The benefits are generally expressed as a percentage, not of the patient's costs, but the conventional tariff (TC) or reimbursement basis (BR), set by Social Security for the various health benefits. The amounts announced by the insurers take into account the reimbursement of Social Security.
Examples of reimbursement for a patient respecting the course of care and consulting his general practitioner in the free-fee sector (sector 2), whose consultation price is 50 euros:
- 100% TC means that Who will reimburse the insured up to 100% of the conventional rate (TC) of Social Security, the conventional rate being 25 €.
In this case, Social Security covers 70% of the conventional rate, i.e., € 17.5 (€ 25 x 70%).
Complementary health insurance covers 30% of the conventional rate. The amount reimbursed by the complementary health insurance will therefore be € 25 - € 17.50 (social security part) - € 1 (the fixed part not reimbursed), or € 6.5 (amount reimbursed by the health supplement).
It will be reimbursed in total: € 17.50 by Social Security + € 6.5 by complementary health insurance, i.e., € 24. The sum remaining payable by the patient will be € 26.
- 200% TC means that What will reimburse the insured up to 2 times the conventional Social Security rate, i.e., € 50 (2 x € 25).
In this case, the complementary health insurance covers: € 50 - € 17.50 (amount reimbursed by Social Security) - € 1 (the fixed portion not reimbursed), i.e., € 31.5.
It will be reimbursed in total: € 17.50 by Social Security + € 31.50 by complementary health insurance, i.e., € 49. The amount remaining payable by the patient will be € 1, amount corresponding to the non-reimbursed lump sum
What are the characteristics of supplementary insurance contracts?
- Variable contributions
The prices depend on the reimbursement ceiling for the various services, on the scope of cover, on the domicile, and the age of the insured.
- Waiting or waiting periods
This is a period counted from the subscription and variable depending on the contracts (from a few days to 12 months), during which the insurer does not cover certain services. During this period, the insured person will not benefit from reimbursements for the services concerned. In the same contract, these deadlines may differ depending on the nature of the illness or the medical acts.
Examples:
- in the event of pregnancy, a waiting period of 9 months for the pregnant woman may be applied for guarantees such as obstetrics, the maternity package, or even the private room;
- a waiting period of 6 to 9 months may be applied in the event of dental reimbursement;
- What may impose a waiting period of 7 days to benefit from compensation following a work stoppage.
For a 3-month waiting period, starting on January 15, the contract's effective date, the insured's protection will begin on April 15. If an event occurs between January 15 and April 15, the insured is not covered. If the event occurs after April 15, the insurer will pay for it.
In the event of an accident, most often, the benefits are due upon subscription.
- The third-party payment
Agreements signed between insurers and certain health professionals (pharmacists, pharmaceutical laboratories, radiologists, etc.) make it possible to exempt the insured from the advance of all or part of the care costs left to them by the compulsory scheme taken out additional insurance with an insurance company.
In practice, the insured needs to present the healthcare professional with a third-party payment certificate issued by the insurance company.
- Evolution of guarantees and contributions
The insurer cannot reduce the guarantees or increase the rate on a case-by-case basis. The contracts may provide an annual adjustment of guarantees and contributions based on an index (AGIRC point, the price per day of hospitalization, composite index, etc.). Independent of this adjustment, the contribution can be revised for other reasons, such as the change of the age group when the contribution has been fixed.
- How to terminate the contract?
The insured have the right to terminate their complementary health contract following the general conditions provided for in the contract.
In applying the Chatel law [1], the insurer is required to inform his client each year on the notice of expiry of the possibility of terminating the insurance contract and the deadline for exercising this right. When the insured receives the notice of expiry less than fifteen days before this date, the insured has a period of twenty days following the date of sending the notice to terminate his contract.
The Chatel law only applies to members of individual health insurance contracts.
The insurer can also terminate the contract following the general conditions.
How to choose the proper complementary health?
Choosing the right health insurance is not always easy. To choose a complementary health plan that suits them, the insured must:
- favor contracts that indicate the coverage offered and the reimbursements obtained; examine the amount of Social Security reimbursement for each medical act and the amount that remains payable after reimbursement of supplementary health;
- adapt the guarantees to their budget, their family, and their medical consumption, taking into account, in particular, the following elements:
- - the family unit (how many dependent children?);
- - the state of health of each;
- - the professionals consulted (depending on the region, it is more or less difficult to find approved doctors. It is also useless to take out a contract that reimburses the overruns if approved doctors are only consulted).
In all cases, it is essential to request a table of benefits summarizing all reimbursements, as well as the general conditions, and above all to compare several quotes for one or more options of the proposed complementary health contract.
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