Customers confused about health insurance policies, ombudsman report finds

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

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

“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,” 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 more than 300 different plan options available or Irish customers.

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

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The report includes 1,850 decisions on complaints made by policy holders up to the end of July. Many of the complaints were about waiting times and eligibility especially for people with pre-existing conditions.

A new customer is not covered for five years for the cost of treatment for any condition or symptoms which existed in the six months prior to taking out a health insurance plan, regardless of whether or not the customer was aware of the condition.

“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,” said Ms McGovern.

An example of a case like this involved a claim of €10,892 for Robotic Assisted Laparoscopic Surgical Prostatectomy (RALSP).

The man who made the claim informed his insurance company that he had symptoms of his condition before upgrading his policy.

Therefore, the terms of his old policy were applicable since there was a two-year waiting period applied to treatment for any condition that existed prior to the upgrade in cover.

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

The ombudsman decided to reject the man’s complaint.

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

In one case, the ombudsman decided that an insurer must pay a claim of €67,778 and compensation of €2,000 to a woman who complained that her request for pre-approval to get treatment in another EU country was declined.

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

However, there was no evidence that the insurer’s medical advice group had considered any literature about this treatment.