Guide for insurance contracts

22 Aug


Health insurance obliges the insurer to pay certain amounts and costs of medical and pharmaceutical assistance; in the health care insurance the insurer undertakes to pay the insured health care services directly through its own structure or by payment of expenses.


Health insurance is to protect the insured from the economic consequences of an abnormal condition of the body. The insured risk is the disease, understood as the more or less severe impairment of health. Often see how illness policies provide for a grace period, i.e., a time period from the insurance in which the risk is not covered. This clause must expressly have accepted in writing and be worded clearly and precisely.

In the health care insurance provision does not consist in the payment of any amount (such as health insurance), but to assume the costs of care health, either paid directly to the doctor, or reimbursing the insured for expenses incurred. in such insurance is customary for the insured has a small final participation in the cost of medical care, so that every time you use these services must satisfy a small amount. It is advisable to read well the policy to meet these expense items.

If you think the insurer is engaging in any improper practice, complain to the service customer of the company (or to the ombudsman if the company has one).

Warnings and precautions in recruitment


Check with the entity or its mediator what the main features of it are and express what their priority needs and what you really want to secure.

Get the insurer or the mediator all necessary and sufficient information prior to purchase insurance. It is a right. Therefore, ask all the explanations and clarify all doubts regarding the insurance that you are hiring.

It is essential that you read all the conditions of the policy well and know the compensation limits and exclusions of coverage before concluding the insurance contract, especially regarding hedges in which claims are more frequent.

The insurance contract is perfected by consent, notwithstanding which must be in writing. That is, the contract exists from both parties (insurer and policyholder) agree that it is carried out, although it is not firm. If you have not written, either party may request to be formalized in writing.

The insurer must use all means at its disposal to facilitate the signing of the contract. Before signing it, make sure you know and understand all the clauses of the contract, especially the limitation clauses whose validity is subject to excel in the policy are as you are specifically accepted by the policyholder by signature.

Keep all documentation provided to it. It can be useful in case of complaints. However, if you lose the policy you can request a duplicate to your organization.

There may be cases in addition to the contracted guarantees, granted some additional security to be implicit in the mode, such as: Call for minor emergencies, second medical opinion for serious illnesses, etc.

Specific health insurance

It is common practice that when signing a health insurance, whether the mode of service delivery, refund or compensation, the insurer asks you to fill out a health questionnaire. In these cases:

You should make sure to be informed about the significance of the findings in the health questionnaire, especially the consequences that could have the omission of relevant information about your health.

To avoid misinterpretations, the policyholder must answer all questions asked in the health questionnaire. However, in no case the lack of response to any questions of the questionnaire, it can lead to understand that the answer is negative.

It is necessary that the policyholder once read, understood and filled out a health questionnaire, sign it personally. Failure to sign the questionnaire by the policyholder causes its invalidity.

The policy may have grace periods, which is a time period from the signing of the contract in which some features are not covered. In these cases, it is advisable to request detailed information of the services that are excluded during this period.

In any case, the necessary urgent assistance to those referred to in Article 103 of the Law 50/80, it is mandatory that they are covered during the grace period. You can define “necessary assistance urgent” as assists medical and health issues (including transport), which if not paid imminently could endanger the patient’s life or physical integrity or cause permanent impairment on their health.

The need for this healthcare should be assessed based on the symptoms presented by the patient before receiving health care, i.e. it must be paid if the symptoms manifested by the patient show that could be in a situation risky.

The waiting period for pregnancy and childbirth cannot exceed eight months.

In most health insurance policies, the premium is determined for only one year before the expiration contacting insurance premium next year. It is recommended to request the Underwriter sufficient information on the criteria that the entity to determine the premium in subsequent years.

You should be aware that in most cases, the premium will be increased depending on the age of the insured still advisable to gather information on how these increases by age apply (if by age and weight of each section). It is advisable to analyze at the time of recruitment which could be the premium for the same insurance contract for different ages.

The policyholder should know and consider before signing the policy, if the contract includes all expectations in terms of diagnostic tests, treatment and performing medical acts, since policies can provide a catalog of different benefits to the health public. If the insurer denies providing any diagnostic test, because there is a clause in the contract that determines the exclusion of diagnostic tests that are not common practice in the National Health System, have sufficient proof of this fact by of the insurer.

Unless expressly consents to the insured, the insurer should not oppose the renewal of the contract by reason of being diagnosed with a chronic illness covered by the policy.

In claims:

In the accident insurance is the medical act, diagnostic tests, etc. Therefore, this insurance does not operate the obligation in the Law of Insurance Contract communicate the incident within a maximum period of 7 days.