Chronic conditions - examples of cover

The following are typical examples of chronic conditions and how PHC would usually deal with them: These examples are based on a policy which offers a full range of inpatient and outpatient benefits and that the condition is not excluded under the underwriting terms.

Example 1

Mr A has been with PHC for many years. He develops chest pain and is referred by his GP to a specialist. He has a number of investigations and is diagnosed as suffering from angina. Mr A is placed on medication to control his symptoms.

We would provide benefit for investigations and initial treatment to stabilise Mr A’s condition. Once the condition has been stabilised, we would advise that further regular review consultations purely to monitor and manage his condition would not be covered.

Two years later, Mr A’s chest pain recurs more severely and his specialist recommends that he has a heart by-pass operation.

We would confirm to Mr A that benefit would be available for this operation. We would also cover any appropriate post-operative consultations until the condition has stabilised and only requires ongoing medical management and monitoring.

Example 2

Mrs B develops a lump in her left breast, which is diagnosed as breast cancer. Her specialist recommends that she has a mastectomy (breast removal) followed by a course of chemotherapy and radiotherapy.

We would provide benefit for the consultations and diagnostic tests in order to establish the diagnosis. We would also provide benefit for her mastectomy and appropriate Chemotherapy and Radiotherapy with the intention of curing her condition.

Once Mrs B’s course of treatment has been completed, her specialist recommends that she has regular check-ups to ensure that she remains free from a recurrence of the disease.

We would provide benefit for the cost of check-ups for 5 years following completion of the treatment. Benefit would then be withdrawn if Mrs B has suffered no further symptoms.

Example 3

Mrs C has been with PHC for three years when she develops hip pain. Her GP refers her to an osteopath who treats her every other day for two weeks and then recommends that she return once a month for additional treatment to prevent a recurrence of her original symptoms.

We would provide benefit for Mrs C’s two weeks of treatment so long as this was eligible within her policy limits. We would advise that the proposed monthly treatment would not be eligible as the condition has stabilised and further osteopathy is designed to prevent symptom recurrence. We would of course be prepared to provide benefit for Specialist consultation and tests if Mrs C’s condition deteriorated.

Example 4

Mr D has been with PHC for 2 years when he develops symptoms that indicate he may have diabetes. His GP refers him to an endocrinology specialist who organises a series of tests to confirm the diagnosis and he then starts on oral medication to control the diabetes. After several months of regular consultations and some adjustments to the medication regime, the specialist confirms that the condition is now well controlled and explains that he would like to see him every 4 months to review the condition.

We would provide benefit for all investigations and tests up to the point of diagnosis. We would explain to Mr D that we could not continue to provide benefit for consultations as his condition has now stabilised. We would of course provide benefit for one additional consultation following this to allow Mr D to make alternative arrangements.

One year later Mr D’s diabetes becomes unstable and his GP arranges for him to go into hospital for treatment.

We would provide benefit for eligible treatment and tests to stabilise his condition. Once his condition had been stabilised we would provide benefit for one further check up to confirm his status.

Example 5

Mrs E has been with PHC for 5 years when she develops breathing difficulties. Her GP refers her to a specialist who arranged for a number of tests. These reveal that Mrs E 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 she states that her breathing has been much better so the specialist suggests she has check-ups every 4 months.

We would agree to provide benefit for Mrs E’s initial consultation and tests to establish her diagnosis. Once the condition has been stabilised, we would cease benefit as further treatment would be aimed at long-term medical management and monitoring of the condition.

Eighteen months later, she has a bad asthma attack.

We would provide benefit for eligible treatment and tests to stabilise her condition. Once her condition has stabilised, we would provide benefit for one further check-up to confirm her status.