he demand for health insurance has increased in recent times, mainly due to difficulties in accessing the Portuguese National Health Service (SNS) and long waiting lists. Additionally, there is a growing desire for greater freedom to choose healthcare professionals and access to higher-quality services.

Given its importance, health insurance should be carefully chosen and understood before contracting. To assist, we share in this article everything you need to know about health insurance.

What is health insurance?

Health insurance is coverage that addresses risks related to healthcare provision. Regulated by the Portuguese Insurance and Pension Funds Supervisory Authority (ASF), it is a contract entered into with an insurer. Through the payment of a premium, the insurer is responsible for fully or partially covering the medical expenses of the insured person. The customer thus has access to healthcare services in the private sector at a reduced price.

Health insurance differs from health plans.

Does health insurance replace SNS coverage?

Health insurance does not replace healthcare provided by the SNS. Although it serves as a good complement, health insurance has limits and exclusions, so there are situations where it cannot be used.

What is the difference between the policyholder and the insured?

The policyholder is the person who enters into the contract with the insurer and is responsible for premium payments. On the other hand, the insured person is the one who benefits from the insurance protection. The policyholder and the insured can be the same person.

What are the main coverages of health insurance?

Different health insurance policies may offer different coverages, i.e., services or situations covered for the benefit of the insured. The main coverages provided by health insurance are:

  • Outpatient Care: includes consultations, diagnostic auxiliary exams, emergencies, treatments, and all medical acts that do not require hospitalisation.
  • Hospitalisation: expenses associated with hospital stays exceeding 24 hours.
  • Childbirth: all costs associated with childbirth, whether normal, by c-section, or voluntary termination of pregnancy. Although this coverage is often included in hospitalisation coverage, the waiting period is longer (usually one year).
  • Dentistry: covers expenses related to dental care, including consultations and treatments.
  • Medication: expenses for medications.
  • Prostheses and Orthoses: expenses for the acquisition or rental, according to medical prescription, of prostheses and orthoses (frames, graduated contact lenses, hearing and ophthalmic prostheses, orthopaedic footwear, wheelchairs, crutches, among others).
  • Second Medical Opinion: an opinion from a specialist regarding a diagnosis previously established by another doctor. Specific conditions of the insurance should be consulted, as the second medical opinion applies only to some serious illnesses.
  • International Medical Coverage: expenses resulting from treatment abroad for a serious illness.

Other coverages may be available depending on the chosen insurer. Before contracting health insurance, it is necessary to check if all the necessary coverages for each situation are included.

What are the most common exclusions in health insurance?

Exclusions in health insurance refer to situations not covered by the insurance and must be entirely paid for by the customer. Like coverages, exclusions vary from insurer to insurer, so it is necessary to check the specific conditions of each insurance. However, there are situations excluded from most insurance policies, including:

  • Occupational diseases;
  • Workplace accidents;
  • Nervous disorders and psychiatric illnesses;
  • Disorders caused by alcohol or drug abuse;
  • Organ or bone marrow transplants;
  • Weight loss treatments;
  • Fertility treatments;
  • Aesthetic or reconstructive plastic or cosmetic surgeries, except in case of accidents;
  • Stays in psychiatric establishments, thermal centres, nursing homes, retirement homes, or detox centres for alcoholics or drug addicts;
  • Pre-existing conditions.

What are pre-existing conditions?

Pre-existing conditions are, as the name suggests, those that already exist at the time of contracting the insurance. The law, in Article 216 of Decree-Law Nº. 72/2008, establishes that these diseases, when declared by the policyholder at the time of contract celebration, are covered by the insurance, unless expressly excluded, which happens in many cases.

What is the waiting period? Are there health insurance policies without a waiting period?

Insurance can only be contracted to cover unforeseeable or uncertain events. For this reason, the insurer establishes a waiting period for coverages as protection against fraud attempts.

The waiting period corresponds to the time from the signing of the insurance contract until the moment the coverages become active. For the same insurance contract, different waiting periods may exist depending on the coverage in question.

Due to the reasons mentioned above, health insurance policies without a waiting period are not common. However, there may be exceptions.

What is the network of providers?

The network of providers includes doctors and other healthcare professionals, hospitals, and clinics with whom the insurer has an agreement. In these cases, there is cost-sharing of expenses, and the customer pays only the agreed-upon amount. If the insured person chooses professionals or establishments outside the network of providers, they will have to pay the full expense and may then, according to the insurance conditions, be reimbursed for part of the amount.

How is payment for healthcare services made by insurance?

Payments covered by health insurance can be made through a reimbursement system or a network of agreed providers, with some insurance policies combining both.

  • In the reimbursement system, the insured person chooses the provider and pays the full expense, later being reimbursed by the insurance company at the defined percentage.
  • In the agreed provider network system, the insured person must use providers with an agreement with the insurance entity, i.e., those that are part of the network of providers. Payment is made directly to the provider by the insurer, with only a portion (according to the contract) being the responsibility of the customer.

Generally, the amount that the insured person is responsible for is higher for services outside the network of providers, where there is reimbursement.

What are the options for deductibles in health insurance?

In insurance, the deductible corresponds to the part of the risk (amount, days, or percentage) borne by the policyholder. Specifically, it is the amount above which there is participation by the insurer.

In the case of health insurance, the deductible can be a fixed amount (fixed value or percentage) or a time period. Here are some examples:

  • Fixed amount deductible per medical act: If a health insurance policy has a deductible of €100 per medical act and the act costs €90, the entire amount is borne by the policyholder. If the medical act costs, for example, €150, €50 will be paid by the insurer.
  • Fixed annual deductible: In an insurance policy with an annual deductible of €200, all appointments and medical acts performed up to this limit are paid by the policyholder. Once the deductible amount is reached, the policyholder is entitled to reimbursements or co-payments defined in the contract.
  • Percentage deductible: Like in other insurance types, there may be a percentage deductible. In this case, in an €100 medical act with a 10% deductible, the policyholder pays €10.
  • Time-period deductible: If an insurance policy has a 60-day deductible, it means that using the insurance during this period requires the customer to pay the entire medical act.

When choosing health insurance, it is essential to check for an associated deductible. Insurance with deductibles is generally cheaper (lower premium), but depending on the expected use of the insurance, it may turn out to be more expensive than opting for insurance without a deductible.

Why have health insurance?

There are several reasons why contracting health insurance is important, with the main one being security and greater predictability of healthcare expenses.

According to data available from the Portuguese Health Insurance Observatory at ASF, the main reasons for acquiring health insurance include difficulty accessing the SNS, reducing waiting times, higher service quality in the private sector, and the desire to be followed by a specific specialist.

The number of insured individuals in Portugal has been growing, both due to the increased individual purchase of insurance and the greater concern of companies seeking to improve the conditions for their employees.

What are the prices of health insurance?

The price of health insurance varies primarily with the age of the insured and the included coverages. Other factors include the health status and medical history of the insured.

How to choose health insurance?

There are several essential aspects to consider when choosing health insurance. It is best to list all necessary coverages and compare proposals from various insurers. For better time management, you can turn to an intermediary working with multiple insurers who can easily present and compare proposals.

Coverflex acts as an intermediary for the best plans and partners in the Portuguese market, including Advancecare, Multicare, Tranquilidade, Fidelidade, Médis, Mgen, Allianz, Lusitania, Real Vida Seguros, Victoria, Ageas, and Scor. You can transfer your employees' insurance for free or request a quote without any commitment. Find out the advantages of managing your insurance with Coverflex.