Health Insurance Act , 1994

PART I Preliminary and General

1. Short title and commencement.

(2)F1[This Act] shall come into operation on such day or days as the Minister shall fix by order or orders either generally or with reference to any particular purpose or provision and different days may be so fixed for different purposes and different provisions.

1A. F2[Principal objective of Minister and Authority in performing respective functions under Act.

1A.—F3[(1)The principal objective of this Act is to ensure that, in the interests of the common good and across the health insurance market, access to health insurance cover is available to consumers of health services with no differentiation made between them (whether effected by risk equalisation credits or stamp duty measures or other measures, or any combination thereof), in particular as regards the costs of health services, based in whole or in part on the health risk status, age or sex of, or frequency of provision of health services to, any such consumers or any class of such consumers, and taking into particular account for the purposes of that objective—

(a)the fact that the health needs of consumers of health services increase as they become less healthy, including as they approach and enter old age,

(b)the desirability of ensuring, in the interests of societal and intergenerational solidarity, and regardless of the health risk status or age of, or frequency of provision of health services to, any particular generation (or part thereof), that the burden of the costs of health services be shared by insured persons by providing for a cost subsidy between the more healthy and the less healthy, including between the young and the old, and, without prejudice to the generality of that objective, in particular that the less healthy, including the old, have access to health insurance cover by means of risk equalisation credits,

(c)the manner in which the health insurance market operates in respect of health insurance contracts, both in relation to individual registered undertakings and across the market, and

(d)the importance of discouraging registered undertakings from engaging in practices, or offering health insurance contracts, whether by segmentation of the health insurance market (by whatever means) or otherwise, which have as their object or effect the favouring of the coverage by the undertakings of the health insurance risk of the more healthy, including the young, over the coverage of the health insurance risk of the less healthy, including the old.]

(2)A registered undertaking shall not engage in a practice, or effect an agreement (including a health insurance contract), which has as its object or effect (whether in whole or in part) the avoidance of the achievement of the principal objectiveF4[…].

(3)Nothing in this section shall affect the operation ofsection 7(5)or7A.]

2. Interpretation.

F5["Act of 2001" means theHealth Insurance (Amendment) Act 2001;]

F6[…]

F7["authorised officer" means a person appointed undersection 18Eto be an authorised officer;]

“the Authority” means the Health Insurance Authority established by section 20;

F8["community rated health insurance contract" means a health insurance contract which complies withsection 7(1)or which would comply with that section but for its falling withinsection 7(5)or7A;

"community rating" means measures which, whether in whole or in part, apply towards the achievement of the principal objectiveF9[…];]

F10["day patient service" means a health service provided in, or by persons attached to, a hospital in the following circumstances—

(a) the patient concerned is admitted on an elective basis for care or treatment or both,

(b) such care or treatment does not require the use of a bed overnight, and

(c) the patient is discharged as scheduled;]

F11["effect", in relation to a health insurance contract or other agreement, means to enter into or renew such contract or agreement, as the case may be;]

“establishment day” means the day appointed under section 19;

F7["frequency of provision of health services" includes history of health insurance claims;]

F12["functions" includes powers and duties and references to the performance of functions include, as respects powers and duties, references to the exercise of the powers and the carrying out of the duties;]

“health benefits undertaking” means a person (including a body established under the laws of a place outside the State) carrying on health insurance business;

“health insurance business” means the business of effecting health insurance contracts;

F13[“health insurance contract" means, without prejudice tosection 2A, a contract of insurance, or any other insurance arrangement, the purpose or one of the purposes of which is to provide for the making of payments by an undertaking, whether or not in conjunction with other payments, specifically for the reimbursement or discharge in whole or in part of fees or charges in respect of the provision of hospital in-patient services or relevant health services, but does not include—

(a) a contract of insurance, or any other insurance arrangement, the sole purpose of which is to provide for the making of payments, directly to the person who effected the contract or entered into the arrangement or to any of the persons named in the contract or the arrangement, by an undertaking in respect of sickness, injury or disease of amounts calculated by reference only to the duration of—

(i) the sickness, injury or disease, or

(ii) the treatment of the sickness, injury or disease,

or

(b) a contract of insurance, or any other insurance arrangement, the sole purpose of which is to provide for the making of payments by an undertaking, to or on behalf of a dependent person (within the meaning of theHealth (Nursing Homes) Act, 1990), in respect of the provision, other than as hospital in-patient services, of nursing care to such a person, or

(c)F14[…]

F15[(d)a contract of insurance, or any other insurance arrangement, the purpose of which is to provide for the making of payments specifically for the reimbursement or discharge of fees or charges in respect of the provision of hospital in-patient services or relevant health services to persons or any dependants of any of them and one of the following conditions is satisfied—

