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Private Fees - Handling insurance report requests

Dr Rob Rosa provides extra insight into an area of non-NHS work almost all GPs undertake for insurers.

Dr Rosa: 'The full general practitioner report attracts the highest fee, but if it is returned late, expect a reduced fee' (Photograph: Author image)
Dr Rosa: 'The full general practitioner report attracts the highest fee, but if it is returned late, expect a reduced fee' (Photograph: Author image)

This subject gets little coverage in medical education, yet disclosing the patient medical record to insurers has profound implications for the patient in terms of being accepted or declined for cover and determines the level of protection they can obtain.

Three key areas
Insurance requests to GPs cover three key areas: income protection, life cover and critical illness.

Income protection policies provide payments should someone become unable to work due to accident or sickness after a period of time, from say, four to 52 weeks.

Life cover pays out on death. The commonest reason for taking out a policy is to protect an outstanding mortgage.

Critical illness pays a lump sum following diagnosis of certain life expectancy impairing events (for example, MI, significant cancers, MS) although the patient must have honestly declared their past medical history and meet certain criteria. These policies sometimes have part payments where the effect of a condition is recognised but its severity does not meet a full benefit.

Speediness and accuracy
The insurer's underwriter is responsible for deciding the premium rate and needs a swift return of information to make the correct decision for patient and insurer. The insurance policy is often required to get a mortgage so delays can be problematic for patients.

GPs sometimes complete request forms incorrectly, send information that is not detailed enough, misses key facts or contains third party references.

Here the danger is breaching confidentiality or disclosing information not required, such as predictive genetic testing. There is a BMA/Association of British Insurers (ABI) agreement not to request or provide this information.

Gold standard
The general practitioner report (GPR) is largely seen as the gold standard and attracts a fee of £80 to £100 depending on insurer. In the spirit of the BMA/ABI agreement, reports must be honest and factually correct: the underwriting decision will apply for the duration of the policy and the premiums are not revisited if the patient's health changes. A GPR is not a simple printout of the patient's record.

Underwriters use epidemiology, survival data and actuarial calculations for each condition to interpret risk and assess premium levels. Conditions are rated based on severity, time from diagnosis or treatments received or anticipated. If the GPR is incorrect or has information missing, the insurer may decide to postpone acceptance of the risk or decline to insure it.

Ratings are applied as a percentage or per £1,000 of cover. For instance, a plus-50% rating for asthma may reflect a rise of a few pounds a month, whereas a cancer patient just in remission may attract a substantial loading of, for instance, four to eight times - an extra £4 or £8 a year for each £1,000 cover requested.

To avoid premium rises patients have been known not to disclose information to the insurer. This can happen for genuine reasons, such as being unaware of the importance of disclosing everything, genuinely forgetting about a condition or trivialising a condition by not realising its importance.

Insurers try to mitigate this by ensuring their application forms only ask for relevant information and use plain English. If they do not comply with industry standards, the Insurance Ombudsman may rule in the patient's favour.

Where an illness has not been disclosed, the GP has an obligation to prepare a factual report irrespective of the possible financial impact on the patient.

Insurers are bringing out new methods of evidence gathering to streamline this process and reduce the GPR turn-around time. Targeted reports are now used to specifically request information on a given set of symptoms or a set condition. Other methods include telephone interviews with the patient and requesting the entire medical record in a 'subject access report'.

Top tips
  • You must check computerised printouts of patient records for accuracy and to remove third party references.
  • GPs are obliged to notify the insurer of a condition if your patient has not done so. It is better to get the right information assessed at the outset than to deal with an angry widow whose house is being repossessed when the claim on the couple's joint mortgage cover is refused because the late husband omitted to disclose a heart attack which predated the policy.
  • Musculoskeletal conditions are often excluded from income protection policies even if they have only happened once. Do not underestimate the importance of time off work for back pain.
  • Vague or unexplained neurological symptoms invariably lead to difficulties in obtaining insurance, increases in their premiums or certain conditions being excluded.
  • Do not disclose predictive genetic testing or STI testing.

Symptoms and sick leave
The consequences of non-disclosure for the patient can be severe. It can invalidate a policy if a claim is made, which when investigated, finds an illness that pre-dates the policy.

With income protection it is important to disclose all symptoms however small, especially musculoskeletal pains. A single entry of back pain in the medical record could lead to back problems being excluded from the cover.

Vague neurological symptoms trouble underwriters who have to determine whether they reflect a condition, such as MS, that may evolve at some point later in the client's life.

The insurance industry is looking at streamlining the process of gathering evidence to save time and costs. The full GPR attracts the highest fee for GPs but if it is returned late, expect a reduced fee. Targeted reports and subject access reports command a much lower fee reflecting the reduced workload expected from the GP.

  • Dr Rosa is a GP in Salisbury and chief medical officer for reinsurers Swiss Re in London

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