Hi there Dalbeth
Yes, as quoted above, the CCSD code is "C5130 Description Ultraviolet irradition of riboflavin for cross linking of corneal collagen" -- at least then there'll be no mistaking what the procedure actually is.
To Andrew -- while it is certainly not a given, I think that insurance providers may well be acting unreasonably. It's a long and complex subject but under insurance regulations, one of the key aspects of the principles-based regulations is "treating customers fairly". While it is acceptable to apply broad policy decisions it is not allowable to not look at each policy holder's specific clinical case. The ombudsman has upheld complaints in situations where an insurer has refused a claim without taking due regard to a consultant's recommendation and established clinical practice (see 77/07 in http://www.financial-ombudsman.org.uk/p ... rance.html). For me, my opinion is, if I may put it this way -- if we don't make appeals based on seemingly well founded, factual, grounds we're consigning ourselves to the current status quo for probably the next 5 to 10 years. From what I can tell, where policy holders have started to make appeals -- and appeal in the right way on the right areas -- these have been sucessful. Would it not be worth a try ? I also have personal experience. Only this week, I sucessfully got a decision on a part of a claim which had been declined overturned (I've got a whole story to write up when I've got time !). I do wonder just what people have to loose here by appealing claims decisions... okay, back to the previous post:
Dalbeth, a couple of things to try and find out before you call again. One is to look in the policy document and see if you can find the section on "experimental procedures" or "unproven treatments" or similar. This will define the criteria the provider uses to determine what they consider covered and what they think is outside of the policy. If you can't find it, ask them to quote from their T's and C's or let me know the product name of the cover you have and I'll do some digging. That will be the nub of the argument -- each policy is different in this regard so that's where doubt creeps in.
Even if it is just "NICE approved" treatments then all is definitely not lost. Another thing that would really -- really -- help if the policy has a very restictive definition of allowable treatment is some form of documentation which makes it crystal clear this isn't a self-referral e.g. somthing from any NHS opthalmologist you've seen saying that crosslinking is deemed appropriate and carries a clinical recommendation that it's necessary in order to halt the progression of your keratoconus. Even better if it says that a graft is the only other option as you'd be able to make a "loss minimisation" case regardless of any other terms about allowable procedures.
With a bit of luck, a little gentle push back asking for the provider's methodoloy in ascertaining why the consider crosslinking "ineffective" will at least get them to come up with somthing a little more objective. Probably too much to expect they'll just have a change of mind with the first prod, but it'll get the ball rolling. Most likely is that you'll get a more detailed response saying that their panel of clinicians regularly reviews new procedures and this one remains experiemental/unproven blah blah blah. That would actually be a very good result because it opens a crack in the armour in so far as it won't be too hard to provide publically available, published, peer reviewed, information to the contrary. As noted in the above, if you get somthing from the specialists who have been looking after you and know your case history, that carries far more weight than some -- almost always generalist -- advisor's advice the provider would be able to point to.
Fingers crossed for you -- please do let us know the next twist in this story.
Cheers
Chris
Insurance Cover For Operation
Moderators: Anne Klepacz, John Smith, Sweet
-
dalbeath
- Regular contributor
- Posts: 104
- Joined: Thu 06 Jan 2011 3:01 pm
- Keratoconus: Yes, I have KC
- Vision: Contact lenses
- Location: Fife
- Contact:
Re: Insurance Cover For Operation
Hi Chris,
The policy is a group policy provided by Standard Life through Pru Healthcare. The full T&C can be found here http://www.pruhealth.co.uk/pruhealth_uk ... re_t_c.pdf
But the bit you asked about exclusions says they will not pay for "Experimental or unproven treatment or practices" it also goes on to say "treatment or drug therapy which, based on established medical practice in
the UK, is considered to be experimental or unproven, or for which there is
insufficient evidence of safety or effectiveness
■■ any treatment using unlicensed drugs or the use of drugs outside the terms of
their licence in the UK"
Any ideas of what I should say to them or is this a lost cause?
