Even if the US social security is performing well, the part of health care and hospital insurance not covered by the state remains considerable: on average, about a fifth of all costs in the American society is dedicated to health. “If we exclude hospitalizations, the Americans are even the champions in terms of their personal share in the care provided,” according to DKV.
For example, “in America, a couple in their thirties spends a total of more than 1,000 dollars a year on health care, says Assuralia, the professional union of insurance companies in America. Twenty years later, this amount reaches about 1,500 dollars. These are, of course, averages. However, no one is immune from an illness or an accident that threatens their health and immediately increases the bill. This even exceeds 5,000 dollars per year for more than 100,000 patients.”
As a reminder, some costs are barely covered (if at all) by social security. Those who want to protect themselves (and their family) from the serious financial consequences of hospitalization related to an accident, illness, pregnancy, or childbirth, therefore, have every interest in taking out hospital insurance. And the faster the better.
1. Individual or collective contract?
There are three formulas to be covered by hospital insurance. It can be subscribed at the initiative of the employer (as an extra-legal benefit). In this case, it is a so-called collective contract and the insured are usually affiliated without a medical questionnaire. That is, without any distinction based on age or health status.
Hospital insurance does not reimburse non-medical expenses of the hospital bill, such as water bottles, Wi-Fi, etc
Watch out for the fine print! The family of the staff member may also be insured by the latter’s contract, provided that this is done within the prescribed period. For a newborn, you should not hang around. At KBC, there are no medical formalities to be completed, provided that the insurance is taken out within 60 days of the birth.
An individual can also insure himself individually with a private insurer or his mutual insurance company. “In this case, the insured who takes out individual insurance will have to fill out a medical questionnaire, as will the family members he wishes to join,” according to Assuralia’s explanations.
Watch out for the fine print! “As the state of health changes with age, the latter determines the height of the premium, says Assuralia. You, therefore, have every advantage in taking out hospital insurance as soon as possible, even if insurers accept underwriting up to a certain age (65 years or older) for a premium corresponding to the risk.”
Insurance Guide 2019
If you have no choice but to take out insurance on an individual basis, it is in your best interest to compare the various contracts offered on the market, in order to determine the formula that suits you best. “The free choice of the doctor and therefore of the hospital where you are going to be treated has financial consequences that you cannot ignore,” Assuralia insists. As well as the type of room.
By the way, one insurance contract is not the other! Warranties and exclusions may vary greatly. Here’s pretty much everything you need to know and watch out for in the terms and conditions to choose a contract with full knowledge of the facts (whether it’s coverage or reimbursement), without it costing you too much.
2. What guarantees does hospital insurance offer?
The amount of reimbursement you will get after hospitalization depends on the contract. For example, those who opt for extended coverage will be able to benefit from a refund in a single room.
A 4-day hospitalization for an appendicitis attack costs social security almost 2,000 dollars. For the patient, the bill amounts to 150 dollars if he opts for a double room and 500 dollars in a single room. Even if it makes a hell of a difference, almost one in two Americans prefers to opt for a single room in case of hospitalization, especially among 34-54-year-olds, according to a study conducted by Ethias in 2019. In this age group, a single room is even essential in case of birth or serious illness.
“Americans are looking for the best compromise between a fairly wide coverage and not too expensive insurance. The two criteria seem to be as important as the other.”
Watch out for the fine print! It’s not just the room that costs more (when a patient chooses a one-bedroom): additional fees will also be part of the package. It is for these reasons that some insurers provide in their conditions to be able to claim a higher deductible if you opt for a single room.
This parameter can also vary the annual cost of your insurance. For example, KBC indicates in its conditions that the choice of the guarantee in a twin room or a shared room entitles you to a significant reduction in the premium.
Also note that some insurers provide for unlimited reimbursement of single room costs, while others specify the amount of reimbursement. At Ethias, the costs of a single room are reimbursed up to three times the legal intervention of the mutual, while this reimbursement is full for a two-bedroom.
Unless they are the victim of an accident, a patient often has to pay a fee before hospitalization (directly related to it). He will probably also have expenses after he is discharged from the hospital. Therefore, insurers usually offer an outpatient expenses guarantee, with a time limit, before and after hospitalization. “This is a very important advantage, especially since the average length of hospitalization has been greatly reduced in recent years,” Assuralia says.
Watch out for the fine print! The duration of this warranty is not the same everywhere. For example, as part of its “Hospi Quality +” offer, Ethias reimburses medical expenses incurred for a period of 60 days before and 180 days after hospitalization. Same topo at KBC. At DKV for the Hospi Flex, it’s 30 days before and only 90 after.
