The insurance industry uses its own terminology. Understanding it is essential to take out the guarantees that meet your needs, and even to know with whom you are contributing. An amalgam is often made in terms of health insurance. What is the difference between complementary health insurance and mutual health insurance? While both complement the mandatory scheme, significant differences emerge between the two organizations. Explanations.
Mutual health insurance and health insurance: different statuses
Joining a mutual insurance company or subscribing to health insurance are different responses to the same need: obtaining reimbursement of health costs in addition to the Social Security share; as well as additional benefits for care not reimbursable by the compulsory scheme.
However, the organizations do not operate in the same way:
- The mutual is subject to the Mutuality Code.
- The Complementary Health is issued by an insurer, therefore governed by the Insurance Code.
- The pension fund is governed by the Social Security Code.
Insurance, Mutuals, Provident Institutes: different operations
Depending on whether the health contract is taken out with an insurer, a mutual insurance company or a provident institute, the way in which it is administered is different. Each of these entities has its own operation.
Mutuals
The mutual is driven by values of democracy, freedom, independence and solidarity. It must respect the balance between benefits and contributions, without seeking to make a profit. It has no shareholders. Each member has a voice at the General Assembly to vote on the major internal decisions of the mutual. Delegates are elected by the members to represent them.
The insurance
The insurer is a private organization, which can as such make profits and remunerate shareholders. It is capital company (SA, SARL, etc.) or mutual insurance companies. In the first case, the leaders decide on internal policy. In the second case, the members elect their representatives who vote on the decisions. Solvency rules lead insurers to reinsure themselves with third parties for certain contracts.
Provident institutions
Provident institutions, known as IPs, are private non-profit organizations. They deploy collective contracts with professionals for their employees. Decisions are taken by representatives of employers and employees.
What are the differences between health contracts?
The differences in status between mutuals, insurance and provident institutes can lead to differences in the health contract themselves.
A similarity: completing the compulsory diet
For the insured, the health contract, whether taken out with a mutual insurance company, an insurer or a provident institute, aims to obtain reimbursement of the additional portion of health costs.
The Social Security fund takes care of the compulsory scheme, leaving a balance to be paid in many cases.
The payment of the co-payment and any reimbursement of excess fees accrue to the supplementary plan.
Other services may be offered as part of the health contract or in addition: assistance guarantees, provident insurance, social action, etc.
Different conditions
Signature of the membership form and prices may differ depending on the nature of the contract and the organization covering the health risk.
Membership or subscription
The conditions for subscribing to the health contract are made without a health questionnaire among mutualists.
Most insurers also exempt their policyholders from such a declaration. Particularly in the context of responsible and solidarity contracts. Their premiums should not be affected by the state of health of the member/subscriber.
For certain guarantees, in particular provident insurance, health quiz can be maintained and condition the subscription.
Some health contracts target a particular clientele: employees of a given company within the framework of a collective contract for example, or even young people, civil servants, etc.
Subscription to an individual health contract is optional. Subscription to a collective contract may be compulsory.
The rates
As mutuals do not seek profit, it is the balance of their accounts that dictates the evolution of tariffs. The fee schedule is often set according to age, beneficiaries, geographical area and level of guarantee.
On the side of insurers and provident institutions, premiums are defined according to the same criteria. Studies show a more substantial increase in prices in 2023 compared to those of mutuals.
Mutual and complementary health contracts are both commonly referred to as health insurance. This common term sometimes leads to confusion between these entities, which are nevertheless very distinct despite their common purpose: the reimbursement of health costs. However, becoming a member, member or insured entails different rights for the contract holder. Especially when it comes to making your voice heard during major decisions that impact the life of the contract and the organization.