Health Insurance Laya Simplicity - Reduced amount paid for an Outpatients claim.

[horusd]

Short story: I went for an ophthalmic appointment in the Wellington Clinic in the Beacon Sandyford. Fee was 300 Euros which included quite a few tests and a consultation. I submitted an outpatients claim to LAYA, the cover is normally for 50% of the fee - they decided to pay 125 as "We have allowed up to the amount that is considered to be reasonable & customary as per the laya healthcare Scheme rules & table of benefits." This term does exist within the LAYA documents, they saved themselves 25 euro but have left a somewhat bad taste in my mouth as a customer. I do get the reasonability aspect, but to apply it where extensive tests were carried out seems odd and given they saved 25 quid hardly seemed to warrant all the effort that went into it. thru took three weeks to get back to me.

 

[RedOnion]

This term does exist within the LAYA documents

Do you have a "scheme rules" document? Point (b) below looks to be what they're relying on.

8. What is covered under
the scheme
(a) We will pay benefits for treatment a person
receives while they are a member of their
scheme. We will pay benefits under the
scheme of which they were a member at
the time they received the treatment and
according to the rules and Benefit Table of
the scheme that applied to them at that time.
We will not pay benefits for treatment which
a person receives while he or she is not a
member of the schemes.
(b) We will only pay fees and charges for
treatment, services and facilities that are
reasonable and customary and in any event
only up to the limits shown in the Benefit
Table. By reasonable and customary we
mean that what you are charged for and how
much you are charged is not more than what
the majority of our other members of the
schemes are charged in Ireland for similar
treatment services or facilities.

 

[horusd]

Yes. this is it. I generally like LAYA, but this seemed a bit stingy TBH.

 

[mtk]

I got stung for an initial “double “ physio appointment which cost 130 but laya would only pay based on 90 max if I recall correctly . Relied on same clause ,