Preparation for oral exams in claims management and business development of the BTS Assurance. We will explore different questions about health insurance.
Can you cancel a health contract with the Hamon law ?
ATTENTION !!!!!!!! it is impossible to cancel a health contract with the Hamon law
What is the difference between a supplementary health insurance and a mutual insurance ?
The supplementary health insurance thus takes effect in addition to the health insurance, fully or partially covering remaining healthcare costs borne by the insured.
The mutuals are legal entities. They are non-profit and governed by the mutuality code.
Mutuals are also characterized by their operation; they have no shareholders, and their representatives are elected by members.
Unlike health insurance, which is subject to the “insurance codes” and has a commercial purpose.
Does an insurer have the right to cancel a health contract following a significant risk occurrence ?
No, they do not have the right, because according to article 6 of the Évin law, “the insurer cannot modify the guarantees based on age limits nor after a claim.
How can an insured cancel a supplementary insurance ?
The insured can cancel at the end of a one-year period by sending a registered letter with acknowledgment of receipt to the insurer, with a notice period of 2 months before the due date.
The insured can use the Châtel law : each year, the insurer must remind the insured of the cancellation deadline. This reminder is sent with the issuance of the renewal notice. If this renewal notice is sent less than 15 days before the cancellation deadline, the insured has 20 days from the date of sending to cancel. If the renewal notice is not transmitted, the insured can cancel at any time. (L113-15 CA)
In case of a premium increase exceeding the variation of the index
What is the purpose of supplementary health insurance ?
Supplementary insurance covers expenses not reimbursed by the mandatory scheme, namely the copayment (TM). It provides additional benefits for medical, surgical, and hospitalization costs.
What are the two main types of subscription methods ?
We have individual and collective methods through an employer.
Is supplementary insurance mandatory ?
Since 2016, companies are required to have a supplementary health insurance linked to the company through the ANI (Interprofessional National Agreement), meaning the employer funds 50% and the other part is paid by the employee.
Which organization can sell supplementary health contracts ?
First, mutuals are involved; there are three categories of mutuals: professional mutuals (hospitals), civil servant mutuals (like MGEN), and interprofessional mutuals (covering multiple professions).
Next, we have insurance companies, which include public limited companies (SAs) and mutual insurance companies like MAAF, Matmut, GMF…
Is there an age limit for subscribing to supplementary health insurance ?
Yes, there is an age limit for traditional contracts. The age range is between 18 and 70 years. Before 18, children are covered by their parents’ supplementary insurance.
After 70 years, it is still possible to subscribe to a “senior” supplementary insurance, but it will be much more expensive.
What are the steps to subscribe to a contract ?
The first step is preliminary information; it is necessary to understand the client’s needs. The insurer must provide a form indicating the amount and guarantees.
The second step is the insurance proposal. According to article L113-2 of the insurance code, “the insured is obliged to respond to assess the risks taken by the insurer. The insured must make a true declaration; otherwise, they risk sanctions provided in articles L113-8 and L113-9 of the insurance code.
The final step is signing the contract. During the signing, the insured is provided with a copy of the special conditions as well as the general conditions. Once signed, the insured commits to the insurer.
What does the supplementary insurance not reimburse ?
Supplementary health insurance does not cover:
The flat-rate participation for consultations (1€) and medications (0.5€)
The surcharge due to non-compliance with the coordinated care pathway (PSC)
The franchises applicable to medications, paramedical acts, and transportation costs
You now know how to answer various questions in the health domain. Some cases may present different health-related questions.
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