The risks of downgrading health cover

Good advice. We downgraded our cover in Jan 13 and Murphy's Law being what it is, I discovered I need a hip op in May 13. My doctor recommended a particular consultant, I had no reason to query this. Met with the consultant last July where I found out that he only does his surgery in Vincents Private Hospital or Cappagh. As our cover didn't include private hospitals, merely semi/private in public hospitals, I have now been on a waiting list for 7 months for this op. If I had known at the time to query the consultant and where he operated, I'm sure I'd be lepping around the place now after the hip replacement. The cost of having the procedure done in a private facility would buy a new car, even though this particular op is so fine-tuned now that one can be in and out of hospital in 3 or 4 days. Lesson learned.

Eithneangela said:

Good advice. We downgraded our cover in Jan 13 and Murphy's Law being what it is, I discovered I need a hip op in May 13. My doctor recommended a particular consultant, I had no reason to query this. Met with the consultant last July where I found out that he only does his surgery in Vincents Private Hospital or Cappagh. As our cover didn't include private hospitals, merely semi/private in public hospitals, I have now been on a waiting list for 7 months for this op. If I had known at the time to query the consultant and where he operated, I'm sure I'd be lepping around the place now after the hip replacement. The cost of having the procedure done in a private facility would buy a new car, even though this particular op is so fine-tuned now that one can be in and out of hospital in 3 or 4 days. Lesson learned.

Click to expand...

What does public hospital insurance cover; just different accommodation or does it get you seen faster?

What's the point in having insurance for public if you still have to wait 7 months?

We thought we'd have cover in any public hospital for any potential serious illness, with maybe a little bit of comfort in a semi/private area in a public hospital. Now, it looks like that's a dream - if we need cover for an event - whatever it is - it appears that we need top health insurance cover to get treated in any humane way. Bit disgruntled here.

Sorry, I didn't reply to the q about why insure for public? I didn't - I thought by seeing (and paying €150) for a private consultant, and paying for PHI, that I would somehow be sorted out. Little did I know!

Eithneangela said:

Good advice. We downgraded our cover in Jan 13 and Murphy's Law being what it is, I discovered I need a hip op in May 13. My doctor recommended a particular consultant, I had no reason to query this. Met with the consultant last July where I found out that he only does his surgery in Vincents Private Hospital or Cappagh. As our cover didn't include private hospitals, merely semi/private in public hospitals, I have now been on a waiting list for 7 months for this op. If I had known at the time to query the consultant and where he operated, I'm sure I'd be lepping around the place now after the hip replacement. The cost of having the procedure done in a private facility would buy a new car, even though this particular op is so fine-tuned now that one can be in and out of hospital in 3 or 4 days. Lesson learned.

Click to expand...

Not sure I understand. Are you saying that you are waiting seven months to be treated privately by a consultant in a public hospital?

Yes - the consultant put me down last July for admission to Cappagh. I had a pre-assessment carried out last November and assumed I'd get a call within weeks. Still waiting.

Sorry, I've just reread your query - I am still waiting to be treated as a public patient in Cappagh - my private Health Insurance doesn't make a darn difference in this situation apparently. So, I had to pay for a private consultation with the nominated consultant (my PHI doesn't cover this either because it's an outpatient consultation) and because my cover didn't include private hospitals, I've been put on the public waiting list for Cappagh where my consultant also works.

So the issue is that your insurance doesn't cover hip relacements rather than the issue of cover in certain hospitals?

Hi Eithne

This looks very interesting and important so I have moved it to a separate thread.

What does your health insurance cover?

Brendan

We downgraded last year from Laya Company Health Plus to Essential First. In discussion with the Laya customer service person at the time, I was assured that the only thing not covered was inpatient care in Private or High-Tech hospitals.
When I discovered I needed a hip op, my GP got an appointment for me with an orthopaedic consultant in St. Vincents Hospital. I had to get an xray done in the Wexford General Hospital prior to meeting the hospital. This xray cost €50 because I had PHI (it would have been free if I had no PHI!). The consultant decided I needed a replacement hip and on discovering that my PHI did not cover private hospitals (such as St. Vincents Private where he also operates) he put me down for admission to Cappagh hospital where I joined the waiting list like all those without PHI.

I paid for this consultant visit (€150). That was last July. Since then, I've had a pre-assessment at Cappagh and continue to wait for the op.

So our Essential First basically covers us for inpatient treatment and care in public hospitals. In reality, this means that the PHI covers the cost of inpatient treatment but does not speed up access to the treatment. I had assumed that by going to the consultant privately that this would speed up the process but in fact it has absolutely no effect on the public hospital waiting lists.

I think the only way to be assured of timely access to inpatient treatment is to pay for cover in Private Hospitals. With that cover, I could have had the op scheduled for the following month.

I have often wondered about a policy that only covers semi private in a public hospital, I know our local hospital only has 6 bed+ rooms and private rooms, there are only one or two private rooms per ward and in effect only very very seriously ill people end up in them. The likelihood of ever getting one based on PHI would be slim I imagine, certainly in my locality.

However I did think you would at least get into the system quicker even if there was another half dozen in the room with you if you had the PHI but based on your story there is no advantage.

It actually does get you in quicker guys as I have a family member waiting for hip replacement in a public hospital as a public patient for 2 years now! But at same time I agree that you are better off to have cover for private hospitals to avoid this. Looks like the consultant was only too happy to take your money and I think consultants should do the decent thing and tell you before you fork out all the money if your better off just going public

Hi Eithne

Would it be worth upgrading now to the level which would get you cover?

Do hips tend to go in twos?

