HEALTH INSURANCE ACT, 1994

AN ACT TO REGULATE FURTHER, IN THE INTERESTS OF THE COMMON GOOD, THE PROVISION OF VOLUNTARY HEALTH INSURANCE SO AS TO PROVIDE, INTER ALIA, FOR THE ESTABLISHMENT OF THE HEALTH INSURANCE AUTHORITY, FOR THE ESTABLISHMENT OF SCHEMES FOR THE EQUALISATION OF RISKS BETWEEN HEALTH BENEFITS UNDERTAKINGS, FOR A MINIMUM RANGE OF COVER UNDER SUCH INSURANCE, FOR UNIFORMITY OF THE PREMIUMS CHARGED BY EACH PARTICULAR SUCH UNDERTAKING IN RESPECT OF SPECIFIED RANGES OF SUCH COVER AND FOR THE ESTABLISHMENT OF A REGISTER OF SUCH UNDERTAKINGS AND TO PROVIDE FOR RELATED MATTERS. [30th June, 1994]

BE IT ENACTED BY THE OIREACHTAS AS FOLLOWS:

PART I Preliminary and General

1. Short title and commencement.

1. — (1) This Act may be cited as the Health Insurance Act, 1994.

• (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 objective F4[…].

• (3) Nothing in this section shall affect the operation of section 7(5) or 7A.]

2. Interpretation.

2. — (1) In this Act, save where the context otherwise requires—

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

F6[…]

F7["authorised officer" means a person appointed under section 18E to 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 with section 7(1) or which would comply with that section but for its falling within section 7(5) or 7A;

"community rating" means measures which, whether in whole or in part, apply towards the achievement of the principal objective F9[…];]

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 to section 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 the Health (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 the Health 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 the Taxes 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 the Taxes 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 the Taxes 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 of section 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 the Insurance 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 in section 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 by section 6A(1);]

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

  F9[…]

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

  F11["year of assessment" has the same meaning as in section 2 of the Taxes 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.]

F18[Certain arrangements by employers to constitute health insurance contracts.

2A. — (1) Subject to subsections (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 the Civil 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) In subsection (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.

3. — (1) The Minister may—

• (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 under section 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.

4. — (1) A person who contravenes a provision of this Act shall be guilty of an offence and shall be liable—

• (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 under subsection (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 the Petty 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 of subsection (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.

5. — Sections 22, 23 and 24 of the Voluntary Health Insurance Act, 1957, are hereby repealed.

6. Expenses.

6. — Any expenses incurred by the Minister in the administration of this Act shall, to such extent as may be approved by the Minister for Finance, be paid out of moneys provided by the Oireachtas.

PART II Health Insurance Contracts

6A. F24[Interpretation of Part II.

F25[6A. — (1)In this Part and Schedules 3 and 4—

"advanced cover" shall be construed in accordance with section 11E(4);

"age group" means age group as prescribed in regulations made under section 7D, and includes any age group, whether or not by reference to any one or more of the following:

• (a) being less than a specified age;

• (b) being of a specified age or over such age but under another specified age; or

• (c) being of a specified age or over such age;

"age-related tax credit" has the same meaning as in section 470B(4) of the Taxes Consolidation Act 1997;

"approved accounting standards" means accounting standards which are in accordance with generally accepted accounting principles in the State;

"changed existing contract" has the meaning assigned to it by F26[section 7AB(2)];

"cumulative net financial impact", in relation to a registered undertaking or former registered undertaking which has furnished the Authority with information under section 7F(1) in respect of a period, means the difference between—

• (a) the total amount of the age-related tax credits and risk equalisation credits recorded in accounts for that undertaking in respect of that period as extracted from that information by the undertaking in respect of that period, and

• (b) the total amount of the stamp duty referred to in section 125A of the Stamp Duties Consolidation Act 1999 recorded in accounts for that undertaking in respect of that period as extracted from that information by the undertaking in respect of that period;

"draft report" has the meaning assigned to it by section 7F(7);

"Fund" means the Risk Equalisation Fund established under section 11D;

F27["Health Service Executive approved drugs" means—

• (a) drugs which are included in one or more of the following lists:

• (i) the Reimbursement List established and published by the Health Service Executive under section 17 of the Health (Pricing and Supply of Medical Goods) Act 2013;

• (ii) the list maintained by the Health Service Executive under the programme commonly known as the National Cancer Control Programme;

• (iii) the list maintained by the Health Service Executive under the programme commonly known as the HSE Access and Integration Drug Management Programme (formerly known as the Acute Hospitals Drugs Management Programme);

• (iv) the list maintained by the Health Service Executive under the programme commonly known as the HSE Medicines Management Programme,

• (b) drugs which—

• (i) are normal human immunoglobulin products assigned the code J06BA under the Anatomical Therapeutic Chemical classification system established by the World Health Organisation, and