(i)neither the said persons nor any such dependants are ordinarily resident in the State, or

(ii)where any of the persons to whom the said contract or arrangement relates are temporarily resident in the State during the subsistence of the said contract or arrangement—

(I)those persons are so resident solely for the purpose of carrying out their duties as employees, and

(II)those persons constitute not more than—

(A)20 per cent of the total number of persons (other than dependants of them) to whom the said contract or arrangement relates, and

(B)20 of the total number of persons employed in the State by the one person;]]

“health services” means medical, surgical, diagnostic, nursing, dental, chiropody, chiropractic, eye therapy, occupational therapy, physiotherapy or speech therapy services or treatment or services or treatment provided in connection therewith, or similar services or treatment;

F13["hospital in-patient services" means in-patient services within the meaning of theHealth Act, 1970, and includes any day patient service;]

F7["health risk status", in relation to any person (howsoever described), includes—

(a)the present use of, or likely future use of, hospital services by the person,

(b)the sexual orientation of the person, and

(c)the suffering or prospective suffering of the person from a chronic illness or other medical condition or from an illness or medical condition of a particular kind;]

F5["in-patient indemnity payment" means any payment made pursuant to a health insurance contract by a registered undertaking for the purposes of reimbursing or discharging, in whole or in part, fees or charges in respect of the provision of hospital in-patient services.]

F16[“net premium" —

(a)in relation to a health insurance contract effected for a period other than a period commencing on or after 1 January 2013, means the premium payable under the contract in respect of an individual in any year of assessment after—

F17[(i)excluding the effect (if any) on the premium, for that year of assessment, of section 470 of theTaxes Consolidation Act 1997, and]

(ii)the deduction (if any) made from the premium to which the individual is entitled, for that year of assessment, by virtue of section 470B of theTaxes Consolidation Act 1997,

(b)in relation to a health insurance contract effected for a period commencing on or after 1 January 2013, means the premium payable under the contract in respect of an individual in any year of assessment after—

F17[(i)excluding the effect (if any) on the premium, for that year of assessment, of section 470 of theTaxes Consolidation Act 1997, and]

(ii)taking into account the part (if any) of the premium which the individual is entitled not to have collected from the policy holder concerned, for that year of assessment, by virtue ofsection 11C(1);]

“the Minister” means the Minister for Health;

“out-patient services” has the meaning assigned to it by section 56 of the Health Act, 1970;

F13["premium" has the meaning assigned to it by theInsurance Act, 1936, and, in relation to a health insurance contract, includes any payment made to the undertaking concerned in respect of each person party to or named in the contract;]

“prescribed” means prescribed by regulations made by the Minister;

F7["principal objective" means the principal objective specified insection 1A(1);]

“quarter” means a period of three months ending on the 31st day of March, 30th day of June, 30th day of September or 31st day of December;

“registered”, in relation to an undertaking, means registered in the Register and cognate words shall be construed accordingly;

“the Register” means the Register of Health Benefits Undertakings established under section 14;

“the Registrar” means the Registrar and Chief Executive of the Authority;

F10["relevant health services" means out-patient services, general medical practitioner services and services consisting of the supply of drugs or medical preparations;]

“restricted membership undertaking” means an undertaking which effects health insurance contracts with its members and the membership of which is restricted to persons and their dependants of a common vocational, occupational or other group or class;

F9[…]

F7["risk equalisation credits" has the meaning assigned to it bysection 6A(1);]

F7["Risk Equalisation Scheme" shall be construed in accordance withsection 11A;]

F9[…]

“undertaking” means a health benefits F8[undertaking;]

F11["year of assessment" has the same meaning as in section 2 of theTaxes Consolidation Act 1997.]

(2) (a)In this Act a reference to a section or a Schedule is a reference to a section of, or a Schedule to, this Act unless it is indicated that reference to some other enactment is intended.

(b)In this Act a reference to a subsection, paragraph or subparagraph is a reference to a subsection, paragraph or subparagraph of the provision in which the reference occurs unless it is indicated that reference to some other provision is intended.

(c)References in this Act to any enactment or to regulations are to any such enactment or regulations as amended.

F7[(3)In this Act a reference to—

(a)a disease includes a reference to an illness, and

(b)an illness includes a reference to a disease.]

2A.—(1)Subject tosubsections (2) and (3), any arrangement entered into by an employer whereby he or she agrees to reimburse or discharge the whole or a part of fees or charges which have been or may be incurred by an employee, or any dependant of an employee, of the employer in respect of the provision to the employee or such a dependant of hospital in-patient services shall be deemed to be a health insurance contract for the purposes of this Act and, accordingly, an employer who enters into such an arrangement shall be deemed, for the purposes of this Act, to be carrying on a health insurance business.

