Laya Health Insurance
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12-05-2022 8:52pm#1
Hi, need some advice. I'm with Laya Insurance and I contacted there GP service last September with a problem I was having with a pain in my chest. He recommended I get a scan done, endoscopy and sent me the referral letter. A month later I get the scan done in Barrington's. The scan showed i had a Hiatal Hernia, bit it wasn't causing the pain I had. The consultant recommended I get a CT scan, which I got that day. Roll on January and still no results from that even after numerous emails and phone calls. it caused me a lot of anxiety. Then in January I get a letter from Laya that they need the results from the hospital to process the claim. Since I had gotten no where with Barrington's I decided (for the first time) to contact my GP. He managed to get the CT results and found they where all clear. I sent that info to Laya. A month later I get another letter from Laya saying they need the letter from the GP so I go back but he has retired. They give me the paper work they have and I send it off. Another month later I get the same letter and then I get on on to Barrington's who say they is normal and that they'd send on any info they have to Laya. The two weeks ago I get another letter from Laya (btw these letters always come on a Friday so I can't get anything done until the Monday) saying the same thing , that they need more info from the GP. Annoyed by this and their incompetence I email them and inform that I had never gone through my GP regarding the procedure , I used there's, and that I had given them everything I had. I gave them my GP's number, informed them he had retired and that if they needed anything they could contact him. Today I get an email (after closing time so I can't contact them) that my claim wouldn't be processed and that I would have to pay the full hospital fees totalling €1100 aprox. I'm not sure what to do now, it's caused me a lot of anxiety and stress and I'm on an expensive plan that I will be cancelling. Is there someone I can't contact regarding it, I really don't know what to do.
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I prescribe phoning Laya rather than dealing with emails and letters.
And 4 paragraphs, taken twice daily.
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rang em this morning, they say they're looking for a letter I gave them already, the incompetence is unbelievable , They're to get back to me in "2 working days". Should get money back for stress and hassle caused.
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An update, apparently laya, who rang on a Friday evening again, claim that it was a pre existing condition. They claim I was taking medication for it, which I had to think long and hard about as it was a year ago and I remembered finally I may have been taking an over the counter drug for about a week prior to calling them which did nothing for me and wasn't anything to do with my issue, although I'm not entirely sure about that.. I do know the laya GP prescribed that drug to me as it's written down. 25 minute call , during work,where I lost customers, the laya rep couldn't tell me how long you need to have a pre existing condition for. I've had unbroken health insurance for over a decade, started with laya in June and this issue started in September. I looked back on the records on their app and under medication it said none. It's unbelievable how awful they are. It had completely ruined yet another weekend stressing about it. Eventually she said she'd open an appeal.. I said I'd be contacting a solicitor.. does anyone know what to do next, small claims court maybe? How do I go about it.. it's 5am and I can't sleep.its awful what this horrible company had done to me.. and also ive paid more to them in the year than what the procedure would have cost.. if I went public it wouldn't have even cost anything
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Do Laya know you have unbroken insurance for more than 10 yrs? There should be no 'pre existing' stuff if it's more than 5 yrs assuming you have not upgraded policy in recent past as that may cause an issue with 'pre existing' if the hospital/procedure is part of the new cover and you were not covered under previous policy you may have a waiting period.
If new cover is not the case then they may not have a record of your insurance, if they don't you may need to send them proof, I ran into similar issue few years back with Laya but it wasn't really Laya's issue but an issue with transfer of details from one company to another.
I can't actually remember the full details now but apparently the insurers have access to some database or other to show you previously had insurance which maintains the continuity of your cover but in one of those takeovers few years back when Bupa or whoever was amalgamated with another not all records transferred properly. I got a call from the hospital evening before a procedure saying insurer had said I was not covered due to pre existing and only having cover for a year, now I knew I was so went ahead and sorted the issue later and it all boiled down to there being no record of my insurance for the year I was with a different company which showed as a break in my cover. Now as luck would have it I found one paper record of an interaction with the company with the policy number on it, in these days of paperless everything I had nothing else at this stage from that company to prove I had a policy and apparently they crowd that took them over couldn't find it!
