Private medical insurance policies lack clarity on cancer care

Cancer insurance policies offered by PMI providers have been criticised for lack of clarity and ambiguous terminology that may result in people being excluded from treatment, according to a study by Mercer and Cancerbackup, the cancer charity.

The study, ‘Covering Cancer: Survey of Corporate healthcare / Private Medical Insurance (PMI) providers', surveyed 11 major UK PMI providers to assess each of their main corporate medical insurance policies for cancer, including issues such as scope and standard of cover, treatments included within the cover and limits on cover.

According to Steve Clements, principal in Mercer's health & benefits team, "One in three people in the UK will be diagnosed with cancer at some stage in their life. Some of the new and sometimes expensive treatments which are now emerging are, as yet, unavailable through the NHS. So understandably, cancer cover is an area of focus for companies purchasing private healthcare.

"PMI providers are using it to differentiate themselves from their competitors. Whilst there have been substantial improvements, there is continued ambiguity over what is and isn't covered in some cases. Eligibility rules for chronic conditions, for example, can sometimes mean cancer treatments will effectively be excluded or cut short. Transparency and clarity must be improved."

Mr Clements continued: "New therapies are coming into the market. Some of these will lead to long-term treatments where the goal is to slow the spread of the disease, prolong life or improve the quality of life by easing the symptoms, rather than to cure. PMI providers must be clearer about whether or not these will be covered in their policies."

The report highlights that, while PMI providers have a similar view on how cancer care should be covered in the context of private medical insurance, the cover varies from one PMI provider to the next. For example, there are differing views on the funding of high cost monoclonal antibodies or biological therapies such as Herceptin, Avastin and Velcade.

Most PMI providers who completed the questionnaire said that they did not cover palliative care or treatment for terminal cancer. Some PMI providers, however, were less specific. Rather than ceasing cover when cancer reaches a certain stage, they apply eligibility rules to specific cancer treatments, so they fall under the chronic rules and are therefore not covered. The report noted that most PMI providers did not actually define cancer as a chronic condition.

The report also notes that PMI providers often use the phrase ‘active treatment' for cancer to govern their decisions on cover for a particular course of treatment. This allows certain treatments to be covered for very specific reasons (e.g. radiotherapy to shrink a tumour) but others to be excluded (e.g. hormone therapy of on-going control of spread and symptoms). The term active treatment is often only loosely explained in the policy document. Mercer also notes that the term is not currently recognised by the Association of British Insurers (ABI).

According to Derryn Borley, head of Cancer Support Services at Cancerbackup, "It's not imperative to buy the most expensive cover but there should be total clarity on what is and isn't covered. There should be clear and seamless mechanisms in place to transfer the treatment from private care into public care and back into private when necessary. Ultimately the patients' treatment should not be compromised. PMI providers' decisions on whether certain treatments are covered or not are taken on a case by case basis. There is a need to improve the openness and transparency around the extent of the coverage for cancer. People need to fully understand the term ‘Active Treatment' when it's used.."

According to the report, companies looking to provide their employees with an uncompromised level of cancer cover should consider the AXA PPP Healthcare ‘Corporate Healthcare, VIP & Executive Plan' with the optional enhanced cancer cover, the BUPA Premier Insurance Policy and the PruHealth Comprehensive policy. These policies meet the ‘Gold Standard'. The gold standard of cancer cover is defined by Cancerbackup as the funding of all treatment intended to affect the growth of the cancer by shrinking the cancer, stabilising it or slowing the spread of the disease, as well as relieving symptoms.

"There is a price attached to the ‘Gold Standard' and so other PMI policies are all viable options for corporate healthcare plans in the right scenario" commented Steve Clements, "but the purchaser should be aware of the lesser levels of cover for cancer care through these policies.

"It's vital that companies seek clarity from the PMI provider on how cases will be managed when employees reach the limit of their cover but still need treatment, particularly if this treatment is unavailable through the NHS. Most of the PMI providers we surveyed do have some flexibility around the cover they provide in this area, and so may be able to offer tailored solutions so that clients can strike the right balance between comprehensive cover and affordability."