• (ii) were granted a marketing authorisation (within the meaning of Regulation 3(1) of the Medicinal Products (Control of Manufacture) Regulations 2007 (S.I. No. 539 of 2007)) prior to the commencement of section 17 of the Health (Pricing and Supply of Medical Goods) Act 2013,

or

• (c) drugs which have been approved for reimbursement or funding through the public health system by the Health Service Executive having regard to the criteria set out in Part 3 of Schedule 3 to the Health (Pricing and Supply of Medical Goods) Act 2013;]

F28[F29["high cost claim" means a claim, or more than one claim, arising in any period of 12 months prescribed for that purpose relating to an insured person under a health insurance contract or contracts effected by the same registered undertaking—

• (a) the amount, or the cumulative amount, of which claim or claims, as the case may be, exceeds the high cost claim threshold, and

• (b) which has or have been paid by the undertaking,

other than a claim for the cost of drugs that are not Health Service Executive approved drugs;]

"high cost claim credit" means the amount that is equal to the high cost claim quota share multiplied by the amount by which the high cost claim exceeds the high cost claim threshold;

"high cost claim quota share" means the percentage that is specified in paragraph 2 of Schedule 5 as the high cost claim quota share, being the portion of a high cost claim in excess of the high cost claim threshold payable from the Fund as a high cost claim credit;

"high cost claim threshold", in relation to a high cost claim, means the sum of the following amounts:

• (a) the amount that is specified in paragraph 1 of Schedule 5, and

• (b) the amount (if any) of any other risk equalisation credits (other than high cost claim credits) claimed from the Fund relating to the insured person under a health insurance contract or contracts arising in the period of 12 months to which the high cost claim relates;]

F30["hospital utilisation credit" means the relevant amount payable from the Fund in respect of each hospital stay (whether on an overnight accommodation or day case basis) in private hospital accommodation, on or after 31 March 2013 if the stay is on an overnight accommodation basis and on or after 1 March 2016 if the stay is on an overnight accommodation or day case basis, by a person who is an insured person under a health insurance contract effected for any period commencing on or after the date concerned;]

"information return" means an information return referred to in section 7D(1);

"non-advanced cover" shall be construed in accordance with section 11E(4);

"positive", in relation to the cumulative net financial impact on a registered undertaking or former registered undertaking which has submitted one or more information returns to the Authority in respect of a period, means that, for that period and that undertaking, the amount specified in paragraph (a) of the definition of "cumulative net financial impact" in this subsection exceeds the amount specified in paragraph (b) of that definition;

F30[ "private hospital accommodation" means—

• (a) accommodation in a private hospital, whether or not in a hospital bed, or

• (b) accommodation in a publicly funded hospital where a charge is payable under section 55 of the Health Act 1970;]

"relevant amount", in relation to the definition of F31["hospital utilisation credit"] in this section and an insured person referred to in that definition, means the lower of the following:

• F30[(a) the amount concerned specified in Schedule 3 for the purposes of that definition multiplied by the number of nights on an overnight accommodation basis, or, as applicable, the number of days on a day case basis, that the insured person stayed in private hospital accommodation which fall within the hospital stay concerned referred to in that definition F28[but only if that number of nights’ or days’ accommodation were paid under the health insurance contract concerned];]

• (b) the sum of all benefits paid under the health insurance contract concerned referred to in that definition in respect of hospital in-patient services provided during the hospital stay concerned referred to in that definition of the insured person;

"relevant contract" has the meaning assigned to it by section 125A(1) of the Stamp Duties Consolidation Act 1999;

"relevant contract (advanced cover)" means a relevant contract which is not a relevant contract (non-advanced cover);

"relevant contract (non-advanced cover)" means a relevant contract which falls within a type of relevant contract specified in regulations under section 11E as a type of relevant contract in respect of which the Authority is satisfied under that section that it does not provide for advanced cover;

"relevant financial provisions" means—

• (a) the Risk Equalisation Scheme,

• (b) section 125A of the Stamp Duties Consolidation Act 1999, or

• (c) section 470B of the Taxes Consolidation Act 1997,

or any combination of any of the Risk Equalisation Scheme (including any constituent provision of the Scheme) and any section referred to in paragraph (b) or (c);

"relevant market sector", in relation to information returns made to the Authority for any period of 6 months referred to in section 7D(1), means all the registered undertakings or former registered undertakings which have made those returns;

"relevant period" has the meaning assigned to it by section 7D(1)(b);

"risk equalisation credits"—

• (a) in relation to an individual insured under a health insurance contract effected by a registered undertaking for any period commencing on or after 1 January 2013, means—

• (i) the payment from the Fund to the undertaking on behalf of the individual of any F31[hospital utilisation credits] which the individual is entitled to have so paid, F32[…]

• F28[(ia) the payment from the Fund to the undertaking on behalf of the individual of any high cost claim credits which the individual is entitled to have so paid, and]

• (ii) the payment from the Fund of the part (if any) of the premium payable under the contract which the individual is entitled to have so paid by virtue of section 11C(1),

and

• (b) in relation to such undertaking and such contract, means—

• (i) the amount of the F31[hospital utilisation credit] (if any) referred to in paragraph (a)(i), F32[…]

• F28[(ia) the amount of the high cost claim credits (if any) referred to in paragraph (a)(ia), and]

• (ii) the amount of the part (if any) of the premium payable referred to in paragraph (a)(ii) that it has not collected from the policy holder by virtue of section 11C(1);

"type of cover" means a specific health insurance contract which provides for the payment of prescribed benefits where either—

• (a) the particulars relating to the contract are contained in The Register of Health Insurance Contracts, or

• (b) the particulars relating to the contract were once contained in that Register but, notwithstanding that such particulars are no longer contained in that Register, prescribed benefits are still payable under the contract.

