Health Insurance VHI Dental reversed claim settlement

tnegun

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I'm tyring to figure out if I have any options after VHI recently reversed a previous claim settlement and deducted it from a claim almost 12 months later and in a different policy year. To give some background my wife was in a bad accident and has required significant dental reconstructive work over the last 12 months with a final bill shy of 20k. Shortly after her accident, my wife had a denture made up by her dentist whilst we figured out what options were available to her. VHI covered 70% of this cost amounting to a few hundred euros.

In the last year my wife has had major reconstructive work done by a dental surgeon and prosthodontist and I submitted the final claim to VHI recently. The way the policy is structured of the 8 teeth she needed replaced they contributed to a fraction of the cost for 1 of those and then applied the policy limit of €600 and made no contribution towards the other 7 but showed them on their settlement statement.

Now for the kicker as all the teeth were replaced they reversed the decission to pay out for the denture as they determined it to be temporary and deducted it from the €600 limit for this years policy. Of the 8 teeth missing the denture replaced 6 so my argument is that their contribution was towards 1 of the teeth not covered by the denture and us paying for the replacement of the others is irrelevant and the denture payment should stand. Is this a valid argument? They also are applying a single years policy limit to two policy years as they class all of the treatments as occuring in a single year since the first of several commenced in the first year. Is this normal practice?
 
I'm confused after reading that and can't identify the key issues.

Do you know that the claim should have been paid?
If so make an appeal/complaint to VHI.
If they stick to their guns and don't explain things clearly then get a final response letter from them and take it to the Ombudsman?
 
Did your wife get a code from the dentist and check with VHI if it was covered before she got the dental treatment done?
 
I'm confused after reading that and can't identify the key issues.

Do you know that the claim should have been paid?
If so make an appeal/complaint to VHI.
If they stick to their guns and don't explain things clearly then get a final response letter from them and take it to the Ombudsman?
My issue with the denture is that they covered it as per her policy @ 70% originally. We then paid 100% for 7 of the 8 implants that replaced it and VHI is making a contribution towards just one of them. Now based on this they determined that the denture was temporary(she wore it for 11 months) and deducted that amount from the implant claim. If I get pedantic the denture only covered 6 teeth, I could say VHIs contribution was towards one of the teeth not covered by the denture so what business is it of theirs if she subsequently at her own expense replaced the others with implants they didn't contribute too! I've submitted a complaint and am awaiting their response I just wanted to get some opinions on here too while I wait for their reply.

Did your wife get a code from the dentist and check with VHI if it was covered before she got the dental treatment done?

In dental, there doesn't appear to be any codes used as in health, or at least I haven't seen them. The dentist completes a claim form once treatment is completed.

VHI did request a treatment plan and was provided with it they originally said up to €850 would be covered but revised this down to €600 once I submitted the claims. The €600 is the annual limit for all of the treatments she required the originally said €850 which is part of my complaint. My wife has had multiple treatments, extractions, dentures, implant fixtures, bridge and implant crowns. These spanned two policy years but VHI is implementing a single year's limit as they consider them all as one treatment.
 
Seems like very "deliberate" to ask for a treatment plan then consider any treatments under the plan as one treatment and thus restricted to a single year cap.

Is there an ombudsman for insurance. I assume there is. You could ask them.
 
Thanks for the replies, I'm awaiting the response to my complaint for this and I'll keep here updated. Infuriatingly the €850 figure is contained in the response to a previously upheld complaint I made to VHI when no one would give me a straight answer as to what I could expect to be covered. There was no mention of an annual limit in it or that proceeding with treatments would invalidate previous payouts.
 
1. Could you identify the exact VHI product involved as I would be curious to compare their actions as against the actual policy wording ?

2. In relation to an appeal / complaint you can proceed as follows ;
(a) Invite VHI to review their decision.
(b) If (a) fails you ask VHI for a final decision letter.
(c) When you have a final decision you can then refer it to the FSPO for adjudication. You need a final decision letter before the FSPO will deal with
the matter.
 
Its Vhi Dental Corporate 1. Thanks for the advice and info. I've asked them to review the decision as it also somewhat contradicts their response to a complaint I submitted in January.
 
Had a quick look at VHI Dental Corporate 1.

I will not pretend to know exactly what has gone here such is the confusing way that you seem have been dealt with !

As far as the denture is concerned could you argue that it was a necessary intermediate step in the overall restorative process.
Could this be inferred from the treatment plan if VHI saw it and approved it - if the denture had been mentioned ?

I am amazed at VHI deducting a recovery from another claim to give effect to their view. I would seriously doubt that they have a proper entitlement to operate such a set-off at their discretion especially if it was not agreed with you previously.
 
I think a large part of the problem is that VHI has had issues understanding the policy too. Any time I spoke to them they had to call or write back with clarifications. It also hasn't helped that every claim I submitted was treated like it was the first they knew of her accident. They either rejected or put the claim on hold pending further information often without notifying me, I'd only find out when I followed up some weeks later. In fact after the first or second claim they already had all the further information on file and only progressed the claim when I reminded them of this.
 
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