The Dubai Health Authority (DHA) promulgated Policy Directive Number 1 of 2015 (PD 01/2015) (Policy Directive) pursuant to Health Insurance Law (No 11 of 2013) of the Emirates of Dubai (the “Law”).
What does this mean for authorised and licenced DHA insurers?
DHA Insurers offering the minimum benefits under the Essential Benefits Plan(EBP) must now address their maternity benefits for the purposes of underwriting to avoid over-charging and anti-selection against the insurers.
While the Law addressed the benefits, limits and conditions on maternity coverage pursuant to the minimum benefit levels, it did not provide or specify who should be covered.
The Policy Directive addresses and clarifies:
Circumstances where females should be covered for this benefit, whether pregnancy occurs at the time of enrolment or after enrolment;
The application of additional premiums to cover maternity benefit levels; and
Where refunds may be applicable for additional premiums, which have been charged for maternity benefits in respect of females without child-bearing capacity and how such premiums are to be refunded.
All married females of child-bearing capacity must be covered for the maternity benefit pursuant to the EBP and the Law.
Females without child-bearing capacity should not be charged additional premiums for the maternity benefits within the Emirates of Dubai. This also includes non-married females even to the extent that they are of child-bearing capacity who should not be offered coverage.
There is no legal definition of “child-bearing capacity” other than guidance given by the DHA in the Policy Directive specifically stating that “the question of child-bearing capacity is one for the judgment of a suitably qualified medical professional and is not restricted by specific age.”
Where does this leave insurers in terms of its standard approach to underwriting this group?
Insurers will need to make their own judgment as to the question of child-bearing capacity based on sound medical underwriting advice within their operations.
Generally, all married females of child-bearing capacity need to be insured for this benefit, subject to different wait period and underwriting based on the type of insurer covering the benefits – i.e. Participating Insurer (PI) or Insurers operating under the Health Insurance Permit (HIP).
PI can impose a 9-month wait period to insured members, while HIP can apply normal underwriting as well as a 9-month wait period for non-working spouses to protect against anti-selection.
What about pooled risk and standard book rate prices for group coverage?
There is express reference in the Practice Directive under “Charging additional premiums to cover a known or potential risk of maternity expenses.” “…to average the total premium for all such females across the female insured member population (either total females or only those of child-bearing capacity).” There is also reference to factored risk within the Policy Directive.
In the absence of any express provisions, the construction of this wording assumes that a standard book rate approach can be used. The standard book rate charge for all these members is charged at a set rate based on a standard book rate for average total premium for each member. This in our view, is applicable to the entire female population of the book.
With this approach, there is no loading or differential treatment, which would NOT prejudice non child-bearing capacity females, which is the purpose of PD.
DHA Insurers will however need to refund premiums that have been charged to females of non child-bearing capacity, which in our view would include unmarried females and females of non child-bearing capacity on individual coverage, where the charge for the premium cannot be justified based on loading or differential treatment applied to those females.
What actions must DHA Insurers take?
Disclosure should have already be made to the DHA confirming that insurers have not charged additional premiums since 1st April 2014; or
Provide details of the over-charged premiums to the DHA not later than 29th August; and
Confirm a refund of any over-charged premiums not later than 12th August 2015.