Seeking clarity on medical cover

Health insurance: Patients being wheeled off ambulances and into hospital accident and emergency departments will usually be in too much pain and distress to focus on the ins and outs of their health insurance policy.

So if a figure of authority such as a hospital consultant tells them they are covered for the cost of a treatment, they will probably accept that assurance and go back to describing their symptoms, signing consent forms and coping with their physical discomfort.

But can patients who are worried about the cost of treatment really trust what hospital staff tell them?

Consumers who say they were told by a consultant that they were covered for a particular treatment only for their claim to be rejected later by their health insurer are making an increasing number of complaints to the financial services ombudsman, Joe Meade, according to his annual report.

Mr Meade has cautioned consultants not to give advice to patients about insurance. "When for any one of a variety of reasons a claim is then declined, the consumer feels that he had a legitimate expectation that the claim would be met, based on the assurances given to him by the consultant," he said.

"But the treating consultant is not privy to the contract of insurance between the consumer and the insurance company and is, therefore, not the appropriate party to make such representations. The only people who can give you advice about whether you are covered or not is the insurance company."

Mr Meade's warning follows a case highlighted by the Government Ombudsman, Emily O'Reilly, in her report on the public health service, published in May.

In the case, a seriously ill student admitted to an A&E department was asked to complete a form confirming her VHI membership and was then placed in a semi-private ward.

It was later discovered that her VHI membership did not cover the semi-private accommodation as the standard 26-week waiting period that applies to new members had not yet expired, and she was sent an invoice for more than €2,500.

The ombudsman said the process whereby a seriously ill patient could be held responsible for the completion of a form under the circumstances was "inherently unreasonable". After the ombudsman discussed the matter with the health board in question, it agreed to waive the charges.

Ms O'Reilly has written to all local health authorities in relation to the issue and received "positive responses", according to her report. The lesson from the complaint, she said, was that hospital administration should not be so rigid and inflexible that they are unfair on individuals.

The health insurance market is far more complicated now than it was in the days of the VHI monopoly.

The entry of Vivas Health to the market in October 2003 coincided with the launch of a new suite of plans by VHI. All three main health insurers - VHI, Vivas and Bupa - have also strayed into the market for day-to-day medical expenses cover that used to be the sole preserve of "cash plan" companies such as HSF and HSA Healthcare.

As a result, the number of health plans consumers can choose from has spiralled from fewer than 40 before the launch of Vivas to more than 100. In addition, the range of treatments covered under the plans has expanded to include areas such as complementary medicine, cosmetic procedures and home-help services.

Remembering details such as exclusions, policy excesses - the first part of a claim that the consumer must pay themselves - and waiting periods isn't all that easy.

With advertisements proliferating for different plans and policy booklets getting thicker, there is also a greater risk that consumers will be so inundated with information that they just switch off, pay the premium and hope they never have to make a claim.

Exactly what their plan entitles them to may only sink in after the person falls ill or has an accident - at which point, worrying about their finances will be the last thing they need.

"It is entirely possible that someone who is not involved in the minutiae of the plans won't know what is covered and what is not covered," says a spokeswoman for VHI.

"We would stress that people should get in touch with our contact centre, which is based in Kilkenny, if they are in doubt about what their policy covers," she says.

The health insurers give customers wallet-sized cards with the contact numbers they should ring if they need to make an inquiry or if they have a medical emergency when overseas.

In general, VHI says it finds that hospital staff members are good at telling patients to consult their insurer, while Bupa says its claims team has met hospital admissions staff to talk about some of its newer policy benefits. In some private hospitals, certain treatments are "pre-authorised" by the insurer, reducing any confusion when the time comes for the bill to be settled.

As part of its information campaign, the Health Insurance Authority (HIA) compares the policy benefits offered under the main health plans on its website at www.hia.ie.

But the health insurers, too, have realised that the growing complexity of their products has put the onus on them to explain clearly the cover they are offering and to remind customers what is excluded.

"Legally, the responsibility to know what cover they have is with the patient," says Seán Murray, Bupa's head of marketing. "But from a customer service point of view, that is perhaps not good enough."