Laya was wrong not to pay for patient’s private care at height of Covid-19 pandemic, ombudsman finds

The family of a patient who received treatment when private hospitals were under the State’s control during the Covid-19 pandemic has written to doctors’ organisations highlighting a ruling by the financial ombudsman that a health insurer was wrong not to pay for her care.
John Slattery from Cork said he wanted to raise awareness of the case and to ensure that “insurance companies will never again put a total block on insurance claims”.
The case dates from May 2020, when the HSE had effectively taken over the country’s private hospitals in anticipation of a surge of patients needing treatment after contracting Covid-19.
Mr Slattery maintained that while the State had taken control of private hospital beds and facilities under the “safety net” agreement with the HSE, a consultant had provided private treatment for Mr Slattery’s wife in a side room.
However, the consultant’s invoice for €945 was sent back by the patient’s health insurance company on the basis that all those who were treated in a private hospital on or after March 30th, 2020, were deemed to be a public patient and consequently no private fees were eligible to be raised.
The insurer also maintained that during the three-month period in which the State had effectively taken over the private hospitals, it had redirected claim cost savings back to its policyholders. It said €390 in total had been transferred to the bank account of the complainants.
In its finding the Financial Services and Pension Ombudsman maintained that in declining the payment of benefit in respect of the private outpatient fees incurred on May 11th, 2020 – after Nphet had lifted the pause in non-essential health services – and that in doing so, for reasons outside of the policy terms and conditions that governed the contract of insurance between the provider and the complainants, the provider acted wrongfully, having taken a position that breached the terms of the contract in place, and was contrary to law.
The financial ombudsman directed that the insurer either pay the consultant’s bill or reimburse the subscribers if they had already paid the charge.
The ombudsman said there was disagreement between the complainants and the company over whether any payment should be seen to be made on an ex gratia rather than on a contractual basis.
In a letter to the main medical representative bodies earlier this month Mr Slattery said the consultant had now been paid but that the financial ombudsman had unfortunately withdrawn a preliminary decision recommending that health insurers review all similar claims they had rejected.
“So it requires each doctor and consultant to reactivate claims rejected,” he said.
The Financial Services and Pensions Ombudsman said it could not “comment on individual complaints or confirm receipt of complaints in relation to any individual financial service provider, pension provider or complainants”.
The company concerned, Laya Healthcare, told The Irish Times that the case did not set a precedent for other claimants.
It said all private patients who received care in a private hospital during this period were treated as a public patient and it had paid the public fees.
The company said that although it accepted the ombudsman’s ruling, the claim had been declined originally on the basis private procedures were not eligible to be carried out during the period of the “safety net agreement” in a private hospital.
“Only public charges were eligible to be raised during this period and the claim form for this member stated this elective procedure was carried out in a side room in a private hospital during an unprecedented national crisis.”
“Throughout the adjudication of this case, Laya Healthcare made every effort to look after our member and to ensure they didn’t incur any financial burden.”
The department of Health said Minister for Health Stephen Donnelly had received a very small number of representations (fewer than three) in relation to payments for procedures carried out while the “Safety Net” programme was in operation.
“Where the Minister receives a representation in relation to complaints about private health insurance cover, the individual concerned is directed to utilise the appropriate complaints procedure”, it said.