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Limits of cancer coverage in private medical plans still unclear

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Elements of cancer cover and care are confusing to corporate decision makers selecting medical plans, as well as claimants covered by those plans, according to research from Mercer.

The report, Covering Cancer, in association with Oliver Wyman and HCA International also found providers’ discretion on coverage causes claimant complaints that decisions aren’t truly fair.

It also criticised cancer coverage policies of private medical plans for lagging behind the advancement of drugs and treatments, a delay that was creating further ambiguity and claimant dissatisfaction The report analysed policy information from 11 UK Private Medical Insurers (PMI) providing cancer cover to the corporate and private healthcare market. The report says that because PMI providers reserve the right to exercise discretion regarding certain claims, some sufferers feel that claims are declined unfairly. This is becoming more of a problem because new cancer therapies which fall outside traditional provider classifications are entering the market. For example, more patients are being offered long-term treatments, which aim, not to cure, but to slow the spread of the disease and prolong, or improve, the quality of life by easing symptoms.

Many of the problems with declined claims arise from how cancer treatments, eligible for coverage, are defined in provider documents. Some charities, for example, argue that treatment intended to slow the spread of the disease is “active treatment” so should be covered by PMI providers. PMI providers have to set their written rules at a given point in time and then determine their stance in respect of new treatments as they become available. This can be troublesome to claimants who may experience delays before they have clarity regarding what precisely is and isn’t covered, and may find that that some treatments are not covered that perhaps should be. The report also notes that efforts to improve transparency over what is and isn’t covered has had some success in the corporate market but there remain challenges for both purchasers and users alike in understanding how real life situations will play out in relation to the available choices and the written rules.

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