Key Post A guide to private health insurance

Discussion in 'Health Insurance and healthcare costs' started by NovaFlare77, Feb 26, 2011.

  1. NovaFlare77

    NovaFlare77 Frequent Poster

    Specialist intersts

    Maternity cover (thanks to huskerdu for this summary)
    Here is a summary of what PHI covers for Maternity in Ireland. If my figures are incorrect or out-of-date, please let me know.

    If you decide to see a consultant privately for ante-natal care, the cost will be approx €2,500 to €3,500. PHI does not cover this, but some plans pay a contribution. VHI/Aviva/Quinn pay between €200-€500 towards this, depending on the plan. €300 seems to be an average for a lot of plans.

    PHI pays for the consultant fee for the birth, the anaestitist fee if you have an epidural or section, blood tests and 3 nights in a private ward, in a public hospital. If you have any medical complications during the pregnancy or birth that necessitates a longer hospital stay, this is covered. In a normal birth with no medical complications, only 3 nights are covered.

    If you attend a private hospital, PHI will pay a total of between €2275/€4000 depending on the plan. My understanding is that the average bill for 3 nights in a private Maternity hospital is in excess of this.
    If you are a private patient, you must pay for all ultrasound scans. This may be fully or partially covered by PHI, depending on the plan.
  2. NovaFlare77

    NovaFlare77 Frequent Poster

    The real benefit of private health insurance in Ireland is that you will get a medically necessary but non-emergency operation without having to go on a waiting list. Private Health insurance covers you for private in-patient hospital care, the cost of the bed in the hospital, the cost of the anestetist, and all radiology and blood tests necessary. Most policies have other benefits, but they are add-ons only.

    What kind of hospitals do you want cover in?
    In Ireland there are public hospitals (state owned or funded. Primarily public patients but access to private facilities), private hospitals (privately owned) and hi-tech hospitals (large private hospitals with very specialised equipment Blackrock, Mater Private and ).

    In terms of costs, products that give full cover in public hospitals are cheaper than those that give full cover in private hospitals. And products that give full cover in h-tech hospitals are the most expensive.

    Most people in Ireland are on a product that gives them cover in public and private hospitals and partial cover in hi-tech hospitals. For most, this gives them as wide a choice as hospital options, without breaking the bank. Some products include an excess for treatment in private or hi-tech hospitals, so make sure you’re aware of this.

    Even if you use a hospital not fully covered by your plan (e.g. your plan covers public hospitals and you use a hi tech hospital), most plans, but not all, will partially cover the hospital costs with you paying the balance.

    What kind of accommodation do you want in hospital?
    When in hospital you have two accommodation choices: a private room (room to yourself) or a semi private room (shared room with up to 5 other people).

    If you have a preference for a private room in your chosen hospital type, pick a product that covers that. Bear in mind though that neither insurers nor hospitals can guarantee the availability of a private room.

    Something else to bear in mind is that some private hospitals, especially the newer ones, only have private rooms – e.g. Whitfield Clinic in Waterford, Cork Medical Centre in Cork. If there’s a particular private hospital you want cover for, it wouldn’t be any harm to check what kind of rooms they have first.

    What illnesses are covered?
    For each insurer, any illness covered by their top level of cover will be covered by their most basic plan: the important thing is where you’re treated (i.e. hospital and accommodation) and not what you’re treated for.

    In other words, you don't need to buy the most expensive plan to have all illnesses covered. In fact, some of the benefits of the most expensive plans (cover in h-tech hospitals for major heart surgery and out-patient radiotherapy) is available on the most popular plans.

    Out-patient cover
    Most traditional health insurance plans have very limited (i.e. as good as none) out-patient cover for GPs, physio, consultants, etc. However, alot of the newer products do, but still not full cover (usually around 50 to 60% cover).

    In any case, PAYE workers get tax relief at the standard rate (currently 20%) for some of these costs.

