Health Ins Claim Refused

intothewest

Hi All. My mother is almost 77, and at the beginning of the year my Dad died. Her and Dad had a policy for the last 55 years with same health insurer. Dad had different treatments over the last 15/16 years, but my mother has only had two hospital related claims. One was in 2019 for a day patient operation in the Hermitage.

She had to change policy this year cos Dad passed away, and it was due for renewal at the end of June. She asked me to help navigate the quagmire that is health insurance, but I wasn't able to make any inroads, despite looking at comparison websites etc. In the end, my mother called them and asked them to advise her on what option to take. We think this was around May time. My understanding from a conversation with them around this time, was that she wasn't covered for two years in some hospitals for pre-existing conditions. At that time (May) she had no pre-existing conditions. She had stomach problems on and off for years, but her GP had been treating them as ulcers.

In June, her GP decided to send her for a scan for something and it showed up something which required a keyhole operation. She rang health insurer on June 22nd about the operation being covered, and they asked her to get a hospital code. She got that and asked me to check with them. I contacted them on webchat on June 25th with the code and they said they would have to call me back about it (I am waiting for them to forward me that webchat as I don't recall the details of it). They said they called me on the 26th, but I don't recall a missed call from them. The 'new' policy kicked off on Jul 1st.

Both my mother and I are certain though that we did get confirmation from them that it was ok for her to proceed with the op in the Hermitage. She did proceed, but at start of this month, got a letter from ins co saying they had rejected her claim, on the basis that her policy didn't cover her for two years for a pre-existing condition. There was no break in cover at any stage. Customer of 55 years,

She's now super worried, has been back to her GP (who is writing a letter) and has been through enough this year to be frank. Also, her new policy, that they recommended to her was a better policy from her previous one, not a downgrade with less cover. Any recommendations of how to approach this? It's currently with their complaints dept. Thanks.

coylemj

On the general issue of confirming cover before the procedure, I would have let the people in the Hermitage take care of that.

Did you pay the Hermitage for the procedure or was it carried out on the basis that the insurance would pay them direct? Because if the Hermitage got the ok from the insurance to say that they would be paid, it's now their problem, not yours.

On the question of a pre-existing condition, that does not apply if she had continuous cover. If she did have continuous cover, the 'two year' rule they're quoting relates to extra benefits that you get when you upgrade your policy to one that has additional cover. You cannot claim any of those additional benefits for two years.

You say that your mother's new policy was a better policy that the old one, did the old policy cover treatment in the Hermitage? Because if it didn't, the two year rule would apply and the new insurer would be within their rights to reject the claim. Even if you hadn't moved to a different insurer but simply upgraded the policy, that rule would still apply.

intothewest

Hermitage were not paid no. It was carried out on basis that insurance would pay them direct. The bill came from the Hermitage on Dec 3rd. Op was Sept 3rd. She had had a procedure done in the Hermitage in 2019 (covered under her previous policy).

She had continuous cover yes. She didn't look for an upgrade, she was asking them to advise her if there was a more suitable package for her based on the fact that she was now on her own, and not two people (due to Dad passing away in Feb). She couldn't tell if her former plan was more suited for a couple and if there was a better individual option for her. So she asked the insurer to advise her.

It seems to me that the Hermitage was an option for her on her old policy, but only for certain procedures it must be. Not a blanket yes for any procedure.

She didn't move insurer, changed policy with same insurer.

coylemj

intothewest wrote: »

Hermitage were not paid no. It was carried out on basis that insurance would pay them direct. The bill came from the Hermitage on Dec 3rd. Op was Sept 3rd.

Is the Hermitage now saying that your insurance won't cover the bill? Have they said why not? Didn't they (as most clinics do) verify cover beforehand?

If they're saying that they can't get paid by the insurance, your response should be that your mother went ahead with the procedure based on the fact that they got the ok from her insurance.

Gael23

We need a bit more information here.
Was the new policy a better or lower one than her previous one?
You should always conform cover prior to admission

daheff

I had a similar problem with Hermitage before. Was told my insurance would cover a procedure which then was not covered. After a long discussion with Hermitage they agreed to cover the cost as I would not have had the procedure if Hermitage had not told me it would be covered.

My advice is talk to their accounts department and tell them similar and see what they say.

intothewest

Had the Hermitage or you recordings of those discussions?

intothewest

So they called me. The claim is still rejected. Mam rang them on June 22nd about the op. Policy changed July 1st.

They said it was pre-existing, therefore the 2 year waiting period applied. I said she had only had the scan that week, so while the new policy discussed was in May, she wasn't aware of it, it wasn't on her radar. So I tried to argue that it wasn't pre-existing at the time of the policy upgrade enquiry - but they said that once there have been any signs/symptoms, even if you weren't aware of it, that it's deemed as pre-existing. They base it off the consultants notes.

I called on 25.06 with the code, but they weren't able to tell me, they had to transfer me to another dept to confirm it but there was a wait, so they said they would call me back cos there was a wait and I must've been on work calls. They said they called back on 26.06, but I don't recall a missed call. Yet, when I enquired online the other day on webchat about the hosp code, they could tell me straight away.

