S.I. No. 383/1996 - Social Welfare (Consolidated Payments Provisions) (Amendment) (No. 9) (Treatment Benefit) Regulations, 1996.

S.I. No. 383 of 1996.

SOCIAL WELFARE (CONSOLIDATED PAYMENTS PROVISIONS) (AMENDMENT) (NO. 9) (TREATMENT BENEFIT) REGULATIONS, 1996.

The Minister for Social Welfare, in exercise of the powers conferred on him by sections 4 (as amended by section 37 of the Social Welfare Act, 1996 (No. 7 of 1996)and 117 of the Social Welfare (Consolidation) Act, 1993 (No. 27 of 1993), hereby makes the following Regulations:—

1 Citation and construction.

1. (1) These Regulations may be cited as the Social Welfare (Consolidated Payments Provisions) (Amendment) (No. 9) (Treatment Benefit) Regulations, 1996.

(2) These Regulations and the Social Welfare (Consolidated Payments Provisions) Regulations, 1994 to 1996 shall be construed together as one and may be cited together as the Social Welfare (Consolidated Payments Provisions) Regulations, 1994 to 1996.

2 Commencement.

2. These Regulations shall come into operation on the 1st day of January, 1997

3 Definitions.

3. In these Regulations —

"the Principal Regulations" means the Social Welfare (Consolidated Payments Provisions) Regulations, 1994 ( S.I. No. 417 of 1994 ); and

"the Regulations of 1996" means the Social Welfare (Consolidated Contributions and Insurability) Regulations, 1996 ( S.I. No. 312 of 1996 ).

4 Revocations.

4. The Regulations specified in column (2) of the Schedule to these Regulations are hereby revoked to the extent specified in column (3) of that Schedule opposite the mention of those Regulations in column (2).

5 Treatment Benefit.

5. Part II of the Principal Regulations is hereby amended by the insertion after Chapter 8 of the following Chapter:

"CHAPTER 9

Treatment Benefit

Interpretation.

67A. In this Chapter —

'appliance' means an appliance provided as benefit under these Regulations including the repair thereof;

'claimant' means a person who has made a claim for dental benefit, medical appliance benefit or optical benefit, as the case may be;

'dental treatment' means the performance of any dental operation and any examination, treatment, advice, opinion or attendance usually performed or given by a dentist, including the fitting, insertion or fixing of dentures, which is included in the Schedule of Treatments for the time being fixed by the Minister;

'dentist' means a person registered in the Register of Dentists for Ireland established under the Dentists Act, 1985 (No. 9 of 1985), who has entered into an agreement with the Minister to provide dental treatment under the Principal Act;

'dependent spouse' means —

(a) a spouse who is an adult dependent as defined in section 2(2) and extended by article 6 (as amended by article 3 of the Social Welfare (Consolidated Payments Provisions) (Amendment) Regulations, 1996 ( S.I. No. 95 of 1996 )); and

(b) a spouse who would be an adult dependant as so defined, but for the receipt by that spouse of a carer's allowance under Chapter 10 of Part III in his own right;

'relevant contribution year' means the last complete contribution year before the beginning of the benefit year in which the relevant date occurs or, where the claimant has attained pensionable age, either of the last two complete contribution years before the relevant date;

'relevant date' means the date on which benefit is claimed or, where the claimant is over pensionable age, the date on which he attained pensionable age;

'scale of charges' means, as respects any benefit, the scale of fees or charges appropriate to such benefit for the time being fixed by the Minister; and

'treatment benefit' means, dental benefit, medical appliance benefit, or optical benefit, as the case may require.

Benefit to be provided.

67B. The treatment benefit to be provided under section 117 shall be

(a) dental benefit, ,

(b) medical appliance benefit, and

(c) optical benefit.

Entitlement to treatment benefit.

67C. (1) Subject to this Chapter, a person shall be entitled to treatment benefit if—

(a) he satisfies the contribution conditions in article 67D, and

(b) does not have an aggregate of reckonable income and reckonable earnings in excess of £35,000 in the last complete contribution year before the beginning of the benefit year in which the relevant date occurs, or in such subsequent period as a deciding officer or an appeals officer may consider appropriate.

(2) Paragraph (b) of sub-article (1) shall not apply in the case of a person who has attained pensionable age.

Contribution conditions for entitlement.

67D. (1) Subject to this Chapter the contribution conditions for entitlement to treatment benefit shall be—

(a) in the case of a claimant who is under the age of 21 years, that he has qualifying contributions in respect of not less than 39 contribution weeks between the date of his entry into insurance and the relevant date,

(b) in the case of a claimant who is of or over the age of 21 years and under the age of 25 years —

(i) that he has qualifying contributions in respect of not less than 39 contribution weeks between the date of his entry into insurance and the relevant date, and

(ii) that he has qualifying contributions or credited contributions in respect of not less than 39 contribution weeks, of which at least 13 must be qualifying contributions, in the relevant contribution year, and

(c) in the case of a claimant who is of or over the age of 25 years —

(i) that he has qualifying contributions in respect of not less than 260 contribution weeks between the date of his entry into insurance and the relevant date, and

(ii) that he has qualifying contributions or credited contributions in respect of not less than 39 contribution weeks, of which at least 13 must be qualifying contributions, in the relevant contribution year.

