- The personal health statement may not include inquiries about Down’s Syndrome and other congenital characteristics of the insured which do not constitute a disease by themselves.
- Coverage exclusions contained in health insurance policies may not have generic names, such as “congenital anomalies,” since they prevent the contracting party from being certain of which health conditions must be known or diagnosed in order to declare them.
August 31, 2020 – The Financial Market Commission (CMF) has published for consultation a Circular Letter for insurance companies and insurance brokers establishing the conditions that must be met by statements of risks and exclusions in health insurance coverage. The consultation process will be open until September 11, 2020 for comments from the market and general public.
The objective of the regulation is to reinforce the obligations of insurance companies and brokers to guarantee a fair treatment to people who take out health policies. Said policies help finance medical expenses incurred by policyholders and their families. Therefore, the CMF deems relevant that insurance companies and brokers act with due care and diligence in all phases or a health policy, especially in its design and sale.
Although insurance companies can decide whether or not to accept a particular risk, the way in which the declaration of a person’s risk status is made and how exclusions are established must allow customers to have full knowledge of the coverage they are taking out, as well as any diseases or health situations that will be partially covered or not covered at all.
The Circular Letter states that exclusions established in the general conditions of the policies must be specified and may not have generic denominations such as “congenital anomalies.” It also notes that the statement on risk status required from the customer must include all aspects deemed necessary by the insurer to accept or reject such risks. All aspects that are not specifically nominated and included in the risk status application will not be considered for the purposes of errors, reticence, or inaccuracies of the contracting party. Accordingly, inquiries on Down’s Syndrome and other congenital characteristics of the insured that do not constitute illness by themselves must be excluded from the health statement.
To access the details of the regulatory proposal, interested parties can visit the Draft Rules and Norms section of the CMF website. In addition, the Commission also makes available a Regulatory Report evaluating the impact of the proposal.