Critical & Serious Illness Decision Reference 2023-0262

Case OutcomeRejected
Date29 November 2023
Subject MatterCritical & Serious Illness
Finantial SectorInsurance
Conducts Complained OfRejection of claim – partial rejection
Decision Ref:
Product / Service:
Critical & Serious Illness
Conduct(s) complained of:
Rejection of claim partial rejection
The Complainant holds a Health Insurance Policy with the Provider. The complaint
concerns the Provider’s assessment of the Complainant’s request in July 2019, for the
preapproval of the cost of a neurosurgical procedure which the Complainant underwent in
an overseas medical facility. The policy period in which this complaint falls, is from 1 April
2019 to 31 March 2020.
The Complainant’s Case
The Complainant says that her treating clinician in Ireland referred her to an overseas
medical facility where, on 24 July 2019, she underwent a neurosurgical procedure not
available in Ireland for the treatment of [type redacted] disorders, at a cost of GBP
£67,425.00 (sixty-seven thousand four hundred and twenty-five Sterling Pounds), which
she calculates as amounting to €80,896.84 (eight thousand eight hundred and ninety-six
Euros and eighty-four Cents)
The Complainant says that in advance of undergoing this surgery, she had, from 25
January 2019, considerable telephone communications with the Provider in respect of the
funding for the procedure and that her first telephone call with it, in relation to his matter
was, as she submits in her letter of complaint to this Office dated 16 March 2020:
“…one of many whereby [Provider] did not demonstrate any form of reasonable
assistance to me and in fact were obstructive to me accessing funding for my
- 2 -
The Complainant says she completed an Overseas Pre-approval Form to the Provider on
10 July 2019, seeking for it to preauthorise cover for the cost of the surgery under the
Elective Overseas Referral benefit included in her Health Insurance Policy.
The Complainant says that the Provider informed her on 18 July 2019 that it had pre-
authorised the amount of €23,668.48 towards the cost of her overseas surgery.
The Complainant says that when, during a telephone call with the Provider on 18 July 2019
she expressed her dissatisfaction with the pre-authorised amount, the Agent advised her
that the shortfall was something she could discuss with the HSE.
The Complainant says that following subsequent engagement with her Representative, the
Provider advised on 22 July 2019 that it had increased the pre-authorised amount to
€31,122.00 (thirty one thousand one hundred and twenty-two Euros). The Complainant, in
her letter of complaint to this Office dated 16 March 2020, submits, among other things,
“In reviewing my application [Provider] restricted the payment for overseas
treatment costings to award me just [€31,122.00] even though my policy allows for
up to €65,000 in respect of overseas treatments. This award is unfair as [Provider]
applied costings from Ireland to a treatment which is not available in Ireland … It is
my contention that [Provider] may not in good faith use a notional cost for a
treatment which is specifically not available in Ireland as a basis for a
reimbursement to a patient accessing a treatment abroad … It would be
understandable in a situation where a treatment is available in Ireland…that
[Provider] would limit the level of reimbursement to that which [Provider] would
have incurred if the patient were accessing the healthcare in Ireland. But in a case
where the patient cannot access the treatments in Ireland then the provision of the
policy to cover necessary healthcare should apply in full.
[Provider] assigned a value of €31,122 to the cost of the treatment in the UK
effectively ensuring I could not access the healthcare which had an actual cost of in
excess of £67,425”.
The Complainant says that because the Provider was only willing to contribute €31,122.00
towards the GBP £67,425.00 cost of her overseas surgery, and because it was not willing
to make payment directly to the overseas medical facility, she could not have proceeded
with the surgery on 24 July 2019 as scheduled, without the financial assistance of the HSE.
The Complainant sets out her complaint in the FSPO Complaint Form she completed, as
“Failure of [Provider] to fund treatment in the UK which is not available in Ireland.
The funding awarded was just over €31,000 but the treatment is £65,000 stg.
[Provider] refused to pay [the medical facility overseas] directly, risking my ability
to access the treatment.

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