This mother paid 1,000 to health insurers – but when she found a lump they refused to pay upJudith Hitchins, 39, had private health insurance but found it difficult to claim compensationCompany PruHealth claimed that Judith's condition was pre-existing as well as a result of child-birth and refused to pay
Complete guide to avoid being ripped off on private health insurance
00:06 GMT, 9 December 2012
The problems started a couple of months after Judith Hitchins gave birth to her second son. ‘The first thing I noticed was some discomfort, but when I pressed on my tummy I could feel a lump – it was about the size of a ping-pong ball,’ recalls the 39-year-old from Warrington, Cheshire. ‘Obviously, I was worried – when you find a lump you instantly think cancer.’
Her GP referred her to an NHS gynaecologist, who said it was likely to be nothing but that it should be removed and tested to make sure. ‘They said this operation would allow them to make a proper diagnosis,’ says Judith.
There would be a three-month wait to have surgery on the NHS – but in 2010, Judith had taken out private health insurance with PruHealth. ‘I was pleased I’d finally get to use it, and hoped I could be seen in a matter of weeks. That’s why you take out these policies,’ she says.
Anger: Judith Hitchins, pictured with her sons Will and James, fought against her private health insurance company for six months over compensation
Judith contacted PruHealth, and during a conversation with a telephone operator mentioned that she had suffered from endometriosis in the past – a common condition that causes growths around the uterus.
This admission triggered a chain of events that led to her claim being held up for six months, and ultimately being turned down. She managed to have the decision reversed – but only on the night before her operation.
Judith says the whole experience was ‘incredibly stressful’ and made her question why she’d bothered to pay into a policy in the first place.
And hers is not an isolated case. A perfect storm is brewing in Britain’s 5 billion-a-year private medical insurance industry.
Premiums are rising, policyholder numbers are falling – and complaints about high charges and poor service have triggered an official investigation by watchdogs the Competition Commission.
Health how-to: Make sure you are not caught unawares by the small print of your health insurance policy
In theory, private medical insurance
allows you to avoid NHS waiting lists and get treated where, when and by
whom you choose, ideally in your own room at a private hospital or on a
private NHS ward. But cover is being reduced on every type of policy.
Those with comprehensive plans are being hit as firms slash the amount
they pay surgeons for carrying out popular procedures.
A year ago Bupa paid private doctors up to 761 per eye for cataract surgery. Today it’s 289. It means many top surgeons are no longer available to Bupa customers. If policyholders want to see them, they have to pay the difference.
The Financial Services Ombudsman has seen
a surge in complaints from policyholders over shrinking lists of
approved surgeons and hospitals, rising premiums and the availability of
new or ‘experimental’ cancer drugs.
There are many arguments over the
small print that governs what will and won’t be covered. In Judith’s
case, it was her honesty about having suffered a possibly related
pre-existing condition that caused her problems.
says: ‘In the months after my first conversation with a telephone
operator, I called at least eight times, always having to start from the
beginning with someone new.
‘They said they covered only diagnostic procedures, which this was. But because I’d mentioned my pre-existing condition, they said the op was a treatment for that, which wouldn’t be covered. In fact, the doctors just didn’t know what the lump was, and all this time I was worried and in pain. They told me “We have to be careful of fraudulent claims”, which made me even more angry.’
In the end Judith, 39, who lives with her husband Chris and two boys, James, four, and nine-month-old Will, turned to their insurance broker, which called PruHealth on her behalf and got approval for the procedure.
Then, in September, two days before her operation, the insurer called again to say her claim had been declined.
‘I’d mentioned the position of the lump – close to my caesarean scar – to their rep. The guy explained that it had been decided the problem was related to the birth, and therefore not covered. I just exploded. They’d only got all this information because I was honest when answering questions.’
Judith went back to her broker, who successfully intervened a second time, and the operation went ahead.
‘I got the green light the night before the op. The lump was benign, but the whole process was utterly stressful.’
Brian Walters, of medical insurance broker Regency Health in Cheltenham, helped Judith get her claim paid. He says her case shows how important it is to have someone on your side in the event of a dispute.
‘Brokers can be your advocate and should have the contacts and the inside knowledge to pursue your claim effectively,’ he explains.
David Priestley, at PruHealth says:
‘We try to make every claim as smooth as possible but sometimes we need
extra information from policyholders and professionals so claims can’t
always be agreed in a single phone conversation. However, in this
instance our claims process was not up to its usual high standards for
which we are very sorry.’
you don’t have access to an independent broker, the best advice is to
be cautious when you contact your insurer and to simply read out the
details on your referral rather than talking to – and risking getting
tripped up by – the phone operator.
world of health insurance has become a minefield. To help, we have
quizzed insurance insiders, doctors and patients to take the temperature
of an industry on the edge of a crisis.
of Britons say private medical insurance has saved their lives. Access
to the right specialists at the right time can make any premiums worth
But critics say
policies promise more than they deliver, with confusing small print. So
how do you choose and make the best of a private provider
'I am fit… but no one will cover me'
No cover: Cystic fibrosis sufferer Cavan Arrowsmith
Cavan Arrowsmith knows that claiming on private medical insurance won’t be easy – because it’s been hard enough getting quotes in the first place.
Cavan, 26, is an IT technologist for a mortgage company in Birmingham. He’s fit and healthy – but because he has cystic fibrosis, policies are only ever offered on special terms.
He says: ‘The big providers such as Aviva, Axa and Bupa won’t cover anything related to that pre-existing condition.
'I’m happy using the NHS to keep my CF in check but I’m concerned that any illness or disease in later life won’t be covered because of it.’
Most insurers say pre-existing conditions can start to be covered after at least two problem-free years.
As something like CF may require changing treatment, it may never lose its ‘pre-existing’ tag.
Cavan is now discussing policies with an independent broker – and experts say he is right to get help.
‘Nowadays it is all but impossible for consumers to make a reliable comparison when they buy private medical insurance. It is complicated at the best of times and individual medical circumstances add a further layer of complexity,’ says broker Brian Walters.
'I paid three times over'
Paying out: Gretchen Pierce
Gretchen Pierce, 45, made a successful claim for foot surgery via Axa in 2011, and chose a surgeon who had performed a metatarsal operation for Wayne Rooney.
Gretchen’s operation was a success and she was soon back at work promoting London’s museums to tourists.
But her policy stopped paying out when she reached the 1,000 limit for physiotherapy, even though she needed four extra sessions at 90 a time.
Private prescriptions weren’t covered either so Gretchen, left, spent almost 100 on painkillers.
Sarah Pennells of SavvyWoman financial advisers, says: ‘Insurers put a lot of emphasis on the things they cover and skate over the things they don’t.
'As a consumer you need to think about the full picture when you decide on a policy.’