Glossary

An allowable amount/expense is the portion of the cost of outpatient services such as GP visits and physiotherapy that you are allowed to claim back from your insurer. For example, if your health insurance policy has an allowable expense of €20 per GP visit, you can claim back only €20 per GP visit even if the cost of the visit was €60. This maybe shown as a percentage or as a specific amount in your health insurance policy documentation.

A benefit is a health care treatment or service covered under a health insurance policy. These are listed in the table of benefits in your health insurance policy documentation. For example, inpatient, psychiatric or maternity cover.

A cash plan provides money for a range of medical events, such as visits to the GP and other outpatient expenses. Cash plans also provide fixed amounts per night spent in hospital. However, unlike inpatient private health insurance plans, the money that you can claim back is a fixed amount, and it is not linked to the cost of your hospital stay. Usually, you can claim only for a portion of the cost, otherwise known as an allowable amount/expense. For example, you may be able to claim €50 per night spent in hospital.

These are lists of cardiac and non-cardiac procedures that the insurer has negotiated a fixed price for with the hospital. We don’t have access to these lists. Contact your insurer directly for details.

A co-payment is a fixed out-of-pocket amount that you pay each time you access certain health services or procedures. To find out if you have to pay a co-payment for a medical procedure or service, check your health insurance policy documentation. You must pay the co-payment directly to the medical service provider or hospital. It’s not reimbursable under your health insurance policy and it is not counted in the cost of any excess or outpatient claim. For example, if your policy has a €2,000 co-payment for knee replacement surgery, you must pay €2,000 directly to the hospital.

Community rating is a system that means that health insurance companies must charge the same rate for a given level of cover regardless of factors like age, gender, health risk status or the provision of health services in the past. This is a key difference in comparison to other types of insurance such as car insurance, where the amount you pay is based on the assessed risk of the consumer. However, there are some exceptions:

• If you buy health insurance for the first time when you are aged 35 or over, or if you have a break in health insurance cover of longer than 13 weeks while you are aged 35 or over, you will have to pay an additional Lifetime Community Rating loading on top of the cost of your policy.
• The cost of a policy may be reduced by up to 10% for members of group schemes.
• The cost of a policy for children must be no more than 50% of the adult premium.
• The cost of a policy for those aged 18-25 may be reduced.
• The cost of a policy for pensioners who are members of restricted membership insurers may be reduced.

A company policy is a health insurance policy that is marketed towards companies. However, anyone can buy a company policy, even if you are not an employee of the company itself.

Laya Healthcare currently charge consumers an additional 3% of the cost of their health insurance policy for paying on a monthly basis. You can avoid this extra charge by paying annually.

Day-patient treatment is treatment that you receive in hospital in a day care bed that doesn’t include an overnight stay.

Day-to-day benefits are benefits that cover everyday medical costs. For example, GP visits, physiotherapy or osteopathy.

A dependant is a person that is included in your health insurance policy but who is not the main policy holder. For example, your spouse, cohabiting partner or child.

An EAP is an Employee Assistance Programme. This usually includes telephone or face-to-face counselling.

An excess is the specified amount for each claim that you must pay yourself. The rest of the cost of the claim is covered by your insurer.

• An inpatient excess is the initial amount you pay for a private hospital claim. For example, if your treatment or procedure cost €800 and your excess was €50, you will have to pay €50 directly to the hospital.
• An outpatient excess is the amount that must be exceeded before you receive a refund on day-to-day medical costs such as GP visits. For example, if your annual outpatient excess is €100, you will have to claim more than €100 in allowable expenses before you get a refund. The refund will usually be only a portion of the total cost, for example you may get 50% back on GP visits.

An exclusion is a condition or treatment that you are not covered for under your health insurance policy.

An insurer may offer a discount of up to 10% on any policy to a group of persons. For example, an employee of a company, or a member of a Credit Union Health Insurance Group Scheme. This is at the insurer’s discretion.

Hi-tech hospitals are private hospitals that offer treatment for complex conditions, including orthopaedic and cardiac conditions. The Blackrock Clinic, the Mater Private, and the Beacon Hospital are some of the facilities that are considered hi-tech hospitals.

Inpatient treatment is treatment you receive during an overnight stay in hospital.

Lifetime Community rating is a system where you have to pay more for your health insurance policy if you buy health insurance for the first time when you are aged 35 or above. This additional amount is called a loading. The loadings start at 2% of the gross cost of your policy from age 35 onwards, up to a maximum of 70% of the gross cost of your policy for age 69 or above. Lifetime Community Rating loadings were introduced in 2015 to encourage people to join the health insurance market at a younger age. For more information, go to Lifetime Community Rating.

Lifetime cover protects you by guaranteeing the right to renew your health insurance policy regardless of your age, risk status or claims history. Once you have health insurance, an insurer cannot stop your cover or refuse to renew your policy except in very limited circumstances.

Under Open Enrolment, health insurers must accept all applicants for insurance cover regardless of risk status, age or claims history.

Open membership insurers provide insurance to everybody who wants to buy it from them. Currently, there are four open membership insurers operating in Ireland: Irish Life Health, Laya Healthcare, Vhi Healthcare, and HSF Health Plan. However, HSF Health Plan offers only cash plans.

Outpatient treatment is treatment that does not involve staying in a hospital bed overnight or day care procedures in a hospital. For example, GP visits or physiotherapy.

A policy limit is the maximum amount that you can claim for outpatient benefits.

A "pre-existing condition” means an ailment, illness or condition, where, on the basis of medical advice, the signs or symptoms of that ailment, illness or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the contract.

A premium is the amount that you pay each year for your health insurance policy.

A private room is a hospital room with a single bed.

These are unlisted procedures that the insurer has not negotiated a fixed price for with the hospital. We don’t have access to these lists. Contact your insurer directly for details.

Restricted membership undertakings provide insurance to people who are members of a particular group. This is normally a vocational group or employees of a particular organisation and their dependants. For example, there are restricted membership schemes for members of An Garda Síochána.

A schedule of benefits is a document outlining the details of the benefits and cover included in your health insurance policy. This is also known as a table of benefits.

A semi-private room is hospital room that has up to five beds.

A shortfall is the amount on your hospital bill that is not covered by your health insurance policy that you must pay out-of-pocket. It is generally applied on a nightly basis.

A waiting period is the amount of time that must pass from the start date of your health insurance policy before full cover is available. You may have to serve waiting periods if you buy health insurance for the first time or if you upgrade your cover. For more information, go to waiting periods.