Health Insurance Question

castie

Person A in good faith takes out Health Insurance with Company Y.

3 years pass by and Person A is diagnosed with a condition C.
Condition C may have been present since birth but was never diagnosed previously.

Condition C requires regular visits to a GP and Hospital for procedures.

Is Company Y within its rights to claim that Person A is not covered for Condition C on the basis that it may have been present since birth?

tommy21

Sounds complicated. I'd imagine it depends what is in the tiny print you signed day one? Is there a clause that covers them for that sort of a development?

castie

Unsure as its not actually affecting me but someone I know.

I would of thought they couldnt do it on the basis of a a person entering the contract in good faith at the time.

It raised a question in my head for the scenario that if a person developed cancer but the Company could prove that it had been present previous to the insurance being taken out even without the persons knowledge of it that they could refuse cover?

tommy21

castie wrote: »

Unsure as its not actually affecting me but someone I know.

I would of thought they couldnt do it on the basis of a a person entering the contract in good faith at the time.

It raised a question in my head for the scenario that if a person developed cancer but the Company could prove that it had been present previous to the insurance being taken out even without the persons knowledge of it that they could refuse cover?

You know Castie I just don't know. I know in the US it has been the source of many court cases as many insurance companies there would not honour such claims (pre-existing conditions that the individual never knew about).


I think your friend needs to get a copy of contract and policy document and go through it thoroughly. It will either be clear-cut and say it does not cover it or it may not mention it. It sounds like your friend has not approached insurance company yet re the claim?

castie

Had a quick look around and found this section in the latest terms and conditions for the Company.

e) 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
This rule is applicable to all benefits other than those outlined in Section 9 of your Table of Benefits as well as those benefits in Section 10 that are
subject to an excess.
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.

Seems they can deny you coverage if your not covered longer than the minimum period. That kind of sucks....

castie

tommy21 wrote: »

You know Castie I just don't know. I know in the US it has been the source of many court cases as many insurance companies there would not honour such claims (pre-existing conditions that the individual never knew about).


I think your friend needs to get a copy of contract and policy document and go through it thoroughly. It will either be clear-cut and say it does not cover it or it may not mention it. It sounds like your friend has not approached insurance company yet re the claim?

Theyve actually denied the claim and took there time about doing it so his bills have piled up as he was assuming the insurance company would be covering it.

Neyite

1. read the small print of the policy.
2. be persistant with the claims office
3. contact the financial regulator if you are getting nowhere.

it might just be the claims office declining the claim automatically but if its questioned that it gets investigated.

also depends on the insurance company, but if your friend is persistant, and their medical records back up the fact its never been diagnosed, you might have a good outcome.

i took out a policy after i damaged an eardrum and they are still covering me for an operation. i worked in insurance (not specifically health, but travel claims, where there was some medical claims) and usually if someone whose claim was declined was persistant, management would work out all or partial settlement to make them go away.

tommy21

castie wrote: »

Theyve actually denied the claim and took there time about doing it so his bills have piled up as he was assuming the insurance company would be covering it.

That sucks, to be honest I can't understand the legal mumbo jumbo. No doubt someone better qualified here will give you some advice as to whether you should be looking for legal advice or if the insurance company is right.

metrovelvet

I think its considered pre exisisting if the diagnosis was made after you signed up.

Our man in Havana

Haemochromatosis (as an example) is present from birth so no insurance company will cover it until the long waiting period is served out.

castie

Haddockman wrote: »

Haemochromatosis (as an example) is present from birth so no insurance company will cover it until the long waiting period is served out.

Thats exactly what it is.

castie

My real worry here is that he cannot afford to continue paying himself until the 5 years are up which is April I think.

tommy21

castie wrote: »

My real worry here is that he cannot afford to continue paying himself until the 5 years are up which is April I think.

Completely my own opinion but - I would assume that now it is an underlying condition and they know about it, then he will not be able to get cover for it? Hope I'm wrong.

castie

The Company have said they will cover the expenses when the 5 years have passed.

However this condition when first discovered is at its most expensive.
It requires very regular treatments until the iron levels in the blood return to normal amounts.

Then after this it could be every 3 months. So basically he will have to pay himself until April meaning by then it could be as little as once every 3 months.
I cant understand how this can be legal really.

metrovelvet

Could he go to the healthboard with it?

castie

metrovelvet wrote: »

Could he go to the healthboard with it?

Not sure exactly what his options are. Im not up on whats available to people really.
Any advice Ill gladly pass on.

amdublin

metrovelvet wrote: »

I think its considered pre exisisting if the diagnosis was made after you signed up.

This sentence does not make sense to me.

You sign up. Ten years later you get sick and diagnosed with cancer.
"No sorry that was pre exisiting"

Please can you clarify.

amdublin

@OP:

Check the Terms and Conditions.
Likely this scenario covered in them and your friend does not have a valid claim.

amdublin

castie wrote: »

It raised a question in my head for the scenario that if a person developed cancer but the Company could prove that it had been present previous to the insurance being taken out even without the persons knowledge of it that they could refuse cover?

Well this seems similar to the OP's question.

Eg. it could be a heart condition from birth, it could be cancer from 6 months ago. Does not really matter us debating loads of different scenarios.

It should all be covered in the terms and conditions: this is the contract you agreed and accepted when signing up for the health cover.

metrovelvet

amdublin wrote: »

This sentence does not make sense to me.

You sign up. Ten years later you get sick and diagnosed with cancer.
"No sorry that was pre exisiting"

Please can you clarify.

It may have been latent when you sign up. Right? So it was there but no symptoms. You go to the doc years later, get the diagnosis. Its not until you have an official diagnosis that you are technically sick.

I think it will depend on the company though.

amdublin

metrovelvet wrote: »

It may have been latent when you sign up. Right? So it was there but no symptoms. You go to the doc years later, get the diagnosis. Its not until you have an official diagnosis that you are technically sick.

Interesting. Hmmm.

But I imagine it would be a very rare situation that a doctor would tell you:
"You have cancer. And you know all those years where you had no symptoms and felt completely well? Yeah you had cancer then as well".

Whereas! More likely you have not been feeling well/have some kind of symptoms but just getting on with things. Eventually you are diagnosed with cancer and putting two and two together you probably had it for a lot longer than the official diagnosis. If this is recorded in your medical reports I guess the Health As co. could try argue you had a pre-existing condition (note, not cancer!!!) which you were aware of (ie. your symptoms and not feeling well, NOT the actual diagnosis of cancer) and that you should have told them of these symptoms/unwellness.

The above is all just surmisation though!!!!!!!!!!

The terms and conditions is the document that needs to be checked to see what is and what is not covered.

I know some people may think the OP's situation is unfair (and it does sound a bit unfair tbh) but it is like any kind of insurance eg.car insurance: one takes it out and tends to think "oh yeah I'm covered for anything and everything" then once something happens and you check the terms and conditions it then become apparent that not Everything is covered (unfortunately).

Eg. Car insurance: Your windscreen gets smashed and people say to you claim under your insurance. You check your t's & c's and realise you don't have windscreen cover on your policy.

amdublin

castie wrote: »

However this condition when first discovered is at its most expensive.
It requires very regular treatments until the iron levels in the blood return to normal amounts.

Then after this it could be every 3 months. So basically he will have to pay himself until April meaning by then it could be as little as once every 3 months.

Can he go public?

castie

What do you mean by "go public". I have no real experience of the health system here Thank god.

Our man in Havana

Have the HSE pay for the treatment in public facilities.

castie

What criteria would he need to meet?

Our man in Havana

None, being sick is enough.

He needs his doctor to refer him for public treatment.