VHI - Waiting period / Will I have to pay for Op?

Free_bee

Hi

I've just come out of hospital 3 days ago having had my gallbladder removed (keyhole surgery) as I had gallstonees. Went privately assuming VHI (family plan plus) would cover me. However as I only joined in Nov 07 they say I may not be covered as this may have been a pre-existing condition, even though I didn't know I had them!:eek: (only diagnosed Nov 08)

Am really scared now that I may have to pay for this myself and I have no idea how much an operation and 2 days in (public) hospital cost. I am being made redundant next month and am sole bread winner so really concerned now.

does anyone have any idea what the costs woud be?

Incidentally. . so far no-one from the Hospital has asked me for my VHI policy details and I haven't signed anything except medical consent form... did they mistakenly treat me a public patient - I'm too scared to ask

I should be sitting here recouperating but now stressed like crazy. Any advice would be appreciated.

shellyboo

How were you admitted, referral or through A&E? I had my appendix out last year and only paid like 100e for the two days in hospital - because I was admitted through A&E I didn't have to pay for the OP, apparently. Didn't make much sense to me, but I didn't complain!

Free_bee

I was referred for a scan by Gp then onto the consultant - as it was taking ages to get an appointment date i booked to see him privately/ then straight into hospital 3 weeks later . . .

penexpers

shellyboo wrote: »

How were you admitted, referral or through A&E? I had my appendix out last year and only paid like 100e for the two days in hospital - because I was admitted through A&E I didn't have to pay for the OP, apparently. Didn't make much sense to me, but I didn't complain!

When you go publicly through A+E, the cost of the operation is covered but you need to pay the hospital overnight fees (which I think might vary from hospital to hospital).

In the OP's case, they went privately. If the VHI won't cover it, then I think they'll be liable for the cost of the operation and the cost of any overnight fees which if it was a private/semi-private room will be a lot more than 100 euro for 2 days.

ntlbell

if it was diagnosed in nov 08 your still under their 6 month waiting perioid

did you not check with VHI first?

the total cost if you got a private room is about 4.5k

sorry just noticed you joined in 07

nevermind!

damn right they should pay!!

Free_bee

Thanks for that

I was in the general ward so they should make it cheaper.

I wonder who decides how old my gallstones were? bizarre situation really as no-one will ever actually know - I will see what unfolds

ntlbell

Free_bee wrote: »

Thanks for that

I was in the general ward so they should make it cheaper.

I wonder who decides how old my gallstones were? bizarre situation really as no-one will ever actually know - I will see what unfolds

i'm not sure it's something they can prove was an existing condition. unless they have some sort of carbon dating measure for gal stones

I got mine done last year with BUPA and they never asked any questions.

jor el

For it to be a pre-existing, it would have to be diagnosed before you took out the VHI insurance. The hospital will have your medical records, which will show when it was diagnosed. If this is after the date you started with the VHI, then I can't see where there would be a problem.

Who exactly is saying it might not be covered?

Free_bee

Well I rang VHi today to ask about the lack of paperwork .. and the woman I spoke to said that they would only pay if it wasn't pre-existing . I said it no it wasn't because it wasn't diagnosed until Nov 08 and she said that didn't matter ....it went on how long I'd had the condition before that .. seems crazy :mad:

ntlbell

Free_bee wrote: »

Well I rang VHi today to ask about the lack of paperwork .. and the woman I spoke to said that they would only pay if it wasn't pre-existing . I said it no it wasn't because it wasn't diagnosed until Nov 08 and she said that didn't matter ....it went on how long I'd had the condition before that .. seems crazy :mad:

so did she say how you would prove it wasn't pre exisiting?

surely this would have only been established after the consultant confirmed it?

really happy i'm with BUPA VHI have some horror stories.

Free_bee

No _ i was too stresssed at the prospect of them maybe not settling my claim to pursue it at the time. I will definately investigate:cool:

dudara

ntlbell wrote: »

if it was diagnosed in nov 08 your still under their 6 month waiting perioid

He joined in Nov 07, and was diagnosed in Nov 08.

silversurfer

If you weren't diagnosed with it before joining VHI, then you didn't have it.

When did it start up? (the illness/ condition)

Free_bee

I went to the Drs in Nov 08 because of excruiating pain - like trapped wind only worse (called biliary colic) First time of anything like that.

Hopefully they will pay up if not What's the point of having the cover ?

_Whimsical_

Op really sorry to hear that you have been ill and now have this huge stress hanging over you.

The period of exclusion of coverage for pre-existing conditions is 5 years once you switch to a new insurer.I'm pretty sure that period applies to all insurers in Ireland.

