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Samenvatting Personenverzekeringen 1 - ziekte
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Samenvatting van het boek Ziekteverzekeringen van Ann Deferme, voor het vak Personenverzekeringen 1. Deel van personenverzekeringen is apart verkrijgbaar.
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SAMENVATTING ZIEKTEVERZEKERINGENINHOUDSTAFEL
SAMENVATTING ZIEKTEVERZEKERINGEN INHOUDSTAFEL................................2
1 ZIEKTEVERZEKERING, GEMEENSCHAPPELIJKE PRINCIPES............................6
1.1 Wetgeving...................................................................................................6
1.1.1 Wet Verwilghen – wet tot wijziging van de private
ziekteverzekeringsovereenkomsten..........................................................6
1.1.1.1 Achtergrondinformatie.............................................................................................................6
1.1.1.2 Cijfers...................................................................................................................................6
1.1.1.3 Krachtlijnen van de Wet Verwilghen...........................................................................................6
1.1.1.4 Begrippen..............................................................................................................................6
1.1.1.5 Levenslange waarborg.............................................................................................................7
1.1.1.6 Onbetwistbaarheid..................................................................................................................8
1.1.1.6.1 Termijn...............................................................................................................................8
1.1.1.6.2 Informatieverplichting van de verzekeringnemer......................................................................8
1.1.1.6.2.1 Spontane mededelingsplicht................................................................................................8
1.1.1.6.2.2 Medische informatie...........................................................................................................9
1.1.1.6.2.3 Vragenlijst in levens- en ziekteverzekeringen........................................................................9
1.1.1.7 Voorwaarden tot wijziging voorwaarden en tarief........................................................................9
1.1.1.7.1 Medische index anno 2010.....................................................................................................9
1.1.1.7.2 Medische index anno 2017...................................................................................................10
1.1.1.7.2.1 Nieuwe medische index....................................................................................................10
1.1.1.7.2.2 Werkwijze.......................................................................................................................10
1.1.1.8 Regeling chronisch zieken en gehandicapten.............................................................................10
1.1.1.8.1 Art. 206 Verzekeringswet....................................................................................................10
1.1.1.8.2 Bemiddelingscommissie ziektekostenverzekering....................................................................10
1.1.1.9 Individuele voortzetting.........................................................................................................11
1.1.1.9.1 Niet-beroepsgebonden overeenkomsten................................................................................11
1.1.1.9.2 Beroepsgebonden overeenkomsten.......................................................................................11
1.1.1.9.2.1 Individuele voorzetting.....................................................................................................11
1.1.1.9.2.2 Informatieverplichting......................................................................................................12
1.1.1.9.2.3 Procedure bij verlies van het voordeel door de hoofdverzekerde.............................................12
1.1.1.9.2.4 Procedure bij verlies van het voordeel door de bijverzekerde.................................................12
1.1.1.9.2.5 Aanvang van de individuele overeenkomst..........................................................................13
1.1.1.9.2.6 Voorfinanciering – wachtpolis (art. 209 Vwet)......................................................................13
1.1.2 Anti-discriminatiewetgeving........................................................................13
1.1.2.1 Achtergrondinformatie...........................................................................................................13
1.1.2.2 Weerslag op de ziekteverzekeringen........................................................................................14
1.1.2.2.1 Specifieke anti-discriminatieregel..........................................................................................14
1.1.2.2.2 Tarifering..........................................................................................................................14
1.1.2.2.2.1 Beroep en hobby’s...........................................................................................................14
1.1.2.2.2.2 Lichaamsgegevens en gewoontes.......................................................................................14
1.1.2.3 Arbeidsongeschiktheid...........................................................................................................14
1.1.2.4 Ziektes en ongevallen, hospitalisaties.......................................................................................14
1.1.2.5 Woonplaats..........................................................................................................................15
1.1.2.6 Verzekerde risico’s................................................................................................................15
1.1.3 Begrip wachttijd – carenstijd.......................................................................15
1.1.3.1 Wachttijd.............................................................................................................................15
1.1.3.2 Carenstijd............................................................................................................................15
1.1.3.2.1 Gewaarborgd inkomen........................................................................................................15
1.1.3.2.2 Hospitalisatieverzekering.....................................................................................................15
1.1.4 Recht om vergeten te worden......................................................................15
1.2 Uitsluitingen.............................................................................................15
1.2.1 Wettelijke uitsluitingen...............................................................................16
1.2.1.1 Opzet..................................................................................................................................16
1.2.1.2 Zware fout...........................................................................................................................16
,1.2.1.3 Oorlogsrisico.........................................................................................................................16
1.2.1.4 Terrorisme...........................................................................................................................16
1.2.2 Gewoonlijke uitsluitingen............................................................................16
1.2.2.1 Voorafbestaande aandoeningen...............................................................................................16
1.2.2.2 Risicovolle sporten, hobby’s en beroepen..................................................................................16
1.2.3 Psychische ongeschiktheid..........................................................................16
1.2.3.1 Gewaarborgd inkomen...........................................................................................................16
1.2.3.2 Hospitalisatieverzekering........................................................................................................16
1.2.4 Zwangerschap of bevalling..........................................................................17
1.2.4.1 Gewaarborgd inkomen...........................................................................................................17
1.2.4.2 Hospitalisatieverzekering........................................................................................................17
1.3 Fiscaliteit..................................................................................................17
1.3.1 Verzekering gewaarborgd inkomen...............................................................17
