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Insurance: understanding the mutual insurance table of guarantees

It is quite rare to know what percentage of the coverage of the mutual, except when you need it! And at that time we sometimes discover that we are not 100% covered for a large expense, e.g. dentist. All these percentages are collected in the table of guarantees. Let’s take a look at this document and the important information to know.

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A table of mutual guarantees, what exactly is it?

Each mutual fund formula offers different guarantees and repayment levels. To know the details, you must study what is called the guarantee table, which shows the type of guarantees and the allowances the contract provides. Note that in a table of guarantees, each guarantee is listed by family or reimbursement area: “Hospitalisation”, “Routine care”, “Optics”, “Dental” and sometimes “Assistance”.

If all this information might seem opaque before, things have changed. According to a study by UNOCAM (National Union of Complementary Health Insurance Organizations), 92% of the organizations that had committed to making complementary health insurance guarantees ready by the end of 2020 had implemented the harmonization of expenditure items in their presentation of their offer. A good point for them.

What are the main guarantees for a mutual?

The health insurance only partially reimburses health expenses and to cover the rest, it is strongly recommended to take out supplementary health insurance, which reimburses part of the expenses or all of the costs you have incurred.

The guarantees refer to the costs incurred for:

  • Hospitalization: accommodation costs, daily hospital pack, surgery and anesthesia costs, transportation, single room costs, etc.;
  • routine treatment: general or specialized medicine, alternative medicine, medical aids, medical imaging, pharmaceuticals, etc.;
  • optics: glasses and frames, contact lenses, ophthalmology consultation, etc.;
  • dental care: scales, cavities, dentures, implants, etc.;
  • and sometimes assistance: psychological support, legal advice, etc.

Coverage for each of the guarantees is stated as a percentage of the reimbursement base for social security (BR or BRSS) or the moderation ticket (a portion of your healthcare costs that remains your responsibility once the health insurance has reimbursed its share). Depending on the formula you have chosen, these percentages vary.

How do I know if my health insurance charges extra?

Some specialists exceed the convention rate set by Social Security and practice more or less significant fee overruns. It is sector 2 contract doctors who are allowed to exceed fees and non-conventional sector 3 doctors who set their rates completely freely.

To find out what your mutual insurance company provides, study the reimbursement rates in the table of guarantees (for example, 200% for a specialist consultation is equivalent to a reimbursement of 2 times the reimbursement base for Social Security) and check whether the indicated percentage includes part already reimbursed by the health insurance or not. Also pay attention to the mention of fixed rates corresponding to what your mutual will cover per year (a fixed rate of 150 euros/year for e.g. contact lenses).

See the details of your table of guarantees available in your customer area or on the application offered by your mutual insurance company, often stored under the “your contracts” tab. You may also have received it in paper form. If in doubt, don’t hesitate to call an advisor who will be able to tell you if your formula supports fee overruns and at what level.

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What should you pay attention to in your table of guarantees?

Be careful because the percentage refund of BRSS may or may not include the share of Social Security, which can change everything! In most coverage tables, the co-payment is denoted by the abbreviation “TM”. If this table bears the indication “BR”, it is Sygesikringen’s reimbursement basis, which includes the moderation ticket. Also pay attention to the reimbursement of hospitalization expenses if you are over 65 years of age. The bill can add up quickly if you have to stay in hospital. In any case, do not hesitate to compare health insurance policies to limit your expenses and at the same time be well protected.

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