Cover or no cover: ‘I know mistakes happen . . . but it really is a mess’

A reader called Elizabeth took out a health insurance with Laya Healthcare at the start of January 2017 on "a bargain-basement plan" and a year later she upgraded it to a better one.

In January 2019, she moved to another plan with the company and then at the start of this year upgraded her health insurance again.

“In 2018 I had a niggling pain in my right shoulder-blade and couldn’t raise my arm fully above my head,” she writes. “I spoke to the GP in September and he sent me for an MRI. That came back fairly normal and I went for some physio sessions for ‘frozen shoulder’.”

Then last year Elizabeth had “much worse pain, at the front of my shoulder and down my arm”.

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She went back to the doctor in late April and he said he would send her to a consultant at the Hermitage.

I was sure everything was fine but I had changed my plan so thought I should just double check

“I called Laya and was told I could see the consultant there. On a call yesterday they said that I was told at that point I wouldn’t be covered if I became an in-patient at a private hospital. I don’t remember that, but it’s certainly possible. I didn’t think it was going to be an issue, I never thought I’d need surgery,” she writes.

She saw the consultant last July and had an ultrasound last August followed by a cortisone injection.

"Then I went to physio through the autumn, but with no improvement. In November 2019 I contacted [the consultant's] secretary to ask what the next step should be and was put forward for surgery called a biceps tenodesis. She said this could be done in either the Hermitage or the Bon Secours Glasnevin and gave me a code to check with Laya."

‘Unfortunate’

Elizabeth called Laya in November to ask if she was covered for the procedure and was told that she was but would have to pay an excess of €500 if she was in overnight and €149 for day case.

“That was fine, I knew that was the case with my policy. I distinctly remember the lady I spoke to asking when symptoms started, and saying that I was covered as long as I didn’t have symptoms before January 2017, when I took out my health insurance with Laya.”

She was scheduled for surgery on last Tuesday at the Bon Secours Glasnevin. “I am booked to be in overnight but was told I can go home if I’m feeling well. I was told I would need to take two weeks off work, so I have been working over-time in the past couple of weeks to have everything covered. My partner planned to take two days off so that he could help me in the early stages.

My November call was about surgery, with the exact code of the procedure, and they said it was covered

“I only received my letter from the hospital yesterday. It stressed that checking insurance was my responsibility and gave the code again. I was sure everything was fine but I had changed my plan (upgraded though) so thought I should just double check.

“I spoke to a lady who said I was not covered, as it’s a pre-existing condition from 2018. My current plan would cover it, but not until a two year waiting period has passed. So I’m not covered until January 2021.

“I explained that I had been told otherwise on my November call, and had only proceeded because of that. She said she would check and come back to me, which she did, after half an hour or so. She and a supervisor had gone back over previous communications. She said I shouldn’t have been told I could have the procedure and that she appreciated it was unfortunate.”

Error

Laya insisted that she was told in April that she didn’t have private cover so should have known. “I can’t remember the April call, I had forgotten there had even been one but I know that what I called about then was seeing the consultant not surgery.

“My November call was about surgery, with the exact code of the procedure, and they said it was covered. I know mistakes happen, and this obviously was one, but it really is a mess.”

She said she did not have a way of knowing how much her treatment would be delayed by because of the mistake “but if I had been on the correct list, for the correct hospital, I imagine I would have been seen sooner and without all the stress. I am in so much pain. The thought of waiting much longer for the operation is unbearable really.”

We contacted the company and they said that Elizabeth had been told in error last November that the procedure would be covered. The company accepted that it was its mistake and while she was not covered for the procedure they agreed to make an exception.

The full statement from Laya reads: “While rare, mistakes do happen unfortunately and on this occasion we gave our member incorrect information regarding her cover when she rang us. We’ve contacted the member to apologise and assure her that we will fully cover her upcoming procedure. We hope it all goes well and will follow up with her to ensure she gets all the support she needs to make a speedy recovery.”

Last Tuesday, our reader had the surgery and she got in touch with us after it had taken place to say that all was well.