• (2) F33[…]]]

6B. F34[Duration of entrustment act

6B. — (1) The entrustment act shall endure until the relevant date whereupon it shall cease to be in force.

• (2) The Minister may, after consultation with the European Commission and the Minister for Finance and having regard, if such be the case, of the need to continue the Risk Equalisation Scheme for the purposes of assisting in the achievement of the principal objective and of the period for which the Scheme needs to so continue, make an order specifying a date for the purposes of paragraph (b) of the definition of "relevant date".

• (3) An order made under subsection (2) shall be laid before each House of the Oireachtas as soon as may be after it is made and, if a resolution annulling the order is passed by either such House within the next 21 days on which the House sits after the order is laid before it, the order shall be annulled accordingly, but without prejudice to the validity of anything previously done thereunder.

• (4) In this section—

"entrustment act", in relation to paragraph 15 of the European Union framework for State aid in the form of public service compensation (2011) (2012/C 8/03)1 , means—

• (a) this Part, and

• (b) section 125A of the Stamp Duties Consolidation Act 1999 ;

"relevant date" means—

• (a) subject to paragraph (b), 31 March 2027, or

• (b) the later date (if any) specified for the purposes of this paragraph in the last order made under subsection (2).]

7. F35[Prohibition of non-community rated health insurance contracts.

7. — (1) Subject to subsection (5) and section 7A—

• (a) a registered undertaking shall not make an offer to effect a health insurance contract of a particular type—

• (i) unless the offer is maintained—

• (I) for a period of not less than F36[60] consecutive days commencing on the day on which the offer is first made, and

• (II) throughout that period on the same terms and conditions on which the offer is first made,

and

• (ii) unless the offer is to effect that contract for a period of 12 consecutive months except that the offer may be to effect the contract for a shorter or longer period if, and only if—

• (I) in all the circumstances of the case, there is good and sufficient reason for doing so, and

• (II) the entering into of the contract by the undertaking does not in any way prejudice the achievement of the principal objective, F37[…]

and

• (b) the net premium payable for each insured person 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 net 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 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.

• (2) A registered undertaking shall not contravene subsection (1).

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

• F36[(a) the health risk status, age or sex of, or frequency of provision of health services to, a person, or]

• (b) F37[…]

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

• (4) Subject to subsection (6), the amounts of the payments provided by a health insurance contract in respect of the health services to which it relates shall not be varied by reference to the age, sex or sexual orientation of the person to whom those services are provided.

• (5) Notwithstanding subsections (1) to (3), a net 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 net premium being not more than 50 per cent of the net 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—

• F38[(i) (I) to a person who is of or over the age of 18 years and under the age of 21 years, such a net premium being not more than 50 per cent of the net 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 of or over the age of 21 years and under the age of 22 years, such a net premium being not less than 51 per cent and not more than 60 per cent of the net premium in respect of a person other than the persons specified in this subsection under a health insurance contract effected by that undertaking,

• (III) to a person who is of or over the age of 22 years and under the age of 23 years, such a net premium being not less than 61 per cent and not more than 70 per cent of the net premium in respect of a person other than the persons specified in this subsection under a health insurance contract effected by that undertaking,

• (IV) to a person who is of or over the age of 23 years and under the age of 24 years, such a net premium being not less than 71 per cent and not more than 80 per cent of the net premium in respect of a person other than the persons specified in this subsection under a health insurance contract effected by that undertaking,

• (V) to a person who is of or over the age of 24 years and under the age of 25 years, such a net premium being not less than 81 per cent and not more than 90 per cent of the net premium in respect of a person other than the persons specified in this subsection under a health insurance contract effected by that undertaking, and

• (VI) to a person who is of or over the age of 25 years and under the age of 26 years, such a net premium being not less than 91 per cent and not more than 100 per cent of the net 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 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 net premium being, if it is reduced, not less than 90 per cent of the net premium in respect of a person other than the persons specified in this subsection under a health insurance contract effected by that undertaking.

• F39[(5A) Where a registered undertaking proposes to reduce the net premium payable in the manner provided by subsection (5)(b)(i), it shall do so in relation to all classes of persons referred to in clauses (I) to (VI) of that subsection in the manner provided in those clauses.]

