Modifies Law N 18.933 °, Think Superintendence Of Health Insurance Institutions


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"Article 1.-Introducense the following amendments to the law N ° 18.933: 1-replaced article 7 °, by the following:" article 7.-against the resolution to revoke replacement, the affected person may claim, within fifteen working days of its notification, the Court of appeals that appropriate, which shall be dealt in mind on the admissibility of the claim and whether this has been lodged within the legal term. ""
Admitted the claim, the Court will transfer by fifteen working days to the Superintendency. Evacuated the transfer court ordered to bring the cars "in a relationship", adding the cause in an extraordinary way to table the following day, prior drawing room where appropriate. If the Court does not decretare measures to better resolve, will issue a ruling within a period of thirty days, and if enjoin them, within the period of ten days of evacuated them.
To claim against resolutions that impose fines it must be previously recorded in the account of the Court, an amount equal to twenty per cent of the amount of such penalty, which may not exceed five tax units per month, according to the value of to the date of the claimed resolution, which will be applied in tax benefit if it is declared inadmissible or rejected the appeal. In other cases, the consignment shall be equivalent to five tax units per month, in force at the date of the resolution claimed, also aiming to be in the event of inadmissibility or rejection of the appeal.
The resolution issued by the Court of appeals shall be final within the next five days, appeal that will get to know note a Chamber of the Supreme Court, without waiting for the appearance of the parties, unless it considers bringing cars "in a relationship".
Resolutions of the Superintendency shall constitute a executory titles and be applicable the provisions of article 174 of the code of Civil procedure.
Notice of the filing of the appeal does not suspend the effects of the ordered by the Superintendent, without prejudice to the right of the Court to impose an order not to innovate. The resolutions that apply fine, cancel or refuse the registration of an institution, must be only met once rendered the respective resolution.
The Superintendent may delegate to these effects the judicial representation of the Superintendency, in compliance with article 10, point (d)), of this law; in this case officials who have shouldered such delegation, shall take statements before the courts referred to in this article, through written reports, which will constitute legal presumptions about the facts they personally observed, without prejudice to the Faculty of the Court to summon them personally as a measure for best to resolve.
The Superintendent shall be exempt from the obligation to carry out judicial appropriations. "."
2. replace article 9 °, by the following: "article 9.-the SVS will be organized in four departments and will feature a Prosecutor's Office which will be advisory body."
In accordance with the provisions of articles 28 of law N ° 18.575 and 10, letter a), of this Act, the Superintendent will determine the roles that correspond to the Prosecutor's Office and each of the departments for the exercise of the functions assigned to the Agency in charge by article 3 of this law. "."
3 repeal articles 11, 12, 13 and 14.
4. replace article 15, by the following: ' article 15.-the SVS will have, for all legal purposes, the nature of audit institution, in terms of the title I of the Decree Law No. 3.551, 1981. "
Article 15 bis.-the SVS staff shall be governed by the administrative statute approved by law No. 18.834 and, in particular, that performs audit functions, will be fond of article 156 of this legal text. "."
5 replacements articles 16 and 17, by the following: "article 16.-the SVS officers shall be appointed by resolution of the Superintendent and may be it plant or freelance."
Plant officials will be who belong to the stable organization of the institution, on a permanent basis.
Officials to hire will be those who will play temporarily in the Superintendency. Freelance designations may be carried out by part-time and, in this case, the compensation will be proportional to it.
The Superintendent may also hire professionals or experts on specific subjects on the basis of fees for the execution of specific tasks.
The staff from the national health fund, which was pigeonholed in the plant of the Superintendent will keep its pension scheme, without prejudice to the option referred to in the Decree Law No. 3,500 of 1980. "."
6 repeal articles 18, 19 and 20.
7 insert, then of article 21, the following article 21 bis, new: "article 21 bis.-health institutions social security should provide sufficient and timely information to its affiliates with respect to the core subjects of their contracts, such as values of health, general terms and conditions of granting plans."
The social security health institutions shall also keep available to its affiliates and third-party the information referred to in the preceding paragraph. "."
