Consequences of non-payment of supplementary insurance contributions
ARTICLE 5 TER
TYPES OF MEMBERS
§ 1. Introduction
Depending on their situation with regard to the payment of supplementary insurance contributions within the meaning of article 5 bis, a person affiliated to the health insurance company may be:
- 1° either a member who can receive a benefit from these departments;
- 2° or a member whose possibility of receiving a benefit from these departments has been suspended;
- 3° or a member whose possibility of receiving a benefit from these departments has been removed.
Payment or non-payment of supplementary insurance contributions also has consequences in terms of:
- the possibility of benefitting from the advantages provided for by the articles of association of the national union with which the health insurance company is affiliated; in this regard, reference is made to the articles of association of the National Union of Neutral health insurance companies;
- the possibility of benefitting from the insurance coverage that the member has taken out with the health insurance company Hospiplus or Neutra, and affiliation with this health insurance company; In this regard, reference is made to the articles of association of this health insurance company.
Payment or non-payment of supplementary insurance contributions has no consequences regarding the right to benefit from compulsory health care and compensation insurance. There can be no compensation between unpaid supplementary insurance contributions and compulsory health care and compensation insurance benefits.
§ 2. The member who can benefit from an advantage from supplementary insurance
This is the member who is up-to-date with his contributions for supplementary insurance services within the meaning of article 5 bis:
1° for the month during which the event which, under the article of associations, may give rise to the granting of the benefit occurred.
In this regard, the member who is up-to-date with his contributions for the services concerned for at least 24 months is presumed, until proven otherwise, to be up-to-date with his contributions for these services for the three months immediately following the aforementioned period.
When the member has been affiliated without interruption with different Belgian health insurance companies as a policyholder for more than 24 months, and he has been up-to-date with his contributions for the services concerned for this period, it is presumed, until proof on the contrary, to be up-to-date with his contributions for the services concerned, for the three months immediately following the aforementioned period.
When the member has been affiliated for the first time to a Belgian health insurance company as a policyholder for less than 24 months, and he is up-to-date with his contributions for the services concerned since the beginning of his affiliation, he is presumed, until proven otherwise, to be up-to-date with his contributions for the services concerned for the three months immediately following the aforementioned period.
The member who, as of December 31st 2018, can benefit from the advantages of supplementary insurance is presumed, until proven otherwise, to be up-to-date with his contributions for the first quarter of 2019.
2° for the preceding 23-month period.
If the person affiliated for the first time as a policyholder with a Belgian health insurance company less than 23 months before the month of the event referred to in 1°, he or she must be up-to-date with contributions for the services concerned, for the entire affiliation period which precedes the event referred to in 1°.
If, during the reference period referred to in this point 2°, the person:
- has been affiliated as a policyholder without interruption with different Belgian health insurance companies, he or she must have been up-to-date with contributions for the services concerned to be able to benefit from the advantage in question, in each of the health insurance companies, for the months during which she was affiliated with it as a policyholder during this period;
- has not been affiliated with a Belgian health insurance company for a period of one or several months, this period of interruption is assimilated;
During a period for which the member was up-to-date with contributions when this person:
- is not a member whose possibility of benefitting from the advantages of supplementary insurance has been removed and who has not completed the “right recovery” period referred to in § 4, paragraph 5;
- is in one of the following situations:
- the member was up-to-date with his contributions for supplementary insurance services for all the months during which he was affiliated as a policyholder with a Belgian health insurance company during the 23 months mentioned above;
- the member was not up-to-date with his contributions for the aforementioned services for all the months during which he was affiliated as a policyholder with a Belgian health insurance company during the 23 months mentioned above but he pays these arrears to the entity or entities concerned, at the latest the month during which the new affiliation after the interruption period takes effect;
ii° to a period for which the member was not up-to-date with his contributions for the aforementioned services, in situations other than those referred to under b, i°.
In calculating the reference period referred to in point 2°, the contributions that the member is legally prevented from paying due to a collective settlement of debts or bankruptcy, that is to say prior to the judgment of eligibility or the declaration of bankruptcy, are considered paid.
The member who was affiliated as a dependent during part of the reference period referred to in point 2° and who, since becoming a member during this reference period, is up-to-date with his contributions, is presumed to be up-to-date with his contributions for the entire reference period and, until proven otherwise, for the three months immediately following the aforementioned period.
The member who has been up-to-date with contributions since January 1st 2019 is deemed, until December 31st 2020, to determine whether he or she is entitled to benefit from an advantage due to an event which occurred after December 31st 2018, be in order with contributions for the period prior to January 1st 2019. This provision does not prejudice the fact that action for payment of contributions for supplementary insurance services within the meaning of Article 5 bis, expires five years from the end of the month to which the unpaid contributions relate.
§ 3. The member whose possibility of benefitting from a supplementary insurance benefit has been suspended
If a person is not up-to-date with his/her contributions, for supplementary insurance services within the meaning of article 5 bis, for a period which does not go back beyond the 23rd month preceding the month during which the event which may give rise to the granting of the benefit has occurred, the possibility for the person to benefit from an advantage from the supplementary insurance is suspended.
