Medical Insurance

In the past all proper medical care was provided by independent private doctors, except for whatever was available from the charity hospitals ‘for the poor’! The contract of care was specifically directly between the doctor and their patient, with the patient being fully responsible for the doctor’s fees in full.

Nowadays the majority of patients receiving private medical care have actually got private medical insurance, which gives them access to consultant delivered care in decent, clean, safe private hospitals.

However, fundamentally, the relationship between the doctor and their patient has not really changed: any doctor seeing a patient still has a specific duty of care to that patient, and a contract of care exists between the patient and the doctor, with the patient still being responsible for their own fees. With most insurance companies, doctors are now encouraged to bill the insurance company rather than directly billing the patient. The insurance company will then pay the consultant (and the hospital) fees – even though there can frequently be delays of several months in this.

Some of the better insurance companies cover consultants’ fees in full. Some will cover part but not all of the fees. In this instance this leaves a shortfall, and it is then up to the patient to pay this difference directly to the consultant. It should, however, be noted that this ‘shortfall’ is actually an Insurance Benefit Shortfall, i.e. it means that your insurance policy might not actually be good enough or sufficiently comprehensive to cover all of the standard medical fees.

What is worrying, however, is that some insurance companies are increasingly trying to forcibly cap consultants’ fees, even actively trying to persuade patients not to see ‘expensive’ consultants and instead diverting patients to the cheaper consultants.

The tick box Argos catalog style approach to medical care is dangerous!

Some insurance companies claim to know which are the best consultants. This is highly questionable at best! Who is the ‘best’ knee surgeon? … is it the busiest, is it the fastest, is it the nicest, is it the most famous, is it the cheapest??? The answer is probably ‘none of the above’. However, of all of them it is least likely to be the last one – the cheapest! Indeed, those consultants who are less busy and who have a less successful practice because they either have less of a reputation and/or less experience are precisely the ones most likely to bow to the pressures imposed by bullish insurance companies and agree to charge reduced fees in return for patients actually being actively directed their way.

A detailed report from the Office of Fair Trading into healthcare in the private sector, published in December 2011, stated very clearly that


The ‘gold standard’ factors that should influence a patient’s decision as to which consultant they might want to go and see should be:-

  • word of mouth (from friends/family, based on their previous experiences)
  • specific advice from a GP
  • specific advice from a physiotherapist
  • information about the consultant’s experience and specialist expertise that might be available from sources such as websites.

GPs and physios have their patients’ best interests absolutely at heart, and they tend to spend years developing a knowledge of which local consultants are best for what particular specific conditions, based on outcomes, patient reported satisfaction, complication rates and communication/service. Insurance companies do NOT have this same level of information or knowledge and make their decisions based entirely on cost.

To put this in perspective, most people think nothing of spending £20,000 or more on a car, which they change every few years. The difference between most consultants’ fees for those in proper fully independent practice vs those consultants signed up to the insurance companies’ capped fee rates is rarely more than a couple of hundred pounds at most. It is very hard to understand why some people might seemingly put so little value into having the best consultant for their knee problem rather than trusting some profit-orientated FSA regulated insurance company to truly make the best decision for their health.

To put this in further perspective, the total cost for an operation like a knee replacement in the private sector can be anything from £10,000 to £15,000. This includes the hospital fees, the surgeon’s fee and the anaesthetist’s fee. However, the surgeon’s fee for the operation is likely to be somewhere in the region of about £1000 to £1500 – ie the surgeon’s fee makes up less than 10% of the overall cost of the operation! What should also be noted is that the insurance companies pay the private hospital’s fees in full (because private hospitals tend to be part of large groups that have big negotiating power/leverage) … but it is the consultants who are not in a position to fight back who are squeezed!

It should, however, be noted that there have been cases brought to the FSA where patients have insisted on being reimbursed by their insurance company for seeing the consultant of their choice and the FSA has ruled in the patients’ favour!

Not all consultants are the same, and at the end of the day, quite simply – you get what you pay for … one would seriously question the sense of picking a builder simply from the Yellow Pages; likewise, should you really trust your life/limb to someone without first knowing that you’re seeing the right/best surgeon for the job? Whether you choose to trust your own judgment from doing your own research, whether you choose to trust the proper medical opinion of your GP or your physio, or whether you’re happy for an insurance company to dictate to you who you can or can’t see, and potentially have them simply send you to someone who’s just ‘cheap’ is something that’s entirely your decision.

Please note that we do offer a comprehensive revision surgery service!

For further information from the Federation of Independent Practitioners Organisations CLICK HERE.

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Written by Mr Ian McDermott Consultant Knee Surgeon, London

Last updated 4-5-17