Health Insurance Seeking legal expert to help with VHI treatment expense

Hi everyone,

I am looking for a legal expert who can help me make sure that VHI covers my treatment expense. I am concerned that my insurance company may not cover all of the costs of my treatment, and I want to be prepared in case they try to deny my claim. I am looking for a lawyer who has experience with VHI. Any recommendations?

Thanks!

I am not sure that it's a lawyer you need.

Try one of the health insurance brokers first of all. They might well be able to advise you on how best to maximise your chances of being covered.

Or give the details here and someone might be able to advise you.

And if you do end up in a dispute, the Financial Ombudsman is the way to go - not the legal route.

Brendan

Surely the policy booklet terms and conditions should be the first port of call and should clarify most questions about cover?

Brendan Burgess said:

I am not sure that it's a lawyer you need.

Try one of the health insurance brokers first of all. They might well be able to advise you on how best to maximise your chances of being covered.

Or give the details here and someone might be able to advise you.

And if you do end up in a dispute, the Financial Ombudsman is the way to go - not the legal route.

Brendan

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Thanks. Could you kindly elaborate how to approach a health insurance broker? I am currently covered by a health insurance plan paid for by my employer. Which brokers do you recommend?

Have you already had the treatment?

Usually, you would check with the insurer if the treatment is covered before you have it

business_hero said:

Which brokers do you recommend?

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Dermot Goode works on a fee basis so I would recommend him.


If he thinks that you need legal advice, I am sure that he would tell you.

Brendan

business_hero said:

I am concerned that my insurance company may not cover all of the costs of my treatment, and I want to be prepared in case they try to deny my claim

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They definitely won't cover it if it's not part of the policy cover. Your post seems to suggest that you're assuming that even if it is covered by the policy then they might try to diddle you out of cover. Why is that? That's not how health insurance providers work.

ClubMan said:

That's not how health insurance providers work.

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I'm impressed with your unending optimism with modern day business practises.

DannyBoyD said:

I'm impressed with your unending optimism with modern day business practises.

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I haven't a clue what you're on about or why you think that your post is a useful contribution to this thread, but insurance companies don't generally try to diddle customers out of legitimate cover. If you have evidence to the contrary that such practices are widespread in the health insurance industry then feel free to post it.

To get straight to the point: : The situation involves a family member, not myself.
To provide some context without diving too deeply, there's an urgent need for a breast implant removal due to its rupture (the removal, however, requires breast reconstruction). The urgency of the situation means that it cannot be delayed. The insurance policy generally covers breast reduction, but it stipulates that VHI must be informed and provide approval 20 days prior to the procedure, and - in most cases - requiring a third-party appraisal. However, during a preliminary discussion with the insurance company, they indicated they don't cover procedures linked to aesthetics, which includes the removal since it's stemming from an aesthetic surgery.
Therefore, before making a formal request, we're looking for guidance on how best to approach this to enhance chances of approval. Even partial coverage would be beneficial due to the cost of the surgery.

Hi @business_hero,

In light of the urgency attached to your enquiry, and no other recommendations so far, perhaps it would be best as recommended by Brendan above, for your relative to contact Dermot Goode at totalhealthcover.ie asap. Perhaps send an e-mail today followed up with a telephone call tomorrow.

business_hero said:

To get straight to the point: : The situation involves a family member, not myself.
To provide some context without diving too deeply, there's an urgent need for a breast implant removal due to its rupture (the removal, however, requires breast reconstruction). The urgency of the situation means that it cannot be delayed. The insurance policy generally covers breast reduction, but it stipulates that VHI must be informed and provide approval 20 days prior to the procedure, and - in most cases - requiring a third-party appraisal. However, during a preliminary discussion with the insurance company, they indicated they don't cover procedures linked to aesthetics, which includes the removal since it's stemming from an aesthetic surgery.
Therefore, before making a formal request, we're looking for guidance on how best to approach this to enhance chances of approval. Even partial coverage would be beneficial due to the cost of the surgery.

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Vhi Company Plans T&C's document, section 7 "Exclusions" part xix) Cosmetic treatment, (including tests, investigations and consultations) and treatment of any complications arising from cosmetic treatment – unless it is needed (i) to restore Your appearance after an accident or (ii) because You were severely disfigured at birth."

Can you get treated publicly?
Generally with health insurance in Ireland, it ends up being black and white when the ombudsman does an investigation after a complaint. If it says no in the T&C's than usually your chances of getting the claim accepted are extremely low.

Sue Ellen said:

Hi @business_hero,

In light of the urgency attached to your enquiry, and no other recommendations so far, perhaps it would be best as recommended by Brendan above, for your relative to contact Dermot Goode at totalhealthcover.ie asap. Perhaps send an e-mail today followed up with a telephone call tomorrow.