    Other benefits
    There are a plethora of other benefits available. For example, maternity cover, emergency cover while abroad, cover to travel abroad for treatment, screening, lifestyle benefits, nurselines, GP lines, cover in nursing homes after a hospital stay... and alot more. Have a think about what you think you'd like included on your cover and shop around accordingly.

    The most important stuff
    At this stage, starting out, probably the key thing to get right at the start is the kind of hospital cover you want as that's where the biggest expense is and it’s what the waiting periods primarily apply to. With regards to the other stuff (out-patient, lifestyle, nurselines, etc) don't get too bogged down in it right now.

    A few points about joining - There's no medical to complete, it's a simple application (name, address, date of birth, etc). When you start health insurance for the first time, there are waiting period to serve, i.e. lengths of time to wait from the date of joining before certain types of cover kick in. This are age related and for under 55s they are:

    Initial waiting period of 26 weeks - Nothing is covered for the first 26 weeks except for hospital treatment due to an accident or injury.

    Maternity waiting period of 52 weeks - see above

    Pre existing waiting period of 5 years. This means any hospital treatment related to a condition present prior to your joining date isn't covered for the first 5 years of membership. You don't have to declare any illnesses; it's ultimately based on what a consultant says on a claim form. This is why I think you're ALWAYS best to ring your insurer before any treatment.

    The waiting periods above apply to hospital cover and increase depending on the person's age. Some insurers apply shorter waiting periods to out-patient cover, especially if there's a low or no excess on the cover.
  3. Brendan Burgess

    Brendan Burgess Founder

    If you don't have health insurance, you can pay for private care in a private hospital yourself.
    If you have the money, you can pay for your own hospital treatment.

    Compare different plans using the Health Insurance Authority website

    You may be entitled to a 10% discount on the individual quoted price.

    The price charged through a broker is the same as going directly. The companies are not allowed charge different prices. A broker may get you more suitable cover. The only company to pay commission to brokers is Aviva, so there may be a bias in recommending them.

    There are some brokers which advise on health insurance, although I am not sure what the point of them is. Only Aviva pays commission to brokers, so there could well be a bias. If you do use a broker, consider paying a fee for the advice.

    All companies have the same maximum waiting periods.
    Waiting periods for a medical condition not existing when you take out your policy
    • 26 weeks in respect of a person who is under the age of 55 years.
    • 52 weeks in respect of a person who is of or over the age of 55 years and under the age of 65 years.
    • 104 weeks in respect of a person who is 65 years and over. They impose a waiting period of 52 weeks in respect of maternity benefits

    Waiting periods for existing medical conditions
    • 5 years, for a person who is under the age of 55 years.
    • 7 years, for a person who is of or over the age of 55 years and under the age of 60 years.
    • 10 years for a person who is 60 years or over.

    These waiting periods may apply from the date of policy commencement. It should be noted that whether or not a condition existed at the time that an insured person began serving a waiting period is decided on the basis of medical advice. Whether or not the insured person was aware that they had the condition at the time that they started serving the waiting period may be considered not to be relevant by the insurer. If this matter is important to you, you should consider clarifying it with your insurer.

    You can take out cover for semi-private accommodation, but take private accommodation and pay the difference yourself.
    This is a bit like an excess

    There is probably little point in paying for private accommodation in a public hospital
    As it's usually not available.
  4. Brendan Burgess

    Brendan Burgess Founder

    Health Insurance Authority FAQ
    Q Can anyone buy any product?

    Yes. An insurer must sell you the plan you request. Some plans are marketed towards certain groups such as companies or professions. You are entitled to these plans regardless of whether or not you are a member of the group to whom it is being marketed.

    Q Can I change my mind after buying health insurance?

    You can cancel your health insurance contract within 14 days of commencement and receive a full refund of premiums. No claims will be paid for the 14 days.

    Q What are the main benefits of private health insurance?

    • Cover for private and semi private hospital accommodation.
    • Cover for in-hospital consultant services as a private patient.
    • Other cover including maternity, overseas, psychiatric and out-patient benefits.

    Q What kind of hospital accommodation will I get with private health insurance?