Brendan

Just a thought. Why did your GP refer you to a consultant who only works in private hospitals. There are dozens of excellent orthopaedic surgeons who work in public hospitals where you could have quick access to a semi private or private room. I think the initial referral pathway is the problem here. Always inform your GP as to the level of cover you have. If this problem is causing you pain/ distress I would go back to the GP and get a copy of your referral letter for the private rooms of a surgeon in a public hospital. Better still ring a few orthopaedic doctors rooms and ask how long their waiting list is for private patients with your level of cover for this type of surgery. I'd be surprised if you would have to wait any longer than 3 months. It should be easier to access this now with so many people giving up their health insurance. You don't have to stick with your GPs choice of doc.

The cost of PHI in Private Hospitals is prohibitive for us at the moment. In any event, no matter what you upgrade to, at our age (60+), we would have a minimum of 5 years before any pre-existing condition could be treated in one of these hospitals.

Hips don't usually go in twos - what often happens is the bad one causes more wear and tear on the 'less bad' one and once the initial hip is done, the second one needs to be done after a few years.

I think at the moment that all public hospitals are so stretched in terms of bed occupancy that private/semi-private beds are being used just to get people off trolleys from the Emergency Department.

I fully understand that the public health system is over-stretched at the moment, but I think this has a major impact on those of us with private health insurance which depends on the public system to deliver the goods.

I don't know what the solution is - in my case, I could fork out for the consultant on a private basis which at least got me on to the waiting list for treatment. I could have picked my date for the op if I'd had cover for private hospital. When we made the decision to downgrade our cover, it was totally based on the fact that we don't need private room, private hospital etc. Never realised that having PHI meant absolutely nothing in my scenario.

In response to Laois1, my consultant works in both private and public hospitals. It does not matter a whit in the public hospital scenario - there is no bumping up the list because one has PHI.

Eithneangela said:

In response to Laois1, my consultant works in both private and public hospitals. It does not matter a whit in the public hospital scenario - there is no bumping up the list because one has PHI.

Click to expand...

Well then I don't understand what PHI for public hospitals is for? Can anyone explain this?

You don't have to stick with cappagh, there could be long waiting lists there for various reasons e.g reduction in theatre capacity because of budgetary concerns, bed closures, a lot of patients blocking beds awaiting nursing home beds etc. Have you called the admissions office they should be able to give you an indication of what is going on ? You have private health insurance you can go to many other hospitals and see what their waiting times are like. Just call the surgeons secretaries. You are not a public patient stuck with wherever your GP sends you. You have options. Personally I wouldn't go near a fully private hospital for any major op. If something goes wrong you are better off in a public hospital with properly staffed ICU facilities and access to consultants in a wide variety of other specialities if you need them. I would not bother with top end private insurance for this reason. Last summer I had the option of mount Carmel for an op within 10 days or wait three months for St. James's. I chose the latter and was glad I did even though I never got a semi private or private bed which I was entitled to as they were all full.

Pros
If you cannot afford a middle/high PHI plan, then the very basic plans are useful for maintaining coverage until you can afford to upgrade. This is particularly important for anyone with pre-existing conditions or those aged 50+, as breaking coverage and trying to get re-insured can mean a waiting period of several years.

Caveats
PHI in public hospitals will entitle you to a semi-private or private room where one is available. Priority is given to those with higher plans, so someone on the very expensive package will get a room ahead of someone on the basic package.

A major problem is that these rooms are often (or usually) taken up by public patients who are critically ill, dying, highly infectious, etc. etc. so you could have the fanciest PHI plan and still be in a ward with 7 other people. There just aren't enough rooms in hospitals, full stop.

Many cheaper plans were brought in by new entrants to the PHI market to attract young people who would enjoy low premiums and would be unlikely to ever claim on the insurance. People often get stung when they go to access private services and find that they are either not covered at all or that there is a large excess.

Cons
Be cautious also with some of the mid-range plans that offer partial cover for cardiac and orthopaedic procedures - the reason for this is that these are the most expensive categories of procedures and the ones that the PHI companies make the lowest margins on. For example, if a cardiac procedure is 85% covered it may sound like a good deal, but it could still cost you thousands.

While cheaper plans look attractive, they can be false economies and the best option, where affordable, may be to get a plan with a higher deductible. In a public hospital public patients pay €75 per night, up to a maximum of €750 per year. If you go through A&E without a GP referral letter then there is an extra €100 on to that.

If you are a private patient in a public hospital then you can be charged even higher fees.

With mid-range PHI in a private hospital, you will face some fees, but often these are not far off the public prices. If speed of access matters to you, then a mid-range PHI is vital.

Of course, you must factor in your personal health history, family history, age, lifestyle, etc.

Agree with laois1 re: finding another hospital. It's a pain, but if you call around you may find a consultant in your area who has a shorter list. Your GP should be able to advise and may know which hospital catchment area you live in.

laois1 said:

Personally I wouldn't go near a fully private hospital for any major op. If something goes wrong you are better off in a public hospital with properly staffed ICU facilities and access to consultants in a wide variety of other specialities if you need them.

Click to expand...

This image of private hospitals may have been true to some degree in the past, but things have changed a lot in the last 10 years. Many of the private hospitals are now teaching hospitals with full-time private consultants, teams of junior doctors, A&Es and full-staffed ICUs. Private A&Es were originally intended for minor injuries but they now regularly admit seriously ill patients as people are keen to avoid trolleys in public hospitals. All private hospitals are held to an independent international accreditation standard called JCI, which sadly very few of our public hospitals could meet.

Obviously, standards vary from hospital to hospital, and from consultant to consultant, but the same is true in public hospitals.

Public hospitals are really strained at the moment with staff shortages among nurses, doctors, and other areas. Doctors in particular are moving abroad or joining the private sector. Sadly this means that many of the best docs are now working only in private hospitals, which is unfortunate for public patients.