• (6) Where any person named in a health insurance contract effected by a registered undertaking—

• (a) is the spouse, a child or a dependent of a party to the contract, or

• (b) is the spouse, a child or a dependent of another person named in the contract,

then the undertaking may aggregate or combine, as it thinks fit, claims in respect of health services, other than in-patient services, for the purposes of calculating payments, other than in-patient indemnity payments, to be made by it pursuant to the contract.]

7A. F40[Premiums which may be charged under health insurance contracts in certain circumstances.

7A. — F41[(1) In this section, "insured person" means any person, other than the registered undertaking, who—

• (a) is party to or named in the health insurance contract concerned (other than a health insurance contract of a type referred to in section 10(3)), and

• (b) is of or over the age of 30 years.]

• F41[(2) F42[Notwithstanding section 7, but subject to subsections (2A) and (3), a registered undertaking shall require,] on account of any of the circumstances referred to in paragraph (a), (b), (c), (cc) or (d) of subsection (4), the payment under a health insurance contract of a net premium the amount of which is greater than that of the net premium (in this section referred to as the "unadjusted net premium") which could have been required to be paid if this section had not been enacted.

F43[(2A)(a) Subject to paragraph (b), a registered undertaking shall ensure that any requirement it has made under subsection (2) is not withdrawn and otherwise continues to have effect.

• (b) A registered undertaking shall ensure that any requirement it has made under subsection (2) is withdrawn and otherwise does not continue to have effect in relation to an insured person who has, since 1 May 2015—

• (i) a continuous period of cover of not less than 10 years, or

• (ii) 2 or more continuous periods of cover totalling not less than 10 years.

• (c) In this subsection, "continuous period of cover" shall be construed in accordance with the Health Insurance Act 1994 (Determination of Relevant Increase under section 7A and Provision of Information under section 7B) Regulations 2014 (S.I. No. 312 of 2014).]]

F42[(3)Any obligation to require the payment of such greater amount is subject to regulations under subsection (6) (whether made before, on or after the commencement of section 3 of the Health Insurance (Amendment) Act 2014).]

• (4) The following are the circumstances mentioned in subsection (2)—

• (a) the insured person has not previously effected or been named in a health insurance contract with the registered undertaking concerned or any other undertaking,

• F44[(b) the insured person has previously effected or been named in a health insurance contract with a restricted membership undertaking.]

• (c) in the period of the F41[13 weeks] preceding the date on which the registered undertaking concerned was requested to effect the health insurance contract (not being a contract that falls within paragraph (b)) no health insurance contract was in force to which the insured person was a party or in which he or she was named,

• F45[(cc) in the period of the 13 weeks preceding the date on which the registered undertaking concerned was requested to effect the health insurance contract, a health insurance contract was in force in respect of which the insured person was a party to or named in the contract and in respect of whom any registered undertaking providing that contract could have required the payment of a net premium that was greater than the unadjusted premium,]

• (d) the following conditions are complied with in relation to the health insurance contract concerned—

• (i) the contract provides more favourable terms to the insured person (whether in respect of the health services to which the contract relates or the nature or the amounts of the payments to be made by the registered undertaking concerned in respect of those services) than those provided to the insured person in the contract prior to its being renewed or, as the case may be, than those provided to the insured person in the health insurance contract lastly effected with another undertaking to which the insured person was a party or in which he or she was named,

• (ii) the provision of those more favourable terms has been made at the request of the insured person.

• (5) The difference between the amount of the F41[net premium] which a registered undertaking requires to be paid by virtue of this section and the amount of the F41[unadjusted net premium] is referred to in this section as the "relevant increase".

• (6) The Minister may by regulations provide that the amount of the relevant increase—

• (a) shall be determined by the registered undertaking concerned in a manner specified in the regulations (in subsection (7) referred to as the "relevant method"),

• (b) shall not, in any case, be greater than such percentage as is specified in the regulations of the amount of the F41[unadjusted net premium].

• (7) Regulations under subsection (6) may—

• (a) specify a different relevant method or a different percentage of the amount of the F41[unadjusted net premium] by reference to—

• (i) the different circumstances referred to in paragraphs (a) to (d) of subsection (4) on account of which the relevant increase is required to be paid,

• (ii) different cases involving any of those circumstances that may occur,

• (b) require that the registered undertaking concerned, in determining the amount of the relevant increase, take into account, to the extent and in the manner specified in the regulations, any previous period or periods during which the insured person was a party to or named in a health insurance contract effected with that or any F43[other registered undertaking,]]

F46[(c) require that the registered undertaking concerned, in determining the amount of any relevant increase, take into account, to the extent and subject to any conditions specified in the regulations—

• (i) in respect of a person who has been an insured person for a period of not less than 3 years, any period or periods (each of which period is not less than 6 months) totalling not more than 3 years where, during that period or periods, the insured person concerned ceased to be an insured person for the purposes of this section,

• (ii) in respect of a person who has resided outside the State for a period of not less than 6 months, the period during which that person so resided, provided he or she becomes an insured person within a prescribed period of ceasing to reside outside the State,

• (iii) in respect of a person who was formerly a member of the Permanent Defence Force, the period during which he or she was such member, provided he or she becomes an insured person within the prescribed period of ceasing to be such member,

• (iv) in respect of a person who resides in the State and is insured under the Joint Sickness Insurance Scheme of the European Institutions, the period during which he or she has been a member of that scheme.]