(2) In the case of a person who would be entitled to treatment benefit but for the fact that he does not satisfy the condition of having qualifying contributions in respect of at least 13 contribution weeks in the relevant contribution year, that person shall be entitled to treatment benefit —

(a) in the case of a person who has attained pensionable age, if he has qualifying contributions in respect of at least 13 contribution weeks in the contribution year preceding the relevant contribution year or in a subsequent contribution year, and

(b) in any other case, if he has qualifying contributions in respect of at least 13 contribution weeks in either of the two contribution years preceding the relevant contribution year or in a subsequent contribution year.

(3) The contribution conditions contained in this sub-article 1(c) (ii) requiring the claimant to have qualifying contributions in respect of 13 contribution weeks in the relevant contribution year shall not apply in the case of a person who has attained pensionable age before the 6th day of July, 1992.

(4) The contribution condition contained in sub-article (1) (c) (i) requiring the claimant to have qualifying contributions in respect of at least 260 contribution weeks between the date of his entry into insurance and the relevant date shall –

( a ) in respect of a person who has attained pensionable age before the 1st day of October, 1987, have effect as if '156 contribution weeks' were substituted for '260 contribution weeks', and

( b ) in respect of a person who has attained pensionable age before the 6th day of July, 1992, have effect as if '208 contribution weeks' were substituted for '260 contribution weeks'.

(5) The contribution condition contained in sub-article 1 (b) (ii) and (1) (c) (ii) requiring the claimant to have qualifying contributions in respect of at least 13 contribution weeks in the relevant contribution year shall not apply in the case of a person who-

(i) is in receipt of -

( a ) disability benefit under Chapter 7 of Part II for a period of not less than 312 days in respect of any period of interruption of employment,

( b ) retirement pension under Chapter 13 of Part II,

( c ) invalidity pension under Chapter 15 of Part II,

( d ) unemployment assistance under Chapter 2 of Part III and is a person to whom section 121 (1) (a) (as amended by section 22 of the Social Welfare Act, 1996 ) applies,

( e ) pre-retirement allowance under Chapter 3 of Part III, or

( f ) carer's allowance under Chapter 10 of Part III, or

(ii) not being in receipt of any benefit under Part II or assistance under Part III, is of or over the age of 55 years and is entitled to employment contributions credited under the provisions of article 58 of the Regulations of 1996 in respect of proved unemployment.

Contribution conditions for volunteer development workers.

67E. The contribution conditions to be satisfied by a volunteer development worker for treatment benefit in respect of any claim made in the benefit year in which he returns to the State from a developing country or in the next succeeding benefit year shall be -

( a ) that he has qualifying contributions paid in respect of not less than 26 contribution weeks in the period from his entry into insurance to the relevant date, and

( b ) that he has qualifying paid or credited contributions in respect of not less than 26 contribution weeks in the relevant contribution year.

Treatment benefit for dependent spouse.

67F. (1) A dependent spouse shall be entitled to treatment benefit where -

( a ) the contribution conditions specified in article 67D or 67E, as the case may be, are satisfied by his spouse's insurance, and

( b ) that person's spouse does not have an aggregate of reckonable income and reckonable earnings in excess of £70,000 in the last complete income tax year or in such subsequent period as a deciding officer or appeals officer may consider appropriate.

(2) Paragraph (b) of sub-article (1) shall not apply in the case of the dependent spouse of a person who has attained pensionable age.

Continued benefit to dependent spouse after the death of an insured person.

67G. On the death of an insured person whose dependent spouse, at the date of the death, was or would have been entitled to treatment benefit under article 67F, the dependent spouse shall continue to be entitled to treatment benefit for as long as that person remains a widow or widower, as the case may be.

Continued entitlement after attaining age 60.

67H. Where an insured person, on attaining the age of 60 years, is or would be entitled to treatment benefit under this Chapter he shall thereafter continue throughout his life to be so entitled.

Reckoning of contributions paid under National Health Insurance Acts.

67I. (1) For the purposes of this article an 'existing contributor' means a person whose insurance as an employed contributor or a voluntary contributor under the National Health Insurance Acts was effective immediately before the 5th day of January, 1953.

(2) In determining for the purposes of satisfying the contribution condition for treatment benefit contained, in subparagraph (i) of article 67D(1) (c), whether an existing contributor has qualifying contributions in respect of not less than 260 contribution weeks, every two contributions paid by or in respect of such contributor since the date of last entry under the National Health Insurance Acts shall be reckoned as three qualifying contributions paid under the Principal Act, and any odd contribution under the said Acts shall be reckoned as two qualifying contributions paid under the Principal Act.

Claim for treatment benefit.

67J. A claim for treatment benefit shall be made in the form and in such manner for the time being approved by the Minister.

Limitation on benefit for a claimant who is a member of the Defence Forces.

67K. A claimant who is a member of the Defence Forces shall be entitled to dental benefit and optical benefit to the extent specified in articles 67Q and 67X and to no other treatment benefit.

