Chronic conditions

Chronic Conditions

CHRONIC CONDITIONS

About chronic conditions

It’s important to understand that private medical insurance is designed to cover treatment for curable (acute) conditions. It does not usually cover long-term treatment of chronic conditions where the purpose of that treatment is primarily just to keep the symptoms under control. Unfortunately, the cost of covering treatment of such conditions would make private medical insurance prohibitively expensive.

  • It needs ongoing or long-term monitoring through consultations, examinations, check-ups, and/or tests
  • It needs ongoing 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

This information is designed to help you understand more about what we mean by chronic conditions and when we will and will not cover treatment of these. Please note that this does not include reference to cancer treatment. For further information about cancer treatment, please refer to the plan terms and conditions.

What is a chronic condition?

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

- it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and/or tests

- it needs ongoing 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 PruHealth we cover the cost of treatment for acute conditions. These are conditions that respond quickly to 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. However, there are certain medical conditions that can end up needing regular consultations and treatment over a long period of time. These are the kinds of conditions which we, and the medical profession, usually refer to as chronic conditions. We will normally not cover treatment of a chronic condition if the purpose of the treatment is just to control the symptoms.

What does this mean in practice?

Do be reassured that when you first become ill with a chronic condition we will pay for any specialist consultations and diagnostic tests* you need to have in order to find out the cause of your symptoms. We will also pay for any initial hospital treatment you require in order to stabilise your condition. However, there may come a point when the kind of treatment you are receiving appears only to be monitoring your state of health or keeping the symptoms of your condition in check rather than actively curing it. When such circumstances arise, we will discuss the situation with you. We may also ask for your consent to contact your GP or specialist to obtain further information about your condition and treatment. We will always take into account your own specific circumstances and we will never withdraw cover for that condition without giving you a reasonable amount of time to make alternative arrangements. (*providing your plan covers these)

What if your condition gets worse?

Although we might have withdrawn cover for a chronic condition, it does not mean that cover is permanently withdrawn. If your condition gets worse and this is not part of the normal progress of the illness or a recurring relapse, then we may cover the treatment necessary to return you to the state of health you were in before your condition worsened.

Examples of Chronic conditions

The following are typical examples of chronic conditions and how we would usually deal with them. All of these examples assume that the chosen plan provides cover for the particular condition and treatment, that the plan premiums are being paid and that the first symptoms of the condition arose after the start of cover.

1. Alan

Alan has been with PruHealth 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. Alan is placed on medication to control his symptoms.

We cover Alan’s initial consultations and tests and advise him that we will cover further consultations with his specialist until his symptoms are well controlled.

Two years later, Alan’s chest pain recurs more severely and his specialist recommends that he has a heart bypass operation.

We confirm to Alan that we will cover this operation as it will substantially relieve his symptoms and stabilise the condition. We also advise him that we will cover his post-operative check-ups for one year to ensure that his condition has been stabilised.

2. Eve

Eve has been with PruHealth 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 cover Eve’s consultations and tests and agree to pay for her next check-up. However, we advise her that we will not be able to cover her regular check-ups after this because her condition is now well controlled.

Eighteen months later, Eve has a bad asthma attack.

Due to the severity of the asthma attack, Eve needs an emergency admission to an NHS hospital which our plans are not designed to cover. However, once her condition has stabilised, we agree to cover the cost of one follow-up consultation with her specialist to make sure that her symptoms are well-controlled again.

3. Deirdre

Deirdre has been with PruHealth 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 to the medication regime, the specialist confirms that the condition is now well controlled and explains that he would like to see her every four months to review the condition.

We pay for the treatment of Deirdre’s condition up to this point. However, we advise her that because her condition is now stabilised we will not be able to continue to cover her regular four month check-ups. We tell Deirdre that we will cover one more check-up so that she has time to make alternative arrangements. We will not cover her medication at any time.

One year later, Deirdre’s diabetes becomes unstable and her GP arranges for her to go into hospital for treatment.

Assuming the admission is on an emergency basis, then this will usually be to a NHS hospital which our plans are not designed to cover. However, once she has been discharged we will pay for one further check-up to make sure that her condition is now stable.

4. Bob

Bob has been with PruHealth 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.

As Bob’s plan includes cover for alternative therapies, we pay for two weeks of treatment as this helps stabilise his symptoms. We also tell him that we cannot cover his regular monthly treatments, as these are designed just to keep the symptoms in check but that if his symptoms worsen he should contact us again.   

If Bob’s condition did deteriorate significantly and his consultant recommended a hip replacement, PruHealth would cover the cost of this. As the operation would replace the damaged hip and thereby cure Bob’s problem, we would pay for all the costs relating to this operation.

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