Health Insurance

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Health or “Private Medical” insurance is designed to cover the costs of private medical treatment for curable short-term illness or injury (commonly known as acute conditions). Most people buy this type of insurance to gain the reassurance that in the case of illness or injury the treatment will be available promptly. As a private patient you can choose when treatment will take place, the specialist who treats you and the hospital.

As with all insurances, make sure you read your policy document to familiarise yourself with its terms and conditions.

When looking at cover, it is useful to know that treatment is often categorised in the following way:

1. In-patient Treatment. This consists of treatment you receive when you are hospitalised and have to stay for one or more nights.

2. Day-patient Treatment. This is sometimes referred to as day-care, or day-case. You may need to go to hospital for treatment or investigations without the need to stay in hospital overnight.

3. Out-patient Treatment. This consists of treatment you receive from your doctor or consultant which does not require you to stay in hospital either as an in-patient or day-patient.

There are various policies with varying levels of benefits – starting from low-cost schemes, offering limited cover, to those which offer wide-ranging cover and benefits. Most schemes offer cover for both in-patient and day-patient care, but do not always offer a full refund. Some are limited to cover treatment in the Maltese Islands whilst others are extended to cover treatment overseas as well.

It is important to note that benefits described as ‘full refund’ will be limited to what the insurer considers as “customary and reasonable” charges. When an insurer determines the amount that is "customary and reasonable" for a claim, it examines the amounts it had already paid in claims for those services as well as the "reasonable cost of service" for your particular medical condition. Unfortunately, getting access to that information may be difficult for patients. Some insurers publish these rates on their website. However, medical practitioners are not bound by these rates.

It is best if you ask the doctor's office how much the medical intervention is going to cost. Once you have that amount, call your insurer, explain that you have an appointment for a particular service, and you need to know the customary and reasonable rates for that service.

Insurers usually have agreements with private hospitals to enable direct settlement with the hospital provider concerned. This depends on the level of cover you have chosen. Direct settlement may not be possible with some medical practitioners. You should therefore check with your insurer before undergoing treatment. This can be done either by calling them or by referring to their website.

Choose the scheme or plan that suits your requirements and budget.

You may approach an insurer or insurance intermediary. Not all insurance companies or agencies offer this class of insurance. So shop around.

You will be required to fill in an application and this must be completed with full details of all the persons to be insured. Remember that failure to disclose relevant information could invalidate your insurance cover.

Before you buy private medical insurance, you need to understand the following:

  • You agree to give the insurance company all the information (including detailed medical history) it needs. If you don’t give accurate details, your insurance company can refuse to pay your claim or could cancel your policy.

  • A medical insurance policy is an annual policy, renewable every twelve months. You can choose to pay either annually, quarterly or monthly if the company offers such options. If you don’t pay instalment premiums, your cover will stop.

  • The cost of your premium may increase when you renew your cover.

  • If your insurance company plans on making changes and improvements to a scheme, policyholders will be informed before their next annual renewal. Policyholders can continue with their cover on the new scheme which would replace the expiring schemes.

  • If you change insurance companies, you may not be covered for conditions or treatments that your existing policy covers.

Once you have received your policy, read it carefully. Make sure you understand what you are covered for or not covered for. Read the policy wording in full and ask questions if you don’t understand anything.

You must keep to the terms and conditions of your policy.

Insurance companies may accept your application for health insurance cover on the basis of a medical history declaration. This is known as “Medical Underwriting”.

You will be asked to fill in a proposal form which will include full details of your medical history and that of any members of your family to be insured. The insurer may then decide to obtain further medical reports and may also approach your family doctor or check your hospital records for further details. Based on the information you provide, the insurer will decide the terms and conditions of your cover. Insurers and insurance intermediaries are bound by law to treat all such information under strict confidential terms.

The following factors can affect your premium:

  • Increase in medical costs is the major cause of increases in premium. New methods of treatment are improving quality of life at a cost. Most private medical insurance policies aim to cover these treatments as they become established medical practice and available privately. Likewise, the sophistication and complexity of tests used to diagnose illness and injury is also increasing. Such tests are becoming far more widely available in private hospitals.
  • Moving into an older age bracket will also generally mean an increase in your premium. As people get older they are more likely to need and receive medical treatment.
  • Joining through a group may entitle you to a group discount.
  • Your choice of benefits will also affect what premium you pay:

    1. Choosing a scheme with more limited cover e.g. a basic scheme or a private clinic rather than a private hospital plan is less expensive. To reduce the premium one can opt for an in-patient only scheme or opt for an excess.

    2. Scheme including overseas treatment are more expensive.

 

It is your choice to change insurance companies. However, a new company may not cover existing medical conditions, which may have developed since you took out your policy. You may also forfeit any premiums you have paid up front.

It is best to check with your new company as to how the change may affect your cover.

Children under 18 years of age are minors and cannot be insured in their own name. However, you may insure them as the dependants of an adult i.e. with the mother, father or legal guardian.

In the case of a newborn child, most insurers will include your newborn child for free until the next renewal date. Make sure you inform your insurer as soon as possible after birth. Some insurers may impose a time limit for this notification, so check carefully. Subsequently, when your medical insurance policy comes up for renewal you may choose whether you want your child to remain insured or not.

Insurance companies will not refuse to cover you because you are disabled. As with other pre-existing conditions, your insurance provider may exclude cover related to your disability.

