Tuesday 25 June 2019

Which procedures result in co-payments?

Your questions answered

If you find yourself on a policy with a shortfall or co-payment, it is always worthwhile to check in with the hospital (stock image)
If you find yourself on a policy with a shortfall or co-payment, it is always worthwhile to check in with the hospital (stock image)

Barbara Sheahan

Q Could you tell me what cardiac, orthopaedic and ophthalmic procedures co-payments typically arise on? My husband and I are both in our fifties and our children are in their teens. We are currently all insured under VHI's Health Plus Extra plan. To save money, I'm considering moving the family onto VHI's cheaper One Plan Family plan - but I'm concerned about co-payments as there is a history of heart illness on my side of the family, and my husband has ongoing hip pain. Margaret, Cavan town

There are a number of plans on the market which have cardiac, orthopaedic and ophthalmic restrictions in private and high-tech hospitals. These differ with each provider and level of cover. Laya Healthcare offers the best orthopaedic cover - having no shortfalls for replacements on the majority of its plans. Irish Life Health has a list of 10 restricted orthopaedic procedures which carry a co-payment of €2,000. It also has a list of plans which carry a cardiac co-payment in private hospitals - most of these plans are outdated though, so if you are on a plan of this type, it is time to review your cover. These lists are all available to view on the Irish Life Health website.

VHI has a number of procedures which are only 80pc covered in private hospitals. These procedures include orthopaedic and ophthalmic procedures but unfortunately this list is not available to the general public.

You mention that you have your full family insured on 'Health Plus Extra'. Firstly, you do not have to have your children on the same plan as yourself. There would be no need for a child to be on this level of cover and there are plenty of alternatives which offer more affordable and appropriate cover for children. The high price tag on your existing 'Health Plus Extra' plan with VHI is due to the fact that it fully covers cardiac procedures and orthopaedic replacements in private hospitals without any co-payment. Placing your children on a Level 2 plan without this cover will reduce your premium considerably over the year. (Level 2 plans cover a semi-private room in a private hospital).

By moving to 'One Plan Family', you would be decreasing your cover for cardiac procedures in high-tech hospitals to 90pc while restricted orthopaedic and ophthalmic procedures will only have 80pc cover. Given your family history of cardiac conditions and your husband's existing hip problem, I would not recommend moving to this plan. In addition, this plan does not cover Level 2 fixed-priced cardiac procedures, so while the €1,200 saving may seem attractive, this could end up costing you in excess of €40,000 if you required one of these cardiac procedures in the future. (In this case, Level 2 is one of the two levels which VHI splits listed cardiac procedures into. These lists are common cardiac procedures which take place in the high-tech hospitals.)

Another important point to note is that if you were to downgrade your plan and wish to increase it again in the future, you would have to serve a two-year waiting period for the increased benefits if you have an existing condition at the time of the upgrade.

If you find yourself on a policy with a shortfall or co-payment, it is always worthwhile to check in with the hospital. Many of the private and high-tech hospitals often waive these shortfalls - though this won't always be the case.

Upgrading health insurance

Q My husband and I are in our early forties. We've three young children - all under the age of eight. During the recession, we moved to a cheaper private health insurance plan. We're now considering upgrading to a plan which covers day-to-day medical expenses. Is there a plan which you'd recommend which provides good cover for day-to-day medical expenses, as well as a good level of hospital semi-private cover? We're spending about €3,000 a year on our current plan so I would like to keep the cost as close to this as possible.
Joanna, Newbridge, Co Kildare

A good comprehensive plan to cover public, private and certain listed procedures in the high-tech hospitals, as well as day-to-day benefits, will cost a minimum of €1,100 per person. If you pay any less than this, it is likely to exclude some hospitals or not include day-to-day cover. The budget you mentioned will give you access to some of the best corporate schemes. These plans give superior cover for hospital cover and day-to-day benefits to other health plans available on the market. Corporate plans are specifically designed for large companies who pay for their employees' health policies. Legally, these plans must be made available to anyone who asks for one, irrespective of occupation or employment status.

Here are some good corporate plans. VHI's PMI 07 10 costs €1,188.15 per adult and €299.84 per child for the year. This plan has a once-off excess (first part of a claim which you must pay yourself) of €150 for overnight stays in private hospitals and a day case excess of €50. Furthermore, Level 1 fixed price cardiac procedures and other specified fixed price procedures are fully covered. Good day-to-day cover with 50pc back on GP and consultant visits is also included.

Laya Healthcare's 'Simply Connect' plan costs €1,100 per adult and €275.26 per child for the year. It has a €150 excess per claim on the first two overnight stays in a private hospital, a €50 excess on day cases, and it offers full cardiac and orthopaedic cover.

However, there is a nightly shortfall for specified fixed price procedures in the high-tech hospitals. This plan has good day-to-day cover with 50pc back on GP and consultant visits and is subject to an outpatient limit of €500 per person (outpatient cover is for hospital treatment which doesn't require an overnight stay). 'Simplicity' would be a good alternative if you felt you needed a higher outpatient limit.

Irish Life Health's '4D Health 2' which is priced at €1,213 per adult and €301.20 per child per year, has a €150 excess per claim and a €75 excess on day cases. Cardiac and listed fixed price procedures are fully covered with a €150 excess per stay. Good day-to-day cover is included with 50pc back on GP and consultant visits. You can also add two personalised packages to this plan for free.

Health cover for counselling

Q My children need to attend counselling after being involved in a car accident recently. Which are the best private health insurance plans out there for counselling - and if I upgrade to such a plan, is there a waiting period before they're covered for counselling?
Tom, Letterkenny, Co Donegal

There are many day-to-day plans on the market which will offer money back on counselling visits. The best options from Irish Life Health would be any of its '4D Health' range. There are five plans in this range and with these plans, you can add additional personalised packages for free. One of these packages is called 'Children Extra' and this includes money back on children's counselling. The higher the plan number, the more money you get back per visit.

Any of the better VHI plans with day-to-day benefits will give money back on child counselling. One worth considering is VHI's Company Plan Plus Level 1.3 which is priced at €286.93 per child and it gives €25 back per child counselling visit - up to a maximum of seven visits per policy year.

Laya Healthcare's '360 Care Select' is the best plan on the market for child counselling. It allows you to claim 90pc back per visit, there is no outpatient excess and the outpatient limit (that is, the amount of outpatient expenses you can claim back) is a generous €7,650. The annual cost of this plan is €480.86 per child which is excellent value if you should happen to require or avail of these services.

Laya doesn't apply waiting periods for day-to-day cover. VHI applies a 26-week waiting period if you are over 50 and Irish Life Health applies a 26 week waiting period if you are over 55 - so no waiting period will apply for your children. Only practitioners registered with their qualifying body will be covered by health insurers.

Barbara Sheehan is health insurance expert with healthinsurancehelp.ie

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