Health Insurance
(Medical Benefit) (General Provisions) (Jersey) Order 1967[1]
1 Interpretation[2]
In this
Order, unless the context otherwise requires –
“account”
means an account to which Article 5(1) relates and which complies with the
requirements of that paragraph;
“draft” means
a voucher, cheque, postal draft, payable order or any other instrument
whatsoever payable through a post office or a bank;
“Identity Card”
has the same meaning as in the Health Insurance (Evidence) (Jersey)
Order 2007;
“Law” means
the Health Insurance
(Jersey) Law 1967;
“prescription”
has the same meaning as in the Health Insurance
(Pharmaceutical Benefit) (General Provisions) (No. 2) (Jersey)
Order 2002.
2 Approval of medical practitioners
(1) An
application by a medical practitioner for approval under Article 26(1) of
the Law shall be in the form set out in Schedule 1 to this Order.
(2) The
Minister shall issue to every approved medical practitioner a certificate to
that effect and every approved medical practitioner shall exhibit such
certificate in a conspicuous position at the principal place from which he or
she carries on his or her practice.
3 Services which are not medical services for the purposes of the Law[3]
For the purposes of the Law,
the expression “medical service” shall not include –
(a) the issue by an
approved medical practitioner of a medical prescription for the treatment of an
insured person or any child of his or her household –
(i) which
is in substantially the same terms as a medical prescription previously issued
in respect of that person (whether or not by that same medical practitioner),
(ii) in connection
with which that person has not been medically examined by the medical practitioner;
(b) any medical service
provided by an approved medical practitioner to an insured person or any child
of his or her household in conjunction with any dental treatment provided by a
dentist to that person;
(c) any
medical service provided by an approved medical practitioner to a company
carrying on the business of insurance of any kind in connection with
which –
(i) an
insured person (as defined in the Law) or any child of his or her household has
been medically examined, and
(ii) a
report thereon has been furnished to such company,
in respect of which a fee
or other remuneration is payable to the approved medical practitioner by such
company;
(d) any
medical service provided by an approved medical practitioner in connection with
which –
(i) an
insured person or any child of his or her household has been medically
examined,
(ii) such
examination has been requested by the employer of the person examined, and
(iii) a
report thereon will be received by such employer,
in respect of which a fee
or other remuneration is payable to the approved medical practitioner by such
employer;
(e) subject
to the provisions of any agreement such as is referred to in Article 34 of
the Law, any medical service provided by an approved medical practitioner which
consists of a consultation held outside Jersey;
(f) any
medical service provided by an approved medical practitioner which consists of
a consultation by telephone with an insured person or any child of his or her
household;
(g) any
medical service (within the meaning of Article 20A of the Law) for which
the Minister has entered into a contract under Article 20B of the Law; or
(h) the
supply of vaccines for which the Minister has entered into a contract under
Article 20C of the Law.
4 Production of identity cards[4]
On each occasion when
medical services are provided to an insured person any child of his or her
household by an approved medical practitioner, the insured person’s
Identity Card shall be produced and shown to the medical practitioner.
5 Provisions as to the submission of accounts
(1) Every
account in respect of the fees charged for the provision of medical services by
an approved medical practitioner to an insured person or any child of his or
her household shall be in the form set out in Part 1 or 2 of Schedule 2,
whichever is appropriate.[5]
(2) Every
account shall be submitted in duplicate to an insured person not later than the
end of the month next following the month in which the medical services to
which the account relates were provided:
Provided that where an
approved medical practitioner has failed to submit an account to an insured person
by the end of the period specified in this paragraph, it shall be treated as
having been so submitted if the approved medical practitioner proves to the
satisfaction of the Minister that there was good cause for such failure.[6]
(3) [7]
6 [8]
7 Payment of accounts[9]
(1) When
an insured person pays an account in the form specified in Part 1 of
Schedule 2, he or she shall deliver both copies of the account to the
approved medical practitioner to whom payment is made and that practitioner
shall –
(a) receipt
the copies of the account delivered to him or her; and
(b) not
later than 2 days after the date on which payment was made, return the
copies to the insured person.
(2) But
where an approved medical practitioner has failed to return the copies within
such period, he or she shall be treated as having done so if he or she proves
to the satisfaction of the Minister that there was good cause for such failure.
