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16 1994

HEALTH INSURANCE ACT, 1994

PART II

Health Insurance Contracts

Prohibition of non-community rated health insurance contracts.

7. —(1) (a) Subject to subsection (3), the premium payable under any health insurance contract effected by a particular registered undertaking shall be the same as that payable under every other such contract (after due allowance has been made in respect of the payment of any premium by instalments) that—

(i) is effected by that undertaking,

(ii) is in respect of the same period as that to which the first-mentioned contract relates,

(iii) relates to the same health services or ancillary health services as those to which the first-mentioned contract relates, and

(iv) provides for the same payments by the undertaking in respect of those services as those provided for by the first-mentioned contract.

(b) A registered undertaking shall not effect a health insurance contract that contravenes paragraph (a).

(c) A health insurance contract that complies with paragraph (a) shall be known as a community rated health insurance contract and “community rating” shall be construed accordingly.

(2) Without prejudice to the generality of subsection (1), premiums payable under health insurance contracts shall not be varied by reference to—

(a) the age, sex or sexual orientation or the suffering or prospective suffering of a person from a chronic disease, illness or other medical condition or from a disease, illness or medical condition of a particular kind,

(b) the frequency of the provision of health services or ancillary health services to a person, or

(c) the amounts of payments or the number of different payments to which a person becomes entitled under such a contract.

(3) Subsections (1) and (2) of this section do not apply to health insurance contracts if and in so far as they provide for payments in respect of nursing care, whether provided in an institution or otherwise, for persons who are of or over the age of 65 years or are suffering from a prescribed long term illness or disability, other than such care provided in the course of the provision of hospital in-patient services.

(4) Subject to subsections (1) and (2), a premium payable under a health insurance contract effected by a registered undertaking—

(a) shall, in so far as it relates to a person under the age of 18 years, be—

(i) waived, or

(ii) reduced, such a premium being not more than 50 per cent. of the premium in respect of a person other than the persons specified in this subsection under a health insurance contract effected by that undertaking, and

(b) may be reduced in so far as it relates—

(i) to a person who is of or over the age of 18 years and under the age of 21 years, is receiving full time education and is dependent on the person with whom the contract is effected, such a premium being not more than 50 per cent. of the premium in respect of a person other than the persons specified in this subsection under a health insurance contract effected by that undertaking,

(ii) to a person who is a member of a restricted membership undertaking registered on or before the 1st day of January, 1995, and is in receipt of a pension recognised for the purposes of the undertaking, or

(iii) to a person who is a member, for the purposes of health insurance, of a group of persons, such a premium being, if it is reduced, not less than 90 per cent. of the premium in respect of a person other than the persons specified in this subsection under a health insurance contract effected by that undertaking.

Obligation to provide health insurance.

8. —(1) A registered undertaking, other than a restricted membership undertaking, shall not refuse to effect a health insurance contract with or for a person who is under the age of 65 years or such a person and his or her dependants under that age except in such cases (if any) or in such circumstances (if any) as may be prescribed.

(2) A restricted membership undertaking shall not—

(a) impose as a condition of qualification for membership of the undertaking a requirement as to age in relation to a person who is under the age of 65 years,

(b) refuse to admit to membership of the undertaking a person who is under the age of 65 years and is qualified for such membership and requests to be so admitted, or

(c) refuse to effect a health insurance contract with or for such a person as aforesaid or with or for such a person and his or her dependants under the age of 65 years,

except in such cases (if any) or in such circumstances (if any) as may be prescribed.

(3) The Minister may prescribe the maximum waiting periods for eligibility for payment under a health insurance contract which a registered undertaking may impose in respect of the person effecting the contract or his or her dependants and, in particular, but without prejudice to the generality of the foregoing, in respect of a person who—

(a) is of or over the age of 55 years and under the age of 65 years,

(b) is suffering from a medical condition when the contract is effected,

(c) effects such a contract without previously having effected a health insurance contract in the State, or

(d) effects such a contract with that undertaking having previously effected such a contract with the undertaking whether in respect of the same or different services.

(4) (a) Subject to paragraph (b), where a health insurance contract effected by a person with a registered undertaking ceases to be in force for any reason, that or any other registered undertaking shall not refuse to effect another health insurance contract with the person, irrespective of his or her age, in respect of the same services except in such cases (if any) or in such circumstances (if any) as may be prescribed.

(b) A restricted membership undertaking may refuse to effect a health insurance contract with a person referred to in paragraph (a) if the person is not entitled to membership of the undertaking.

(5) Where a health insurance contract effected by a person with a registered undertaking ceases to be in force for any reason and the person effects such a contract with another registered undertaking within such period after such cesser as may be prescribed—

(a) the waiting period for eligibility for any payment to the person under that contract shall not be longer than it would have been if the person had effected the latter contract at the time he or she effected the former contract, and

(b) there shall be deemed to have expired so much of that period as is equal to so much of the like period under the first-mentioned contract as had expired at the time of the cesser aforesaid.

