BUPA Private Hospital Scheme

Further to our telephone conversation of some days ago I wish to insist that once again BUPA's failure to honour our claim is most unfair.

When we submitted a claim for a consultant's visit, we were informed that no follow-up medical expenses on this claim would be refunded by BUPA since 'it is a chronic condition'. However, we were reassured that, should hospitalisation be required on this particular condition, the policy would cover this expense.

I strongly object to this decision because I insist that the condition is not yet chronic. A regular check-up by a consultant physician is our best assurance that it will never become so. The 'only' treatment required so far has been a visit to a dietician, to advise on a correct diet that would ensure that the condition does not become chronic. Even the expenses incurred for visits to the dietician were deemed by BUPA to be non-refundable.

Our first claim with BUPA was in 1998 and at the time I could not find enough words of praise for their service. I honestly thought that no other health insurer could match BUPA's services. However, when the possibility of a claim for tens of thousands of liri no longer existed, the tone changed drastically and suddenly the rules and conditions had to be strictly adhered to. And it has remained so ever since. Rather than the 'peace of mind' that BUPA promises its subscribers, every claim is proving to be a real ordeal. It seems to me that BUPA will go to great lengths to find the slightest excuse to avoid making any payment. The present claim is definitely one such example.

I am forwarding a copy of this letter to Adrian Muscat Inglott of the Consumer Affairs Column of The Sunday Times because I am convinced that, under the Private Hospital Scheme, follow-up visits to the consultant should be covered by BUPA. It would be interesting to know how other health insurers would handle such a claim. (Sylvia Muscat)

I asked for BUPA's comments:

Thank you for your letter of November 28.

We are sorry to note your disappointment regarding the matter of Roberta's claim. Please rest assured that we do try to offer the optimum service to all our members at all times.

In our opinion, perhaps a slight misunderstanding has arisen regarding the scope of the cover we offer. As a solution, we propose to summarise the cover for you and at the same time answer the points you rightly raised in your letter, as follows:

BUPA cover extends broadly to the reimbursement (according to policy terms and conditions) of expenses incurred for the treatment of acute medical conditions.

Acute medical conditions are those which arise suddenly and unexpectedly, require prompt medical attention, and are resolved swiftly after treatment.

Granted, it is technically debatable as to whether or not this affliction is better described as chronic or non-acute. However, we do feel that in all reasonable fairness, and according to the normal medical definition above, our main contention remains that the condition certainly cannot now be defined as acute. It is not a condition which is swiftly resolved.

Due to the fact that we reimburse for actually existing conditions, it does therefore follow that regular screenings or check-ups do not fall within the scope of the cover. This then becomes the reason why we cannot settle for routine investigations.

You declare that "follow-up visits to a consultant should be covered by BUPA". In our opinion, sweeping statements such as this may prove ambiguous. Clearly, we are bound to follow policy terms and conditions in this regard as with any other.

It is not reasonably possible for us to declare beforehand that any and every visit to a consultant, follow-up or not, will be covered. Every claim is decided entirely on its own merits. Normally, for example, we are very likely to allow at least one follow-up visit after a particularly serious medical procedure, but no two claims are exactly the same. Further follow-ups would then depend entirely on medical reports being shown to us from beforehand, which would confirm to us the eligibility or otherwise of the next visit.

We most certainly maintain that you do in fact benefit from peace of mind, and assure you that we will reimburse you swiftly whenever an eligible claim is presented to us.

On this occasion, before receiving your letter, we had already decided to settle this particular claim on a discretionary basis, in our attempt to offer the best possible service, and you will find our cheque payment enclosed.

However, the status of the condition must now necessarily be deemed to be non-acute, and hence ineligible for further settlements, unless there is a distinct aggravation of the condition resulting in a specific acute phase, in conformity with cover.

We hope that we have now clarified the matter for you, but please do contact us at any time in the event of a query, as we are here to help. (Nick Ripard, head of technical insurance services)

I thank Mr Ripard for his prompt informative reply.