VHI VHI - Pre-existing condition

October03

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Would welcome any help with this, as I am starting to question my own sanity it is so confusing.

My father first took out health insurance with Hibernian Aviva Health in December 2008. He was over 65.

In March 2009 he had a procedure on the public health system.

He switched from Hibernian Aviva to VHI in December 2009.

In October 2013, he had a procedure related to that from March 2009, on the private system.

VHI are refusing to pay for the 2013 procedure, saying it was a pre-existing condition. Their only evidence is the procedure from March 2009, so it is not one of these instances where they're saying he might have had it for months without knowing about it. They have rejected the claim on the basis that the condition existed prior to him joining VHI, saying he would have to serve 10 year waiting period.

I am battling this (for the last 5 months) saying that because he had cover since December 2008 is it not a pre-existing condition. None of his treatment in 2013 relates to any higher cover on the VHI policy vs the original Hibernian Aviva policy.

Does anyone know who is right? I have looked at the original terms & conditions from VHI and the HIA site, but I'm still not 100% clear on what happens when a condition develops after taking out a policy and then switching.

Thanks in advance for any help or insight.
 
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The key documents here are what VHI related paperwork was filled out in Dec 2009 and what the then T&C's said.

Whats important is the T&C's in the month the policy started so do you have those in hard copy?

Its pre-existing VHI, no question of that, its a question of what form was filled out and what the paperwork said about pre-existing.

I don't believe its like the NCB on a car policy that just transfers seamlessly from one insurer to another.
 
I don't believe its like the NCB on a car policy that just transfers seamlessly from one insurer to another.

But wasn't that one of the big things when competition was introduced into the market? I remember campaigns telling people that they can switch insurers without penalty or waiting periods if there wasn't a break in insurance. In the last couple of years, this seems to have all changed. There are more and more cases of insurance companies trying to avoid cover on the basis of pre existing conditions. The regulator really needs to a handle on this. I can see it becoming a media story soon....
 
But wasn't that one of the big things when competition was introduced into the market? I remember campaigns telling people that they can switch insurers without penalty or waiting periods if there wasn't a break in insurance. In the last couple of years, this seems to have all changed. There are more and more cases of insurance companies trying to avoid cover on the basis of pre existing conditions. The regulator really needs to a handle on this. I can see it becoming a media story soon....

I don't know about the competition thingy....
For example, what about insurer B not covering say AIDs, however Insurer A did, and you move from A to B.....

Also waiting/penalty is not the same as pre-existing.

I think "There are more and more cases of insurance companies trying to avoid cover" is more to the point:) Car, house, illness, holiday, the list goes on
The VHI now has a new set of T&C's for each policy that renews in a month so the small print is crazy.
 
Thanks folks,

There is a lot of material on HIA, VHI etc about waiting periods for upgrades in cover, but in this case I don't think that applies as the procedure was covered by the original Hibernian Aviva policy so it's not "extra" cover.

I can't find any application form; I have a feeling the application was done over the phone as crazy as that sounds, but I'll keep digging.

I do have the original 2009 T&Cs from VHI though but the wording is very ambiguous:

"No benefits are payable for medical conditions the date of onset of which is determined on the basis of medical advice to have been prior to the date the member was included on the contract, unless the member has been insured continuously for a minimum period of time. The minimum period is as follows:

Member's Age when he/she is included -> Minimum Period
....
60 or over -> 10 Years
"

This is making me question myself and wonder if VHI are right and Dad wouldn't be covered until he's done 10 years with VHI.

However, then a further Condition says:

"If a person transfers from a health insurance contract with another insurer registered in Ireland under the Health Insurance Acts, 1994 to 2003, the time he/she was insured under the contract will be offset against the normal joining conditions (waiting period, pre-existing illness and maternity).
"

This makes me think I'm right, and that he would only have to serve 2 years in total as the condition arose after he first took out insurance.

There wasn't a Consumer Rights Statement in his first policy pack, but from his first renewal onwards in 2010 there is, which says

"Can I change my health insurance plan or insurer at any time?
You have the right to change your health insurance plan, or insurer, without penalty. The insurer may not impose additional waiting periods unless you are upgrading your cover. Even when you are upgrading your cover, an insurer may only impose an extra waiting period in respect to additional cover in the new policy. However, if you allow your health insurance to lapse for 13 weeks ore more, you may have to start your waiting periods all over again".

There wasn't any additional cover being used for this procedure in the VHI policy and he didn't have a lapse in cover. I just wish I had proof of this as a "Consumer right" for 2009.
 
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Based on the above is it not the case that the time with Hib would only be used to reduce the 10 years based on the preexisting in Dec 2009 as opposed to eliminating the VHI waiting period.

I want you to win here but based on what you have kindly posted here its not looking good.
AsK VHI for the app form, even if done over the fone they will have to have something. something.
 
Thanks ircoha, really appreciate the feedback.

