# VHI - Refusing to Cover Gallstones removal - policy on pre existing conditions



## peno (18 Jan 2008)

Hi,

Can anyone clairy this for me please.

A family member has just been told she needs her gallstones removed. 
She has been a memebr of VHI for 2 years. This is her first health cover so doesn't have any previous years with another company.

VHI are refusing to cover the operation as they say it is a pre existing condition. I know there are terms and conditions setting out pre existing conditions not being covered for 5 years but surely if you discover a preblem that you were unaware of after 2 years then VHI should cover the necessary procedure.

Can someone famialr with health insurance clarify this please.

Thanks


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## ClubMan (18 Jan 2008)

*Re: VHI - Refusing to Cover Gallstones removal*

When were gallstones *first *diagnosed? If it was before cover was taken out then since the 5 year waiting period has not expired then the procedure will presumably not be covered. It should be straightforward as to whether the procedure is covered or not based on when the person took out cover and when the condition was first diagnosed.


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## peno (18 Jan 2008)

*Re: VHI - Refusing to Cover Gallstones removal*

Condition was first diagnosed this week.

VHI are refusing to cover as they say that although not diagnosed they were present at the time the policy was taken out which is 2 years ago.

Is the burden of proof on them to prove they would have been present 2 years ago before the policy commenced?


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## Shannon81 (18 Jan 2008)

*Re: VHI - Refusing to Cover Gallstones removal*

hi

As far as i know the doctor is to state the onset date of the illness-speak to the consultant and see what they have to say.

If you get no joy, then i would send in a letter of complaint and attach the info from the consultant/doctor with the onset of the illness date on it.l


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## ClubMan (18 Jan 2008)

*Re: VHI - Refusing to Cover Gallstones removal*

What is their definition of "pre-existing condition" in the terms & conditions of the policy? I can't find it online.


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## peno (18 Jan 2008)

*Re: VHI - Refusing to Cover Gallstones removal*

Looked online myself and ciuldn't find it. I asked them via email to set out their policy on pre existing conditions and to give details.

Here is their response.

"We do not have a list of conditions that would be considered pre-existing.  A pre-existing condition is any condition that the onset date of which was prior to setting up your policy.  We would determine this when a claim is submitted for benefit.  This information is normally supplied by your G.P. or Consultant on when a claim is being made. 

Note: When determining whether a medical condition pre-exists membership it is important to note that it is the date of onset of the condition that is considered rather than the date of upon which the member becomes aware of the condition, as medical conditions may be present for some time before giving rise to symptoms or being diagnosed."

Looks like we need to see what the doctor estimates is the onset of the condition and from there argue with them.

Thanks for the input


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## efm (18 Jan 2008)

*Re: VHI - Refusing to Cover Gallstones removal*

This policy on pre existing conditions seems a bit mad - what if you had a genetic defect that existed since birth but was only diagnosed in your 20's or 30's - would your VHI cover the surgery or treatment to remedy it?


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## ClubMan (18 Jan 2008)

*Re: VHI - Refusing to Cover Gallstones removal*

As mentioned above if necessary challenge the decision and complain. If you get no joy having exhausted their complaints process then maybe get a "final response" letter perhaps take the complaint to the [broken link removed].


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## Megan (18 Jan 2008)

*Re: VHI - Refusing to Cover Gallstones removal*

I found this on VHI website. 

[broken link removed]

Allways read the small print. My husband pays into a earnings protection insurance policy. 
He had suffered w a blocked nose for a number of years and his GP prescribed a nose spray which he had being using for about 2 years. A year ago he got a bad sinsus infection and his GP was on holidays and he attended another GP in the practise and when he examined him he said he had polyps and refered him to an ENT surgeon. He spent 4 days in hospital. When he claimed on his earingins protection policy they wouldn't pay out as they said he had the symptoms for 2 years before his operation. This was down to how his GP filled out the insurance form.


