Health Insurance Health Ins claim refused - appealing

I contacted them today, and they are saying the former plan did not cover that operation.

Someone said to me on the general issue of confirming cover before the procedure, that they would have let the people in the Hermitage take care of that. Is that correct? And if the Hermitage got the ok from the insurance to say that they would be paid, it's now their problem, not ours. But am I right that this doesn't happen? That it's up to the patient to find out all of this in advance?
 
intothewest said:
Someone said to me on the general issue of confirming cover before the procedure, that they would have let the people in the Hermitage take care of that. Is that correct? And if the Hermitage got the ok from the insurance to say that they would be paid, it's now their problem, not ours. But am I right that this doesn't happen? That it's up to the patient to find out all of this in advance?
Click to expand...

Don't think that's right and yes it is up to the patient to find out all of this in advance. Why would they always recommend that you ring to confirm if the procedure is covered by using the specific code if the Hermitage have already done this. It would also be a lot of extra work for the hospital.
 
intothewest said:
I contacted them today, and they are saying the former plan did not cover that operation.

Someone said to me on the general issue of confirming cover before the procedure, that they would have let the people in the Hermitage take care of that. Is that correct? And if the Hermitage got the ok from the insurance to say that they would be paid, it's now their problem, not ours. But am I right that this doesn't happen? That it's up to the patient to find out all of this in advance?
Click to expand...

Have you appealed?

I think the process is to write an appeal letter first then to contact the financial ombudsman afterwards.
The whole thing is a scam - there is no correct way - they complicate everything in order for you to give up.
 
The hermitage is covered under the vhi one plan 150 - private hospital category 3

----
Table of Benefits – One Plan 150 -
  • Private 1, 2 & 3 hospitals (other than for certain investigations & treatments referred to in Section 1c & 1d)
  • Day care, side room & semi-private accommodation Full cover
  • Private accommodation Semi-private rate
  • Radiotherapy (day care & out-patient) Full cover
  • Hospital excesses - except maternity & certain cancer treatments - Hospital excess per claim – day care and side room €150 - Hospital excess per claim – in-patient admissions (payable only on the first 2 in-patient claims per member per renewal year under Section 1b and 1c) €150
 
When comparing the two plans on the hia comparison tool -

it states several times for the one plan 150 -
No cover for listed cardiac and special procedures in the Hermitage and Galway Clinic

It doesn't state what exactly are the special procedures are for the VHI

One Plan 150 -
Covered; €150 excess (payable only on the first 2 inpatient claims per member per policy year) except: 60% cover for certain orthopaedic and ophthalmic procedures, no excess.
No cover for listed cardiac and special procedures in the Hermitage and Galway Clinic



The link above does state the special procedures for irish life and there is no mention of any gallbladder procedures
So it looks like theres a chance they're wrong, but proving that is hard
 
Curlyfella said:
When comparing the two plans on the hia comparison tool -

it states several times for the one plan 150 -
No cover for listed cardiac and special procedures in the Hermitage and Galway Clinic

It doesn't state what exactly are the special procedures are for the VHI

One Plan 150 -
Covered; €150 excess (payable only on the first 2 inpatient claims per member per policy year) except: 60% cover for certain orthopaedic and ophthalmic procedures, no excess.
No cover for listed cardiac and special procedures in the Hermitage and Galway Clinic



The link above does state the special procedures for irish life and there is no mention of any gallbladder procedures
So it looks like theres a chance they're wrong, but proving that is hard
Click to expand...
OMG - thank you so much. It's info like this I need to hit them with. No be honest, we really thought it was covered, checked and there was nothing said to us that it wasn't. Said they had to call us back and said they rang, but don't remember seeing a missed call. Early last week I asked for a copy of that webchat, and I still have to receive it. I've learned since to save those webchats. I'll know for again.
 
intothewest said:
OMG - thank you so much. It's info like this I need to hit them with. No be honest, we really thought it was covered, checked and there was nothing said to us that it wasn't. Said they had to call us back and said they rang, but don't remember seeing a missed call. Early last week I asked for a copy of that webchat, and I still have to receive it. I've learned since to save those webchats. I'll know for again.
Click to expand...

What is the situation now - are they billing you , the hospital billing you?
How have you gone about the appeal?
 
Curlyfella said:
What is the situation now - are they billing you , the hospital billing you?
How have you gone about the appeal?
Click to expand...
So it got rejected. It was with one section for review, and they said they reviewed the tapes etc, but I haven't received them yet to listen to them all. Once it was still deemed as rejected with them, and we weren't happy with that decision, it was sent by them to their complaints dept for review. Sick at the thought of it now.
 
Intothewest
Dont let it ruin you or your mother's Christmas. If the bill has to be paid, it would be awful esp after she paying them premiums for well over 50 years. I hope they take that consideration into account. I hope you have a happy outcome to this, fingers crossed for you.
 
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 (I am working from home with four small kids and possibly had a call so couldn't wait). 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.
 
It's well worth bringing it to the Ombudsman. It seems like you did everything in your power to get the correct information to them. At least you will have someone in your corner helping you figure it out.
The Ombudsman is objective and they are well used to dealing with the health insurers.
 
intothewest said:
They said they called back on 26.06, but I don't recall a missed call.
Click to expand...

Not sure what type of phone you were using but my cheapie mobile stores calls as far back as Jan/Feb under the 'Recents' tab. You might be able to have a look there if that is of any help.
 
intothewest said:
I contacted them today, and they are saying the former plan did not cover that operation.

Someone said to me on the general issue of confirming cover before the procedure, that they would have let the people in the Hermitage take care of that. Is that correct? And if the Hermitage got the ok from the insurance to say that they would be paid, it's now their problem, not ours. But am I right that this doesn't happen? That it's up to the patient to find out all of this in advance?
Click to expand...

Correct, although in my case when I've been there (on Irish Life) they did tell me that I would have to pay and claim it back and also that one test was not covered by Irish Life in the Hermitage and that I would need to go to the Mater Private for it to stay under cover.
 
intothewest said:
Different insurance company so they said it's irrelevant.
Click to expand...

Pre-existing is not accurate and not the reason why.
It must be the newer policy just didn't cover it - in simplest terms.

But they haven't said what you should have done or exactly what IS covered then or where etc -

This is where it needs to be known in advance - and where is that info -

The ombudsman is a waste, absolutely hopeless.


read the article there -
shorturl.at/fguxP
 
Saavy99 said:
Is that an Irish Times article, can you post the full link please?
Click to expand...

search for - it won't allow me to post any links
Cover or no cover: ‘I know mistakes happen . . . but it really is a mess’
Pricewatch: Reader shares her experience of conflicting phone calls with Laya Healthcare
 
Curlyfella said:
search for - it won't allow me to post any links
Cover or no cover: ‘I know mistakes happen . . . but it really is a mess’
Pricewatch: Reader shares her experience of conflicting phone calls with Laya Healthcare
Click to expand...


[broken link removed]
 
The poster went public and only then did the insurer cover her.

This seems commonplace and if you don't go public, you won't have a case
 
You must log in or register to reply here.
Back
Top