8 replace article 23 with the following: "article 23.-any natural or legal person who has not been recorded for this purpose by the Superintendent, may engage in the giro which corresponds to health institutions in accordance with this law, social security and, in particular, to capture the contributions of health indicated in the second and fourth subparagraphs of article 7 ° of the law N ° 18.469."
You can also put in your local or iron office or notice containing, in any language, expressions that indicate that you it's a health insurance institution; or you can make use of letterhead, posters, titles, forms, receipts, circulars or any other paper that contains names or other words indicating that business to which such person is engaged are the rotation of these institutions. It will be you, likewise, forbidden to make propaganda for the press or other means of advertising in which use is made of such expressions.
Infringements referred to in the preceding subparagraphs of this article, shall be punished with presidio child in grades medium to maximum.
That regardless of the quality of beneficiary, through simulation or deception, obtains the benefits established in this law; and the beneficiary which, in the same way, get one bigger than that apply to you, shall be punished by imprisonment less in their minimum grades to middle. Same penalty incurred which cooperate or provide by any means the Commission of these crimes. "."
9 Article 25, replace by the following: "article 25.-the institutions must prove, at the time of submitting the application for registration to the Superintendency, a minimum capital actually paid, equivalent to five thousand units of building."
The institutions shall constitute, at the time of being registered, a guarantee equivalent to two thousand units of promotion.
Likewise, institutions must maintain a minimum equity equivalent to five thousand units of promotion, which will be integrated by the paid-in capital, the reserve funds, the results of the exercise and the accumulated from prior years. "."
10 article 26, replaced by the following: ' article 26.-for interim compliance with the obligations referred to in articles 28 and 35, institutions remain in the SVS or any specialized entity that is determined, a security equal to one month's perceived contributions, in the form and conditions General and uniform that it shall determine, that shall be unattachable. "
To maintain up-to-date security, the institution must complete it, within the first twenty days of each month, to cover the total amount of contributions received in the previous month, whenever the amount of these exceeds twenty per cent or more the existing warranty.
When the amount of the contribution for a given month is less to eighty per cent of the existing guarantee, the institution may ask the Superintendent refund of the part of such collateral exceed the perceived total quotation amount. The Superintendent shall be within twenty days to make the return, from the date of submission of the application.
The Superintendent may, by resolution established, lower warranty to a percentage not less to twenty per cent of the one mentioned in the first paragraph of this article, which shall be deemed for the purposes of the designated update in the second and third subparagraphs.
Such rebate shall be effective in relation to the level of debt and liquidity of the institution who requests it, and shall be governed in accordance with the procedure of general application that determines the Superintendency through instructional and circular in this regard.
However, when conditions de liquidity of the entity whose warranty reduction was authorized have diminished, or debt levels have exceeded the limits designated by the Superintendent pursuant to the preceding paragraph, this may require reset warranty in accordance to instructions and circulars issued to that effect.
In any case, the guarantee can never be less than the equivalent in national currency, two thousand units of promotion.
The warranty must be in cash or in the instruments indicated in letters a) and b) article 45 of Decree Law No. 3,500 of 1980, which shall have a period of no more than 90 days maturity. At the request of two or more Provisional health institutions and on the basis of rules of general application issued by the Superintendent, may maintain the warranty in instruments other than those listed above in this subsection.
The Superintendent may require, by means of resolution, up to ten percent of the guarantee is in cash, which will be expressed in u.f. for purposes of updating. "."
11. Add the following article 32 bis, new: "article 32 bis.-every time they are decommitted surpluses of the legal price relative to the price of the plan agreed, in the terms referred to in the following paragraph, these surpluses will be owned by the affiliate and indefeasible, increasing the estate in the event of death, unless affiliate surrender them and allocate them to finance the additional benefits of contracts concluded according to" Article 39 of this law.
For the purposes of determining surpluses referred to in this article, be deemed legal quote the perceived by the institution and that which has been declared, even though you have not actually heard.
The surpluses that are decommitted will increase an individual current account that the institution must open for affiliate, unless the fee paying renounces it and prepacte with the institution of health welfare that any surplus that may occur during the respective year are intended to finance a health plan that provides greater benefits.
