Health Insurance Law (2003 Revision) HEALTH INSURANCE LAW

Health Insurance Law (2003 Revision) Supplement No. 2 published with Gazette No. 16 of 11th August, 2003. HEALTH INSURANCE LAW (2003 Revision) Law 15 of 1997 consolidated with Law 28 of 2001 and as amended by the Cayman Islands (Constitution) (Amendment) Order 2003 (U.K.S.I. 2003 No. 1515). Revised under the authority of the Law Revision Law (1999 Revision). Originally enacted - Law 15 of 1997-19th June, 1997 Law 28 of 2001-26th September, 2001. Originally made- U.K. Order-12th June, 2003. Consolidated and revised this 8th day of July, 2003. Health Insurance Law (2003 Revision) 2 Health Insurance Law (2003 Revision) HEALTH INSURANCE LAW (2003 Revision) ARRANGEMENT OF SECTIONS 1. Short title. 2. Definitions. 3. Compulsory health insurance. 4. Insurance for high risk insurance persons. 5. Payment of premium. 6. Premium of spouse and children. 7. Unlawful deductions by employer. 8. Employees to provide information to employer. 9. Duty of employer to provide information to employee. 10. Recovery of damages from employer in default. 11. Voluntary health insurance. 12. Termination of contract. 13. False declarations, etc. 14. Liability of officers of corporate bodies. 15. Recovery of payment by provider of a health benefit. 16. Approved provider shall pay benefit directly to health provider. 17. Disputes. 18. Appeals. 19. Regulations. 3 Health Insurance Law (2003 Revision) 4 Health Insurance Law (2003 Revision) HEALTH INSURANCE LAW (2003 Revision) 1. This Law may be cited as the Health Insurance Law (2003 Revision). Short title 2. In this Law- Definitions “approved provider” means an insurer licensed under the Insurance Law (2003 2003 Revision Revision) as a Class “A” insurer and approved by the Authority to provide standard health insurance contracts; “Authority” means the Cayman Islands Monetary Authority; “child” means a person who is- (a) under 18 years of age; or (b) over 18 and under twenty-three years of age who is a full time student at a university or other educational institution; and is (i) a child of both parties to a marriage; or (ii) a child who has been treated by both parties to a marriage as a child of the family and includes a step child, adopted child or foster child; or (iii) a child born out of wedlock. “compulsorily insured person” means a person in respect of whom an employer is required to effect a standard health insurance contract under section 3; “employee” means any individual who enters into or works under a contract of employment with an employer whether the contract be oral or written, express or implied, and the term includes a person whose services have been interrupted by a suspension of work during a period of leave or temporary lay-off; “employer” means any person who has entered into a contract of employment with an employee, and includes any agent, representative or manager of such person who is placed in authority over an employee; “group employee” means a person who is employed by the Government on a temporary basis and who is paid at an hourly rate; “health care facility” includes the George Town Hospital in Grand Cayman, the Faith Hospital in Cayman Brac and any public hospital or health care centre established or operated in the Islands by the Government, and any private hospital or medical practice approved under the Health Practitioners Law (1995 1995 Revision Revision); 5 Health Insurance Law (2003 Revision) “high risk insurance person” means a person who, by reason of a medical condition or a history of illness, has been refused cover at the standard premium under a standard health insurance contract by two or more approved providers; “indigent person” means a person who, in the opinion of the Minister for the time being responsible for social services acting on the advice of the Director of Social Services, is unable, by reason of inadequate financial resources, to pay for health insurance or medical services; “partially uninsurable person” means a person who has been provided with cover under a standard health insurance contract by an approved provider and who is, by reason of a medical condition or a history of illness, subject to an exclusion or limitation of cover; “prescribed” means prescribed by regulations under section 19; “prescribed health care benefits” means the minimum benefits prescribed by regulations under section 19 to be included in a standard health insurance contract; “registered medical practitioner” means a person registered to practise medicine 1995 Revision under the Health Practitioners Law (1995 Revision); “seaman” means a person who is a member of the Veterans’ and Seamen’s Society of Cayman Brac and Little Cayman or of the Cayman Islands’ Seamen’s Association; “self employed person” means a person over school leaving age whose earnings (otherwise than in the capacity of an employee) derive from his production (in all or part) of goods or services in or from the Islands; “standard health insurance contract” means a contract issued by an approved provider to provide insurance cover in respect of the prescribed health care benefits, being a contract that complies with the prescribed terms and conditions; “standard premium ” means a premium charged under a standard health insurance