She said she will bring it to her manager, but I don't hold out much hope. She said the next step would be the Ombudsman, but I am sure they would be the same.

intothewest

Is this true? Do most clinics confirm patient is covered before a procedure? Or is that meant to be done completely by the patient?

phormium

I don't know if all hospitals do it, it's safer to check yourself obviously. I know when my grandson was due to have a procedure the hospital rang the day before and said insurer had told them he wasn't covered so the hospital had obviously rang to check.

We hadn't checked as we knew he was covered, sure enough it turned out he was, the insurance company was incorrect as they couldn't find a record of continuous insurance for him as we had switched companies a few times in his 5 yrs. Taught me keep a paper record! Luckily I had a letter confirming details of previous policy as it could not be found with the new company which was previously some other company and all records had not transferred correctly I was told!

coylemj

intothewest wrote: »

So they called me. The claim is still rejected. Mam rang them on June 22nd about the op. Policy changed July 1st.

They said it was pre-existing, therefore the 2 year waiting period applied.

There is no waiting period for pre-existing conditions if you have continuous cover. Which in this context means no gaps of 13 weeks or more.

https://www.hia.ie/consumer-information/waiting-periods/new-customer-waiting-periods

Did your mother supply the new medical insurance company with details of her previous policy?

ec18

sounds like the procedure was covered in the hermitage on the new benefits on the insurance policy or at least that's what the insurance company have found

Shazamm

phormium wrote: »

I don't know if all hospitals do it, it's safer to check yourself obviously. I know when my grandson was due to have a procedure the hospital rang the day before and said insurer had told them he wasn't covered so the hospital had obviously rang to check.

We hadn't checked as we knew he was covered, sure enough it turned out he was, the insurance company was incorrect as they couldn't find a record of continuous insurance for him as we had switched companies a few times in his 5 yrs. Taught me keep a paper record! Luckily I had a letter confirming details of previous policy as it could not be found with the new company which was previously some other company and all records had not transferred correctly I was told!

So if you never found the documents they wouldn't have been able to find the previous cover either?

ted1

You are only not covered for ire existing conditions if they were not covered by your old policy.

It’s to stop people upgrading when they find a condition.
The ombudsman can advise

Shazamm

ted1 wrote: »

You are only not covered for ire existing conditions if they were not covered by your old policy.

It’s to stop people upgrading when they find a condition.
The ombudsman can advise

The ombudsman are no help.
The insurance companies are being told to deny cover now as a cost saving measure in the hopes the patients will not challenge them.
There's many articles on this now.

ted1

Shazamm wrote: »

The ombudsman are no help.
The insurance companies are being told to deny cover now as a cost saving measure in the hopes the patients will not challenge them.
There's many articles on this now.

The ombudsman will help it’s literally his job.

Shazamm

ted1 wrote: »

The ombudsman will help it’s literally his job.

I've experience of the ombudsman.
Absolutely zero help. Unfortunately.
The process can take years.

Jim2007

Shazamm wrote: »

The ombudsman are no help.
The insurance companies are being told to deny cover now as a cost saving measure in the hopes the patients will not challenge them.
There's many articles on this now.

Well in that case then you’ll have no problem providing us with a reference as to who is instructing insurance companies to deny cover to anyone as that would be a very serious matter?

Shazamm

https://www.independent.ie/business/personal-finance/latest-news/patients-left-to-foot-bill-as-insurers-refuse-to-pay-37557642.html


Patients are being forced to pay towards meeting the cost of medical procedures despite having health insurance, an industry expert has warned.

Dunraven Health Services said there had been a huge rise in rejected, or partially paid, claims for treatments.

---

Read the link -
Its not just a random person on boards relaying this information - the industry are in the business of rejection

And that article is 2 years old - theres more articles if do your research

phormium

Shazamm wrote: »

So if you never found the documents they wouldn't have been able to find the previous cover either?

I imagine they would have found it eventually! Someone would have needed to go through the archived stuff.

My main experiences have been with Beacon Hospital, and they always out it to me that it is my responsibility to check if I'm covered. However sometimes things value Ed that were beyond my control. I had major surgery in 2016 which my insurer VHI said was covered in the hospital. It is surgery that quite often has complications where you end up in ICU for a bit, and I ended up with a massive consultant's bill for ICU which VHAi said they were refusing to cover. Was told I should have phoned VHI before agreeing to be taken to ICU, which was totally impractical as my level of consciousness was low at the time and I hadn't capacity to give consent. In the end I just argued it out and said not an extra cent was coming out of my purse and they would have to bring me to court if they had any hope to get it. They left well enough alone, but don't know how they worked it out between them. The fact is that often enough the patient has no control over what they are covered for.

