S.I. No. 189/1950 - National Health Insurance (Decisions and Appeals) Order, 1950.

S.I. No. 189 of 1950.

NATIONAL HEALTH INSURANCE (DECISIONS AND APPEALS) ORDER, 1950.

The Minister for Social Welfare in exercise of the powers conferred on him by subsection (3) of section 20 of the Social Welfare Act, 1950 , and of every other power him in this behalf enabling hereby orders as follows :—

PART I. GENERAL.

1 Short title.

1. This Order may be cited as the National Health Insurance (Decisions and Appeals) Order, 1950.

2 Definitions.

2. In this Order unless the context otherwise requires the following words and expressions shall have the meanings herein-after respectively assigned to them :—

Acts.

" the Acts " means the National Health Insurance Acts, 1911 to 1950 ;

Appeals Officer.

" appeals officer " means an appeals officer appointed under Article 7 of this Order and includes two or more appeals officers acting together ;

Award.

" award " means an award or decision of an insurance officer ;

Claim.

" claim " means a claim for benefit or any other right conferred by the Acts which before the 1st day of August, 1950, could have given rise to a dispute within the meaning of section 67 of the National Insurance Act, 1911, or subsection (1) of section 27 of the National Insurance Act, 1913, and the word " claimant " shall be construed accordingly ;

Hearing.

" hearing " means oral hearing;

Insurance Officer.

" insurance officer " means an insurance officer appointed under Article 8 of this Order ;

Minister.

" the Minister " means the Minister for Social Welfare.

3 Commencement of Order.

3. This Order shall come into operation on the 1st day of August, 1950.

PART II. MODIFIED APPLICATION TO NATIONAL HEALTH INSURANCE OF CERTAIN PROVISIONS OF OR MADE UNDER THE WIDOWS' AND ORPHANS' PENSIONS ACTS, 1935 TO 1948.

4 Application and modification of enactments.

4. Sections 46 , 49 , 50 , 51 and 52 of the Widows' and Orphans' Pensions Act, 1935 (No. 29 of 1935) modified in the manner appearing in Part III of this Order, shall apply to National Health Insurance.

5 ..

5. Articles 4 to 16 and 18 of the Widows' and Orphans' Pensions (References) Regulations, 1936 (S.R. & O., 1936 No. 115), modified in the manner appearing in Part IV of this Order, shall apply to National Health Insurance.

6 ..

6. The Schedules to the Widows' and Orphans' Pensions (References) Regulations, 1936 (S.R. & O., 1936, No. 115) modified in the manner appearing in the Schedule to this Order, shall apply to National Health Insurance.

PART III. PROVISIONS IN RELATION TO THE APPOINTMENT OF INSURANCE OFFICERS AND APPEALS OFFICERS AND THE FUNCTIONS AND POWERS OF SUCH OFFICERS.

(Modified application to National Health Insurance of sections 46 , 49 , 50 , 51 and 52 of the Widows' and Orphans' Pensions Act, 1935 .)

7 Appeals officers.

7.—(1) The Minister may appoint such and so many persons as he thinks proper to be appeals officers for the purposes of the Acts, and every person so appointed shall hold office is appeals officer during the pleasure of the Minister.

(2) Appeals officers shall be civil servants serving in the Department of the Minister.

8 Insurance officers.

8.—(1) The Minister may appoint such and so many persons as he thinks proper to be insurance officers for the purposes of the Acts, and every person so appointed shall hold office as such officer during the pleasure of the Minister.

(2) Insurance officers shall be civil servants serving in the Department of the Minister.

9 Claims and appeals.

9.—(1) Every claim shall be made to the Minister and every question arising on such claim or in relation thereto or in respect of any award which has been previously made shall be determined by an insurance officer.

(2) If any claimant is dissatisfied with an award the question shall, on notice of appeal being given in accordance with the provisions of Article 12 of this Order, be referred to one or more appeals officers selected either by the Minister or by an officer of the Department of Social Welfare designated for the purpose by the Minister.

