1.1 Insured persons
The individual, residing in Spain, beneficiary of the health care insurance of HEALTH INSURANCE ISSUER in its individual contracting modality.
1.2 Individual insurance modality
For the effects of the contracting, it is considered that the insurance policy is of an individual modality when it includes a minimum of one insured person and a maximum of nine, linked by a bond other than the interest of insuring, being first degree relatives (the holder, spouse or common law partner, and their non-emancipated children under 30 cohabiting in the same family residence), and whose coverage in any case is carried out by means of obligatory adhesion (closed collective) or voluntary (open or cofinanced collectives) to some contracting conditions and/or single contract previously agreed with HEALTH INSURANCE ISSUER and the contracting collective.
1.3 Duration of the insurance The same as that of the main coverage of the health care insurance.
To be able to take advantage of the guaranteed services, the insured person should have his habitual home and reside in Spain.
Complementary exclusive coverage
The contracting of the insurance policy in its individual modality is the only one that grants the insured person access to the following additional guarantees:
2.1 Refund of health care expenses from abroad for serious illnesses
2.1.1 Territorial scope
The insured person may access the medical and/or surgical treatment of any of the serious diseases listed below and included in this guarantee, in the form of reimbursement of expenses, with coverage and limits that are listed. To do so, it is necessary to accredit it as one of these aforementioned diseases, through a medical report, with it having been previously diagnosed in Spain while the insurance policy is in vigour.
2.1.2 Object of the coverage The maximum coverage of HEALTH INSURANCE ISSUER for the illnesses stipulated below is 80% of the amount of the invoices paid by the insured person for his treatment, up to a total limit of 16.000 EUR per insured person and year, provided these invoices have been raised abroad and correspond to expenses derived from the provision of health care services included in the insurance policy (See section 4 “Description of the coverage” of the general conditions):
184.108.40.206 Heart attack: illness that consists of the permanent occlusion of a portion of the main trunk or an important branch of those coronary arteries, and of its post-heart attack complications (cardiac arrhythmia, cardiac inadequacy, heart blockages and residual angina).
220.127.116.11 Cancer: illness that manifests itself with the presence of a malign tumour characterised by its uncontrolled growth and proliferation of malign cells, the invasion of tissues including the direct extension or metastasis, or high numbers of malign cells in the lymphatic or circulatory systems as in Hodgkin’s lymphoma or leukaemia. In skin cancer, only the invasive melanoma is covered, other skin cancers are excluded. In all the cases the cancer diagnosis will depend on a histopathological result of malignancy.
18.104.22.168 Cerebrovascular illness: cerebrovascular illness or accident that produces neurological consequences of a permanent nature as a consequence of a stroke of cerebral tissue, haemorrhages and blood clot in-situ or extra cranial.
22.214.171.124 Transplant of organs: being the receiver of a cornea heart, liver, bone marrow and kidney transplant, (the medical coverage of the donor is excluded).
126.96.36.199 Paralysis / paraplegia: total and permanent functional loss of the use of two or more limbs as a consequence of a spinal cord section or neurological illnesses. Also, the expenses of health care abroad for these serious illnesses are covered, but with the limits and specified coverage exclusions specified in the general conditions of the policy (See section 5 “Excluded coverage” and section 6 “Periods of grace”).
2.1.3 Access to the coverage: specific regulations
- a) For the effects of this coverage, the claim is understood to have been made when the insured person requests the refund of the medical expenses that were produced abroad by a serious illness previously diagnosed in Spain during the validity of the insurance and covered by this guarantee, and present the medical reports with the definitive medical diagnosis that confirms he is suffering from the same.
- b) In a maximum term of fifteen days, the policy holder or insured person must request the refund of the medical expenses covered by the present guarantee and submit the invoices paid by him to HEALTH INSURANCE ISSUER, with a breakdown of the medical acts carried out, the prescription and the medical reports that specify the origin and the nature of the illness. For the presentation of this documentation, HEALTH INSURANCE ISSUER will provide him with the refunds form with the minimum administrative processes that the invoices should fulfil to be refunded, which are described on the back of this document. The insured person and his relatives should facilitate the reports and checks that HEALTH INSURANCE ISSUER considers necessary. The non fulfilment of this duty may result in the refund being rejected.
- c) The refund of expenses will be made in the following way:
> Once presented the refund form has been submitted together with the reports and original invoices accrediting the services received, HEALTH INSURANCE ISSUER will refund the expenses, according to the percentage and the coverage limits indicated previously.
