Claims and excesses

Excesses

An excess is the first part of any insurance claim that you have to pay yourself. There are two types of excesses – inpatient excess and outpatient excess:

• An inpatient excess is the amount you might pay on private hospital stays. For example, if your treatment or procedure cost €5,000 and your inpatient excess is €50, you will have to pay €50 directly to the hospital. The insurer pays the rest of the treatment, in this example that amount is €4,950.
• An outpatient excess is the amount that you pay yourself for health services such as consultant visits, GP visits, and physiotherapy visits. You may be able to claim a portion of this cost back from the insurer.

Shortfall

A shortfall is the amount of your treatment that is not covered by your insurance. You must pay this amount yourself. You generally have to pay it on a nightly basis, compared an excess which you generally pay only once per hospital stay. For example, if your policy has a shortfall of €150 for a private room in a private hospital, you will have to pay €150 for each night you spend in a private room in a private hospital. Your insurance will cover the rest of the cost of the treatment.

Outpatient Claims

You have to pay upfront for outpatient services like GP visits and physiotherapy. You should keep a copy of the receipt and submit a claim to your insurer. Many health insurance policies have the following features in relation to outpatient claims:

• Most policies have an outpatient policy limit, which means there is a maximum amount you can claim in total outpatient claims per year. For example, if your outpatient policy limit is €1,000, once you have received €1,000 back for outpatient services, you can’t claim any more.
• Most policies have an annual outpatient excess. For example, if your outpatient excess is €250, you will have to submit more than €250 in allowable expenses before you get any money back for outpatient services. In this example, if you can claim €60 per consultant visit under your policy, you would have to submit five claims to your insurer before you get any money back (4 x €60 = €300, you would get €50 back for your fifth consultant visit). You can see more examples of how this works in Example A and Example B.
• Some policies have an annual outpatient excess of €1. If you are more likely to make outpatient claims, you should considering paying a bit extra for this type of policy.

Some policies will have all three of these features. It could be the case that even though the total of your outpatient expenses is more than the out-patient excess, you might still not be in a position to claim because your total allowable expenses have not yet reached the level of the out-patient excess.

Family Excess

If there is more than one person on your policy, the insurer may apply a larger family excess to your claims. You will have to meet this family excess before you can get money back for outpatient services. If there is more than one adult on your policy, you will need to consider whether it is more cost-effective to have each adult on a separate policy with an individual excess, or all on the same policy with a family excess applied to all outpatient claims.