Anyway it was all sorted as they tracked it down when I provided policy number. Hopefully it's something similar in your case.
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They do know about he unbroken insurance because when I changed over they asked for details. They were pissy about that too at the time. I had been with VHI for ages and one year about 8 years ago I switched to another for just a year so I had to get proof of being with the other insurer. Luckily I had an email with the info cause I couldn't remember any of that.
Your second point has me worried though. The reason I switched from VHI to Laya was that I needed an operation (unrelated to the latest issue) during the pandemic. I then only realised that the plan I was on with VHI only covered public hospitals for that procedure. Of course at the time public hospitals weren't doing procedures so I argued with them that the policy was useless. VHI didn't budge so I decided to switch once my policy was up. But before that the Doctor considered it emergency and did through some scheme the government set up.
I just checked my old plan with VHI and it mentions CT Scan in private is included but no mention of gastropathy. I didn't know and it was never explained that that would be an issue. I mean I would have gone public if I'd known. And the hospital checked my plan and said the procedure would be covered if it didn't relate to the surgery I had earlier on in the year, which it didn't.
Health insurance companies are really awful
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although saying all that, the reason they gave me was because I had mentioned to the Laya GP that I had been taken over the counter medicine for a few weeks before I contacted them ....
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The people on the phone at laya are useless. Had a scan rang them prior was told I was covered. It was a new policy through work so hadn't gone through the details (I know my fault). Gets down it and the scan cost isn't covered because of the excess, which wasn't mentioned on the call.
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I really feel your pain, OP. I have had major complex health issues in the past, so have been through mainly private system and one emergency surgery in public system.
I’ve had countless dealings with health insurance, and to tell you the truth it is an ever moving goal-post, it is impossible to actually keep up with what’s covered as medicine is rapidly evolving. But going by what you detail here, I believe you are likely being wronged by insurance company, with all the services being very frustrating for you.
Having explored the whole thing in a lot of detail I remained with VHI as they were offering the best cover I potentially need, and they are generally speaking “ok” to deal with.
I’ll give you an example of how frustrating it all is. I had to undergo removal of my entire colon in 2016 and I now have a permanent ileostomy. I checked prior to surgery would I be fully covered in a certain private hospital and was assured I was. And mostly I was. However I got a large fee for intensive care where I ended up for a few nights owing to blood loss and general instability. VHI advised that I should have consulted with them before conceding to go into intensive Care. I was brought there in and out of consciousness, incapable of making a call and would have died without ICU care. Such a ridiculous argument. It completely defeats the purpose of private health insurance if you lose capacity to consent to additional services required to keep you alive! Private medicine here is getting more like USA in this regard. Anyway, the upshot was I refused to pay, and they wrote it off as I started to make life hell for them all 🤣
Presuming here, facts are as you present them here, do NOT get intimidated by them. They are only office processes, churning out those letters. Treat your side of things as a process, fire off your defence that you have unbroken cover. It is highly likely you will, as I did, get letters from a medical debt collecting agency. Don’t be intimidated by them or let them stress you, although that’s very hard to do in practice!
You mention “gastropathy” which is a medical term for some structural change in stomach lining but no active inflammation. It could be from prior inflammation, possibly from acid reflux, or taking NSAID painkillers. But it needs be a doctor explaining this, and sometimes they are not great at informing patients exactly what is likely to have been going on with them. You said a doctor said your discomfort is unrelated to a Hiatal Hernia, which was diagnosed. I have that condition too, and it causes reflux, gastric & esophageal issues at times. It seems strange to me that your doctor pronounced that it couldn’t have been related to your symptoms, but it depends on how you described them to your doctor.
If English is not your first language, maybe there is an issue in communication with medical terminology and description of symptoms? Whether that would be related to the insurance cover, I’m not sure, but insurance companies have ways of trying to determine you are not covered because of this or that, and it can get technical.
My instinct here is that doctors have left you and the insurance company short of an adequate description of your condition. The insurance companies employ doctors to evaluate the descriptions of our treating doctors and if that falls short, the insurance company’s own doctor (the one looking after the profitability of the company, not your interests) concludes “insufficient evidence of the need for the procedure/test in the first place”.