7AB. F47[Submission of new type of health insurance contract and furnishing of certain other types of health insurance contract to Authority.

F48[7AB. — (1) A registered undertaking shall not offer in the State a new type of health insurance contract (and regardless of whether the contract is already offered outside the State by the undertaking or any other person) unless it has submitted a sample of the contract to the Authority not later than 30 days before first making such offer.

• (2) Subject to subsection (3), a registered undertaking shall not change in any material particular the benefits payable under a type of health insurance contract that it offers in the State unless it has submitted a sample of the contract as so changed (in this Act referred to as a "changed existing contract") to the Authority not later than 30 days before first making such change.

F49[(3)(a) A registered undertaking shall not in any calendar year change the benefits payable under a type of relevant contract (non-advanced cover) that it offers in the State such that it becomes a type of relevant contract (advanced cover) except—

• (i) in the case of a calendar year before 1 January 2017, with effect from 1 March of that calendar year, and

• (ii) in the case of the calendar year 2017 and any subsequent calendar year, with effect from 1 April of each such calendar year.

• (b) A registered undertaking shall not in any calendar year change the benefits payable under a type of relevant contract (advanced cover) that it offers in the State such that it becomes a type of relevant contract (non-advanced cover) except—

• (i) in the case of a calendar year before 1 January 2017, with effect from 1 March of that calendar year, and

• (ii) in the case of the calendar year 2017 and any subsequent calendar year, with effect from 1 April of each such calendar year.]

• (4) Without prejudice to section 7(1)(a), a registered undertaking may vary the premium payable for effecting a type of health insurance contract if it gives notice in writing of the variation to the Authority not less than 30 days before the variation takes effect.

• (5) Notwithstanding subsection (1), a registered undertaking which has made an offer in the State to effect a health insurance contract of a particular type and which has maintained the offer for not less than the 60 consecutive days required by section 7(1)(a)(i)(I) may cease to make that offer in the State if it gives notice in writing of the cesser to the Authority not less than 30 days before the cesser takes effect.

• (6) Without prejudice to the operation of subsection (5), the notice in writing required to be given to the Authority under that subsection by a registered undertaking in respect of a cesser referred to in that subsection may be given before the expiration of the 60 consecutive days referred to in that subsection.

• (7) Nothing in subsections (2) to (6) shall be construed to prejudice a health insurance contract of the type referred to in subsection (5) effected before the cesser referred to in subsection (5) takes effect and, accordingly, the contract continues in being in accordance with the terms and conditions on which it was effected.]]

7AC. F50[Register of Health Insurance Contracts.

7AC. — (1) The Authority shall, as soon as may be after the commencement of section 8 of the Health Insurance (Miscellaneous Provisions) Act 2009, establish and maintain a register to be known as The Register of Health Insurance Contracts.

• (2) F51[Subject to section 11E, The Register] of Health Insurance Contracts shall be in such form and shall contain such particulars relating to any type of health insurance contract on offer in the State on or after the establishment of the Register as may be specified by the Authority.

• (3) The Authority shall ensure that the contents of The Register of Health Insurance Contracts are available for inspection by members of the public free of charge at the office of the Authority during normal working hours.

• (4) The Authority may make the contents of The Register of Health Insurance Contracts available for inspection by members of the public free of charge on the Authority’s website.]

7B. F52[Provision of information.

7B. — (1) In this section—

"any insured person concerned" means any person who is a party to or named in the health insurance contract referred to in subsection (3) (other than the requester);

"the first-mentioned undertaking" shall be construed in accordance with subsection (2);

"the requester" shall be construed in accordance with subsection (2).

• (2) The Minister may by regulations require each registered undertaking ("the first-mentioned undertaking") to furnish to another registered undertaking ("the requester"), if—

• (a) the requester needs the statement for the purposes referred to in subsection (3),

• (b) the requester makes a request for the statement, and

• (c) the information concerned is in the possession of, or may reasonably be procured by, the first-mentioned undertaking, a statement in writing of—

• (i) the period or periods during which any insured person concerned was a party to or named in a health insurance contract effected with the first-mentioned undertaking,

• (ii) unless a statement of this matter would fall to be provided under subparagraph (iii), the extent to which the first-mentioned undertaking could have been required to discharge or pay fees or charges in relation to hospital accommodation under the health insurance contract lastly effected by it, being a contract to or in which any insured person concerned was a party or named,

• (iii) in respect of each (if any) health insurance contract effected by the first-mentioned undertaking, being a contract to or in which any insured person concerned was a party or named and under which the undertaking required or could have required the payment of a premium of an amount referred to in section 7A(2), the extent to which the undertaking could have been required under that contract to discharge or pay fees or charges in relation to hospital accommodation, and

• (iv) such other matters as may be prescribed for the purpose of facilitating compliance by the requester with section 7A.

