The benefits provided by PMI plans

Benefit Tables are produced by an insurer to inform the subscriber of the benefit/cover offered and the maximum amounts they are prepared to pay on the subscriber’s chosen scheme. The Benefit Table will vary slightly from Product to Product, and Insurer to Insurer, but for most general Private Medical Insurance Schemes benefits fall under the following categories:

Hospital Charges

These would include charges for:

• Accommodation and Nursing
• Theatre Fees
• Drugs and Dressing
• Consultations, Pathology, Radiology and Physiotherapy, and
• Prosthesis Fees for In-patient and Daycare treatment.

As long as subscribers choose to receive treatment in the correct scale of bed for their scale of cover then usually they will receive a full refund on the above charges.

Specialist Fees

This consists of benefits towards the fees charged by surgeons and anaesthetists for performing surgical procedures.

Surgical procedures are usually classified according to complexity and time involved i.e. Minor, Intermediate, Major Plus and Complex Major Operations. Limits are set on the amount paid to surgeons and anaesthetists for each operation.

Procedure classifications are set to provide a pricing guideline for specialists thereby preventing overcharging.

Some of the most frequently performed procedures in the private sector were:

• Wisdom Teeth Extraction
• Laparoscopy
• Hysterectomy
• Hernia Repair
• Varicose Vein
• Tonsillectomy
• Hip Replacement
• Haemorrhoidectomy
• Injection into joints
• Heart by-pass
• Knee Replacement

Outpatient Services

This provides fees for outpatient treatment e.g. consultations, pathology, radiology and/or physiotherapy. This benefit would normally have a maximum benefit amount per year and in some low cost schemes may even be excluded.

In some cases outpatient treatment (such as diagnostic tests) have been excluded altogether. In most cases, particularly on budget plans, outpatient benefits will only be paid following GP referral and in some cases outpatient treatment will only be covered if it relates to recent in-patient treatment.

Providers may have different definitions for outpatient services. Some providers offer a full refund for diagnostic outpatient services but will impose annual benefit limits for consultations and therapies. Therefore, again, it is vital to check all terms closely.

Complementary Medicines

Recent developments have seen further recognition for treatments known as complimentary medicines, such treatments would include osteopathy (manipulation of bones and muscles to treat most symptoms) and homeopathy (treating the illness by strengthening the immune system with mild quantities of the cause).

Treatment by a Chiropractor or Osteopath, cover pregnancy complications and travel cover for medical expenses. Precise terms will vary between plans. Indeed most GPs will refer patients on to such practices and some hospitals will have resident complimentary medicine specialists.

Standards are also improving, a good example being Osteopaths who train for as long as a mainstream doctor and must become registered with the governing body the General Council of Registered Osteopaths.

These advances have led to the inclusion of these treatments on many PMI plans and their popularity has increased.

Other Benefits

Other benefits listed on a benefit table may include set benefit amounts per year for:

Home Nursing

Home nursing is offered by most budget plans. If it is required then the cost (subject to any limits or restrictions) will be covered under the policy. However it must be remembered that PMI policies do not cover chronic condition so if an acute condition becomes a chronic condition payments for home nursing will cease. Therefore most claims for home nursing do not last very long. Prime Health says that nursing only accounts for 0.1% of total PMI payments and that typically claims last for one or two weeks.

Private Ambulance Charges

Private ambulance is covered by around half of all budget plans. Apart from transport to hospitals, private ambulances are also used for transfers between hospitals. Caps are incorporated and may prove to be insufficient in some cases.

Cash Benefit for NHS In-patient treatment provided by a specialist.

NHS cash benefits per night are also available on some budget plans. If the policyholder opts for treatment in NHS bed instead of in a private hospital, a nightly cash benefit is paid to the policyholder. In addition, many providers will pay any NHS cash benefit for emergency overnight stays in hospital.

This option gives the policyholder extra freedom. In many cases NHS treatment will be opted for when emergency treatment is required, as this extra cash will pay for additional costs such as babysitters or travel.

Some brokers will say that in non-emergency situations cash benefits give an additional incentive not to opt for private healthcare, going against the whole ethos of PMI. Although in most cases the NHS cash benefits are much lower than that of private healthcare costs, therefore providers usually save money.