Terms and Conditions of Pooling

Pooling is based on terms and conditions that vary according to the covered group, i.e. on the number of certificates in the group (one certificate corresponds to one member, with or without dependents).

These terms and conditions incorporate two parameters, namely:

• the pooling threshold: this is the amount per certificate above which claims are pooled among participating insurers and employee benefit plan administrators;

To be eligible, the claims must have been submitted and paid during the year in question and be for medications covered by the private plan;

• the annual pooling factor: for insured groups, this is a portion of the insurance premium reserved for compensation of the pooled amounts; for non-insured groups, it is an assessment paid to the Compensation Table for the purpose of pooling.

How do we define terms & conditions ?

A larger group is better able to absorb high claims from the sum of premiums or contributions paid. Therefore, the more certificates the group has, the higher the pooling threshold and the lower the annual factor.

The methods of mutualisation are established and validated on the basis of a test of reasonableness (Monte Carlo test) based on multiple actuarial assumptions. These assumptions take into account past claims, cost, and use of drugs.