> The payment will be made to the designated current account. The payment carried out by this means is fully valid, effective and final for HEALTH INSURANCE ISSUER.
> The invoicing of expenses generated and paid in foreign currencies by the insured person will be paid in Spain in Euros at the exchange rate on the day of the payment. If this is not available, it will be carried out with the exchange rate corresponding to the issue date of the invoice or, else, to that of the provision of the service.
> The cost of translating the report, invoices or receipts of medical fees will only be paid by HEALTH INSURANCE ISSUER if they are in English, German, French or Portuguese. If they are in another language, they must be paid by the insured person.
- d) Once the refund of expenses has been made, HEALTH INSURANCE ISSUER is entitled to exercise the subrogation right, with the limits specified in these conditions general (See section 3.5 “Subrogation clause”).
2.1.4 Delimitations of the coverage
The health care expenses abroad for the serious illnesses detailed in this Appendix are covered with the modality, territorial scope, form of access, limits of coverage and excluded risks that are stipulated in Appendix II itself: Section 2 “Basic Concepts. Definitions”, Section 3 “Modality and extension of the insurance policy”, Section 4 “Description of the coverage”, Section 5 “Excluded coverage” and Section 6 “Periods of grace”.
2.2 Refund of the expenses for services of family care and/or care for dependence, having been awarded a grade 3 dependence due to an accident
2.2.1 Object of the coverage HEALTH INSURANCE ISSUER guarantees in the event of the insured person and/or person acting on his behalf (legal guardian) demonstrating the recognition awarded by the “System for autonomy and care or dependence” (SAAD) of a state o situation of Dependence Grade 3 after an accident covered by the insurance policy, starting from the effective date of this coverage, the refund of 100% of the amount of the invoices paid for family care services and/ or care for dependence, up to a maximum limit of 10.000 euros per insured person. The compensation is guaranteed provided it corresponds to expenses for social health care services included in this coverage, and subject to the limitations and exclusions specified in the General Conditions of the policy (see Section 5.a 5.c 5.d 5.e “Excluded coverage”) and Appendix II (section 2.2.3). For the effects of this coverage, Dependence Grade 3 due to an accident is defined as an irreversible state in which the dependent person will neither be fully independent again nor be able to pass to a grade of lower dependence. The social-health care services and family care services or care for dependence, carried out by profesional assistants, which this guarantee covers, are: 188.8.131.52 Care services in the home: Those that provide, by means of suitably qualified and supervised personnel, a series of useful care services for people that have suffered a decrease of their faculties and personal mobility, experiencing difficulties with getting up, personal hygiene, getting dressed and preparing daily meals and who require a permanent assistant.
- a) Personal Care:
> Personal hygiene
> Mobility in the home
> Change of posture and personal hygiene for the bedridden
> Companionship at home
- b) Care of the home:
> Cleaning of the home
> Domestic shopping
> Kitchen service
184.108.40.206 Residential care service: Services provided in residences and day or night centres staffed by teams of highly qualified people that guarantee complete care; such as doctors, male nurses, physiotherapists, psychologists or occupational therapists, among others. This service includes temporary and permanent stays and day centres.
> Specialized care day centres
> Night centres
220.127.116.11 Fixed and portable teleassistance service: Portable or permanent communication devices permanently connected to a central switchboard in case of an emergency. It offers a personal, made to measure service, staffed by social workers, psychologists and doctors 24 hours a day, 365 days a year, inside and outside of the home, providing access through a specific terminal. The only condition established is that the beneficiary must have sufficient cognitive functions to be able to use the corresponding technology.
18.104.22.168 Home adaptation service: Consists of a set of items intended to adapt the home to their needs. These products allow for improved access and mobility throughout the home. The insured person and/or person acting on his behalf (legal guardian) may request the refund from HEALTH INSURANCE ISSUER of the total expenses generated by the services of family care and/ or care for dependence described in this section, up to a maximum limit of 10.000 euros per insured person. To do so it is essential to present the resolution awarding the insured person the situation of Dependence Grade 3 (level 1 or 2) from the competent administrative body of the “System for autonomy and care for dependence” of their autonomous community, specifying the causes and circumstances of the dependence situation. The coverage of dependence is cancelled in an automatic and definite way when the insured person receives the maximum guaranteed capital of 10.000 euros for this concept during the validity of the insurance policy, through the modality of refund of expenses.
2.2.2 Access to the coverage:
- a) Requirements to be beneficiary of the coverage of dependence:
> To be entitled to the benefit for dependence in Spain and to fulfil the legal requirements to access the same.