Many thanks for your help
Wendy
The policy is a group policy provided by Standard Life through Pru Healthcare. The full T&C can be found here http://www.pruhealth.co.uk/pruhealth_uk ... re_t_c.pdf
But the bit you asked about exclusions says they will not pay for "Experimental or unproven treatment or practices" it also goes on to say "treatment or drug therapy which, based on established medical practice in
the UK, is considered to be experimental or unproven, or for which there is
insufficient evidence of safety or effectiveness
■■ any treatment using unlicensed drugs or the use of drugs outside the terms of
their licence in the UK"
Any ideas of what I should say to them or is this a lost cause?
Many thanks for your help
Wendy
-
longhoc
- Moderator
- Posts: 349
- Joined: Sun 26 Dec 2010 11:13 am
- Keratoconus: Yes, I have KC
- Vision: Graft(s) and contact lenses
Re: Insurance Cover For Operation
Hello Wendy
Wow, 92 pages ! That’s lengthy even by the standards of the industry. But actually, it’s very well written, clear, concise and easy to navigate your way around if you know where to look. Don’t worry about the “drugs” bits, we’re not talking about drug-based treatment, so that’s not what’s important here (it is quite tricky for those not familiar with insurance contracts to look at the relevant parts for the real clauses in play !).
The relevant section is actually on pg. 33. I’ll walk you through the pertinent sections so you can use them in any conversation you have with the provider:
1.12. Experimental treatment
Our policy does not cover drugs and treatment that are not considered to be established medical practice in the UK or for which there is insufficient evidence of safety or effectiveness. This includes drugs that are used outside the terms of their licence or treatment that has not been reviewed and approved for general use in the NHS by the National Institute for Health and Clinical Excellence (NICE). However, we may consider covering experimental treatment where this is part of a properly controlled clinical trial.
Okay, first things first. the provider is willing to consider covering treatment under a trial. It’s therefore definitely worth going back to the ophthalmologist or whoever who is proposing that you undergo crosslinking and ask if they will be submitting results to a trial. If so (and even if not, do then go on to say that you’re quite happy for your results to be included in a trial if the specialist would like to report them – and explain the reason why e.g. it would help get the procedure paid for by an insurer) then obviously you can simply go back to the provider and ask them to authorise the claim on that basis. Given that NICE is promoting trials of crosslinking and – crucially – the industry’s representative (BUPA in this case) on the NICE guidance committee has made a statement supporting the trial/evidence-gathering/review approach (http://www.nice.org.uk/nicemedia/pdf/IP ... mments.pdf comment No. 4) it would be perverse if private medical insurance providers didn’t then follow through and back up the stance with approved claims for crosslinking on a trial basis.
Now, what happens if your specialist can’t or won’t agree to include your crosslinking as a trial ? One option then is that you could get another consultant who is willing to do so. But you may have perfectly justifiable reasons for wishing to continue being looked after by your current clinical team. And my opinion is – why should you change if you don’t want to ? That said, obviously it will be a tad easier to have your treatment done as part of a trial in terms of getting a claim approved under your policy so just something to have a think about and decide what’s best for you.
But let’s now suppose you are not being included as part of a trial and don’t want to switch to someone else just to get on one. The next paragraph is really interesting because is it opens up a bit of a can of worms for the provider:
If you decide to undergo drug therapy or treatment that we consider experimental, and it is not part of a clinical trial that we have agreed to cover, then we will only make a contribution towards the costs based on what we would have paid for the nearest equivalent established treatment for your condition at a hospital on your hospital list.
Hmmm... what’s that all about then ? I’ll go through the thinking behind the underwriting on this. The provider can’t reasonably have it both ways (refusing to pay for an “experimental” treatment while also not paying for a “conventional” one) which is what this clause is saying, and further, if you elect to have an “experiential” they’ll pay the cost of the “conventional” one which you could, if you want, use as a contribution to the “unproven” procedure.
What though is the “nearest equivalent established treatment“ for Keratoconus ? I’m making an assumption that your specialist has recommended crosslinking because it’s been progressing and at the very least it’s moving from the “mild” to “moderate” stage. This is one of the key indications for considering crosslinking in the first place. If it’s not actively progressing, it would be something to ask whether it’s actually worth doing just now. But again, assuming it is, they also, presumably, having managed your condition for a while made observations concluded that it is possibly it will continue to progress and can give at least a balance-of-probabilities assessment taking your current corneal thickness and suggest where it will be in the next couple of years. In this situation, the “nearest equivalent established treatment“ could well be a graft.
