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Private health insurance

Information

A number of companies offer voluntary private health insurance in Ireland.

The Voluntary Health Insurance Board (VHI) is the largest provider of voluntary private health insurance. It is a statutory body whose board is appointed by the Minister for Health. Laya Healthcare, formerly QUINN-healthcare, Aviva, GloHealth and HSF Health Plan (does not provide cover for hospital in-patient costs) also operate as voluntary private health insurance providers in Ireland. There are a number of long-established health insurance providers that deal only with particular groups of employees; membership is confined to employees and retired employees and their dependants. These schemes are known as restricted membership schemes. Examples include the Gardaí, prison officers and ESB employees. The rules governing health insurance apply equally to all providers with some limited exceptions for the restricted membership schemes.

Using health insurance

Health insurance is used to pay for private care in hospital or from various health professionals in hospitals or in their practices. The arrangements vary from one company to another but most companies have agreements with hospitals that the company will pay the hospital directly. In general, for outpatient costs you pay the health professional and then claim from the health insurance company. You should check with your own company as to exactly what procedures they use.

Health Insurance Authority

The Health Insurance Authority (HIA) is the independent statutory regulator for the private health insurance market in Ireland. It monitors the operation of health insurance business in Ireland and advises the Minister for Health in this regard, including assessing the effect of any regulations or new legislation on consumers. The HIA aims to ensure that consumers are aware of their rights and that policies and publicity material describe cover in a fair and comparable way. The Authority also reviews the appropriateness of the procedures used by insurers in their dealings with consumers.

The Health Insurance Authority has useful publications called My Rights, My Choices and Selecting a Private Health Insurance Product. You can read them online or request a hard copy.

You can also compare the benefits and prices of different health insurance products using their product comparison tool.

Risk equalisation

One of the Health Insurance Authority's functions relates to the operation of a Risk Equalisation Scheme. Risk equalisation is a process that aims to equitably neutralise differences in insurers' costs that arise due to variations in the age profile of their members. This process is relevant to the customer in so far as it may affect matters such as the operation of community rating or competition between insurers. The HIA administers a Risk Equalisation Fund which pays health credits to the insurance company for people over 60 to help to meet their higher claims costs. The health credits vary by age, gender and by level of cover. These credits are funded by a community rating health insurance levy paid by health insurers.

Tax relief

The Health Insurance Tax Credit reduces the amount of the health insurance premium that you pay.

Rules

All private health insurance providers must be registered with the Health Insurance Authority. Typically, insurers must also satisfy various prudential requirements, which are appropriate to the Central Bank of Ireland - these are requirements that apply generally to all insurance and financial services companies and relate to matters like their financial operation and their investment policies.

Minimum level of benefits

At present, companies that are offering cover for in-patient hospital services must offer a minimum level of benefits. They must provide a minimum level of cover in respect of:

  • Day care/in-patient treatment
  • Hospital out-patient treatment
  • Maternity benefits
  • Convalescence
  • Psychiatric treatment and substance abuse

The minimum accommodation level is semi-private in a public hospital.

Other insurance contracts

Companies are allowed to offer contracts limited to certain health services, e.g., dental and optical services, without being subject to the general requirements about community rating, open enrolment and lifetime cover. They may also offer contracts in relation to GP and out-patient services without having to meet minimum benefit requirements.

Access

There are three general principles that apply to health insurance:

  • Open enrolment
  • Lifetime cover
  • Community rating

Open enrolment

At present, health insurance companies must accept anyone who wishes to join, subject to any applicable waiting periods before cover takes effect, regardless of age, sex or health status - this is known as "open enrolment". Restricted membership schemes must accept everyone who is qualified to join.

Lifetime cover

Once you join and continue to pay your premiums, the insurance company cannot refuse to provide you with cover - this is called "lifetime cover".

An individual or family, having already served both the requisite waiting periods relevant to their age when first taking out private health insurance and any waiting period for a pre-existing condition may switch from one insurer to another, and if such an occurance takes place within 13 weeks, those waiting periods will not have to be served again. Therefore, persons can normally move from one insurer to another without loss of cover.