Correction on this : The 5 year period of exclusion of cover relates only to people who
(a) have never had insurance before.
(b) have had insurance before but let it lapse for more than 13 weeks
(c) have had insurance elsewhere and not have fully served the 5 year period there.
If you switch insurance companies, provided you do not fit into any of the above conditions, you will be covered for a pre-existing illness with a new insurer for exactly the same level of cover as you were previously entitled to with your last insurer.You have a waiting period to serve(2yrs if you are under 59) to be entitled to upgrades in cover for a pre existing condition.

silversurfer wrote: »

If you weren't diagnosed with it before joining VHI, then you didn't have it.

Unfortunately this is not always true. I've heard of other instances where the VHI have been extremely sticky on what constitutes a pre existing condition.I know someone who joined VHI and sometime later was diagnosed with Haemochromotosis. He had never had symptoms before his diagnosis but the VHI claimed that although the condition may not have presented with symptoms before, it was still present. The person I knew took part in a Joe Duffy radio show about people in the same situation a year or two ago.As far as I know they got no where with their complaint as the waiting period was a condition of the contract.

I remember one Doctor on that show saying that he had had the VHI query whether some cancers that were detected at an advanced stage could have been present before a patient took up VHI coverage a year or two earlier.He said most consultants will write letters claiming this is not so in their opinion even if it may be true and patients rarely/never have to pay up in these instances.

I realise that this is all hear say.I couldn't find the relavent passage to quote online but I see Nody has beaten me to it so see his post on the next page to confirm the above!

You should check out and see what sort of appeals procedure the VHI have in these cases.Maybe you should make an appointment to speak to your doctor/surgeon and see if he/she can help sort this out or intervene on your behalf with the VHI.As your surgeon will be the only one to have seen your gallstones he/she may be able to claim that it is unlikely in his/her opinion that it took a year and 3 months for yours to form.

I really hope they'll pay up. I think this clause in their contract is extremely unfair.

MunsterCycling

chilly wrote: »

The period of exclusion of coverage for pre-existing conditions is 5 years once you switch to a new insurer.I'm pretty sure that period applies to all insurers in Ireland.

Back this up.

MC

Nody

MunsterCycling wrote: »

Back this up.

MC

Section 3D wrote:

d) No benefits are payable for medical conditions the date of onset of which is determined on the basis of medical advice to
have been prior to the date the member was included on the contract, unless the member has been insured continuously for
a minimum period of time. The minimum period is as follows:
MEMBER’S AGE WHEN HE/SHE IS INCLUDED MINIMUM PERIOD
Under 55 5 years
55 - 59 7 years
60 or over 10 years
When determining whether a medical condition pre-exists membership it is important to note that it is the date of onset of the condition that is considered rather than the date upon which the member becomes aware of the condition, as medical conditions may be present for some time before giving rise to symptoms or being diagnosed

From the VHI member book. That is the only thing I found at a quick check.

_Whimsical_

chilly wrote: »

The period of exclusion of coverage for pre-existing conditions is 5 years once you switch to a new insurer.I'm pretty sure that period applies to all insurers in Ireland.

MunsterCycling wrote: »

Back this up.

MC

I was just checking this out this morning.

I was wrong about it. The 5 year period of exclusion from cover for pre existing conditions only relates to someone
(a)who has never had insurance cover before
(b)who has had insurance with any insurer before and has let it lapse for more than 13 weeks
(c) is still serving a waiting period with another insurer.

If you are joining an insurer in either of the above situations you will not be covered for an existing illness for 5 years or longer depending upon your age and on the insurer.

See Nody's post above for details on VHI policy on this.

See here under "what are exclusion periods" for into on Hibernian Aviva policy:http://www.hibernianavivahealth.ie/help/individual-family/#comp0000474a8541000000079f2e24

For other insurers ring up because it seems nearly impossible to find info online.

OP try not to worry yourself silly. If you are made redundant and a sole bread winner there is a chance that the hospital you were treated in may understand your situation and may be able to make some special provisions for your expenses.

MunsterCycling

cheers for that info, scam is all you can say to that!

ARGURIOS1

Oh my....Im due in for the same op next week...Ive been with VHI for a long time now so hope I wont have any probs. Hope all is well with you now and that this gets sorted for you in a good way!.

GerardKeating

MunsterCycling wrote: »

cheers for that info, scam is all you can say to that!