The entire model of private hospitals is changing since Covid, and has already been implemented in some of them. Previously it was typically to be in a shared room even in a private hospital, but obviously this is changing. Recently I was in a fairly small room of three beds in a private hospital and with the acoustics in the room I heard every intimate detail of the other patients medical & personal history. One of them took extremely seriously ill, quite unexpectedly, and without going into detail here, the private hospital protocol proved to be very disadvantageous in the circumstance. With COVID, and indeed any infectious diseases, it is not good to be sharing a small room. The only real advantage of private cover is:

1) "Queue jumping" to get quicker access to elective surgery.

2) Privacy, but only if you have a private room.

coylemj

Deleted User wrote: »

The entire model of private hospitals is changing since Covid, and has already been implemented in some of them.

I don't understand the point of your post.

The physical layout of beds and wards hasn't changed in any private hospital as a result of the virus. So how has Covid altered the way patients are allocated to single, twin or triple bed wards?

You said that 'the private hospital protocol proved to be very disadvantageous in the circumstance' How would it have been different if you had been in a triple bed ward in a public hospital?

intothewest

It's very definitely developed to favour the insurance company and not the customer.

coylemj

coylemj wrote: »

I don't understand the point of your post.

The physical layout of beds and wards hasn't changed in any private hospital as a result of the virus. So how has Covid altered the way patients are allocated to single, twin or triple bed wards?

You said that 'the private hospital protocol proved to be very disadvantageous in the circumstance' How would it have been different if you had been in a triple bed ward in a public hospital?

Mater Private has got rid of its multiple occupied rooms to being solely single occupied. I was told when recently in Beacon that they are changing likewise but have not done so yet; they are expanding into adjacent building. The thing about the room I recently occupied was that it was smaller than a public one I occupied in Vincent's public hospital. My point is that there wasn't much of an advantage in having private insurance to achieve this pretty identical level of comfort/privacy. My admission was not elective for surgery.

Also I was listening today about health insurance in the radio and how eg, VHI are no longer fully covering joint replacement surgery, at least on my plan of over €3K and that many other insurance plans no longer fully cover such surgeries. It's becoming less attractive to have health insurance in my experience.... except I want to have it there as a "safety net".

Shazamm

Deleted User wrote: »

Mater Private has got rid of its multiple occupied rooms to being solely single occupied. I was told when recently in Beacon that they are changing likewise but have not done so yet; they are expanding into adjacent building. The thing about the room I recently occupied was that it was smaller than a public one I occupied in Vincent's public hospital. My point is that there wasn't much of an advantage in having private insurance to achieve this pretty identical level of comfort/privacy. My admission was not elective for surgery.

Also I was listening today about health insurance in the radio and how eg, VHI are no longer fully covering joint replacement surgery, at least on my plan of over €3K and that many other insurance plans no longer fully cover such surgeries. It's becoming less attractive to have health insurance in my experience.... except I want to have it there as a "safety net".

What show was this on?

It seems its all the companies now - they all have co-payments of €2000 or 80% coverage at best.

Tails142

If you put up the names of the old plan and new plan, we'd be able to advise you better, but sounds like the level of cover increased.

www.hia.ie is probably the most reliable comparison site, it's run by the health insurance authority, will show you what the cover levels were on the old and new policy.

coylemj

[Deleted User] wrote: »

Also I was listening today about health insurance in the radio and how eg, VHI are no longer fully covering joint replacement surgery, at least on my plan of over €3K and that many other insurance plans no longer fully cover such surgeries. It's becoming less attractive to have health insurance in my experience.... except I want to have it there as a "safety net".

I think the operative words there are 'at least on my plan'. What appears to be happening is that there is a form of creeping inflation happening with medical insurance whereby if you stay on the same plan, your coverage gets degraded. An ageing population and younger workers who can't afford decent medical insurance because of high rents probably means that there are not enough new subscribers coming on board to help spread the burden.

What I'm saying is that you can get the necessary level of cover, just expect to pay more for it.

coylemj

coylemj wrote: »

I think the operative words there are 'at least on my plan'. What appears to be happening is that there is a form of creeping inflation happening with medical insurance whereby if you stay on the same plan, your coverage gets degraded. An ageing population and younger workers who can't afford decent medical insurance because of high rents probably means that there are not enough new subscribers coming on board to help spread the burden.

What I'm saying is that you can get the necessary level of cover, just expect to pay more for it.

The experts who come on the radio always advise at least to phone own insurance company and discuss what cover you want, and if remaining on same plan is best for you. I did this last year and a whole lot of plans were explained but to cut a long story short none of them would cover the stuff that I as a 60 year old with plenty of conditions would need. Got a knee replacement two years back and with the negotiation advised by them with hospital they agreed to take the amount offered from the cover without forking out.

Far too many people like me having joint replacements, and ironically as people do more running (not my thing) etc joints are getting worn down more quickly, and in younger people. They are going to cover less and less of these amounts. Too much keep fit can be costly, so advice might be to put aside a savings for potential future medical costs if you don't want to go in long public list, or to have it done in a country where it is cheaper if you don't have medical insurance, but bearing in mind one cannot fly back home until sufficiently healed.

