Health policy Laya Everyday Medical Expenses Cover

Due to the ongoing upward premium increases of health insurance I like most people change plans on a regular basis but generally look for a policy that provides most if not all of the cover of the last policy. Last year we moved from Control 300 Create at €1744 to Inspire Plus at €1546 which we thought was a good compromise
We lost a bit of cover on the "Specified orthopaedic" 20% shortfall but we gained on the "everyday medical expenses" mainly that we get covered for 50% of all claims

But last Monday I made a claim for a 24 hour blood pressure monitor that my Doctor requested me to get as it was 4 years since the last official one
I will admit my blood pressure went into the red zone when I saw the price of €120 compared to €100 four years ago
But that's the price I had to pay the practice, it's not like I can haggle a better price with the receptionist

But when Laya processed the claim I noticed that they didn't refund me the 50% or €60 but only refunded €55 that's 46% of the claim citing,
"We will pay fees and charges for treatment, services and facilities that are reasonable and customary and only up to the limits shown in the Benefit Table."

So I've lodged an appeal but was wondering if anybody else has run into this problem before with Doctors fees or any other area covered in the everyday medical cover

The main reason I'm asking and will be contacting Laya about this is the optical cover, I intend getting new glasses this year and the brands I use are Lindberg for the frames and Zeiss for the lenses and these are not cheap even with a 50% discount compared to Specsavers prices

HI, I had this exact issue with Laya only last week. I had a 'specialist' GP extended visit and it cost €200; submitted the receipt and got €82.50 back; (my policy covers 3/4 of the cost of GP visits). I queried it with Laya and got a response that GP's are supposed to comply with reasonable fees and €100 is the cap on a GP fee.
Last year I submitted a receipt for €110; it was composed of €70 for GP and €40 for Bloods (the GP took the bloods on this occasion) and I had a consultation re another matter. I was kind of half expecting they wouldn't cover it in full but they did. it was at the start of my policy year and they cover the first 2 GP visits in full
I suppose (certainly in your case) it wasn't just a GP visit, but then again they don't have a separate claim item for items such as :24 hour BP monitor/ bloods / ECG etc. I was with Irish Life before and when submitting a claim for e.g. bloods there was a separate line item to claim under.

I've been with Laya for years and have always had a cap.on optical cover. I think it's something like a max of €150, every 2 years. It doesn't cover the cost of my glasses, but between the PRSI component and the Laya cover, it takes the sting out of it.
Check your policy details and see if there's a specified limit for optical.

It would seem to be Laya policy that there is an upper limit on refunds for GP and physio. They paid just €55 of €130 (first appointment at Blackrock Clinic physio) last year, instead of the usual 50%.

Regarding optical cover both my husband (Inspire Plus) and I (Simply Connect Plus) have each received refunds of up to €350 (50%) in the past few years - €270 for me last year). This was more than we expected and the claims weren't questioned or disputed. If I were you I'd just send your claim in.

GAAmam said:

Last year I submitted a receipt for €110; it was composed of €70 for GP and €40 for Bloods (the GP took the bloods on this occasion)

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Yeah, yesterday I visited my Doctor to discuss the BP readings and renew prescriptions but he also took bloods as well
I never remember them charging for this before as I always thought it was for free, it was before in the hospital IIRC
So I got charged €70 for the consultation and €20 for the bloods so €90 in total and am expecting €45 back

I've just checked my optical cover. It's 75% of costs up to €250 per year. So more than I thought!

POC said:

Check your policy details and see if there's a specified limit for optical.

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It says in the policy that I can claim a refund up to €1000 and the "Optical" section is 50% but with an asterisk
"We will pay fees and charges for treatment, services and facilities that are reasonable and customary and only up to the limits shown in the Benefit Table."

So what is reasonable and customary??
I've been wearing this brand of glasses and lenses since '92 so it's very much "customary" for me??

mct1 said:

If I were you I'd just send your claim in.

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I think I'd have to check with them beforehand to see what the upper limit is as it will be the decider as to whether I just replace lenses
Or treat myself to a new frames as well, if you could call Lindberg Air, frames

Just a quick update, rang Laya there and queried the refund and the limits for optical
My claim for the BP Monitor was processed incorrectly as a GP visit which has a cap of €110
And not as a medical device which I think she said has a cap of €200
So their correcting that and issuing me the full refund

With regards to the optical benefit there is no cap other than the policy limits
So might be a new pair of glasses in it for me this year

Thanks all who replied

Cervelo said:

I will admit my blood pressure went into the red zone when I saw the price of €120 compared to €100 four years ago

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That's expensive! Had one done couple of weeks ago, docs normal price is €60 but as I have it done every year it's considered a repeat and I paid €30 for which I'm hoping to get my €15 back from Laya.

