MRI cover with VHI Plan B option (family)

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Can anyone tell me what the situation with MRI cover is for Plan B option (family). My brother is on my parents VHI and was referred by his GP for an MRI (foot) in a private hospital (category 1 hospital AFAIK).

My parents were told that there will be an excess of a few hundred. But according to the policy documentation it seems to be fully covered (outpatient MRI at least).
Is there something i could be missing here.

Also, what is the cover for a basic Xray (referred in the same way).

And where can i get more detailed info on individual policies. Don't think the VHI website have these details.
Thanks.

NuMarvel

VHI have full cover agreements in place with particular MRI centres around the country, but it only applies for a set list of medically necessary reasons (called clinical indictors). It's possible that the reason your brother's scan is needed isn't on that list and therefore isn't covered. Can I ask who told your parents that the scan won't be covered?

A breakdown of the cover on Plan B Options is on there website here - https://www.vhi.ie/pdf/products/TOBPlanBOption.pdf. And the full terms and conditions (including a list of MRI centres and MRI clinical indicators) are here - https://www.vhi.ie/downloads/termstable.jsp#a-eoptions.

The cover for standard x-rays seems to be half the cost back, up to a maximum of €500 per year, subject to the overall out-patient excess of €250 per member. GP, consultant and other visits can be claimed subject to that overall excess as well

take everything

NuMarvel wrote: »

VHI have full cover agreements in place with particular MRI centres around the country, but it only applies for a set list of medically necessary reasons (called clinical indictors). It's possible that the reason your brother's scan is needed isn't on that list and therefore isn't covered. Can I ask who told your parents that the scan won't be covered?

A breakdown of the cover on Plan B Options is on there website here - https://www.vhi.ie/pdf/products/TOBPlanBOption.pdf. And the full terms and conditions (including a list of MRI centres and MRI clinical indicators) are here - https://www.vhi.ie/downloads/termstable.jsp#a-eoptions.

The cover for standard x-rays seems to be half the cost back, up to a maximum of €500 per year, subject to the overall out-patient excess of €250 per member. GP, consultant and other visits can be claimed subject to that overall excess as well

Thanks.
Yeah i've looked at those documents already but it's hard to tell if the excess of 250 euro applies to outpatient MRIs as well (in section 8). Or is the excess restricted to the section 9 stuff.
The centre he's using is category 1 (so it's "full cover) and he satisfies the indications in the pdf (that clinical indicators pdf says it covers joints).

So the only thing i'm stumped on is:
Does "full cover" mean full cover. Or does that sneaky 250 euro excess also apply to this "full cover" MRI (section 8).

BTW, the hospital told my parents MRIs for extremities (arms and legs) aren't covered (despite the clinical indicators pdf clearly saying otherwise).
The excess thing is the main thing i'm wondering about though.

NuMarvel

take everything wrote: »

Thanks.
Yeah i've looked at those documents already but it's hard to tell if the excess of 250 euro applies to outpatient MRIs as well (in section 8). Or is the excess restricted to the section 9 stuff.
The centre he's using is category 1 (so it's "full cover) and he satisfies the indications in the pdf (that clinical indicators pdf says it covers joints).

So the only thing i'm stumped on is:
Does "full cover" mean full cover. Or does that sneaky 250 euro excess also apply to this "full cover" MRI (section 8).

BTW, the hospital told my parents MRIs for extremities (arms and legs) aren't covered (despite the clinical indicators pdf clearly saying otherwise).
The excess thing is the main thing i'm wondering about though.

An MRI scan in a Category 1 centre is fully covered, no excess. A scan in another listed centre is subject to an excess of €125. The excess in Section 9 doesn't apply.

However, the clinical indicators apply (or at least should apply) to both types of cover. That's according to Rule 8m at least. So the hospital shouldn't be saying telling you that it can be claimed back subject to the excess.

