S.I. No. 81/1996 - Health Insurance Act, 1994 (Open Enrolment) Regulations, 1996.

S.I. No. 81 of 1996.

HEALTH INSURANCE ACT, 1994 (OPEN ENROLMENT) REGULATIONS, 1996.

The Minister for Health in exercise of the powers conferred on him by section 3 and 8 of the Health Insurance Act, 1994 (No. 16 of 1994) hereby makes the following Regulations—

PART I GENERAL

1. These Regulations may be cited as the Health Insurance Act, 1994 (Open Enrolment) Regulations, 1996.

2. These Regulations shall come into operation on the 28th day of March, 1996.

3. In these Regulations—

"insured person" means a person named in a health insurance contract as an insured person or an infant born to a person named in a health insurance contract as an insured person provided that in the case of an infant the person who effected the health insurance contract requests that the health insurance contract be altered to name such infant as an insured person, and pays the appropriate premium in respect of such infant, within 13 weeks of the date of birth of the infant.

4. The age of a person for the purposes of these Regulations is the age attained at the contract start date.

PART II AGE AT ENTRY

5. A registered undertaking, other than a restricted membership undertaking, shall not refuse to effect a health insurance contract with a person, or refuse a request to name a person as an insured person, where—

( a ) such person is under the age of 65 years, except where such person has had a previous contract terminated or not renewed under article 4 (a) of the Health Insurance Act, 1994 (Lifetime Cover) Regulations, 1996 ( S.I. No. 82 of 1996 );

( b ) such person is of or over the age of 65 years and was named in a former health insurance contract which had expired less than thirteen weeks previously except where such person has had a previous contract terminated or not renewed under article 4 (a) of the Health Insurance Act, 1994 (Lifetime Cover) Regulations, 1996 ( S.I. No. 82 of 1996 ).

6. A restricted membership undertaking shall not refuse to effect a health insurance contract, or refuse a request to name a person as an insured person, where—

( a ) such person is qualified for membership of the undertaking and is under the age of 65 years except where such person has had a previous contract terminated or not renewed under article 4 (a) of the Health Insurance Act, 1994 (Lifetime Cover) Regulations, 1996 ( S.I. No. 82 of 1996 );

( b ) such person is qualified for membership of the undertaking and is of or over the age of 65 years and was named in a former health insurance contract which had expired less than thirteen weeks previously except where such person has had a previous contract terminated or not renewed under article 4 (a) of the Health Insurance Act, 1994 (Lifetime Cover) Regulations, 1996 ( S.I. No. 82 of 1996 ).

PART III MAXIMUM WAITING PERIODS

7. (1) The maximum waiting period for eligibility for payments under a health insurance contract which a registered undertaking may impose in respect of an insured person shall be—

(i) 26 weeks, in respect of a person who is under the age of 55 years provided that no maternity benefit shall be payable for the period of 52 weeks next following a person being named as an insured person;

(ii) 52 weeks, in respect of a person who is of or over the age of 55 years and under the age of 65 years.

(2) An infant shall be eligible to receive payments under a health insurance contract immediately from his or her date of birth where the infant has been named as an insured person within 13 weeks of his or her date of birth.

(3) An insured person shall be eligible for minimum payments immediately in respect of health services prescribed pursuant to section 10 of the Health Insurance Act, 1994 where such health services are provided as a result of an accident or injury which occurred while that person was named as an insured person.

(4) The maximum waiting periods prescribed in this article shall be known as the "initial waiting periods".

8. (1) The maximum waiting period for eligibility for payments under a health insurance contract in respect of an insured person's medical condition, the date of onset of which is determined on the basis of medical advice to have been prior to the date he or she is first so named, other than where the insured person is an infant and has been so named within 13 weeks of his or her date of birth, shall be—

(i) 5 years, for a person who is under the age of 55 years;

(ii) 7 years, for a person who is of or over the age of 55 years and under the age of 60 years;

(iii) 10 years, for a person who is of or over the age of 60 years and under the age of 65 years.

(2) The maximum waiting periods prescribed in this article shall be known as the "pre-existing condition waiting periods".

9. Notwithstanding articles 7 and 8, where a person is named as an insured person in a contract of health insurance having previously been so named in such a contract then such a person shall be deemed to have served so much of the initial and pre-existing condition waiting periods as is equal to so much of the like periods as had expired at the time of the expiration of the former contract, where that contract had expired less than thirteen weeks previously.

10. Subject to articles 8 and 9, where a person is named in a contract of health insurance, herein referred to as the "higher contract", in respect of the increase in the level of hospital in-patient or ancillary health services or a more expensive type of hospital accommodation having previously been named as an insured person under a health insurance contract with the undertaking or another undertaking, the maximum waiting period for eligibility for payments in respect of the increased level of hospital in-patient services or ancillary health services or the more expensive type of hospital accommodation, shall be—

(i) 2 years for a person under the age of 65 when first named under the higher contract; or

(ii) 5 years for a person of or over the age of 65 years when first named under the higher contract.

11. For the purposes of section 8 (4) (a) of the Health Insurance Act, 1994 the following case is hereby prescribed as the exception to the requirement to effect a health insurance contract that is where such a person has had a previous contract terminated or not renewed under article 4 (a) of the Health Insurance Act, 1994 (Lifetime Cover) Regulations, 1996 ( S.I. No. 82 of 1996 ).

12. For the purposes of section 8 (5) of the Health Insurance Act, 1994 the period of thirteen weeks after the cesser of a health insurance contract is hereby prescribed.

13. Articles 5 to 12 of these Regulations are hereby declared to be penal Regulations for the purposes of section 4 of the Health Insurance Act, 1994 .

GIVEN under the Official Seal of the Minister for Health, this 28th

day of March, 1996.

MICHAEL NOONAN,

Minister for Health.

EXPLANATORY NOTE.

These Regulations provide that registered undertakings cannot refuse health insurance cover to a person under the age of 65 except in certain limited circumstances. They also provide for maximum waiting periods for eligibility for payment under a health insurance contract, excluding payments resulting from injury or accident, in respect of first entry to health insurance and in respect of pre-existing medical conditions. They provide for persons whose cover has ceased for less than 13 weeks to become insured again without affecting their position as regards waiting periods served, provided the same level of cover is involved. The Regulations prescribe the waiting period applicable when a subscriber effects a health insurance policy which provides a higher level of cover. They also provide for cover from date of birth where an infant has been named as an insured person within 13 weeks of that date.