Without prejudice to the provisions of article 38, the accumulated current account balance may be required by the Member or beneficiary only for the following purposes: 1) to cover the contributions in the event of unemployment;
(2) copay, i.e. that part of the benefit which is in charge of affiliate;
3) to fund health benefits not covered by the contract;
4) to cover additional voluntary contributions, and 5) to finance a health plan when the member meets the requirements established by law for retirement, during the covered period between the request for retirement and the time that it becomes effective.
At any time, affiliate may resolve the fate of the surplus in its current account, according to the preceding paragraph.
At the time of the agreement of health or in its subsequent annual adjustments, the amount of the surplus to allocate to the individual current account shall not exceed 10% the legal contribution for health, calculated on the average of the last three months of compensation, income or pension depending on the case, without prejudice to the established legal stop. However, the totality of the surplus always increase the individual current account of the user.
Funds accumulated in the account is reset according to the variation which experience the index of prices to the consumer and shall accrue the current interest for readjustable operations in national currency referred to in article 6 of law No. 18.010. Reset and interest must be paid every six months in the current account by the respective health insurance institution. Moreover, the institution may charge twice a year to each fee paying for the maintenance of the account a percentage of the maximum amount of which will be fixed by the health welfare institutions Superintendence, provided the balance of it is positive.
However, when for any reason it put an end to a contract, the institution must give to affiliate, in a maximum period of 30 days from the end, a settlement in which detail the amount of the accumulated in the account opened by it in his favor, duly updated. Equal clearance must be put into knowledge of the affiliate with at least 60 days prior to the fulfillment of the annuity.
The surplus produced during the respective annuity that are not used for any reason, will accumulate for the following period.
In the event that will put an end to the health agreement and the applicant be incorporated into another Isapre, such funds shall be transferred to the respective institution of health welfare. If the person concerned decides, thereafter, make their contributions in the national health fund, existing assets in his favor should be transferred to the Fund. "."
12 article 33, replace by the following: "article 33.-for the granting of benefits and health benefits that standard this law, persons referred to in article 29 shall sign a contract with the institution of health social security choice."
In this contract, the parties may freely agree grant, form, mode and conditions of benefits and health benefits, and must stipulate, in clear terms, unless the following: to) benefits and other benefits agreed upon, including coverage rates and values on which they will apply.
(b) the form in which contributions and contributions, benefits and benefits, will be changed by addition or removal of the legal beneficiaries of the family group.
Without prejudice to the provisions of article 41 of this law, shall settle in what conditions, during the term of the contract, the new beneficiaries, noting, in fact, will be the way how is determined the additional contribution will be charged for them.
(c) mechanisms for the granting of benefits referred to in article 35.
(d) price of the plan and the unit that will be agreed, noting that the price expressed in that unit only may vary once fulfilled the respective annual periods. In addition, the tariff or valued catalogue of benefits with their respective stops to be considered to determine the financing of benefits, the unit will be expressed and the way and opportunity that reset must be reported. The reference tariff will at least see benefits contained in the tariff of the national health fund to that referred to in article 28 of the law N ° 18.469, or which replaces it.
However the above, the social security health institutions can sell plans that do not include all the features that appear in the referred tariff, prior information to the Superintendent, which shall adopt general implementing rules with regard to the way in which these plans will be offered.
(e) maximum amounts of benefits for each beneficiary, if any, either, maximum amounts established for any or some benefits, if it is the case, always with the limitation established in subsection first article 33 bis.
(f) restrictions on coverage. They can only be referred to pre-existing illnesses declared, for a maximum period of eighteen months, from the signing of the contract, and will have the limitation set forth in subsection above first article 33 bis.
In the case of pregnancy must indicate clearly that coverage will be proportional to the period remaining to make happen the birth.
(g) provision of accurate exclusions, if any, referred to the benefits referred to in the second subparagraph of article 33 bis.
Tariff, and the limits of benefits or benefits, only can be expressed in the currency of legal tender in the country or in UF. The price of the plan must be agreed in u.f., legal tender in the country or in the percentage equivalent to the legal price of health.