(3) An insurance officer may, if he so thinks proper, instead of determining it himself, refer in accordance with the provisions of Article 24 of this Order any question which falls to be determined by him under this article to an appeals officer selected in the manner provided for the selection of appeals officers in the immediately preceding sub-article.

(4) The decision of an appeals officer on any matter referred to him under this article shall be final and conclusive and, if there has been an award, such award shall, if necessary, be revised by an insurance officer in accordance with the decision of the appeals officer.

10 Revision of awards and decisions.

10.—(1) Subject to the provisions of this article, an insurance officer may, at any time and from time to time, revise any award made under sub-article (1) of the immediately preceding article, if it appears to him that the award was erroneous in the light of new evidence or of new facts brought to his notice since the date on which it was made or by reason of some mistake having been made with respect to the law or the facts, and the provisions of this Order as to appeals shall apply to such revised award in the same manner as they apply to an original award.

(2) The provisions of the immediately preceding sub-article shall not apply to an award relating to a matter which is the subject of an appeal under sub-article (2) of Article 9 in this Order unless the revised award would be in favour of the claimant.

(3) If, in any case, in which a decision has been given by an appeals officer with respect to a matter referred to him under the immediately preceding article, it appears to the Minister that the appeals officer might properly be asked to reconsider the decision in the light of new evidence or of new facts brought to his notice since the date on which the decision was given, the Minister may direct that the matter shall be referred to the appeals officer for reconsideration.

(4) If, in any case in which a decision has been given by an appeals officer with respect to a matter referred to him under the immediately preceding article, it appears to the Minister that theappeals officer might properly be asked to reconsider the decision in view of any apparent inconsistency between the decision and any other decision given by an appeals officer, the Minister may direct that both decisions shall be referred for reconsideration to the appeals officer concerned or to an appeals officer selected in the manner provided for the selection of appeals officers in sub-article (2) of Article 9 of this Order.

(5) The decision of an appeals officer on any matter referred to him under this article shall be final and conclusive and if there has been an award, such award shall, if necessary, be revised by an insurance officer in accordance with the decision of the appeals officer.

(6) A revised award made by an insurance officer under sub-article (1) of this article shall take effect as follows :

(a) where by virtue of the revised award benefit will be disallowed or be reduced it shall take effect, if made owing to the original award having been made or continued by reason of any statement or representation (whether written or oral) which was to the knowledge of the person making it false or misleading in a material respect or by reason of the wilful concealment of material facts, as from the date when the original award took effect ; provided that in a case where the benefit involved is by way of periodical payment the original award may, in the discretion of the insurance officer, continue to apply to any period covered by such original award to which such false or misleading statement or representation or such wilful concealment of material facts does not relate :

(b) in any other case it shall take effect as from the date considered appropriate by the insurance officer, provided that any benefit already paid at the date of revision shall not be affected.

(7) Where a decision is revised under this article by an appeals officer, the revised decision and any award made for the purpose of giving effect thereto shall have effect from such date as the appeals officer may determine.

11 Powers of appeals officers to take evidence on oath.

11. An appeals officer or officers shall on the hearing of any matter referred to him or them under the Acts have power to take evidence on oath, and for that purpose such appeals officer or, where there are two or more appeals officers, any one of such appeals officers may administer oaths to persons attending as witnesses at such hearing.

PART IV. PROCEDURE ON APPEALS.

(Modified application to National Health Insurance of Articles 4 to 16 and 18 of the Widows' and Orphans' Pensions (References) Regulations, 1936).

12 Notice of appeal.

12.—(1) Any claimant, who is dissatisfied with an award and desires to appeal against such award, shall give notice in that behalf, in writing, to the Minister.

(2) The time within which an appeal may be made shall be any time up to the expiration of four weeks from the date of notification of the award by the insurance officer ; provided that an appeal made after the end of that period may, with the consent of the Minister, be entertained.

(3) Any person desiring to withdraw an appeal may do so by sending to the Minister a notice of withdrawal.

13 Contents of notice of appeal.

13.—(1) The notice of appeal shall contain a concise statement of the facts and contentions upon which the claimant intends to rely.

(2) The claimant shall send to the Minister along with the notice such documentary evidence as the claimant desires to adduce in support of his appeal, and the appeal shall contain a list of any such documents.

