Health Insurance (Amendment) Act 2001

1. Definition.

1.—In this Act “Principal Act” means the Health Insurance Act, 1994.

2. Amendment of definition of “health insurance contract” in Principal Act.

2.—The following definition is substituted for the definition of “health insurance contract” in section 2(1) of the Principal Act:

“‘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) a contract of insurance that complies with the following conditions—

(i) it provides for the making of payments in respect of the provision of relevant health services but not hospital in-patient services,

(ii) the premiums payable under it are payable on the basis of community rating,

(iii) it is effected by a person (including a body established under the laws of a place outside the State) who—

(I) on 1 May 2000 effected or offered to effect contracts of insurance which, had section 2 of the Health Insurance (Amendment) Act, 2001, been in operation on that date, would have fallen within subparagraphs (i) and (ii), and

(II) on or before that date had been informed by the Minister that he was not required to be registered for the purpose of effecting such contracts,

and

(iv) it is not effected on or after the date (being a date falling after the commencement of section 2 of the Health Insurance (Amendment) Act, 2001), if any, on which the person is entered in the Register pursuant to an application by him in that behalf,

or

(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 the following conditions are satisfied—

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

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

(I) those persons are so resident 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;”.

3. Further amendment of section 2(1) of Principal Act.

3.—Section 2(1) of the Principal Act is further amended by—

(a) the deletion of the definition of “ancillary health services”,

(b) the insertion of the following definition after the definition of “the Council Directives”:

“‘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;”,

(c) the substitution of the following definition for the definition of “hospital in-patient services”:

“‘hospital in-patient services’ means in-patient services within the meaning of the Health Act, 1970, and includes any day patient service;”,

(d) the substitution of the following definition for the definition of “premium”:

“‘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;”,

(e) the insertion of the following definition after the definition of “the Registrar”:

“‘relevant health services’ means out-patient services, general medical practitioner services and services consisting of the supply of drugs or medical preparations;”,

and

(f) the substitution of the following definition for the definition of “risk equalisation”:

“‘risk equalisation’ means the sharing of prescribed costs of registered undertakings between the undertakings (being costs incurred in respect of payments under health insurance contracts to or in relation to the persons party to or named in such contracts) by means of payments made by or to such undertakings in accordance with the terms and conditions of a scheme;”.

4. Certain arrangements by employers to constitute health insurance contracts.

4.—The following section is inserted after section 2 of the Principal Act:

“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.”.

5. Prohibition of non-community rated health insurance contracts.

5.—The following section is substituted for section 7 of the Principal Act:

“7.—(1) (a) Subject to subsection (4) and section 7A, 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 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) (or which would comply with that paragraph but for its falling within subsection (4) or section 7A) 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 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) 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.

(4) Notwithstanding 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 23 years, is receiving fulltime 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 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.”.

6. Premiums which may be charged under health insurance contracts in certain circumstances.

6.—The following section is inserted after section 7 of the Principal Act:

“7A.—(1) In this section, ‘insured person’ means any person, other than the registered undertaking, who is party to or named in the health insurance contract concerned and is of or over the age of 35 years.

(2) Notwithstanding section 7, a registered undertaking may require, on account of any of the circumstances referred to in paragraph (a), (b), (c) or (d) of subsection (4), the payment under a health insurance contract of a premium the amount of which is greater than that of the premium (in this section referred to as the ‘unadjusted premium’) which could have been required to be paid if this section had not been enacted.

(3) Any requirement to pay such a greater amount is subject to regulations under subsection (6).

(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,

(b) the insured person had previously effected or been named in a health insurance contract with a restricted membership undertaking of the kind referred to in subsection (2)(b) of section 12 that has served on the Minister a notice under the provision of a scheme mentioned in that subsection before the date specified for the purposes of that subsection,

(c) in the period of the 12 months 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,

(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 premium which a registered undertaking requires to be paid by virtue of this section and the amount of the unadjusted 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 unadjusted premium.

(7) Regulations under subsection (6) may—

(a) specify a different relevant method or a different percentage of the amount of the unadjusted 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 other registered undertaking.”.

7. Provision of information.

7.—The following section is inserted after section 7A (inserted by this Act) of the Principal Act:

“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.”.

8. Obligation to provide health insurance.

8.—The following section is substituted for section 8 of the Principal Act:

“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 of whatever age or such a person and his or her dependants 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,

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