VHI won't cover endoscopy. Is this right/fair?

Brosso · 07-09-2013 5:35pm #1

Hope I'm in the right thread.

My Dad's GP sent him for an endoscopy on July 2nd. He presumed this procedure was covered by the VHI as no one told him differently.

Furthermore he underwent a colonoscopy 12 months previous to this and it was covered.

Now, an invoice of €500 has been sent to him from the VHI, stating that the procedure was not carried out "for one of the clinical indications listed in the Schedule of Benefits for Professional Fees". How can this be and why was he not informed prior to the procedure??

I am going to contact the VHI on his behalf but before this I'm hoping to hear from someone who has been in a similar situation. It seems so unfair to charge him this amount when he has spent thousands and thousands on health insurance with the VHI over the past number of years.

Any advice/guidance would be really appreciated!

Scortho · 07-09-2013 5:54pm

Brosso wrote: »

Hope I'm in the right thread.

My Dad's GP sent him for an endoscopy on July 2nd. He presumed this procedure was covered by the VHI as no one told him differently.

Furthermore he underwent a colonoscopy 12 months previous to this and it was covered.

Now, an invoice of €500 has been sent to him from the VHI, stating that the procedure was not carried out "for one of the clinical indications listed in the Schedule of Benefits for Professional Fees". How can this be and why was he not informed prior to the procedure??

I am going to contact the VHI on his behalf but before this I'm hoping to hear from someone who has been in a similar situation. It seems so unfair to charge him this amount when he has spent thousands and thousands on health insurance with the VHI over the past number of years.

Any advice/guidance would be really appreciated!

You'd really need to read the fine print of the insurance plan that he was signed up too. Just because you've got health insurance, doesn't mean that you're covered for everything, your only covered for what you've paid for.

If his plan states that the procedure was covered then it should be paid for by vhi.
As to why he wasn't informed, was he asked how he wished to pay for it?

coylemj · 08-09-2013 1:02am

Brosso wrote: »

Now, an invoice of €500 has been sent to him from the VHI, stating that the procedure was not carried out "for one of the clinical indications listed in the Schedule of Benefits for Professional Fees". How can this be and why was he not informed prior to the procedure??

You need to put that question to the hospital/clinic where the procedure was carried out. They normally ask for your VHI membership number and can quickly tell you if the procedure is covered, otherwise they ask for a credit card.

What happened in your father's case is strange, it appears that the VHI have already paid the clinic for the procedure and then had second thoughts so now they're asking your father to pay them.

broker2008 · 08-09-2013 10:03am

This highlights the importance of checking with the insurer in advance of ANY procedure being carried out. Insurers contracts with hospitals can be at any time and a procedure that used to be covered in the past might no longer be covered the next time that the same procedure is carried out. Clinical indicators have changed for MRI & CT's as well. You should think long and hard about the lead up to getting the endoscopy carried out. The GP is not going to know whether it is covered or not. Did you ask the hospital if it was covered? Did you ring Vhi to ask was it covered? If not, you haven't much chance. If the hospital gave the impression that it was covered you could dispute the bill by writing to both Vhi and the hospital stating your version of events. Vhi don't make their Schedule of Benefits available. Perhaps when they eventually get regulated by the end of this year, this will change. Even so, it is a difficult document to understand for a layperson. Was it treated as a outpatient expense ? If so, you might be able to claim something back.

ted1 · 08-09-2013 10:07am

His policy would list the hospitals covered so he was told as its on his policy. That's the answer you'll get

lonestargirl · 08-09-2013 8:52pm

ted1 wrote: »

His policy would list the hospitals covered so he was told as its on his policy. That's the answer you'll get

It's not the hospital that is the issue it's the clinical indication for the scope. VHI will have a list of clinical situations under which they will cover certain procedures or tests and presumably the reason his doctor referred him is not on this list.

coylemj · 08-09-2013 10:11pm

It's a bit strange though that the VHI is asking him for the money. You'd have thought that the clinic where the procedure was carried out would have verified his eligibility for VHI coverage before performing the tests. I suspect that what happened here is that the clinic got the green light from the VHI, billed them, got paid and now someone in the VHI realises that they screwed up and is asking the subscriber to pay up. That's the only circumstances under which the VHI would come back looking for the subscriber to pay them for a procedure which has already happened. In normal circumstances, they would tell the clinic that they will not cover the procedure in which case the patient would be asked for a credit card.

I'd refuse if I was the OPs father on the basis that if the VHI agreed to pay the clinic then that's between them and the clinic and the subscriber shouldn't have to pay for their (VHI) mistake. What he needs to tell the VHI is that he wouldn't have undergone the procedure if he knew he was going to have to pay for it.

Down South · 08-09-2013 10:17pm

Same happened me recently. Consultants office confirmed it was covered by VHI. I called VHI myself to be sure.Later I get a bill for over €1k. VHI said that it was my 2nd within 3 years and because the reason was not one of the listed reasons it wasn't covered. At no point was the VHI advice in advance qualified in this respect.

Went back to the consultant and was told that they would probably have to write a more detailed letter saying why it was needed. that was 3 weeks ago and no news yet.

calfmuscle · 08-09-2013 10:22pm

the insurance company are being mean and saying that you didn't need the procedure. just call your doctor and ask for a detailed letter stating why they referred you and that should be the end of it. At the end of the day no insurance person can override the clinical reasoning of a health professional!

broker2008 · 08-09-2013 10:42pm

calfmuscle wrote: »

. At the end of the day no insurance person can override the clinical reasoning of a health professional!