    Private health insurance products offer two different types of accommodation. The types of accommodation offered are semi-private and private accommodation. Semi-private accommodation could involve sharing a room with up to 4 other people. It should be noted that although health insurance contracts provide cover for a certain level of accommodation, if that level of accommodation is not available a lower level of accommodation may be provided. While the hospital cover under different contracts may vary, private health insurers in Ireland generally group Irish hospitals into three categories:

    • Public hospitals (i.e. hospitals that are funded by the State)
    • Private hospitals
    • Some hospitals are usually only covered under a higher level of cover (e.g. The Blackrock Clinic, the Mater Private Hospital, and the Beacon Hospital)
    Consumers should check their policy to determine the extent of cover offered by their policy.

    Q Will my private health insurance cover my consultant's fees?

    Most health insurance contracts cover the cost of consultant services provided during a hospital stay. An exception to this would be stand alone, day to day or out-patient policies. Consumers should check their policy to determine the extent of cover offered by their policy. There will normally be a list of consultants, whose services are covered, available from each insurer

    Q What kind of maternity benefits should I expect?

    Treatment received in respect of illnesses, injuries or complications during pregnancy, if covered, would be considered as part of the hospital cover part of your contract. Routine treatment received during the course of a normal pregnancy and delivery would be covered under the maternity section of your contract. Often this section will provide full cover for a limited stay in hospital and a fixed amount for the consultant care in the hospital. Some policies also provide some cover for out-patient consultant care.
    You will not normally be able to claim under the maternity section of your contract until you have served a waiting period of 52 weeks. This only applies if taking out health insurance for the first time, if you are upgrading your policy to a higher level of cover or if you have allowed your health insurance to lapse for more than 13 weeks.

    Q What can I claim for under out-patient benefits?

    Out-patient benefits differ from policy to policy, but typically it allows you to claim for a portion of the cost of GP, out-patient consultant, diagnositc tests and dental visits, physiotherapy, sight tests and an allowance for glasses or contact lenses subject to an annual excess.

    Q Are out-patient and day-patient treatments the same?

    No. Out-patient treatment differs from day-patient treatment. Neither day-patient nor out-patient treatment involves overnight stays in hospital. However, day-patient treatment normally involves more serious procedures and any cover you have for it would be included in the hospital cover section of your contract. Your insurer or your consultant can advise whether your procedure is a day-case or out-patient treatment.

    Q How do I work out my claim for out-patient expenses?

    With some products it is difficult to see exactly how much you can benefit from this cover as it can be quite complex. You will have to pay for the treatment first, keeping a receipt and claim at the end of your policy year. Features of this cover often include the following:

    • There is often a maximum level of benefit that is paid in relation to out-patient cover.
    • There is often an annual excess i.e. an amount you must pay before you can claim anything.
    • Usually, you can only claim for a portion of the cost of the visit to your practitioner. This is called the ‘allowable expenses'. For example, a GP's visit may cost €50 but you may only be allowed to claim €20. The €20 is the allowable expenses.
    Some policies will have all three of these features. It could be the case that even though the total of your out-patient expenses is more than the excess, you might still not be in a position to claim because your total allowable expenses have not yet reached the level of the excess. For example, consider a case where the allowable amount for a visit to your GP is €20 and the outpatient excess is €300 in each year. Then assuming that your only out-patient expenses relate to your GP visits, you will not be able to make a claim from your insurance company unless you have made 15 visits to your GP in a year (i.e. 15 X €20 = €300). Thereafter you will only be able to claim €20 per visit even though the visits may cost you €50.
    If there is no excess on your policy you may claim immediately according to the benefits on your policy.

    Q What is an exclusion?