(3) When
an insured person pays an account in the form specified in Part 2 of
Schedule 2, he or she shall deliver such number of copies of the account
as may be required to the approved medical practitioner to whom payment is
being made.
(4) That
medical practitioner shall deliver a copy of the account to the Social Security
Department in accordance with Article 8 and –
(a) such
delivery shall be treated as a claim for medical benefit; and
(b) the
Minister shall, though the intermediary of the medical practitioner, pay to the
insured person the medical benefit to which he or she is entitled in respect of
the medical services to which the account relates.
8 Claims for medical benefit[10]
(1) Subject
to the provisions of this Order, a claim for medical benefit shall be made not later
than the last day of the sixth month next following the month in which the
medical services to which the claim relates were provided, by delivering to the
Social Security Department one receipted copy of the account relating to those
medical services, duly completed:
Provided that where an
approved medical practitioner has failed to submit an account or to return the
receipted copies thereof within the periods specified in Article 5 or 7,
as the case may be, but has satisfied the Minister that there was good cause
for such failure, a claim for medical benefit in respect of the medical
services to which that account relates may be made not later than 7 days after
the last date by which the claim would otherwise have had to have been made.[11]
(2) Subject
to the provisions of this Order, a person shall be disqualified for the receipt
of medical benefit unless the person makes a claim therefor within the time and
in the manner specified in this Order.
9 Information to be given when making a claim for medical benefit[12]
Every person who makes a
claim for medical benefit shall, in addition to complying with the provisions
of Article 7 or 8, as the case may be, furnish to the Minister such
certificates, documents, information and evidence for the purpose of determining
the claim as may be required by the Minister and, if reasonably so required,
shall for that purpose attend at such office or place as the Minister may
direct.
10 Amendment of claims
If an account delivered
in connection with a claim for medical benefit has not been duly completed, the
Minister may, in his or her discretion, return it to the claimant, and, if the
account is returned duly completed within 14 days from the date on which it is
so returned, the Minister may treat the account as if it had been duly
completed in the first instance.
11 Late claims
If in any case a person
fails to claim medical benefit by the date by which, in accordance with the
provisions of Article 8, a claim for medical benefit is to be made, but
proves that there is good cause for such failure, the Minister may treat the
claim as if it had been duly made by that date:
Provided that the
Minister shall not so treat any claim in respect of medical services provided
more than 12 months before the date on which the claim is made.[13]
12 [14]
13 Extinguishment of right to sums payable by way of medical benefit
which are not obtained within the prescribed time[15]
(1) The
right to any sum payable by way of medical benefit shall be extinguished where
payment thereof is not obtained within the period of 6 months from the date on
which that sum is receivable in accordance with the following provisions of
this Article:
Provided that in
calculating the said period of 6 months no account shall be taken
of –
(a) any period during which
a draft containing the sum is in the possession of the Minister or any post
office or bank at which it is payable, other than a period after written notice
has been given that the draft is available for collection;
(b) any period during which
the Minister has under consideration any representation that a draft containing
the sum has not been received or has been lost, mislaid or stolen;
(c) any period during which
the person concerned is for the time being unable to act by reason of a lack of
capacity within the meaning of Article 4 of the Capacity and
Self-Determination (Jersey) Law 2016, subject to the qualification
that the total period disregarded on account of such inability to act shall not
exceed one year; or
(d) any period during which
the determination of any question as to such extinguishment is pending.[16]
(2) For
the purposes of this Article, a sum payable by way of medical benefit contained
in a draft shall, subject to the provisions of paragraphs (3) and (4), be
receivable –
(a) if the draft is sent
through the post, on the date on which it would be delivered in the ordinary
course of the post; and
(b) in any other case, on
the date of issue of the draft.
(3) In
determining when a sum is receivable under the provisions of paragraph (2)
or (3), the following provisions shall apply –
(a) if a person proves that
through no fault of his or her own he or she did not receive any draft until a
date later than the appropriate receivable date determined in accordance with
the provisions of paragraph (2) or (3), the sum contained in the draft
shall be receivable –
(i) on that later
date, or
(ii) on
the date which is 6 months after the said appropriate receivable date,
whichever is the
earlier;
(b) if a person proves that
through no fault of his or her own he or she has not received any draft, the
sum contained in the original draft shall be receivable –
(i) on the date
determined in accordance with the provisions of paragraph (2) or (3) on
the basis of the issue of any further draft in respect of that sum, or
(ii) on
the date which is 6 months after the receivable date determined in accordance
with the provisions of paragraph (2) or (3) on the basis of the original
draft,
whichever is the
earlier;
(c) subject to the
provisions of sub-paragraph (b), a sum which in accordance with the
foregoing provisions of this Article was receivable on any date shall remain
receivable on that date notwithstanding the issue, since that date, of a draft
in respect of that sum or any part thereof.