When I said it was opening a can of worms for the provider, that’s the can. If the “pay for a trial” route is a no-go then you might well want to hand them the can and ask if they really do want to open it up and start poking around. Simply ask them for their view on what the “nearest equivalent established treatment“ is, if not crosslinking. It’s in your best interests to say nothing at all on this subject, not even to ask your existing specialist. In order to get an answer to that one, the provider will need to form their own clinical judgement.
One possible outcome is that the provider will opine that the only way to obtain the benefit of the policy is to wait until you’re sufficiently advanced to undergo a graft. They’d then pay for the graft. While this may be narrowly correct under the letter of the policy, waiting for your customers to get sicker before paying out fails the smell test. If that does turn out to be where you end up, it’s definitely worth appealing if only because the provider would end up looking so dubious. They'd probably want to avoid actually having to come out and say that.
It seems that your policy is part of a corporate arrangement (I’m guessing here but it looks a typical “corporate” job in terms of policy design – not the bare minimum, but hardly top of the range !). The customary practice is that the corporation and the provider set up a trust to control the operation of scheme. This is good because it adds a layer of bankruptcy remoteness and independent governance. The trust would be expected to have a “fiduciary duty” towards employees which means they would have to act in “utmost good faith” in protecting the interests of the beneficiaries. If this does turn out to be a case of the provider insisting that you have to get more advanced before it would then pay for a graft rather than coughing up for crosslinking now, you should definitively contact the administration trust in your organisation. If I’ve got the wrong end of the stick – and you are the actual policy holder because you purchased it yourself – then it would be the Financial Ombudsman.
Have covered an awful lot of ground there – let me know if you’re still no clearer about where to start !
(for anyone else reading this thread, it's worth saying again "each policy is written differently" -- there really is a huge variation. So it's definitely worth looking at your own policy T's and C's before thinking that any or all of the above would apply to your situation)
Kind regards
Chris
Wow, 92 pages ! That’s lengthy even by the standards of the industry. But actually, it’s very well written, clear, concise and easy to navigate your way around if you know where to look. Don’t worry about the “drugs” bits, we’re not talking about drug-based treatment, so that’s not what’s important here (it is quite tricky for those not familiar with insurance contracts to look at the relevant parts for the real clauses in play !).
The relevant section is actually on pg. 33. I’ll walk you through the pertinent sections so you can use them in any conversation you have with the provider:
1.12. Experimental treatment
Our policy does not cover drugs and treatment that are not considered to be established medical practice in the UK or for which there is insufficient evidence of safety or effectiveness. This includes drugs that are used outside the terms of their licence or treatment that has not been reviewed and approved for general use in the NHS by the National Institute for Health and Clinical Excellence (NICE). However, we may consider covering experimental treatment where this is part of a properly controlled clinical trial.
Okay, first things first. the provider is willing to consider covering treatment under a trial. It’s therefore definitely worth going back to the ophthalmologist or whoever who is proposing that you undergo crosslinking and ask if they will be submitting results to a trial. If so (and even if not, do then go on to say that you’re quite happy for your results to be included in a trial if the specialist would like to report them – and explain the reason why e.g. it would help get the procedure paid for by an insurer) then obviously you can simply go back to the provider and ask them to authorise the claim on that basis. Given that NICE is promoting trials of crosslinking and – crucially – the industry’s representative (BUPA in this case) on the NICE guidance committee has made a statement supporting the trial/evidence-gathering/review approach (http://www.nice.org.uk/nicemedia/pdf/IP ... mments.pdf comment No. 4) it would be perverse if private medical insurance providers didn’t then follow through and back up the stance with approved claims for crosslinking on a trial basis.
Now, what happens if your specialist can’t or won’t agree to include your crosslinking as a trial ? One option then is that you could get another consultant who is willing to do so. But you may have perfectly justifiable reasons for wishing to continue being looked after by your current clinical team. And my opinion is – why should you change if you don’t want to ? That said, obviously it will be a tad easier to have your treatment done as part of a trial in terms of getting a claim approved under your policy so just something to have a think about and decide what’s best for you.
But let’s now suppose you are not being included as part of a trial and don’t want to switch to someone else just to get on one. The next paragraph is really interesting because is it opens up a bit of a can of worms for the provider:
If you decide to undergo drug therapy or treatment that we consider experimental, and it is not part of a clinical trial that we have agreed to cover, then we will only make a contribution towards the costs based on what we would have paid for the nearest equivalent established treatment for your condition at a hospital on your hospital list.
