Laya When is a day case not a day case?

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bakedbean

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Hi all, my mum is with Laya on an Advantage 500 explore. She needs a gastroscopy which will be carried out as a day case (no anaesthetic, no overnight stay) at the Hermitage. The cost will be 800 euro and Laya say they will cover 300 but mum has to pay 500 excess (not day case excess of 150). They say that even though she is not overnighting it does not count as a day case, it is in patient.

Anyone else faced a similar situation? It seems a little unfair to charge someone for an overnight when they've told here the whole procedure should take 10 mins.
 
Is it a side room procedure or something like that? Or did the hospital actually state it was a day case? I know I had a small procedure done and if they had given me an extra injection at the time it would have turned it into a day case procedure, but as they didn't need to as it happens it ended up as a side room procedure which is different apparently (even though there would have been a miniscule difference in terms of time etc. and zero difference in terms of staffing and resources etc.!)
 
That's a good question gravitygirl and I don't know the answer. The Hermitage didnt actually state it was a day case but I would have assumed a day case is one that doesnt involve an overnight?
 
I had this procedure done in the mater private last year. It was classed as a side room procedure. My statement of benefits (vhi) lists side room and day case separate to in patient cover. I was only charged the side-room excess. Did you get a procedure code from the hermitage? Maybe check that they gave you the correct code if you did.
 
The HIA website doesn't actually define a "day case", but your situation does not meet its definition of "In-patient".
http://www.hia.ie/consumer-information/jargon-buster

It defines a "Day-patient" as: "Treatment received during a hospital stay in a day care bed which does not include an overnight stay."
It defines "In-patient" as: "Treatment received during an overnight stay in hospital."

The LAYA glossary is vaguer, and either could be applied to your situation.
https://www.layahealthcare.ie/glossary/
"Inpatient cover pays for treatment, procedures and accommodation in a hospital once you are admitted to a hospital. This may vary from being admitted for a few hours, a day, a night, or more."
"Day-case treatment covers you when you have to be admitted into a hospital and occupy a bed during the day, but you don’t stay overnight."

Reading between the lines, possibly this situation is classed as inpatient because there is a procedure involved?

But, for €350 I think a formal complaint to LAYA would be worth it... at the very least I think you have grounds for complaint in that the communication is unclear on the material difference between the two.
 
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I think if you speak to Laya they will tell you to let them know in advance the procedure and they will tell you if it is covered or not. It seems the only safe way to know or not if something is covered. It's a pain doing it, but it can save some nasty surprises.
 
I agree with Clamball.

The 500 explore is so called due to the 500 excess on that particular policy, a local anaesthetic is sprayed in the area but that is it, nothing to worry about, had it done myself in the Hermitage.
 
I have the same policy and I would have thought that an in-patient was an overnight stay. And anything else was out-patient or day patient. I would be annoyed if they charged me a €500 excess.

Well worth taking it to the Financial Services Ombudsman.

Brendan
 
What real people do is say that they are not feeling well and insist on staying in hospital overnight. No more day case.
 
Thanks all, especially for turning up that Laya glossary odyssey06 - it just goes to show there is a lack of clarity on it. And Brendan that's exactly where I am at - language is not transparent!
 
cremeegg said:
What real people do is say that they are not feeling well and insist on staying in hospital overnight. No more day case.
Click to expand...

Do you mean that people in "day care" must tell lies now to avoid paying added excess?
 
Leper said:
Do you mean that people in "day care" must tell lies now to avoid paying added excess?
Click to expand...

My impression over many years is that there is widespread rigging of claims to get around the invidious restrictions in policies to maximise payout from health insurance. I don't believe that claiming a day case as as inpatient case is possible, but simply staying overnight in hospital to change a day case to an inpatient case is something I have heard of often and I think is very widespread.
 
cremeegg said:
My impression over many years is that there is widespread rigging of claims to get around the invidious restrictions in policies to maximise payout from health insurance. I don't believe that claiming a day case as as inpatient case is possible, but simply staying overnight in hospital to change a day case to an inpatient case is something I have heard of often and I think is very widespread.
Click to expand...

That is why it is sometimes useful to talk to the private hospital to see if they can do an "ethical fudge" to give you a procedure classification that suits them and you to best financial advantage as regards insurers.

If you tell a private hospital what cover you have (you will be asked) they will know what the situation is. If you tell them that you might have to go elsewhere because of your policy limitations you might be pleasantly surprised at how helpful they can be.

My mother did this with a certain private hospital over a hip replacement operation whereby she effectively wangled a special offer out of them in such a way that there was no cost to her. She did it again three years later for the other hip. Against this however is the more modern practice of selling health insurance with large excesses of varying forms to give policyholders the illusion that they have got good cover at a reasonable price. In many cases it becomes a glorified exercise in paying twice when you have the misfortune to need to make a claim....
 
The truth is we must tell lies to receive some "daycare" in hospitals for which we have paid expensive private health insurance - Ireland Ltd is full of situations where lies must be told. We have waiting lists for our hospitals (different subject, I know) and while people can lie through their teeth to obtain beauty treatments (yes beauty treatments) in our hospitals at an "excess" cost (€125.00). Something is wrong somewhere . . .

"ethical fudge" - "rigging of claims" - let's shove in "alternate facts" -Seems to be the way of life here for years. No wonder I had to heavily fork out to put our kids through 3rd Level with accommodation, fees etc. Then I claim through Dept of Social Protection (should I have said Dept of Ethical Fudge?) for something minor and I am grilled like I was running an illegal business at home and sign more declarations than Donald Trump.

Sorry Guys - rant over and it's Friday . . .
 
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