This contract is subject to Insurance Contract Law 50/1980 dated October 8.
The contract consists of the following documents:
> The application form
> The health declaration
> The general conditions
> The particular conditions
> The special conditions (where applicable)
The client may select the means through which he would like the reply to be made and address at which to receive it. The complaint will be answered in writing within two months.
The age of each insured person on his closest birthday (past or future) to the effective date, or the date of extending the policy.
Biological medication that acts on the growth factor of the vascular endothelium (VEGF) essential for the formation of new blood vessels (angiogenesis) inhibiting their growth.
Biological or synthetic material
Also known as biological prostheses, these are implanted by means of special techniques to replace, regenerate or add to an organ or its function. Includes cell transplants for regenerative purposes.
Materials, natural (biological of either animal or human origin) or artificial (manmade), used in the production of items or sanitary products that interact with biological systems, applied in various medical specialties.
The activities required from a physical point of view to restore an optimum functional level after an acute heart attack.
Specialist area of Psychology that deals with the treatment and rehabilitation of anomalies and disorders of human behaviour.
Graduate in Psychology who specialises in Clinical Psychology.
Collective insurance modality
For the effects of the contracting, it is considered that the insurance policy is of a collective modality when it includes a minimum of ten insured persons linked by a bond other than the interest of insuring, that fulfil the legal conditions for insuring and whose coverage is made by means of obligatory adhesion (closed collective) or voluntary (open or co-financed collectives) to some contracting conditions and/or single contract previously agreed with HEALTH INSURANCE ISSUER and the contracting collective.
Complete medical care
Includes all the specialties and health care services included in the insurance policy in the modules of primary care, specialists and complementary means of diagnosis and treatment, and hospital care and surgery.
Congenital abnormality, defect, illness, or injury
Present at the moment of birth as a result of hereditary factors or medical conditions acquired during pregnancy up to the moment of birth itself. A congenital condition may show up and be recognised immediately after the birth, or be diagnosed later at any time during the individual’s life
The preset amount for each medical act that the policy holder or insured person accepts for the use of the corresponding Covered Health Care Network according to the modality contracted, and which is stipulated in the “Table of groups of medical acts and contributions” of the Particular and/or Special Conditions of the policy.
Cytotoxic medication used in oncological chemotherapy that is able to stop the development of the cancer acting directly on the integrity of the chains of deoxyribonucleic acid (DNA) and the cellular mitosis, inhibiting normal cellular multiplication, both of healthy and tumour cells. This therapeutic subgroup includes, for their action mechanism: the alkylating agents, the antimetabolites, plant alkaloids and of other natural products, cytotoxic antibiotics, those made from platinum and methylhydrazines.
Enzymatic and /or molecular inhibitor
Biologically directed pharmaceuticals that act on a therapeutic, intra or extra cellular target, inhibiting the generation and transmission of signals for cellular growth. This therapeutic subgroup includes enzymatic transcription inhibitors of different levels (e.g. inhibitors of the protein kinase, of the tyrosine kinase, of proteasomes, etc). External means Doctors and centres not included in the corresponding Covered Health Care Network according to the modality contracted. Extra premium Additional quantity or complementary premium paid for a risk which is excluded from the general conditions.
The process that allows the treatment of hereditary illnesses, cancer, infections and other illnesses, by means of the modification of cellular genome. Genetic therapy consists of inserting, by means of different vectors, genetic material in a target cell to obtain a therapeutic effect (synthesis of a protein of interest, to compensate a genetic deficit, to stimulate the immune response to a tumour or resistance to infection by a virus).
Health Care network
The list of professionals and hospitals associated to HEALTH INSURANCE ISSUER throughout Spain, adapted for each modality of the policy contracted.
Heliocoidal radiation therapy or tomotherapy
Real time image guided helical radiotherapy, also called tomotherapy, integrates TAC and a multilayer binary linear accelerator (64) in a single device. It is an advanced radiotherapy modality that enables you to obtain a three-dimensional image of the tumour before administering the radiation and to focus the radiation on the tumour from many different directions by rotating the machine’s radiation source around the patient in a spiral manner. It is also called helical tomotherapy.
High medical technology
Refers to the new applications of electronics, computer science, robotics and bioengineering in the field of medicine, especially in diagnosis technologies and medical treatment. These techniques are characterised by a high investment cost, the need for specialised personnel, and are subject to reports from the health technologies assessment agencies (AETS) to verify whether their security and effectiveness in the different indications are sufficiently strong to replace the existing technology.
Hospital care is the care that is given in a hospital centre with admission for at least 24 hours for the insured person’s medical or surgical treatment.
