General And Special Conditions

The Types Of Paying Third parties proposed:

When talking about third – party payment, it is for the patient to be exempted from the advance fees to the practitioner.

There are now four types of third-party payers: mandatory, optional, full or partial.

The mandatory third-party payer applies:

If you benefit from the Complementary Universal Health Cover (CMUC)

If you benefit from State Medical Aid (AME)

If you benefit from the Health Supplement Payment Assistance (ACS)

If you are a victim of an accident at work or an occupational disease

During preventive actions in the context of screening (for example, a mammogram performed during breast cancer screening)

If you are hospitalized in an institution under contract with Health Insurance

If you are under the age of 15 and you consult a health professional for your contraception

If you have a long-term condition (ALD)

If you are pregnant

The optional third-party payer may apply:

When the pharmacist delivers medicines reimbursed by the social security system

During examinations, care, provided by the radiology or medical analysis cabinets.

When consulting your doctor, if you are facing financial difficulties for example.

The full third-party payment applies when the patient has no fees to pay on the spot. In the context of a consultation with a general practitioner for example, instead of paying 25 $ for consultation, the patient pays nothing. The practitioner will be paid by the social security and by the mutual Uae-plans of the patient or via the help that he perceives (CMUC, ACS, and AME).

The partial third-party payer does not intend to practice the absence of advance costs only on the part of the act repayable by social security. The co-payment, the fixed participation of 1 $ (what is called the “rest dependent”), must be paid by the patient directly on the spot.

The amounts of the deductibles:

There are 3 types of deductibles that will remain your responsibility because they are applied by social security and cannot be reimbursed by your mutual.

The medical exemption:

Which applies when you buy medicines, if you use paramedical acts or if you use a medical transport. This medical deductible is capped at $ 50 per year and per beneficiary.

The fixed participation of 1 $ :

which concerns all the adults and which applies on the consultations and acts of the doctors (generalist or specialist), as well as the examinations of radiologies and the medical analyzes. It is capped at 50 $ per year and per person.

The 18 $ package:

Which is your responsibility when you undergo a medical act equal to or greater than 120 $ (or whose coefficient is equal to or greater than 60).

The package of 18 $ can sometimes and under certain conditions be supported by some mutuals.

The franchise is therefore an amount that will remain your responsibility:

Health insurance Uae-plans and mutuals may provide deductibles on certain reimbursement items. These franchises are generally expressed in euros.

Thus, it is quite common to see amounts of dental reimbursements expressed as follows: dental prostheses will be reimbursed up to 350% of the social security reimbursement base, with a deductible of 60 $. This means that 60 $ will remain your responsibility and that your mutual will intervene beyond 60 $, up to 350% of the reimbursement base within the limit of the expenses that you have incurred.

Waiting periods:

The waiting period (sometimes referred to as waiting period or probationary period) corresponds to a period during which the mutual insurance Uae-plans company does not intervene. As a general rule, this period applies to dental, optical, hospitalization and maternity posts.

In other words, your contract provides for guarantees, which you can only use on the items concerned after a waiting period. For example, you have a very large dental guarantee. Your mutual provides for a waiting period of 6 months, this means that you can only use these guarantees after a period of 6 months, not before.

It is necessary to be very vigilant when subscribing to your contract, especially if you choose very high guarantees on the positions mentioned above.

However, some mutuals or insurance companies do not provide for waiting periods in their contracts. Which means that all the guarantees can be used immediately after the subscription.

Warranty exclusions:

In all types of contracts, you will find exclusions of guarantees. Complementary and mutual health are no exception. You will find them in the general conditions of your contract, which must be given to you with this one.

The exclusions usually common to all health contracts are related to the faulty behavior of the insured person himself (suicide attempts, alcohol-related injuries, or damage suffered as a result of a fight, for example).

The care practiced in certain establishments can also constitute an exclusion (center heli-marine or of thalassotherapy, centers of long stays, cure of sleep, detoxification, etc …). Some personal care is also generally excluded from mutuals (cosmetic surgery does not follow an accident or illness, aesthetic laser treatment …)

General and special conditions:

Your health insurance Uae-plans contract will therefore consist of two elements: the general conditions (which govern the general rules applied to the type of contract you have just subscribed) and the special conditions (which constitute your contract).

The general conditions are information provided by the insurer on the legal conditions of application of its services. They are expressed in general terms and cannot, in general, be modified. The general conditions of a contract have a common origin and are fixed either by the insurance code or by the code of mutuality.

The special conditions are your contract. They are unique and individualized to fit your needs. They list your choices: your levels and amounts of guarantee and deductibles, your contribution, the effective date of your contract. They are personalized (with your coordinates, among others).

Good to know:

Although equally important, in case of dispute, special conditions always take precedence over the general conditions.

The cost of contributions:

The insurance or mutual health insurance Uae-plans contribution consists of several parameters:

The nature of the risk:

Depending on your age, the composition of your household and your location, the premium will vary. For example, a person living in Paris over the age of 50 will use statistically more medical care than a person living in the Creuse and less than 20 years old.

The level of guarantees you have chosen: it is obvious that the longer the contract provides for repayment, the higher the contribution will be.

Fees and taxes:

Insurers and mutuals will impact their operating costs (premises, salaries, fixed costs …) and their management fees (drafting contracts, claims management …) on the contracts they make subscribe. Mutuals are not subject to VAT but to specific taxes. Insurers for example are taxed between 7% and 9% (depending on conditions).

All of these parameters will therefore constitute your insurance contribution.

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