Shazamm

Deleted User wrote: »

The experts who come on the radio always advise at least to phone own insurance company and discuss what cover you want, and if remaining on same plan is best for you. I did this last year and a whole lot of plans were explained but to cut a long story short none of them would cover the stuff that I as a 60 year old with plenty of conditions would need. Got a knee replacement two years back and with the negotiation advised by them with hospital they agreed to take the amount offered from the cover without forking out.

Far too many people like me having joint replacements, and ironically as people do more running (not my thing) etc joints are getting worn down more quickly, and in younger people. They are going to cover less and less of these amounts. Too much keep fit can be costly, so advice might be to put aside a savings for potential future medical costs if you don't want to go in long public list, or to have it done in a country where it is cheaper if you don't have medical insurance, but bearing in mind one cannot fly back home until sufficiently healed.

can you explain what cover they did or did give in regards to your knee replacement?
And do you mean that the plan you are currently is good for example for orthopaedics but not for another area?

Shazamm

Shazamm wrote: »

can you explain what cover they did or did give in regards to your knee replacement?
And do you mean that the plan you are currently is good for example for orthopaedics but not for another area?

Knee replacement January 2018, on what was once called the old VHI Plan C Options. I phoned to check cover before op, VHI said there would be a shortfall but to phone Beacon & try & negotiate with them, which I did. They went through the patter that it wasn't normally covered but that they would do so on this occasion. I don't know on what criteria they agreed to make the exception. Maybe if I started quickly needing another joint done they'd refuse to cover the shortfall. I think it is an operating theatre cost rather than bed cost, because the VHI mumbled something about the fact that "high tech hospitals are not fully covered for orthopaedic procedures", and I asked them what hospital they considered "non high tech", and Vincent's Private was one such, although most private hospitals in Dublin area are apparently considered "high tech".

Had a major very big surgery in Beacon in 2016, a full colectomy with ileostomy, which they agreed to entirely cover at the outset. However I got a bill subsequently for ICU consultant fee, and VHI told me they weren't going to cover that, and in future I should phone them before agreeing to treatment in a private ICU. Now I was not very conscious at the time, needing resus etc, not in a position to take up a phone & negotiate etc. The bill I received was €8000, I firmly refused to pay it, and was let off. The consultant seems to have agreed to take less than what he wanted or else he negotiated a bit more than VHI were willing to pay him. My care required his close attention over 3 days.

Things keep changing, so what applied to me above may not apply anymore, it is really difficult to keep abreast of things. You might take out cover, thinking it is suitable, then you get sick and undergo a procedure or get emergency treatment only to be told that what has happened you is no longer covered. I don't think folk realise just how unpredictable and precarious medical insurance cover is. Ideally you need to have a little savings pot of about €10K to cover these shortfalls should you be surprised. And one must bear in mind that any hospital admission, even for an apparently minor procedure, can unexpectedly incur complications which medical insurance doesn't quite cover. Sepsis can just set in out of the blue. There are too many changing variables to always ensure you have the right cover at the right time. You are playing against an ever moving goal-post.

Shazamm

Deleted User wrote: »

Knee replacement January 2018, on what was once called the old VHI Plan C Options. I phoned to check cover before op, VHI said there would be a shortfall but to phone Beacon & try & negotiate with them, which I did. They went through the patter that it wasn't normally covered but that they would do so on this occasion. I don't know on what criteria they agreed to make the exception. Maybe if I started quickly needing another joint done they'd refuse to cover the shortfall. I think it is an operating theatre cost rather than bed cost, because the VHI mumbled something about the fact that "high tech hospitals are not fully covered for orthopaedic procedures", and I asked them what hospital they considered "non high tech", and Vincent's Private was one such, although most private hospitals in Dublin area are apparently considered "high tech".

Had a major very big surgery in Beacon in 2016, a full colectomy with ileostomy, which they agreed to entirely cover at the outset. However I got a bill subsequently for ICU consultant fee, and VHI told me they weren't going to cover that, and in future I should phone them before agreeing to treatment in a private ICU. Now I was not very conscious at the time, needing resus etc, not in a position to take up a phone & negotiate etc. The bill I received was €8000, I firmly refused to pay it, and was let off. The consultant seems to have agreed to take less than what he wanted or else he negotiated a bit more than VHI were willing to pay him. My care required his close attention over 3 days.

Things keep changing, so what applied to me above may not apply anymore, it is really difficult to keep abreast of things. You might take out cover, thinking it is suitable, then you get sick and undergo a procedure or get emergency treatment only to be told that what has happened you is no longer covered. I don't think folk realise just how unpredictable and precarious medical insurance cover is. Ideally you need to have a little savings pot of about €10K to cover these shortfalls should you be surprised. And one must bear in mind that any hospital admission, even for an apparently minor procedure, can unexpectedly incur complications which medical insurance doesn't quite cover. Sepsis can just set in out of the blue. There are too many changing variables to always ensure you have the right cover at the right time. You are playing against an ever moving goal-post.

