100% health cover claim is deceptive

Judging by the advertisements in your informative journal and the letters and telesales calls which I currently receive, mutual top up business is big business.

However, let the buyer beware when taking out these policies because they have their own version of the truth and the English or French language; where “top up” and “100% cover” are woolly terms indeed.

I was informed by my insurers, one of which advertises with you, they will top up the amounts paid by the caisse primaire d’assurance maladie (Cpam).

Sadly, that is far from the truth. Having been insured with the same company since 1998, I have had no claims except for some low value generic drugs for tension control and a pair of spectacles.

Last July my ophthalmic doctor said I should have an operation on both eyes to remove cataracts. He carried this out at our local hospital in October.

I passed the paperwork, the Facturation Destinée à l’Assurance Maladie Complémentaire, to my insurers and, although some of the honoraires were paid by Cpam, a balance of some €430 were reste à charge pour l’assuré – for the insured person to pay.

The insurer’s Tableau de Garanties Actualisés table of guaranteed repayments clearly states my cover includes, under the heading honoraires, 100% payable.

Naturally I expected to recover my expenditure. Wrong. This 100% refers to a tariff imposed by somebody or other.

I pay €80.55 per month for my insurance which, since the fall of the pound, is now about 10% of my state pension.

Let the buyer beware. I am considering cancelling my policy and will continue to argue my case. Does anyone out there have any advice?

R.J. Hubbard
Auzon 30500

Larry Fulton, of Exclusive Healthcare, says insurance cover is more complicated than just the 100% figure, which applies to the base tariff for the appointment, medicine or procedure. Some policies give 150%, 300% or 500% of this base tariff.
Some consultants cost more than the base figure and the government imposes restrictions on repayments. For example, you say the ophthalmic doctor suggested treatment which may mean you went to the consultant directly and not through the medecin traitant. Going off the official treatment route incurs a penalty “charge” which insurers are forbidden to pay. Contact your insurance provider for an explanation why the cost is not covered.