> To be included in the health policy as an insured person at the moment of the occurrence of the accident, of the application for the refund of expenses for Dependence Grade 3, and for the payment of the benefit.
> The accident that took place is not a consequence of activities or circumstances excluded from the general coverage of the health insurance policy (section 5.a 5.c 5.d and 5.e “Excluded Coverage” of the General Conditions) or specifically excluded from the dependence coverage (section 2.2.3 of this Appendix).
> To be in a situation of Dependence Grade 3, according to the grades established in the Law of Dependence 39/2006 of December 14, and the Scale of valuation of dependence (Real Ordinance 504/2007, of April 20) currently valid in Spain.
> The resolution, dated and signed, with the qualification or recognition of the situation of Dependence Grade 3 granted by the competent administrative body of the “System for the Autonomy and Attention to the Dependence” of the Autonomous Region, which specifies the causes and the circumstances of the dependence situation.
- b) Documentation required for the recognition of the benefit
To be a beneficiary of the dependence refund, the insured person must present the whole granting of dependence procedure contributing the following documents (original or validated copies):
- Personal, family and professional data of the insured person who is recipient of the benefit.
- Qualification granted by the competent administrative body of the “System for the Autonomy and Care for Dependence.” Specifying the causes and the circumstances of the dependence situation.
- Medical reports with the conditions of the dependent’s health, and the social report made by the social worker. 4. All the additional documents required to be able to grant the right to receive the benefit
- Resolution issued and the date, with the qualification or recognition of the situation of Dependence Grade 3, starting from which the entitlement to the refund of the social health care is valid. The non-fulfilment of the previous requirements may lead to the refund being refused.
- c) The refund of expenses will be made in the following way:
> Once the refund form has been presented, with the reports and original invoices demonstrating the services received, HEALTH INSURANCE ISSUER will reimburse the expenses paid, according to the percentage and coverage limits previously indicated.
> The payment will be made to the current account designated for such. The payment made in this way is fully valid, effective and final for HEALTH INSURANCE ISSUER.
> The invoicing of expenses paid in foreign currencies by the insured person will be paid in Spain in euros according to the exchange rate on the day of the payment. If this is not given, it will be made according to the exchange rate corresponding to the date of issue of the invoice or, else, on that of the receipt of the service.
> The cost of translation of the reports, invoices or medical fees will be met by HEALTH INSURANCE ISSUER exclusively if they are written in English, German, French or Portuguese. If they appear in another language, they will be paid by the insured person.
2.2.3 Excluded risks of the coverage
Excluded from the coverage for dependence:
- The refund of expenses for services of family care and/or care for dependence not detailed in Appendix II of the general conditions
- The refund of expenses for services of family care and/or care for dependence detailed in Appendix II of the General Conditions, when the situation of Dependence grade 3:
- a) is produced by an accident caused by activities or in circumstances expressly excluded from the general coverage of the health insurance policy (section 5.c 5.d, 5 e. of the general conditions).
- b) is a consequence and/or after effect, or complication of injuries that occurred in an accident that took place prior (pre-existing) to the date of each insured person’s inclusion in the policy.
- c) is due to an accident that took place in a situation of mental derangement, under the influence of alcohol or drugs of any type or psychoactive substances in general, although these have not been the cause of the accident.
- d) is a consequence of accidents whose origin were in acts of rash imprudence or serious fault, attempted suicide, and those derived from the participation in bets, competitions, challenges, fights or aggression.
- e) is produced by accidents derived from the practice of the following sports: automobile or motorcycle races and in any of their modalities, hunting, scuba diving, sailing in crafts not dedicated to the public transport of passengers, horse riding, climbing, mountaineering, pot holing, boxing, wrestling in any of its modalities, martial arts, parachuting, ballooning, freefalling, gliding, and in general any sport or recreational activity of a seriously dangerous nature.
- f) is due to accidents that occurred while travelling, either as a passenger or manning of aircraft with a capacity of fewer than ten passenger seats.
- The refund of the expenses for services of family care and/or care for dependence, with the right to the benefit having been extinguished, on the insured person having previously received the maximum capital guaranteed by this concept during the validity of a health care insurance policy of individual modality.
The policy holder, to the effects stipulated in Article 3.º of the Law of Insurance Contracts, recognises having received a copy of the present General Conditions and Appendices of the contract, accepting them by means of his signature and expressly states his full acceptance of the limiting and delimiting clauses included within, and especially, the exclusions of coverage that are expressly stipulated in Section 5.º which have been clearly, explicitly and separately indicated and whose content he is aware of and understands as having been read.