Health Insurance (Miscellaneous Provisions) Act 2009
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Further amendment of Act of 1994. |
9.— The Act of 1994 is amended by inserting the following sections after section 7B: | |
“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 Act 1997 , 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. | ||
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 subsection (5), 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, | ||
(b) the total number of persons insured, or a class thereof, in each age group and the gender profile 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. | ||
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 and, without limiting the generality of the foregoing, having particular regard to— | ||
(i) the average insurance claim payment per insured person made by the relevant market sector during the relevant periods for each age group to which the returns relate in respect of the total number of persons insured in that age group, 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 the total number of persons insured, or a class thereof, during the relevant periods, | ||
(iii) the age groups for which the average insurance claim payment referred to in subparagraph (i) is in excess of the average insurance claim payment referred to in subparagraph (ii) in respect of the same relevant periods, | ||
(iv) in the case of age groups which fall within subparagraph (iii), the extent of the excess referred to in that subparagraph attributable to each such age group, and | ||
(v) the net financial impact on each registered undertaking or former registered undertaking of the relevant financial provisions during the relevant periods, | ||
and | ||
(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 specified period, | ||
(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), | ||
(iii) the amounts of the age-related tax credits that the Authority considers, after having regard to such evaluation and analysis, would need to be afforded, under section 470B(4) of the Taxes Consolidation Act 1997 , to persons insured by registered undertakings (other than restricted membership undertakings) having regard to the principal objective specified in section 1A(1) (in so far as that objective relates to health insurance contracts that provide for in-patient indemnity payments) and to achieving the aim of avoiding overcompensation being made to a registered undertaking or former registered undertaking under the operation of the relevant financial provisions, 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 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 Exchequer of the total of the amounts referred to in subparagraph (iii). | ||
(2) The Minister shall, after having regard to— | ||
(a) the principal objective specified in section 1A(1), | ||
(b) the need to facilitate competition between registered undertakings, and | ||
(c) any report furnished to him or her pursuant to subsection (1)(b), | ||
make recommendations to the Minister for Finance relating to section 470B of the Taxes Consolidation Act 1997 or section 125A of the Stamp Duties Consolidation Act 1999 . | ||
(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. | ||
Overcompen-sated undertaking required to make payment to Exchequer if it has made more than reasonable profit. | ||
7F.— (1) A registered undertaking or former registered undertaking shall, in respect of each year— | ||
(a) maintain and furnish to the Authority (before 1 April 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 health insurance business in the State which falls within paragraph (b) of section 7D(1), and | ||
(ii) such other health insurance services, provided by the undertaking, as may be prescribed, | ||
(b) maintain and furnish to the Authority (before 1 April of the next succeeding year), in such form as may be specified by the Authority, a balance sheet in respect of— | ||
(i) its health insurance business in the State which falls within paragraph (b) of section 7D(1), and | ||
(ii) such other health insurance services, provided by the undertaking, as may be prescribed, | ||
and | ||
(c) furnish to the Authority (before 1 April 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 health insurance business as it relates to those persons receiving age-related tax 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. | ||
(4) The Authority shall, as soon as may be after the expiration of each year commencing from and including 2009, determine what would constitute a reasonable profit for a registered undertaking in respect of its health insurance business in respect of the period from 1 January 2009 to the end of the year concerned. | ||
(5) The Authority shall— | ||
(a) evaluate and analyse the information furnished to it under subsection (1) by a registered undertaking or former registered undertaking, and | ||
(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 the period from 1 January 2009 to the end of the year to which the information relates and, if so, the amount by which the cumulative net financial impact is positive. | ||
(6) (a) Where the Authority determines under subsection (5)(b) that there is a positive cumulative net financial impact on a registered undertaking or former registered undertaking in respect of a period, it shall make a determination as to whether the undertaking has or has not, in respect of that period, made a profit which is in excess of the reasonable profit determined under subsection (4) in respect of that period. | ||
(b) Where the Authority determines under paragraph (a) that a registered undertaking or former registered undertaking has made a profit which is in excess of a reasonable profit in respect of a period, it shall make a further determination as to the monetary equivalent amount of the profit which is in excess of the corresponding monetary equivalent amount of such reasonable profit in respect of that period. | ||