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I spoke to Dermot Goode and they responded the following:

"Unfortunately we can not advise on cover for a specific procedure. It would be best to contact VHI directly to check your coverage for this."

Starrynights said:

Vhi Company Plans T&C's document, section 7 "Exclusions" part xix) Cosmetic treatment, (including tests, investigations and consultations) and treatment of any complications arising from cosmetic treatment – unless it is needed (i) to restore Your appearance after an accident or (ii) because You were severely disfigured at birth."

Can you get treated publicly?
Generally with health insurance in Ireland, it ends up being black and white when the ombudsman does an investigation after a complaint. If it says no in the T&C's than usually your chances of getting the claim accepted are extremely low.

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I cannot get treated publicly.

Is there any chance that there is a legal expert to advise on this matter? We would be happy to pay a compensation based on how much VHI are going to cover.

Have you not talked to VHI yet? It's 9 days since you told us the query and more importantly the treatment are urgent.

business_hero said:

Is there any chance that there is a legal expert to advise on this matter? We would be happy to pay a compensation based on how much VHI are going to cover.

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Hasn't this been addressed already and it been clarified that VHI specifically exclude the treatment needed here?

business_hero said:

However, during a preliminary discussion with the insurance company, they indicated they don't cover procedures linked to aesthetics, which includes the removal since it's stemming from an aesthetic surgery.

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Starrynights said:

Vhi Company Plans T&C's document, section 7 "Exclusions" part xix) Cosmetic treatment, (including tests, investigations and consultations) and treatment of any complications arising from cosmetic treatment – unless it is needed (i) to restore Your appearance after an accident or (ii) because You were severely disfigured at birth."

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That being the case I'm not really sure what you expect to get out of them?

If it cannot be done publicly then it sounds to me like it'll just have to be done privately with no cover from VHI? In case it helps at all you can presumably claim tax relief at standard rate on the cost.

OP, this is not a legal issue and talking to a solicitor is a waste of time and money.

Your cover depends on your Vhi plan terms and conditions.

You need to get the procedure code from the surgeon who will be removing the implant. You then need to ask Vhi if you are covered for that procedure. They will probably ask you some clarifying questions and they may request a letter from your surgeon.

If you have already gone through this process then the chances of them changing their minds are slim but not zero. You can ask to appeal and make your case. I don't think they will cover this but it's worth a shot.

You said you can't get treat publicly - what makes you believe this?

Have you considered going to your GP to see if they consider the matter to be a surgical emergency ?
If, on clinical grounds, it could be regarded as a surgical emergency a referral to the local ED might produce a result in terms of timely attention.
I am mindful that some leaking implants might be injurious depending on their origin and that is what would worry me here.

See attached link HSE waiting times. See data for breast surgery and for plastic surgery.

The background seems to be ;

1. An implant was emplaced.
2. The implant has leaked and must be removed.
3. The removal will require additional reconstruction surgery.
4. Post #10 VHI "don't cover procedures linked to aesthetics, which includes the removal since it's stemming from an aesthetic surgery."

Random thoughts ;

1. Who said that the original procedure was actually aesthetic or cosmetic in nature ?
2. Even if it was aesthetic why does that seem to automatically invoke exclusion as researched and described at post #12 ?
3. Who says, evidentially, that what has happened here is an actual complication arising from cosmetic treatment ?
4. The initial procedure took place but we do not know how long afterwards the leak was discovered. If the leak was soon after surgery that might reinforce VHI's argument. However, if the elapsed time was something like a year or more how can VHI assert credibly that this was a complication.
5. Generally, I would have thought that VHI should carry the evidentiary burden of their assertion.
6. If there was a long time delay between implantation and leakage could it be argued that the leakage was a new and independent event that is not causally linked to the original surgery and, thus, is not a complication arising from the original surgery ?.

I hope that some of this might help OP's consideration of the various issues in terms of how this might be argued. This is a really tricky one. With great respect I would contend that this is actually a contractual issue. I suspect that the cost of all of this could be very high so a consultation with a solicitor might not be out of order.

ClubMan said:

They definitely won't cover it if it's not part of the policy cover. Your post seems to suggest that you're assuming that even if it is covered by the policy then they might try to diddle you out of cover. Why is that? That's not how health insurance providers work.

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I think that problem cases often stem from the interpretation of the policy terms and conditions.

I have had a dispute or two with insurers who sought to apply narrow or strict constructionalist type interpretations.
Against that, I have experienced insurers who have stretched a point and were reasonable about it.
Lady Luck has some part in this in terms of who you are dealing with !