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FAQGENERAL QUESTIONS ON THE OPALE HEALTH INSURANCE CONTRACTWhat is the difference between the 4 options of the OPALE plan? Option 1 – Private Health (100%) Cover This option is for people who need comprehensive or private health insurance. It provides cover for a wide range of medical expenses at 100% of the French Social Security’s ‘Tarif de Convention or Base de Remboursement’ (e.g. € 23.00 for a consultation with a GP). This option therefore includes basic top-up cover and will reimburse consultations with a doctor, medicines, hospitalisation, dental and optical treatment, and all medical treatment included in the French Social Security’s list of professional acts. Option 1A – Economy Private Health Cover (Consultations Excluded) This option is for people who need comprehensive or private health insurance and who are prepared to pay for the cost of their consultations themselves. It covers the same types of treatment as Option 1, with the exception of all consultations and visits with a general practitioner or specialist as well as all associated supplements and all specialty and technical acts performed at the doctor’s surgery, unless they are carried out during the course of a covered in-patient hospitalisation. Option 2 – Hospitalisation Cover This option is for people who are prepared to pay the cost of their everyday medical treatment themselves and just want to be insured in the event that they need to be hospitalised (for at least one night). This option provides cover at 100% of actual expenses for accommodation costs and at 300% of the Tarif de Convention for medical and surgical fees (medical treatment included in the French Social Security’s list of professional acts). Option 3 – Top-Up Cover This option is for people who already have basic cover, either with the French Social Security, with another scheme or under Option 1, and want to top this up. These top-up health insurance policies are known as complémentaire or mutuelle in France. The percentage reimbursed is in excess of 100% of the Tarif de Convention as some healthcare providers in France charge more than the official rate. I am moving to France from outside the European Economic Area. Can I be covered? Yes, cover can be taken out by persons of any nationality who are resident in the European Economic Area and Switzerland. Is cover valid outside the European Economic Area? Yes, cover is valid worldwide for any stay of up to 3 months. Medical expenses incurred abroad will be reimbursed in Euros in accordance with the French Social Security’s Tarif de Convention. If my circumstances change, can I upgrade/downgrade the level of my cover? Yes, if you need 100% cover initially on arrival in France because you are affected by the recent change in legislation for expatriates, you can ‘downgrade’ this to top-up cover when you become entitled to cover under the French state scheme. Conversely, if you have taken out top-up cover in conjunction with your E106 on moving to France, you can ‘upgrade’ this to 100% cover when this document expires if you find that you need private insurance. I am interested in your products, where can I get further information? Details of benefits and premiums, the general conditions and the policy summary are available on the ‘documents to download’ page of our website. If you have difficulty downloading or printing these documents, please contact us and we will send you a hard copy by post - Freephone from France 0800 900 258. Do premiums go up with age? No, you will retain the same age bracket as when you joined for as long as you remain a member. Premiums go up on 1st January each year by a percentage determined by inflation and the claims experience of the group. What happens when I get to 80? This is the maximum age at which you can join the Opale plan. Cover is lifelong and your premium will be based on the above paragraph. How will I be reimbursed? If you have Private Health cover (Option 1), Economy Private Health cover (Option 1A) or Hospitalisation cover (Option 2), you should send us your original treatment forms and invoices, along with the corresponding prescriptions etc. For Top-Up cover (Option 3), you should send us the original of the breakdown of your reimbursement by the French Social Security or other basic scheme so that we can reimburse the difference. The majority of claims are processed on the day of receipt and are paid either by cheque or by transfer directly into your bank account. Please note that original documents will be required and we will not be able to process claims sent by email or fax. For Top-Up cover, what does 150% or 250 % of the Tarif de Convention mean? The benefit levels indicated in the table of benefits for Option 3 of the Opale health insurance contract include reimbursements from all other basic medical insurance schemes, including any reimbursements received under the other options of the Opale plan. For example, if you pay your GP € 50.00, the French Social Security will reimburse you on the basis of € 23.00 (the Tarif de Convention) and will pay you 70% of this amount, i.e. € 16.10. If you have chosen Level 1 top-up cover, we will reimburse you on the basis of 150% of the Tarif de Convention, after deducting the Social Security’s payment, i.e. € 18.40: € 23.00 x 150 % = € 34.50 - € 16.10 = € 18.40 You will therefore be € 15.50 out of pocket. If you have chosen Level 2 top-up cover, we will reimburse you on the basis of 250% of the Tarif de Convention, after deducting the Social Security’s