Key Post Health Insurance excesses & shortfalls, how they are applied with some examples.

Discussion in 'Health Insurance and healthcare costs' started by BazzaDP, Feb 28, 2013.

  1. BazzaDP

    BazzaDP Frequent Poster

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    Probably an obvious question to most, but I'm new to Irish healthcare, so can someone explain (ideally with examples) about excesses and shortfalls, how they are applied, and in what order?

    For example if I have 10 treatments costing a €100 each and have a €200 excess and €40 shortfall for this treatment what happens?

    Is the excess applied to each treatment (so I get nothing in this case as each treatment individually is less that €200 excess?) or is the excess for the year of cover (in which case I can apply for cover for the 2nd - 10th treatment)? Does it matter if the treatments are related? I.e. would an insurer expect me to claim 10 physio treatments for one leg injury as 10 separate claims, or as 1 claim?

    Similarly with shortfalls.

    As I see it, depending how you understand this, I could pay:
    €1000 - I pay 10 * €100 full amount as no individual treatment below excess.
    €600 - The insurer will pay €60 per claim minus the excess, meaning they pay (€60 * 10) - 200 = €400. So I'm left with €600 to pay.
    €520 - I pay full price of €100 for first two treatments as below excess and eight treatments at forty euro excess only: (2 * €100) + (8 * €40) = €520
    €240 - I pay the excess and the shortfall on the total amount.

    How would this work out differently if this was definitely one treatment?

    For example if I have to stay for 10 nights in a hospital costing a €100 each and have a €200 excess and €40 shortfall per night what happens?

    Sorry if that's not the most clear but as you can see I'm very confused about all this!
     
  2. ajapale

    ajapale Moderator

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    7,704
  3. snowyb

    snowyb Frequent Poster

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    973
    Hi BazzaDP,

    Welcome to AAM.

    First of all, to answer your question regarding out-patient excesses and how they are applied:

    The correct answer to your example for 10 treatments is 600euro.
    The out-patient excess applies for a full year of insurance cover from date of renewal say 1/2/2013 to 31/1/2014.
    A person usually sends in a claim for a refund for all outpatient expenses incurred throughout the year at the end of their insurance year,
    ie - after the renewal date.
    It doesn't matter if the treatments are related.


    A very good website to check out with regard to all aspects of the private health insurance system in Ireland is;

    www.hia.ie

    Under the heading, 'Consumer Information' it covers all the basic information and rules regarding private health insurance.
    It has a special section dealing with excesses, called 'Claims and Excesses', with examples and explanations.

    www.hia.ie/consumer-information/claims-and-excesses/

    There are 2 types of excess;

    1. Inpatient hospital excess - this is a one off payment on admission to a private or hi-tech hospital. Example 75. It is NOT payable to any
    public hospital on admission.

    2. Outpatient excess - this amount is deducted from your total allowable health expenses in a year. the ideal excess amount to
    have on any plan is 1 euro, this maximises the refund you will get.

    A standard private health insurance policy is divided into 6 different sections as follows;

    1. In-Patient Cover - this means type of hospital cover - 3 types of hospital cover in Ireland; Public,Private,Hi Tech.
    2. Maternity Cover - details of cover for a maternity hospital.
    3. Out-Patient Cover - list of the type of day to day medical expenses allowed, ie gp visits,dentist, etc and the amount allowed per visit.
    4. Out-Patient Radiology - details of cover for all types of scans,x-rays etc.
    5. Overseas - details of cover for surgery abroad if not available in Ireland.
    6. Psychiatric Cover - details of inpatient and outpatient psychiatric care available on the plan.

    All the insurance plans are listed and can be viewed in detail on www.hia.ie
    There are 4 different companies providing private health insurance in Ireland - VHI Healthcare, Laya Healthcare ,Glohealth, Aviva.
    Now the only problem is that there are around 300 health insurance plans to choose from covering all levels of hospital cover etc.

    Regarding the second query re a 10 night stay in hospital for treatment, this stay will be fully covered by your health insurance.
    The type of hospital that you can stay in will depend on the details in your plan regarding the level of hospital cover.
    There are 3 levels of hospital cover - public, private and hi-tech hospital.

    Snowyb
     
  4. huskerdu

    huskerdu Frequent Poster

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    2,024
    THe issue of the excesses and shortfalls in interesting and confusing, and worthy of a sticky, IMHO.

    Here is my contribution of a worked out example to show how the excess works.

    My Health Insurance policy pays

    €60 per consultant visit
    €25 per GP visit, subject to a maximum of 7 per year
    The excess is €200 ( This excess is for outpatient claims only and is different and separate from an excess for hospital claims.

    Last year, I visited a consultant 7 times at a cost of €150 per visit and a GP 9 times at a cost of €55 per visit. Total cost =

    7 Consultant visits * 60 = 420
    7 GP visits * 25 = 175
    TOTAL allowance expenses = 595

    The total that the HI will pay is 595 - 200 = €395
     
  5. BazzaDP

    BazzaDP Frequent Poster

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    82
    Thanks all. Much clearer now.

    Yeah think a stinky on this could be helpful as is a fundamental part of Health Insurance. Could one of the mods either make this thread sticky or write a cleaner version of it?
     
  6. trojan

    trojan Frequent Poster

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    194
    Just came across this subject which i think causes much confusion but when one fills up the claim form you realise you are only getting 395 euro following an outlay of 1545 euros. However the tax refund of 20% of 309 euros makes the picture better.
     
  7. Hesadub

    Hesadub Registered User

    Posts:
    11
    Hi Trojan. I see that you calculated your tax refund on the full outlay of 1545 euros before insurance claim. IMO Revenue will not accept this. The 20% refund applies to your final out-of-pocket costs after your insurance claim, ie 1545-395 = 1150 euros. At 20%, your ultimate tax refund should amount to just 230 euros.