Of course they can. The procedure is not on the schedule of benefits with the relevant clinical indicators. ONE MUST CHECK in advance of any treatment with the insurer. If a doctor or dr's secretary says otherwise, take it up with them for misleading you.

MagicMarker · 08-09-2013 10:45pm

calfmuscle wrote: »

At the end of the day no insurance person can override the clinical reasoning of a health professional!

It's a health insurance company, do you not think they have their own health professionals?

coylemj · 08-09-2013 10:47pm

calfmuscle wrote: »

At the end of the day no insurance person can override the clinical reasoning of a health professional!

If that was the case there would no such thing as different schemes, the main differentiator between the different schemes is the list of procedures which are and are not covered.

Ultimately it's the bean counters in the insurance companies who get to decide.

Brosso · 08-09-2013 10:56pm

Thanks to all for the advice.

I'll get him to request a more detailed letter from his GP and hope that works.

I'll also contact the VHI and query why they initially paid for the procedure and then reversed this decision.

I'll raise the point also that the hospital would have looked for payment on the day (with a credit card or otherwise) if the procedure was not covered.

broker2008 · 08-09-2013 11:19pm

coylemj wrote: »

If that was the case there would no such thing as different schemes, the main differentiator between the different schemes is the list of procedures which are and are not covered.

Ultimately it's the bean counters in the insurance companies who get to decide.

Nothing to do with it at all. If the procedure is not covered on one plan it is not covered on any. You won't see it on the table of benefits that is issued on your plan. The only place that will show is on the Schedule of Benefits.

Here is an example of clinical indicators for a particular capsule endoscopy:

Repeat

No consultant or hospital benefits are payable for repeat GI endoscopy within 12 months of the initial examination except for the following clinical indications: -

1. Histological diagnosis of Gastric ulcer. 2. Coeliac disease - recheck for 3 month healing - one only check 3. Achalasia 4. post banding of oesophageal varices 5. Stent blockage 6. Re-biopsy of an oesophageal ulcer 7. Barrett’s mucosa with dysplasia 8. Gastric mucosa showing dysplasia 9. a new clinical indication unrelated to the original endoscopy, which is/are and identified indication, will not be excluded by a prior endoscopy.

coylemj · 08-09-2013 11:20pm

OP, can you say which plan your father has with the VHI?

broker2008 · 08-09-2013 11:22pm

OP, what is the procedure code that the invoice relates to?

chuky_r_law · 09-09-2013 11:56am

im on vhi one plan 125. had colonoscopy/endoscopy done a few years back. paid excess. turned out i was fine

the consultant recomended to me that i should have it done again in another 12 months. i said fine lets do that.

turn up 12 months later. book in. give policy details. was told that my insurance only covers me for this procedure once every 2 years and that it would cost me €900 on the day to get it done. am thinking to myself....wtf?????

surely someone in the consultants office would have explained this to me prior to the day rather than me just turning up. probably should have checked myself but seeing as it was on my consultants recommendation that i have the repeat procedure a year later then i presumed i was covered.

anyway, told the consultant where he could stick his colonoscopy.

also, learned that day that when it comes to insurance PRESUME NOTHING. always ring your insurance company well in advance if you are having a procedure. even if your doctor/consultant is recommending you for some procedure check where you stand with your insurance company, since they are the ones paying the bills

coylemj · 10-09-2013 11:04am

chuky_r_law wrote: »

anyway, told the consultant where he could stick his colonoscopy.

Your consultant recommended you have a procedure, the bean counters in your insurance company refused to pay for it so you verbally abused the consultant!

If you ever do decide to have another colonoscopy, may I recommend you get a different consultant - just in case!

magmay · 24-09-2013 12:29pm

broker2008 wrote: »

Nothing to do with it at all. If the procedure is not covered on one plan it is not covered on any. You won't see it on the table of benefits that is issued on your plan. The only place that will show is on the Schedule of Benefits.

Here is an example of clinical indicators for a particular capsule endoscopy:

Repeat

No consultant or hospital benefits are payable for repeat GI endoscopy within 12 months of the initial examination except for the following clinical indications: -

1. Histological diagnosis of Gastric ulcer. 2. Coeliac disease - recheck for 3 month healing - one only check 3. Achalasia 4. post banding of oesophageal varices 5. Stent blockage 6. Re-biopsy of an oesophageal ulcer 7. Barrett’s mucosa with dysplasia 8. Gastric mucosa showing dysplasia 9. a new clinical indication unrelated to the original endoscopy, which is/are and identified indication, will not be excluded by a prior endoscopy.

I am making an appointment for a 5 yr repeat procedure. My VHI policy was renewed in March 2013. My consultant states that the procedure is no longer covered as VHI have issued a new Clinical Indicator report on 1st June 2013 to all consultants which now excludes the procedure. As a policy holder I was not informed about any changes to my cover, can VHI change the guidelines without notification mid policy?

LostArt · 24-09-2013 3:51pm

magmay wrote: »

I am making an appointment for a 5 yr repeat procedure. My VHI policy was renewed in March 2013. My consultant states that the procedure is no longer covered as VHI have issued a new Clinical Indicator report on 1st June 2013 to all consultants which now excludes the procedure. As a policy holder I was not informed about any changes to my cover, can VHI change the guidelines without notification mid policy?

No they can't, if you had the cover on your plan on March 1st you retain that cover until your next renewal.

VHI won't cover endoscopy. Is this right/fair?

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