1.3.1.1 Individuele polis....................................................................................................................17
1.3.1.1.1 Premietaks........................................................................................................................17
1.3.1.1.2 Fiscaal voordeel premie.......................................................................................................17
1.3.1.1.3 Taxatie van de uitkering......................................................................................................17
1.3.1.2 Beroepsgebonden polis..........................................................................................................17
1.3.1.2.1 Premietaks........................................................................................................................17
1.3.1.2.2 Fiscaal voordeel premie.......................................................................................................17
1.3.1.2.3 Taxatie van de uitkering......................................................................................................17
1.3.2 Hospitalisatieverzekering............................................................................18
1.3.2.1 Individuele polis....................................................................................................................18
1.3.2.1.1 Premietaks........................................................................................................................18
1.3.2.1.2 Fiscaal voordeel premie en taxatie van de uitkering.................................................................18
1.3.2.2 Beroepsgebonden polis..........................................................................................................18
1.3.2.2.1 Premietaks........................................................................................................................18
1.3.2.2.2 Fiscaal voordeel premie en taxatie van de uitkering.................................................................18
2 GEWAARBORGD INKOMEN...........................................................................18
2.1 Eerste pijler..............................................................................................18
2.1.1 Werknemers..............................................................................................18
2.1.1.1 Ziekte en privé-ongevallen.....................................................................................................18
2.1.1.1.1 Primaire arbeidsongeschiktheid............................................................................................18
2.1.1.1.2 Invaliditeit.........................................................................................................................19
2.1.1.2 Arbeidsongevallen.................................................................................................................19
2.1.1.2.1 Tijdelijke ongeschiktheid......................................................................................................19
2.1.1.2.2 Blijvende ongeschiktheid.....................................................................................................19
2.1.2 Ambtenaren..............................................................................................19
2.1.2.1 Ziekte en privé-ongevallen.....................................................................................................19
2.1.2.1.1 Ziekteverlof.......................................................................................................................19
2.1.2.1.2 Disponibiliteit.....................................................................................................................20
2.1.2.2 Arbeidsongevallen.................................................................................................................20
2.1.2.2.1 Tijdelijke ongeschiktheid......................................................................................................20
2.1.2.2.2 Blijvende ongeschiktheid.....................................................................................................20
2.1.3 Zelfstandigen............................................................................................20
2.2 Waarborgen van de aanvullende verzekeringen........................................21
2.2.1 Begrippen.................................................................................................21
2.2.1.1 Fysiologische invaliditeit.........................................................................................................21
2.2.1.2 Economische ongeschiktheid...................................................................................................21
2.2.1.3 Polisvoorbeeld.......................................................................................................................21
2.2.2 Schadevergoeding......................................................................................21
2.2.2.1 Invaliditeitspercentage...........................................................................................................21
2.2.2.2 Uitkeringen...........................................................................................................................21
2.2.2.2.1 Rente................................................................................................................................21
2.2.2.2.2 Terugbetaling premie..........................................................................................................22
2.2.2.2.3 Overzicht...........................................................................................................................22
2.2.3 Formules...................................................................................................22
2.2.3.1 Waarborg ziekte en/of ongeval................................................................................................22
2.2.3.1.1 Begrip ziekte......................................................................................................................22
,2.2.3.1.2 Begrip ongeval...................................................................................................................22
2.2.3.1.3 Waarborg ziekte en/of ongeval.............................................................................................22
2.2.3.2 Soorten rentes......................................................................................................................22
2.2.3.2.1 Polisvoorbeeld....................................................................................................................22
2.2.3.2.2 Constante rente.................................................................................................................22
2.2.3.2.3 Klimmende rente (toenemende rente na schade)....................................................................23
2.2.3.2.4 Ideaal klimmende rente (toenemende rente voor en na schade)...............................................23
2.2.3.3 Voorbeelden.........................................................................................................................23
2.3 Duur van het contract...............................................................................23
2.3.1 Tot stand komen van de overeenkomst.........................................................23
2.3.1.1 Aanvaardingsvoorwaarden......................................................................................................23
2.3.1.1.1 Normaal risico....................................................................................................................23
2.3.1.1.2 Bedrijfsinkomsten...............................................................................................................23
2.3.1.1.3 Woonplaats in België...........................................................................................................23
2.3.1.1.4 Medische formaliteiten........................................................................................................23
2.3.1.2 Het verzekeringsvoorstel........................................................................................................24
2.3.2 Duurtijd van de overeenkomst.....................................................................24
2.3.2.1 Niet-beroepsgebonden overeenkomst......................................................................................24
2.3.2.2 Beroepsgebonden overeenkomst.............................................................................................24
2.4 Premie......................................................................................................24
2.4.1 Elementen die de premie beïnvloeden...........................................................24
2.4.2 Wijzigingen in de loop van de overeenkomst.................................................24
2.5 RIZIV-polis...............................................................................................24