Hmmm... what’s that all about then ? I’ll go through the thinking behind the underwriting on this. The provider can’t reasonably have it both ways (refusing to pay for an “experimental” treatment while also not paying for a “conventional” one) which is what this clause is saying, and further, if you elect to have an “experiential” they’ll pay the cost of the “conventional” one which you could, if you want, use as a contribution to the “unproven” procedure.
What though is the “nearest equivalent established treatment“ for Keratoconus ? I’m making an assumption that your specialist has recommended crosslinking because it’s been progressing and at the very least it’s moving from the “mild” to “moderate” stage. This is one of the key indications for considering crosslinking in the first place. If it’s not actively progressing, it would be something to ask whether it’s actually worth doing just now. But again, assuming it is, they also, presumably, having managed your condition for a while made observations concluded that it is possibly it will continue to progress and can give at least a balance-of-probabilities assessment taking your current corneal thickness and suggest where it will be in the next couple of years. In this situation, the “nearest equivalent established treatment“ could well be a graft.
When I said it was opening a can of worms for the provider, that’s the can. If the “pay for a trial” route is a no-go then you might well want to hand them the can and ask if they really do want to open it up and start poking around. Simply ask them for their view on what the “nearest equivalent established treatment“ is, if not crosslinking. It’s in your best interests to say nothing at all on this subject, not even to ask your existing specialist. In order to get an answer to that one, the provider will need to form their own clinical judgement.
One possible outcome is that the provider will opine that the only way to obtain the benefit of the policy is to wait until you’re sufficiently advanced to undergo a graft. They’d then pay for the graft. While this may be narrowly correct under the letter of the policy, waiting for your customers to get sicker before paying out fails the smell test. If that does turn out to be where you end up, it’s definitely worth appealing if only because the provider would end up looking so dubious. They'd probably want to avoid actually having to come out and say that.
It seems that your policy is part of a corporate arrangement (I’m guessing here but it looks a typical “corporate” job in terms of policy design – not the bare minimum, but hardly top of the range !). The customary practice is that the corporation and the provider set up a trust to control the operation of scheme. This is good because it adds a layer of bankruptcy remoteness and independent governance. The trust would be expected to have a “fiduciary duty” towards employees which means they would have to act in “utmost good faith” in protecting the interests of the beneficiaries. If this does turn out to be a case of the provider insisting that you have to get more advanced before it would then pay for a graft rather than coughing up for crosslinking now, you should definitively contact the administration trust in your organisation. If I’ve got the wrong end of the stick – and you are the actual policy holder because you purchased it yourself – then it would be the Financial Ombudsman.
Have covered an awful lot of ground there – let me know if you’re still no clearer about where to start !
(for anyone else reading this thread, it's worth saying again "each policy is written differently" -- there really is a huge variation. So it's definitely worth looking at your own policy T's and C's before thinking that any or all of the above would apply to your situation)
Kind regards
Chris
-
Lynn White
- Optometrist
- Posts: 1398
- Joined: Sat 12 Mar 2005 8:00 pm
- Location: Leighton Buzzard
Re: Insurance Cover For Operation
Longhoc,
CXL Is not uniformly conducted throughout the UK by the NHS. There are a few PCTs that support it but if you seriously want CXL, you have to go privately. NICE has indicated that CXL still needs more research and the NHS/Private health services still feel grafts are the only "cure". They see CXL as something that may still mean progression and do not even recognise medically necessary contact lenses (even though the NHS does).
In my experience as a practitioner trying to get my patients private cover, any attempt to fight this issue would take so long that CXL treatment would become irrelevant.
I am sorry to be so negative, but if you are a person with KC considering CXL at this moment in time and need it urgently, forget fighting the private medical insurance system and pay for it yourself. If you have time on your side, then go down paths suggested by Longhoc.
Longhoc, until we as a group come together and fight for change, then the insurance industry will not get its act in gear.
I am seriously up for helping anyone to change this situation, so please do contact me if you are of like mind!
