Doctor warns on emergency care cover in private hospitals

People could die because health insurance companies do not fully cover emergency care in private hospitals for patients who suffer complications while undergoing some treatments, a Blackrock Clinic consultant has warned.

Dr Stephen Frohlich, who works in the areas of anaesthesia and intensive care medicine, said a reduction in the number of Intensive Care Unit (ICU) beds in the public system, coupled with a growing number of people having complex surgeries in private clinics rather than joining public waiting lists, have put pressure on the system and is putting lives at risk.

“The landscape of the health care system has completely changed in recent years,” Dr Frohlich said. “The number of ICU beds in the public system has fallen by around 50 over the last five years and we are seeing more patients choosing private medical care. They feel they have little choice but to do that.”

With more complex surgeries being done in private clinics and hospitals “there is obviously going to be a greater number of people who become seriously ill as a result of complications,” he said.

However, with only 5 per cent of health insurance policies fully covering emergency care in private hospitals the vast majority of those who become seriously ill while undergoing treatment in private hospitals are in danger of being heavily financially penalised or denied vital care.

Dr Frohlich said that until recently private hospital patients could be admitted to public hospitals without difficulty if they fell seriously ill in clinics but he said that avenue had largely being closed as a result of ICU bed shortages in the public system.

“Obviously we would prefer to treat all our patients until they fully recovered but our hands have been tied because of insurance issues. In the past if private patients without complete cover became seriously ill they could be transferred into the public sector,” he said. “Today even if we wanted to transfer a patient without cover who needed urgent care we would often not be able to do so because there just isn’t the space available in the public system. That safety net is gone.”

Dr Frohlich cited the example of a person admitted for a routine hernia operation on an outpatient basis. If they suffer complications and need urgent care or life support, their health insurance policies will – typically – not cover the full cost of on-site treatment.

In some instances only the outpatient procedures are covered and after that the patient is effectively on their own or at least they would be if they were not offered support by the clinic. In other cases admission with significant cash shortfalls could apply .

“The bottom line is that health insurers need to cover their members for treatments they need. If insurers are going to pay for a procedure in a private hospital then they should be willing to pay the cost of that procedure. Cover can’t be based everything going perfectly well all the time,” he said.

The health insurers’ response

VHI Healthcare said the “premise of insurance” is that it provides cover for unexpected events.

“The level of cover taken out aligns to various levels of risk deemed acceptable by the customer,” a spokeswoman said. “For example, if somebody purchases a plan at a less than full cover, they are accepting the risk that there will have a partial financial liability in certain facilities that would require a full cover plan.”

She said these rules were “common to all insurance. If for example, just because an event was unexpected a partial cover insurance plan had to cover in full, nobody would pay for the higher level of insurance plans and the industry would not be viable.”

Aviva said members who develop complications in a private hospital will have ICU admission covered at the same rate as the procedure. It cited the example of a member having a hip replacement and developing a post-operative infection requiring ICU admission. The level of cover for the ICU stay will be the same as that for the hip replacement. It said the company’s most popular plans extend 90 per cent cover in such instances.

GloHealth said members who fall ill while being treated for a day case procedure in a private hospital and require an overnight stay may be liable for an excess for the stay in hospital, depending on the plan the member has chosen.

A spokeswoman for Laya Healtcare said the “level of access and treatment in private and hi-tech hospitals is dependent on a member’s scheme benefits; and subject to scheme excess or short fall payments”.

She said a member undergoing treatment in a hospital who develops complications and needs intensive care treatment in that hospital will have the full cost covered by their scheme “once the treatment is deemed medically necessary”.