Help with health insurer and deductible | Legal aid centre

Questioner

In 2013, I obtained information by telephone from health insurer Aevitae regarding a hospital admission. I was clearly informed that the deductible at the start of the period in 2013 would be charged to 2013, regardless of the duration of the treatment, with a possible carryover to 2014. I started the process at the end of 2013 and it ended in 2014. Now, in retrospect, I am told the opposite and I should pay the deductible. I have everything neatly in my email. A friendly request if you can help me with this?

Lawyer

If you have proof of what was agreed, you may not have to pay the deductible.

Lawyer

You indicate that the promise was only made by telephone. Without proof of the promise, you unfortunately have no chance.

Lawyer

Health insurers, or at least their customer services, are often still too rigid when an individual or customer tries to explain a complaint. A legal stick behind the door works and you will see that you will get out of the impasse. Now that I read that you have everything on the stick, I could get started on it by putting the health insurer in default, for example. You could best post the letter yourself because a health insurer requires an official signed power of attorney.

Lawyer

The question is what 'I have everything neatly on the mail.' means. That could well only refer to the correspondence conducted later, given the comment about the telephone information gathering, without any proof of the promise.

Lawyer

No, it would be good if the email confirmed the contents of the previous telephone conversation.

Lawyer

My predecessors assume that the health insurer is in breach of contract. There is talk of agreements and default. This is all happening too fast for me. A health insurer is the executor of the Health Insurance Act (Zvw) with regard to basic insurance. The deductible is part of this law. You will receive the invoice from the health insurer, but it will draw up the invoice based on the law and information it receives from the healthcare provider. Hospitals worked with so-called DBCs in 2013. This stands for Diagnosis Treatment Code and includes all care for a specific care requirement. A DBC has a maximum duration of 365 days. If you still need care for the same care requirement after that duration, the hospital can open a follow-up DBC. The initial DBC counts for the year in which it was opened. The follow-up DBC counts for the year in which it was opened. It could therefore be possible that two care products have been declared for you that count towards the deductible for both 2013 and 2014. It is also possible that the hospital closed the initial DBC too early (this happens very often). If they then (wrongly) open a follow-up DBC in the new year, this will count towards your own risk for the new year. In short, I think it is too early to say that the health insurer has made a mistake. It is possible, I do not rule this out, but it could also be different. In any case, the health insurer should investigate this very thoroughly. I advise you to submit your complaint by letter to the insurer for the attention of the complaints handling department. Your complaint will usually be examined more thoroughly here than by a call centre. If you cannot reach an agreement with the insurer, you can then submit a complaint to the SKGZ (Health Insurance Complaints and Disputes Foundation) in Zeist. However, you must first have gone through the complaints procedure with the health insurer. If you have any questions, please let me know. You can also contact me directly if you prefer.