Not all health policies offer such cash benefit. Moreover, such a benefit may only apply according to the scheme you have chosen.

If your policy offers such benefit, this is normally subject to you spending at least one night in a non-paying / government hospital or undergoing surgery as a day case. Emergency treatment received at such hospitals does not entitle you to a cash benefit.

  • You cannot take out an insurance covering treatment for a medical condition that you already know about.

  • Your insurer will also exclude any pre-existing medical conditions or chronic illnesses. This means that a medical condition that you have suffered from, received treatment for had symptoms of or for which you sought medical advice in the past before you applied for medical insurance may not be covered. This exclusion could be indefinite or for a set period of time. If an insurer excludes a pre-existing medical condition that you suffered from before joining, the insurer may eventually offer you cover for that condition if you do not receive any treatment, advice or medication for a number of years.

  • Standard health insurance policies also exclude certain types of treatment such as routine checks, preventive treatment or dental care. Preventive treatment is considered beyond the scope of a health insurance policy since it is predictable and not treating a medical condition.

  • Out-patient treatment if you choose an in-patient and day-case cover only policy.

  • Most insurance policies also exclude medical visits for routine pregnancy, fertility treatment, sterilisation, treatment of sexual problems, AIDS/HIV and cosmetic surgery, the cost of vaccinations, medical screening and treatment to remove any tissue that is not diseased.

  • Certain insurers do not cover congenital conditions except for medical treatment undertaken in an emergency operation carried out within twenty eight days of birth. These are medical conditions existing before or at birth and may be inherited or caused by environmental factors.

Remember that health insurance policies are there to cover treatment by a medical specialist who is a medical practitioner (doctor) who has received specialist accreditation and who is recognized as such also by the insurer. Cover for physiotherapists, alternative treatment practitioners such as acupuncturists etc may be covered under certain policies but will be stated as such in the benefit table. Cover for podology and certain other practitioners is usually very limited if existent at all in most policies.

Therefore, never assume that your policy covers for all medical conditions. Check your policy and, if in doubt, contact your insurer

Apart from emergency admissions to a hospital, all treatment has to start with a referral by your family doctor who may refer you to a specialist. However, some schemes accept specialist fees without referral by your family doctor for example in certain instances such as visits to gynaecologists, or paediatricians.

These are some important guidelines which you may follow in the event of a claim: 

  1. Go to your family doctor and ask him to complete your claim form. Your family doctor may refer you to a specialist. Remember, you are entitled to claim back consultation fees or medical fees within the terms of the policy but you are not entitled to a reimbursement of the clinic fee for the use of waiting room facilities. 

  2. The specialist may in turn refer you to further tests or admit you to hospital. In patient or day care treatment as well as certain outpatient tests require a pre-authorisation from your insurer. Therefore before you commence any treatment you should check your policy and contact your insurance company if necessary. Ask the insurer to quote the particular section in the policy which entitles you to claim under your policy

  3. The insurance company will guide you as to the extent of your cover and whether direct settlement of bills may be effected. If direct settlement is not pre-authorised by your insurer you may have to settle hospital and specialist fee directly and then claim from your insurer. However the hospital may ask you to sign a document guaranteeing payment. 

  4. You should always check how much the specialist is going to charge for the treatment and verify that the amount is what the insurer will pay. Some insurers may have a list of consultants who do not accept direct settlement and require policy holders to settle their fees and then recover from the insurer. In these cases there may be a shortfall between what the specialist charges and what the insurer is willing to pay.

In certain cases an insured may get a pro-rata refund as long as he/she has not submitted any claims during that policy year, but one needs to check the cancellation clause of the policy.

The European health insurance Card (“EHIC”) benefits EUcitizens by providing them with a single personalised card that demonstrates their right to access public healthcare during temporary visits in another EU Member State as well as in Norway, Iceland, Liechtenstein and Switzerland.

With the EHIC, if you will need unplanned medical treatment while visiting an EU country or Iceland, Liechtenstein, Norway and Switzerland, you will get the same access to public sector health (e.g. a doctor, a pharmacy, a hospital or a health care centre) as a national of these countries. If you receive medical treatment in any of these countries at a charge, you will be reimbursed either immediately or on your return home. However, to receive this beneficial treatment you will need to take your EHIC with you.

It is important to note that the card does not cover your health costs while abroad if you are to obtain treatment for an illness or injury that you had before travelling.


You can either apply online at:
(https://ehealth.gov.mt/healthportal/strategy_policy/eu_healthcare_entitlement_unit/applying_ehic.aspx)
or personally at the Entitlement Unit, 23 St John Street, Valletta, or send the relative application form which you can obtain from any Local Council.

Only persons who meet the following criteria may apply for an EHIC:

If you are an ordinary resident in Malta and you are:

• A national of Malta.
• A spouse or minor child of a Maltese national.
• A non-Maltese national and paying NI contributions or receiving a state pension from Malta.
• An EU or EEA national in possession of a certificate of Entitlement.
• A stateless person or refugee.
• A full time student following a course at the University of Malta or MCAST.

There are no fees for this card.

If you disagree with a decision about your claim, your first step should always be to raise this directly with the insurer who should have a complaints procedure.

If you cannot resolve the matter then you can lodge a complaint with the Consumer Complaints Manager at MFSA. Click here for more information about the role of the Complaints Manager.



Last updated: Sep 07, 2016