The fee-paying of Isapre and persons referred to in article 41 of this law, may use the institutional modality to curative medical assistance of law N ° 18.469, according to article 26 of the same, subject to the tariff for non beneficiaries of the law in cases of urgency, or absence or inadequacy of the specialty that motivates the attention , or absence or shortage of professional services in the specialty concerned. Persons referred to in this subsection shall be paid the total value set in the tariff applicable to non-beneficiaries of the law N ° 18.469, except that, because of existence of agreement between the institution of health insurance and the health service, the payment is made it directly that.
The respective Regional Ministerial Secretary will qualify the concurrence of the qualifying requirements referred to in the preceding paragraph. Also, ensure that attention to not beneficiaries of the law N ° 18.469 does not cause prejudice to the attention of the beneficiaries of this law. "."
13. Add the following article 33 bis, new: "article 33 bis.-Notwithstanding the provisions of article 33 of this law, not can sign contracts that benefits, with respect to some benefits, agreed by values lower than 25% coverage of that same provision in the general agreed, without prejudice to the provisions of article 35." The clauses that violate this rule will be by unwritten.
In addition, you can convense exclusion of benefits, except those relating to plastic surgery for the purpose of beautification or other benefits for the same purpose; particular care nurses; hospitalization for purposes of rest and health benefits required by the beneficiary as a result of their participation in acts of war, and acts qualified as a criminal offence by law insofar as is criminally responsible; as also features covered by other laws up to the amount of covered; preexisting conditions not stated in the terms of the fifth paragraph of this article, and all those features not covered by the fee referred to in point (d)) of article 33.
For the purposes of the provisions of the preceding paragraph, shall not be considered for the purpose of beautifying plastic surgery intended to correct malformations produced the creature during pregnancy or repairing deformities caused on the occasion of the birth. Either plastic surgery to repair deformities produced on the occasion of an accident shall be deemed for the purpose of beautification.
For the purposes of this law, it shall be deemed that diseases or diseases that have been known to the affiliate and diagnosed medically prior to the signing of the contract or the incorporation of the beneficiary, if any are pre-existing.
Without limiting the foregoing, after a period of five years, counted from the contract or from the incorporation of the recipient, where appropriate, the institution must attend the payment of benefits for preexisting conditions not stated, in the same terms stipulated in the contract for benefits due to preexisting covered by the plan, unless with regard to the first, the institution proves that the pre-existing pathology required medical attention during the above five years and affiliate knowingly hid in order to promote this legal provision.
There may be no waiting periods during which non-enforceable provisions and agreed benefits, except those for pregnancy and pre-existing illnesses, in the terms laid down in article 33, letter f). "."
14 article 35, replaced by the following: ' article 35.-institutions will be required with respect to its beneficiaries to comply with provisions of law N ° 18.469, as regards the granting of consideration of preventive medicine, protection of women during pregnancy and until the sixth month of the birth of the child and the child up to six years; " as well as for the payment of subsidies where appropriate. The Parties shall establish the mechanism to provide benefits, either by the institution or by entities or specialized people with whom this agree, or with others, which will be presented in the terms of law N ° 18.469, or higher, if the parties agree it. Procedures and mechanisms for the granting of these mandatory benefits will be subjected to the institutions to the knowledge of the Superintendent for approval.
The fee paying may have recourse to the Committee on preventive medicine and disability corresponding to the address that set in the agreement, in its case, when it deems that it retrieved by concept of cash benefits referred to in the preceding paragraph, is inferior to provisions of law N ° 18.469. The claim must be presented in writing directly to such a Commission, pointing precisely to its foundations.
Preventive medicine and disability Commission will meet the claim in single instance, prior report of the claimed institution, which shall issue it, at the latest within the three first days following the request.
After period of ten working days, counted from the date of presentation of the claim, with or without the report that referred to in the preceding paragraph, the Committee on preventive medicine and disability issue resolution and it will lock the term, conditions and modalities for its implementation.