2.5.1 Wat?........................................................................................................24
2.5.2 Voorwaarden.............................................................................................25
2.5.2.1 Apothekers...........................................................................................................................25
2.5.2.2 Artsen..................................................................................................................................25
2.5.3 Bedrag.....................................................................................................25
3 HOSPITALISATIEVERZEKERING...................................................................25
3.1 Eerste pijler..............................................................................................25
3.1.1 Ziekte- of privéongeval...............................................................................25
3.1.1.1 Ziekenhuisopname................................................................................................................25
3.1.1.1.1 Opnameformulier................................................................................................................25
3.1.1.1.1.1 Wanneer?.......................................................................................................................25
3.1.1.1.1.2 Verplichte inhoud.............................................................................................................25
3.1.1.1.2 Erelonen............................................................................................................................26
3.1.1.1.3 Verblijfkosten.....................................................................................................................26
3.1.1.1.4 Forfaits.............................................................................................................................26
3.1.1.1.5 Farmaceutische kosten........................................................................................................26
3.1.1.1.6 Andere kosten....................................................................................................................27
3.1.1.1.7 Transportkosten.................................................................................................................27
3.1.1.1.7.1 Dringend ziekenvervoer....................................................................................................27
3.1.1.1.7.2 Niet-dringend ziekenvervoer..............................................................................................27
3.1.1.2 Daghospitalisatie...................................................................................................................27
3.1.1.3 Ziekenhuisfactuur..................................................................................................................27
3.1.2 Ambulante kosten......................................................................................27
3.1.2.1 Erelonen..............................................................................................................................27
3.1.2.2 Medicijnen............................................................................................................................28
3.1.2.2.1 Magistrale bereidingen........................................................................................................28
3.1.2.2.2 Farmaceutische specialiteiten...............................................................................................28
3.1.3 Systeem derdebetaler.................................................................................29
3.1.3.1 Eerste pijler..........................................................................................................................29
3.1.3.2 Assurcard en Medicard...........................................................................................................29
3.1.3.3 AssurPharma........................................................................................................................29
3.1.4 Arbeidsongeval..........................................................................................29
3.1.4.1 Ziekenhuisopname................................................................................................................29
3.1.4.2 Ambulante kosten.................................................................................................................29
3.1.4.2.1 Erelonen............................................................................................................................29
3.1.4.2.2 Medicijnen.........................................................................................................................29
, 3.2 Formules...................................................................................................29
3.2.1 Systeem dagvergoeding..............................................................................29
3.2.2 Terugbetaling van de werkelijke kosten........................................................30
3.3 Waarborgen..............................................................................................30
3.3.1 Hospitalisatie.............................................................................................30
3.3.1.1 Definities..............................................................................................................................30
3.3.1.1.1 Verpleeginstelling...............................................................................................................30
3.3.1.1.2 Ziekenhuisopname..............................................................................................................30
3.3.1.2 One day clinic (dagkliniek)......................................................................................................30
3.3.2 Pre- en post..............................................................................................30
3.3.3 Zware ziekten............................................................................................30
3.3.4 Ambulante kosten......................................................................................30
3.3.5 Palliatieve zorgen.......................................................................................31
3.3.6 Kosten die eventueel niet worden vergoed....................................................31
3.3.6.1 Niet-terugbetaalbare prestaties door de verplichte ziekteverzekering...........................................31
3.3.6.2 Alternatieve geneeswijzen......................................................................................................31
3.3.7 Vrijstelling.................................................................................................31
3.4 Premie......................................................................................................31
3.4.1 Elementen die de premie kunnen beïnvloeden...............................................31
3.4.1.1 Leeftijd bij onderschrijven van de polis.....................................................................................31
3.4.1.2 Gekozen waarborgen.............................................................................................................31
3.4.1.3 Gezondheidstoestand.............................................................................................................31
4 VLAAMSE SOCIALE BESCHERMING...............................................................31
4.1 Verplichte verzekering..............................................................................32
4.1.1 Inwoners van Vlaanderen............................................................................32
4.1.2 Anderen....................................................................................................32
4.2 Zorgkassen...............................................................................................32
4.3 Bijdrage....................................................................................................32
4.3.1 Hoeveel?...................................................................................................32
4.3.2 Sancties i.g.v. niet-betaling of te laat betalen van de bijdrage.........................33
4.3.2.1 Bijdrage niet of gedeeltelijke betaald op 30 april.......................................................................33
4.3.2.2 Bijdrage niet of gedeeltelijke betaald op 31 december................................................................33
4.4 Uitkering...................................................................................................33
4.4.1 Bedrag.....................................................................................................33
4.4.2 Vaststelling graad van zorgbehoevendheid....................................................33
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