Hospital care for social or family reasons
Admission to, or extended stay in, hospital for reasons unrelated to objective medical pathologies and therefore not requiring hospital care in the judgement of a HEALTH INSURANCE ISSUER doctor, but rather for social and/or family motives. Such cases are not covered by the policy. Hospital or clinic All public or private establishments that are legally authorised for the medical treatment of illnesses, body injury or accidents, with permanent medical staff and equipped with the means required to carry out diagnoses and surgical operations.
Illness or injury
Alteration of health that occurs while the policy is effective, not resulting from an accident, the diagnosis and confirmation of which is carried out by a legally recognised physician in the place where he provides his services.
Sanitary product designed to be total or partially inserted in the human body by surgery or special techniques, with a diagnostic, therapeutic and /or aesthetic purpose, intended to remain there after this surgery.
Immunotherapy or biological therapy
Immunotherapy or biological therapy (also sometimes called biotherapy or biological answer modifier therapy) is based on modifying, stimulating or restoring the capacity of the immune system to fight against cancer, infections and other illnesses. It is also used to diminish certain secondary effects that some oncological treatments can cause. The substances or medications used in anti tumour immunotherapy are: nonspecific immunomodulating agents, interferons, interleukins, growth factors or colony stimulants, monoclonal antibodies or specific antigen-anti tumour agents, therapies with cytokines and vaccines.
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, commonly 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 co-financed collectives) to some contracting conditions and/or single contract previously agreed with HEALTH INSURANCE ISSUER and the contracting collective. Insurance application The questionnaire made available by HEALTH INSURANCE ISSUER in which the policy holder describes the risk he wishes to insure with all the circumstances that he is aware of and which may influence the evaluation of the said risk.
The individual who receives the health care.
Intensity modulated radiation therapy (IMRT)
A type of specifically shaped three dimensional radiotherapy that uses computer generated images, by means of inversely planned computer programs, to show the size and exact shape of a tumour, to direct beams of radiation from multilayered linear accelerators at different angles and varying intensities toward the tumour, concentrating the maximum intensity on the tumour itself, and limiting the dose that the healthy adjacent tissues receive. It is also called RIM
Life threatening emergency
A situation that requires medical health care immediately or without delay (in a few hours) as a delay could affect the life or cause irreparable damage to the physical state of the patient.
Agreement stipulated in the insurance policy, by means of which the extension of the guarantee is limited or which leaves it without effect when some risk related circumstances arise.
Major outpatient surgery
All surgery carried out in an operating theatre with general, local or regional anaesthetic or sedation that requires little post-operative and short term care, which does not require hospitalisation and therefore patients can be discharged a few hours after the operation.
Medical and surgical fees
Professional fees corresponding to surgery and/or a stay in hospital. Includes the fees of the surgeon, assistants, anaesthetists, midwife, and those of any other staff who were strictly necessary for the surgery or treatment given.
Medical or surgical hospital care
A stay in hospital that is required to receive medical or surgical care. Includes the costs arising from a stay in hospital, medical fees corresponding to the surgical-medical treatment given and the prosthesis, if applicable.
Minor outpatient surgery
Health care processes that require surgical procedures or other simple interventions that are carried out in consultations, on superficial tissue and that generally require, local anaesthetic. The techniques most used are surgical exeresis and cryotherapy.
All medical or surgical treatment that affects a new born baby during the first four weeks (28 days) of his life. N.I.C.E clinical guides. The National Institute for Health and Clinical Excellence (NICE) is a nonprofit public organisation created in 1999, belonging to the Department of Health of the United Kingdom, responsible for providing information and guidance to staff related to the health sector for the prevention and treatment of diseases, as well as make recommendations based on the available scientific evidence regarding the therapeutic usefulness (safety and cost-effectiveness) of certain health and medications (including radiopharmaceuticals and anti-tumour or cancer).
Clinical practice guidelines are world renowned and the most widely developed, therefore they have been selected as a reference to assess chemotherapy and radiation oncology with efficiency criteria, having based their recommendations on articles with the highest level of evidence, and not on publications of expert groups, or any other convenient source.
Anatomical piece or element of any kind used to precent or correct body abnormalities.
Orthopaedic material and arch supports
Sanitary products for permanent or temporary external use that are specifically adapted to the patient. They are designed to modify the structural or functional conditions of the neuromuscular or skeletal system, without their fitting ever requiring surgery.
Piece or element of any kind used in the joints of fractured bones, or to link ends of joints. Out-patient health care Refers to the diagnostic and /or therapeutic care that is habitually given in surgeries, at the patient’s home and/ or at a hospital or clinic without an overnight stay or a stay of less than 24 hours (eg. casualty, day visits). This concept does not include major out-patient surgery. Own means Doctors and centres included in the corresponding Covered Health Care Network according to the modality contracted.
Medical service specialised in the treatment of chronic pain.
Period of grace
The period of time after the insurance is in force, during which some of the coverage included in the guarantees of the policy is not effective.