14 Submission to appeals officer.

14. The Minister shall, as soon as may be, cause to be supplied to the appeals officer a copy of the notice of appeal, together with a statement showing to what extent are admitted or disputed the facts stated in the appeal and setting out any further facts and the contentions which will be relied upon at the hearing, and shall forward to the claimant, a copy of that statement.

15 Request for further particulars by appeals officer.

15. The appeals officer may at any time require the claimant or the Minister to furnish to him, in writing, further particulars with respect to the appeal, and may, at any stage of the proceedings, allow the amendment of any notice of appeal, statement, or particulars and may fix the time for furnishing any statement or particulars upon such terms as he may think just.

16 Summary determination of appeal.

16. If the appeals officer is of opinion that the case is of such a nature that it can properly be determined without a hearing, he may dispense with a hearing and may determine the appeal summarily.

17 Time and place of hearing.

17. If, in the opinion of the appeals officer, a hearing is required he shall, as soon as may be, fix a date and place for the hearing, and shall send to the Minister not less than twelve days' notice of the date and place fixed for the hearing and the Minister shall thereupon cause to be sent to the claimant not less than seven days' notice of the date and place fixed for the hearing.

18 Appearances at hearing, etc.

18.—(1) The claimant may appear at the hearing in person. He may be represented at the hearing by any member of his family, or, with the consent of the appeals officer, by any other person.

(2) The Minister may be represented at the hearing by such officer of his Department as he may appoint for the purpose.

(3) The appeals officer may postpone or adjourn the hearing from time to time as he may think fit.

(4) The appeals officer may, if he thinks fit, admit any duly authenticated written statement or other material as prima facie evidence of any fact or facts in any case in which he thinks it just and proper so to do.

(5) The appeals officer may, if he thinks fit, call for such documents and examine such witnesses as appear to him likely to afford evidence relevant and material to the issue although not tendered on behalf of the claimant or the Minister.

(6) An appeals officer may, by giving notice in that behalf in writing to any person, require such person to attend at such time and place as is specified in such notice to give evidence in relation to any matter referred to such appeals officer under the Acts or to produce any documents in his possession, custody or control which relate to any such matter.

19 Default in appearance at hearing, etc.

19.—(1) If after notice of a hearing has been duly given either of the parties fails to appear at the hearing, such order or decision may be made, and such proceedings may be taken with a view to the determination of, or in reference to, the appeal as the appeals officer may think just.

(2) The appeals officer may consider and decide any question duly referred to him for consideration and determination, notwithstanding the failure or neglect of any person to comply with any request or requirement of the appeals officer.

20 Procedure at hearing.

20. The procedure at the hearing shall be such as the appeals officer may determine.

21 Submission of further facts and contentions.

21. The claimant and the Minister shall not, without the leave of the appeals officer, be entitled to rely upon any facts or contentions other than those set out in the notice of appeal and in the statement required to be supplied under Article 14 of this Order respectively.

22 Decision of appea's officer.

22.—(1) The decision of the appeals officer shall be in writing signed by him and shall be sent, as soon as may be, to the Minister.

(2) An appeals officer may award such costs and expenses as he considers reasonable to any person in relation to any matter referred to him under the Acts.

(3) The Minister shall, as soon as may be after the receipt of the decision, cause a memorandum thereof to be drawn up in the form set out in the Schedule to this Order and shall send a copy of the memorandum to the claimant.

23 Mode of sending notices.

23. Any notice or other document required or authorised to be sent to a claimant for the purpose of this Part of this Order shall be deemed to be duly sent if sent by post addressed to the claimant at his ordinary address.

24 References under Article 9(3).

24.—(1) A reference by an insurance officer to an appeals officer under sub-article (3) of Article 9 of this Order shall be made in accordance with the Form provided for the purpose in the Schedule to this Order.

(2) Where a reference is made under the provisions of sub-article (3) of Article 9 of this Order, the procedure for dealing with the reference shall, with the necessary modifications, be the same as if the reference were an appeal made under sub-article (2) of Article 9 of this Order.