Cost of medical certificates and travelling expenses.

67L. A claimant for treatment benefit may be granted -

( a ) the cost of any medical certificate required by the Minister for the purposes of the claim, and

( b ) such travelling and other expenses necessarily incurred for the purpose of enabling him to secure any treatment, service or appliance in respect of treatment benefit as may be determined.

Time limit for obtaining treatment benefit.

67M. (1) The Minister may fix a time within which any treatment, service or appliance is to be obtained.

(2) The Minister may, if he is satisfied that there are good grounds for so doing, extend the time within which any treatment, service or appliance is to be obtained.

(3) A grant of treatment benefit which is not obtained within the time as fixed or extended by the Minister shall lapse to the extent which the benefit has not been obtained.

(4) The Minister may, on such terms and subject to such conditions as he thinks fit, renew a grant of treatment benefit which has lapsed.

Decisions on claims for treatment benefit.

67N. (1) The Minister shall cause notification of the decision on a claim for treatment benefit to be given to the claimant and of the procedure to be complied with by him for the purpose of obtaining such benefit.

(2) The claimant shall be advised where he is required to pay any sum towards the cost of the treatment benefit and of the amount of such sum, if known.

Payment by the Minister.

67O. The Minister shall, on being informed in writing by the claimant that he has received to his satisfaction the treatment, service or appliance authorised in respect of treatment benefit, pay the sum which the Minister is liable to pay in respect of the benefit.

Dental panel.

67P. (1) The Minister shall, from time to time, prepare and publish a list of the dentists with whom agreements have been made by the Minister for the provision of dental benefit in accordance with this Chapter.

(2) The list referred to in sub-article (1) shall be known as the Dental Panel.

Limitation on dental benefit for claimant who is a member of the Defence Forces.

67Q. The dental benefit to which a claimant who is a member of the Defence Forces shall be entitled, shall be the provision of dentures and repairs, additions and alterations thereto and remodelling thereof.

Amount of payment by the Minister and the claimant in respect of dental benefit.

67R. The payment to be made by the Minister in respect of dental benefit shall be so much of the cost of the dental treatment in accordance with the scale of charges as may from time to time be fixed by the Minister and the remainder of the said cost, if any, shall be paid by the claimant.

Benefit provided in respect of medical appliances.

67S. The appliances to be provided as benefit under articles 67T and 67U shall be contact lenses and hearing aids.

Amount of payment by the Minister and the claimant.

67T. The payment to be made by the Minister in respect of medical appliance benefit under this article and article 67U shall be so much of the cost of providing or repairing an appliance as may be determined in any particular case, and the remainder of the said cost shall be paid by the claimant.

Claims for and payment of medical appliance benefit.

67U. (1) A claimant for medical appliance benefit shall submit with the claim a recommendation from the medical practitioner attending him and an estimate of the cost of appliances supply or repair, as may be appropriate, from a supplier approved by the Minister.

(2) The Minister may, if he thinks fit, dispense with the submission of a recommendation from the medical practitioner where the benefit claimed is in respect of the repair of an appliance.

(3) When a claim for medical appliance benefit is granted, the Minister shall notify the claimant and the supplier.

(4) Medical appliance benefit shall not be payable unless the appliance is, as may be appropriate, purchased from or repaired by a supplier approved by the Minister.

Optical Panel.

67V. (1) The Minister shall, from time to time, prepare and publish a list of the opticians who have entered into agreements with the Minister for the provision of optical benefit.

(2) The list referred to in sub-article (1) shall be known as the Optical Panel.

Claims for and payment of optical benefit.

67W. (1) Optical benefit shall not be payable unless the appliance is, as may be appropriate, purchased from or repaired by a person whose name is for the time being on the Optical Panel.

(2) The Minister may require a certificate of an ophthalmic surgeon to be submitted with a claim for optical benefit.

(3) Where a claim for optical benefit is granted, the Minister shall notify the claimant and the optician.

Limitation on optical benefit for claimant who is a member of the Defence Forces.

67X. The optical benefit to which a claimant who is a member of the Defence Forces shall be entitled, shall be the provision of optical appliances.

Amount of payment by the Minister and the claimant.

67Y. The payment to be made by the Minister in respect of optical benefit shall be -

( a ) such sum as may from time to time be fixed by the Minister for examination, advice and, if necessary, prescription by an ophthalmic surgeon, and

( b ) such sum as may from time to time be fixed by the Minister towards the cost of optical appliances.

Sight tests.

67Z. (1) A person shall only be entitled to payment of that part of optical benefit, which consists of a sight test, in respect of one such test in any period of two years, save where the Minister is satisfied that there are good clinical reasons in a particular case for obtaining such tests more frequently.

(2) Sight tests provided by way of optical benefit shall be undertaken at the optical practitioner's normal place of business.".

SCHEDULE

Article 4.

Regulations Revoked

GIVEN under the Official Seal of the Minister for Social Welfare

this 10th day of December, 1996

PROINSIA DE ROSSA

Minister for Social Welfare.

EXPLANATORY NOTE

These Regulations consolidate all of the existing regulatory provisions relating to Treatment Benefit.