Monbretia said:

That's expensive! Had one done couple of weeks ago, docs normal price is €60

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Have to agree with you there, when I was doing a bit of research last night if found some pharmacy's were offering the service for €60/70
Might have a little chat with him next time about his pricing
But I'm sure I'll get the lecture on the costs of running a practice and changing his SUV every three years

HI,
I could understand the price being €120 if it included a follow-up consultation to discuss. Our GP charges €75 for 24 hour BP monitor; a text message is sent if results are ok and/or GP doesn't want to change medication etc. If they want to follow up and change something the nurse calls and asks you to book in with doctor.
The other practice where I live (Centric) charge €125 but that includes consultation with doc to discuss results regardless of outcome.

Our local pharmacy offers 24 hour BP monitor too, think its €60; seems to be the pharmacist that reviews the readings. Wonder do they pass on the detail to the GP...

I didn't have follow up with doc, just an email to say all ok and €20 for renewal of prescription, reasonably good value these days! Interestingly going through old spending diaries last week during a clean up and the same doc was €10 for consult back in 1994

GAAmam said:

I could understand the price being €120 if it included a follow-up consultation to discuss

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Not sure if mine includes a follow up consultation, don't think so but definitely a phone call to discuss
I booked an appointment for the following day as I wanted to see him about other things and renew prescriptions

I know the €20 for the prescription renewal isn't a massive amount but just wondering if you can submit the receipt (or do you get a receipt)?
My doctors practice charges €25 for a repeat prescription; GP charges €70 per visit and I get €52.50 back. Think its cheaper for me to go back into the Doctor (albeit not by much) than to get a repeat prescription!! Don't get me wrong, I am not into wasting the Doctors time and would prefer that someone genuinely ill and in need of a doctor visit can avail of the appointment. Plus, I have better things to be doing than sitting in a Doctors waiting room..
Just making the point iykwim..

Gosh, I never knew Laya covered optical, I had better dig out my receipt. I must be poor at this because I got a few rejected claims over the last year from Laya, mostly dental. They seem to want the receipt to say clean and polish rather than dental hygienist. The dental hygienist is covered but it is how the receipt is expressed is the issue.

I am not sure if I like how American Laya is going, my daughter got a Dexa scan but they did not cover it as they did not cover the clinic that did the scan, something I would not have thought about before, but now there seems to be lots of health clinics springing up for scans so there must be profit in it somewhere.

Clamball said:

they did not cover it as they did not cover the clinic that did the scan, something I would not have thought about before

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All the health insurers always tell people to check with them before going ahead with procedures. VHI have the option to log in on their website and once you have the procedure code (usually provided by the consultant's secretary) you can check the cover yourself.

GAAmam said:

My doctors practice charges €25 for a repeat prescription;

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So does mine but some regular medication prescriptions can be renewed by health insurance online/telephone doctors for no extra charge (a family member got theirs this way recently) and pharmacies are supposed to be able to issue renewal prescriptions in some cases now but when I asked Chemist Warehouse about this they told me that I had to get it from my doc... At least it's possible to get 12 month prescriptions now for regular meds.

As far as I recall - Payment for MRI scans can be complicated - sometimes cover depends who makes the referral. Physio / GP / Consultant. But the Laya website does say which centres are fully covered and who must make the referral. Some centres have partial cover - so you must pay then claim it as an Every Day expense. My family and I have had a good few scans that were fully covered - but we did check beforehand.

POC said:

Laya website does say which centres are fully covered and who must make the referral

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I discovered this a few years ago when my Doctor wanted me to go for an ECG and asked where, Blackrock or Beacon
I chose Blackrock not thinking there would be an issue but it turns out Laya only cover certain "Day care" cases in Blackrock and this was one
But cover them fully in the Beacon

So now if my doctor suggest a procedure I tell him I have to check with Laya first before he sends out the referral letter

Clamball said:

I am not sure if I like how American Laya is going, my daughter got a Dexa scan but they did not cover it as they did not cover the clinic that did the scan

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Mrs C had one of these recently but she went public in Michaels hospital, think it took 4 months from Doctors appointment to scan
The reasons she went public was
A. It wasn't a time sensitive scan
B. The nearest clinic that Laya would cover it in full, Mrs C wasn't impressed with the clinic when she contacted them

Clamball said:

Gosh, I never knew Laya covered optical, I had better dig out my receipt

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Yeah check the "Everyday Medical Expenses Cover", there's lots of things in there that are covered now that weren't covered a few years ago
My policy "Inspire Plus" covers many many things at a 50% refund with a max refund of €1000 in the policy year
Where before I used to only get €100 back on optical, now with this policy if I combine this years cover and next years cover
I should be able to get the full cost of my glasses reduced by 50%, that's a win win in my books