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## aircobra19 (18 Jan 2008)

*Re: VHI - Refusing to Cover Gallstones removal*

I guess if you notice yourself getting older then thats going to exclude a lot of things. Lots of things have symptoms that could be a minor, like  cold or infection, but are much more serious which only becomes apparent over time. Seems to me like this is a real get out clause though I realise there are people who abuse it, this is taking it a bit far. Who wants to intentionally delay their treatment?

I no its kinda off topic but do other insurers have the same condition?


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## ClubMan (18 Jan 2008)

*Re: VHI - Refusing to Cover Gallstones removal*

I think most health insurers have waiting/exclusion periods for certain pre-existing conditions.


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## scuby (18 Jan 2008)

peno said:


> Condition was first diagnosed this week.
> 
> VHI are refusing to cover as they say that although not diagnosed they were present at the time the policy was taken out which is 2 years ago.
> 
> Is the burden of proof on them to prove they would have been present 2 years ago before the policy commenced?



the burden of proof is not on them, they go by what the consultant and gp gives them on the claim forms. There is no medical book anywhere that will tell you how long a conditions is there. The medical history is usually clarified by the consultants, who indicates how long the condition was there, prior to the visit to them for the complaint.



Shannon81 said:


> hi
> 
> As far as i know the doctor is to state the onset date of the illness-speak to the consultant and see what they have to say.
> 
> If you get no joy, then i would send in a letter of complaint and attach the info from the consultant/doctor with the onset of the illness date on it.l



agree, that the consultant clarifies the info, not the insurance comp.



efm said:


> This policy on pre existing conditions seems a bit mad - what if you had a genetic defect that existed since birth but was only diagnosed in your 20's or 30's - would your VHI cover the surgery or treatment to remedy it?



well once your waiting periods is up, you are covered. Thats why companies have waiting periods for pre-existing conditions ! if you find out today you have a heart problem, join tomorrow, then go for an operations costing thousands a few days later, you can hardly expect them to cover it !!



ClubMan said:


> I think most health insurers have waiting/exclusion periods for certain pre-existing conditions.


correct.


Has the claim been rejected ?? you can always get your consultant+gp to write a report and send it to them to pre-certify it. Think this can be done if the consultant is not sure if an operation will not be covered..


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## snuffle (19 Jan 2008)

*Re: VHI - Refusing to Cover Gallstones removal*



aircobra19 said:


> I guess if you notice yourself getting older then thats going to exclude a lot of things. Lots of things have symptoms that could be a minor, like  cold or infection, but are much more serious which only becomes apparent over time. Seems to me like this is a real get out clause though I realise there are people who abuse it, this is taking it a bit far. Who wants to intentionally delay their treatment?
> 
> I no its kinda off topic but do other insurers have the same condition?



I think it's used as a get out clause for the insurers no doubt. Someone I know was told initially by their health insurer that they would cover the cost of an op to get tonsils removed (person was in their late twenties going for the op). When they went to claim cost of the operation back, the insurer said they noted from medical records that the person had had a minor throat infection at age 10, therefore the condition was pre-existing??? 
I can't imagine there are many people around who have not had some form of throat infection over their entire lifespan, but to blame the need for a tonsilectomy in adulthood on a minor throat infection at age 10, to get out of paying for the op sounds ludicrous.


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## scuby (20 Jan 2008)

*Re: VHI - Refusing to Cover Gallstones removal*



snuffle said:


> I think it's used as a get out clause for the insurers no doubt. Someone I know was told initially by their health insurer that they would cover the cost of an op to get tonsils removed (person was in their late twenties going for the op). When they went to claim cost of the operation back, the insurer said they noted from medical records that the person had had a minor throat infection at age 10, therefore the condition was pre-existing???
> I can't imagine there are many people around who have not had some form of throat infection over their entire lifespan, but to blame the need for a tonsilectomy in adulthood on a minor throat infection at age 10, to get out of paying for the op sounds ludicrous.



that sounds strange.. the insurance comp could not reject a claim for that ! unless it was directly connected with the tonsil complaint..


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