Thanks for your reply.

according to the link below -

https://www.justlanded.com/english/Ireland/Ireland-Guide/Health/Hospitals-Clinics



Private and high-tech hospitals
Irish hospitals can be generally grouped into 3 categories. Apart from public hospitals, which offer treatment for all Irish residents and EU-citizens, there are also private and high-tech hospitals. This categorization is important when you consider buying private health insurance, as the latter two are only covered by private insurance schemes. The group of private hospitals includes all private operated clinics except the Mater Private Hospital, the Blackrock Clinic and the Beacon Hospital. These three hospitals are referred to as high-tech hospitals and are only covered by the most expensive schemes of private insurance.


But on the irish life link below, there is a different answer again.

https://help.irishlifehealth.ie/hc/en-us/articles/360000480858-What-Is-a-High-Tech-Hospital-

What Is a High-Tech Hospital?
The Blackrock Clinic, the Mater Private and the Beacon Hospital are the only three high-tech hospitals in Ireland.

These are private hospitals with specialised equipment and they treat complex conditions including cardiac, oncology (cancer) and orthopaedic conditions.

On Level 1 plans* the high-tech hospitals are the Blackrock Clinic, the Mater Private and the Beacon Hospital, the Hermitage Clinic and the Galway Clinic.

So, yes its made to be confusing on purpose.

The ICU bill - that is a common trick done by all private hospitals.
The patient is admitted to ICU after a procedure in order to charge the insurance a hefty fee that was not approved beforehand.

The patient is usually not conscious and that's how they get away with it.

They are admitted to ICU - even when it is not necessary in order to profit.

Many times the patient is never aware of the bill when the insurance company settle this directly.

Your last statement about the ever-moving goal post is just so spot on.

There are over 300 plans on the market.

The link below is very interesting stating the shortfalls on nearly every plan now - or €2000 euro co-payments necessary for any procedure.


https://www.askaboutmoney.com/threads/20-shortfall-on-specified-orthopaedic-procedures.221673/

intothewest

So basically, they are charging the same or more, making policies impossible for the ordinary person to understand/work through, and saying policies over less/saying higher excesses have to be paid.

I find the two year wait for an elderly, long term customer astounding - someone who wasn't looking for an upgrade, who was just enquiring if a more suitable policy was available to them cos their husband had died.

Shazamm

Shazamm wrote: »

Thanks for your reply.

according to the link below -

https://www.justlanded.com/english/Ireland/Ireland-Guide/Health/Hospitals-Clinics



Private and high-tech hospitals
Irish hospitals can be generally grouped into 3 categories. Apart from public hospitals, which offer treatment for all Irish residents and EU-citizens, there are also private and high-tech hospitals. This categorization is important when you consider buying private health insurance, as the latter two are only covered by private insurance schemes. The group of private hospitals includes all private operated clinics except the Mater Private Hospital, the Blackrock Clinic and the Beacon Hospital. These three hospitals are referred to as high-tech hospitals and are only covered by the most expensive schemes of private insurance.


But on the irish life link below, there is a different answer again.

https://help.irishlifehealth.ie/hc/en-us/articles/360000480858-What-Is-a-High-Tech-Hospital-

What Is a High-Tech Hospital?
The Blackrock Clinic, the Mater Private and the Beacon Hospital are the only three high-tech hospitals in Ireland.

These are private hospitals with specialised equipment and they treat complex conditions including cardiac, oncology (cancer) and orthopaedic conditions.

On Level 1 plans* the high-tech hospitals are the Blackrock Clinic, the Mater Private and the Beacon Hospital, the Hermitage Clinic and the Galway Clinic.

So, yes its made to be confusing on purpose.

The ICU bill - that is a common trick done by all private hospitals.
The patient is admitted to ICU after a procedure in order to charge the insurance a hefty fee that was not approved beforehand.

The patient is usually not conscious and that's how they get away with it.

They are admitted to ICU - even when it is not necessary in order to profit.

Many times the patient is never aware of the bill when the insurance company settle this directly.

Your last statement about the ever-moving goal post is just so spot on.

There are over 300 plans on the market.

The link below is very interesting stating the shortfalls on nearly every plan now - or €2000 euro co-payments necessary for any procedure.


https://www.askaboutmoney.com/threads/20-shortfall-on-specified-orthopaedic-procedures.221673/

Just to be clear about the ICU admissions in my case, I was admitted for 24 hours post surgery as I had required 6 units of blood during surgery and had Hg of about 6, so was fairly unstable. When I was operated on there were an unexpectedly large number of inflammatory adhesions full of blood vessels (after years of inflammatory bowel disease) which took them by surprise, then within a day or do of being transferred to ward I suffered severe Afib following further blood loss, lung collapse had cardioversion, and had to be taken back to ICU for a further 48 hours, more transfusions etc. It was totally necessary if I was to survive. A severe post-op infection then further delayed discharge from hospital. I had practically all the potential complications that were explained could possibly happen.