The terms are so confusing that it's almost as if the decision will be down to interpretation of the rules, which probably won't be in my favour.

I was hoping it could be interpreted that, because the condition didn't exist when my father took out Hibernian cover, he would then only be obliged to complete 2 years waiting period before it would be covered and that VHI wouldn't be allowed to add any waiting period to this. However, I understand what you're saying and think VHI will probably be able to claim the '10 year' rule as their reasoning.

I can try to get the application details although I'm 99% certain I didn't even ask about pre-existing conditions when we took it out. VHI have launched their formal complaints & appeal process for this now so I think I'll just have to wait and see what the outcome is. Hopefully they will be more forthcoming with their reason for rejecting - it's been impossible thus far to get any explanation from them and I ended up getting it from the consultant's secretary who has been really helpful thank goodness.

I'm just not sure that if they reject it again, whether I will have any leverage to take it to the Ombudsman.
 
Hi, I was in a similar position.

I did a sleep test and was only charged the excess.

Prior to my admission I rang Vhi customer desk and they confirmed that I was covered and about one month after my discharge a bill of over €1,000 arrived in my post, stating that my condition was pre-existing.

Indeed it was pre-existing with my policy inception with VHI but before start with them I was insured with AVIVA. Both corporate's policies.

I luckily had the help of a friend who advised me that because I was insured with AVIVA, VHI could not consider my condition pre-existing.

Therefore I sent to VHI all the documents from my previous insurer, explaining the dates of coverage as well as a letter complaining and they end up paying my admission. Possibly they share expenses with AVIVA?


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Just a heads up here: since this day, I always ensure to get a confirmation of my treatments in writing. So ensure to ask the advisor to email you back confirming you are covered for the treatment you required.


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am +1 with Ichang - strongly recommend you fight this. One ground on which to fight it, which you may not have covered, is that the rules are ambiguous. You seem to suggest this in your posts. The onus is on the VHI to ensure the rules are easily understandable by the lay person. Where the rules are not then precedent is to find in favour of the complainant who has been disadvantaged by the rules.

Good luck!
 
The key question is was the original procedure covered by Hibernian Aviva? Reading above it seems it was covered by public system so not by insurance company? IF you had tried to claim it would have been denied by them as a pre-existing condition as presumably the condition started before you got cover even if the treatment didn't start until after.

After you moved to VHI this didn't change and it was still a pre-existing condition and so it (and any other pre-existing conditions you may or may not be aware of) are not fully covered until 2018 after you have served 10 full years with any insurance company.

Corporate agreements sometimes waive waiting periods so perhaps that's what happened with the other poster. Or perhaps they just didn't have records that they had been covered previously.

Pre existing conditions are usually decided by doctors treating you and not just based on claim date. They ahold be based on when you took out insurance that would cover this procedure with any insurance company and not when you joined your current insurance company (unless you upgraded when moving in which case any procedures included on your new policy are subject to the upgrade waiting period).

Waiting periods, complicated as they are, are basically designed to stop someone getting ill, and then taking out insurance to cover that illness - which would be great for individuals but be massively unfair to insurance companies. They are necessarily because of the way health insurance works here in Ireland where everyone pays the same, you cannot be refused cover, and you don't need a medical before taking out health insurance. They are especially onnerous for older people as 10 years is a LONG time to wait before you know you have full cover. The flip side being the fact they would be very expensive to insure otherwise which would result in everyone's premiums being higher.

Challenge the decision by all means, and hopefully for you you'll be successful, but from my reading of the situation they are correct to say this isn't covered.
 
Thanks again everyone,

lchang, Orga - you've given me hope that I could fight this - if not with VHI then with the Ombudsman perhaps.

BazzaDP - I understand your analysis and completely appreciate the rationale for pre-existing conditions, but in this instance VHI are not trying to claim the condition pre-existed before March 09 or the Hibernian policy. I don't want to say what exactly it is, but I think they would find it very difficult to try to claim it was pre-existing the Hibernian policy in December 08. If they go down that path then it will be a different battle.

The original procedure wasn't covered by Hibernian because there is a 2 year waiting period for over-65s after you take out insurance for the first time and develop a new illness or condition. However, this would mean I expected him to be covered for this condition from December '10 onwards and thus by VHI last year.

Sincerely appreciate all the feedback - I'll keep the thread updated on how this plays out.
 
lchang, Orga - you've given me hope that I could fight this - if not with VHI then with the Ombudsman perhaps.

Go for it.

I was involved in a complaint against the VHI, followed their complaints procedure, they investigated thoroughly and sent us a detailed reply outlining the various reasons why our claim was been rejected, it seemed hopeless.

We then put our complaint to the FSO who appears well able to work his way around the maze of T&c’s in any VHI policy, as he put a number of specific and well-structured questions to the VHI, most of which we had not thought of.