Prohibition of termination of, or refusal to renew, health insurance contracts.

9. —A registered undertaking shall not terminate or (irrespective of whether or not the contract provides for its renewal) refuse to renew a health insurance contract without the consent of the other party to the contract except in such cases (if any) or in such circumstances (if any) as may be prescribed.

Minimum level of health insurance cover.

10. —(1) A health insurance contract effected by a registered undertaking (other than such a contract relating solely to ancillary health services or solely to the public hospital daily in-patient charges made under the Health (In-patient Charges) Regulations, 1987 (S.I. No. 116 of 1987))—

(a) shall relate, at least, to such health services and ancillary health services as may be prescribed, and

(b) in so far as it relates to services prescribed under paragraph (a), shall provide for the payment by the undertaking in respect of those services of amounts that are not less than such amounts as may be prescribed.

(2) The Minister may engage a person whom he or she considers competent and qualified to do so to advise him or her in relation to the performance of the functions of the Minister under this section.

Prohibition of inducements by registered undertakings.

11. —A registered undertaking or a person acting on behalf of such an undertaking shall not—

(a) make or offer to make a payment to a person,

(b) forego or offer to forego a payment or part of a payment from a person,

(c) give or offer to give any goods to a person,

(d) provide or offer to provide any service for a person, or

(e) give or provide or offer to give or provide any other thing of value to or for a person,

as an inducement to the person—

(i) to terminate or not to effect or renew a health insurance contract with that undertaking, or

(ii) (I) to forego a payment to or on behalf of the person in respect of a hospital in-patient service or an ancillary health service under a health insurance contract effected between the undertaking and the person, and

(II) to avail of his or her entitlements under Chapter II of Part IV of the Health Act, 1970 , as respects the service.

Risk equalisation schemes.

12. —(1) The Minister may, if he or she so thinks fit, having regard to the effects or likely effects of the operation of sections 7 to 11 , prescribe a scheme or schemes of risk equalisation (which or each of which shall be known as a risk equalisation scheme and is referred to in this Act as “a scheme”).

(2) (a) A scheme shall apply to each registered undertaking and each such undertaking shall comply with the terms and conditions of the scheme.

(b) Paragraph (a) shall not come into operation as respects a restricted membership undertaking lawfully carrying on health insurance business in the State on the 30th day of June, 1994, before the 30th day of June, 1999.

(3) A scheme may contain such terms and conditions as the Minister considers necessary or expedient and may, without prejudice to the generality of the foregoing, provide for—

(a) the making of payments by registered undertakings to the Authority of such amounts as may be determined by the Authority,

(b) the making of payments by the Authority of such amounts as may be determined by the Authority to such registered undertakings as may be so determined in such manner and by reference to such matters as may be specified in the scheme,

(c) the establishment and maintenance by the Authority of a fund into which all moneys paid to the Authority under the scheme shall be paid and out of which all moneys paid by the Authority under the scheme shall be paid, and

(d) the keeping by the Authority of specified accounts in relation to the scheme and the furnishing of copies of those accounts, as audited by the Comptroller and Auditor General, and copies of the reports of the Comptroller and Auditor General thereon to the Minister at specified times.

(4) (a) A registered undertaking shall, in respect of each quarter or such other period as may be prescribed, make a return to the Authority and, in respect of such periods as aforesaid before the establishment day, to the person engaged under subsection (5) in relation to such matters concerning its health insurance business as may be prescribed.

(b) The first return under paragraph (a) shall be made in respect of such period as may be prescribed.

(c) Returns under paragraph (a) shall be made not later than 60 days after the end of the period to which they relate.

(d) The contents of returns under paragraph (a) shall, in so far as they can be related to individual undertakings, be disclosed only where necessary for the purpose of the functions of the Authority or the person engaged under subsection (5).

(5) (a) The Minister shall engage a person whom he or she considers to be competent and qualified to do so to advise him or her and consult with him or her in relation to the functions of the Minister under this section.

(b) It shall be a function of a person engaged under paragraph (a) to evaluate and analyse returns made to him or her under subsection (4) for the purpose of advising the Minister in relation to the functions of the Minister under this section, including the determination of the question whether regulations should be made under subsection (7).

(6) A payment due by a registered undertaking to the Authority under a scheme may be recovered by it from the undertaking as a simple contract debt in any court of competent jurisdiction.

(7) (a) A scheme under this section shall come into operation on such day (if any) as may be prescribed.

(b) The Minister shall make regulations under paragraph (a) if, but only if, he or she is satisfied that it is necessary to do so having regard to the effects or likely effects of the operation of sections 7 to 11 .

Advertising and promotion of health insurance business.

13. —The Minister may, if he considers it appropriate to do so for the purpose of ensuring that any advertising or promotion of health insurance business is accurate and truthful, is not misleading or exaggerated and does not convey an impression that is false, misleading, inaccurate or exaggerated, make regulations providing for the control and regulation of such advertising and promotion.