121 Healthcare Ltd

Are you buying Private Medical Insurance?

Take a look at this guide before you buy

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This independent guide is published by the Association of British Insurers. Reproduced with permission.

  1. About this guide
  2. What is Private medical insurance?
  3. How do I buy private medical insurance?
  4. How do I choose the right cover?
  5. What am I covered for? What does my cover not include?
  6. What will affect my premiums?
  7. Will I need to provide details of my health?
  8. Will my cover be affected if I am disabled?
  9. How do I make a claim?
  10. How is private medical insurance controlled?
  11. What if I want to change to a new insurance company?
  12. Your checklist
  13. Useful addresses

1. About this guide

We have designed this guide to help you understand more about how private medical insurance works, so that you can make an informed choice before you buy a policy.

We are publishing this guide on behalf of all insurance companies who offer this type of cover, whether they are members of the Association of British Insurers or not. We are the recognised trade organisation for insurance companies operating in the United are currently members and between them they account for more than 96% of the UK's insurance business.

As well as this guide, the literature you receive from companies providing private medical insurance should contain an outline of the products which you are considering buying. These outlines are meant to help you compare the benefits offered by different products. They give you a brief overview of what is, and is not, covered.

We hope you find this guide useful. If you have any questions, your sales person or insurance company will be able to answer them.

2. What is Private medical insurance?

Private medical insurance is designed to cover the costs of private medical treatment for curable short-term illness or injury (commonly known as acute conditions).

Most people buy this type of insurance to gain the reassurance of knowing that treatment is available promptly, if they become ill or are injured.

As a private patient you can often choose when treatment will take place, the specialist who treats you and the hospital. You will usually have the privacy of an en-suite room, complete with TV and other home comforts.

Some illnesses and treatments will not be covered by a private medical insurance policy and these are common to most schemes (see Section 5 of this guide). It is also important to remember that this insurance is not designed to replace all the services offered by the NHS. Some, such as accident and emergency, are beyond the scope of most private hospitals.

3. How do I buy private medical insurance?

Insurance companyIndependent advisorsBank or building society
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By phoneFace to faceBy post
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 The insurance company
receives your filled-in
application form
 
Down arrow
 The insurance company sends
you a policy
 

How do I buy private medical insurance? 3 Insurance company Independent advisers By phone By post Bank or building society The insurance company receives your filled-in application form The insurance company sends you a policy. Face-to-face

'Cooling-off period'

If you do not receive full details of the terms of your cover at the time you decide to buy the policy, you will be given enough time in which to change your mind. If you decide not to go ahead you will usually receive a full refund of premiums you have already paid, unless you have made a claim. However once the cooling-off period is over, you will not usually be entitled to receive a refund of premiums already paid.

4. How do I choose the right cover?

When looking at cover, it is useful to know that treatment is categorised in the following way.

In-patient

This is when you go into hospital for private treatment or investigations and stay for one or more nights.

Out-patient

This is when you receive treatment or investigations or consultations which do not need you to stay in hospital either as an in-patient or day-patient.

Day-patient

This is sometimes referred to as day-care, or day-case. It is when you go into hospital for private treatment or investigations but do not need to stay in hospital overnight.

There is a large variety of schemes available - from low-cost schemes, offering limited cover, to those which offer wide-ranging cover and benefits. Most schemes offer cover for in-patient and day-patient care, but not always out-patient.

This is how the treatment usually works

Go to your GP If you have private
medical insurance
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Your GP recommends you to see a specialistRight arrowYour GP can arrange for you to see a specialist privately
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Out-patient consultation with a specialist who may recommend further tests.Right arrowIf tests are needed these can be arranged promptly.
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Your specialist recommends either in-patient or day-patient treatment.Right arrowIf you need treatment, it can be arranged promptly.
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Your specialist helps you to arrange hospital treatment.Right arrowYou may be treated in the comfort of a private hospital or in an NHS hospital, as a private patient, at a time to suit you.

You will need to decide what sort of cover you want.

The answers you give to questions such as these could have a significant effect on the premium that you pay (please see Section 6).

5. What am I covered for? What does my cover not include?

Remember, private medical insurance is designed to cover treatment for curable, short-term illness or injury (commonly known as acute conditions). Some illnesses and treatments are never covered and these are common to most schemes.

Usually included

Sometimes included

Usually not included

As well as those listed above as 'Usually not covered', the following conditions or treatments are normally outside your cover:

Drug abuse, self-inflicted injuries, out-patient drugs and dressings, HIV/AIDS, infertility, normal pregnancy, cosmetic surgery, gender reassignment (also known as sex change), preventive treatment, kidney dialysis, mobility aids, experimental treatment, experimental drugs, organ transplant, war risks, injuries arising from dangerous hobbies (often called "hazardous pursuits").

6. What will affect my premiums?

Whichever scheme you choose, it is likely that your premiums will rise above the rate of general inflation.

This is because of factors which affect how healthcare is provided in all western economies.

Choices chart

It is unlikely that you will find all these options in any one product, but a combination will probably be available.

7. Will I need to provide details of my health?

As described under Section 5, there are a number of medical conditions which you will not be able to get private medical insurance cover for. You won't normally be covered for an illness from which you are suffering, or have already had (commonly known as pre-existing conditions). Insurance companies may accept your application for cover in one of two ways.

