Preventive medicine and health check-ups in your health insurance policy

Imagine you have been living in Marbella for two years, you have just settled in and you want to have a full blood test, an electrocardiogram and a blood pressure check. You call your health insurer and they tell you that none of that is covered until next year. Nobody had explained this to you. That is exactly what happens with the preventive medicine and health check-up benefit, and it happens far more often than you might think.

What exactly is preventive medicine in a health insurance policy?

It is the range of check-ups, tests and vaccinations that your insurer covers before you fall ill, with the aim of detecting problems early or avoiding them altogether. We are not talking about visiting the doctor because something hurts — we are talking about going precisely when you feel perfectly well.

Put like that, it sounds very comprehensive, but what each policy actually covers varies considerably. Some include a general medical check-up, others only certain specific tests, and others place such tight restrictions on use that the benefit ends up being little more than window dressing. That is why it is well worth understanding what to look for before taking anything for granted.

What do people think is covered that actually is not?

Many people assume that "preventive medicine" means a full general medical check-up once a year, and that is the most common misunderstanding surrounding this benefit. In some policies, that general check-up is not included, even though other preventive tests such as blood tests or specific screenings may be.

It is also frequently confused with routine medical care. When you visit the doctor because you have a temperature or something is worrying you, that is curative treatment, not preventive care. They are two separate benefits within the same policy, and the limits of one do not apply to the other.

Another point that often comes as a surprise: vaccinations. Some policies exclude all vaccinations without exception, including those on the official childhood immunisation schedule. However, in a number of policies, childhood vaccinations on the official schedule are typically included, so do not assume anything is excluded without reading your own policy's terms and conditions.

Then there is periodic colonoscopy screening, which many people would expect to find under a preventive care benefit. In some policies it is not included within preventive medicine, although it may be covered through a different avenue depending on the medical indication.

When does this benefit apply and when does it not?

In some policies, preventive check-ups are not available until you have held the policy for at least two years. In other words: you sign up, you pay your premiums, and when you try to use that particular benefit, you are told you have to wait until the second year of cover. It is perfectly legal, it is in the contract, but nobody highlights it in the brochure.

Bear in mind that Article 3 of the Insurance Contract Act requires that any clauses restricting your rights must be clearly highlighted and that you must have expressly accepted them in writing. If a restriction of this kind does not appear in that form in your policy, it may be open to challenge. Even so, the most practical course of action remains reading the particular conditions — the section of the contract that is personalised for you — before taking out cover.

Here are some concrete examples of how this works in practice:

• Annual blood test: in many policies this is included under preventive care, but the number of parameters covered can vary.
• Childhood vaccinations: in several policies, those on the official immunisation schedule are typically included; in others they are completely excluded. Do not assume — check.
• General medical check-up: in some policies this does not appear under this benefit, although it may be available in higher-tier versions of the same insurance.
• Childhood preventive care: in some policies this is not included in the basic tier, but is available in Premium or open-choice versions.
• Periodic colonoscopy: in some policies this is not covered as a routine preventive screening.

What is the difference between preventive medicine and the rest of your health cover?

Preventive medicine is a specific benefit with its own limits within the policy. What it covers does not affect the sub-limit — the monetary cap that applies to a specific benefit within the policy — of other benefits such as hospitalisation or specialist consultations.

This also means that if you exhaust your preventive care allowance, you can continue using the rest of your policy as normal for other needs. They are separate compartments.

What all benefits do share is that they must be used within your policy's network of doctors and medical centres on the Costa del Sol, unless your tier of cover includes freedom of choice of doctor. In that case, the reimbursement conditions differ, and it is worth knowing the percentage you will be refunded before booking an appointment anywhere.

What should you check in your policy before using this benefit?

• Is there a waiting period? Check whether preventive check-ups are available from day one or whether you need to wait until the second year of cover.
• What tests are included exactly? Look for a specific list. "Preventive medicine" without further detail can mean very little or quite a lot.
• Are vaccinations included? And if you have children, does that include those on the official immunisation schedule? Do not assume — verify.
• Is a general medical check-up included, or only individual tests? They are different things: a check-up involves a consultation with a doctor plus a package of tests; individual tests do not always include the consultation.
• Is there a monetary sub-limit or a maximum number of uses per year? Some insurers set a limit of, for example, one blood test per year or a cap in pounds for preventive tests.
• Does your tier of cover include childhood preventive care? In some policies this is only available in higher-tier versions.
• Is colonoscopy included as a preventive measure? If it has been recommended based on your age or family history, check whether your policy covers it under this benefit or whether it requires a medical referral under a different benefit.

If you have a health insurance policy and are not entirely sure what your preventive medicine benefit includes, do not wait until the moment you need to use it to find out. The unpleasant surprise always arrives at the worst possible time.