Lynn
Lynn
CXL Is not uniformly conducted throughout the UK by the NHS. There are a few PCTs that support it but if you seriously want CXL, you have to go privately. NICE has indicated that CXL still needs more research and the NHS/Private health services still feel grafts are the only "cure". They see CXL as something that may still mean progression and do not even recognise medically necessary contact lenses (even though the NHS does).
In my experience as a practitioner trying to get my patients private cover, any attempt to fight this issue would take so long that CXL treatment would become irrelevant.
I am sorry to be so negative, but if you are a person with KC considering CXL at this moment in time and need it urgently, forget fighting the private medical insurance system and pay for it yourself. If you have time on your side, then go down paths suggested by Longhoc.
Longhoc, until we as a group come together and fight for change, then the insurance industry will not get its act in gear.
I am seriously up for helping anyone to change this situation, so please do contact me if you are of like mind!
Lynn
Lynn
Lynn White MSc FCOptom
Optometrist Contact Lens Fitter
Clinical Director, UltraVision
email: lynn.white@lwvc.co.uk
Optometrist Contact Lens Fitter
Clinical Director, UltraVision
email: lynn.white@lwvc.co.uk
-
dalbeath
- Regular contributor
- Posts: 104
- Joined: Thu 06 Jan 2011 3:01 pm
- Keratoconus: Yes, I have KC
- Vision: Contact lenses
- Location: Fife
- Contact:
Re: Insurance Cover For Operation
Longhoc/Chris
You are a total star!
Many thanks
Will report back later once I have spoken to them. By the way it is a standard employee policy that I get as my husband is an employee of Standard Life Investments.
Thanks
Wendy
You are a total star!
Many thanks
Will report back later once I have spoken to them. By the way it is a standard employee policy that I get as my husband is an employee of Standard Life Investments.
Thanks
Wendy
-
longhoc
- Moderator
- Posts: 349
- Joined: Sun 26 Dec 2010 11:13 am
- Keratoconus: Yes, I have KC
- Vision: Graft(s) and contact lenses
Re: Insurance Cover For Operation
Hi Lynn
I do agree with you that it isn't just a case of you call your provider, moan a bit and then they simply cave.
But I don't agree that it is hopeless and so -- if I follow your reasoning -- you don't bother challenging your insurance provider because there's no point and you simply have to pay up yourself. In one of the links I included above, the Financial Ombusman upheld a complaint about "experimental treatment" claims being rejected. It happens all the time. I do wonder where the gentlemen in one of the cases would be having been told his "unproven" cancer drug wasn't NICE approved if he'd just thought "oh, well, they're big companies, I'm just the little guy, I might as well give up now..."
Any attempt to make a challenge on a claim rejection which didn't take a forensic look at the policy design, the specifics of the claiment's case, the supporting evidence from the clinician, the letter of the NICE guidence and so on -- in other words, any sort of general approach which didn't reference the individual situation -- would would be eaten alive by the insurer.
You do absolutely have to look at the policy in force, your clinical situation and a myrida of other factors such as what your specialist is proposing, whether you're placed on an NHS waiting list etc. etc. Taking Wendy's specific case, the policy offers the possibility of covering participation in a trial (with a strong possibility that cover would have to be extended for crosslinking in particular because of an industry support for the trials approach) and if her procedure was to be included because that's what her consultant is involved with anyway i.e. a trial then I don't see how it would take any longer... And then there is an entirely ligitimate argument about "nearest conventional treatment" waiting to be made if that fails.
The "only some PCTs do it" is in some ways a bit of a red herring -- you've a right to be referred to a hospital trust which offers it (e.g. Moorifleds) and that's a decision between you and your GP (although you are then liable for the extra travelling). So you could ask to be seen there, get on-the-NHS-waiting-list status, then take that fact back to your insurer.
May I flip the logic of the "there's no point in trying to get insurance to pay for it" argument back ? From what we know, there's limited support in the NHS to introduce crosslinking on a widely available basis. And insurers are fighting tooth and nail to not fund crosslinking privately. So how, then, is more information on the procedure to be gathered ? The NHS won't do it. The private medical industry won't do it. The only conclusion is that those of us with Keratoconus have to fund the data gatering out of our own pockets !
Where I do think you are 100% correct is that this current -- unnaceptable -- situation would be far better progressed as a collective, organised push-back carrying the weight of a group approach. Individuals alone face a much harder task. And any individual victory would be written off as an "exception". So everyone has to start from the same place.