contract for any person other than a high risk insurance person; “unemployed spouse”, in respect of an employer or employee, means (in the case of a male employer or employee) a woman, or (in the case of a female employer or employee) a man, to whom that employer or employee is married and who- (a) is not living apart from that employer or employee under a deed of separation or order of the court; (b) is not an employer or employee; and (c) is resident in the Islands, and includes a retired person; 6 Health Insurance Law (2003 Revision) “uninsurable person” means a person who, by reason of a medical condition or a history of illness, has been refused cover under a standard health insurance contract by two or more approved providers; and “Veterans’ Association” means the Cayman Islands Veterans’ Association. 3. (1) Every person resident in the Islands shall, unless he is - Compulsory health insurance (a) covered by a contract of insurance effected by an employer under subsection (2); (b) covered by a contract of insurance effected by Government under subsection (3), or where Government does not effect such a contract, medical services are provided to him by Government in accordance with Chapter 18 of the General Orders of the Government; or (c) an uninsurable person, effect a standard health insurance contract in respect of himself, his unemployed spouse and children. (2) Subject to this section, every employer shall effect and continue on behalf of- (a) himself; (b) his unemployed spouse and children; (c) each of his employees; and (d) any child and unemployed spouse of an employee, a standard health insurance contract. (3) Government may effect and continue on behalf of- (a) each officer in a pensionable office or on probation to such an office; (b) each officer serving under a local or an overseas contract; (c) each group employee; (d) each officer in a temporary office; (e) each public office pensioner; and (f) indigent persons, a contract of health insurance on such terms and conditions as are specified in regulations made by the Governor in Cabinet. (4) Government may, on written application to it by or on behalf of- (a) a seaman over the age of fifty-five or his unemployed spouse; (b) a widow of a seaman; 7 Health Insurance Law (2003 Revision) (c) a member of the Veterans’ Association or his unemployed spouse; or (d) a widow of a former member of the Veterans’ Association, where that person is not covered by a contract of health insurance, agree to effect with an approved provider health insurance on behalf of such person on such terms and conditions as are specified in regulations made by the Governor in Cabinet in respect thereof. (5) Government may, on written application to it by or on behalf of a partially uninsurable person, agree to pay for health care services provided to that person at a government health care facility in respect of any medical condition of that person which is the subject of an exclusion or limitation in his standard health insurance contract, and that person shall, unless he is indigent, repay the cost of such health services to the Government. (6) If a spouse ceases to be the unemployed spouse of an employee within the meaning of section 2, the obligation imposed on the employer shall cease to have effect. (7) Subsection (1) shall not require more than one health insurance contract to be effected in respect of any person and, accordingly, if a person is employed by more than one employer, insurance must be effected on his behalf and on behalf of his unemployed spouse and children by his principal employer. (8) Where a person is employed by two or more employers, an employer shall be deemed to be a principal employer of that person if that employer employs that person for more than fifteen hours a week. (9) Where a person is employed by two or more employers and each employer employs him for a similar amount of hours a week or for less than fifteen hours a week, the principal employer shall be that employer who first retained the services of the employee. (10) The children of two employees who are spouses of each other shall be covered under only one insurance contract which shall be determined by the employees. (11) The employer of a child shall not be required to effect a contract of health insurance in respect of a child where that child is employed on a part-time basis or only during school holidays. 8 Health Insurance Law (2003 Revision) (12) Subsection (1) shall apply to every self-employed person, and every partner in a partnership shall be regarded as self-employed. (13) Whoever fails to comply with subsection (1) or (2) is guilty of an offence and liable on summary conviction to a fine of five thousand dollars, and on conviction on indictment to a fine of ten thousand dollars. 