Poor understanding of cover entitlements, a lack of understanding about waiting periods and confusion about pre-existing conditions are among the main reasons for complaints that are being made to the financial services watchdog about health insurance.
The Financial Services and Pensions Ombudsman (FSPO) has published a digest of its decisions on complaints that were submitted to it about the sector.
Acting ombudsman MaryRose McGovern noted that private health insurance, costing on average €1,410 per adult annually, "can represent a significant amount of a household's budget".
She said it is important consumers understand what they are buying and that not all insurance policies are the same.
The report highlights 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.
Ms McGovern said the policy holder may not believe that there was a pre-existing condition, because it had not been given a name at the time of the investigations.
"It is important for consumers to be aware that a pre-existing condition can exist, without a formal diagnosis, and it is the signs and symptoms within the period, which are relevant," she said.
"Issues surrounding health insurance are often fraught with additional worry and stress, very often during a period when the people involved can be feeling very unwell," she said.
"Health insurance policies will not cover you for every eventuality, so it is worth taking some time now, to familiarise yourself with your cover and its associated waiting periods before you need it."
"It is important that customers do not wait until they have symptoms to take out private health insurance and then expect to be covered for those illnesses."
The Digest of Decisions provides summaries of decisions issued between 2018 and 2022 and highlights the difficult circumstances experienced by consumers which lead to a complaint to the FSPO.
Some examples of decisions made by the Ombudsman include a direction to 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.
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The woman's insurer had maintained that the treatment was not consistent with a proven form of treatment for her condition, in accordance with the listed criteria in her plan's rules book.
In another case the insurer was ordered to pay €3,000 to a customer who rang to confirm cover for her dental work, which was due to cost €7,000.
The insurer advised the woman that she would be covered for 70% of the cost of the treatment but failed to tell her that her plan would renew in five days’ time, with lower dental benefits.
It also paid the benefit to the wrong bank account.
However, not all cases are decided in favour of the patient.
In one listed in the digest the FSPO rejected a complaint about a claim of €10,892 undertaken by a man for Robotic Assisted Laparoscopic Surgical Prostatectomy (RALSP).
When queried, the man's insurance company informed him that he had signs and symptoms of his condition, in the form of a raised PSA before he upgraded his policy.
As a result, the terms of his old policy were applicable since there was a two-year waiting period applied to treatment for any ailment, illness or condition that existed prior to the upgrade in cover and he was only entitled to benefit of €6,441.
The man argued that because 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 was satisfied that the insurer had correctly applied the terms and conditions applicable to new registrations or renewals when concluding that Matthew's condition preceded his upgrade in cover.