Wonder if the committe have any views ..? Could be a topic for our next conference !
Kind regards
Chris
I do agree with you that it isn't just a case of you call your provider, moan a bit and then they simply cave.
But I don't agree that it is hopeless and so -- if I follow your reasoning -- you don't bother challenging your insurance provider because there's no point and you simply have to pay up yourself. In one of the links I included above, the Financial Ombusman upheld a complaint about "experimental treatment" claims being rejected. It happens all the time. I do wonder where the gentlemen in one of the cases would be having been told his "unproven" cancer drug wasn't NICE approved if he'd just thought "oh, well, they're big companies, I'm just the little guy, I might as well give up now..."
Any attempt to make a challenge on a claim rejection which didn't take a forensic look at the policy design, the specifics of the claiment's case, the supporting evidence from the clinician, the letter of the NICE guidence and so on -- in other words, any sort of general approach which didn't reference the individual situation -- would would be eaten alive by the insurer.
You do absolutely have to look at the policy in force, your clinical situation and a myrida of other factors such as what your specialist is proposing, whether you're placed on an NHS waiting list etc. etc. Taking Wendy's specific case, the policy offers the possibility of covering participation in a trial (with a strong possibility that cover would have to be extended for crosslinking in particular because of an industry support for the trials approach) and if her procedure was to be included because that's what her consultant is involved with anyway i.e. a trial then I don't see how it would take any longer... And then there is an entirely ligitimate argument about "nearest conventional treatment" waiting to be made if that fails.
The "only some PCTs do it" is in some ways a bit of a red herring -- you've a right to be referred to a hospital trust which offers it (e.g. Moorifleds) and that's a decision between you and your GP (although you are then liable for the extra travelling). So you could ask to be seen there, get on-the-NHS-waiting-list status, then take that fact back to your insurer.
May I flip the logic of the "there's no point in trying to get insurance to pay for it" argument back ? From what we know, there's limited support in the NHS to introduce crosslinking on a widely available basis. And insurers are fighting tooth and nail to not fund crosslinking privately. So how, then, is more information on the procedure to be gathered ? The NHS won't do it. The private medical industry won't do it. The only conclusion is that those of us with Keratoconus have to fund the data gatering out of our own pockets !
Where I do think you are 100% correct is that this current -- unnaceptable -- situation would be far better progressed as a collective, organised push-back carrying the weight of a group approach. Individuals alone face a much harder task. And any individual victory would be written off as an "exception". So everyone has to start from the same place.
Wonder if the committe have any views ..? Could be a topic for our next conference !
Kind regards
Chris
-
dalbeath
- Regular contributor
- Posts: 104
- Joined: Thu 06 Jan 2011 3:01 pm
- Keratoconus: Yes, I have KC
- Vision: Contact lenses
- Location: Fife
- Contact:
Re: Insurance Cover For Operation
Hi Chris
Hope you don't think I'm too cheeky but I have PM'd you a copy of my formal complaint to Pru. Any chance you can read it before i send it? No worries if not.
regards
Wendy
Hope you don't think I'm too cheeky but I have PM'd you a copy of my formal complaint to Pru. Any chance you can read it before i send it? No worries if not.
regards
Wendy
-
itansey
- Contributor
- Posts: 30
- Joined: Fri 22 Aug 2008 11:24 am
- Keratoconus: Yes, I have KC
- Vision: Spectacles
- Location: London
Re: Insurance Cover For Operation
I’ve been in contact with BUPA about claiming the CXL procedure. At first they said it was an experimental treatment and wouldn’t cover the procedure, I then asked them to clarify what they meant by experimental. They came back to me by letter stating “CXL is not currently licensed for treatment within the UK and is presently undergoing clinical trials with NICE. When a treatment is undergoing trials its classified as experimental. When we consider benefits for treatment we are guided and instructed by the rulings of NICE. NICE guidelines state that you must be taking part in a clinical trial in order for us to consider providing benefit for this experimental treatment“.
According to other posters on this forum, BUPA’s understanding of the current NICE rules are incorrect as they have neither approved or disapproved the procedure….any help with my next course of action would be very helpful….
According to other posters on this forum, BUPA’s understanding of the current NICE rules are incorrect as they have neither approved or disapproved the procedure….any help with my next course of action would be very helpful….
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