Many patients face unexpected large bills despite having medical cover, ombudsman warns

People with health insurance cover have been warned to ensure they do not have to pay extra when having expensive medical procedures carried out.

Often people find out too late that their health insurance does not cover them for certain procedures, according to the Financial Services and Pensions Ombudsman’s (FSPO) office.

It confirmed that it is dealing with a large number of cases where people have health insurance but they only realised afterwards, that the procedure they had done is not covered by their insurer.

This often happens as health insurers will not cover some pre-existing conditions. 

Commenting on the publication of the Digest of Decisions on private health insurance the Financial Services and Pensions Ombudsman (Acting), MaryRose McGovern, said: “Private 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. This insurance provides peace of mind to many, by providing supplementary access to both public and private hospitals, and outpatient care, to limit the financial impact of the cost of medical treatment that may be required.

Recent research carried out on behalf of the FSPO revealed that 51% of participants reported having private health insurance. However, Ms McGovern said there can be issues with what is covered by the insurance.

"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," Ms McGovern said.

The recent market research carried out by the FSPO 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.

Complaints brought to the FSPO highlight that people are not aware that medical investigations, X-rays or blood tests, which were required before they took out cover, can result in a condition being defined as being pre-existing.

"The policy holder may not believe that there was a pre-existing condition, because it had not been given a name 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,” Ms McGovern said.