• (3) The purposes mentioned in subsection (2) are the determination by the requester of the amount of the relevant increase (within the meaning of section 7A) it proposes to require a person to pay to it under a health insurance contract to be effected or effected by it with that person.]

7C. F53[Registered insurers shall make all reasonable efforts to obtain certain information in respect of insured persons, etc.

7C. — (1) A registered undertaking shall, in respect of each health insurance contract that provides for the making of in-patient indemnity payments and that is effected by it on or after 1 January 2009, make all reasonable efforts to obtain the relevant information in respect of each insured person.

• (2) A registered undertaking may, for the purposes of obtaining, in respect of a health insurance contract referred to in subsection (1), the relevant information in respect of each insured person, request in writing the policy holder to furnish the undertaking with the relevant information in respect of each insured person not later than 30 days from the date of receipt of the request.

• (3) A request under subsection (2) shall be accompanied by a copy of this section.

• (4) The policy holder, the subject of a request under subsection (2), shall comply with that request.

• (5) A registered undertaking which has obtained relevant information for the purposes of subsection (1) shall not make use of, or disclose, the relevant information except—

• (a) for the purposes of making a claim referred to in section 470(3)(b)(ii) or 470B(6)(b)(ii) of the Taxes Consolidation F54[Act 1997,]

• F55[(aa) for the purposes of making a claim referred to in section 11C(2), or]

• (b) for the purposes of complying with section 125A of the Stamp Duties Consolidation Act 1999.

• (6) In this section, " relevant information ", in relation to an insured person, means—

• (a) the name of the person,

• (b) the sex of the person,

• (c) the date of birth of the person, and

• (d) the Personal Public Service Number (within the meaning of section 262 of the Social Welfare Consolidation Act 2005) of the person.]

7D. F56[Obligation to make information returns to Authority.

7D. — (1) A registered undertaking or former registered undertaking to which this subsection applies by virtue of subsection (4) shall, not later than 30 days (or such longer period as the Authority may permit in its discretion) after the expiration of each period of 6 months, the first such 6 months period commencing on 1 January 2009, make an information return to the Authority—

• (a) in such form as may be prescribed, and

• (b) subject to subsections (2) and (5), containing such information concerning the undertaking’s health insurance business or former health insurance business, as the case may be, during the period of 6 months concerned (in this Part referred to as the "relevant period") as may be prescribed.

• (2) Subject to F58[subsections (5) and (6)], the information referred to in subsection (1) which may be prescribed includes—

• (a) the total number of persons insured, or a class thereof, with the registered undertaking or former registered undertaking concerned during the relevant period,

• F57[(b) the total number of persons insured, or a class thereof, in each age group, the gender profile of each age group, and the type of cover of each age group, in respect of the relevant period,]

• (c) the total number of persons in each age group, or a class thereof, effecting health insurance contracts during the relevant period,

• (d) the in-patient indemnity payments, or a class thereof, made by the registered undertaking or former registered undertaking concerned during the relevant period,

• (e) information relating to the health insurance services provided during the relevant period, and

• (f) such other information relating to the relevant period, other than personal data, which may reasonably be considered to be information which will enable or assist the Minister or the Authority to perform their respective functions under this Act.

• (3) The information concerning a registered undertaking’s or former registered undertaking’s health insurance business or former health insurance business, as the case may be, to be contained in an information return may include information that came into existence before the enactment of this section.

• (4) Subsection (1) applies to each undertaking that was a registered undertaking, but not a restricted membership undertaking, for all, or any part of, the period of 6 months concerned.

• (5) The references in subsection (1) to health insurance business and former health insurance business shall not include so much of any such business which is comprised of health insurance contracts to which the relevant financial provisions do not apply, and the references to information in that subsection and subsection (2) shall be construed accordingly.]

F59[(6)(a) Where the benefits payable under a type of cover to which an information return relates have materially changed, regulations made under this section may require a registered undertaking or former registered undertaking to which subsection (1) applies to make separate information returns in respect of each material level of benefit.

• (b) Regulations made under this section may require a registered undertaking or former registered undertaking to which subsection (1) applies to make separate information returns in respect of the sum of all types of cover to which an information return relates.]

7E. F60[Evaluation and analysis of information returns, etc.