Soon after the FSO’s first letter, the VHI offered to settle in full, if we confirm we no longer want the complaint adjudicated on by the FSO.

Complete U-Turn on their original stance.
 
if he joined in Dec 2008, what was his pre-existing waiting period at the time ? if 10 years, then this would apply and he would not be covered until 2018

Have you contacted the Dr, to ask them to submit an appeal, as any insurance company will review the information provided on the claim form, in addition to date of first visit with their GP etc.. The Dr may also have given information on the claim form, deeming it as pre-existing Pre-existing conditions are based on the medical condition, and not when the patient finds out about it. Some conditions can be genetic and be pre-existing due to being there from birth etc.
Also, no company could give confirmation by e-mail that a procedure will be covered, until the claim form is received with the medical info reviewed etc. There are times when the procedure described by the patient may differ from what is actual performed and lead to non coverage. We are not in the US version or pre-certifying procedures
 
if he joined in Dec 2008, what was his pre-existing waiting period at the time ? if 10 years, then this would apply and he would not be covered until 2018
This is only true if the condition was pre-existing in Dec 2008. The first procedure was in March 2009 - so, for example, if the procedure was because he was run over by a bus in March 2009, then the condition was not pre-existing in Dec 2008 and he should not have to serve a 10 year pre-existing condition waiting period.

The OP doesn't want to give details of the procedure but seems fairly sure it could not be considered as pre-existing at Dec-2008. VHI seem to be taking an alternative view - that even if the condition wasn't known about until March 2009, it was pre-existing at Dec-2008. There's really no other reasonable explanation for their actions.
 
Obviously, if an an accident occurred, it not pre-existing, if it happened after joining !

If the condition was there prior to joining, even if they did not know they had it, it's pre-existing.
The patient originally joined an insurance company in Dec 2008, and had a procedure performed in March 2009, as a public patient, and also they they were only insured for 3 months at that stage?
As the original procedure was done as a public patient, we do not know if that would also have been rejected as a pre-existing condition at the time ? and we do not know 100% what waiting periods applied to the patient after taking up insurance in Dec 08

If someone was diagnosed with arthritis/chronic conditions etc, then they will have been present for some time. Unless the OP gives details of the condition we cannot argue the point of this being pre-existing or not, and the vhi decision to reject must be based on the actual condition being treated, or the information provided on the claim form by the Dr.

If the OP wishes to appeal this with the ombudsman, ask vhi for the Final Response, and upon receipt, can contact the Ombudsman to ask them to review the case.
 
Would welcome any help with this, as I am starting to question my own sanity it is so confusing.

My father first took out health insurance with Hibernian Aviva Health in December 2008. He was over 65.

In March 2009 he had a procedure on the public health system.

He switched from Hibernian Aviva to VHI in December 2009.

In October 2013, he had a procedure related to that from March 2009, on the private system.

VHI are refusing to pay for the 2013 procedure, saying it was a pre-existing condition. Their only evidence is the procedure from March 2009, so it is not one of these instances where they're saying he might have had it for months without knowing about it. They have rejected the claim on the basis that the condition existed prior to him joining VHI, saying he would have to serve 10 year waiting period.

Thanks in advance for any help or insight.

You have 2 issues here.
1. Does your fathers condition per exist joining any health insurance company? It doesn't have to be 10 years with Vhi. If his condition for which he had surgery in March 2009 was present in Dec 2008 then it is preexisting. In reality very few conditions develop in 3 months to the point where they require surgery so unless he had an accident then I would have thought it is most likely a pre existing condition.

2. You say the second surgery in October 2013 was related to the March 2009 surgery. If it was to treat a complication of the 2009 surgery then it will never be eligible for benefit (even after 10 years) as far as I know.
 
Hi everyone,

Just wanted to let you know VHI have addressed the complaint (surprisingly!) quickly and have turned around their decision and approved the claim. I'm very relieved I'm not having to take this to the ombudsman although I was fully prepared to do so.

Also, it was the first time I've got a detailed reply indicating the details of their assessment; it's just a shame I had to jump through so many hoops to get to that stage. I don't think I explained here before that VHI already had my father's GP medical history and consultant's reports (given to them over the last 5 months), so no new information was given to them between when they rejected it a few weeks ago and now approved it. It's almost as if someone 'made a mistake' during the assessment and it's taken this formal complaint to have it re-checked. I haven't really got any clear explanation for why it was rejected in the first place as they don't seem to have any contention at all around whether the condition pre-existed Dec 2008. I can only assume that someone missed the fact that he had a policy with Aviva for a year before VHI.

I really appreciate all of you taking the time out to reply and give me some practical and moral support. This has been a mini nightmare to work through so it really helped to get some impartial perspectives. For me at least, this has cleared up any ambiguity about waiting periods when transferring insurers so hopefully it might help someone else in the future.
 
That's great to hear, must be a weight off your shoulders, all right.

Thanks for letting us all know how it turned out.
 
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