25 Forms in Schedule

25. The forms set out in the Schedule to this Order or forms to the like effect, may be used in all cases to which these forms are applicable.

GIVEN under the Official Seal of the Minister for Social Welfare this 24th day of July, 1950.

WILLIAM NORTON,

Minister for Social Welfare.

SCHEDULE.

(Modified application to National Health Insurance of the Schedules to the Widows' and Orphans' Pensions (References) Regulations, 1936.)

Form A. 1.

Articles 12 and 13.

NATIONAL HEALTH INSURANCE ACTS, 1911 TO 1950.

NOTICE OF APPEAL.

To the Minister for Social Welfare:

I...............................................of.................................................being dissatisfied with the award give on the............day of..........................., 19....... in connection with my claim for...................................................do hereby appeal against the said award and apply that the matter be referred to an appeals officer for determination.

The facts and contentions upon which I rely in support of my appeal are set forth in the Particulars hereto attached.

Dated this........day of....................................... 19......

(Signature)............................................................ .

Claimant's Particulars.

(Here set out a concise statement of the facts and contentions upon which the claimant relies and insert lists of all documents sent with this appeal.)

Form A. 2.

Article 14.

NATIONAL HEALTH INSURANCE ACTS, 1911 TO 1950.

NOTIFICATION OF APPEAL.

To the Appeals Officer:

...................................................of.................................................being dissatisfied with the award on.........day of........................................ 19......, in connection with his (her) claim for.............................................has appealed against the said award and has applied that the appeal be referred to an appeals officer for determination.

A copy of the appeal is enclosed.

A statement of the facts and of the contentions which will be relied upon at the hearing is set out hereunder.

Dated this.........day of....................................... 19......

(Signature)............................................................ ..

(Here set out a concise statement of the facts and contentions which will be relied upon at the hearing.)

Form A. 3.

Article 14.

NATIONAL HEALTH INSURANCE ACTS, 1911 TO 1950.

To............................................................ ............................................................ ..........................................................

............................................................ ............................................................ ........................................................

Your appeal in the matter of the award on your claim for..............................has been referred to an appeals officer for determination.

A copy of statement which has been sent to the appeals officer showing to what extent are admitted or disputed the facts stated in your appeal and the further facts and contentions which will be relied upon in support of the award is attached hereto.

(Signature)............................................................ ..

Form A. 4.

Article 17.

NATIONAL HEALTH INSURANCE ACTS, 1911 TO 1950.

NOTICE OF HEARING OF APPEAL UNDER ARTICLE 9 OF THE NATIONAL HEALTH INSURANCE (DECISIONS AND APPEALS) ORDER, 1950.

In the matter of an appeal by............................................................ ............................................................ ......

............................................................ ............................................................ .........................................................

Take notice that............................................................ ...................the Appeals Officer selected for the purpose will proceed with the hearing of the above appeal at.....................................................on.................day, the.........day of.......................................... 19.........at the hour of..................o'clock in the..................noon; and that if you do not attend either in person or by your duly authorised representative at the time and place above mentioned, such order or award will be made and proceedings taken as the Appeals Officer may think just and expedient.

Dated this.........day of....................................... 19......

(Signature)............................................................ ..

To...........................................

........................................

Form A. 5.

Article 22(2)

NATIONAL HEALTH INSURANCE ACTS, 1911 TO 1950.

MEMORANDUM OF DECISION OF APPEALS OFFICER UNDER ARTICLE 9(2) OR 9(3) OF THE NATIONAL HEALTH INSURANCE (DECISIONS AND APPEALS) ORDER, 1950.

In the matter of............................................................ ............................................................ ................

............................................................ ............................................................ ...........................................

The decision of the Appeals Officer in the above matter is as follows :—

Form A. 6.

Article 24.

NATIONAL HEALTH INSURANCE ACTS, 1911 TO 1950.

To the Minister for Social Welfare :

Pursuant to Article 9(3) of the National Health Insurance (Decisions and Appeals) Order, 1950, I hereby refer the following question for determination by an appeals officer.

............................................................ ........

Insurance Officer.

Date............................................................ ..................