Knee surgery patient (70s) wakes up to €3,000 bill after change made during procedure

Having and then recovering from surgery is stressful at the best of times but imagine how stressful things must be if you try to do your homework to ensure the operation is covered by your health insurance, only for the procedure to be changed while you’re under anaesthetic and you wake up to a bill for thousands of euro.A man in his 70s from Donegal does not have to imagine how stressful this must be. He knows all too well.The patient did not contact us but his GP – and son – did, expressing concern about the experience his father had and how complicated the health insurance maze is and how it can sometimes work against those it is meant to support. Our reader starts his mail by saying his patient has been hit with a “substantial and entirely unexpected personal liability” following knee replacement surgery at the Galway Clinic earlier this year.READ MOREThe patient in question is in his 70s and had Laya Healthcare’s Simply Connect policy until July 2025, when – doing what Pricewatch is always telling people to do – he shopped around and switched to an Inspire policy offered by the same provider.He was subsequently booked for a partial knee replacement at the Galway Clinic.Now before admission, our reader says, his parents “were specifically concerned to ensure that his planned procedure was covered by his health insurance and, in particular, that they would not face an unexpected co-payment or shortfall. Otherwise they had intended to use the cross-Border scheme”. “They did not,” he stresses “simply assume that the procedure was covered.”So, with his assistance, they sourced the relevant procedure code from the Galway Clinic and checked that code with Laya Healthcare and made enquiries in advance “specifically to establish what financial liability, if any, would arise from the proposed treatment. In fact they did this twice just to be sure.” [ ‘Tipping point’: Why are people giving up their health insurance?Opens in new window ]Our reader says they were not advised that the procedure code could change during surgery and that such a change could result in materially different insurance cover or that the patient could consequently become personally liable for a hospital bill running into thousands of euro.“During the operation, the clinical decision was made to convert the planned partial knee replacement to a full knee replacement,” our correspondent writes. His dad “was, of course, under anaesthetic and plainly had no opportunity at that point to investigate the insurance consequences of this change”.His mother, waiting anxiously for her husband to come round, was also not in a position to make any calls. Following the procedure, which was a success, the couple discovered that the full knee replacement was not covered by their Laya Healthcare policy on the same basis as the partial knee replacement which they had specifically checked in advance. “To add insult to injury it would have been covered on their plan which they changed from six months previously,” their GP son writes. His parents were subsequently presented with a bill from the Galway Clinic in excess of €3,000 which, after some discussion, was reduced to approximately €2,000.[ Skyrocketing costs of private health insuranceOpens in new window ]He says the reduction is welcome but does not address the main issue, which is that his father “is being asked to pay approximately €2,000 as a consequence of a change in procedure which occurred while he was undergoing surgery, despite the fact that he and his wife had taken specific and reasonable steps beforehand to establish whether his treatment was covered.”The bill is unaffordable for the couple and they have been left “extremely distressed by the situation”. They are also facing the prospect of being pursued by a debt collection agency, something that is particularly upsetting for a couple who have spent their lives assiduously paying their bills. Our reader makes it very clear that the central issue “is not whether there was a valid clinical reason to convert the procedure from a partial to a full knee replacement”.The couple, their GP and, indeed, Pricewatch have no reason not to trust the medical professionals who made that call in the operating theatre.The issue, he stresses, is that neither Laya Healthcare nor the Galway Clinic appears to have sufficiently “warned them that this foreseeable change in procedure could fundamentally alter his insurance cover and expose him to a liability of several thousand euro”.He says if a partial knee replacement can reasonably be converted to a full knee replacement during surgery, and the financial consequences under a patient’s insurance policy are materially different, then this is information which should be communicated to the patient before surgery. “Otherwise, what is the practical value to a consumer of obtaining a procedure code and checking it with both the hospital and insurer?”It is wholly unrealistic to expect an elderly patient without specialist knowledge to understand the potential interaction between hospital procedure codes, changes made during an operation, individual policy benefits, hospital accommodation entitlements and co-payments or shortfalls— GPHe points out that the couple “did precisely what responsible consumers are repeatedly advised to do: they checked the proposed treatment in advance. They cannot reasonably be expected to understand the intricacies of hospital coding, procedure codes, insurer schedules of benefits, intra-operative coding changes and the different consequences of a partial versus full joint replacement unless those matters are properly explained to them.”There is another element to this story that has added to the stress of the couple. The patient remained in hospital for an additional night because he wished to receive further physiotherapy before discharge.