Under covered – the ambiguity of medical insurance policies

by Tim Tonkin

A lack of clarity in medical insurance policies can affect the quality and standard of care. In response, the BMA has produced guidance to help patients pick a plan. Tim Tonkins reports.

Location: UK
Published: Tuesday 12 November 2019
BMA private practice committee chair Shree Datta

Transparency and trust are the cornerstones of any relationship or transaction and are mutually valued by doctors and patients with regard to healthcare.

This is as true of those doctors and patients who choose to work in or receive treatment privately as those in the NHS. However, in the case of the former, there is a third party to the doctor-patient relationship: the medical insurer responsible for financing the care provided.

Practising or receiving healthcare privately is meant to be a matter of choice. However, the complexity of the requirements and conditions set by different insurance policies determining what treatments are and are not covered is having an increasingly detrimental effect on doctors and patients.


Lack of clarity

Many private insurance policies do not, for example, cover costs associated with medical emergencies, chronic conditions, elective surgery or even routine check-ups from GPs.

This lack of clarity not only affects patients but potentially makes the job of the doctor looking to provide them with the best treatment that much more difficult.

‘Because there are so many different variations on the policies that are available, you’re not always aware what is covered and what isn’t – either as the doctor or as a patient,’ explains consultant in obs and gynae and BMA private practice committee chair Shree Datta.

‘An insurer might allow me to perform an operation as a treatment for my patient but when it comes to prescribing antibiotics post-operatively to prevent infection, these may not be covered by them so the patient is therefore left out of pocket. It’s a real dilemma for them at the time of greatest need.

‘Sometimes these decisions don’t really make sense, and yet they do have a direct impact on the quality and standard of care we’re able to provide.’


No contract

Unlike staff working in the NHS, there is no contract of employment between a private doctor and a medical insurer, only a recognition of agreement which cannot be contested legally.

According to the PPC, this reality has enabled insurance firms to exert increasing levels of control over the way access to treatments and doctor-patient interactions take place.

This includes the use of ‘open referrals’ – a process which effectively allows insurers’ policies to pick and choose which consultant a patient can see, rather than allowing a GP to make this decision. Added to this is the fact that many insurers’ policies will only sanction treatment from a doctor included on their list of recognised clinicians.

This not only reduces patient choice but also serves as leverage on doctors who can face derecognition if they do not meet insurers’ wishes – whether this is reducing their fees or failing to agree to exclude patients from the treatment invoicing process.


The treatment patients are able to access is dependent on what their insurers are happy to cover.

Raise awareness

In an effort to help inform and thus empower patients looking to take out private medical insurance, the PPC has created guidance, which has been reviewed by the BMA patient liaison group.

The guidance focuses on the information patients should consider prior to purchasing private medical insurance.

‘To a large extent, the treatment that they [patients] are able to access is wholeheartedly dependent on what their insurers are happy to cover and what they themselves can bear as a cost,’ says Miss Datta. ‘Often patients have to contact their insurer along every step [of their treatment] to clarify what parts of the treatment and investigations are covered.

‘Insurers are [also] very clear that patients can only have access to doctors who are recognised by them [the insurer] and are not able to top up their fees to see a clinician of their choice.’


Freedom of choice

The undue influence being exerted on doctors and patients by medical insurers was roundly condemned at this year’s BMA annual representative meeting.

In a unanimously backed motion, the BMA criticised the restrictions on patients being able to access a consultant of their choice, the disempowerment of GPs in the referral process and the use of recognition and derecognition against doctors in the private sector.

The PPC has said that it will continue to meet with medical directors of the insurance industry to make their concerns known and push for a fairer deal for doctors and patients alike.

Responding to the concerns outlined by doctors, a spokesperson from the Association of British Insurers said that medical insurers would always seek to make policies as clear and transparent as possible.


You’re not always aware what is covered and what isn’t – either as the doctor or as a patient.

Competitive market

They added that the open referrals process was designed to keep premiums competitive, while patient safety was part of the decision-making process for recognised clinician lists.

They said: ‘Private medical insurance is a competitive market, with various products available to cater to different needs and budgets of customers. Some policies may specify specialist consultants or hospitals in an area. This will depend on individual insurers, and sometimes different policies provided by the same insurer. This can help keep premiums competitive while ensuring patients get the most appropriate and convenient treatment.

‘Insurers continually review the medical specialists they use, with patient safety and outcomes part of the decision process. In occasions when the patient wants to use a medical specialist other than the one specified by their insurer, the patient should discuss this with their insurer.’