For the application of the preceding paragraph:
1° the months of the above-mentioned period during which the said person lost his status as a policyholder in the aforementioned sense and became a dependent of a policyholder are assimilated to months for which the contributions were paid;
2° contributions that the member is legally prevented from paying due to a collective settlement of debts or bankruptcy, that is to say prior to the eligibility judgment or the declaration of bankruptcy, are considered to have been paid.
If, during the reference period referred to in paragraph 1, the person was affiliated as a policyholder without interruption with different Belgian health insurance companies, the months of non-payment of supplementary insurance contributions during affiliation as a policyholder in a previous health insurance company are taken into consideration for the application of paragraph 1.
If, during the reference period referred to in paragraph 1, the person has not been affiliated with a Belgian health insurance company for a period of one or more months, this interruption period is assimilated:
1° to a period for which the member was up-to-date with contributions when he/she:
- is not a member whose possibility of benefitting from the advantages of supplementary insurance has been removed and who has not completed the “recovery of the right” period referred to in § 4, paragraph 5;
- is in one of the following situations :
- the member was up-to-date with his/her contributions for supplementary insurance services for all the months during which he was affiliated as a policyholder with a Belgian health insurance company during the 23 months mentioned above;
- the member was not up-to-date with contributions for the aforementioned services for all the months during which he was affiliated as a policyholder with a Belgian health insurance company during the 23 months mentioned above but he makes, at the latest the month during which the new affiliation after the interruption period takes effect, payment of these arrears to the entity or entities concerned.
2° during a period for which the member was not up-to-date with his/her contributions for the aforementioned services, in situations other than those referred to under 1°.
Without prejudice to the application of the prescription referred to in article 48 bis of the law of August 6th 1990, the member whose possibility of benefiting from an advantage from supplementary insurance is suspended will not be able to receive a benefit from the additional insurance until payment has been made for all of the contributions due for the 23-month period concerned and for the month during which the event which, under the articles of association, may give rise to the awarding of the benefit.
§ 4. The member whose possibility of benefitting from the advantages of supplementary insurance is removed
If a person is not up-to-date with their contributions for supplementary insurance services within the meaning of Article 5 bis, for a period which exceeds 24 months, the possibility for him or her to receive a benefit from the supplementary insurance is removed.
For the application of the preceding paragraph:
1° the months of the above-mentioned period during which the aforementioned person loses his status as a policyholder in the aforementioned sense and becomes a dependent of a policyholder are assimilated to months for which the contributions have been paid.
2° contributions that the member is legally prevented from paying due to a collective settlement of debts or bankruptcy, that is to say prior to the eligibility judgment or the declaration of bankruptcy, are considered as paid.
If, during the period referred to in paragraph 1, the person was affiliated as a policyholder without interruption with different Belgian health insurance companies, the months of non-payment of supplementary insurance contributions during affiliation as a policyholder in a previous health insurance company are taken into consideration for the application of paragraph 1.
If, during the period referred to in paragraph 1, the person has not been affiliated with a Belgian health insurance company for a period of one or more months, this period of interruption is assimilated:
1° to a period for which the member was up-to-date with contributions when he/she:
a) is not a member whose possibility of benefitting from the advantages of supplementary insurance has been removed and who has not completed the “recovery of the right” period referred to in paragraph 5;
b) is in one of the following situations:
1° the member was up-to-date with his/her contributions for supplementary insurance services for all the months during which he was affiliated as a policyholder with a Belgian health insurance company during the 24 months mentioned above;
2° the member was not up-to-date with his/he contributions for the aforementioned services for all the months during which he was affiliated as a policyholder with a Belgian health insurance company during the 24 months mentioned above but he makes, at the latest the month during which the new affiliation after the interruption period takes effect, the payment of these arrears to the entity or entities concerned;
2° during a period for which the member was not in order to pay contributions for the aforementioned services, in situations other than those referred to under 1°.
Without prejudice to the application of the prescription referred to in article 48bis of the law of August 6th 1990, the member whose possibility of benefitting from an advantage from supplementary insurance is removed will only be able to benefit from a supplementary insurance advantage again within the meaning of article 5 bis after a subsequent period of 24 months for which the contributions must have been paid for these services without being able to receive any benefits from the supplementary insurance.
The 24-month period referred to in the preceding paragraph is suspended:
1° during the period during which this member, who has started paying contributions for a subsequent period, is legally prevented from paying due to a collective settlement of debts or bankruptcy;
2° during the period during which this member, who has started payment of contributions for a subsequent period, has lost the status of policyholder and has the status of dependent of a holder who is not in order to pay the contributions for supplementary insurance.
When a member whose possibility of benefitting from the advantages of supplementary insurance is removed has been, during the period of “recovery of the right” referred to in paragraph 5, affiliated without interruption with different Belgian health insurance company as a policyholder, the 24 months are counted from the 1st day of the month for which the contributions for the aforementioned services of the health insurance company with which he was first affiliated during this period were paid.
In the event of interruption of affiliation with a Belgian health insurance company as a policyholder after the start of the “recovery of the right” period referred to in paragraph 5, the interruption period suspends the aforementioned period of 24 months for which contributions must be paid without being able to receive any benefit from supplementary insurance services; this suspension cannot, however, exceed five years.