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Sorry it's a chronic condition


If a condition can be cured and is not a long-term problem, your insurance company will classify it as acute and should meet the cost. If your problem is incurable or it's a problem that, despite appropriate treatment, will be with you for a long time, then your insurance company will classify it as chronic - and no, you won't be covered.

But deciding whether a condition is acute or chronic is fraught with problems. It's rarely a black and white decision and this can lead to a major area of conflict between policyholder and insurer.

It's clear that asthma and diabetes are chronic conditions as you're almost certain to suffer from them for the rest of your life. So those categories of illness are not covered.

Problems arise when Doctors initially consider a patients' condition to be curable, but the condition later deteriorates and the medical team changes its' mind, it's now become incurable. This can sometimes happen, especially in the treatment of certain types of cancer.

In these circumstances, the condition is initially defined as acute and is therefore insured, but deteriorates and becomes chronic - and outside the terms of cover. This is possible as insurers retain the right to reclassify a condition from acute to chronic during treatment.

Sorry - it's too long term The insurance company will not pay out for long term treatment. But you need to check your policy documents to see how they define long-term. You can find the situation where a course of drugs extends for say 12 months, but the insurer will only pay for ten months.

Sorry it's preventative Your insurance is designed to pay for the treatment and cure of conditions when they arise. It is not designed to pay for treatments that are used to prevent an illness.

Again, the problem of definition arises. Sometimes it is arguable whether a treatment is preventative or a cure. Take the drug Herceptin for example. This drug can be used in the early stages of breast cancer. Research shows that Herceptin can halve the incidence of cancer returning for women who have a particularly virulent form of the cancer known as HER2. In this situation, is Herceptin offering a cure or is it a preventative?

Insurance companies are split on the debate. Norwich Union, WPA, BUPA and Standard Life Healthcare will pay for Herceptin for HER2 patients whereas Legal and General and Axa PPP will not.

Sorry the drug is not approved Two of the main attractions for taking out medical insurance are: to jump the queues at the NHS, and to get the latest treatments and drugs. But there's a rider.

The Institute for Health and Clinical Excellence exists to approve the use of new drugs by the NHS in England and Wales. Until that body has approved the drug your insurer is unlikely to pay for its use. The problem is that the Institute's brief is to perform a cost/benefit analysis to ensure that the financial benefits to the nation from using the drug, outweigh the costs of using it in the NHS. A difficult brief and it has placed the Institute under scrutiny for the extended delays in drug approval.

The compromise hit on by the Financial Ombudsman is that if your medical policy won't pay for the use of experimental treatments, then it should meet the cost of an approved conventional treatment with the policyholder footing the bill for the balance if the experimental treatment is more expensive.

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