Chronic conditions explained

When you take out a PHC private medical insurance policy we believe it is important to understand what is covered.

In common with other annual insurance policies, medical insurance is designed to cover claims for expenses incurred as a result of unexpected events. Therefore, it is important to understand when buying medical insurance that policies are designed to cover treatment of medical conditions that respond quickly to treatment, referred to by us as 'acute conditions'. Medical insurance is not intended to cover you against the cost of recurrent, continuing or long-term treatment of chronic medical conditions since these treatments become a series of predictable, rather than unexpected, events.

This leaflet is designed to help you understand more about what we mean by a chronic condition and provide practical examples of when we will or will not cover treatment of those conditions.

What is a chronic condition?

A "chronic condition" is a disease, illness or injury which has at least one or more of the following characteristics:

  • it needs on-going or long term monitoring through consultations, examinations, check ups and/or tests.
  • it needs on-going 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 PHC 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 suffering the condition, or which leads to your full recovery. This includes short-term medical intervention 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, your condition may fall within the definition of a chronic condition. If you have been receiving ongoing or continuing treatment or treatment that is intended to manage your condition or keep your symptoms in check, we will review your treatment to assess whether it remains eligible 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 your particular circumstances. We may ask them for confirmation of the diagnosis of your condition and details of the treatment you are currently receiving and to give us a future prognosis for the condition.

In line with other medical insurance policies, our plans are designed to cover claims for expenses incurred as a result of unexpected events and we do not go on paying for recurring or continuing treatment of medical conditions that will continue indefinitely or that keep recurring. Should the information we have indicate that you have a chronic condition we will write to tell you we will stop paying benefit for the continuing or recurrent treatment of 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 how we deal with 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 examples below 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 policy booklet 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 PHC 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 checkups with the specialist to ensure that his condition remains stabilised. This benefitwould only be available on policies with out-patient cover and while the policy remains in force.

Example 2 – Asthma

Eve has been with PHC 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 – Diabetes

Deidre has been with PHC 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 4 – Hip Pain

Bob has been with PHC 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.

Please click here for the Chronic Conditions Explained leaflet