Insurance policies

Customers confused over health insurance policies, ombudsman report says

Many private health insurance customers are unsure of the details of their policy, despite the average cost reaching €1,410 per year per adult, according to a review by the Pensions Ombudsman

The Office of the Financial Services and Pensions Ombudsman (FSPO) has released its latest Digest of Decisions report outlining the confusion among many Irish private health insurance customers.

“As with all financial products, it’s so important to understand what you’re buying and to be aware that not all insurance policies are the same,” said Acting FSPO MaryRose McGovern.

Research carried out on behalf of the FSPO showed that 51% of survey participants held private health insurance and that there are over 300 different plan options available or Irish customers.

“Many people will be looking to 2023 and thinking about reviewing or renewing their private health insurance, and perhaps even switching providers, especially in light of the current cost of living pressures,” Ms McGovern said.

The report includes 1,850 decisions on complaints filed by policyholders through the end of July. Many complaints were about wait times and eligibility, especially for people with pre-existing conditions.

A new client is not covered for five years for the cost of treatment for any condition or symptom that existed within the six months prior to enrollment in a health insurance plan, whether or not the client was aware of the condition.

“Complaints to the FSPO point out that people are unaware that medical investigations, X-rays or blood tests, which were required before purchasing coverage, can cause a condition to be defined as pre-existing,” said said Ms. McGovern.

An example of a case like this involved a €10,892 claim for a robot-assisted laparoscopic surgical prostatectomy (RALSP).

The man who made the claim told his insurance company he was showing symptoms of his condition before upgrading his policy.

Therefore, the terms of his old policy applied since there was a two-year waiting period applied to the treatment of any condition that existed before the coverage upgrade.

But the man argued that since his date of diagnosis was after his policy upgrade date, that should dictate whether the condition was pre-existing or not.

The mediator decided to dismiss the man’s complaint.

There were also examples of insurance companies not giving clear information to their customers about policy coverage in the report.

In one case, the ombudsman ruled that an insurer should pay a claim of €67,778 and compensation of €2,000 to a woman who had complained that her request for prior authorization to seek treatment in another country of the EU had been refused.

The woman’s insurer argued that the treatment was not consistent with a proven form of treatment for her condition, according to the criteria listed in her insurance plan.

However, there was no evidence that the insurer’s medical advisory group considered the literature on this treatment.