Graduate or Doctor in medicine who is legally qualified and authorised to provide medical or surgical treatment for the illness, ailment or injury that the insured person is suffering.
The insurance contract, the document that contains the general conditions, the particular conditions, the special conditions, plus the supplements or appendices that are issued to establish additions to or change the above. the application form and the health declaration also form part of the policy.
The individual or legal entity that subscribes this contract with HEALTH INSURANCE ISSUER and accepts the obligations derived from the said contract, except for the obligations of the insured person.
Health condition (for example pregnancy), alteration or organic disorder that existed before the moment of taking the policy out or it becoming effective and which is normally determined by signs or symptoms, regardless of whether or not a medical diagnosis has been given.
Pre-existing health condition
Health state or condition, not necessarily pathological (for example pregnancy), that began before the inclusion of the insured person in the policy.
Premature or preterm childbirth
Premature or preterm childbirth is considered to be that occurring after the twentieth week and before the thirty seventh week of gestation, provided that the pregnancy had not begun and the insured person could not have been aware of it before the date of its inclusion in the policy.
The price of the insurance. The receipt includes the surcharges and taxes that are legally applicable.
Method of treatment for a person suffering a psychic conflict, with the indication or prescription of a psychiatrist.
Questionnaire or health declaration
Question sheet which forms an integral part of the insurance policy made available to the policy holder and/ or insured person by HEALTH INSURANCE ISSUER, whose aim is to determine his state of health, in addition to discovering the circumstances that could influence the evaluation of the risk and the contracting of the policy.
Radical or oncologic surgery
Surgical process on the breast or other types of organs following an oncologic diagnosis
Includes techniques of tissue regeneration, cellular or molecular therapy, implants or transplants of mother cells and tissue engineering.
All the acts prescribed by a orthopaedic surgeon, neurologist, rheumatologist or specialist in rehabilitation and carried out by a specialist in rehabilitation or a physiotherapist in rehabilitation centres, with the purpose of returning functionality to the parts of the locomotive apparatus that have been affected by the consequences of an illness or accident caused while the policy is effective.
Robotic or computer assisted surgery
Surgical acts that a robot carries out, guided by images or computer assisted, following the instructions of a surgeon aided with a telerobotised laparoscopic system and/or assisted by a virtual reality computerised system or navigator with computer obtained 3D images.
Special care unit
Section or area that is specially equipped and staffed by doctors and nurses who specialise in giving specific treatment.
Diagnostic or therapeutic act carried out by means of an incision or other internal approach by a surgeon or surgical team usually requiring the use an operating theatre of a legally authorised hospital.
Permanent or temporary health care products that in the event of the absence, defect or anomaly of an organ or part of the body substitute or restore, total or partially, its physiological function.
Accident suffered by the insured person as a pedestrian; user of public transport, scheduled or charter flights; car driver or passenger; whilst riding a bicycle or motorbike on all kinds of public roads or private road open to the public.
Modality and extension of the insurance policy
3.1 Object of the insurance by means of this policy, HEALTH INSURANCE ISSUER covers medical, surgical and hospital care, within the limits established in these conditions and the particular and special conditions and/or health questionnaire, for all kinds of illnesses or injuries included in the specialities that appear in the description of the coverage of the policy; after payment of the relevant premium Diagnostic and therapeutic advances in medical science that appear during the coverage of the policy will only be included to form part of the coverage of the policy when
1. Studies of their safety and effectiveness have been verified by means of a positive report by the Health Technology Assessment Agencies depending on the regional health care services or the Ministry of Health.
2. They are expressly included in Section 4 “Description of the coverage” of the General Conditions. With each renewal of the policy HEALTH INSURANCE ISSUER will explain the techniques and treatment that will form part of the new coverage of the policy for the subsequent period.
3.2 Modality of the insurance policy provides medical and surgical care on a national level through the corresponding Covered Health Care Network according to the modality contracted for all kinds of illnesses or injuries included in the specialities that appear in the description of services in the policy. This policy is based on the free choice of the physicians and hospitals included in the corresponding Covered Health Care Network according to the modality contracted. If some of the services included in the contract are not available in a particular area, the insured person has the right to choose a location where they are offered.
The right to the free choice of physician and hospital implies the lack of direct, joint or subsequent responsibility of HEALTH INSURANCE ISSUER for their acts which HEALTH INSURANCE ISSUER cannot control due to the professional secrecy, confidentiality of health data and denying unwarranted access to third parties in the health sector. The modality of the service provided is that specified in article 105 paragraph 1º Law of Insurance Contracts- payment of health care expenses-, without assuming directly the provision of those services supplied by professionals and qualified centres.
