Health insurers are to insist that patients seeking treatment outside mainstream medicine are referred by a doctor or they will not pick up the bill.

The move is being enforced as more people use services based outside hospitals, such as chiropractors and chiropodists, and the insurance bill is escalating.

The decision was attacked this week by Dr. Donald Ray, a chiropractor in Bermuda for 15 years, who said patients were baulking at the extra cost and deciding not come for treatment.

Dr. Ray says it will inevitably signal the closure of his business unless the decision is reversed.

"People have been calling and we have been informing them of the restrictions and they have elected not to come,'' he said. "I have noticed a decline in the number of patients.'' The Health Insurance Association of Bermuda, which represents all health insurers bar one, has written to all medical professions both mainstream and outside, outlining its decision.

The letter, obtained by The Royal Gazette , states: "The Association has been concerned for some time at the increasing number of services outside of the hospitals and the escalating use of these services.

"This has been of particular concern in the professions supplementary to medicine and in the medical areas which are currently unregulated in Bermuda.'' As a result from June 1 it was decided to enforce an existing requirement that eligibility for reimbursement would depend "on the referral from a licensed physician''.

The letter adds: "In order for your patients to receive maximum benefits under their insurance plans please advise them of this requirement.

According to Dr. Ray, professions "supplementary to medicine'' include himself and people such as dieticians, physiotherapists and chiropodists.

However, he believes those areas have a closer affiliation to doctors and will have no trouble getting referrals.

"Most of the insurance companies have something in their policies that say services such as mine are only available on the recommendation or referral of a medical doctor.

"But I have been here 15 years and I have never had to have a referral, yet the policies have always been there.'' Dr. Ray added: "I have told the Association that I have been here for 15 years and I have never been required to have a referral and that by one stroke of the pen my livelihood has been taken away.

Mrs. Jacquie Heaney, an Island chiropodist, said her profession would also be affected, although not as badly as Dr. Ray's, and pointed out that doctors would charge insurance companies for simply writing a letter of referral.

She said she also believes that some insurance companies did not have the requirement referred to in the Association's letter and that people's policies were being changed mid-term.

"It is ludicrous for a doctor to have to refer to us, we are the only profession that knows about the feet and lower limbs,'' said Mrs. Heaney.

Association President, Mr. Nicholas P. Warren, said the group was meeting again today to discuss the issue again and he hopes a meeting can be set up with the chiropractors and chiropodists.

Mr. Warren said there had been a significant growth of services based outside family doctors and hospitals and the "straw which broke the camel's back'' was when one started advertising.

He said it was costing the insurance companies more money and therefore the employers more through increased premiums.

However, he added: "There is a middle ground here and I think it would be appropriate to discuss this further with the chiropodists and chiropractors. I will be recommending that at the meeting on Friday.''