Health Insurance Act 1994

F33[Prohibition of non-community rated health insurance contracts.

7

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 F34[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, F35[]

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—

F34[(a) the health risk status, age or sex of, or frequency of provision of health services to, a person, or]

(b) F35[]

(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—

F36[(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.

F37[(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.]

Annotations

Amendments:

F33

Substituted (19.07.2009) by Health Insurance (Miscellaneous Provisions) Act 2009 (24/2009), s. 6, commenced on enactment.

F34

Substituted (26.12.2012) by Health Insurance (Amendment) Act 2012 (45/2012), ss. 7(a)(i), (b), commenced on enactment.

F35

Deleted (26.12.2012) by Health Insurance (Amendment) Act 2012 (45/2012), s. 7(a)(ii), commenced on enactment.

F36

Substituted (1.05.2015) by Health Insurance (Amendment) Act 2014 (42/2014), s. 2(1)(a), commenced as per subs. (2).

F37

Inserted (25.12.2014) by Health Insurance (Amendment) Act 2014 (42/2014), s. 2(1)(b), commenced on enactment.

Editorial Notes:

E44

Previous affecting provision: section substituted (19.11.2001) by Health Insurance (Amendment) Act 2001 (17/2001), s. 5, S.I. No. 514 of 2001, art. 3(d); substituted (26.12.2012) as per F-note above.