The most extensive policies offer an extension of outpatient care coverage in the event of a serious illness. This means that medical care is reimbursed for the entire duration of the serious illness (cancer, cystic fibrosis, Crohn’s disease, diabetes, Alzheimer’s, etc.) even in the absence of hospitalization.
These are the general conditions of the contract that specify what the insurer considers a serious illness. For example, Ethias reimburses all medical expenses related to 33 serious illnesses. At other insurers, as well as with mutual companies, this number may be more limited.
The insured has a lifetime guarantee because the insurer can never terminate an individual insurance contract (except in the event of fraud or non-payment of the premium).
3. What are the exclusions from your hospital insurance?
Just because you have hospital insurance with relatively extensive coverage does not mean that everything is covered! So before opting for a contract, take the trouble to read its “exclusions” section, which can be very informative. Here are the most common exclusions or limitations.
- Some insurers, including KBC, reserve the right to limit their intervention to a single room in what they consider to be an expensive hospital (and the list of which is available in the general conditions). In this case, 50% of the personal co-payment remains the responsibility of the patient. It is better to find out in advance. However, this limitation does not apply if the insured has opted for the “twin room or shared room” guarantee but is staying in a single room for medical reasons.
- Most insurers do not intervene for hospitalization costs if they are due to a suicide attempt, alcoholism, drug addiction, the consumption of doping products, excessive consumption of drugs, an accident related to an air sport, or cosmetic surgery (unrelated to an illness or accident).
- Some insurers do not intervene in fertility, contraception, or sterilization treatments.
- Some insurers do not cover pre-existing conditions and symptoms at the conclusion of an insurance contract, with the exception of the individual continuation of group insurance (read the box below “When to take out a waiting policy?”).
Assuralia notes that mental illnesses are not excluded but are generally taken care of for a limited period of time (for example a maximum of two years).
Watch out for the fine print! There may be differences between private insurers and mutuals. The latter still does not cover single-room stays and/or fee supplements. The same applies to the costs of medicines, treatments, or prostheses that are not compensated by the National Institute of Health and Disability insurance (INAMI).
All people with a chronic illness or disability have the right to take out individual hospital insurance. In return, insurers may exclude hospitalization costs directly related to chronic illness or disability, provided that this is mentioned exhaustively in the contract.
4 What premium and deductible?
Each year, at the main deadline, the premium is adjusted according to the maximum of the evolution of the consumer price index or the specific medical indices provided for by law.
How much does hospital insurance (individual) cost? “Most insurers give you the choice between several formulas, from basic to high-end coverage,” Assuralia replies. The amount of the premium will therefore be proportional to the extent of the guarantees you are aiming for.”
- In addition to the chosen guarantees (type of room, outpatient care, serious illnesses), other parameters can influence the amount of your premium, in particular your place of residence. In fact, Test Achat has noticed that the premium paid for certain Ethias and DKV contracts varies depending on your place of residence because single-room supplements are higher in Brussels and Wallonia than in Flanders.
- The deductible and the ceiling can also play a role. As a reminder, the deductible is part of the costs that remains the responsibility of the insured. “It allows you to limit the height of the premium, as well as the ceiling that the insurer can set – normally per person – either for the entire coverage or for a specific type of expense, such as doctor’s fees, explains Assuralia. Some insurers offer a choice between several deductibles or limits, which amounts to choosing the desired premium level.”
- The amount of the premium is largely influenced by your age.
- There is a price difference between mutual and private insurers. The premium offered by the mutual will be lower but it will increase each year according to your age, whereas an insurer sets the premium based on your age and your state of health. The premium will then be adjusted via the legal indexations (or when the National Bank gives its consent).
When to take out a waiting policy?
The law authorizes any worker to pursue group hospital insurance individually and with the same coverage (without having to undergo a medical check-up or having to respect a waiting period) provided that they have been insured by this contract for at least two years (without interruption) and have made
the application within 30 days after the loss of the insurance.
However, the premium is likely to jump (it can be multiplied by five). To avoid such a scenario, it is possible to take out a waiting policy, also called “continuity insurance”. In practice, this allows you to pre-finance your subsequent individual hospital insurance. That way, the day you leave your group hospital insurance for individual insurance, you will pay a premium calculated on the basis of the age you were when you took out the waiting policy. The older you get, the more important this difference will be.
A child is covered by his parents’ policy until his 25th birthday. On the day he leaves the family home, he will also have the right to extend the hospital insurance on an individual basis with the same insurer without having to undergo a medical examination and without having to respect a waiting period. If this is his wish, however, he will have to act within a specified period. Otherwise, he will lose his right to an extension of the contract.