(4) Any
sum payable by way of medical benefit to a person who is for the time being
unable to act shall be receivable in accordance with the foregoing provisions
of this Article, notwithstanding the person’s inability to give a receipt
therefor.
14 Recovery of amount of medical benefit from approved medical
practitioner in certain circumstances
An insured person shall
be entitled to recover from an approved medical practitioner the amount of any
medical benefit which the insured person has become disqualified for receiving
by reason of the failure on the part of the approved medical practitioner to
comply with any of the requirements of Articles 5 and 7.
15 Approved medical practitioners leaving Jersey permanently to notify Minister
Where an approved medical
practitioner proposes to leave Jersey permanently, he or she shall notify
the Minister accordingly.
16 Withdrawal
An approved medical
practitioner may at any time give notice to the Minister that he or she no
longer wishes to be approved for the purposes of the Law, and, where such
notice is given, the medical practitioner shall cease to be an approved medical
practitioner at the expiration of 3 months from the date of such notice or of
such shorter period as the Minister may agree:
Provided that if
representations are made to the Minister under the provisions of Article 27
of the Law that the conduct of an approved medical practitioner has been such
as to be prejudicial to the efficient administration of the Law or as to create
an unreasonable charge on the Health Insurance Fund, the medical practitioner
shall not, except with the consent of the Minister and subject to such
conditions as the Minister may impose, be entitled to give notice under this Article
pending the determination of the proceedings on such representations.
17 Persons unable to act[17]
(1) In
the case of any person to whom medical benefit is payable or who is alleged to
be entitled to benefit or by whom or on whose behalf a claim for medical
benefit has been made, if that person is unable to act and –
(a) has
not been received into guardianship in pursuance of a guardianship application
under Article 29 of the Mental Health (Jersey)
Law 2016;
(b) does
not have, acting on his or her behalf –
(i) a delegate
appointed under Part 4 of the Capacity and
Self-Determination (Jersey) Law 2016, or
(ii) a
person acting under the authority of a lasting power of attorney conferred
under Part 2 of that Law; and
(c) does
not have a tuteur,
the Minister may, on
receipt of a written application, appoint a person to act on the person’s
behalf.[18]
(2) However,
such appointment shall terminate –
(a) if
the person is received into guardianship, or has appointed, in relation to him
or her, such a person as mentioned in paragraph (1)(b) or a tuteur;
(b) at
the request of the person seeking appointment;
(c) if
revoked by the Minister; or
(d) if
the claimant becomes able to act.[19]
18 Payments on death
(1) On
the death of a person who has made a claim for medical benefit or who is
alleged to have been entitled to benefit, the Minister may appoint such person
as he or she thinks fit to proceed with or to make a claim for the benefit, and
the provisions of this Order shall apply, subject to the necessary
modifications, to any such claim.
(2) Subject
to the provisions of paragraph (3), any sum payable by way of medical
benefit on a claim proceeded with or made under paragraph (1) may be paid
or distributed by or on behalf of the Minister to the executor or
administrator, or to or amongst persons claiming as the legatees, heirs or
creditors, of the deceased (or, where the deceased was illegitimate, to or
amongst other persons) and the provisions of Article 13 shall apply to any
such payment or distribution:
Provided that the receipt
of any such person who has attained the age of 16 years shall be a good
discharge to the Minister and the Health Insurance Fund for any sum so paid.[20]
(3) Paragraph (2)
shall not apply in any case unless written application for the payment of any
such sum is made to the Minister within 4 months from the date of the
deceased’s death or within such longer period as the Minister may allow
in any particular case.
(4) The
Minister may dispense with the strict proof of the title of any person claiming
in accordance with the provisions of this Article.
19 Citation
This Order may be cited
as the Health Insurance (Medical Benefit) (General Provisions) (Jersey)
Order 1967.