Complementary health insurance

 

Benefits paid by Social Security represent 77% of the total amount spent on medical care and goods. To supplement compulsory health insurance schemes, insurers (provident institutions, mutual societies, private insurance companies, insurance subsidiaries of banks) offer complementary health insurance contracts. The healthcare reimbursement system involves an assortment of players (social security, insurance, health professionals).

To choose their complementary insurance, the patient must fully understand how this system works.

What is complementary health insurance?

Complementary health insurance is a contract that aims to cover all or part of the health expenses relating to sickness, accident, and maternity, not covered by compulsory health insurance.

Individual or collective contract?

Supplementary health insurance can be taken out either individually, by contacting an insurer, a mutual or a bank directly, or by signing a group contract through the employer or professional associations or no.

Since 1 st January 2016, all employees, regardless of their business size, receive supplementary collective health. The health coverage put in place in the company contains minimum guarantees. Thus, employees benefit from the payment of the amount of the co-payment (the part left to the insured after reimbursement by Social Security based on the conventional rate) for consultations, acts, and services reimbursable by the insurance. Disease with a few exceptions.

The company's supplementary plan also covers the following:

• the entire daily hospital rate in the event of hospitalization;
• dental costs (prostheses and orthodontics) up to 125% of the conventional rate ;
• Optical costs on a flat-rate basis per period of 2 years (annually for children or in the event of vision changes) with a minimum coverage set at 100 € for a simple correction, 150 € (or even 200 € ) a complex correction.

Who are the people insured?

What can take out supplementary health insurance for the benefit of one or more family members? In the case of a group contract taken out, for example, the employer for employee benefit may extend the right to join in some instances to members of the employee's family.

What guarantees are offered?

The reimbursement guarantees for the costs of care and medical goods vary according to the insurers' contracts. They range from the payment of the single user fee to the total or partial reimbursement of the costs left to the insured's charge, which can also be added guarantees and additional services.

Coverage for healthcare costs and medical goods

The nature of the costs of medical care and insured medical goods varies according to the contracts. Support is generally provided for:

• the costs of medical or surgical hospitalization act, and costs of surgery;
• the daily hospital fee and, sometimes, the supplement for a private room;
• consultations and visits by general practitioners or specialists;
• pharmaceutical costs;
• analysis and laboratory costs;
• acts of current medical practice and acts of medical auxiliaries;
• acts of electrobiology, neuropsychiatry, obstetrics;
• optical costs: frames, glasses, and lenses;
• the cost of dental care and prostheses;
• The costs of orthopedics and prostheses.

So-called "responsible" contracts

Most of the contracts sold on the market are so-called "responsible" contracts that comply with the payment conditions defined by regulations. The services of a so-called "responsible" contract are as follows:

• 100% of the social security reimbursement base on current care (consultations and drugs with significant medical benefit reimbursed at 65%);
• 100% of the daily flat rate billed by hospitals, with no time limit;
• 100% of the social security reimbursement base for routine dental care (consultations and a care such as scaling or caries treatment.);
• 100% of the social security reimbursement base for optics. For optical costs that are beyond the conventional rate, the complementary health insurance can optionally offer, cumulatively, limited coverage as follows:
• a pair of glasses every two years at most (annually for children or in the event of vision changes);
• frame up to 150 €;
• Minimum and maximum limits depending on the equipment's complexity (example: for a single glass, reimbursement between € 50 and € 470).

Depending on the contracts, complementary health insurance may offer to cover specific excess fees for professionals who have signed up to access care contracts.

Responsible contracts do not support:

• the flat-rate contribution of € 1 for each consultation procedure carried out by a town doctor, in an establishment or hospital, up to a limit of € 50 per year and per person;
• Medical deductibles were payable by the insured for medicines and medical transport. The amount of the excess is capped at € 50 per year and per person;
• an increase in the insured's contribution for non-designation of a treating doctor or consultation of another doctor without a prescription from the treating doctor ("outside the treatment path");
• Excess fees when the insured consults a specialist to which the law does not allow direct access without going through an attending physician.

The different levels of coverage

In general, there are three levels offered by insurers to meet various care needs:

• a basic cover which guarantees the reimbursement of the user fee based on the convention rate of the compulsory scheme Thus are reimbursed the fees of doctors and care not exceeding the agreed rate of Social Security;
• More extensive coverage, which goes beyond current expenses. It also offers better services in the event of hospitalization;
• Complete coverage which guarantees all or part of the excess fees (150%, 200%, or even above the agreed tariff of the compulsory scheme), but without exceeding the amount of the actual costs justified by the insured. It also offers better care for cures and hearing aids, dentures, glasses, contact lenses, etc.

Guarantees and additional services

What may also offer provident guarantees in some instances to supplement the benefits of the compulsory scheme.

• Temporary incapacity guarantee

This guarantee provides for the payment of a daily allowance in the event of a work stoppage following an illness or an accident. Its amount is fixed when the contract is taken out according to the income of the interested party. It cannot exceed the amount of the actual loss of income which remains the insured's responsibility after the intervention of social organizations.

As a general rule, daily allowances are only paid after the expiration of a certain period, known as the excess (for example, from the 7th day of sick leave ). This deductible is sometimes different depending on whether it is an accident or an illness. The maximum duration of payment usually extends over one year (3 years in some contracts).

• Disability guarantee

According to the provisions of the contract, it provides for the payment of a capital or an annuity in the event of the permanent, total, or partial disability following an illness or an accident.

The insurer's expert doctor sets the disability rate according to the reference scale specified in the contract.

Some insurers offer formulas that include other additional services such as:

• a maternity premium or a birth package;
• the cost of care or prevention not covered by the compulsory scheme;
• A funeral package.

Some support services are also provided in the supplementary health insurance policies. 

They can take different forms:

1. telephone assistance, health advice platform, information service;
2. housekeeper, nurse;
3. child care;
4. tutoring ;
5. animal care;
6. Repatriation.