Not sure about VHI, but it is clearly printed on the Quinn-Health membership cards that you have to call them FIRST to confirm that the prodecure/treatment is covered

shannon82

the claim will be assessed on what the doctor puts on the claim, blame the doc not VHI

ARGURIOS1

GerardKeating wrote: »

Not sure about VHI, but it is clearly printed on the Quinn-Health membership cards that you have to call them FIRST to confirm that the prodecure/treatment is covered

Ya got me thinking that it might be a good idea to run this by VHI.... I did so and there was some probs but managed to get it sorted in the end. The surgeon wasnt showing as registered with the particular hosp I was having the op done in and they said they wouldnt pay out as a result. Turns out it was only an admin thing but Im glad I checked all the same!.

Magenta

ARGURIOS1 wrote: »

Ya got me thinking that it might be a good idea to run this by VHI.... I did so and there was some probs but managed to get it sorted in the end. The surgeon wasnt showing as registered with the particular hosp I was having the op done in and they said they wouldnt pay out as a result. Turns out it was only an admin thing but Im glad I checked all the same!.

That's great. Make sure you get any treatment pre-approved in future if at all possible

MunsterCycling

Just shows what a fu€kin joke health insurance is in this banana republic

Cabaal

MunsterCycling wrote: »

Just shows what a fu€kin joke health insurance is in this banana republic

Cause its better in the likes of America?
:eek:

DundalkDuffman

If you didn't sign a private room form and an insurance form then you were treated as a public patient. 75euro per night stay, inclusive of all radiology/pathology/anaesthetist/surgeon work. It's tough luck on the hospital if you didn't sign a consent to be treated as a private patient as distinct from a medical consent form.

qf3l3k

Just want to warn you before anyone will decide to go with Hibernian Aviva.
They act as <snip>
I rang them before surgery procedure, requesting information if my case will be covered and there is no issues with that.
On the phone I was given straight confirmation that I can go for it and whole cost will be covered, no problem.
When it came to claim they refused to pay putting as excuse pre-existing condition, which in Hibernian Aviva might be anything as by terms and conditions it fits to any possible situation, which gives them ability to refuse any payment requests.

Unfortunately I had them on the phone not in writing, Having this in writing would probably give me ability to get money of those <snip>.

Currently I'm in progress and can't get any straight answers from those <snip>. It is easy for them to lie on the phone where nothing is registered.. if you request infotmation in writing it is very difficult to get anything.

If someone had similar case please let me know if you found solution how to resolve it.

dudara

qf3l3k - Please do not refer to businesses in such a manner. Allegations are easy to make but may have long-lasting consequences.

Did you disclose the pre-existing condition to them when taking out the policy or at any stage?

If they feel that you did not disclose something, then the insurance product that they sold to you may not cover particular things or may indeed be rendered completely null and void.

NuMarvel

qf3l3k wrote: »

Just want to warn you before anyone will decide to go with Hibernian Aviva.
They act as <snip>
I rang them before surgery procedure, requesting information if my case will be covered and there is no issues with that.
On the phone I was given straight confirmation that I can go for it and whole cost will be covered, no problem.
When it came to claim they refused to pay putting as excuse pre-existing condition, which in Hibernian Aviva might be anything as by terms and conditions it fits to any possible situation, which gives them ability to refuse any payment requests.

Unfortunately I had them on the phone not in writing, Having this in writing would probably give me ability to get money of those <snip>.

Currently I'm in progress and can't get any straight answers from those <snip>. It is easy for them to lie on the phone where nothing is registered.. if you request infotmation in writing it is very difficult to get anything.

If someone had similar case please let me know if you found solution how to resolve it.

Ask Aviva for a recording of the telephone call you made before the surgery. If they don't have this, ask for either a transcript of the call or a copy of the notes that the customer service agent made of the call. They must have some record of the call and under data protection laws, you are entitled to a copy of the record that they hold. Try to have the date or approximate dates of the call, as it would speed up matters.

It's also possible that the consultant who filled in the claim form entered information that indicated to Aviva that the condition is pre existing. As well as the call, ask Aviva for a copy of the claim form. Again, they can't refuse to give this to you.

If they give you the run around on either of the two points above, get onto the Data Protection Commissioner's office.

If the information on the claim form matches the information you gave to the agent at the time of checking the cover, then I'm not sure what grounds Aviva have for rejecting the claim. Unlike most other types of insurance, you're not obliged to declare illnesses at the time of joining. It helps for your own clarity, but it's not a pre requisite for a claim to be covered. If the information does match, I would submit a formal complaint in writing and specify that you want replies from them in writing.

If the complaint isn't dealt with to your satisfaction, you have recourse with the Financial Services Ombudsman.

If the information doesn't match (e.g. the consultant states the onset date is earlier than you thought), perhaps talk to the consultant to clarify why that information was put down. I used to work for BUPA/Quinn and now and again, consultants would put incorrect information on the claim form. If it's a case of incorrect information being submitted, ask Aviva how this can be corrected and how to go about having the claim re-assessed.