Your best bet is ring VHI and check. It might not be any harm for your brother to check with the consultant what clinical indicator he's being referred for.

broker2008

Which hospital is it ?

VHI might not cover but Quinn & Aviva do. Alternatively, by getting the MRI carried out in another hospital might be the difference in paying a couple of hundred euro and nohing at al. There are no waiting periods for the MRI by switching to Quinn or Aviva BUT VHI will only let you switch at renewal.

take everything

An MRI scan in a Category 1 centre is fully covered, no excess. A scan in another listed centre is subject to an excess of €125. The excess in Section 9 doesn't apply.

Thanks. Do you have direct experience of this. This was my first impression as well but that policy document is still ambiguous (it doesn't say to what exact section the 250 euro excess applies).

However, the clinical indicators apply (or at least should apply) to both types of cover. That's according to Rule 8m at least. So the hospital shouldn't be saying telling you that it can be claimed back subject to the excess.

The hospital were trying to make out that MRIs for extremities aren't covered at all (in direct contradiction of the VHI's MRI clinical indications pdf (musculoskeletal section)).
So that seems to be nonsense.

Your best bet is ring VHI and check. It might not be any harm for your brother to check with the consultant what clinical indicator he's being referred for.

Yeah i'll do that.
Thanks.
The ambiguity in the policy is annoying.

take everything

broker2008 wrote: »

Which hospital is it ?

VHI might not cover but Quinn & Aviva do. Alternatively, by getting the MRI carried out in another hospital might be the difference in paying a couple of hundred euro and nohing at al. There are no waiting periods for the MRI by switching to Quinn or Aviva BUT VHI will only let you switch at renewal.

It's a category 1 private hospital.
That means it's "full cover" according to page 3 of the policy
What i'm trying to get copperfastened is:
Does that 250 excess at the bottom of page 4 of the policy still apply to category 1 outpatient MRI, notwithstanding it being "full cover".
VHI told my mother it did apply.
I'll ring them again (just wondering if anyone had direct experience of this).

broker2008

Which category 1 hospital though ?

take everything

broker2008 wrote: »

Which category 1 hospital though ?

Why does this matter.
It's a category 1 hospital listed in the vhi mri directory.
There's nothing detailing which hospital it has to be.

NuMarvel

take everything wrote: »

Thanks. Do you have direct experience of this. This was my first impression as well but that policy document is still ambiguous (it doesn't say to what exact section the 250 euro excess applies).

No direct experience, but I used to work for a different health insurer a few years ago, so I know my way around health insurance terms and conditions (I need to get out more!)

On page 13 of the rule book, underneath the list of approved MRI centres, it summarises the cover, including this line:

Out-patient Category 2: Agreed MRI charges may be claimed upon receipt of paid accounts and are subject to an excess of €125 per scan. Refer Section 8 of your Table of Benefits.

The out-patient excess (€250 in this case) is only applicable to Section 9. Rule 9e in the rule book says:

Out-patient cover
We will pay benefits for eligible expenses listed in Section 9 of your Table of Benefits as a lump sum at the end of each year. We will only pay the
benefits when you send us a claim form which you have completed and signed, together with receipts. You must do this within three months of
the end of the year.
• Please note that receipts will not be returned following assessment of your claim. Therefore, you may wish to retain copies prior to submission.
• We will deduct an annual excess (as specified in Section 9 of your Table of Benefits) from the eligible expenses of each member insured on the
policy.

NuMarvel

take everything wrote: »

Why does this matter.
It's a category 1 hospital listed in the vhi mri directory.
There's nothing detailing which hospital it has to be.

Just to be sure, have you looked at a copy of the terms and conditions (i.e. rule book) that applied at the last renewal, here - https://www.vhi.ie/downloads/termstable.jsp#a-eoptions.

It should be the same, but there's no harm in double checking the applicable rule book just to be certain.

broker2008

take everything wrote: »

Why does this matter.
It's a category 1 hospital listed in the vhi mri directory.
There's nothing detailing which hospital it has to be.

