Health insurance made simple

When you take out health insurance for the first time there is a waiting period that must be served before full cover takes effect. During this time, you’ll be covered for accident, illness and injury treatments, but not pre-existing conditions that you might already have such as heart disease or asthma. Once the waiting period has passed, you’ll be able to claim all your scheme’s benefits, including any pre-existing conditions. Find out more about waiting periods.

If you already have health insurance with another provider and have served all your waiting periods with them, then you don’t need to start again. We’ll recognise all that time. That’s if you have had no gap in that health insurance cover lasting longer than 13 weeks.

An Inpatient excess is the initial amount of a private or hi-tech hospital claim you pay, with the remaining balance covered by the insurer. An Inpatient excess does not apply to public hospitals.

The excess can apply for both day-case and overnight procedures.

There is a common misconception that an excess applies to each night you stay in the hospital but that’s not case. You pay the excess once per hospital admission, but this may differ as per your chosen level of cover. You can check your cover easily in your Member Area.

If your Inpatient excess is €150 and you go to the hospital for 7 nights, you pay €150 and we cover the rest.

The Outpatient excess is the amount that you must exceed per membership year before you can receive any refunds on your everyday medical expenses. Things like GP visits, Physio visits and much more.

The amount you will be refunded is not what you pay for each expense. The amount you can claim back is the allowed amount per benefit less the Outpatient excess on your plan. You can check your cover easily in your Member Area.

The allowed amount which you claim back can be shown in monetary and/or percentage values.

If you already have health insurance with another provider and there are no gaps in that cover when you transfer to us, then you are not liable for any age loadings.

However, since the 1st May 2015 if you are over the age of 34 when you first take out health insurance, you must pay extra for your cover under the Lifetime Community Rating (LCR) loadings. These loadings can be applied to a premium for a maximum of 10 years.

It works out at an extra 2% of your premium for each year above 34, up to a maximum of 70%. Find out more about Lifetime Community Rating.

What is a shortfall on Specified Orthopaedic and Ophthalmic Procedures?

For certain orthopaedic and ophthalmic procedures, a shortfall applies to your hospital charges. This can include accommodation and other hospital costs. It's the percentage of these hospital costs that you pay, rather than laya healthcare. It applies to specific procedures – most commonly hip, knee or shoulder replacements, or cataracts – and the percentage is set out on your Table of Benefits. The consultant's fee for the procedure is covered in full, provided they're a fully participating consultant.

For example, a shortfall on orthopaedic procedures is typically 20% (approx. €2,700) or 40% (approx. €5,400). These figures are illustrative only – different hospitals charge different rates for these procedures, so we'd recommend checking with the hospital directly if the need for a procedure arises.

What is an accommodation shortfall?

An accommodation shortfall is an amount that applies if your accommodation isn’t fully covered on your plan.

 For example, if you're covered for a semi-private room but occupy a private room, a shortfall would apply for each night at the rate specified on your plan.

Your Table of Benefits sets out the shortfall for your plan, so it's worth comparing schemes to make sure you're comfortable with the level of shortfall you'd be expected to pay.

Not sure whether a shortfall applies to you, or what it would mean if it did? Call us on 021 202 2000 or contact us and we'll be happy to talk you through it.

Irish legislation states that a minimum level of benefits should be available on all plans including day care/in-patient treatment, Hospital out-patient treatment, maternity benefits, convalescence, psychiatric treatment and substance abuse.

Regardless of whether they are needed, they must be included on each scheme.

If you live in Ireland and intend to stay here for at least one year, then you are entitled to a range of health services either free of charge or at a reduced cost through the public system. If you’re ok with long waiting lists, then you’ll be fine under the public system. 

However, if you want to choose your doctor/consultant or where and how fast you’re treated, then that’s the major advantage of having private health insurance.

Of course, some charges still apply in public hospitals if you are admitted overnight as a public patient. From January 1 2017, in-patients are charged a standard fee of €80 per night, up to a maximum of €800 in one year.

We hope that you find this information useful in making health insurance a little simpler to understand. If you’re still confused, you’ll find more answers on our FAQ page.

The HIA (Health Insurance Authority Ireland), a statutory regulator of the private health insurance market also has a glossary.

Anyone with private health insurance who is admitted to a public hospital through A&E is given a waiver form. This is called the Private Insurance Patient Form.

If you are given one of these forms and sign it, the cost of your stay as a private patient can be 10 times higher than the public rate, whether or not you get any additional treatment.

This significant extra cost directly affects health insurance premiums, as these are related to the cost of health insurance claims. It’s vital,
therefore, to know your entitlements as a private patient. Before you sign a waiver form, ask if you’ll receive any additional services and benefits if you waive your right to be treated as a public patient.

For more on this charge go to Insurance Ireland.