VHI Plan B and Out-patient cover

W

wonderlust

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If a person has a procedure carried out in the out-patients department of a private hospital and the procedure has a code covered by VHI, is this paid for in full by VHI?

VHI Plan B for Private hospitals states:

Day-care & side room Full cover

My question boils down to whether the cover "Day-care & side room" applies to out-patient treatment as well as those who are admitted to the hospital and go home the same day.
 
This is what the VHI rule book has to say about cover for out-patient procedures:

Vhi Healthcare benefit is payable for out-patient procedures carried out in an approved hospital listed in the Directory of Hospitals and which is covered by your plan. Where an out-patient procedure is carried out in a hospital listed in the Directory of Hospitals which is not covered by your plan, professional fee benefit is payable in accordance with rule 6b. Hospital charges listed within Section 9 of your Table of Benefits may be included under the out-patient scheme and are subject to the out-patient excess. No professional fee or hospital benefit is payable for Out-patient Radiotherapy carried out in a hospital listed in the Directory of Hospitals, which is not covered by your plan.​

FYI, these are the definitions of day-case, side room and out-patient procedures:

"Day care procedure - Treatment or investigation which is marked as Day Care in the Schedule of Benefits for Professional Fees and the Schedule of Benefits for Private Hospital Services.

Out-patient procedure - Treatment given to an out-patient which is listed in the Schedule of Benefits for Professional Fees or the Schedule of Benefits for General Practitioners.​

Side room procedure - Treatment or investigation which is marked as side-room in the Schedule of Benefits for Private Hospital Services and for which an extended period of recovery is not required."​

If the procedure was an out-patient procedure carried out in a hospital covered by Plan B, it would appear to be covered, subject to the usual cavaets (waiting periods, participating consultant, membership paid, up, etc). It is odd though that out-patient procedures aren't mentioned in the hospital cover part of the Plan B table of benefit, but that may be down to the way it's classified. What seems like out-patient to you and I may be classed as side room for VHI.

Your best bet is to ring VHI to check what your procedure code is classified as. Your consultant or his/her secretary should also be able to give you this info, but I think VHI may be a better bet as ultimately they will be assessing the claim at the end of the day.
 
Looking at [broken link removed] would lead one to believe it does.

The terms and conditions as supplied by VHI with your renewal documentation should confirm but might be best to give them a call to double check as small print can be misleading sometimes.

Make sure also to take the name, time and date of the person confirming the cover even though the calls are recorded.
 
Thanks for the feedback on this. Sounds good but I suppose ultimately I need to confirm it with VHI. Thanks!
 
just ring VHI, give them the procedure code given to you by the Dr. ultimately it will depend on what info the Dr gives on the claim form when it is submitted to vhi for payment.
 
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