One can be unlucky. In a recent admission another person on ward took unexpectedly very bad in front of my eyes, and had to be put on a ventilator. These things can happen so quickly that co sent cannot be obtained. All I can say is that it seems to me that more truly adequate medical insurance will cost at least 5000, but I would still imagine shortfalls occur.

I was virtually born into private health insurance in 1960s when there was only the semi-state operator, VHI, and no such thing as the specialised tech stuff there is now. People sometimes occupied hospital beds for a week after surgeries where they'd now be discharged one or two days later. Gallbladders had two week stays which are unheard of now unless somewhere goes wrong. Your insurance was to pay for bed occupancy time as much as anything else.

Medicine is evolving rapidly, equipment needs to be paid for, of course Major surgeries are being done robotically, sometimes with 24 hour discharges, and it seems whether your operation uses such equipment or not your costs contribute to paying for it. Insurance has become r dry but as complex as the procedures, and probably more incomprehensible to be honest. We are ever more approaching USA type medicine costs. I am actually far more boggled by the insurance than the medical aspect, at least the former is a bit of fascinating science.

intothewest

So not only have you to decipher the various shortfalls etc for all types of ailments, but if you do have to be admitted for something, you have to then enquire what the costs would be should you hit complications, as you did. There are stats of risks to anything, so someone has to to be unlucky and hit additional problems. Asking people to do that when they are being admitted to ICU is nuts. What you'll find happening is people masking ailments, leaving too early so they don't rack up a bigger bill. Modelling the States as you said. It's very depressing.

Shazamm

intothewest wrote: »

So not only have you to decipher the various shortfalls etc for all types of ailments, but if you do have to be admitted for something, you have to then enquire what the costs would be should you hit complications, as you did. There are stats of risks to anything, so someone has to to be unlucky and hit additional problems. Asking people to do that when they are being admitted to ICU is nuts. What you'll find happening is people masking ailments, leaving too early so they don't rack up a bigger bill. Modelling the States as you said. It's very depressing.

Great point.

"to decipher the various shortfalls for all types of ailments" - when it is any ever-changing system and the information for the ailments is not freely available and can change at the drop of a hat.

The health insurance authority has an email system and the latest news section which they share on Facebook.

https://www.hia.ie/news/latest-news

There are changes constantly - every month, to every package.

It is impossible to follow

For example - the policy I'm on changed mid-policy-year and has completely different rules now previous to the change.

I'm only aware of it due to the hia link above and there is no information or contact from the insurance about the changes***

They should share any changes to your policy and give you a chance to navigate things better but they don't.

I was looking at the new Mater Private "Day Hospital" centres in north and south suburbs, whereby you have all your tests on an outpatient basis without having to go within the hospital premises in the city, which to me sounds like a splendid kind of idea, and avoids unnecessary footfall in the hospital building. However I was told by somebody working there that it is not (yet anyway) covered by any form of medical insurance and is purely "self-pay", ie you pay the full cost yourself. Seems the insurance companies want you to occupy hospital beds, but then when you find yourself in one unnecessarily as per insurance company, you get the bill.

Example I give here. In the midst of the complications (which spanned a couple of months) of that major surgery I had in 2016 and which landed me a few times as inpatient), the Beacon phoned me to tell me they had an overnight bed for a procedure and to come in to admissions that afternoon. I had had already undergone a couple of postoperative procures to drain a recurrent abscess, so I had my bag on the ready and obeyed instructions to turn up. Next morning I was told by consultant that he hadn't ordered me in overnight, and there must have been confusion. I got a big bill, which I refused to pay, and after trying it on, and my threatening to sue for their error at calling me in, they relented and withdrew the invoice. You have to stand up to them on these things, and it will not come against you,

My general advice about private v public hospital treatment is that if you have a full emergency (chest pain, severe unfamiliar head pain, extreme abdominal pain that lasts over 15 hours at high level & especially if accompanied by vomiting, leg swelling with pain that appears like a clot, respiratory infection with severe breathlessness, very high temperature with rash, or signs of a stroke) go to a public hospital emergency department and avoid private facilities where attention may be delayed by phone triage or referral system & no paramedics to attend to you on your journey. If you want to speed up an orthopaedic procedure or one to remedy a painful/inconvenient but non life-threatening condition, by all means consider private; most of all private comes into its own when speeding up endoscopy procedures to detect potential cancer where an undue delay may be feared in the public system.

It is worth remembering that a major public hospital has a wealth of expertise on hand when things go pear-shaped, and can provide timely interventions. When admitted to a private hospital one relies majorly on one's consultant for the care pathway. Often likes of gastroenteric surgeons in the hospitals have mini teams (similar to public hospitals) to step in and escalate care should things get complicated. I have have witnessed an incident in a private hospital where somebody unexpectedly took very seriously ill and needed ventilation. The patient's non-surgical consultant was asleep at home in bed at the time, and although nurses and one of two doctors on duty helped to keep patient resuscitated they could not be put on ventilation until the arrival of the elderly consultant to sign permission. I have heard consultants advise against having care in a private hospital if there is any kind of complicated scenario on the cards.

intothewest

What happens in that scenario, where the terms of the policy change mid policy? Would they refuse a claim I wonder, or honour it based on when you entered the policy?

