Choosing Cash Plans
The complexity of cash plan products can pose difficulties for consumers in understanding and comparing different plans and ultimately in selecting the plan that is most appropriate for their circumstances. However, the onus remains on the consumer to select the most appropriate plan for their circumstances as the Health Insurance Authority is not in a position to recommend one plan or health insurer over another.
Here are the explanations to some of the more common questions that a person may ask when buying a cash plan for the first time.
Q What are the main benefits of cash plans?
• Monetary amounts for out-patient expenses such as GP or Physiotherapy visits.
• Monetary amounts per day spent as an in-patient.
• Some policies may provide personal accident cover.
Q Will my cash plan cover my consultant's fees?
Cash plans allow the consumer to claim for a proportion of some expenses, such as GP and physiotherapy visits and in some cases consultant’s fees. Consumers should check their policy to determine the extent of cover offered by their policy.
Q What kind of maternity benefits should I expect?
Cash plans may provide benefits such as:
• A monetary amount per day spent in hospital
• A birth/adoption grant
• Pre/post natal care benefit
You will not normally be able to claim under the maternity section of your contract until you have served a waiting period.
Q How do I work out my claim for out-patient expenses?
For all insurers you will have to pay for the treatment first, keep a receipt and claim either at the end of your policy year or during the policy year depending on your policy's terms and conditions. Features of this cover often include the following:
• There is often a maximum level of benefit that is paid in relation to out-patient cover.
• Usually, you can only claim for a portion of the cost of the visit to your practitioner. This is called the ‘allowable expenses'. For example, a GP's visit may cost €50 but you may only be allowed to claim €20. The €20 is the allowable expenses.
Q What is an exclusion?
Private Health Insurance contracts normally have a list of exclusions, which are circumstances under which the insurer may not pay a claim. For example:
• Treatment received during waiting periods.
• Treatment, which in the view of the insurer's medical director is experimental or not medically necessary.
• Treatment related to birth control or assisted reproduction.
• Cosmetic surgery other than for the correction of congenital, accidental or disease related disfigurement.
• Treatment received in a hospital or from a medical practitioner that the insurer does not recognise and the insurer has informed you that it does not recognise the medical practitioner.
• Medical expenses which you are entitled to recover from a third party.
The above is not a comprehensive list of exclusions. Your contract may include some or all of the above, which will be set out in your contract details. You should review these carefully.
Q What does maximum level of cover mean?
There are often limits on the level of cover provided. Sometimes a policy will only cover you for a certain number of days of treatment, or it may only pay out benefit up to a particular amount for an illness, after which you will not be able to claim again during that policy year irrespective of how many days you may have been ill. In all cases you should consult your policy documentation in order to determine the extent to which benefits are provided.
Q What kind of cover do I want?
Most cash plans offer substantial out-patient benefits. Monetary amounts towards stays in hospital and personal accident cover may also be available. If you already have a health insurance plan from Aviva, Quinn or Vhi you should review your current level of hospital and out-patient cover to ensure you are not duplicating your cover. It is also worth investigating if it is more beneficial to buy a single plan which covers in-patient and out-patient expenses from the same insurer or whether you specifically want the benefits of a cash plan as an add-on plan or stand-alone plan.
Q Which benefits would be of most value to me?
There may be elements of your lifestyle or you may have plans for the future which would make some benefits more attractive to you than others. For example, you might be planning to have a baby, in which case maternity benefits might be of particular interest to you.
Q How much could I benefit?
Sometimes it can be difficult to gauge the value that a benefit can provide, especially when it involves excesses, allowable amounts and maximum claim amounts. It might be useful to consider how often you would expect to make a claim under a particular benefit and work out whether it makes financial sense to opt for this benefit in your policy, based on the number of times you would claim.
Q How much risk am I willing to accept?
You may choose a policy with a small amount of cover, thereby taking the risk that you will not require an unusual amount of visits to say, your GP or physiotherapist, but allowing you to pay a lower premium.
Q Which product offers the best value for my circumstances?
After considering all of the above, as well as any other factors you feel are relevant, you should look at all the plans that you consider are suitable for your circumstances. You should then consider the differences between the plans and decide whether the differences in benefits provided are worth the differences in premium.
Q How to make a complaint
If you have a problem with your private health insurance, you should first discuss it directly with your insurer. If you are unable to resolve your complaint, you may contact the Financial Services Ombudsman. The decision of the Financial Services Ombudsman is binding on all parties but when one party is dissatisfied with the decision, it may be appealed to the High Court. You also have a right of access to the courts in respect of disputes with insurers.
