Health insurance mix-up: Medical treatment of €10,000 not covered by woman’s policy

The case of Susan’s costly health insurance mix-up, was just one of many complaints handled by the ombudsman charged with protecting our finances last year. The Financial Services and Pensions Ombudsman (FSPO) which was published last month.

Susan had private health insurance. She needed a particular medical procedure and wanted to have it in a particular private hospital.

“Her health insurer asked her for the procedure code of the treatment as she was covered for some procedures in that hospital, but not all,” the report says.

“When her health insurer checked the code, it was on a list of limited treatments covered by Susan’s policy in that hospital, so the treatment went ahead, and the claim paid.”

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One of the things this page is always telling people to do is review their health cover regularly and that is what Susan did. She decided to switch her policy to one she felt “covered benefits that were of more use to her, and which reduced the cost”.

Later that year Susan became ill. “Her GP told her to attend A&E. Susan decided to attend the A&E in the particular private hospital in which she had been treated before, as her medical records were there along with her treating consultant.” On that day, Susan was given a test which led to a medical intervention which cost about €10,000.

Susan’s claim was not paid as she had not noticed that she was not covered for this particular hospital under her new policy.

Susan had assumed she was covered due to having previously been covered for a procedure in the same hospital. “Susan thought it was very unfair that she had to think of issues like this when she was in the middle of a medical emergency,” the report says.

When call recordings were examined it emerged that the insurer had previously given warnings about changes in cover and the need to check every procedure code before seeking treatment.

“Susan accepted that she was not covered for this treatment and decided to take the issue up with the hospital, as she had no recollection of the hospital ever advising her to check her cover before treatment. The complaint was closed on that basis.”

[ Health insurance mix-up: Medical treatment of €10,000 not covered by woman’s policy ]

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* The Financial Services and Pensions Ombudsman investigates customer complaints in relation to the financial sector, including banks, building societies, credit unions, brokers, money lenders, hire-purchase providers, health insurance companies and retail credit firms. Given the complexities of the cases – and the sometimes intimidating responses from financial institutions when challenged – the process can be slow. But it can often get results that are beyond individual consumers.

Details of how to make a complaint plus all the necessary documentation can be found on its website – fspo.ie. It can also be contacted at 01 567 7000.