Ombudsman finds Laya made mistake by not paying for private patient care at height of Covid-19 pandemic – The Irish Times

The family of a patient who was treated when private hospitals were under state control during the COVID-19 pandemic have written to doctors’ organisations to emphasise that the Financial Ombudsman has ruled that the health insurer was wrong not to pay for her treatment.

John Slattery, from Cork, said he wanted to raise public awareness of the issue and ensure “insurance companies never again completely block compensation claims”.

The case relates to May 2020, when the HSE took control of the country’s private hospitals in anticipation of a sharp increase in the number of patients needing treatment after contracting COVID-19.

Mr Slattery claimed that while the State took control of hospital beds and facilities as part of a “safety net” agreement with the HSE, the consultant provided Mr Slattery’s wife with private treatment in a side room.

However, the consultant’s invoice for €945 was returned by the patient’s insurance company with the justification that all individuals treated in the private hospital from and including 30 March 2020 were considered public patients and therefore no private service charges were eligible for collection.

The insurer also claimed that during the three months in which the state effectively took over the private hospitals, it had redirected the savings in claims costs back to its policyholders. It said that a total of €390 had been paid into the complainants’ bank accounts.

In its finding, the Financial Services and Pensions Ombudsman upheld that by refusing to pay the benefit in respect of private outpatient care charges incurred on 11 May 2020 – after Nphet lifted the non-essential health service suspension – and by doing so for reasons beyond the scope of the policy terms governing the insurance agreement between the provider and the complainants, the provider had acted improperly, taking a position that was in breach of the terms of the applicable contract and contrary to law.

The Financial Ombudsman ordered the insurer to pay the consultant’s bill or refund subscribers if they had already paid the fee.

The Ombudsman found that there was no agreement between the complainants and the company as to whether the payment should be regarded as having been made on a voluntary or contractual basis.

In a letter to the sector’s main representative bodies earlier this month, Mr Slattery said the consultant had already been paid but the Financial Ombudsman had unfortunately withdrawn an initial decision recommending that health insurers review all similar claims they had rejected.

“Accordingly, every doctor and consultant is required to reconsider rejected claims,” he said.

The Financial Services and Pensions Ombudsman said it could not “comment on individual complaints or acknowledge receipt of complaints in relation to any individual financial services provider, pension provider or complainant”.

The company, Laya Healthcare, told The Irish Times that the case did not set a precedent for other claims.

The company said all private patients who received care at the private hospital during that period were treated as public patients and that it covered the public charges.

The company said that while it accepted the ombudsman’s decision, its claim was initially rejected on the basis that private treatments could not be carried out during the period of a “safety net agreement” at a private hospital.

“Only public charges were allowed during this period and this member’s claim form indicated that this elective procedure was performed in an isolated room of a private hospital at a time of unprecedented national crisis.”

“While processing this matter, Laya Healthcare has made every effort to look after our member and ensure he does not incur any financial burden.”

The Department of Health has announced that Health Minister Stephen Donnelly has received a very small number of letters (fewer than three) regarding payments for procedures carried out during the period in which the Safety Net scheme was in operation.

“Where the Minister receives a letter regarding complaints regarding private health insurance, the person concerned is requested to use the appropriate complaints procedure,” it said.