Employee Private Healthcare - Help advice needed!

[LB145]

Not sure if this is the correct forum but was always helpful with finance information - so apologies if not!

 

My adult son has a employment  benefit of private healthcare, he has been diagnosed with an eye condition called Keratoconus that will lead to loss of sight, his vision had deteriorated rapidly and this cannot be corrected with glasses,  we spoke to our GP and also thoroughly researched the condition and consultants who specialise in this, my son contacted the healthcare provider and fortunately the Professor who specialises is available through our local private hospital

 

so my son contacted the healthcare provider and they said that the "specialist consultant" was on their approved consultants list and he could have a consultation at a private hospital (the hospital was also on their approved list and there is a £500 excess to pay).  Our GP told us that the private route would be quicker especially if he has private healthcare, the NHS will could be a long wait. 

 

My son had a consultation and the professor confirmed the condition and that it was a matter of urgency that he has treatment, he would need a more intensive and thorough assessment of his eyes at another  clinic that he operates from.   My son had the assessment and the clinic confirmed that he needs two procedures 1) most deteriorated eye -  Crosslinking and Athens Protocol procedure (£3000)   2) Then three months later Crosslinking on the other eye (£2000) which has not deteriorated at the same speed.   

 

So My son has been given  dates of when the most damaged eye can be treated late Dec/early Jan, he contacted the healthcare provider and they have informed him that the clinic where the Professor will carry out this procedure  is not on their list.  If he does not have this procedure he will eventually need cornea transplants (far greater cost to the health care provider).  This is not a vanity procedure, the Athens Protocol will make it possible for him to have his sight corrected with the use of glasses  to give him improved vision.  Any advice if possible please as to which way forward with the health care provider.

[stu007]

Hi

sorry to hear about the eye condition

 

Now you say it was via Employment Benefit Private Healthcare do you have a copy of the Terms & Conditions if not ask for a copy and read it fully to understand any exemptions/clauses.

 

The issue I see is the Insurer yes stated this professor was on there list for the hospital that they were initially seen and diagnosed for treatment.

 

This professor advised treatment due to diagnosis at his own private hospital that they operate from and you accepted this.

 

This is where this issues arises as the insurer only said the professor was on there list and the initial hospital diagnosed at was authorised by the insurer but they did not authorise treatment elsewhere at a different hospital not on there authorised list.

 

Did you inform the Insurer of the diagnosis and further treatment required at this other hospital and it was authorised by them?

 

Who is the Healthcare Insurer?

 please be patient as other will be along to advise

[honeybee13]

Hi.

 

I've moved your thread to the insurance forum so you should get more views.

 

Did the insurer say why they don't want to use the other hospital?

 

HB

[LB145]

My son contacted and informed the insurance company at every stage so far, if I am reading this correctly if he has the treatment at another clinic not listed then they will pay 60% of the cost plus the consultants fees?

 

WHICH HOSPITALS ARE ELIGIBLE UNDER
YOUR PLAN?
• If you have one of our hospital list options,
you should only go to a hospital on your
chosen list, as you’re only covered in full for
treatment at those hospitals. If you go to a
hospital that’s not on your list, then you’ll have
to pay 40% of the costs of your treatment
(excluding your consultants' fees).
• Some consultants can arrange for diagnostic
tests and scans to be carried out in a number
of different hospitals. It is important that
you check that the hospital your consultant
suggests you attend is eligible on your plan.
• If your employer has chosen our Consultant
Select option, you must contact us before
having treatment so we can arrange for you
to see a consultant on our panel. Alternatively
you can make an appointment with a
Vitality GP who will arrange for you to see a
consultant. The consultant will then choose
the hospital you are treated in. We will not
pay for treatment we have not authorised
in advance.

[LB145]

The provider is Vitality. 

[honeybee13]

I wonder if it's worth speaking with the consultant or his/her secretary in case they've come across this before and can advise. 

 

Thank you for the name of the company, it means we can check them out. 

 

HB

[LB145]

19 minutes ago, honeybee13 said:

I wonder if it's worth speaking with the consultant or his/her secretary in case they've come across this before and can advise. 

 

Thank you for the name of the company, it means we can check them out. 

 

HB

Consultant and his Secretary said that some companies try this but when informed this is necessary not cosmetic then they may change their mind or part payment.

 

[stu007]

Hi

 

I think you need to get a letter from the Consultant explaining the urgent need for treatment and his recommendation that it was done at this other hospital he works from due to his own workload, urgent treatment needed etc and then send it direct to the insurer to see what they say.

 

 

 

[LB145]

On 04/12/2019 at 01:15, stu007 said:

Hi

 

I think you need to get a letter from the Consultant explaining the urgent need for treatment and his recommendation that it was done at this other hospital he works from due to his own workload, urgent treatment needed etc and then send it direct to the insurer to see what they say.

 

 

 

Thank you

[stu007]

Hi

 

Something else I think you need to ask the Insurer for Clarification on is.

 

That you require full clarification on which clauses within the Terms & Condition of the Policy they are using to refuse payment under the Policy.

 

 

I would also consider sending the Insurer a Subject Access Request simply asking for 'ALL DATA' this covers whatever format they hold it in whether it be email/telephone recording/written format etc. (note: if they require you to use their own subject access request form always put 'ALL DATA' on their form)