4. High risk insurance persons shall be insured as prescribed by regulations Insurance for high risk made by the Governor in Cabinet. insurance persons 5. (1) An employer shall be liable to pay under section 3(2)- Payment of premium (a) the total cost of the standard premium payable under any standard health insurance contract effected in respect of an employee who is not a high risk insurance person; and (b) the total cost of the premium payable under any health insurance contract effected in respect of an employee who is a high risk insurance person, but shall be entitled to deduct, from the salary, wage or other remuneration of each employee- (i) in the case of an employee specified in paragraph (a), an amount not exceeding fifty per cent of the premium so paid in respect of the employee; and (ii) in the case of an employee specified in paragraph (b), the difference between the amount of the premium paid by the employer and the amount the employer would have been liable to pay if the employee was not a high risk insurance person and was covered under a standard health insurance contract. 6. An employer shall be liable to pay the total cost of the premiums under any Premium of spouse and standard health insurance contract effected in respect of the unemployed spouse children and children of an employee under section 3(2), but shall be entitled to deduct from the salary, wage or other remuneration of the employee, in addition to any amount deducted under section 5, the total cost of the premiums so paid in respect of the unemployed spouse and children of that employee. 7. An employer who deducts from the salary, wage or other remuneration of an Unlawful deductions by employee more than the amount which he is entitled to deduct in respect of any employer person under section 5 or 6 is guilty of an offence and liable on summary conviction to a fine of two thousand dollars, and on conviction on indictment to a fine of five thousand dollars. 9 Health Insurance Law (2003 Revision) 8. (1) Every employee shall keep his employer informed of all facts related Employees to provide information to employer to the employer’s liability under section 3(2) and of any change of circumstances which would affect the employer’s liability under that section. (2) An employee who contravenes subsection (1) is liable to his employer for any expense incurred by the employer for which he would otherwise not have been liable. Duty of employer to 9. (1) An employer, shall within fifteen days after the commencement of an provide information to employee’s employment with that employer, give a written statement to the employee employee consisting of- (a) the name and address of the approved provider with whom the employee’s standard health insurance contract has been effected; (b) the effective date of cover under the contract; and (c) the insurance number of the contract of health insurance. (2) An employer who contravenes subsection (1) is guilty of an offence and liable on summary conviction to a fine of one thousand dollars. Recovery of damages 10. (1) Where an employer to whom this Law applies fails or neglects- from employer in default (a) to effect any contract of health insurance which he is required to effect by section 3; or (b) to comply with the requirements of this Law or any regulations made thereunder relating to the payment of premiums and submission of records, and, by reason thereof, any person has lost any benefit to which he would have been entitled if such failure or neglect had not occurred, that person shall be entitled to recover from the employer in a court of summary jurisdiction as a civil debt a sum equal to the amount of the benefit so lost. (2) In any proceedings brought under subsection (1), a certificate issued by the Authority specifying the amount of any benefit which would, in the absence of any failure or neglect of an employer, have been payable for any benefit under the standard health insurance contract shall be evidence of the facts stated therein. (3) In any proceedings under this section relating to the failure or neglect of an employer to comply with this Law in respect of the unemployed spouse and children of an employee, it shall be a defence for the employer to prove that he did not know, and could not reasonably be expected to have known, that the employee in question had a spouse or children or that such spouse or children 10 Health Insurance Law (2003 Revision) were persons in respect of whom he was required to effect a contract of insurance. 11. Notwithstanding section 3, nothing in this Law shall be construed as Voluntary health preventing any person from concluding with any insurer any other contract of insurance health insurance providing benefits either for himself, his employees, his spouse or children which are greater than those contained in a standard health insurance contract. 12. (1) An approved provider shall not terminate or fail or refuse to renew a Termination of contract standard health insurance contract except where- (a) the premiums under the contract are thirty days or more in arrears; (b) the contract was obtained- (i) by non-disclosure of a material fact; or (ii) by representation of a fact that was false in some material particular; or (c) the employer has given written notice to the approved provider that- (i) a new contract of health insurance has been effected with an approved provider; or (ii) the employer’s business has been taken over by or amalgamated with another employer. (2) A standard health insurance contract terminates on the first day of the month next following the date of termination of employment of an employee; but if that employee does not become compulsorily insured with any other employer, cover under the contract shall continue for a period of one month from the date of termination of employment. (3) An employee shall be liable to pay the total cost of the premiums payable under a contract of health insurance which has been continued pursuant to subsection (2). 