Labour pains
Labour pains
Former Health Insurance editor Moira O’Neill looks at how PMI providers are struggling to deal with the complex issue of pregnancy
Moira O’Neil is deputy editor of Money Observer. She is also a former editor of Health Insurance
The reputation of NHS maternity units has taken a battering recently, with several television documentaries highlighting shortages of midwives and poor maternity care. The latest was from Channel 4’s Dispatches programme which investigated a maternity unit in North London and alleged serious problems. It is possible that this type of coverage will lead to increased demand for private maternity treatment. But at present, the likelihood is that a prospective mother’s private medical insurance (PMI) policy will not cover her for a private birth – in fact, it probably will not cover her for anything related to pregnancy.
Many employees with PMI believe they are covered for scenarios for which they are not. I thought I did not fall into this category since, having reported on the health insurance industry for a couple of years, I was armed with inside knowledge.
I was comfortable with the fact that normal pregnancy is rarely covered by a PMI policy. I knew also that PMI does not cover in-vitro fertilisation. However, when my own pregnancy became complicated by a rare pelvic condition called symphysis pubis dysfunction, I was surprised to find out that my company PMI policy – which is with one of the major health insurers – would not cover me for the necessary physiotherapy.
To get physiotheraphy on the NHS I was told I would have to wait six weeks – what seemed like an awful long time to wait in pain. So I stumped up the money for private treatment, spending much more than the annual policy premium in the process. It was irritating, but, unlike some consumers, I understand the essence of insurance and why such exclusions are necessary.
Insurance is designed to protect my financial wellbeing in the case of unexpected loss. The purpose of PMI is to guard against unforeseen medical needs of an acute nature. As I had planned the pregnancy, I had prior knowledge to which the insurer was not party.
If every normal pregnancy was paid for, premiums would have to be set at a level which would make it impossible for many people to protect themselves against much less routine events such as open heart surgery.
Jan Lawson, managing director of the Private Health Partnership, the intermediary based in Baildon, West Yorkshire, says: “There shouldn’t ever be any insurer that excludes unrelated treatment just because you are pregnant. But excluding physiotherapy for a pregnancy-related condition is usual practice. The insurers’ attitude is that pregnancy is self-inflicted and something that the NHS is particularly good at.
“It’s fair to say that the amount of cover has been reducing in this area over the last few years. This is due to the growth in elective caesareans. Insurers have found it difficult to distinguish between truly medically necessary caesareans and ones which the patients have chosen. There have been so many disputed claims. As a result, insurers are either tightening up or totally withdrawing the cover for maternity.”
In any analysis of maternity cover, you have to acknowledge the key difference between someone wanting to use the private sector from the beginning of their pregnancy through to birth and someone having a complication and then choosing to go privately (for example requiring a caesarean). Few UK insurers now cover normal pregnancy. In fact, the international arena is the main place you will find cover for normal pregnancy.
According to Lawson, Carte Blanche, the top of the range contract created by Clinicare, the former PMI provider now owned by Groupama Healthcare, used to cover normal pregnancy but now does not. Some other top-end policies offer such cover. Julian Ross, head of policy communications at Standard Life Healthcare, says: “We offer private maternity cover on our top-of-the-range plan, Primecare Gold. It is also now available as an option on our new business healthcare product which is open to SMEs from 1 to 249 employees.”
The cover on both is the same and comprises the following: private ante-natal and post-natal care, including specialist consultations, diagnostic tests and investigations, and delivery for a normal pregnancy in a private hospital or the private patient unit of an NHS hospital. There is a maximum limit of £3,000 for this benefit and the mother has to have been insured with Standard Life Healthcare for two years before they can start claiming.
Ross continues: “I think it’s important to say that the take-up of this benefit is quite low, probably for two reasons. First, it’s quite expensive because people want this option specifically with the intention of claiming on it at some stage [in other words it is about when this will happen rather than if].
“Second, access to private maternity care is actually quite restricted. In fact, there are really only a few private hospitals, primarily located in central London, where this type of care is available.”
Dr David Costain, medical director of AXA PPP healthcare, an insurer, says: “Private obstetrics is getting quite rare because the doctors have to pay the litigation procedures. Damaged baby claims can be millions. Insurance premiums from the medical malpractice side are astronomical.
“Not all maternity units offer private facilities, although the Portland Hospital in London is still doing them.”
A normal delivery at London’s Portland Hospital now costs £3,300, while an emergency caesarean section will set you back £4,450, and that is just for the first 24 hours. Additional nights start from £995.
Cover for pregnancy complications is a complex area. In 2002, AXA PPP healthcare took the high profile decision to cease providing cover for caesarean sections in its PMI policies. The insurer believed it was increasingly difficult to distinguish between medically necessary sections and sections that are a personal or lifestyle choice, and as an insurer it covered risk not choice.
More than one in five births (22%) in the UK are now by caesarean section. In 1970 it was 11%; in the 1950s 5%. The World Health Organisation recommends that the caesarean rate should be 10% of all births.
Dr Costain of AXA PPP explains the decision not to cover caesareans: “We haven’t ever paid for ordinary maternity. Our standard PMI policy doesn’t include normal maternity. We used to cover unexpected event in pregnancy, such as emergency caesareans. But we changed that because people started having elective caesareans. We didn’t have any way of policing it. However, there are a few genuine unexpected complications of pregnancy that we will pay for.”
Lawson says UK insurers take three different approaches to paying for maternity-related claims. The first group cover “pregnancy complications” but do not define them in the literature. These include BUPA, Norwich Union Healthcare and Standard Life Healthcare.
The second group restricts cover to specified obstetric procedures. The literature says something along the lines of “Nothing is covered except XYZ”. PruHealth and AXA PPP take this approach.
Finally there are the insurers who give no cover at all. These include BCWA, WPA and Exeter Friendly Society.
Where cover for maternity is offered, it is on the basis that you are not pregnant when you join the scheme. There is therefore usually a 10 to 12 month waiting period.
Lawson concludes: “If someone is taking out PMI, is likely to become pregnant and there is a family history of pregnancy complications, then perhaps they should veer towards BUPA, Norwich Union and Standard Life Healthcare.”
Pregnancy and PMI – the standard insurer stance
BUPA’s standard scheme rules on pregnancy and childbirth does not pay for treatment for, or any condition arising from, pregnancy, childbirth or termination of pregnancy. This includes:
- pre-eclampsia (a condition in which elevated blood pressure, fluid retention and the presence of protein in urine occurs in late pregnancy)
- eclampsia (a seizure or coma during pregnancy)
- pregnancy induced hypertension (raised blood pressure during pregnancy)
treatment of an embryo or foetus
Exception 1: BUPA pays for eligible treatment of the following conditions:
- miscarriage or when the foetus has died and remains with the placenta in the womb
still birth - hydatidiform mole (abnormal cell growth in the womb)
- foetus growing outside the womb (ectopic pregnancy)
- heavy bleeding in the hours and days immediately after childbirth (post-partum haemorrhage)
- afterbirth left in the womb after delivery of the baby (retained placental membrane)
complications following any of the above conditions.
Exception 2: BUPA also says it may pay for eligible treatment for delivering a baby by caesarean section when the mother has been a member of the scheme for at least 12 months before the delivery. However, it stresses that it requires full clinical details from the mother’s consultant before it can give our decision.
Health Insurance Magazine 05 October 2007