I am still waiting to receive the recordings of the calls we had with them, nor have I received the transcript of the online chat that I had with them, despite both being requested and being told the former was being sent to me about three weeks ago.

Nuna

Firstly, if you look for the hospital benefits for both plans you should be able to see if they both cover private hospitals easily enough. If they both cover private hosptials then you could contact the billing department in the Hermitage and ask if the procedure would have been covered in full under the old plan. If the answer is yes than the 2 years waiting period is irrelevant.

Nuna

Firstly, if you look for the hospital benefits for both plans you should be able to see if they both cover private hospitals easily enough. If they both cover private hosptials then you could contact the billing department in the Hermitage and ask if the procedure would have been covered in full under the old plan. If the answer is yes than the 2 years waiting period is irrelevant.

Shazamm

[Deleted User] wrote: »

I was looking at the new Mater Private "Day Hospital" centres in north and south suburbs, whereby you have all your tests on an outpatient basis without having to go within the hospital premises in the city, which to me sounds like a splendid kind of idea, and avoids unnecessary footfall in the hospital building. However I was told by somebody working there that it is not (yet anyway) covered by any form of medical insurance and is purely "self-pay", ie you pay the full cost yourself. Seems the insurance companies want you to occupy hospital beds, but then when you find yourself in one unnecessarily as per insurance company, you get the bill.

Example I give here. In the midst of the complications (which spanned a couple of months) of that major surgery I had in 2016 and which landed me a few times as inpatient), the Beacon phoned me to tell me they had an overnight bed for a procedure and to come in to admissions that afternoon. I had had already undergone a couple of postoperative procures to drain a recurrent abscess, so I had my bag on the ready and obeyed instructions to turn up. Next morning I was told by consultant that he hadn't ordered me in overnight, and there must have been confusion. I got a big bill, which I refused to pay, and after trying it on, and my threatening to sue for their error at calling me in, they relented and withdrew the invoice. You have to stand up to them on these things, and it will not come against you,

My general advice about private v public hospital treatment is that if you have a full emergency (chest pain, severe unfamiliar head pain, extreme abdominal pain that lasts over 15 hours at high level & especially if accompanied by vomiting, leg swelling with pain that appears like a clot, respiratory infection with severe breathlessness, very high temperature with rash, or signs of a stroke) go to a public hospital emergency department and avoid private facilities where attention may be delayed by phone triage or referral system & no paramedics to attend to you on your journey. If you want to speed up an orthopaedic procedure or one to remedy a painful/inconvenient but non life-threatening condition, by all means consider private; most of all private comes into its own when speeding up endoscopy procedures to detect potential cancer where an undue delay may be feared in the public system.

It is worth remembering that a major public hospital has a wealth of expertise on hand when things go pear-shaped, and can provide timely interventions. When admitted to a private hospital one relies majorly on one's consultant for the care pathway. Often likes of gastroenteric surgeons in the hospitals have mini teams (similar to public hospitals) to step in and escalate care should things get complicated. I have have witnessed an incident in a private hospital where somebody unexpectedly took very seriously ill and needed ventilation. The patient's non-surgical consultant was asleep at home in bed at the time, and although nurses and one of two doctors on duty helped to keep patient resuscitated they could not be put on ventilation until the arrival of the elderly consultant to sign permission. I have heard consultants advise against having care in a private hospital if there is any kind of complicated scenario on the cards.

Great points.
There is a debate over which consultants are actually better ....private or public.

Private - are incentivised to operate and they'll be paid well.....versus public who have a limited budget and get paid either way.

the two tier system does not work

Shazamm

intothewest wrote: »

What happens in that scenario, where the terms of the policy change mid policy? Would they refuse a claim I wonder, or honour it based on when you entered the policy?

I am still waiting to receive the recordings of the calls we had with them, nor have I received the transcript of the online chat that I had with them, despite both being requested and being told the former was being sent to me about three weeks ago.

It seems you have to know what you entitled otherwise you'd accept their refusal.

Look at the articles again about the insurance companies turning down everything first and foremost in the irish times and only relenting when forced....eg ombudsman....legal etc.

But the ombudsman is useless and only is for public systems.
The financial ombudsman is for insurance and again seems hopeless.


You will probably not receive the recordings as they want you to ....disappear and accept the scenario.

They exercise this so you won't be able to appeal.

intothewest

The Hermitage originally told us to check with VHI to see if she was covered, so I am not sure they will be able to/want to tell me if the procedure was covered under the old scheme. VHI themselves told me her old policy didn't cover it. But did it not cover it under the policy as it stands right now (as a poster above said they regularly change schemes mid policy) or was it not covered under it ever? Which is something new I need to find out.

