Health Insurance Health insurance jargon clarified

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ClubMan

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A thread to try to clarify some of the jargon used in private health insurance documentation.

I'll kick it off with the following.
  1. "Co-payment" - what is this? Another name for an excess that the policyholder has to foot? Or is it a fixed amount that the insurer pays towards a particular procedure?
  2. "Certain orthopaedic procedures" - I've seen #1 mostly mentioned in relation to these but could never ascertain what these were.
  3. "Special procedures" - what are these?
 
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ClubMan said:
A thread to try to clarify some of the jargon used in private health insurance documentation.

I'll kick it off with the following.
  1. "Co-payment" - what is this? Another name for an excess that the policyholder has to foot? Or is it a fixed amount that the insurer pays towards a particular procedure?
  2. "Certain orthopaedic procedures" - I've seen #1 mostly mentioned in relation to these but could never ascertain what these were.
  3. "Special procedures" - what are these?
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Might 3 include the costs of what is now called gender reassignment?
 
1) a copayment is where the insured pays a percentage of the cost of the claim (eg insured pays 20% and the insurance company pays 80%). An excess is where insured pays the first €x euro.
2) certain orthopaedic procedures are a list of surgeries such a hip and knee replacements. Cover for these procedures is typically important to people aged 55+ and not at all important to younger people. It is used as a way of making policies that provide limited cover for these procedures to be unattractive to older people. As a result these plans are priced more competitively because the overall claims cost on these plans are lower as relatively fewer older people (who have higher claims across the board) insured on these plans.
3) Special procedures are a list is common procedures performed in high tech hospitals for which the insurers have negotiated a fixed price. (So the insurance company has limited its exposure to high cost claims from very long lengths of stay in expensive private hospitals)
 
dishwasher said:
1) a copayment is where the insured pays a percentage of the cost of the claim (eg insured pays 20% and the insurance company pays 80%). An excess is where insured pays the first €x euro.
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Thanks. But on the HIA site I see several policies which say things like "co-payment of €2k applies to certain orthopaedic procedures". I.e. nothing about percentages. What does that mean?

Apart from that it seems to me that there is little difference between an excess and a co-payment (or whatever the customer's part of a co-payment is called)?
dishwasher said:
2) certain orthopaedic procedures are a list of surgeries such a hip and knee replacements.
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[Where] do insurers clarify what the mean by "certain ... procedures"? I couldn't find anything in my Irish Life documentation when I was due to go in for surgery. And the IL help desk was no help either. I had procedure codes and asked if any of them were "special" but they couldn't/wouldn't tell me.
dishwasher said:
3) Special procedures are a list is common procedures performed in high tech hospitals for which the insurers have negotiated a fixed price. (So the insurance company has limited its exposure to high cost claims from very long lengths of stay in expensive private hospitals)
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Again who defines this list and where?

Thanks for the feedback @dishwasher.
 
1) Different health insurance companies manage this differently - 80%/20% split can end up being a varying amount to the parient depending on the surgery they are having, whereas a €2000 co-payment is a set charge with the patient knowing at the outset that their bill will be €2000.

In both instances, you can have an excess payment ontop of the shortfall/co-payment.

2) The orthopaedic procedures are the shoulder/hip/knee replacements and are generally a 'lifestage' issue.

3) Special procedures can literally be any procedure where there is a fixed charge regardless of the length of stay. They include but not limited to spinal surgery, heart procedures, prostate procedures, The most advanced procedures available in Ireland are on these lists.

The insurance company defines this list themselves so while it can vary, you'll find very little difference between each company

Clubman, with codes it is very easy for a company to tell you if it is a special procedure or not. Just to add further confusion, please note that while it might be a special procedure in one hospital, it may not be special in another. Either way though the agent should absolutely be able to tell you this.
 
Don,t be frightened by "pre existing conditions".It only means a new condition IN THE PREVIOUS 6 MONTHS.[learned this from Laya].Cheers.
 
DK123 said:
Don,t be frightened by "pre existing conditions".It only means a new condition IN THE PREVIOUS 6 MONTHS.[learned this from Laya].Cheers.
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I've been thinking, if you did have a pre-existing condition, and there's meant to be a 5 year waiting period, can you not just sign up for a cheaper package for a year and then move to a higher one. It seems that there's a 2 year waiting list for upgrading your health insurance so is that a way to cut it to 3 years in stead of 5? Or am I missing something?
 
The Oggster said:
I've been thinking, if you did have a pre-existing condition, and there's meant to be a 5 year waiting period, can you not just sign up for a cheaper package for a year and then move to a higher one. It seems that there's a 2 year waiting list for upgrading your health insurance so is that a way to cut it to 3 years in stead of 5? Or am I missing something?
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At far as I know insurers will ask for evidence of previous cover when deciding if the 5 year waiting period has been served. I very much doubt that the shorter "upgrade" waiting period trumps it.
 
As suggested above, you will not reduce your Pre-existing waiting period by upgrading your cover.

If a condition existed prior to the start date of your policy, or if signs and symptoms existed prior to the start date of your policy, you will not have cover for that condition for 5 years.

If you changed your level of cover after one year, and a condition had developed in that previous year, you will not get the higher benefits for that condition for 2 years. You will have cover as per your original level. You will have cover at the higher level immediately if the condition developed after the cover change was made.

You will continue to have no cover for the 5 years if the condition developed before the original start date of your policy.
 
kitty81 said:
and a condition had developed in that previous year,
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How do you quantify this. For example. Laya offer a free cardiac screening to it's customers. If I take this up and they notice an irregular heartbeat or similar during the consultation....do I now have a "condition"?
 
IsleOfMan said:
How do you quantify this. For example. Laya offer a free cardiac screening to it's customers. If I take this up and they notice an irregular heartbeat or similar during the consultation....do I now have a "condition"?
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Yes. If you look at the t&c's document that compliment the table of benefits you'll find the full definitions. It's usually something like if any "signs or symptoms existed". This essentially means as soon as you state you have a symptom or sign to a doctor and they write it down, it's now written on your record. It doesn't have to be a full diagnoses either, just a symptom which is very likely associated with what you got diagnosed in the future. This paper record is all they have access to when checking claims. So it matters whether it's been written down or not.

Also worth noting, for the 5 year pre existing rule, as was stated by a poster above, for most insurers it's only if "signs and symptoms existed at anytime in the 6 months prior to first taking insurance." In other words the insurer might trawl through 6 months of your medical records prior to first joining insurance when checking a claim, they won't go further than that. This means it's important to know what's been recorded in that time. For example if you had a condition recorded a very long time ago, and that condition was fully resolved, it shouldn't be considered pre existing if it occured again sometime after taking out insurance. However if it was chronic and you were getting treated for it the whole time ( specifically in that 6 month period) then it would be considered pre existing.

The problem is that it can be nerve racking as you'll only know if your claim is not accepted due to a pre existing condition after you've already had the procedure done and the bill is processed weeks or months down the line. There is no way to get pre approval for this.
 
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