Key Benefits:
Regulation of the Minister for Health, Welfare and Sport of 7 June 2011, MC-U-3052256, laying down rules on the processing of personal data by health insurance companies in the implementation of voluntary agreements Sickness Insurance (WMG)
The Minister for Health, Welfare and Sport,
Having regard to Article 68a, fourth paragraph, of the Health Organisation Act ;
Decision:
For the purposes of this arrangement:
a. Law: Health Organisation Act ;
b. Insurer: a health insurance provider as referred to in Article 1 (f) (3) (o) of the Act ;
c. voluntary health insurance: medical insurance other than compulsory insurance under the Law on the Law of the Sea, and other than the insurance of insurance other than the insurance Long-term care law , to which the insured person with an insurer has entered into a health insurance contract on a reciprocal voluntary basis;
ed.
1 °. a description of the performance as established under the Care Act, or
2 °. a description of the performance as agreed between the insured person and the care provider where such care does not require the adoption of a performance description under the law;
e. Declaration scheme: a scheme specified in Article 38, third paragraph, point (b) of the Act ;
f. Formal verification: an investigation into which the insurer assesses, or the rate charged by a healthcare provider for a performance:
1 °. an achievement, delivered to a person insured with that insurer;
2 °. a performance, which belongs to the insured package of that person,
3 °. a performance, to the supply of which the provider of care is competent, and
4 °. the rate, which is fixed for that performance under the law or is a tariff that, subject to compliance with or under the law, has been agreed upon with the care provider for that performance;
g. material control: an examination whereby the insurer has been charged or the performance charged by the care provider has been delivered and that performance was the most appropriate given given the state of health of the insured person;
h. Fraud investigation: an investigation into which the insurer shall verify that the insured person or the healthcare provider commits or tries to commit falsehood, deceit, disadvantage of rightholders or embezzlers, to the detriment of the execution or execution of such an embezzling; persons and organisations involved in health insurance, with the aim of obtaining a performance, remuneration, payment or other benefit to which the insured person or the care provider is not entitled to or may not be entitled;
i. Remedies: The right of the insurer on the basis of Article 7:962 of the Civil Code the damage caused by others than the insured against these third parties;
j. detail check: research by the insurer to personal data related to the healthcare provider with regard to its own insured for the purposes of physical control or fraud investigation;
k. General risk analysis an analysis aimed at determining the data on which material control and fraud investigation will be addressed;
l. specific risk analysis: an analysis aimed at determining what data and on which healthcare providers or categories of healthcare providers the detail control will focus on.
m. Editor: the one intended in Article 1, part (e) of the Personal Data Protection Act .
1 As personal data, including personal data relating to health as intended in the Personal data protection law , which are necessary for insurers for the implementation of voluntary health insurance, are deemed to be the Article 3 personal data.
2 An insurer may use the information referred to in paragraph 1 for the purpose of carrying out formal checks or physical checks for the benefit of:
a. Payment of whole or partial payment to a healthcare provider;
(b) reimbursement of all or part of the compensation to an insured person of the charge charged to an insured person delivered;
(c) the determination of the right of insured person to a payment of a sum of money to that insured person as a result of the establishment of a risk to which sickness insurance relates;
d. the determination of the own contributions of an insured person;
e. the determination of the own risk of an insured person;
f. the determination of the no-claim of an insured person and
g. The conduct of fraud investigation.
3 An insurer may use the data referred to in paragraph 1 for the exercise of the right of redress.
For the purposes of the objectives set out in the preceding Article, the insurer shall have the following information from the insured person:
a. name, address, postal code and place of residence;
b. Policy number, civil service number, sex and date of birth;
c. the performance description of the performance delivered to the insured person;
d. when the performance has been delivered;
e. the fee charged for the delivered performance;
f. the information to be supplied pursuant to a declaration scheme;
g. the data necessary to determine whether the performance belongs to the insured package of that insured under the voluntary health insurance, the Health insurance law or the Long-term care law whether the costs of the delivered health care benefits are borne by the Minister for Security and Justice;
h. the bank or giro number and
(i) other information necessary for the conduct of physical checks or fraud investigations.
1 The healthcare provider is required to Article 3 provide information to:
a. the insurer, or a person designated by that insurer to that effect, if that healthcare provider directly charges the rate for the performance delivered under an agreement entered into by the insurer with the insurer;
b. the insured person, if the health care provider charges the fee for the delivered performance with the insured;
(c) the insured person, if the insured person makes a claim, on the basis of such information under an agreement concluded with the insurer, for the payment of a sum of money in connection with the execution of a risk laid down in that contract.
2 The healthcare provider is required to Article 3 (i) -to supply such data on request to the insurer, or to any person designated by the insurer for that purpose.
3 The person designated by the insurer or editor shall be subject to the same legal provisions relating to the confidentiality of processed data as to the insurer or the editor who has appointed him.
In relation to the conduct of formal and physical control, the conduct of fraud investigations and the survey by an insurer and with regard to the professional secrecy of healthcare providers, it is Articles 7.4 and 7.5 to 7.10 of the Conditions of health insurance of corresponding application for that insurer and the care providers and insured persons concerned.
The insurer shall process the personal data referred to in Article 68a, first and second paragraph, of the Act Only if and where necessary for the implementation of:
a. the voluntary health insurance for targets described in Article 2 of this arrangement,
b. the health insurance and the Health insurance law for targets described in Article 7.1, second paragraph, of the Conditions of Health Insurance or
c. the Long-term care law for targets set out in the Long-Term Care Scheme.
This scheme is cited as: Scheme personal data voluntary health insurance WMG.
This arrangement shall enter into force from the day following the date of issuance of the Official Journal in which it is placed.
TheMinister
of Public Health, Welfare and Sport,E.I. Schippers
