Health Insurance 20% shortfall on specified orthopaedic procedures.

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Saavy99

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How much are these shortfalls costing the insured person. Are we talking several thousand euro here? If a hip replacement cost for argument sake €30,000, it means the patient must fork out 20% of the cost, a total of €6000. It's a huge cost down on top of any other excesses the patient has to pay, and many people are probably not taking this cost on board when chosing a healthcare policy. I note from reading threads on here that this 20% shortfall is beginning to creep in to more and more policies.
How many are unable to afford this extra cost and are therefore forced into the long queues in the public system? This issue is rarely discussed.

As older people are more likely to require joint replacements, is it not discriminatory practise and a way of getting round the community rating to make older people pay more?
 
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Single hip or knee replacement would be between 11k & 15k. Bilateral between 20k to 25k.

Some policies have a maximum co-payment of 2,000.
 
RedOnion said:
Single hip or knee replacement would be between 11k & 15k. Bilateral between 20k to 25k.

Some policies have a maximum co-payment of 2,000.
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My estimated cost was too high, still a €2000 euro excess would still be a huge bill for many patients.
 
Yes, but note some private hospitals waive the shortfall, in certain procedures and policies.

The only one I've specific knowledge of is BlackRock Clinic where shortfall was waived on a knee replacement a few years ago. You can check the cover here, and they tell you what's waived. http://cover.blackrock-clinic.ie/

I understand Mater Private have (or at least had) a similar policy, but only on certain procedures.

I've no knowledge of other hospitals.

I did at one point look into paying privately for a hip replacement for a family member without insurance, and it's a minefield.
 
Saavy99 said:
As older people are more likely to require joint replacements, is it not discriminatory practise and a way of getting round the community rating to make older people pay more?
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It seems exactly that and just one of the ways insurers have tried to get around community rating.

But, hey, health insurers are regulated by the Central Bank so all good, right?
 
That is the cost I presume when all goes well, my father's cost over 40k roughly 12 yrs ago. Fortunately we were with Laya so no co payment, it is always something I look at when deciding but presume they will all got the same way eventually.
 
Monbretia said:
That is the cost I presume when all goes well
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Yes, apologies. That was part of the problem I had when I was looking at paying for an operation. While these procedures are generally seen as 'fixed price', there was effectively no cap to what the costs could be if something went wrong.
 
Great post this is.
This should be pinned at the top of the list.

We are getting fleeced now with these changes.

  • The costs of hip replacements can be up to €20-22k and upwards, according to irish life health and they explained to me the €2000 co-payment is better than the 80% cover
  • There is no cover for complications - or repeat procedures - i.e. you have to pay the fees again
  • These fees go towards the hospital directly - (who knows what for) and the patient has to settle this with the hospital.
  • I have had friends receive bills for hospitals that they were approved for and then billed post op for large amounts.
  • The insurance company does not get involved with these fees apparently - settled directly to the hospital.
  • 80% cover of a €25,000 euro procedure = €5000 payment is needed. This is for every time a procedure is needed, complications, repeat etc
Going on the HIA website and comparing policies - it is now on most policies - its either €2000 co payment or 80% cover and its each company


The only plans that don't seem to have it are -
  1. laya simply connect plus -
  2. laya connect Simplicity
But - they do not clarify any of this as seen below

Specified Orthopaedic & Ophthalmic ProceduresNo excess or shortfall applies for Specified orthopaedic procedures, normal excesses & shortfalls apply for ophthalmic procedures
 
Where they say 'normal' excesses and shortfalls, I think that means the 'per night' or per excess and shortfall you see listed for specific covers e.g. any scan or procedure in the Mater Private might have an excess of €100 and a shortfall per night of €175.

On Connect simplicity I think you are capped at 2 procedure excesses per year.
 
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For orthopaedic cover with Laya if you follow the PDF link on this page it lists the plans which have no procedure shortfalls (but may have excess and per night shortfalls applied as above)

Orthopaedic | Your Member Benefits | Laya Healthcare Ireland

At Laya we look after your hips, knees & more. We are the only health insurance company in Ireland to offer specific Orthopaedic procedures.
www.layahealthcare.ie www.layahealthcare.ie

 
OH how i wish you were right.


But it is for the listed 5 orthopaedic procedure ONLY - hip replacement, hip resurfacing, hip replacement revision, knee replacement, and revisions of knee replacement.

If you need any other procedure that does not apply

3660 Arthroplasty of hip using prosthesis, unilateral
3666 Metal on Metal hip resurfacing arthroplasty, unilateral
3661 Revision of total hip arthroplasty, acetabular and femoral components with or without autograft or allograft
3910 Prosthetic replacement (total) of knee joint, unilateral
3911 Revision of arthroplasty of knee joint, with or without allograft, one or more components
 
Just jumping on this subject, does anyone know the potential impact in terms of cost of the 90% only cover on a few policies for "Blackrock Clinic, the Mater Private and the Beacon Hospital, certain Special Procedures" - how much this 10% shortfall could actually be? It can be easy to move to a policy from 100% to 90% and think that's not much, but how much is it!

Edit - RedOnions' useful Blackrock link is very handy. But I'm confused about one thing, for a parent on Health Plus Extra (like a lot of people!), Blackrock states: "
In Patient Stay (per diem)You are covered. A shortfall of 55% applies for each night of your stay but this fee is waived by Blackrock Clinic. A €200 fee applies per night of your stay

So they waive the shortfall of 55% but charge €200 per night. Not sure which is better, but this is a bit confusing.

And for my own Laya policy:
CategoryCover Information
Day Case / Sideroom ProcedureYou are covered. A once off excess payment of €100 applies.
Non-Cardiac ProcedureYou are covered. A shortfall of €175 applies for each night of your stay but this fee is waived by Blackrock Clinic. A once off excess payment of €150 applies.
Orthopaedic ProcedureYou are fully Covered.
In Patient Stay (per diem)You are covered. A shortfall of € 175 applies for each night of your stay. A once off excess payment of €150 applies.
Cardiac ProcedureYou are fully Covered.

I'm confused by above from Blackrock. The above, but I must be reading it wrong, suggests that for non-cardiac they WAIVE the €175 per night shortfall, but if I have an in patient stay a shortfall of €175 applies per night. Do these 2 statements not contradict? Then I thought ahh, the waiving is for NON cardiac, so maybe that's it. But then at the bottom, they say cardiac covered ?!
 
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I have been advised to "shop around" if I require a hip operation - many surgeons operate in both public and private hospitals. My friend recently negotiated a fee of €800 - operation was done in a public hospital but she was a private patient.
 
Curlyfella said:
How does one .....shop around?
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Seriously....how does this negotiation work?
Does it mean john does negotiates and gets x fee for his hip replacement....and jane doe doesn't or does negotiate and pays something completely different?
 
Curlyfella said:
How does one .....shop around?
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2nd hand parts obviously! ;)

I'm not sure that one can 'shop around'.

One angle that I looked at previously was:
Person without health insurance, and limited means to pay privately. To get a hip replacement as a public patient, there are a few steps, and a delay at each one:
1. Your GP refers you.
2. Eventually you get x-ray appointment.
3. Then there's a waiting period to see the consultant.
4. Once you've seen the consultant, you're then in the waiting list for operation.

What we had looked into doing was presenting to consultant as a private patient to speed up steps 1-3 above, but then going back to the public system.

Ultimately, this wasn't followed in the case I was looking at, so I'm not sure whether or not it would have been any benefit.
 
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