Compensation paid to policyholders after operations refused despite consultant recommendations
Complaints about AXA PPP have almost doubled since 2015 and those against Bupa have risen 10%, The Times reported yesterday.
The article also outlined a case in which AXA refused to pay the full cost of a knee operation despite a consultant recommending it and clinical studies showing that it is effective.
Bupa, meanwhile, refused to fund a heart operation involving an implantable cardioverter defibrillator - also recommended by a consultant - despite it fitting Nice guidelines, according to the broadsheet.
The Financial Ombudsman Service (FOS) ruled in favour of both policyholders and told the insurers to pay compensation.
According to AXA PPP healthcare, latest figures show only a small proportion (around 0.02%) of its members complained to the FOS and in around 75% of cases the service ruled its in its favour, it said.
"We do our best to treat customers fairly and, if they feel we've got something wrong, investigate their concerns," said a spokesperson for the PMI firm."We aim to provide our members with healthcare cover that provides them with access to safe and effective care. We support evidence-based practice and work with medical professional bodies to help identify and promote it.
"We also believe we should play an active part in protecting our members' health and safety and will challenge specialists' practices we consider to be inappropriate, unsafe or unproven."
Bupa told COVER that in 2014 the Competition Markets Authority (CMA) rejected claims by the Federation of Independent Practitioner Organisation (FIPO) that health insurers were acting improperly.
"FIPO's claims are old and were thoroughly investigated and rejected by the CMA in 2014," said a Bupa spokesperson. "The CMA found that there were no problems with the behaviour of health insurers towards consultants. We disagree strongly with FIPO's claims.
"Health insurance gives people fast access to high quality treatment and care. We cover millions of treatments every year for our customers and work with 22,000 private consultants who meet our quality, customer service and cost criteria. We offer our customers a choice of consultants to see depending on their policy. Our customers pay for doctors' fees through their policies, so we work to make sure they pay a fair price.
"We don't overrule a consultant's recommendation. We will only pay for treatment that's in line with medical best practice. Because all surgery carries a risk, our medical reviews protect our customers from inappropriate, unnecessary or unproven surgery."
Bupa said less than 1% of its 2.2 million customers complain each year and 1% refer their complaints to the FOS, it said.
Bupa also told The Times that due to a change in FCA regulation in 2016, more people can now take complaints to the FOS, which drive an increase in the number of Bupa complaints made in 2018 compared to 2015.
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