Advice from The Financial Services and Pension Ombudsman (FSPO)
As we start a new year and all the intentions and resolutions that come with it, health insurance may be the last thing on your mind, but many people’s policies have a renewal date approaching so it is a good time to think about reviewing your cover.
The Office of the Financial Services and Pensions Ombudsman (FSPO) is an independent, impartial, fair and free service that helps resolve complaints from consumers, including small businesses and other organisations, against financial service providers and pension providers. As Deputy Financial Services and Pensions Ombudsman, I have adjudicated on many health insurance related complaints, and it has allowed me to see the difficult circumstances experienced by consumers which lead to a complaint to this Office.
At this time of year, many people will be thinking about reviewing or renewing their private health insurance, or indeed perhaps switching providers, particularly in light of the current cost of living pressures. Health insurance can represent a significant amount of a household’s budget, on average being in the order of €1,410 per adult, per year. It is vital that consumers take some time, before starting the renewal process, to make sure they understand the impact of any decisions they make in upgrading or downgrading their cover.
Recent research carried out on behalf of the FSPO revealed that 51% of participants reported having private health insurance. However, some consumers who purchase private health insurance are not familiar with their cover or do not understand how waiting periods can affect their ability to make a claim on their policy. As with all financial products, it is so important to understand what you are buying and to be aware that not all insurance policies are the same.
The level of hospital cover and outpatient cover is at all times determined by the type of plan chosen by the consumer. With more than 300 different plan options available, there is tremendous choice in the health insurance market, but it can be a challenge to select the best level of cover to suit individual needs. Our recent market research also revealed that 27% of participants who held health insurance felt they had a poor understanding of the cover on their plan, in contrast to 15% who felt they had a very good understanding. The highest level of understanding was amongst the over 65s.
Complaints brought to the FSPO highlight that, very often, people are not aware that medical investigations, X-rays or blood tests, which they had before they took out cover, can result in a condition being identified as being pre-existing. The policy holder may not believe that there was a pre-existing condition, because the issue which led to them having an x-ray or other test, wasn’t named or diagnosed, at the time of the investigations. It is important for consumers to be aware that a pre-existing condition can exist, without a formal diagnosis, and it is the signs and symptoms within the period, which are relevant.
To highlight some of the difficulties that can arise in understanding the complexity around waiting periods, the FSPO has produced a Digest of legally binding decisions, on health insurance complaints, which is available on the FSPO website at www.fspo.ie
This Digest contains some examples of decisions which explain the concept of a ‘pre-existing condition’, and how that issue impacted consumers who bought new health insurance, or who upgraded their level of cover, for example a complaint concerning a claim for €10,892 for a robotic procedure undertaken by Matthew to treat prostate surgery, where he recovered only part of the cost, because the illness was considered to have existed, prior his upgrade in policy level.
MaryRose McGovern, Ombudsman at Financial Services and Pensions Ombudsman
The Digest also includes some examples of issues that can occur when seeking approval of cover, for example a direction made by the Ombudsman to pay a claim of €67,778 and compensation of €2,000 to Debbie, who complained that her request for pre-approval to get treatment in another EU country was declined. There are also details of a direction to pay €3,000 to Alice who rang her insurer to confirm cover for her dental work, which was due to cost €7,000, but she was not given the right information.
Health insurance policies will not cover you for every eventuality, so it is worth taking some time now, to familiarise yourself with your cover and its associated waiting periods, before you need it. Customers who take out private health insurance after they have already developed symptoms, may find that they have no cover for treatment which they ultimately need, if the condition was pre-existing.
If you do have a complaint against your health insurer, first make a complaint directly to it, to give your insurer the opportunity to resolve the complaint. If you are unsatisfied with their response, you may then make a complaint to the Financial Services and Pensions Ombudsman.
Financial Services and Pensions Ombudsman, Lincoln House, Lincoln Place, Dublin 2. www.fspo.ie 01-5677000
