Health Ins Claim Refused

intothewest · 17-12-2020 7:34pm #1

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 · 18-12-2020 2:08pm

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 · 18-12-2020 7:44pm

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 · 19-12-2020 1:35am

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 · 21-12-2020 1:34pm

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 · 21-12-2020 11:18pm

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 · 23-12-2020 11:03am

Had the Hermitage or you recordings of those discussions?

intothewest · 23-12-2020 1:07pm

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 · 23-12-2020 1:18pm

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 · 23-12-2020 1:56pm

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 · 23-12-2020 7:00pm

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 · 23-12-2020 7:08pm

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 · 24-12-2020 1:57am

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 · 24-12-2020 2:01am

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 · 24-12-2020 2:05am

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 · 24-12-2020 2:10am

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 · 24-12-2020 2:11am

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 · 24-12-2020 2:46am

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 · 24-12-2020 3:00pm

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 · 24-12-2020 8:45pm

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.

[Deleted User] · 24-12-2020 9:02pm

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.

[Deleted User] · 24-12-2020 10:00pm

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 · 27-12-2020 6:43pm

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 · 27-12-2020 8:14pm

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

[Deleted User] · 31-12-2020 6:31pm

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 · 01-01-2021 12:55am

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 · 01-01-2021 1:10am

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 · 01-01-2021 3:33am

[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.

[Deleted User] · 03-01-2021 9:05pm

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 · 03-01-2021 9:16pm

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?

[Deleted User] · 03-01-2021 9:38pm

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.

Health Ins Claim Refused

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