Health Insurance VHI 36 13 Fixed Price Procedures

tnegun

Registered User
Messages
372
My wife was in a bad accident a couple of months back so I've been getting up to speed on the shortcomings of our health cover. I've been referred to our policy documentation more times in the last few weeks and been caught out by what I would call deliberate vagueness. The Dublin Dental University Hospital isn't recognised as a public or private hospital for one!

The most recent issue I've had was trying to determine what's covered by their Fixed Price Procedure list. Depending on the consultant and hospital they may or may not cover the procedure but they won't tell you that until after you have paid for the consultation and know what the procedure might be. They won't provide a copy of this document either so that you can make an informed decision. So you could well pay for a consultation and then find that your insurance won't cover the follow-up as they don't cover the hospital the consultant uses. You could potentially have to seek out another consultant in a different hospital, pay for the consultation again and hope it is covered in the hospital they choose. Thankfully it hasn't happened to us yet but that was luck rather than through any deliberate action but we still have two more rolls of that dice.

This seems very unfair to me and is it legal? They claim it is commercially sensitive and not available to the public but it seems to me a convenient way to be able to add and remove procedures from cover without any visibility and certainly makes it more difficult to compare policies. Is this normal practice to have such a list and not share it? How are you supposed to know which consultant in which hospital to use if this practice exists?
 

Starrynights

Registered User
Messages
8
Hi,

Very sorry to hear about the accident.
The Dublin dental hospital not being recognized is an anomaly for sure. I believe it is done this way so as to show that in patient procedures in that hospital are not covered, eg surgery etc. However as a result it seems to extend to any outpatient dental benefit too, so for small procedures or consultations it may be better to go to a private dental practice, where you can claim this benefit back.

VHI plans have a section in the table of benefits which is referred to specifically as fixed price procedures (FPP's). It seems a lot of plans only cover a % of this, around 50-90%.
FPP's are separate to all other procedures and this categorisation is specific to VHI. I am not sure if this is what you are referring to specifically in your title. If this is what you are talking about then FPP's are in general the more complex and expensive procedures, usually only done in what's sometimes categorised as high tech hospitals. If you are a VHI customer you can request this list and they will mail a hardcopy out to you with exactly every procedure on it.

Otherwise all other procedures are covered as per your table of benefits to your plan. Again hospital categorisation is a little different with the different insurers. Eg. With VHI you'll see private hospitals categorised as private 1,2,3, or 4. These procedure codes are negotiated between the hospitals and the insurance company. It should be taken that if the hospital has medical procedures it knows it has to carry out, it will have organsied it with the insurance companies and it will be coded. The insurers state they don't want all of these procedure codes public as they deem it private property. Apparently it costs a lot of money and takes a lot of effort to make, negotiate and update these lists of procedures and if it were public, other insurance companies will just copy their work. I think there was some complaint/ law suit over this issue some years ago.

In terms of worrying about being referred and what you are covered for here is how I tackle it.
If you go to your GP and you need a referral to a specialist, the GP may be inclined to refer you to someone specific straight away or they may ask you. You are well within your rights to specifically ask your GP to send a referral to a particular doctor or hospital. If it catches you off guard and you're not sure you can also always ask your GP to give you a general or open referral. Then you can take this letter to any hospital or consultant directly once you have chosen. This way you can buy yourself time to research consultants/hospitals or contact your insurer to query cover.

As a rule of thumb it may be best to look at which of your nearest hospitals your plan covers that you would want to go to. Make a list and keep this in mind for your whole year of cover. With VHI you can look this up online with the facility finder. Look at the hospital cover vs the table of benefits for your plan. Eg. You may have full cover for both day case and inpatient cases in the Beacon but only day cases in the mater private. If you're put on the spot, you can just ask for a referral to the Beacon, knowing that you have both day and overnight cover (the greatest range of procedures).

Next step is to double check the consultant is approved and working with your insurance company before you attend a consultation. ( If the hospital is covered, very likely the consultant is covered too but this is not always the case so it's always best to look it up. ) With VHI you can check this online.

Once the consultant books you in for the procedure you will get a procedure code, as I am sure you are already familiar with. At that point you contact your insurer and get full confirmation you are covered and confirm how much your excess is, if any.

if you follow a similar sort of steps, it's unlikely you will go to a consultation with a doctor at a hospital that you don't have cover for procedures in.

I know health insurance can be a minefield to navigate so I hope some of this is useful to you and that your wife has a swift recovery. If you have anymore queries I'll do my best to reply.
 