7E. — (1) The Authority shall, for the purposes of enabling the Minister to perform his or her functions under this Act or of enabling or assisting it to perform its functions under this Act—

• (a) evaluate and analyse all information returns made to it F61[together with such other information relevant to those purposes as it considers appropriate,] and, without limiting the generality of the foregoing, having particular regard to—

• F62[(i) the average insurance claim payment per insured person made by the relevant market sector during the relevant periods in respect of the total number of persons insured, or a class thereof, during the relevant periods,

• (ii) the average insurance claim payment per insured person made by the relevant market sector during the relevant periods in respect of subgroups of the total number of persons insured, or a class thereof, during the relevant periods, where such subgroups include such combinations of the following groups of insured persons as the Authority determines to be relevant:

• (I) those in different age groups;

• (II) those of differing sex;

• (III) those with differing types of cover,

• (iii) the F63[hospital utilisation] in respect of each group and subgroup referred to in subparagraphs (i) and (ii), and (iv) the net financial impact on each registered undertaking or former registered undertaking of the relevant financial provisions during the relevant periods, and

• (iv) the net financial impact on each registered undertaking or former registered undertaking of the relevant financial provisions during the relevant periods, and]

• (v) F64[…]

• (b) as soon as may be after the end of each 6 months period, 12 months period, or longer period, as specified by the Minister by notice in writing given to the Authority (in this paragraph referred to as the "specified period"), prepare and furnish to the Minister a report in relation to—

• (i) such evaluation and analysis in respect of the information returns which relate to the F63[specified period (taking into account the objective specified in subparagraph (iii)(II))] F61[and in respect of the other information referred to in paragraph (a)],

• (ii) such matters concerning the carrying on of health insurance business and developments in relation to health insurance generally that the Authority considers ought to be brought to the attention of the Minister (including information in relation to the profitability of any registered undertaking or former registered undertaking where the operation of the relevant financial provisions is expected to result in a positive cumulative net financial impact on the undertaking),

• F63[(iii) (I) subject to subsection (1A), the amounts of the risk equalisation credits that the Authority considers, after having regard to such evaluation and analysis, would need to be afforded, under the Risk Equalisation Scheme, to persons insured by registered undertakings (other than restricted membership undertakings) having regard to the principal objective (in so far as the principal objective relates to relevant contracts), the aim of avoiding overcompensation being made to a registered undertaking or former registered undertaking under the operation of the relevant financial provisions (other than section 470B of the Taxes Consolidation Act 1997), the aim of maintaining the sustainability of the health insurance market and the aim of having fair and open competition in the health insurance market, and

• (II) the objective that the projected net average insurance claim payment per insured person for a relevant age group of insured persons for any period of 12 consecutive months duration should be not less than 125 per cent of the projected net average insurance claim payment per insured person for all age groups of insured persons for that same period, and]

• (iv) if the amounts referred to in subparagraph (iii) were given effect by a statutory provision, the amount of the stamp duty that the Authority considers F65[, after having regard to the aim of avoiding the Fund sustaining surpluses or deficits from year to year (as calculated using approved accounting standards)] would need to be paid, pursuant to section 125A of the Stamp Duties Consolidation Act 1999, by registered undertakings (other than restricted membership undertakings) in respect of the persons insured by them in order to meet the cost to the F66[Fund] of the total of the amounts referred to in subparagraph (iii).

• F67[(1A) The Minister may, by notice in writing given to the Authority, require the Authority to prepare any report to be furnished to him or her pursuant to paragraph (b) of subsection (1), in so far as the report relates to subparagraph (iii) of that paragraph—

• (a) in the case of F69[hospital utilisation credit], on the basis of the amount specified in the notice or on the basis of the amount specified in Schedule 3 or both,

• (b) on the basis of the classes of insured person specified in the notice or on the basis of the classes of insured person specified in column 1 of Table 2 F70[set out in Schedule 4 or both, or]

F71[(c) in the case of high cost claims, on the basis of the amount and percentage specified in the notice or on the basis of the amount and percentage specified in Schedule 5 or both.]]

• F67[(2) The Minister shall—

• (a) first, after having regard to—

• (i) the principal objective (in so far as the principal objective relates to relevant contracts),

• (ii) any report furnished to him or her pursuant to subsection (1)(b),

• (iii) the aim of avoiding overcompensation being made to a registered undertaking or former registered undertaking under the operation of the relevant financial provisions (other than section 470B of the Taxes Consolidation Act 1997),

• (iv) the aim of maintaining the sustainability of the health insurance market,

• (v) the aim of having fair and open competition in the health insurance F72[market,]

• (vi) the aim of avoiding the Fund sustaining surpluses or deficits from year to year (as calculated using approved accounting F72[standards), and ]

• F73[(vii) the objective specified in subsection (1)(b)(iii)(II),]

• (b) second, after taking into account the amendments (if any) that he or she wishes to propose to the relevant financial provisions (other than section 470B of the Taxes Consolidation Act 1997) in view of the regard given the matters referred to in paragraph (a) (and whether or not those amendments accord with any matter set out in the report referred to in paragraph (a)(iii)), and

• (c) third, after consultation with the Minister for Finance on the amendments (if any) referred to in paragraph (b),

make such recommendations to the Minister for Finance relating to section 125A of the Stamp Duties Consolidation Act 1999 as the Minister considers appropriate.].