If the institution does not comply with the ruling, the fee-paying may request payment to the Superintendent, which shall be effective the warranty referred to in article 26, up to the amount of subsidy due to pay it immediately. In such a case, the institution must complete the guarantee, without prejudice to the fine which corresponds. "."
15.-amended article 37, as follows: to) replacements their third and fourth, subparagraphs by the following third, new subparagraph: "If the institution rejects or modifies the medical license, the fee paying may bring before the Committee on preventive medicine and relevant disability, in accordance with the provisions of the second paragraph of article 35. The same right shall be the employer with respect to licences which authorized the institution. "."
(b) add after the third, new subsection following final subparagraph: "the procedural aspects of the exercise of the powers set forth in the preceding paragraph, contained in the regulation, will be controlled by the Superintendency.".
16.-amended article 38, as follows: to) Reemplazanse his first three clauses, by the following: "article 38.-health contracts referred to in article 33 of this law, shall be agreed for an indefinite time, and they may not be without effect during his term, but for breach of contractual obligations or by mutual agreement." However, the institution must offer a new plan if this is required by the affiliate and is based on the severance or permanent variation legal quote, or the composition of the family of the fee-paying, situations that must prove to the institution. Without limiting the foregoing, in the event of dismissal and not being applicable article 32 bis of this law, the institution must Access membership if this is required by the affiliate.
The fee-paying may, after a year of contractual benefits, evict the contract, to which just a written communication to the institution with a copy to the employer or to the payment of the pension entity, as it appropriate, given in advance, at least one month from the fulfillment of the first year or the later date in that the Disenrollment will be effective , leaving him and his charges, if not they opted for a new contract of health insurance scheme, subject to the general regime of contributions, benefits and health benefits that apply them as beneficiaries of the law N ° 18.469. The Superintendent may provide general application instructions on the form and procedure to which the communications listed above must adhere. However, the parties may agree to the maintenance of contract of health for a period of time, during which the Member may not exercise their right to evict him.
Annually, in the month of the contract, the institutions may review contracts for health that apply, and can only match their prices, agreed performance and the nature and the amount of their benefits, to conditions that do not import discrimination between members of a same plan, except in regards to special conditions agreed with each of them at the time of its incorporation to the institution. Revisions may not take into consideration the health status of the Member and beneficiary. These general conditions shall be the same are offered to that date to the new contracting in the plan. Violation of this provision shall give rise to the contract understand existing under the same general conditions, without prejudice to any other sanctions that can be applied. The proposed adaptation must be communicated to the plaintiff by registered letter at least two months prior to the expiration of the period. In such circumstances, the affiliate may to accept the contract with the adjustments proposed by the health insurance institution; and in the event that nothing says, means that you accept the conditions proposed by the institution. In case that does not accept the new conditions, the Isapre must offer other alternative health plans, under equivalent conditions, can the member accept any of them, or leave.
If the Member considers offered plans do not meet the conditions of equivalence referred to in the preceding paragraph, may appeal to the Superintendent, which shall decide on the terms laid down in number 5 of article 3 of this law. "."
(b) interlayer is following its fourth new subsection, the following subsection fifth, also new, passing current subparagraphs fourth, fifth, sixth, seventh and eighth to be sixth, seventh, eighth, ninth and tenth, respectively: "notwithstanding freedom of the Isapres to match the price and its obligation not to discriminate in the terms laid down in the third paragraph, the new value is charged at the time of renewal must maintain the price ratio by sex and age that has been established in the original contract, using as a basis for calculating the age of the beneficiary at that time, with the price list in force in the institution for the plan in which currently is. "."
17. replace article 39, by the following:
"Article 39.-to the conclusion of a contract of health, Parties not may be considered as a condition of the fact of the fee-paying belonging to a specific company or group of two or more workers. In such situations, they may agree only the granting of benefits other than that they could obtain with the single individual quote not mediate said circumstance, which shall be expressly stated in the contract.
In the previous cases, the benefits that they have the right contributors and other beneficiaries must stipulated explicitly in the respective contracts individual, noting, in addition, if there are other conditions for the granting and maintenance of such benefits.