However, if the consultant feels the information is correct, then I don't think you have any other recourse as Aviva have to assess the claim based on the medical information they receive.

cute_cow

I know it’s difficult, but you need to stop worrying. It will do you no good if you are recovering from surgery, you need to relax and try to calm down, which I know is difficult.

The only way that Vhi can prove it was pre-existing, is if you contacted your GP in relation to pain/etc due directly from your gallbladder prior to joining Vhi in November 2007. Did your GP ever mention to you that you may be suffering from gallstones before November 2007? If the answer is no, then it is not a pre-existing condition. Stick to your guns, as *some* (no specific) private health providers tend to insist that it is. If necessary, contact your GP and ask him or her to write a letter to you or Vhi stating this. However, if your GP did mention this to you, or warned you that you may in future develop gallbladder problems, prior to joining Vhi, then you will not be covered.

As you joined in Nov 07, and they were not diagnosed until a year later, you should be covered. There are set waiting times for some payments however, as outlined in your terms and conditions. Example, pre-existing conditions is 5 years (depending on age), maternity cover takes 52 weeks, but an initial waiting period for most things, is 26 weeks.

From my own experiences, when I was admitted to hospital the registrar asked if I had any health cover, and gave her my policy number, so I would contact the hospital ASAP and provide these details. If not, you may expect to receive a bill in the post.

I would contact Vhi as soon as you can, and outline the fact is it not pre-existing, and as mentioned, tell them that you are willing to provide, in writing, from your GP that it has never been an issue prior to November 2008.

But you need to get on the phone to both as soon as you can, and sort it out as soon as possible.

Hope this helps, and hope you get better soon

NUTLEY BOY

AFAIK the concept of what is pre-existant is an objective one as distinct from a subjective one.

You might feel totally healthy and have utterly no symptoms when you take out health insurance. This is your subjective and truthfully stated belief that you have no existing condition.

However, a health insurer's doctor might say that by reference to the medical evidence the condition is one that must have pre-existed in technical medical terms. That is an objective judgment that a condition was pre-existant.

The problem is that the insurer will plead the latter as the only opinion that matters if there is a conflict and they probably have that concept embedded in some paragraph of their rule book. That is the essential point made by nody.

What you need to do is to stop stressing and start focusing. If the insurers deny liability ask them to explain their position in writing. You may find that they will then back off.

As a general observation you need to be quite tough with insurers these days as the levels of competence that they display is shockingly variable and this refers to no company in particular !

In short, get after them and start applying pressure for a decision. Follow them up in writing each time you issue a reminder. Use e-mail so that you have a record of what communication has taken place. if they have a telephone conversation with you get it confirmed in writing so that there are no slip-ups !

Don't worry just yet as this may well resolve itself.

qf3l3k

I will definitely follow up with them as I was given procedure code by surgery specialist and rang them to confirm if everything will be covered.

When you ring Aviva they ask you to provide all details (insurance number, name, date of birth), so they know exactly who they are dealing with.

There was no additional questions asked by call center person and no other warinings given that payment might be eventually refused.

Based on that information I took certain actions and made decisions how to continue with procedure.

In fact it is not big amount of money I have to pay, but in that case it is just principal. If someone commits to something (in that case call center representative is authoritative person who speaks for Aviva) then let's not change mind after the fact especially if that might have financial consequences afterwards.

Also, call center has a purpose right? My assumption is that ringing them I will get proper information. Otherwise it is useless and should be closed.

Will see where I will get with them as for now they didn;t manage to respond for even one email I sent to them. Don't want to talk to them on the phone. Now everything in writing.

Will see how long will take those guys to respond for an email. As for now they don't look much professional as I didn;t even received confirmation that email has been registered with whatever system they have.

Lack of professionalism and total ignorance. At least within 24-hours they should reply saying that case is under investigation and they will come back with more information in X days, or something similar.

Also, on customer portal.. I filed complain and no trace of any ticket or something opened for that, so from my perspective they just directing all emails sent to them to trash (that's my feeling at the moment).

Main thing, to be honest, is the fact that they commit on the phone that there is no issue with covering particular procedure. I just hate this kind of behaviour. If someone commits to something, then be consequent. Don't mislead people for the profit. Also, don't push incompetence of your employees to your customers, becuase that is what probably happened. Call center person didn't bother to mention that procedure might be subject to pre-existing conditions, etc... I stated clearly that I want to be 100% sure that it's covered and ask to do check for me... had confirmation on the phone (unfortunately). Will try to get recording of course as suggested and then we will see.

That is pretty much how I percieve Aviva at the moment.