(7) Where, in respect of a period, the Authority has determined under subsection (5)(b) that the cumulative net financial impact of the relevant financial provisions on a registered undertaking or former registered undertaking was positive, and determined under subsection (6)(a) that the undertaking has made a profit which is in excess of the reasonable profit determined under subsection (4), it shall prepare a report (in this Part referred to as the ‘ draft report ’) setting out— | ||
(a) the reasonable profit determined under subsection (4), | ||
(b) the amount determined under subsection (5)(b) to be the positive cumulative net financial impact on the undertaking, | ||
(c) the monetary equivalent amount determined under subsection (6)(b) to be the profit of the undertaking which is in excess of the corresponding monetary equivalent amount of such reasonable profit, | ||
(d) the cumulative amount of overcompensation, being the lower of the amounts referred to in paragraphs (b) and (c), | ||
(e) the amount of overcompensation to be paid to the Exchequer by the undertaking, being the cumulative amount of overcompensation referred to in paragraph (d) reduced by the total amount of overcompensation paid or due to be paid to the Exchequer pursuant to the operation of subsection (10) in respect of all the periods prior to the first-mentioned period, and | ||
(f) the bases on which it made the determinations, and calculated the amounts, referred to in paragraphs (a) to (e). | ||
(8) (a) The Authority shall, as soon as may be after the preparation of the draft report— | ||
(i) furnish a copy of the draft report to the registered undertaking or former registered undertaking the subject of the report, | ||
(ii) invite the undertaking to make representations to the Authority in relation to the draft report before the expiration of 21 days (or such longer period as the Authority may permit in its discretion) from the day on which the undertaking received the report, and | ||
(iii) take into account any such representations made to it within that period before preparing the final report as soon as is practicable after the expiration of that period of 21 days (or, if applicable, the expiration of the longer period permitted pursuant to subparagraph (ii)). | ||
(b) The determinations of the Authority contained in its final report shall be final and conclusive (including for the purposes of any proceedings concerning the recovery of an amount referred to in subsection (11)). | ||
(c) The Authority shall furnish the final report to the Minister as soon as may be after it has been prepared. | ||
(9) Where the Minister is furnished with a report under subsection (8), the Minister shall, as soon as may be, furnish a copy of the report to the registered undertaking or former registered undertaking the subject of the report together with a copy of this section. | ||
(10) Where a registered undertaking or former registered undertaking is furnished with a copy of a report under subsection (9), it shall, not later than 2 months from the date on which it is given the report, pay to the Exchequer the amount set out in the report pursuant to paragraph (e) of subsection (7). | ||
(11) The Minister on behalf of the Minister for Finance may recover, as a simple contract debt in any court of competent jurisdiction, from the registered undertaking or former registered undertaking by which it is payable, any amount due and owing to the Exchequer pursuant to the operation of subsection (10). | ||
(12) Notwithstanding that the Authority may not, in respect of a particular year, or in respect of a particular registered undertaking or former registered undertaking, be required under subsection (8) to furnish a report to the Minister, the Minister may make a request in writing to the Authority to be furnished, within the period specified in the request (being a period reasonable in the circumstances), with such information relating to any determination it has made under subsection (5) or (6) in respect of a particular registered undertaking or former registered undertaking (including information relating to the basis on which such determination was made) as the Minister specifies in the request. | ||
(13) The Authority shall comply with a request made under subsection (12) by the Minister. | ||
Disclosure of contents of information returns. | ||
7G.— (1) The contents of information returns shall, in so far as they can be related to individual registered undertakings or former registered undertakings, be disclosed only where necessary for the purposes of the functions of the Minister or the Authority under this Act. | ||
(2) Subject to subsection (1), the Authority may, where it considers it appropriate to do so, disclose aggregate data derived from information returns. | ||
(3) Nothing in this section shall preclude the disclosure of information by means of a report furnished to the Minister pursuant to section 7E(1)(b) or 7F(8)(c). | ||
Registered undertaking to provide certain premium information to policy holders or certain other persons. | ||
7H.— Where a registered undertaking effects a health insurance contract on or after the commencement of section 9 of the Health Insurance (Miscellaneous Provisions) Act 2009 (including any renewal of such a contract entered into before that commencement), it shall, at the same time as effecting the contract, or as soon as is practicable thereafter, give— | ||
(a) the policy holder, or | ||
(b) the person to whom the registered undertaking issues the request for payment of the premium due under the health insurance contract, where that person is not the policy holder, | ||
a statement in writing setting out— | ||
(i) the premium payable under the contract in respect of each insured person before any deduction referred to in the definition of ‘net premium’ in section 2 is made from the premium, and | ||
(ii) the net premium under the contract in respect of each insured person.”. |