Some admin people in some of the hospitals can get cover mixed up and give out wrong information. VHI's contracts are being renewed at the moment and will come into effect on 15th November.

I heard of a similar story to yours yesterday for a particular category 1 hospital and I wanted to see was it the same one and wondered are VHI about to change the way it is covered for this hospital? Otherwise, it is as NuMarvel pointed out.

VHI don't pay any money back if scan if done in a non approved centre - not relevant in this instance I would imagine.

take everything

NuMarvel wrote: »

No direct experience, but I used to work for a different health insurer a few years ago, so I know my way around health insurance terms and conditions (I need to get out more!)

On page 13 of the rule book, underneath the list of approved MRI centres, it summarises the cover, including this line:

Out-patient Category 2: Agreed MRI charges may be claimed upon receipt of paid accounts and are subject to an excess of €125 per scan. Refer Section 8 of your Table of Benefits.

The out-patient excess (€250 in this case) is only applicable to Section 9. Rule 9e in the rule book says:

Out-patient cover
We will pay benefits for eligible expenses listed in Section 9 of your Table of Benefits as a lump sum at the end of each year. We will only pay the
benefits when you send us a claim form which you have completed and signed, together with receipts. You must do this within three months of
the end of the year.
• Please note that receipts will not be returned following assessment of your claim. Therefore, you may wish to retain copies prior to submission.
• We will deduct an annual excess (as specified in Section 9 of your Table of Benefits) from the eligible expenses of each member insured on the
policy.

Yeah i saw all that.
Fair enough, maybe that's good enough.
Interestingly though, section 9e of the Table of Benefits (radiology or other diagnostic tests) makes a reference to section 8 (the outpatient MRI stuff). Just wondering if section 9 could indirectly include that part of section 8 (for the purposes of the excess that applies to section 9). I'll probably talk to them again.

One other thing you might know:
If you're getting an XRay, do you know does this include payment for both the scan and a separate payment for radiologist fees.

Overall though, VHI B option seems to be useless for outpatient stuff.
You have to be spending 1000's to get any reasonable percentage back with a 250 euro excess.
Thanks.:)

take everything

broker2008 wrote: »

Some admin people in some of the hospitals can get cover mixed up and give out wrong information. VHI's contracts are being renewed at the moment and will come into effect on 15th November.

I heard of a similar story to yours yesterday for a particular category 1 hospital and I wanted to see was it the same one and wondered are VHI about to change the way it is covered for this hospital? Otherwise, it is as NuMarvel pointed out.

VHI don't pay any money back if scan if done in a non approved centre - not relevant in this instance I would imagine.

Oh OK.
My brother would be using The Bons Tralee FWIW.:)

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broker2008 wrote: »

Quinn say it is not covered

http://www.quinn-healthcare.com/pdf/list.pdf

The MRI centre Tralee is covered in that.
The VHI MRI directory says it's covered is as well.

I dunno.

broker2008

TYpo meant to say that they say it is covered. I don't have Aviva list with me to see if they back it up. It must be something to do with the clinical indicator as NuMarvel says. Have you checked the particular rules and table of cover relating to HIS plan, in case it is plan specific or if there is an option to go and get it carried out in a different hospital.

broker2008

I was just thinking iIt might be something to do with the provider, Alliance Medical, who provide facilities in the Bons Tralee and Galway but not Dublin or Cork.;)

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I found out that MRI is covered.
However the hospital say it has to be very specific what the GP puts down on the form.
Even though joints (such as ankle) and their surrounding tissue are covered, if you put down foot they won't cover you. Stuff like that.

funnyname

take everything wrote: »

Even though joints (such as ankle) and their surrounding tissue are covered, if you put down foot they won't cover you. Stuff like that.

Is that info in the terms and conditions or did you find it out through their claims dept? Just seems like you need a fine tooth comb when going through all the documentation and even then you don't get all the details.