    Private Health Insurance contracts normally have a list of exclusions, which are circumstances under which the insurer may not pay a claim. For example:

    • Treatment received during waiting periods.
    • Treatment, which in the view of the insurer's medical director is experimental or not medically necessary.
    • Treatment related to birth control or assisted reproduction.
    • Cosmetic surgery other than for the correction of congenital, accidental or disease related disfigurement.
    • Treatment received in a hospital or from a medical practitioner that the insurer does not recognise and the insurer has informed you that it does not recognise the medical practitioner.
    • Medical expenses which you are entitled to recover from a third party.
    The above is not a comprehensive list of exclusions. Your contract may include some or all of the above, which will be set out in your contract details. You should review these carefully.

    Q What does maximum level of cover mean?

    There are often some limits on the level of cover provided. Sometimes a policy will only cover you for a certain number of days of treatment, or it may only pay out benefit up to a particular amount. In all cases you should consult your policy documentation in order to determine the extent to which benefits are provided.

    Here are some questions to ask yourself before choosing a policy
    Q What kind of hospital cover do I want?

    Most products concentrate on in-patient and day-patient benefits, although some also offer substantial out-patient benefits. It might be advisable to concentrate on the core benefits of in-patient and day-patient treatment when choosing between products.

    Q Which benefits would be of most value to me?

    There may be elements of your lifestyle or you may have plans for the future which would make some benefits more attractive to you than others. For example, you may need regular physiotherapy or you might be planning to have a baby, in which cases out-patient cover and maternity cover might be of particular interest to you.

    Q How much could I benefit?

    Sometimes it can be difficult to gauge the value that a benefit can provide, especially when it involves excesses, allowable amounts and maximum claim amounts. It might be useful to consider how often you would expect to make a claim under a particular benefit and work out whether it makes financial sense to opt for this benefit in your policy, based on the number of times you would claim.

    Q How much risk am I willing to accept?

    Sometimes private health insurance contracts include an excess. If you are willing to take on the risk of paying part of the cost, choosing a policy with an excess can result in a lower premium. If you are not willing to accept this risk you can choose a product without an excess. In another scenario, you may choose a policy with no significant out-patient benefits, thereby taking the risk that you will not require an unusual amount of visits to say, your GP or physiotherapist, but allowing you to pay a lower premium.

    Q Which product offers the best value for my circumstances?
  5. orka

    orka Frequent Poster

    On some of their plans (eg Parents & Kids which is a popular plan that they moved many of their customers to over the past few years), VHI have recently introduced a restriction (80%) on the amount they will pay for orthopaedic and opthalmic procedures in private hospitals.
    Some of VHI's plans (B, B options, Parents & Kids) limit the % payable (90%) for Cardiac and special procedures at 'hi-tech' hospitals (Mater, Blackrock Clinic...) - full cover is given on some of the more expensive plans.
  6. bluemac

    bluemac Frequent Poster

    Good examples for you brother in law broke his leg in a bad way went private waited 3 weeks for an operation...

    sister in law child needs operation she was waiting for private and has now gone public to get opp quicker.

    my wife has had baby on public its was of the highest quality there was no charges.

    she also had a operation was in hospital 4 days cost €70 a night no extras
    wait 3 weeks from consultant visit.
    I admit the wait to see the consultant was 4 months but due to lost forms by the HSE not waiting lists

    A+E for the child public cost us €100 for a visit

    We spend about €400 a year on doctors and hospital and have been very happy with the public system.

    As i see it, private you get to see the consultant quicker and that is all..
    does any one really care about a private room? when your sick you really dont care.. you just want to get well.

    I have also heard 2 storys of people having private health care going into the hospital having some treatment and finding out its not covered and having to be moved back to the public system.
  7. annet

    annet Frequent Poster

    Categories of Eligibility to Irish Health Services: Public Services: Public Patient

    Category 1 Eligibility

    Category 1 covers General Medical Services (GMS) where eligibility to the public health system is subject to means testing. If you income is above the threshold for eligibility and you have a long-term chronic condition, you may be awarded a discretionary GMS card, if it is deemed that you have insufficient means to meet those medical needs.

    If you are over 70 yrs and your weekly means is below €700 gross pw per individual, or €1,400 gross per couple you may be awarded the full GMS card.

