A Guide: Making Insurance Simple

What is health insurance?

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 of knowing that treatment is available promptly, if they become ill or are injured. In Gibraltar, as a private patient you can often choose when treatment will take place and the specialist who treats you. Some illnesses, conditions and treatments may not be covered by a private medical insurance policy and these are common to most schemes. Some examples are pre-existing conditions, routine or screening tests (such as mammograms, bone density screening or calcium screening, smear or prostate tests), self referred treatment (consultations and treatments without referral from your doctor), chronic conditions, congenital conditions, drug abuse, HIV/AIDS, routine dental care and self-inflicted injuries, amongst others. Pregnancy and childbirth may be subject to special conditions and/or monetary limits.

Make sure you read your policy to familiarise yourself with the cover.

In terms of income tax, in Gibraltar there is the added benefit that the first £1,000 of eligible premiums paid in the tax year by an individual for personal health insurance cover or for the benefit of that individual's spouse or dependent children is fully tax deductible.

How do I choose the right cover?

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

  1. In-patient This is when you go into hospital for private treatment or investigations and stay for one or more nights.
  2. Day-patient This is sometimes referred to as day-care, or day-case. It is when you go into hospital for private treatment or investigations but do not need to stay in hospital overnight.
  3. Out-patient This is when you receive treatment or investigations or consultations which do not require you to stay in hospital either as an in-patient or day-patient. There is a large variety of schemes or plans available - from low-cost schemes, offering limited cover, to those which offer wide-ranging cover and benefits. Most schemes offer cover for in-patient and day-patient care, but not always on a full refund basis. Some are limited to cover treatment geographically whilst others are extended to cover treatment to overseas as well.

Remember to choose the scheme or plan that suits your requirements. Decide whether you need cover as an individual or for your family.

How do I join a health scheme?

You may approach an insurer or insurance intermediary for medical insurance. Your employer may also provide you with some health insurance as a benefit. You will be required to complete an application form and this must be completed with full details of all the proposed members. Remember that failure to disclose relevant information will invalidate your insurance cover.

Will I need to provide details of my health?

Insurance companies may accept your application for medical cover in one of following two ways:

1. Medical history declaration

In this instance you will be asked to fill in a form and provide full details of your medical history and that of any members of your family who will also be covered, at the time of application. 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. Insurers and insurance intermediaries are bound by law to treat all such information under strict confidential terms.

Cover for certain medical conditions may be excluded. A pre-existing condition or a condition that is likely to recur, like chronic conditions, would not be covered. This means that a medical condition that you have suffered from, received treatment for, had symptoms of or for which you sought medical advice during the (usually) five years before you applied for medical insurance would not be covered. Check carefully with your insurer or insurance intermediary. This exclusion could be indefinite or for a set period of time. If you join a scheme and the insurer excludes a pre-existing medical condition that you had suffered from, 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.

2. Moratorium

In this instance the insurer will still ask you to complete a form but will not request full details of your medical history at application stage. The insurer will not cover any medical condition that existed in the last (usually) five years. Further enquiries will be made at the time of a claim.

Normally, the same criteria mentioned above apply, i.e. pre-existing medical conditions will not be covered. These conditions may become eligible for cover, but only if you do not show symptoms, or receive treatment, medication, tests or medical advice for these conditions for a continuous period of (usually) two years, after your policy has started. Other conditions, for example chronic conditions, will probably never be covered because such conditions will need regular or occasional treatment, medication, tests or advice for them.

Check the terms of the "moratorium" carefully and ask for full details when you are not sure.

What will affect my premiums?

Increase in cost of medical care is the first reason which would affect your premium levels. Each year more people claim on their insurance cover for private medical treatment. The number and sophistication of treatments to improve quality and term of life is increasing steadily. 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 as is their cost.

Moving into an older age bracket will also generally mean an increase in your premium rate. As people get older they are more likely to need and receive medical treatment, which means that private medical insurance premiums will usually increase with age to reflect this.

It is good to remember that given that all claims are paid from a central fund, which is made up from the premium payments of all persons insured, it is vital that the amount paid out in claims does not exceed the amount paid into the fund.

Your choice of cover will also affect what premium you pay:

  • Joining through a group may entitle you to a group discount.
  • Choosing a plan with more limited cover.
  • Excluding overseas treatment.

Can I insure my children only?

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 or father.

Will cover be affected if I am disabled?

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

How do I make a claim?

Apart from emergency admissions to a government hospital, all medical treatment has to start with a referral by your GP to an appropriate specialist. However some schemes accept specialist fees without referral by a GP in certain instances such as visits to gynaecologists or paediatricians. Always check with your insurer or insurance intermediary.

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

  • Read your policy document to check whether your condition is covered by your policy.
  • Go to your GP and ask him to help you complete your claim form. Your GP may recommend that you see a specialist. Your GP may charge a small fee which may not be covered by your insurance.
  • Go to your specialist, who may recommend further tests. The specialist may recommend either in-patient, day-patient treatment or further out-patient treatment.
  • Before you commence any treatment privately, you should call your insurance company to check that the costs of the intended treatment are covered. In fact, some insurance companies insist that you do this. Ask them to quote the particular section in the policy which entitles you to claim under your policy.
  • Stay in contact with your insurance company, which will confirm that any treatment you plan to receive is within your cover. Your insurance company will tell you whether a direct settlement of bills may be effected or whether you are expected to settle the bills first.
  • You may choose to settle hospital and specialist fees and then recover them from your insurer. However you may opt for direct settlement by your insurer provided you inform them of the claim prior to or as soon as possible after being admitted to a private hospital. Always agree the claim with your insurer according to your scheme before signing any documents in the hospital.
  • Your insurance company will give you all information required regarding payment.

Different plans offer varying degrees of cover and your insurance provider will be happy to advise you at any stage of the treatment process.

If I receive treatment in a government hospital, can I claim under my medical insurance?

Your scheme may entitle you to a cash benefit according to the levels you have chosen. This is normally subject to you spending at least one night in the government hospital or undergoing surgery as a day case. Always check what your scheme allows and will pay you cash benefits for.

Do I get my premium back if I cancel my policy?

Most insurers will refund you the pro-rata premium for the remaining period of cover provided no claims had been paid out to you or any member of your family insured under the same scheme.

What if I want to change to a new insurance company?

You may change insurance companies. However, it is important to remember that a new company may not cover any previous or existing medical conditions which your current insurance company is covering because the condition developed after you joined their scheme. You may also lose 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.

What should I do before buying medical insurance?

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

  • You agree to give the insurance company all the information they need. If you don't give full and accurate details, your insurance company will refuse to pay your claim or will even cancel your policy.
  • You agree to pay regular monthly or yearly premiums as long as you want cover. If you don't pay premiums, your cover will stop. Your insurance company will only pay for costs you have paid, or agreed to pay up to the last date covered by your premiums.
  • The cost of your premium may increase once a year when you renew your cover.
  • Your individual premiums are not influenced by the number of claims you make but premiums under a group plan may do so.
  • If your insurance company plans on making changes and improvements to a scheme, all customers will be told before they renew. This will not prevent you continuing your cover.
  • 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. You must keep to its terms and conditions.

What should I do if I am having trouble settling my claim?

What should I do if I am having trouble settling my claim?