healthcare claim - any advice?

bishops palace

Hi guys,

2 years ago I was diagnosed with a condition that required treatment asap. My healthcare plan did not cover treatment at hospital X as it was private. I phoned my healthcare provider prior to any treatment and told them my story to ask them what I should do. I was told that my plan wouldn't cover me for admission in the hospital, either overnight or day case. However my plan did have outpatient benefits which meant that they would refund 50% of any fees paid by me to GP's, Consultants or hospital fees on an outpatient basis.

Based on this I decided to undergo the treatment in the private hospital, I figured that although I had to pay a lot, it was a better option for my health and if i got back half, it wasn't so bad.

Now I have sent in my claim for 2008 (in which i spent the most) and it has come back as nearly all ineligible.

My hospital bills are clearly outpatient bills. They include pathology and theatre charges. They have disallowed all.
My Consultant bills are for consultation and procedures. They have disallowed the procedure ones.

I have searched all the documentation I can get my hands on and there is nothing about not covering theatre charges for outpatients. I have contacted them about the claim and but they said that theatre charges are seen as inpatient treatment. The pathology is under review.

They also said that they disallowed the consultants fees for procedures as they only cover specific 'consultancy charges'.

So what was the point of advising me to get treated as an outpatient when they can say to me when they see my bill, "oh sorry that's actually seen as inpatient treatment".
And what's the point of listing 'Consultant Fees(excluding maternity)' in the outpatients benefits section of my agreement when they could've stated that it excludes also any procedures carried out at a hospital not covered.

Bp

Slice

Unfortunately there is a difference between in-patient day-cases and out-patient cases. If you're in any doubt you can take it to the Health Insurance Authority who regulate the private medical insurance market http://www.hia.ie/

bishops palace

Thanks for that

NuMarvel

The HIA should be able to give you some advice on how to proceed, but as an insurance company, your insurer is also under the remit of the Financial Services Ombudsman as well. In fact, if you want to make an official complaint, it's the Financial Ombudsman you need to go through, not the HIA. The HIA's functions are limited when it comes to customer complaints.

Before engaging their services, you need to go through your insurer's internal complaints procedure first. You can find details here.

Also, before you start to go down that road, I think you should get a copy of the call from the insurer. Alot of time has passed since that telephone call, so there's no harm being 100% certain as to what you were told at the time. I used to work in health insurance and I dealt with a number of people that swore black and blue they were told one thing, but when the call was played back they were clearly told another. They weren't lying, it's that what they were told and what they remember being told were different.

If the call wasn't recorded, you can ask for a copy of the notes of the call. If there are no notes of the call then, the insurer is on shakier grounds as it's harder for them to prove that you were told it wasn't covered.