3018 Vhi Health insurance Application Form 4 pager.indd

March 2014
Health Insurance Application Form
Important to know
Can anyone join Vhi Healthcare?
Yes, anyone can join Vhi Healthcare. The Irish healthcare market is community rated which
means that any adult (aged 18 and over) in Ireland, can hold a health insurance policy - no matter
what age or what their health status is. The prices don’t change from person to person and you
don’t need a medical examination first.
Are there waiting periods before I can claim?
Yes there are. They have been put in place to protect current members against rising costs
by people who discover they are sick and only join so that they have cover for that condition.
The waiting periods are as follows:
Illnesses that develop after you join
Age on joining
Waiting period
Accidents
Under 55
26 weeks
No waiting period
55 - 64
52 weeks
No waiting period
65 or over
104 weeks
No waiting period
ILLNESSES THAT EXIST BEFORE
YOU JOIN
Upgrading your level of cover
Waiting period
for NEW
conditions
Waiting period
for existing
conditions
Accidents
Under 55
26 weeks
2 years
No waiting
period
7 years
55 - 64
52 weeks
2 years
No waiting
period
10 years
65 or over
104 weeks
5 years
No waiting
period
Age on joining
Waiting
period
Age at
upgrade
Under 55
5 years
55 - 59
60 or over
A 52 week waiting period applies to maternity/pregnancy benefits.
How many days treatment can you claim in a year?
Cover for in-patient hospital treatment is available for a maximum
of 180 days per member per calendar year.
GenPmiApp4
Hospitals and accommodation
There are two types of hospitals in Ireland:
Public hospitals
These hospitals are state owned and run. If you want private treatment in a public hospital, it pays to
have health insurance.
Private hospitals
These are privately owned and run and all treatment must be paid for by the patient or by their
health insurer. An average cost of one week’s stay in a private hospital is approx. e5,000 – you can
see now why it’s so important to be covered by Vhi Healthcare.
Accommodation types
n Day case/care & side room procedures use ‘day care’ beds and do not require an overnight stay.
n Public rooms have 6 beds or more.
n Semi-private rooms have between 2 and 5 beds.
n Private rooms have 1 bed.
How to claim?
In-patient hospital claims
Vhi Healthcare pays your in-patient hospital bills directly so that you don’t have to. This removes the
need for our members to have to complete claim forms and follow up with consultants and doctors
for signatures. More importantly, it means our members don’t need to have the money ready at
hand to pay for their procedures and in-patient stay.
Day-to-day expenses claims
There may be an excess, depending on the plan held which members need to reach before they can
make a claim.
To claim all you need to do is retain all your medical receipts from visits to your medical practitioners
and submit them to Vhi Healthcare as often as you like, with a completed and signed ‘Day-to-Day
Expenses’ claim form.
You can download a claim form from www.vhi.ie/downloads or call us on
1890 44 44 44 and we’ll post one to you. It’s as simple as that!
Pricing
n Vhi Healthcare does NOT impose surcharges on any instalment payments.
The price remains the same whether payment is made monthly or yearly.
n The Child rate applies to children under 18 years of age. Student rate applies
to students in full-time education up to 21 or 22 years of age depending
on the plan held.
n Your contract will last for one year, unless we agree to a shorter period.
GenPmiApp4
Application form: to be returned to Vhi Healthcare
o Mr.
o Mrs.
o Miss
o Ms. First name
Surname
Address
Date of birth
Email
Mobile
Home telephone
Group name
Number needed for salary deduction
(If in doubt, contact your Payroll or HR Department)
Chosen plan for policyholder and dependants
FIRST NAME / SURNAME
DATE OF
BIRTH
RELATIONSHIP TICK IF
STUDENT1
COLLEGE1
PPS2
CHOSEN HEALTHCARE PLAN
The Child rate applies to children under 18 years of age. The Student rate applies to students in full-time education up to 21 or 22
years of age depending on the plan held. Please do not send your subscription until notified that your application has been registered.
2
Your PPS number is required for Revenue purposes.
1
If any of the named persons has had Vhi Healthcare cover within the last 12 months, please state policy number.
To be signed by the applicant
I agree to be bound by the *Rules of Vhi Healthcare. I agree to have the subscription deducted from my salary/pension where such
arrangements apply. I declare that to the best of my knowledge and belief the information provided is true and complete.
*Rules will be sent on registration or may be had in advance, where requested.
New Vhi Healthcare customers
We may wish to send you information on other products and services which may be of interest to you.
Please indicate your preferences below:
o I do not wish to be contacted via post by Vhi Healthcare in relation to other products or services.
o I wish to be contacted via phone by Vhi Healthcare in relation to other products or services.
o I wish to be contacted via email or SMS by Vhi Healthcare in relation to other products or services.
Existing Vhi Healthcare customers
Your current communication preferences which we hold on file will apply. If you wish to change these preferences, please contact us
at 1890 44 44 44.
Data Protection
The information which you provide to the Vhi Group (“Vhi”) in this form will be used within the Vhi group of companies for processing
your application and claims, customer services and for the administration of any healthcare related products and services of which you
and any other person on your policy avail. Data may also be used for statistical analyses and the detection and prevention of fraud. We
may share your data with trusted third parties who process data on our behalf, inside and outside of the European Economic Area. We
may also share your data with other insurers to verify your cover, and with state bodies as required by law.
By including your details in this form, you explicitly consent to Vhi processing your details for these purposes. You also confirm that you
have explained to each person who is included on your policy why we may ask for this information and what we will use it for, and that
each person has agreed to this.
You have the right, subject to certain exemptions, to access any personal data that we hold about you (for which we may charge you a
small fee) and to have inaccuracies corrected. If you wish to avail of these rights, please write to the Data Protection Office, Vhi House,
20 Lower Abbey Street, Dublin 1.
Vhi’s Data Protection Statement contains a further detailed breakdown of the personal data we collect in relation to our customers
and how we use that personal data. The Data Protection Statement can be found at www.vhi.ie or should you wish to contact us on
1890 44 44 44, you can request a hard copy.
X Signature
Date
For office use only
S.P.I.N.
Policy no.
GenPmiApp4
Date
Comp. by
Your Details
Vhi membership number
Contact phone number
Email address
Payment preference Monthly o
SEPA Direct Debit Mandate
Yearly o
Creditor Identifier IE46SDD300001
Creditor name: Vhi Healthcare
Creditor address: Vhi House, Lower Abbey Street, Dublin 1
By signing this mandate, you authorise:
(a) Vhi Healthcare to send instructions to your bank/building society to debit your account
(b) Your bank/building society to debit your account in accordance with the instructions from Vhi Healthcare
As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your
agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your
account was debited.
Unique Mandate Reference (UMR) (to be completed by Vhi Healthcare)
Type of payment Recurring ü̈
Customer Details (please complete all required fields, marked below*)
*Name
*Address
*IBAN
*BIC
*Signature(s)
X Signature
Date
X Signature
Date
Your rights regarding this mandate are explained in a statement that you can obtain from your bank. Vhi
Healthcare will notify you at least 7 days in advance of the first direct debit on your account and any time the
amount to be debited changes.
Please send to:
Vhi Healthcare
IDA Business Park
Purcellsinch
Dublin Road
Kilkenny
GenPmiApp4
For office use only
Comp. by
Comp. date
UMR