13. Whoever, for the purpose of obtaining a benefit or other payment under a False declarations, etc. standard health insurance contract, whether for himself or some other person, or for any other purpose connected with this Law- (a) knowingly makes a false statement or false representation; or (b) produces or furnishes or causes or knowingly allows to be produced or furnished information or any document which he knows or believes to be false in a material particular, 11 Health Insurance Law (2003 Revision) is guilty of an offence and liable on summary conviction to a fine of two thousand dollars and on conviction on indictment to a fine of five thousand dollars. Liability of officers of 14. (1) Where an offence under this Law committed by a corporate body is corporate bodies proved to have been committed with the consent or connivance of, or to be attributable to any neglect on the part of, a manager, director, secretary or other similar officer of the corporate body, or any person who was purporting to act in any such capacity, that person is guilty of an offence and liable on summary conviction to a fine of two thousand dollars and on conviction on indictment to a fine of five thousand dollars. (2) Where the affairs of a corporate body are managed by its members, subsection (1) shall apply in relation to the acts and defaults of a member in connection with his functions of management as if he were a director of the corporate body. (3) A person may be convicted of an offence under subsection (1) although no proceedings are brought against the corporate body in respect of the offence or the corporate body is found not guilty in respect of the offence. Recovery of payment by 15. A sum due to a health care facility or to a registered medical practitioner in provider of a health respect of medical care provided to a compulsorily insured person may, without benefit prejudice to any other remedy, be recovered as a debt either from that person or from the approved provider. Approved provider shall 16. (1) Subject to subsection (2), an approved provider shall pay directly to a pay benefit directly to health care facility or to a registered medical practitioner the cost of or such part health provider of the cost as the approved provider is liable to pay under a standard health insurance contract of a benefit provided to a compulsorily insured person by that health provider. (2) Where a compulsorily insured person provides a receipt or other evidence that he has paid the cost of a benefit received by him, an approved provider shall reimburse such person the cost of or such part of the cost of a benefit as the provider is liable to pay under the contract. Disputes 17. Any disputed claim to a health benefit or a question arising in connection with a standard health insurance contract shall be determined by the Authority in the first instance after such inquiry as the Authority may deem necessary. Appeals 18. (1) A person aggrieved by a decision of the Authority on any claim or question referred to the Authority under section 17 may, within ninety days of the date on which the decision was given, appeal to the Grand Court. 12 Health Insurance Law (2003 Revision) (2) On an appeal under this section, the Grand Court may confirm or reverse the decision of the Authority. 19. (1) Subject to subsection (2), the Governor in Cabinet may make Regulations regulations for the purpose of carrying this Law into effect and, without prejudice to the generality of the foregoing, such regulations may- (a) prescribe the health care benefits to be covered by the standard health insurance contract; (b) prescribe the terms and conditions of the standard health insurance contract, including allowable exclusions and exceptions, provisions as to termination and cancellation, and automatic renewal; (c) prescribe the way in which deductions may be made from the remuneration of employees to cover premiums paid in respect of standard health insurance contracts; (d) prescribe the reports and records relating to compulsorily insured persons that approved providers shall submit to the Authority and when and how they shall be submitted; (e) provide for the appointment of, and the conferment of powers on, inspectors for the purposes of this Law; (f) provide for the maintenance of records relating to standard health insurance contracts; (g) provide for the manner in which disputed matters may be referred to the Authority and the procedures to be adopted by the Authority when considering such matters; (h) provide for insurance cover for high risk insurance persons; and (i) provide for fines for contravention of the regulations. (2) Regulations made under this Law are subject to affirmative resolution by the Legislative Assembly. Publication in consolidated and revised form authorised by the Governor in Cabinet this 8th day of July, 2003. Carmena Watler Clerk of Cabinet 13 Health Insurance Law (2003 Revision) 14 Health Insurance Law (2003 Revision) 15 Health Insurance Law (2003 Revision) (Price $ 3.20) 16