Private health insurance

Introduction

Health insurance is used to pay for private care in hospital or from health professionals in hospitals or in their practices.

The arrangements vary from one company to another but most companies have agreements with hospitals to pay the hospital directly. In general, for outpatient costs you pay the health professional and then claim back from the health insurance company. You should check with your own company as to their procedures.

The following companies offer voluntary private health insurance in Ireland:

There are also some health insurance providers that deal only with particular groups of employees, for example, Gardaí or prison officers. These schemes are known as restricted membership schemes. The rules governing health insurance apply equally to all providers, with some limited exceptions for the restricted membership schemes.

Minimum level of benefits

Companies that offer cover for in-patient hospital services must offer a minimum level of cover for:

  • 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.

Tax relief

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

Supports during COVID-19 emergency

Private hospitals were used as part of the public healthcare response to the COVID-19 emergency for 3 months to June 2020. Private health insurance providers agreed to give customers rebates for this period. The health insurers had different arrangements to give customers payments and other supports. Check with your insurance company for details.

Regulation of health insurance

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 the HIA product comparison tool.

Risk equalisation

The Health Insurance Authority operates a Risk Equalisation Scheme. Risk equalisation aims to balance out differences in insurers' costs due to differences in the age profile of their members.

The HIA has a Risk Equalisation Fund that pays health credits to an insurance company for members over 60, to help to meet their higher claims costs. These credits are funded by a community rating health insurance levy that is paid by health insurers.

Access to health insurance

Access to health insurance - who can get it and how much it may cost - is affected by 3 principles that insurers must apply:

  • Open enrolment
  • Lifetime cover
  • Community rating

Open enrolment

Health insurance companies must accept anyone who wishes to join, subject to any waiting periods that apply, 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.

You can usually switch insurers without a loss of cover if you complete the switch within 13 weeks. In this case, you do not have serve waiting periods again if you have already served a waiting period for a pre-existing condition, or a waiting period due to your age when first taking out private health insurance. See below for more information about waiting periods.

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, 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

Lifetime community rating means that the amount you pay for health insurance does not depend on the age you are now but can be higher depending on the age you were when you first took out health insurance.

For example, a 50-year-old who has held insurance since they were aged 30 would pay the same as a 30-year-old, but a 50-year-old who purchases insurance for the first time would pay more than a 30-year-old.

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 (2% x 10).

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.

For more information, see the HIA website section Lifetime Community Rating Explained.

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.

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.

When you take out health insurance for the first time, you may have to serve waiting periods before you are fully covered, but accident and injury will be covered immediately.

If you are changing to a health insurance plan with improved benefits there may be a waiting period before the higher benefits apply.

The HIA lists the current waiting periods that are applied by insurers.

Initial waiting periods

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

The maximum initial waiting period is 26 weeks.

For maternity-related claims the waiting period is 52 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 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.

The maximum waiting period is 2 years.

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
D06 FC93
Ireland

Tel: +353 (0)1 406 0080
Locall: 1850 929 166
Fax: +353 (0)1 406 0081

Department of Health

Block 1
Miesian Plaza
50-58 Lower Baggot Street
Dublin 2
D02 XW14

Tel: +353 1 635 4000
Page edited: 24 November 2020