Did you know what an Outpatient Excess on your health insurance REALLY means?

Funnyonion79

Just in case you didn't know....

I had to pay out €1050 last year out of my own pocket for consultants, scans etc for my husband and we have an outpatient excess of €250 on our health insurance policy. I thought this meant that we pay the first €250 and then were eligible to claim for the rest. In our case, this meant that we could claim €60 per consultant visit and claim 50% of the cost of the scan.

We had 4 x consultant visits so claiming €60 per visit = €240.
We had 1 x scan costing €280 and can claim 50% back = €140

Total we should've been able to claim was €380. This is not the case.

Instead, the outpatient excess is deducted from the amount we are eligible to claim - not the total we paid in outpatient fees over the last 12 months. So in our case, €380 less €250 means that we will only be refunded €130 out of the €1050 that we paid out last year out of our own pockets, despite having health insurance. :mad::mad:

Are people aware of this? Anyone I've spoken to assumed like me, that the excess was deducted from the total fees paid. So now you know.

Thankfully I've already changed to another health insurer and my outpatient excess is only €1 so it won't be an issue for me next year. :cool:

Nate--IRL--

Interesting - I'll be checking mine ASAP

Nate

wmpdd3

I used to have quinn and the way you described it is how they explained it to me, bill = 1000, you pay 250 they pay 750. Maybe it has changed recently. we had one clain for a colonoscopy and it came to 1200 and we paid the first 125, it was around 2008 though.

Funnyonion79

wmpdd3 wrote: »

I used to have quinn and the way you described it is how they explained it to me, bill = 1000, you pay 250 they pay 750. Maybe it has changed recently. we had one clain for a colonoscopy and it came to 1200 and we paid the first 125, it was around 2008 though.

I was claiming through Aviva so perhaps they are different...? I'm with Quinn now though.

Ive written a letter to Aviva complaining that It is not clear how the excess will be applied and it should be highlighted in their outpatient benefits, as it would have a bearing on which plan you opt for. The current way it's written is completely misleading. I'm going to forward my complaint to the Financial Ombudsman as well if I don't get a response from them.

homer911

It's always been like that - why are you surprised? Did you not read the policy document before deciding to take out cover?

Funnyonion79

homer911 wrote: »

It's always been like that - why are you surprised? Did you not read the policy document before deciding to take out cover?[/Quote

I've had cover for 8 years and have never had to claim under outpatients fees before. Nothing is mentioned about how the excess is applied in the policy document, hence why I assumed that the outpatient excess would be deducted from outpatient fees. In my opinion, this would've been a reasonable assumption to make.

You were obviously aware of how the excess is applied - the purpose of my thread is to inform those who are not aware.

Funnyonion79

homer911 wrote: »

It's always been like that - why are you surprised? Did you not read the policy document before deciding to take out cover?[/Quote

I've had cover for 8 years and have never had to claim under outpatients fees before. Nothing is mentioned about how the excess is applied in the policy document, hence why I assumed that the outpatient excess would be deducted from outpatient fees. In my opinion, this would've been a reasonable assumption to make.

You were obviously aware of how the excess is applied - the purpose of my thread is to inform those who are not aware.

galah

yeah, got caught badly with that one with BUPA back in the day. Couldn't believe it - it really wasn't clear, and I was outraged.

I think VHI make that excess thing a little clearer in their documentation, must check. But this is the reason why I always choose a policy with a low excess, otherwise you are paying through the nose (well, on top of what you are already paying for...).

broker2008

All 3 insurers have plans that work this way and all 3 have plans that have €1 excess.

http://www.hia.ie/ci/health-insurance-comparison/search-result/23-47-67

The cover is clear for all 3 insurers in the documentation that is issued too.

