A recent Irish Times Pricewatch report has highlighted how complicated private health insurance can become when a planned medical procedure changes during surgery.
The case involved a patient in his 70s who had checked in advance that his planned partial knee replacement was covered by his health insurance. During the operation, the procedure was changed to a full knee replacement for clinical reasons. The family subsequently faced an unexpected hospital bill of several thousand euro.
The circumstances are a useful reminder that checking whether a procedure is covered is not always as straightforward as checking whether a particular operation is generally included in your health insurance.
Why procedure codes matter
Private health insurance in Ireland can involve different levels of cover depending on the policy, hospital, treatment and specific procedure.
As the Irish Times report explains, a partial knee replacement and a full knee replacement can have different procedure codes and different insurance benefits. Confirming cover for one procedure does not necessarily mean that another procedure will be covered on the same terms.
This is particularly important where a consultant has explained that more than one treatment option may be possible.
Before planned treatment, it can be sensible to ask:
- What procedure is currently planned?
- Is there more than one procedure that may be required?
- What are the relevant procedure codes?
- Is each possible procedure covered under my policy?
- Are there any excesses, co-payments or shortfalls?
- Does the hospital have any additional charges?
- Does my policy cover the hospital accommodation associated with the treatment?
- What happens if the treatment plan changes during the procedure?
A clinical decision can have financial consequences
Patients understandably expect medical decisions to be based on what is clinically appropriate.
However, insurance cover is a separate consideration.
A surgeon may need to alter a planned procedure after assessing the patient's circumstances during an operation. A patient under anaesthetic cannot realistically make insurance enquiries at that point.
That makes it especially important to understand the potential financial implications before treatment takes place, where possible.
It is also worth asking your consultant and hospital what alternatives may arise and then checking the insurance position for each relevant procedure with your insurer or broker.
Don't rely on assumptions about your health insurance
Health insurance policies can differ significantly.
Cover can depend on the policy level, insurer, hospital, treatment and the specific terms and conditions of the policy. Exclusions, excesses, co-payments, shortfalls and accommodation limits can also affect what you may have to pay yourself.
For that reason, we don't recommend assuming that a procedure is covered simply because you have private health insurance or because a similar procedure was covered previously.
If you've changed policy, insurer or level of cover, it's particularly important to review your current benefits rather than relying on what was available under an older policy.
How a broker can help
At Dooley Insurance Group, we understand that health insurance terminology and policy benefits can be difficult to navigate.
Our role is to help clients understand their options and make informed decisions based on their individual circumstances. We can help you review your health insurance and understand the factors you should consider when comparing or reviewing cover.
You can learn more about our Health Insurance services or contact our team if you'd like to discuss your circumstances.
Before planned surgery: a practical checklist
If you or a family member is preparing for planned treatment, consider taking these steps:
- Ask your consultant what procedure is planned.
- Find out whether another procedure may become necessary.
- Obtain the relevant procedure code or codes where applicable.
- Check each possible procedure with your insurer or broker.
- Ask specifically about excesses, co-payments and potential shortfalls.
- Check whether hospital accommodation and additional nights are covered on your policy.
- Ask the hospital about any charges that could fall outside your insurance cover.
- Keep written confirmation of the information you've received.
- Review your policy before treatment rather than assuming previous cover still applies.
Most importantly, remember that insurance cover is governed by the specific terms and conditions of your policy. Confirmation of cover for one treatment does not automatically mean that every related treatment, variation or additional service will be covered in the same way.
If you're reviewing your health insurance in Ireland, our team at Dooley Insurance Group can help you understand your options and the questions worth asking before you make a decision.
Contact Dooley Insurance Group to discuss your health insurance requirements.
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