“At no point when making that decision was he advised that the additional night would not be fully covered by his insurance or that remaining in hospital would create an additional personal financial liability,” their son says. “He remained on the reasonable understanding that his hospital treatment was covered. Had he been told that remaining for the additional night would result in a personal charge or shortfall, he would not have stayed the additional night. A patient cannot give meaningful informed financial consent to an additional hospital charge if the existence of that charge is not disclosed before the patient decides to incur it.”[ Older customers targeted as health insurers cut cover despite 11% rise in premiums - watchdogOpens in new window ]Our correspondent makes it clear that he talked to his parents before the procedure about what they should do when it came to the insurance and he advised them to obtain the procedure code from the Galway Clinic and confirm that code and the associated cover with their health insurer.“They followed that advice,” he writes. He adds that even as a medical professional he finds the “private health insurance market increasingly complex and difficult to navigate. It is wholly unrealistic to expect an elderly patient without specialist knowledge to understand the potential interaction between hospital procedure codes, changes made during an operation, individual policy benefits, hospital accommodation entitlements and co-payments or shortfalls.”He reiterates that the couple “did everything reasonably expected of them before treatment. They sought advice, obtained the procedure code and checked the proposed treatment with the relevant organisations. A consumer who takes those precautions should not wake from surgery to discover that a clinical decision made while they were under anaesthetic has resulted in an unexpected personal liability of several thousand euro.”We sent the details of this story to both Laya Healthcare and to the Galway Clinic.In response, a Laya spokeswoman said the company “appreciate[s] this is a difficult time for this member, and we’ve tried to support our member through it as best we can. A situation like this is rare and given that there has been some confusion, this member will not be asked to pay the outstanding balance. We’ll also be carrying out a full suitability assessment with him, to make sure he’s on the level of cover that’s right for his current and future needs.”She said that “looking back over our records, the member and his family were given clear and accurate information about his cover throughout, including being told when he moved to his current Inspire plan that full knee replacement would carry a 20 per cent shortfall. This was confirmed again ahead of his surgery, when cover was checked using the code for a partial knee replacement, which was confirmed as covered in full.”She said that cover “can vary depending on a member’s scheme and level of cover. It’s our responsibility to be clear with a customer on the suitability of their cover and it’s the member’s responsibility to check what’s covered ahead of a procedure. Checking cover is easy to do, once you have the procedure code. Members can check it themselves in the Member App, or call our team, who can confirm it instantly. In this case, cover was checked and confirmed for a partial knee replacement, but not for the full knee replacement his consultant had told him was a possibility.[ Dip in numbers of consumers with health insurance, watchdog data revealsOpens in new window ]“A partial knee replacement and a full knee replacement are different operations, and a full replacement costs more. Confirming cover for one does not confirm cover for the other, each procedure has its own code and needs to be checked separately. We think that’s likely where the confusion arose here.”She said Laya also “encourage[s] anyone whose consultant has discussed more than one possible procedure to get the code for each option and check cover ahead of surgery for each procedure they might need”.A spokeswoman for the Blackrock Health Galway Clinic said the hospital was “sorry to hear of the concerns raised by the patient and family in this case”.She said it was not possible to “comment on the personal or clinical details of an individual case [but] our standard consent process where applicable includes discussion of the proposed treatment, anticipated outcomes and the possibility that the treatment plan may need to be adjusted in response to clinical findings during the procedure.“We remain committed to engaging constructively with patients and families through our usual patient-experience process. Insurance cover is subject to the terms of the relevant policy/provider. Individual billing/payment matters are addressed directly with patients/companies through the appropriate channels. We cannot comment further on the individual circumstances of this case.”