Top up insurance cover

[John Brown]

My wife went into hospital a few weeks ago and we requested a single room. I phoned my health insurance company and I asked if they covered that extra cost. A firm "yes" was the reply but now they are saying "no"

I've phoned 3 times,

The first reason I was given was because I paid the bill for the private room as my wife was discharged and the insurance company will not pay me that amount back to me. The hospital handed me the bill and said the insurance company refused to pay it

The second reason I was given is there is a limit of 35 euro per night paid and I was charged the excess. Another 37.50 per night

100% cover is apparently not 100%

The latest reason I've been given is I should not have paid the hospital and its up to me to claim it back from them

John

[minnie]

Hope your wife is feeling much better now. With regard to your query I have a mutuelle with cover for 150%. I was in hospital last week and my insurance company pays 25 euros towards the cost of a single room. Since the tariff for the room was 60 euros then I had to pay the other 35. This is fairly routine with regard to mutuelles and max paid is usually shown in the small print. Unless you are paying the top level of mutuelle which can be up to 300% then it is quite feasable that you're expected to contribute. Different hospitals charge different sums of money for rooms and cliniques generally charge more (I think). Someone correct me if I'm wrong.

[nomoss]

Our mutuelle pays the difference over the CPAM payment on our hospital bills up to 300% of the Regime Obligatoire prices. The 300% is calculated on the full charges, i.e. it includes  the amount reimbursed by the State system.

However, they pay only up to 25€ for a private room, as the above poster's company does.

Each year when we renew the policy we are sent a schedule which clearly shows what is reimbursable, at what rates, and it also has clear definitions of terms used in the schedule and the policy, so we are in no doubt of what qualifies for reimbursement.

 

Edit: "100% cover" normally means 100% of the Regime Obligatoire prices, not 100% of any bill you may get.

These are the standard costs (Tarifs conventionnels) for services and materials used for calculating what the State System pays out. You can find them here www.ameli.fr

One should ask how a service etc. is being charged if in any doubt.

 

 

[idun]

In France, a 100% for medical cover is not 'good' cover, unfortunately.

Some of our stuff was 300% and I'm sure that there are some things that are covered for even more than that now. And yet, there were things that were not that well covered. Percentages are not always the best way either. For dental things, sometimes it is better to have a calculation of so many times the social security allowance and sometimes plus a fixed amount...... cannot think of the terms just now. Complicated it most certainly is.

Getting very good comprehensive cover is not easy to work out and the more cover you get, the more expensive it is...... so a calculation to do to see if it is worth it.

[John Brown]

Thank you all for your comments and advice

Thankfully this was the first time we have had to test this type of hospital insurance cover so it was all new to us.

It was the different responses from Pacif....... each time I called that caused me to doubt they were telling the truth.

Never mind, we would have booked a private room anyway !

We have Car, House, Content, Legal, Top Up's with them so we started worrying "what if"

Thanks again

John

[NormanH]

It sounds a bit of a c**k up at the Hospital Admin end too.

Usually (I have done this many times now) they ask you to get a statement from the Mutuelle (by fax or letter) of if they will pay the 18€ daily charge and the single room supplement up front or if you have to pay in advance and reclaim it.

I have had a situation when the Mutuelle stated they would pay the 18€ but that I had to advance the single room supplement and another time where the Mutuelle paid both direct so both are possible.

If you have to advance the money the Hospital asks  for a cheque 'de caution' .

When you check out it is important to go and see the reception again 'bureau de sorti' and get your 'bulletin de sortie ' and the receipt for anything you have paid.

You send both of those off to the Mutuelle and should get what is due to you back.

On the 100% issue, remember that a private room is not part of the social security cover.

There will be a separate limit on your insurance policy stating how much per day is paid and for how long.

After that as as been explained there is a tariff set by the social security which may not be the same as the tariff charged.

100% cover gives you 100% of the social security tariff, but if this is only say 100€ for something that the hospital charges 250€ for you will only be reimbursed to 100€ by the combined reimbursements of the two organsations.

[John Brown]

Thanks Norman

Hopefully its a long time till one of us needs to go into hospital but I'll make a note of what you've all said and act on it

Regards John