Please read the rules in your Guide under the ´Cancer Care´ section for more detailed information and any restrictions to cover.
Cancer Care/advanced cancer drugs must be included within your Policy/Group Scheme/selected as an option for cover to be provided. Any Shared Responsibility (co-payment)/excess or maximum annual limits will apply if applicable.
If you do not have cover for premium hospitals please refer to your Guide which confirms the hospitals that are excluded from cover.
These scenarios should be read in combination with your Policy/Group Scheme rules and chosen level of cover.
Please note that example questions are set by industry standards and are not based on any individual customer scenario. Remember that all claims must be pre-authorised; WPA will be in contact with the specialist in charge of your treatment to obtain a full treatment plan including time scales.
Depending on the type of treatment prescribed by your specialist, you will have a choice of where you receive the treatment - as a private patient as an in-patient or day-patient in hospital, as an out-patient or at home. Customers may also choose to have their treatment as an NHS patient and can then claim the NHS hospital cash benefit of up to £6,000 per person per Policy/Group Scheme year (£30,000 for Enterprise Health).
Customer A has been with WPA for five years when she is diagnosed with breast cancer.
Following discussion with her specialists she decides:
Will her Policy/Group Scheme cover this treatment plan, and are there any limits to the cover?
WPA would cover her surgery, radiotherapy and chemotherapy provided that these are active established treatments given with curative intent. The breast reconstruction would be paid for 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 timescale. Follow up treatment by her specialist would be covered for up to 5 years. 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. 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 antibiotics.
Will her Policy/Group Scheme cover this treatment, and are there any limits to the cover?
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. 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.
Five 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:
We would need her oncologist to send us a detailed treatment plan including the type of drugs to be used. Standard EMA licensed chemotherapy is covered in full. Treatment with drugs classed as Targeted/Biological Therapies which 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 seven 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.
Will his Policy/Group Scheme cover this treatment plan, and are there any limits to the cover?
Yes. This treatment MUST be pre-authorised. We will pay for one complete bone-marrow transplant per lifetime for each individual person covered by the Policy/Group Scheme if it is not readily available to them on the NHS.
We must agree to cover this 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 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 five years to see whether the cancer has returned.
Follow up check-ups would be covered for up to five years.
Customer C has been diagnosed with cancer. Her Policy/Group Scheme has a limit and she decides to commence private treatment.
What help will be available if the Policy/Group Scheme limit is reached and she needs to transfer into the NHS?
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 to arrange a timely and smooth transition into NHS care, ensuring no 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.
Will his Policy/Group Scheme cover this, and are there any limits to the cover?
We do not cover 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 contribution to the hospice.