Hospitalisation insurance from health insurance providers
Right to coverage
A health insurance provider can, with respect to the mandatory health and disability insurance, not refuse to cover any affiliated patients. Once they became a member, the health insurance provider cannot refuse the acquisition of a hospitalisation insurance or an insurance that provides a daily compensation for hospitalisation. This “right to coverage” also applies to persons with a chronic illness or with a disability. There is one exception: said person cannot be older than 65 years, unless he was covered by a similar insurance with his previous health insurance provider and has paid all his premiums.
The law does not only guarantee the principle of mandatory coverage, but also the principle of continuity of said coverage. After all, everybody has the right to interchange his or her health insurance provider. In essence, this means that if you already had a hospitalisation insurance with a given health insurance provider, you should immediately be given access to an equivalent coverage, without waiting period or any specific conditions from your new health insurance provider.
Health insurance providers are as of now obliged to cover the costs of pre-existing conditions or illnesses. The health insurance provider is by no means allowed to charge a higher premium.
The only restrictions that can still be imposed are:
- an exclusion of the supplementary fees linked to a single room;
- a reimbursement of a fixed amount instead of one based on the actual costs. The fixed amount will be determined by royal decree and can have a limitation in time.
The General Meeting of the health insurance provider has the authority to decide on the implementation of these restrictions.
Most health insurance providers already have a procedure in place stipulating the specific period – often five years – during which a fixed amount will be awarded in case of a pre-existing condition or illness. After those five years, every hospitalisation due to this pre-existing condition or illness has to be covered by insurance provider.
If a health insurance provider limits its coverage of a pre-existing condition or illness, a medical questionnaire needs to be filled out when purchasing the insurance.
When you have unintentionally concealed or incorrectly presented information in the medical questionnaire regarding the condition or illness, the health insurance provider can refuse or limit coverage. The health insurance provider can only invoke this right in the following circumstances:
- within 24 months of obtaining insurance and
- with regard to a condition or illness of which the symptoms were already presenting themselves at the time of obtaining the insurance and
- of which the diagnosis was made within the same period of 24 months.
The deliberate concealment or incorrect presentation of information regarding the condition or illness continues to be a reason for refusal or limitation of coverage by the health insurance provider after those 24 months.
Adjustment of premiums and conditions
Under certain circumstances, premiums for health insurance can be adjusted, for example in case of an increase of the health index, or an increased cost of medical treatments. The conditions concerning coverage can only be changed on the basis of objective factors and only in a way proportional to those factors.
The adjustment of premiums and conditions is decided at the General Meeting of the health insurance provider. An assessment thereof is subsequently made by the Control Department of the health insurance provider as well as by the national unions of health insurance providers.
Translation: Katia Ombelets