(2)Subsection (1)does not apply to any arrangement entered into by a Minister of the Government with respect to a person holding office under, or in the service of, the State (including a member of the Defence Forces and a civil servant within the meaning of theCivil Service Regulation Act, 1956) or any dependant of such a person.

(3)Subsection (1)does not apply to any arrangement entered into by an employer whereby he or she agrees to discharge the whole or part of an excess amount payable by an insured person or reimburse, in whole or in part, such a person in respect of the payment by the person of such an amount.

(4)Insubsection (3)—

"excess amount" means an amount (not being an amount that exceeds £100 or such other amount as may be prescribed or that is payable to the insurer) payable in respect of the provision to the insured person, on a distinct occasion, of hospital in-patient services and which amount falls to be paid by the insured person by reason of the operation, and the operation alone, of an excess clause;

"excess clause" means a provision of the contract referred to in the definition of ‘insured person’ in this subsection which provides that an amount of the kind referred to in the preceding definition shall not be payable by the insurer;

"insured person" means an employee, or any dependant of an employee, of the employer, being an employee or dependant who is party to or named in a health insurance contract effected with an undertaking other than the employer;

"insurer" means the undertaking which has effected the contract referred to in the preceding definition.]

3. Regulations.

(a)by regulations provide for any matter referred to in this Act as prescribed or to be prescribed, and

(b)make regulations generally for the purpose of giving effect to this Act and, if in any respect any difficulty arises during the period of two years after the commencement of this section in bringing into operation this Act, by regulations do anything which appears to be necessary or expedient for bringing this Act into operation.

(2)Regulations under this Act may contain such incidental, supplementary and consequential provisions as appear to the Minister F20[(or, in the case of regulations undersection 11E, the Authority)] to be necessary or expedient for the purposes of the regulations.

(3)Every regulation under this Act F21[…] shall be laid before each House of the Oireachtas as soon as may be after it is made and, if a resolution annulling the regulation is passed by either such House within the next 21 days on which that House has sat after the regulation is laid before it, the regulation shall be annulled accordingly, but without prejudice to the validity of anything previously done there-under.

(4) F22[…]

4. F23[Offences.

(a)on summary conviction, to a class A fine or imprisonment for a term not exceeding 12 months or both, or

(b)on conviction on indictment, to a fine or imprisonment for a term not exceeding 5 years or both.

(2)A person who contravenes a provision of a regulation under this Act stated to be a penal regulation shall be guilty of an offence and shall be liable on summary conviction to a class A fine or imprisonment for a term not exceeding 12 months or both.

(3)A person who, after conviction for an offence undersubsection (1)or(2), continues to contravene the provision concerned, shall be guilty of an offence on each day on which the contravention continues and for each such offence shall be liable—

(a)on summary conviction, to a class E fine, or

(b)on conviction on indictment, to a fine not exceeding €50,000.

(4)Where an offence under this Act is committed by a body corporate and it is proved that the offence was committed with the consent or connivance, or was attributable to any wilful neglect, of a person who was a director, manager, secretary or other officer of the body corporate, or a person purporting to act in that capacity, that person, as well as the body corporate, shall be guilty of an offence and may be proceeded against and punished as if he or she were guilty of the first-mentioned offence.

(5)Where the affairs of a body corporate are managed by its members,subsection (4)applies in relation to the acts and defaults of a member in connection with his or her functions of management as if he or she were a director or manager of the body corporate.

(6)The Authority may bring and prosecute summary proceedings for an offence under this Act.

(7)Notwithstanding section 10 (4) of thePetty Sessions (Ireland) Act 1851, summary proceedings for an offence under this Act to which that provision applies may be instituted—

(a)within 12 months from the date on which the offence was committed, or

(b)within 6 months from the date on which evidence sufficient, in the opinion of the person instituting the proceedings, to justify proceedings comes to that person’s knowledge,

whichever is the later, provided that no such proceedings shall be commenced later than 2 years from the date on which the offence concerned was committed.

(8)For the purposes ofsubsection (7)(b), a certificate signed by or on behalf of the person initiating the proceedings as to the date on which evidence referred to in that subsection came to his or her knowledge shall be evidence of that date and, in any legal proceedings, a document purporting to be a certificate under this subsection and to be so signed shall be deemed to be so signed and admitted as evidence without proof of the signature of the person purporting to sign the certificate, unless the contrary is shown.

(9)On convicting a person of an offence under this Act, the court shall unless satisfied that there are special and substantial reasons for not so doing, order the person to pay to the Authority the costs and expenses, measured by the court, incurred by the Authority in relation to the investigation, detection and prosecution of the offence.]

5. Repeals.

6. Expenses.