Community rating

"Community rating" means that the insurance company must charge the same rate for a given level of service, regardless of age, sex or health status. So all adults pay the same amount for the same benefits. Unlike motor insurance or life insurance, matters such as age, sex, sexual orientation, health or past record of claims do not affect the price charged for insurance.

Charges may be lower than the normal adult rate for: people aged under 25; retired people who have a special arrangement within their company's health insurance scheme and people in group health insurance schemes. Charges for children must be reduced by at least 50%.

Lifetime community rating

Higher charges apply to people who are 35 years of age or older when they first take out health insurance. There is a 2% loading for each year over 34 years of age. So, for example, if you are 35 the cost is 2% higher than for a person aged 34 but if you are 44 then the cost is 20% higher.

If you previously had health insurance, you can be given credit for the time you were insured, reducing the number of years to which the loading applies.

If you have a break in cover of less than 13 weeks this will not affect your loading.

If you stopped your insurance cover for periods of unemployment since 1 January 2008, up to three years of credits can be provided.

If you live outside Ireland and move to Ireland, a loading will not apply if you get health insurance within nine months and continue to be insured.

The Department of Health has published a list of frequently asked questions about lifetime community rating. The regulations are set out in Statutory Instrument 312 of 2014 (pdf).

Waiting periods

The health insurance company may not refuse to accept you on the basis of your health status but it may restrict the cover it gives you in certain circumstances.

Initial waiting periods

Insurers are entitled to apply an initial waiting period before private health insurance cover becomes effective.

For policies taken out since 1 May 2015, the maximum initial waiting period is 26 weeks.

For maternity-related claims the waiting period is 52 weeks.

For contracts taken out before 1 May 2015, longer waiting periods could be applied to people aged 55–64 (maximum 52 weeks) or aged over 65 (a maximum of 104 weeks).

Pre-existing conditions

The health insurance company may refuse to cover you in respect of pre-existing conditions for longer periods after you join. So, for example, if you are have diabetes, the insurance company may refuse to provide you with any cover for diabetes for a specified period but must cover you for any other illnesses once the initial waiting period has expired.

For policies taken out since 1 May 2015, the maximum waiting period for pre-existing conditions is 5 years.

Any waiting period for a pre-existing condition may switch from one Irish insurer to another. If the switch takes place within 13 weeks, the completed waiting periods will not have to be served again. Therefore, you can normally move from one Irish insurer to another without loss of cover.

For contracts taken out before 1 May 2015, longer waiting periods for pre-existing conditions could be applied to people aged 55–59 (maximum 7 years) or aged over 60 (a maximum of 10 years).

Upgrade waiting periods

If you are switching health insurance plans, a maximum waiting period may be applied to any higher benefit on the new plan.

For contracts taken out since 1 May 2015, the maximum waiting period is 2 years (for contracts before that date a longer waiting period of 5 years could be applied to people aged over 65). For maternity benefits, the maximum waiting period is 52 weeks.

How to apply

You must apply directly to the health insurance company that you wish to join. Each company must abide by the general rules described but, after that, they are free to make their own rules. The level of cover available and the rates charged vary from one company to another.

Health insurance policies are usually 12 month contracts. If you want to switch insurer or insurance plan, you may do so at your next renewal date. Insurers may have restrictions on switching plan during the 12 month term.

It is a general principle in insurance that you must give all relevant information to the insurance company. If you do not, then the entire contract may be void.

If you are experiencing problems with getting cover, you should contact the Department of Health or the Health Insurance Authority.

Where to apply

Further information on the rules about private health insurance is available from:

Health Insurance Authority

Canal House
Canal Road
Dublin 6
Ireland

Tel:+353 (0)1 4060080
Locall:1850 929 166
Fax:+353 (0)1 4060081
Homepage: http://www.hia.ie


Department of Health

Hawkins House
Hawkins Street
Dublin 2
Ireland

Tel:+353 1 635 4000
Locall:1890 200 311
Fax:+353 1 635 4001
Homepage: http://health.gov.ie/

Page edited: 17 May 2016

Language

Gaeilge

Contact Us

If you have a question relating to this topic you can contact the Citizens Information Phone Service on 0761 07 4000 (Monday to Friday, 9am to 8pm) or you can visit your local Citizens Information Centre.