Health Insurance

Advertising for Vhi Healthcare included their brand line “when you need us, we’re there”.

The complainant said her complaint was in relation to the VHI slogan “when you need us, we’re there”. She said, her family, who are paid members of VHI, found out that an eye procedure which her daughter had to undergo called Cross-Linking was not covered by Vhi. She said that contrary to the advertisement Vhi are not there when you need them.

The advertiser stated that as a medical insurance company, their primary function was to provide a range of healthcare plans that provided insurance cover for hospital costs and the associated professional fees arising from an unexpected illness or accident. They said whilst their members may derive value from various medical procedures or therapies, they were not always in a position to extend their benefits to cover these. They said in deciding whether to provide extensions of cover for surgical procedures they had a set of criteria that had to be met, and which generally, amongst other things, sought to establish whether the procedure was safe, effective (both from a clinical and cost perspective) and generally accepted by the medical community. They said in order to comply with this there had to be reliable evidence that the procedure had been the subject of well-controlled studies with clinically meaningful endpoints, which had determined its safety and efficacy compared with standard treatments. They said there had to also be reliable evidence that the consensus among medical experts regarding the procedure was that further studies or clinical trials were not necessary to determine its safety or its effectiveness as compared with standard treatments. They said long term outcomes had to be available unless there were exceptional extenuating circumstances related to specific well-defined population groups for whom there was no reasonable alternative form of treatment otherwise available.

They said generally their customers contacted the Benefits Team before they received treatment for a surgical procedure or medical treatment and it was at that stage that their cover was explained in detail and where necessary they explained why something was not covered. They said in addition medical consultants usually advised the patient to check with their insurer that the intended service was covered.

ADDITIONAL INFORMATION:
The Executive wrote to the advertisers and asked them to advise if corneal cross-linking was covered by any plan.

The advertisers said Corneal Cross-Linking was not covered on Vhi Healthcare plans. They said Vhi Healthcare considered corneal Cross-linking to be an unproven form of treatment as there were no long term randomised trials to support its benefits. They said long term outcomes were defined as 5 years to follow up, unless there were exceptional extenuating circumstances related to specific well defined population groups for whom there were no reasonable alternative form of treatment otherwise available, when they may either accept:
(a) The outcome of 1 year follow up procedures that had been the subject of at least one adequately powered randomised controlled trial or

(b) That it was not feasible to perform a randomised controlled trail for a treatment and there was otherwise good evidence in the medical literature that the treatment was effective and generally accepted by the medical profession as appropriate with regard to good standards of medical practice.

They said if the treatment was carried out in Ireland, it was excluded under the Exclusion Rule 7(k): ‘Experimental drugs or treatments’. If the treatment was carried out abroad, it was excluded under Cover outside Ireland Rule 6(c), section 26(v) – ‘new, not proven forms of treatment’.

They said furthermore should the treatment not be eligible for benefit by Vhi, their members were eligible to have their case reviewed by the HSE under the following two categories: The Treatment Abroad Scheme (TAS) or E112) under the Cross Broder Directive (EU Directive 2001/24/EU). They said separate applications had to be made by either their referring consultant (for the former) or their GP (for the latter).

They said as with all medical expenses not recovered by Health Insurance in Ireland, the member could complete a Med 1 form and receive a % of the eligible charges back – this was dependent on the tax band – usually 20% of the overall costs and the amount of days they had worked in a calendar year.

In relation to the brand line ‘when you need us we’re there’ the advertisers said that this represented the Vhi Healthcare brand promise, and Vhi strived to live up to everything they do. They said, however, as with any medical provider Vhi had to analyse and adhere to the best medical practice – where treatments were not proven or affect customer safety, Vhi cannot cover every treatment.

FURTHER RESEARCH:
The Executive viewed the advertisers’ website, in the context of the advertising claim made, to view any services provided to members. It was noted that, amongst services provided, the advertisers provided an advisory helpline, a second opinion service and ongoing treatment home.

Complaint Not Upheld.

The Complaints Committee considered the detail of the complaint and the advertiser’s response.

The Committee considered that consumers were likely to generally know and accept that insurance policies and the like were not unlimited in providing cover and that terms, conditions and exclusions invariably applied.

The Committee specifically noted that where treatments were not proven insurance cover would not apply and therefore cover would not be provided for every available/potential treatment.

They noted that, apart from a core health insurance product offering related to medical costs for in-patient care, services were also provided for out-patient type eventualities that members could avail of.

While taking account that a particular procedure was not covered, the Committee considered that the brand line was not a definitive statement which could generally be interpreted to mean that provision was being made to be there for members in every medical eventuality.

The Committee did not consider that the advertisement was in breach of the Code.

ACTION REQUIRED:
No further action required.