• Cover for private and semi private hospital accommodation.
• Cover for in-hospital consultant services as a private patient.
• Other cover including maternity, overseas, psychiatric and out-patient benefits.

Private health insurance products offer two different types of accommodation. The types of accommodation offered are semi-private and private accommodation. Semi-private accommodation could involve sharing a room with up to 4 other people. It should be noted that although health insurance contracts provide cover for a certain level of accommodation, if that level of accommodation is not available a lower level of accommodation may be provided. Private health insurers in Ireland generally group Irish hospitals into three categories:

• Public hospitals (i.e. hospitals that are owned and operated by the State)
• Private owned and operated hospitals (other than the Blackrock Clinic, the Mater Private Hospital, and the Beacon Hospital)
• The Blackrock Clinic, the Mater Private Hospital, and the Beacon Hospital (high-tech hospitals)

Most health insurance contracts cover the cost of consultant services provided in relation to a hospital stay. An exception to this would be stand alone cash plans which allow the consumer to claim for expenses, such as GP and physiotherapy visits. Consumers should check their policy to determine the extent of cover offered by their policy. There will normally be a list of consultants, whose services are covered, available from each insurer

Treatment received in respect of illnesses, injuries or complications during pregnancy, if covered, would be considered as part of the hospital cover part of your contract. However, routine treatment received during the course of a normal pregnancy and delivery would be covered under the maternity section of your contract. Often this section will provide full cover for a limited stay in hospital and a fixed amount for the consultant, which may not cover the full cost. You will not normally be able to claim under the maternity section of your contract until you have served a waiting period of 52 weeks. This only applies if taking out health insurance for the first time, or if you have allowed your health insurance to lapse for more than 13 weeks.

Out-patient benefits differ from policy to policy, but typically it allows you to claim for a portion of the cost of GP, out-patient, consultant and dental visits, physiotherapy, sight tests and an allowance for glasses or contact lenses subject to an excess.

No. Out-patient treatment differs from day-patient treatment. Neither day-patient nor out-patient treatment involves overnight stays in hospital. However, day-patient treatment normally involves more serious procedures and any cover you have for it would be included in the hospital cover section of your contract.

With some products it is difficult to see exactly how much you can benefit from this cover as it can be quite complex. You will have to pay for the treatment first, keeping a receipt and claim at the end of your policy year. 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.
• There is often an excess i.e. an amount you must pay before you can claim anything.
• 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.

Some policies will have all three of these features. It could be the case that even though the total of your out-patient expenses is more than the excess, you might still not be in a position to claim because your total allowable expenses have not yet reached the level of the excess. For example, consider a case where the allowable amount for a visit to your GP is €20 and the outpatient excess is €300 in each year. Then assuming that your only out-patient expenses relate to your GP visits, you will not be able to make a claim from your insurance company unless you have made 15 visits to your GP in a year (i.e. 15 X €20 = €300). Thereafter you will only be able to claim €20 per visit even though the visits may cost you €50.

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.

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.

Most products concentrate on in-patient and day-patient benefits, although some also offer substantial out-patient benefits. Usually the out-patient benefits can be added on to the main policy, so it might be advisable to concentrate on the core benefits of in-patient and day-patient treatment when choosing between products.

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 may travel a lot internationally or you might be planning to have a baby, in which cases overseas cover and maternity cover might be of particular interest to you.

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.

Sometimes private health insurance contracts include an excess. If you are willing to take on the risk of paying part of the cost, choosing a policy with an excess can result in a lower premium. If you are not willing to accept this risk you can choose a product without an excess. In another scenario, you may choose a policy with no significant out-patient benefits, 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.

After considering all of the above, as well as any other factors you feel are relevant, you should look at all the products that you consider are suitable for your circumstances. You should then consider the differences between the products and decide whether the differences in benefits provided are worth the differences in premium.

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.