Selecting a Plan

The Health Insurance Authority provides a plan comparison tool of the plans available on the market at www.healthinsurancecomparison.ie. The information can also be obtained by contacting the Authority at 1850 929 166 or 01 4060080.

Here is some useful information concerning the nature of health insurance.

Hard Copy Request

Q Can anyone buy any product?

Yes. An Open Membership Insurer must sell you the plan you request. Some plans are marketed towards certain groups such as companies or professions. You are entitled to these plans regardless of whether or not you are a member of the group to whom it is being marketed.

Q Can I change my mind after buying health insurance?

You can cancel your health insurance contract within 14 days of commencement and receive a full refund of premiums. No claims will be paid for the 14 days.

Q What are the main benefits of private health insurance?

  • 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 outpatient benefits.

Q What kind of hospital accommodation will I get with private health insurance?

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. While the hospital cover under different contracts may vary, private health insurers in Ireland generally group Irish hospitals into three categories:

  • Public hospitals (i.e. hospitals that are funded by the State)
  • Private hospitals 
  • Some hospitals are usually only covered under a higher level of cover (e.g. The Blackrock Clinic, the Mater Private Hospital, and the Beacon Hospital)

Consumers should check their policy to determine the extent of cover offered by their policy.

Q Will my private health insurance cover my consultant's fees?

Most health insurance contracts cover the cost of consultant services provided during a hospital stay. An exception to this would be stand alone, day to day or outpatient policies. 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

Q What kind of maternity benefits should I expect?

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. 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 care in the hospital. Some policies also provide some cover for outpatient consultant care.

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, if you are upgrading your policy to a higher level of cover or if you have allowed your health insurance to lapse for more than 13 weeks.

Q What can I claim for under outpatient benefits?

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

Q Are outpatient and day-patient treatments the same?

No. Outpatient treatment differs from day-patient treatment. Neither day-patient nor outpatient 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. Your insurer or your consultant can advise whether your procedure is a day-case or outpatient treatment.

Q How do I work out my claim for outpatient expenses?

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 annual 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 outpatient 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.

If there is no excess on your policy you may claim immediately according to the benefits on your policy.

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 some 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. In all cases you should consult your policy documentation in order to determine the extent to which benefits are provided.

Q What kind of hospital cover do I want?

Most products concentrate on inpatient and day-patient benefits, although some also offer substantial outpatient benefits. It might be advisable to concentrate on the core benefits of inpatient and day-patient treatment when choosing between products. Your first decision would be whether you want a semi-private or private room, whether you want cover in public hospitals or private hospitals and then in which private hospitals you wish to be covered.

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 may need regular physiotherapy or you might be planning to have a baby, in which cases out-patient cover and maternity cover 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?

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 outpatient 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. Alternatively you may value cover for orthopaedic treatment and you may wish to ensure your policy provides the level of cover you require.

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 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. Consider the health insurance needs of all the family individually-consider different plans and levels of cover for each.

Details of health insurance plans and their prices are available at www.healthinsurancecomparison.ie

Q Can I use a regulated financial advisor to assist me in selecting a suitable health insurance plan?

Yes, a regulated financial advisor or sales person may be able to assist you in selecting a plan that is suitable for your needs. Before you decide to use a regulated financial advisor or sales person, ask about fees or charges for using their services. They may be paid a commission or sales incentive by the insurance company they represent or whose product they sell. They may get more commission or sales incentive from selling one product rather than another. However a regulated financial advisor must act in your best interest. They must make sure the product or service they recommend or offer is suitable for you and they must be able to show you (in writing) why they feel it is suitable for you. You may wish to get a copy of this document.

Q How to make a complaint

If you wish to make a complaint about your private health insurer, 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.

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