Last edited:

tnegun

Registered User
Messages
372
Firstly thanks so much for such a detailed and comprehensive reply.

Dublin dental hospital
VHI refused the Dental Hosptial A&E charges claim despite her being transferred from Blanchardstown A&E after they patched her up for emergency dental treatment.

If you are a VHI customer you can request this list and they will mail a hardcopy out to you with exactly every procedure on it.
They have refused this twice now and told me it's commercially sensitive and that I must call them with the consultant's name, the facility and the procedure code they can then check that all is covered. First, they need to check if the procedure is a FPP, day case or side room and if it is a FPP, is it fully, partially or not covered at the facility the consultant practices in. It seems impossible from the outside to know what VHI will decide the procedure is.

VHI you'll see private hospitals categorised as private 1,2,3, or 4
It seems that everywhere she needs is 3 or 4 e.g. The Hermitage, Mater Private, Blackrock or the Beacon and these have the most restrictions as to what's covered. Here's the Table of Benefits https://www.vhi.ie/pdf/myvhi/TOBPMI 3613 V33 Apr21.pdf .

Part of the trouble I was having at the time was that all consultants have a 6-month waiting list so I was calling around, when I did get a cancellation or appointment for this year I was getting caught by not being able to know in advance if any procedure required would be covered as she needed to see and pay the consultant to get the procedure code. This seemed very unfair and was extremely frustrating as the only way to know seemed to be to pay the €200 consultation fee to get the code. Then VHI would decide if it was covered in the facility chosen by checking the FPP list and if not we would have to find another consultant at least this time armed with the likely procedure code and query if they would cover it for this consultant in the facility that they practice in.
 

Starrynights

Registered User
Messages
8
No problem at all. I only hope this info helps you a bit better and that the recovery is going well.

After having a quick look at your table of benefits it appears that your plan doesn't have any cover for emergency dental, only dental practitioner cover. Perhaps this is why the dental A&E charge isn't being covered.

In terms of VHI refusing to provide you with the FPP list, this is really strange. The FPP list and the general list of procedure codes are two sperate things. I myself requested and got the FPP list mailed to me earlier this year. Perhaps they are getting confused as to what you are asking for. Under your table of benefits section 1 C, it literally says in brackets (contact us for details). I would refer specifically to this section of the table of benefits, read the whole thing out and point out it says contact us for details. It might be the case that newer call centre operatives working from home are just unfamiliar with this and might think that you are requesting all of the general procedure codes as well. If you can get them to check with a supervisor, or better yet get onto the supervisor yourself, I'm fairly certain you should be able to get your hands on a copy. Especially as you are a paying VHI customer and are availing of this plan. Of course there is a small possibility that they changed their terms about sending these out in the past few months but I'd reckon it's more so an issue with whomever you're getting through to in customer service.

Regardless I wouldn't worry about FPP's as your plan provides 100% cover. The only thing it doesn't cover is level 2 cardiac FPP's but as far as I know this is a very specific set of procedures for people who can't have normal cardiac procedures, it's only suitable for a small cohort of people, it's very expensive and very few plans provide cover.

Level 3 hospitals seem like the best general option as you have full cover for day and semi private inpatient.
Level 4 you have day case only (with the exception of FPP's, which you can see are covered 100% in both level 3 and 4 hospitals.)

6 month waiting list seems rather long for a private appointment. Although I have heard certain disciplines of medicine are really suffering from a shortage of consultants. You are right to ask for cancellations. Also if you are given such a long waiting time it may be best to ring/email around to everyone if you are not set on a particular consultant. I had to find a consultant earlier in the year. First secretary I contacted told me it was about an 8 month wait. Contacted a few others and got a 4 week wait.

Even if it was the case that you accidentally attended a consultant not covered or need a procedure in a hospital not covered, if you explain that situation to the consultant/secretary they can often be nice and try help you out. Some consultants work different hospitals so they might carry out the procedure in a hospital you are covered for. They might refer you to a different consultant that you are covered for in a hospital you are also covered for and you could get the procedure directly with no prior consultation. Armed with your procedure code ready I would just explain you've already had a consultation and ran into issues with cover. Ask if they would be able to take you on straight for the procedure as you cannot really afford to pay for a second consultation again to only be told the same information. Of course it depends on how simple the procedure is. If it's complicated surgery for example the other consultant might very well have to review you again, your scans etc to confirm exactly what surgery they want to carry out on you, plan your aftercare etc.

Hopefully you now understand your level of cover in level 3 and 4 hospitals a bit better, and therefore you can rest a bit easier accepting and attending appointments without unnecessary stress.
 
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