Why will companies no longer give unlimited sums insured?
Due to the growth of the accident rate in medical expenses insurance and that the unlimited sum insured does not have technical support from the National Insurance and Bonds Commission, for the next few years, insured sums will no longer be allowed without technical support, for which the sums insured without limit disappear according to provisions 5.1.24 and 5.1.25.
The National Insurance and Bonding Commission, based on the provisions of article 108, section IV of the General Law of Mutual Insurance Institutions and Societies, and in accordance with the agreement by which the Governing Board of the National Insurance NPI Commission and Bonds delegates to the President the power to issue the necessary provisions for the exercise of the powers that the law grants to said Commission and for the effective compliance of the same and of the rules and regulations, issued on December 2, 1998 and published in the Official Gazette of the Federation on January 4, 1999, and WHEREAS, in accordance with the provisions of article 36 section IV of the General Law of Mutual Insurance Institutions and Societies,Insurance Institutions, when carrying out their activity, must indicate clearly and precisely, in the contractual documentation of insurance operations and related to them, the scope, terms, conditions, exclusions, limitations, franchises or deductibles and any other modality that It is established in the coverage or plans that they offer, as well as the rights and obligations of the contracting parties, insured parties or beneficiaries.
That derived from various recommendations of the National Commission for the Protection Defense of Financial Services Users, it has been determined the need to give greater clarity and precision to the contractual documentation of medical expenses insurance in order to provide greater legal certainty to the contracting, insured or beneficiaries in terms of the operability and scope of the insurance policies that they contract.
That in accordance with the provisions of article 36-C of the General Law of Mutual Insurance Institutions and Societies, insurance contracts in general must contain the indications administratively set by the National Insurance and Bond Commission in protection of the interests of the contracting parties, insured parties or beneficiaries, for which it has been considered convenient to clearly and precisely include the operational aspects of the medical expenses insurance contract, in order to generate legal certainty for the contracting parties, insured parties or beneficiaries thereof.
By virtue of the foregoing, this Commission has resolved to issue the following amendment to the Single Insurance Circular in the following terms:
AMENDMENT CIRCULAR 10/12 OF THE ONLY DE SEGUROS
(Provisions 5.1.24 and 5.1.25)
ONLY- Provision 5.1.24 is modified and provision 5.1.25 is added, to read as follows:
5.1.24 In the case of medical expense insurance, the Institutions and Mutual Societies must, in addition to complying with the provisions of these provisions, observe the following:
I. The Institution or Mutual Society will have the obligation to cover the payment of claims that occur within the term of the contract, having as a limit, whichever occurs first:
- The exhaustion of the insured sum
- The amount of expenses incurred during the term of the policy and the benefit period established therein, or
- The recovery of health or vital force regarding the illness or accident that affected the insured.
II. In the policies of medical expenses insurance products, the institution or mutual society may not establish clauses that limit in any way the payment of claims due to the fact that the insured has other policies to cover that risk.
III. Medical expense insurance products must establish limited sums insured, that is, in all cases a certain amount must be defined as the sum insured, either in some type of currency, or in any other unit of account. The maximum insured sum to be offered by the institution or Mutual Society in question must be technically supported at the time of registration with the commission of the respective medical expenses products.
IV. The rates of individual medical expense insurance products must be designed for each age so that the value of the frequency and average costs are gradually updated for each year of age of the insured.
V. On the front page of the policy of individual medical expense insurance products, a warning must be established regarding the importance and magnitude of the annual increases that the premium may reach when the insured reaches advanced age.
SAW. In the policies of the individual medical expenses insurance products, it must be established that when the insured changes plans in the same institution or mutual society, the benefits earned by seniority of the insured will not be affected as long as the new plan contemplates them. The foregoing, without limiting the institution or mutual society in question, to carry out subscription procedures when the insured requests changes in benefits or increases in the sum insured.
VII. Considering that the waiting periods must have as their sole purpose the proper selection of risks and the elimination of possible pre-existing cases, the policies of the medical expenses insurance products may not establish waiting periods for the case of accidents or medical emergencies. , as defined in the policy, which is proven to have occurred within its validity. In this case, it will be the obligation of the Institution or Mutual Society to cover the hospital medical expenses and others that are necessary for the recovery of the health or vital force of the insured, from the effective date or from the discharge date. of the same.
VII. The policies of medical expenses insurance products must specify, where appropriate, the sequence in which the deductible, excess and coinsurance will be applied, in combination with the insured amount, at the time of paying a claim.
IX. The policies of the medical expenses insurance products may establish a clause that provides for the automatic renewal of the insurance, with the exception that said renewal is not carried out when the institution or mutual society or the contracting party, reliably notify its willingness not to renew it, at least twenty business days before the expiration of the policy.
In the case of the automatic renewal referred to in the preceding paragraph, the policies of medical expense insurance products must establish clauses that meet the following conditions:
- The renewal must offer insurance conditions consistent with those originally contracted, so the limitations of risk coverage may not be changed to the detriment of the insured, waiting periods may be extended, age limits may be reduced, or insurability requirements may not be requested, in reason for the seniority right acquired by the insured. Likewise, the new contract must provide for a medical and hospital network service with a quality, service and location that is similar to the one originally contracted, in accordance with the products that are registered with the commission at that time.
- The bases must be established to update, in each renewal, the value of the deductible, excess or coinsurance, and
- The obligation of the Mutual Institution or Society must be established to inform the contracting party or the insured, at least thirty business days before the renewal of the policy, the values of the premium, deductible, excess or coinsurance applicable to it.
X. The policies of the medical expenses insurance products may establish a clause that provides for the renewal of the insurance in a guaranteed manner, with the exception that said renewal is not carried out when the contracting party or the insured reliably notifies their willingness not to renew it, at least twenty business days before the expiration of the policy.
In the case of guaranteed renewal, the policies of the medical expenses insurance products must establish clauses that comply with the conditions indicated in subparagraphs a) and c) of the previous section IX.
5.1.25 The Institutions and Mutual Societies must keep a printed, filmed or recorded on magnetic or optical media, of the technical notes and contractual documentation of the plans in force that have been registered prior to July 17, 2002.
First- This amending circular will enter into force on the business day following its publication in the Official Gazette of the Federation.
Second- Within a period of one hundred and eighty calendar days from the entry into force of this Amending Circular, the institutions and Mutual Insurance Companies must modify and re-register the medical expense insurance products that they have registered with the Commission. in order to comply with the conditions established in these provisions. Said products must be used for the subscription and renewal of their medical expenses insurance within three hundred and sixty calendar days from the entry into force of this Amending Circular.
Third- Those policies that are in force at the entry into force of this amending circular must be renewed in the terms established therein, except those where automatic renewal or guaranteed renewal has been contractually agreed under the same or similar conditions. those originally hired.
The foregoing is made known to you, based on article 108 section IV of the General Law of Mutual Insurance Institutions and Societies and in accordance with the agreement by which the Governing Board of the National Insurance and Bonding Commission delegates to the President the power to issue the necessary provisions for the exercise of the powers that the law grants to said Commission and for the effective fulfillment of the same and of the rules and regulations, issued on December 2, 1998 and published in the Diario Official of the Federation on January 4, 1999.