I mentioned the one case where I was not covered, the care in ICU. But there was another, where I was summonsed into the private hospital for a follow-up procedure. VHI said it was an “unnecessary admission” and refused to cover it. It turned out to be a clerical mistake by the private hospital admin staff, they shouldn’t have phoned me to say to come in overnight. Again I was sent a debt collector’s letter but I refused to pay as it was a hospital error to get me to come in. I stood my ground, again refused to pay, and it was written off.
Hospitals are mostly reluctant to follow up with formal legal action, especially where a staff member of working consultant has fallen short in the communications department, resulting in unnecessary expense to the patient.
I think you probably have little grounds to worry.
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Your response was very helpful, puts me at ease.
Ya I got a book on hiatal hernias that I found very helpful, gave me exercise and diet plans. Described my symptoms exactly. I explained that to my GP and he said it was all wrong, but to be honest I've had little faith in him for years. He's retired now anyways. here is the book btw: https://www.amazon.co.uk/dp/B01GDBQKEO/ref=pe_33573471_635671331_TE_M1DP
Person I talked to was awful. Couldn't answer how long a pre existing condition was for. I was not kind to her I'll admit
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The thing about health insurance, as I said, is that it is a rapidly moving target, no telephone admin person is really qualified to answer instances of what might or might not be covered, and can only talk in more general terms. It’s kind of as complicated as the law itself.
In the days past (my teen years to 40s) of less rapid medical progress, there were only a few medical insurance plans to choose from. Indeed when I started work there was only VHI and no other equivalent provider. Staff could much more definitely tell you what was and wasn’t covered. Definitions of conditions were “simpler”, understanding less advanced. These days scientific advances are interlinking illnesses, and ascribing many genetic causes, so things are going to get more ever complicated. If genetic info is ever required in risk evaluation, I fear to think what we won’t ever be covered for. Scientific advances are great, but accessing them can be costly and complicated, especially before they become mainstream. Bespoke, individually tailored medicine is more and more the future. Even pet medical insurance is complex now.
The determination of whether your particular treatment is covered or not depends a lot on the insurance company’s assessing doctor who technically advises the claim assessor admin person. In My case the company’s advising doctor simply said “Arthur Inexpensive Geese” was administered unnecessarily for a procedure that could have been done on a day case. As it happened I had been in an out of hospital for two months, with post op complications, so it was hard for me to determine what was essential or not. There were weeks I was hospitalised, sent home, told to come back in for drainage procedures, and had the “hospital at home” tram to my house. Talking to insurance admins, they would advise you to phone them before every blessed procedure you undergo in a private hospital, and the hilarious thing is when I suffered a cardiac complication and was sent to coronary care, I think was supposed to phone VHI and ask would this be covered. It was covered but might well not have been. If you go for private medicine and suffer unanticipated life-threatening complications in hospital, you may not be technically covered for the advanced care required to keep you alive, and you are hardly in a position to refuse treatment. And, like, would a public ambulance come and take you to a public hospital where you would have life-saving treatment as any citizen is entitled to.
Private hospitals can, at times, be dangerous places to get seriously unwell in. Last time I was in one, a lady in my room, who had been entirely stable and chatting away, rapidly developed sepsis. I think she underwent a minor surgical procedure but was on immune suppressants. I will never forget that night. Within an hour of chatting casually to her son about schoolwork she was beginning a fight for her life. She could not be placed on a ventilator because her consultant was asleep at home and could not be contacted. The staff present (junior doctor way out of her depth) were trying to resuscitate her until her consultant could sign off on a transfer to ICU. 2 agency nurses who happened to have ICU training were on ordinary routine duty elsewhere in the hospital and they diagnosed the sepsis and performed life-saving measures, giving instructions to the newbie doctor. The whole thing shocked me to the core, and other patients in the hospital went without any painkillers or care that night.
The reality is that the private hospital “system” is not fit for purpose in Ireland. The individual hospitals tend to be small and niche, and used to try & beat waiting lists, and indeed they can be hard to get into these times too. They sometimes are used as places to spend last few days in settings of terminal illness, but again cover might be limited if you survive “too long”.
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