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

• F73[(4) In this section—

"net", in relation to the average insurance claim payment per insured person for—

• (a) a relevant age group of insured persons, or

• (b) all age groups of insured persons,

means after the application of the projected net financial impact of the relevant financial provisions for the 12 consecutive months concerned referred to in subsection (1)(b)(iii)(II);

"relevant age group of insured persons" means an age group of insured persons specified in column 1 of Table 2 set out in Schedule 4 in respect of which, in accordance with section 11C, part of the premium payable in respect of such insured person is, or is expected to be, payable from the Fund.]

7F. F74[ Overcompensated undertaking required to make payment to Exchequer if it has made more than reasonable profit.

7F. — F75[(1) A registered undertaking or former registered undertaking shall, in respect of each year—

• (a) maintain and furnish to the Authority (before F76[1 May] of the next succeeding year), in such form as may be specified by the Authority, a statement of profit and loss in respect of—

• (i) its relevant health insurance business in the State, and

• (ii) such other health insurance services, provided by the undertaking, as may be prescribed,

• (b) maintain and furnish to the Authority (before F76[1 May] of the next succeeding year), in such form as may be specified by the Authority, a balance sheet in respect of—

• (i) its relevant health insurance business in the State, and

• (ii) such other health insurance services, provided by the undertaking, as may be prescribed, and

• (c) furnish to the Authority (before F76[1 May] of the next succeeding year), such other information relating to the year as may be prescribed and, without limiting the generality of the foregoing, such information may include a statement of profit and loss and a balance sheet in respect of its relevant health insurance business in the State as it relates to those persons receiving age-related tax credits, in respect of health insurance contracts effected for any period before 1 January 2013, or receiving risk equalisation credits.]

• (2)
• (a) A statement of profit and loss or balance sheet shall, prior to its being furnished to the Authority pursuant to subsection (1), be certified by an independent accountant in such form as may be specified by the Authority.

• (b) The Minister may prescribe the bases for the calculation of costs, premia and other relevant financial data that are to be included in a statement of profit and loss or balance sheet to be furnished to the Authority pursuant to subsection (1).

• (3) A registered undertaking or former registered undertaking which has furnished the Authority with information under subsection (1) shall provide the Authority with such assistance as is reasonably necessary for the due performance of the Authority’s functions under this section in relation to such information.

F75[(4)(a) F77[…]

• F76[(b) The Authority shall take what would constitute a reasonable profit for a registered undertaking in respect of its relevant health insurance business in the State, in respect of the 3 year period from 1 January 2011 to the end of 2013, as being a return on equity that does not exceed 12 per cent per annum in respect of that business for that period as calculated using approved accounting standards and having regard to the European Union Framework for State aid in the form of public service compensation (2011) (2012/C8/03)¹, (the text of which is set out for convenience of reference in Schedule 2).]

• (c) Paragraph (b) shall, with all necessary modifications, apply to each relevant 3 year period as it applies to the 3 year period referred to in that paragraph.]

• F78[(4A)
• (a) The Authority shall take what would constitute a reasonable profit for a registered undertaking in respect of its relevant health insurance business in the State, in respect of the 3 year period from 1 January 2016 to the end of 2018, as being a return on sales, gross of reinsurance and excluding investment income, that does not exceed F79[6 per cent per annum] in respect of that business for that 3 year period taken as a whole and as calculated using approved accounting standards and having regard to the European Union framework for State aid in the form of public service compensation (2011) (2012/C8/03).

• (b) F79[Subject to paragraph (c), paragraph (a) shall, with all necessary modifications, apply] to each applicable 3 year period as it applies to the 3 year period referred to in that paragraph.]

F80[(c) In respect of each of the following applicable 3 year periods—

• (i) the 3 year period from 1 January 2020 to the end of 2022, and

• (ii) the 3 year period from 1 January 2021 to the end of 2023,

the reference in paragraph (a) to 6 per cent per annum shall, as respects the applicable 3 year period referred to in subparagraph (i), be read as a reference to 4. 9 per cent per annum and, as respects the applicable 3 year period referred to in subparagraph (ii), be read as a reference to 5. 5 per cent per annum and paragraph (a) shall apply accordingly.]

• (5) The Authority shall—

• (a) F81[…]

• F75[(b) as soon as may be, make a determination as to whether or not the cumulative net financial impact of the relevant financial provisions on a registered undertaking or former registered undertaking is positive for—

• (i) F81[…]

• (ii) if paragraph (b) of subsection (4) is applicable, the period from 1 January of 2011 to the end F82[of 2013,]

• (iii) if paragraph (c) of subsection (4) is applicable, the period from 1 January of the first year of the relevant 3 year period to the end of the last year of the relevant 3 year period,

to which the information furnished to it under subsection (1) relates and, if so, the amount by which the cumulative net financial impact is positive.]

• F78[(iv) if paragraph (a) of subsection (4A) is applicable, the period from 1 January 2016 to the end of 2018, or