 – Angina and Heart Disease Alan has been with AXA PPP healthcare for many years. He develops chest pains and is referred by his GP to a specialist. He has a number of investigations and is diagnosed as suffering from angina. Alan is placed on medication to control his symptoms. We would pay for the initial consultation and tests to diagnose the condition and further consultations with the specialist to allow the medication to bring the condition under control. At this point we would advise Alan that further regular review consultations to monitor the condition would not be covered, but we would allow one further consultation to allow Alan to discuss alternative arrangements should he wish to do so. Two years later, Alan’s chest pain recurs more severely and his specialist recommends that he have a heart by-pass operation. We would confirm to Alan that we will cover that operation as it will stabilise his condition and substantially relieve his acute symptoms. We would then explain to Alan that although his policy would not normally cover regular check-ups, in this particular circumstance we would allow for a further ten years of annual postoperative check-ups with the specialist to ensure that his condition remains stabilised. This benefit would only be available on policies with out-patient cover and while the policy remains in force. Example 2 – Asthma Eve has been with AXA PPP healthcare for five years when she develops breathing difficulties. Her GP refers her to a specialist who arranges for a number of tests. These reveal that Eve has asthma. Her specialist puts her on medication and recommends a follow-up consultation in three months, to see if her condition has improved. At that consultation Eve states that her breathing has been much better, so the specialist suggests she have check-ups every four months. We would agree to cover Eve’s initial tests and consultation to establish the diagnosis and also the subsequent consultation to see if there was an improvement. However, we would then advise Eve that regular check-ups are outside the scope of her cover. Eighteen months later, Eve has a bad asthma attack. We would agree to cover the cost of hospital treatment until her condition has been stabilised. We would also pay for one further consultation following discharge from hospital. Example 3 – Cancer Beverley has been with AXA PPP healthcare for five years when she is diagnosed with breast cancer. Following discussion with her specialist she decides to have the breast removed followed by breast reconstruction. Her specialist also recommends a course of radiotherapy and chemotherapy. In addition she is to have hormone therapy tablets for several years. Will her insurance cover this treatment plan and are there any limits to the cover? We would pay for the breast to be removed and initial reconstruction to restore appearance. In addition we would also pay for the course of radiotherapy and licensed chemotherapy aimed at bringing the condition into remission or cure. Hormone therapy tablets (such as Tamoxifen) are out-patient drugs and, in line with other out-patient drugs, are not covered by our policies.
Cara has previously had a breast cancer which was previously treated by lumpectomy,radiotherapy and chemotherapy under her existing policy. She now has a recurrence inher other breast and has decided to have a mastectomy, radiotherapy and chemotherapy. Will her insurance cover this and are there any limits to the cover?We would pay for treating the recurrence as described above for the initial breast cancer. Monica, who was previously treated for breast cancer under her existing policy, has arecurrence which has unfortunately spread to other parts of the body. Her specialist hasrecommended the following treatment plan:• A course of six cycles of chemotherapy aimed at destroying cancer cells to be given over
• Monthly infusions of a drug to help protect the bones against pain and fracture. This
infusion is to be given for as long as it is working (hopefully years).
• Weekly infusions of a drug to suppress the growth of the cancer. These infusions are to
be given for as long as they are working (hopefully years).
Will her insurance cover this treatment plan and are there any limits to the cover?• We would pay for the course of licensed chemotherapy aimed at bringing the condition
• We will pay for up to 3 months for the infusions of licensed drugs to help protect the
• We will pay for the licensed drugs to suppress the growth of the cancer (eg Herceptin).
These chemotherapy treatments that are given for prolonged periods would normally falloutside benefit but in the case of cancer we make an exception. Thus the use of suchdrugs will be covered for a period of time as described in your policy document or for theperiod of the drug’s licence if this is shorter.
Sharon would like to be admitted to a hospice for care aimed solely at relieving symptoms. Will her insurance cover this and are there any limits to the cover?Hospice care is provided by the NHS and charitable institutions at no cost to the patientand we would not therefore cover this. Example 4 – Diabetes Deidre has been with AXA PPP healthcare for two years when she develops symptoms that indicate she may have diabetes. Her GP refers her to an endocrinology specialist who organises a series of investigations to confirm the diagnosis, and she then starts on oral medication to control the diabetes. After several months of regular consultations and some adjustments made to her medication regime, the specialist confirms the condition is now well controlled And the specialist explains he would like to see her every four months to review the condition. We would explain that we cannot continue to provide benefit for the review consultations but, would agree to provide benefit for one more to allow Deidre the opportunity to discuss alternative arrangements for follow up. One year later, Deidre’s diabetes becomes unstable and her GP arranges for her to go into hospital for treatment. We would provide benefit for this admission and for a short period after her discharge. Example 5 – Hip Pain Bob has been with AXA PPP healthcare for three years when he develops hip pain. His GP refers him to an osteopath who treats him every other day for two weeks and then recommends that he return once a month for additional treatment to prevent a recurrence of his original symptoms. We would explain that the monthly visits are not covered by Bob’s policy but that, if he should have further problems or if his condition should worsen to the point where a hip replacement is needed, this would be covered if his GP refers him to a suitable specialist.
If you would like to discuss any of this with us, please call us on the number printed onyour membership card.
AXA PPP healthcare, Phillips House, Crescent Road, Tunbridge Wells, Kent TN1 2PL, United Kingdom.
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