    • GMS System
    Under the GMS system you are entitled to;

    1. Free GP services from a GP on the GMS list in your area
    2. Prescribed drugs and medicines and that’s subject to a dispensing levy of 50c per item up to a ceiling of €10 per month per individual or family.
    3. Free public hospital services (out-patient, A&E and inpatient) as a public patient in a public bed.
    4. Free maternity and infant care services.
    5. Certain dental, aural and opthamology services
    6. Certain community care and social services that may be provided by the HSE and/or in conjunction with private voluntary organisations like physiotherapy, occupational therapist, public health nurse, chiropody, day and respite services.

    • GP Visit Card
    If you are ineligible to the full GMS card, you may be eligible to the GP visit card which is subject to mean-testing. This entitles you to free GP visits.

    Category 2 Eligibility

    People ineligible under Category 1, fall into Category 2 eligibility. Category 2 confers entitlement to;

    • Free out-patient and inpatient public services, subject to an accommodation charge for day and overnight cases. That charge levied for overnight and day-cases, is €75 up to a max of €750 in any twelve consecutive months.
    • You also pay full GP fees and;
    • A&E charges of €100.00 per visit which can be waived following GP referral. If you have to make a subsequent return visit to A&E/OPD for the same illness and/or condition, this is a once-off charge. This charge is also waived for people who are in receipt of the long-term illness scheme (details below).
    • Non-EU and Non Residents pay an A&E charge of €268 per attendance.
    • You pay full prescription costs, although non-GMS holders are entitled to the Drugs Payment Scheme (DPS) which means that no individual or family pays in excess of the threshold of €120 per calendar month.
    Long-Term Illness Scheme

    People who are not GMS or GP visit card holders, and who have certain prescribed conditions, may be entitled to the long-term illness scheme for those prescribed conditions.

    The long-term illness scheme entitles people with a schedule of conditions as below, to obtain free of charge and irrespective of means, the necessary drugs, medicines and /or appliances, inpatient and emergency care related to those conditions.

    The list of scheduled conditions is

    • Learning disabilities.
    • Mental health under 16 yrs.
    • Haemophilia.
    • Diabetes insipidus and mellitus.
    • Cerebral palsy.
    • Phenylketonuria.
    • Epilepsy.
    • Cystic fibrosis.
    • Multiple sclerosis.
    • Spina bifida.
    • Hydrocephalus.
    • Parkinsons.
    • Acute Leukaemia and;
    • Conditions that are associated with thalidomide.
    National Treatment Purchase Fund

    If you are a public patient and you’ve been waiting for more than 3 months on a public waiting list for in-patient or a day-case procedure you, may be eligible to get free treatment under the National Treatment Purchase Fund.

    This is a State initiative that was developed with the aim of cutting long-term waiting lists. It does so by purchasing services from private hospitals throughout Ireland, and this scheme is free of charge to the public patient.

    If you are eligible to be treated under the NTPF, and you’ve been waiting for more than three months for an inpatient treatment or a procedure, you may be able to access this scheme by either;

    • Self referral (by calling 1890 720 820)
    • GP referral
    • Hospital referral
    • Consultant referral
  8. Brendan Burgess

    Brendan Burgess Founder


    That is a really interesting post. We only hear terrible things about the health service. The long waits on trolleys. The long waiting lists etc. But quite a few people have told me that they had a great service. But they won't go onto Joe Duffy to speak up.

    I recall someone telling me that you are much better off in the public hospitals for maternity cover as there are more specialists if there is a problem.

    There was something else which I can't remember but VHI customers are charged for something which public customers are not. But the VHI doesn't pay for that particular procedure. I will see if I can get the details.
  9. NovaFlare77

    NovaFlare77 Frequent Poster

    I missed that. Let me have a dig around my previous posts and see what I can pull out that would be suitable. Might take me a day or two, but I know I've a few posts that would be suitable.