NuMarvel

This is what Aviva say in the Terms & Conditions part of their website:

Out-patient excess
In order to successfully claim for out-patient benefits, a member must submit invoices for out-patient expenses occurring within the term of their current policy. The benefit payable by Aviva regarding those receipts (i.e. the out-patient benefit), without reference to the total value stated on the invoice / receipt concerned, must alone, or in addition to any other submitted invoices /receipts, exceed or equal the member’s out-patient excess. The amount payable by Aviva shall be that portion of the relevant single or combined out-patient benefit(s) which exceed(s) the member’s out-patient excess.

Where a member has already been paid for out-patient expenses under their current policy the out-patient benefit shall be paid in full, subject to any other term or condition contained within this policy.

Please note, notwithstanding the value of a member’s out-patient expenses in terms of the amount listed on any invoice/receipt, only the relevant out-patient benefit will be paid according to the specific terms of a member’s plan.

While they certainly won't be winning any prizes for Plain English, they do make a reference in the first paragraph to the excess being based on the benefit payable by Aviva, and not the total amount. Don't get me wrong, it's about as clear as mud (I know what I'm looking for, and even then I had to read it twice to make sure), but at the same time, nobody reading will get the impression that the excess is based on the total amount.

That said OP, I think you're right to highlight it. People make HUGE assumptions about how their health insurance works, and it's never any harm for people to take the time to get a better understanding.

If I had only one piece of advice to people, it would be to check your cover with your insurer before getting treatment. That's not to say you ring your insurer every time you go to the GP of the emergency department, but definitely do it before going for any high cost treatments like MRI scans or hospital tests, etc. And check it with your insurer, don't just take your doctor's word for it that when they say they're sure you'l be covered.

Funnyonion79

NuMarvel wrote: »

This is what Aviva say in the Terms & Conditions part of their website:

Out-patient excess
In order to successfully claim for out-patient benefits, a member must submit invoices for out-patient expenses occurring within the term of their current policy. The benefit payable by Aviva regarding those receipts (i.e. the out-patient benefit), without reference to the total value stated on the invoice / receipt concerned, must alone, or in addition to any other submitted invoices /receipts, exceed or equal the member’s out-patient excess. The amount payable by Aviva shall be that portion of the relevant single or combined out-patient benefit(s) which exceed(s) the member’s out-patient excess.

Where a member has already been paid for out-patient expenses under their current policy the out-patient benefit shall be paid in full, subject to any other term or condition contained within this policy.

Please note, notwithstanding the value of a member’s out-patient expenses in terms of the amount listed on any invoice/receipt, only the relevant out-patient benefit will be paid according to the specific terms of a member’s plan.

While they certainly won't be winning any prizes for Plain English, they do make a reference in the first paragraph to the excess being based on the benefit payable by Aviva, and not the total amount. Don't get me wrong, it's about as clear as mud (I know what I'm looking for, and even then I had to read it twice to make sure), but at the same time, nobody reading will get the impression that the excess is based on the total amount.

That said OP, I think you're right to highlight it. People make HUGE assumptions about how their health insurance works, and it's never any harm for people to take the time to get a better understanding.

If I had only one piece of advice to people, it would be to check your cover with your insurer before getting treatment. That's not to say you ring your insurer every time you go to the GP of the emergency department, but definitely do it before going for any high cost treatments like MRI scans or hospital tests, etc. And check it with your insurer, don't just take your doctor's word for it that when they say they're sure you'l be covered.

Yes NuMarvel, I agree completely. When I realised how the excess was applied, I looked up the terms and conditions and found the paragraph you're referring to.

As you say,it's difficult to find unless you know what you're looking for (and I will certainly be watching out for this in the future) but my main issue is that in the list of outpatient benefits under my plan, it just says "outpatient excess €250" but doesn't highlight how this is actually applied.

I have sent a letter of complaint to Aviva advising them that this should be highlighted or at the very least - referenced, so that customers can look it up and educate themselves on the implications a high excess could have on their ability to claim.

I mistakenly thought (as did a lot of people) that excess would be applied the way it is with car insurance for example.