VHI Refusing to Pay for Overnight Hospital Stay

EllaC

A relative who has been insured by VHI for decades (on one of their top policies)
received a letter stating that they would not cover the €1200 cost of a recent overnight hospital stay

The procedure required a general anaesthetic and an overnight stay as advised by the surgeon - the relative was not given a choice in the matter.

When queried as to why they will not cover the €1200 cost the VHI's answer is "In our opinion this procedure is a day procedure and does not require an overnight stay". The surgeon has written to them twice outlining his reasons for keeping my relative in - but VHI is refusing to budge on the matter.

VHI has advised my relative to take her case to the Financial Ombudsman which she certainly intends doing

Has anyone else experienced this situation and succeeded in getting the VHI to pay up?

pjproby

If this was a planned procedure, surely your relative sought approval first?

scuby

being devils advocate here ! The Dr has to provide enough info to support the overnight admission.
Were there complications etc post operatively ?
Does the procedure normally require general anaesthetic ? is so, then he will have to say why they were kept in due to complications etc, if not then why was a general anaesthetic given etc
Afaik, the Dr have a book with details of each procedure, and how it's covered, so he should have some idea of what rule apply ?

attached from the vhi.ie website :
10) Day Care Procedures
Hospital benefit is payable for specified day care procedures carried out in an approved day care facility listed in the Directory of Hospitals (and Treatment Centres) and which is covered by your plan. If the day care procedures are performed in an in-patient setting (private or semi-private) the approved day care charges only are payable. If it is medically necessary for the customer to receive the treatment as an in-patient, we will pay the full benefits for the hospital charges in accordance with the level of cover under your plan

coylemj

OP, has your relative already paid the hospital for the overnight stay?

If you're going in for a planned procedure, it's almost always the case nowadays that the hospital takes your insurance details and bills the insurance company directly. If there is any doubt above whether the specific procedure and associated accommodation is covered, the hospital can ask the VHI for approval in advance, sort of like getting a credit card transaction approved.

If your relative was billed by the hospital, paid the bill and is now submitting the receipt to the VHI, I'd be asking why he/she allowed this to happen. If the hospital is billing your relative because the VHI has refused to pay them, I'd be telling the hospital to get lost because your relative submitted to the treatment on the basis that it was all going to be covered by the VHI.

EllaC

Yes it was a planned procedure and was related to surgery she had six weeks previously where there was no issue with any of the costs.

No she has not paid the hospital for the overnight stay.

The doctor obviously felt he had sufficient reasons to keep her in and has already submitted these in writing to the VHI. Surly that should be the end of it?

I find it extremely worrying that the VHI can overide the surgeon's decision and send the patient an enormous bill.

jethrothe2nd

I find it extremely worrying that the VHI can overide the surgeon's decision [/QUOTE]

This is the bit that would concern me as well. How can a pencil pusher in the VHI possibly be in a position to over-ride a surgeons decision. Having said that, I learnt the hard way about contacting VHI before having anything done.

coylemj

EllaC wrote: »

I find it extremely worrying that the VHI can overide the surgeon's decision and send the patient an enormous bill.

Why is the VHI sending anyone a bill?

If the VHI is refusing to pay the hospital then that's the hospital's problem, I'm assuming that your relative submitted to the treatment on the basis that it was covered by the VHI.

If the VHI have already paid the hospital then it's their (VHI's) problem. If they approved the service and told the hospital they would cover it, it's their problem if they change their minds afterwards.

Legally I can't see that the VHI has a leg to stand on, your relative owes them nothing as they didn't deliver the service. I don't see that your relative has anything to worry about.

P. Breathnach

jethrothe2nd wrote: »

...
This is the bit that would concern me as well. How can a pencil pusher in the VHI possibly be in a position to over-ride a surgeons decision. Having said that, I learnt the hard way about contacting VHI before having anything done.

I won't comment on this particular case, because I don't know enough to have an informed opinion.

I would say, however, that as a general principle it is right that the VHI scrutinise claims to ensure that payouts are reasonable and justified. My understanding is that some of the "pencil-pushers" are medically-qualified.

I am sure that some consultants try to maximise their incomes by charging higher fees to those with insurance cover than they charge to other private patients.

Last year I was in a public hospital as an insured private patient for a day procedure. The VHI phoned me to discuss the claim submitted by the hospital. What interested them in particular was that the hospital was claiming for an overnight stay.

jethrothe2nd

P. Breathnach wrote: »

I won't comment on this particular case, because I don't know enough to have an informed opinion.

I would say, however, that as a general principle it is right that the VHI scrutinise claims to ensure that payouts are reasonable and justified. My understanding is that some of the "pencil-pushers" are medically-qualified.

I am sure that some consultants try to maximise their incomes by charging higher fees to those with insurance cover than they charge to other private patients.

Last year I was in a public hospital as an insured private patient for a day procedure. The VHI phoned me to discuss the claim submitted by the hospital. What interested them in particular was that the hospital was claiming for an overnight stay.

I'm not disagreeing that VHI shouldn't do their due diligence. I'm also sure that the assessors have some form of medical knowledge. I also agree that VHI should be contacted before any procedure, however my point still stands. How can someone sitting in an office, who certainly isn't a qualified surgeon, make a determination on whether or not someone needed an overnight stay?

scuby

afaik a medical panel or some kind of review process is undertaken by a medically qualified person when cutting back benefit on a members stay, "pencil pushers" could not be allowed do this. ( I'm sure the Dr's and the IHCA would have challenged this process, if it's not the case )

Also, do you actually know what the Dr wrote in his letter to support the overnight stay? he/she may not have given enough info, or the patient did not medically qualify to be kept in overnight for a procedure that is normally performed on a day admission ?

from the attached link you have to appeal to VHI first, and then if they continue to reject your claim for the overnight stay, you can then submit to the Ombudsman https://financialombudsman.ie/complaints-process/default.asp?m=1

Fred Swanson

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