Medical history declaration

You are asked to fill in a form, giving details of your medical history.

If necessary, the insurance company may write to your doctor for more information. It is essential that you give all the information you are asked for. If you don't, you may find that your insurance company questions claims that you make in the future.

If you are not sure whether or not to mention something, it is best to do so. If you have a medical condition which is likely to come back, the insurance company will issue a policy, but that condition (and any related to it) will probably not be covered, either indefinitely, or for a set period of time.

Moratorium

This is when you are asked to fill in a form, but you are not asked to give details of your medical history. Instead, the insurance company does not cover any medical condition which existed in the last (usually) five years.

These conditions may automatically become eligible for cover, but only when you do not have symptoms, or receive treatment, medication, tests and advice (from your GP or a specialist) for that condition for a continuous period of (usually) two years, after your policy has started.

There are some conditions, for example chronic conditions, that will probably never be eligible for this delayed cover because you will always need regular or occasional treatment, medication, tests or advice for them.

You should not delay getting medical advice or treatment, simply to get cover.

If your insurance company offers a "moratorium", they will give you printed information explaining how their particular moratorium works. You may also want to ask the insurance company, or salesperson, to explain how it works.

8. Will my cover be affected if I am disabled?

Insurance companies will not refuse to cover you because you are disabled. As with other pre-existing conditions, your insurance company may exclude cover for treatment arising directly from your disability. However, it must be reasonable and fair for them to do this.

If you sign a 'medical history declaration', you must reveal all relevant information about your disability. If your policy automatically does not cover pre-existing conditions, then an existing medical condition causing disability, or arising from it, will not be covered. If you would like more information, call the Association of British Insurers on 020 7600 3333 and ask for the information sheet, 'Insurance for disabled people'.

9. How do I make a claim?

Apart from emergency admissions to NHS hospitals, all medical treatment has to start with a referral by your GP to an appropriate specialist.

You

Your insurance company

10. How is private medical insurance controlled?

An industry Code of Practice

Selling private medical insurance comes under our Code of Practice covering selling general insurance and other guidelines which cover private medical insurance. The code and other guidelines cover training, face-to-face and phone selling, as well as standards of documents and handling complaints.

Your application form

Your application form is a very important document. In fact, it forms the basis of your contract with your insurance company. Always fill it in fully and accurately. If you don't, your insurance company may refuse to pay your claim and could even cancel your policy.

Absolute confidentiality

By law all insurance companies have to treat personal information, especially medical details, with absolute confidentiality. Totally anonymous statistical information is sometimes given to outside organisations carrying out research.

A formal procedure for handling complaints

Most insurance companies have their own complaints procedures in place, so if you have a problem with any part of your cover, speak to your insurance company first. If you are not satisfied with the way in which your complaint is handled, you can contact either the Insurance Ombudsman Bureau, or the Personal Insurance Arbitration Service (depending on which one your insurance company uses). These services are free and you can find contact details at the end of this page.

11. What if I want to change to a new insurance company?

You may change insurance companies. However, it is important to remember that a new company may not cover any previous, or existing medical conditions, which your current insurance company may cover. You may also lose any premiums you have paid up front.

It is best to check with your new company as to how the change may affect your cover.

12. Your checklist

Before you buy private medical insurance, you need to understand the following.

  1. You agree to give the insurance company all the information they need. If you don't give accurate details, your insurance company can refuse to pay your claim or could cancel your policy.
  2. You agree to pay regular monthly or yearly premiums as long as you want cover. If you don't pay premiums, your cover will stop. Your insurance company will only pay for costs you have paid, or agreed to pay up to the last date covered by your premiums.
  3. The cost of your premiums may increase once a year when you renew your cover. Your individual premiums are not influenced by the number of claims you make (unless your cover includes a no-claims discount).
  4. If your insurance company plans on making changes and improvements to a scheme, all customers will be told before they renew. This will not prevent you continuing your cover.
  5. If you change insurance companies, you may not be covered for conditions or treatments that your existing policy covers.

Once you have received your policy, read it carefully.

Read your policy document carefully, you must keep to its terms and conditions.

However, if you did not receive all the policy documents before you decided to buy the policy, you will be given a cooling-off period, of around two to four weeks, in which you can make sure the policy is right for you.

If you decide not to go ahead you will usually receive a full refund of premiums you have already paid, unless you have made a claim.

If you want to cancel your policy after the cooling-off period, your insurance company does not have to refund your premiums - even those you have paid up front.

13. Useful addresses

If your insurance company cannot sort out your complaint, the following organisations will tell you how to go about taking the matter further (your insurance company's literature will tell you which one to contact). Their decisions are binding on the insurance company, but do not affect your right to take legal action if you want to do so.

The Insurance Ombudsman Bureau
135 Park Street
London SE1 9EA
Phone: 0845 600 6666


The Personal Insurance Arbitration Service
24 Angel Gate
City Gate
London EC1V 2RS
Phone: 020 7837 4483


For general information on insurance and, more specifically private medical insurance, you can contact:

The Association of British Insurers
51 Gresham Street
London
EC2V 7HQ
Phone: 020 7600 3333



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92 Bath Road,
Cheltenham,
GL53 7JT

Telephone: 01242 513222
Fax: 01242 584008
E -Mail: info@121healthcare.com
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