payment, i.e. € 33.90 € 23.00 x 250 % = € 57.50 (you paid € 50.00) € 50.00* - 16.10 = € 33.90 *The total amount reimbursed cannot exceed the amount you actually spent. Will I get a direct settlement card? You will receive a direct settlement card with your membership certificate which can be used for hospitalisation, outpatient and day case treatment, radiology, medicines and medical tests. This means that instead of you having to pay for treatment up-front and then be reimbursed, we will pay the healthcare provider directly. What do I do if I need to be hospitalised? In the event of hospitalisation, you will be able to request direct settlement of your medical expenses by filling in the reverse of your claim form (demande de prise en charge hospitalisation) and providing the requisite medical information. For non-emergency hospitalisations, we would be grateful if you could send your request to us at least 10 days before you are due to be admitted. Once your request has been processed, the acceptance will be sent directly to the hospital or clinic. QUESTIONS ON APPLYING FOR COVER How do I apply for cover? In order to apply for cover, you should complete the application form (available on the ‘documents to download’ page) and send it to us by post. If you need to be covered quickly, you can send us your completed application by email or fax in the first instance, but we shall need the original signed document by post. How do I calculate the premium payable? The monthly and annual premium rates can be found on the tables of benefits and premiums for each option. Premiums are per person. If you are taking out more than one option, for example Private Health cover (Option 1) and Top-Up cover (Option 3), add the premiums payable for each option together and put the total for each person on the application form. Please note that premiums are calculated according to your age on membership and not by subtracting your year of birth from the current calendar year. What do I put for the date of inception? If you tick ‘immediate’, your membership will take effect on the date we receive your application form. If you would like cover to start at a later, more convenient, date you can stipulate this. What do I put under waiting period? If you had equivalent insurance which expired less than 3 months ago, put NO and attach evidence of this insurance to your application form in order to waive the waiting period. Otherwise, tick YES. What counts as evidence of previous medical cover? The Insurer accepts the following documents as evidence of previous equivalent cover: Option 1 (Private Health Cover): A copy of the ’attestation’ you received with your ‘Carte Vitale’ or a certificate of cancellation from a private insurer indicating the dates of cover and benefit levels Option 1A (Economy Private Health cover): A copy of the 'attestation' you received with your 'Carte Vitale' or a certificate of cancellation from a private insurer indicating the dates of cover and benefit levels Option 2 (Hospitalisation cover): A certificate of cancellation from a private insurer indicating the dates of cover and benefit levels Option 3 (Top-Up cover): A certificate of cancellation from your previous top-up insurer indicating the dates of cover and benefit levels. Do I need to pay the membership fee to Schetland? Yes, the contracts we administrate are group contracts subscribed by the Association for its members. You therefore need to pay the membership fee to the Association in order to benefit from cover. This payment is separate to your insurance premium and cheques should be made payable to AMARIZ LIMITED. You can opt to pay the fee by direct debit if this suits you better. Are pre-existing conditions excluded? Not necessarily. If you were to declare any pre-existing medical conditions, your completed medical questionnaire may be forwarded to the Insurer’s Consulting Doctor who will contact you for further information, and will decide whether a premium loading or an exclusion is appropriate. You do not need to complete the medical questionnaire for Level 1 top-up cover (Option 3). How do I pay my premiums? Premiums are payable in Euros by direct debit on a French bank account, or by cheque or bank transfer. You can choose to pay monthly, quarterly, six-monthly or annually (there is a 5% discount for annual payment). If you choose to pay annually, we shall calculate the premium due until the end of the current calendar year, and thereafter we shall request payment of your annual premium on the 1st January of each year. Unfortunately, we cannot carry out direct debits on UK or foreign bank accounts at present, nor can we accept payments by debit or credit card. Where should I send my application form? All applications for membership should be sent to Amariz Limited in Bristol. Our address is on the last page of the application form. How long will it take to process my application? We process the majority of applications within one business day of receipt and you should receive your membership certificate a few days after this, subject to medical acceptance.
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CONTACT USTel. 0800 900 258 |
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Amariz Limited is registered and incorporated in England and Wales with Company Number 3711064 and is authorised and regulated by the Financial Services Authority. We are members of the Financial Services Compensation Scheme and the Financial Ombudsman Service. Designed by Team Partners |
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