Under GDPR regulations, they have to share those recordings with you if you request them. As they do the web chat.

intothewest

intothewest wrote: »

The Hermitage originally told us to check with VHI to see if she was covered, so I am not sure they will be able to/want to tell me if the procedure was covered under the old scheme. VHI themselves told me her old policy didn't cover it. But did it not cover it under the policy as it stands right now (as a poster above said they regularly change schemes mid policy) or was it not covered under it ever? Which is something new I need to find out.

Under GDPR regulations, they have to share those recordings with you if you request them. As they do the web chat.

Will be very interested to know the outcome of this.

Shazamm

intothewest wrote: »

The Hermitage originally told us to check with VHI to see if she was covered, so I am not sure they will be able to/want to tell me if the procedure was covered under the old scheme. VHI themselves told me her old policy didn't cover it. But did it not cover it under the policy as it stands right now (as a poster above said they regularly change schemes mid policy) or was it not covered under it ever? Which is something new I need to find out.

Under GDPR regulations, they have to share those recordings with you if you request them. As they do the web chat.

This is good to know.
They're taking their time getting things together.

One patient who received contrasting advice over the approval got the cover when the recordings were reviewed.

she would have been refused flat out had she not been proven to have been told the wrong advice.

I always laugh at some of the advice given re health insurance by consumer experts on the radio etc. They will frequently tell us "seek the cover you want....don't go for stuff you won't need". Now, apart from pregnancy cover, this 60 year old woman cannot predict what stuff I might of might not need. It can be hard to predict what might go wrong with you, and what hospital service might best be suited to the ailment of your future. Whatever befalls me, I wanted very substantially covered as I might have run out of spare money to cover shortfalls and I got medical insurance in the first place so as I don't have to sell the house over my head.

The experts often talk about private versus semi private rooms. This is a changing scene too, as private hospitals are mostly converting to fully private rooms, especially as a response to Covid. It is realised that room sharing is a very bad idea in a hospital setting for the sake of infection control. Indeed, if you do develop a transmissible infection you are normally transferred to a sole occupancy room, even in a public hospital. The days of when it was seen as a luxury or price large area disappearing, but of course our insurance will all go up to cover this.

intothewest

So there is little to report back progress wise. Last week I received the CD with the conversation I had with them in June. This was requested early December, and they said they were sending it out then. They also said they would send me the conversation my mother had with them three days before me in June, but the letter with the CD said they couldn't send me that without my mother's permission. This is the first I heard of that, it wasn't mentioned to me in Dec they would need her permission...plus, I am down as a named contact on her policy.

Also, in December, they told me that a webchat I had with them (when I enquired with the operation code) they told me in December that that webchat stated their benefits line was busy, and if I wanted to hold or request a call back. The webchat detail they sent me in the letter with the CV doesn't state that. It says that I would need to call the benefits line to ask that. So what they told me in Dec is different to what I am reading.

Yet, when I asked on webchat in December, if her old policy covered that operation code, they were able to answer me with a yes/no answer on the webchat...

Jim2007

intothewest wrote: »

They also said they would send me the conversation my mother had with them three days before me in June, but the letter with the CD said they couldn't send me that without my mother's permission. This is the first I heard of that, it wasn't mentioned to me in Dec they would need her permission...plus, I am down as a named contact on her policy.

Customer service people are legal experts and it's in their nature to be helpful. I would expect when a compliance officer looked at it, he said no, which is correct. Even if you are named on the policy, you don't have a right to people's private conversations.

intothewest wrote: »

Also, in December, they told me that a webchat I had with them (when I enquired with the operation code) they told me in December that that webchat stated their benefits line was busy, and if I wanted to hold or request a call back. The webchat detail they sent me in the letter with the CV doesn't state that. It says that I would need to call the benefits line to ask that. So what they told me in Dec is different to what I am reading.

Yet, when I asked on webchat in December, if her old policy covered that operation code, they were able to answer me with a yes/no answer on the webchat...

Can you remember this? If they told you that at the time, one would expect that you followed it up, since that was your objective at the time. So there should be more telephone conversations....

intothewest

I understand the GDPR element, I guess my point is that when I asked in December for those call recordings, it wasn't mentioned then that my mother's permission would be needed. I was told then that both her and my conversation were being sent out. They even rang me back to get my postal address as she said she had them ready to send. We are now nearly five weeks after that exchange and only now am I being told they couldn't send me that.

They said they called me back the next day, but I don't recall a missed call from them.

intothewest

If anyone is curious or in a similar situation, you can review cases that were brought to the Ombudsman here.

https://www.fspo.ie/decisions/

Just been highlighted to me so thought I would share it. I'm none the wiser having reviewed some of the cases here that were due to pre-existing conditions.

intothewest

intothewest wrote: »

If anyone is curious or in a similar situation, you can review cases that were brought to the Ombudsman here.

https://www.fspo.ie/decisions/

Just been highlighted to me so thought I would share it. I'm none the wiser having reviewed some of the cases here that were due to pre-existing conditions.

The moral of the story is that if you are suffering symptoms don't expect it to be covered for years by a new insurance product. It's understandable as the purpose of insurance is to cover the unexpected. You just have to go public with your existing ailments.