Please read the following information in conjunction with your Guide, Benefit Schedule and Certificate of Registration (or Certificate of Participation) which together contain the terms and conditions applicable to your Policy/Group Scheme, including details of any exclusions, benefit limits or restrictions on hospital choice that may be applicable.
Cancer Care must be included as standard or selected as a benefit under your Policy/Group Scheme for benefit to be provided. Any Shared Responsibility (co-payment)/excess or maximum annual limits applicable will apply.
Please remember that all claims must be pre-authorised; WPA will contact the specialist in charge of your treatment to obtain a full treatment plan. Depending on the type of treatment prescribed by your specialist, you will have a choice of where you receive treatment (subject to the applicable terms and conditions) as a private patient, as an in-patient or day-patient in hospital, as an out-patient or at home. If your Policy/Group Scheme includes benefit for NHS Hospital Cash Benefit then you may also choose to have your treatment as an NHS patient and claim the cash benefit.
Please note that the example questions are set by industry standards and are not based on any individual customer scenario.
Customer A has been with WPA for 5 years when she is diagnosed with breast cancer.
Following discussion with her specialists she decides:
Is this treatment eligible for benefit?
WPA would provide benefit for her surgery, radiotherapy and chemotherapy provided that these are active established treatments, within the EMA therapeutic licence, given with curative intent. Benefit is available for breast reconstruction provided that it took place within a reasonable period, usually 5 years. We would need a treatment plan for this, setting out the procedures and the timescales. Follow up treatment by her specialist would be covered (see your guide for any timescales that may apply). Hormone treatment prescribed by her GP would not be covered.
During the course of chemotherapy Customer A suffers from anaemia. Her resistance to infection is also greatly reduced.
Yes, as long as it is medically necessary as part of active cancer treatment. Please note that emergency admissions to either a private hospital or critical care unit are not covered.
Despite the injections to boost her immune system, Customer A develops an infection and is admitted to hospital for a course of intravenous antibiotics.
Yes, her admission would be covered. Generally she does have a choice where she receives treatment, based on what her specialist recommends - in hospital as an in-patient, day-patient and out-patient or at home. Please note that emergency admission to either a private hospital or critical care unit are not covered. If she chooses to have treatment in an NHS hospital she could claim NHS hospital cash benefit.
6 years after Customer A´s treatment finishes, the cancer returns. Unfortunately it has spread to other parts of her body. Her specialist has recommended a treatment plan consisting of:
We would need her oncologist (specialist) to send us a detailed treatment plan including the type of drugs to be used. Standard EMA licenced chemotherapy is covered in full. Benefit for treatment with drugs classed as targeted biological therapies is available providing they are:
Drugs given to maintain remission of cancer, where the drugs are used to maintain good health and there are no symptoms, would not be covered.
Customer B has been with WPA for 7 years when he is diagnosed with cancer. Following discussion with his specialist he decides to undergo a course of high dose chemotherapy, followed by a stem cell (sometimes called a ´bone marrow´) transplant.
Yes. This treatment MUST be pre-authorised. We will pay for 1 complete bone marrow transplant per lifetime for each individual person insured by the Policy/Group Scheme if it is not readily available to them on the NHS.
Authorisation must be obtained and granted before the bone marrow or stem cell treatment starts. We reserve the right to ask for a second clinical opinion as to the evidence of efficacy of the proposed treatment for each particular case.
All costs related to a donor are not eligible.
Note: If the Policy/Group Scheme has a maximum annual limit this will apply.
When Customer B´s treatment is finished, his specialist tells him that his cancer is in remission. He would like him to have regular check-ups for the next 5 years to see whether the cancer has returned.
Follow up check-ups would be covered (see your guide for any timescales that may apply).
Customer C has been diagnosed with cancer. Her Policy/Group Scheme has a limit and she decides to commence private treatment.
If the Policy/Group Scheme has a maximum annual limit then this will apply. Otherwise, there are no monetary benefit limits on cancer care as a private patient. If a single aspect of her treatment falls outside the benefit provided by the Policy/Group Scheme and she needs to split her cancer care i.e. have some treatment on the NHS while continuing to have other treatment privately, we will work with Customer C and her oncologist (specialist) to arrange a timely and smooth transition into NHS care, ensuring no clinical detriment to her or her ongoing treatment. Whilst it may sometimes be feasible for the NHS to provide a single aspect of treatment, but for all other cancer care to continue to be given on a private basis, in our experience the NHS may request the patient be transferred to the NHS for the totality of their cancer treatment.
Customer D would like to be admitted to a hospice for care aimed solely at relieving symptoms as no further treatment is appropriate.
We do not provide benefit for end of life care (sometimes referred to as terminal care) i.e. treatment that concentrates on controlling pain and other symptoms when the patient is near or approaching the end of life and active treatment for the causative disease is no longer considered effective or appropriate. Where a patient is admitted to a hospice we will make a donation to the hospice.