    FYI, the Health Insurance Authority already have alot of this covered on their website here and here so you might be able to just link to those pages to cover alot.
  10. pj111

    pj111 Frequent Poster

    Last edited by a moderator: Mar 5, 2011
    Not true. You are not entitled to a 10% discount, it is at the insurer's discretion.

    Not neccessarily so. Service is very important not just one off advice.

    Unless you can buy it at a cheaper rate than those that charge more for the semi private room.

    See above comments

    Last edited by a moderator: Mar 5, 2011
  11. michaelm

    michaelm Frequent Poster

    The health service is good, once you're in (I can only speak about Tallaght, St. James's and St. Vincent's). A&E is like a field hospital. One of the big problems is with chronically ill patients who have an established relationship with the hospital; they may get home for a few weeks/months but many will end up having to be rushed back in but are forced through A&E an onto trolleys.
    If things go wrong in a private maternity hospital they ship you to a public hospital. I have found the Coombe to provide great care.
  12. Brendan Burgess

    Brendan Burgess Founder

    I don't think so, but I am open to correction. Under community rating the same price must be available to everyone.

    How do you mean "service"? But I have changed that bit anyway to

    Sorry, I don't understand your point here at all.
  13. pj111

    pj111 Frequent Poster

    (1) Everyone is entitled to buy any of the 212 plans but are not entitled to a discount. The discount is at the company's discretion.

    Quinn do not offer 10% discount to individuals anymore on any of their plans - the prices on the hia website DO NOT include 10% discount. Discounts to companies are available on a sliding scale determined by Quinn.

    VHI do not generally offer 10% discount to individuals on their business plan range, therefore the prices can be further discounted at VHI's discretion. VHI can and do ADD 10% onto the HIA figures for consumer plans ! i.e you are not guaranteed the 10% discount. I have proof !

    Aviva offer 10% on all consumer plans, anything that doesn't have the word business in its name. They do not offer discounts on their business plans to individuals and discounts to companies are at Aviva's discretion.

    Community Rating allows people to buy the same plan within 10% of the maximum cheapest plan.

    (2) Why is service important ?
    - help with choosing the right policy for the right person at the right time and doing this throughout the year and the next and the next year. A plan is no longer for life. The service and advice on an ongoing basis is much more important than one would consider. The intricasies and subtleties of the Irish health insurance market may not necessarily be found via the internet.

    (3) Plan A with VHI will buy you cover for a semi private room with VHI at a cost of almost €700 per annum.

    Level 1 Hospital with Aviva will save you almost 10% over the VHI price yet offers a private room in a public hospital so superior cover.

    There are other examples, the point is why pay for a lower level of cover for a higher price when you can get a higher level of cover for a lower price with a different plan or provider. There might not be many private rooms available but if you have the cover you will get one quicker than one without who could end up having to pay a shortfall of €120 PER NIGHT. (This could also potentially mean a private room in the "alusive" Merrion wing of Holles Street when going private....but not for those with Plan A or First Plan).

    Hope that helps.

  14. Brendan Burgess

    Brendan Burgess Founder

    Thanks for clarifying that. I have changed it to "you may be entitled to a discount".
  15. The Edge

    The Edge Frequent Poster

    GP Visit Cards:

    Certain people who do not qualify for a medical card may apply for a GP (family doctor) Visit Card. GP Visit Cards allow individuals and families who qualify, to visit their family doctor for free.

    I cannot post URL's to other sites until I have 15 posts, but more information, together with worked examples, are set out in the citizensinformation website.

    Individuals and, in particular, families, with fairly high incomes can qualify. There is a worked example of a family with after-tax annual income of €57,200 who would qualify. The key is that the allowance is made for mortgage/rent child care costs in determining assessable income.
  16. Preginfo

    Preginfo New Member

    Just a slight correction: depending on which maternity hospital you choose the scans are included in the price you pay to the consultant, this is different for different hospitals but in the Rotunda Private Clinic all scans are free.
  17. vigilante

    vigilante New Member

    I know GloHealth do an special Maternity addon (I think it's free?) which could be an answer to the maternity issue?