Health Insurance (Miscellaneous Provisions) Act 2009

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Substitution of section 7 of Act of 1994.

6.— The Act of 1994 is amended by substituting the following sections for section 7:

“Interpretation of Part II.

6A.— (1) In this Part, unless the context otherwise requires—

‘ age group ’ means age group as prescribed in regulations made under section 7D;

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

‘ cumulative net financial impact ’, in relation to a registered undertaking or former registered undertaking which has furnished one or more information returns to the Authority in respect of a period, means the difference between—

(a) the total amount of the age-related tax credits recorded in accounts for that undertaking in respect of that period as extracted from accounts furnished pursuant to section 7F(1)(a) and (b) to the Authority 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 accounts furnished pursuant to section 7F(1)(a) and (b) to the Authority by the undertaking in respect of that period;

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

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

‘ 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 fin ancial impact ’ exceeds the amount specified in paragraph (b) of that definition;

‘ relevant financial provisions ’ means—

(a) section 470B of the Taxes Consolidation Act 1997 , or

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

or both;

‘ 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).

(2) Reasonable profit shall be determined under section 7F(4) in accordance with—

(a) Article 18 of the Community framework for State aid in the form of public service compensation (2005/C297/04) ¹ (the text of which is set out for convenience of reference in Schedule 2), and

(b) any factors that are prescribed as factors that may be taken into account for the purposes of so determining reasonable profit in accordance with the said Article.

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 31 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 specified in section 1A(1),

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—

(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.

(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—

(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 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 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.

(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.”.

¹OJC 297, 29.11.2005, p.4