In the event that, for any cause, eliminate the additional benefits for the cessation of the conditions under which were granted, it can only give rise to contractual modifications relating to the amount of the contribution agreed or the benefits agreed, can always affiliate evict the contract. However, the institution must offer a new health plan, which, in any case, you can contemplate the granting of minor benefits to which they may be according to the legal contribution to worker's compensation give origin at the time of adapt his contract to the fee-paying.
The provisions of this article shall not apply to those contracts of Health concluded people with health insurance institutions whose object is to provide benefits only to employees of a certain company or institution, case in which, the loss of employment may constitute causal anticipated term of the same, unless she has occurred due to the fact of hosting is to pension. Such circumstances should be explicitly established in the contract. "."
18 article 45, replace by the following: ' article 45.-breach by institutions of the obligations imposed by the law, general application instructions, decisions and opinions that say the Superintendent, shall be punished by this with warnings or fines to tax benefit, without prejudice to the cancellation of the registration, if appropriate. "
The fines referred to in the preceding paragraph, may not exceed five hundred units of promotion.
Institutions and their directors or representatives will be jointly and severally responsible for the fines that are imposed on them, except that the latter try their non-participation or opposition to the fact that it generated fine. "."
(19 by amending article 46, in the following manner: a) replaced his number 2, by the following: "2.-breach grave and repeated within a period of twelve months of the obligations established by law or the instructions that provide the Superintendent, properly observed or sanctioned in every opportunity by this.".
(b) replace your number 3, with the following: "3.-when your warranty falls below the limit set in article 26 is not corrected the situation within the term determined by the Superintendent in each case.".
(c) Agreganse, then of the number 4, the following numbers 5 and 6, new: "5.-loss of the legal status of the institution."
6. at the request of the institution itself, in the terms established by the articles 46 bis and 49. "."
20. Add the following article 46 bis, new: "article 46 bis.-the institution that requested the cancellation of its registration shall provide a declaration sworn, public deed, in which the currently enforceable obligations with contributors and their cargoes and other beneficiaries and the Superintendency will be detailed. In conjunction with the filing of the application, the institution shall communicate, agree to deadlines and procedures the Banking Superintendent, its contributors and beneficiaries their intention to close the registry.
Need not be the presentation of an affidavit when the institution certifying that the closure of registration request originated by a fusion of two or more institutions for health insurance, according to article 99 of the law N ° 18,046.
Where, at the date of the request, the institution has obligations on time or conditional pending from those referred to in paragraph first and that they do not attain to be covered by the warranty under the terms established in article 26, shall offer an additional guarantee that caucione the fulfilment of such obligations, which will be qualified by the Superintendent to authorize the cancellation of the registration. "."
21 Article 48, replaced by the following: ' article 48.-cancelled registration and once made effective guarantee of article 26, the Superintendency has to pay obligations that she caucione, within a period not exceeding hundred eighty days. " Such a guarantee will be used to solve: 1) Firstly, subsidies for incapacity for work which have come from medical licenses already granted to the date of cancellation of the registration, fully sufficient funds held or pro rata warranty in case of not being. Except for subsidies which say relationship with maternal licenses which are paid fee the Fund one of family benefits, case in which will correspond to the Superintendent of Social security payment;
(2) once resolved the credits referred to in number 1 of this subsection, and in the event there is a remnant, shall be the payment of bonuses and rebates owed to contributors, loads, and third-party beneficiaries, full or pro rata where applicable, as stated in the previous number;
(3) subsequently, and having a remnant, will proceed to reimbursement of those contributions paid in advance, fully sufficient funds or pro rata, as appropriate;
((4) once solved the listed credits, if left a remnant, be paid contributions that correspond to the institution of health welfare to be have affiliated contributors than the one whose registration is cancelled, or the national health fund, as appropriate, full or pro rata depending on the case, and 5) once solved the listed credits, if left a remnant the Superintendent will turn it in favour of those who represent the institution within the fourth working day following from the end of the liquidation, losing that balance their imprescriptible.
The Superintendent shall appoint the committees on preventive medicine and disability which endorse the medical licenses that apply and which have not been authorised by the institution whose registration is cancelled. "."