In case of incorrect medical or hospital practice, the insured person is under an obligation to make a complaint exclusively against those professionals or centres directly intervening in the provision of the service and their respective insurance companies of civil responsibility, leaving HEALTH INSURANCE ISSUER free of any responsibility. The modality of the insurance policy and determined coverage vary depending on the type of subscription taken out by the insured person. There are two modalities for the effects of contracting, the individual insurance modality with access to some exclusive coverage of this modality (See Appendix II) and the collective insurance modality without access to the same.
The payment of a contribution from the insured person towards some services is included in the regulations. Under no circumstances will cash compensation be paid instead of health care services.
3.3 Access to coverage
HEALTH INSURANCE ISSUER will provide the policyholder with a Medical Card, which is nontransferable and for his personal use, as a means of identification for each beneficiary and information about the Covered Health Care Network adapted to the modality contracted with a breakdown of the associated medical services, healthcare professionals, diagnoses centres, hospital centres, emergency services and complementary services as well as their addresses and timetables. In the corresponding Covered Health Care Network according to the modality contracted, the insured person pays a quantity for each act given (See section. “Frequently asked questions and answers”, Medical Card).
The services covered by the policy may have free access or require previous authorisation from HEALTH INSURANCE ISSUER. Generally, the consultations of primary care, medical- surgical specialists and emergency consultations, as well as basic diagnosis tests have free access. Hospital admissions, surgery, prostheses and surgical implants, psychotherapy sessions, preventative programmes or checkups, transfers by ambulance, therapeutic acts and complex diagnosis tests, which are detailed in the associated list of the corresponding Covered Health Care Network according to the modality contracted, require authorisation.
To identify yourself to any doctor or centre of the corresponding Covered Health Care Network according to the modality contracted as an insured client, just present the Medical card. Similarly, you may be obliged to present your identity card or official means of identification (passport, residence permit, etc.), if required by the health care or auxiliary staff. HEALTH INSURANCE ISSUER will issue the corresponding authorisations to access the services, with the written prescription of a doctor of the corresponding Covered Health Care Network according to the modality contracted and following administrative confirmation, unless the service is not covered by the policy.
To issue the authorisations, process the claims, to inform the client about additional services and/or to administer plans of prevention and promotion of good health, HEALTH INSURANCE ISSUER is authorised to collect medical information related to prescriptions, directly from the doctor and/or centre, and request an additional medical report from the insured person containing the history, risk factors, diagnosis and need for treatment. Despite that mentioned in the previous paragraphs, in emergency cases the order of the doctor of the corresponding Covered Health Care Network according to the modality contracted will be sufficient provided that the insured person, or person acting on his behalf, notifies HEALTH INSURANCE ISSUER of the event in writing to obtain their confirmation and authorisation within 72 hours following admission, or after receiving health care.
In cases of life threatening emergency the insurer will be financially bound until the moment that it expresses doubts about the medical order, in which case it is understood that the policy no longer covers the medical care or the hospitalisation. The authorisations can be requested by telephone, from the Call Centre.
3.4 Care via other means
Health Care Network HEALTH INSURANCE ISSUER does not accept responsibility for the fees of doctors outside of the corresponding Covered Health Care Network according to the modality contracted, the hospitalisation expenses or services that these professionals may request. Nor, does HEALTH INSURANCE ISSUER accept responsibility for the hospital care expenses of the services arising in public or non HEALTH INSURANCE ISSUER associated private centres that are not included in the corresponding Covered Health Care Network according to the modality contracted, whoever their prescribing doctor or author may be. In cases of life threatening emergency, whose concept is defined in this document, and with the express authorisation of the company, HEALTH INSURANCE ISSUER will cover the health care expenses arising in centres outside of the corresponding Covered Health Care Network according to the modality contracted. The insured person must notify HEALTH INSURANCE ISSUER in a demonstrable way, by any means within 72 hours after admission or beginning to receive health care. Provided that his clinical situation allows it, the patient will be transferred to one of the centres in the corresponding Covered Health Care Network according to the modality contracted.
3.5 Subrogation clause or surrender of rights
Once the service has been provided, HEALTH INSURANCE ISSUER can exercise its rights and take the legal steps that due to the nature of the claim correspond to the insured person against persons responsible for the claim up to the amount of compensation paid. The insured person is obliged to provide HEALTH INSURANCE ISSUER with all the necessary documents required to proceed with the subrogation. This right to subrogation cannot be used against the insured person’s spouse nor any other blood relative up to the third degree, adopting father or adopted son, who live with the insured person.
Description of the coverage
The specialities, health care and other services that you are entitled to with this contract are the following:
4.1 Primary care General medicine: Medical care at a surgery or at home, as well as the prescription of basic diagnostic means.
Pediatrics and child care: child care up to 14 years of age, at a surgery or at home, and the prescription of basic diagnostic means.
Includes basic analytic blood tests (excluding hormone, immune, genetic and molecular biological tests), urine tests and standard X-rays (non contrast).
Nursing services: (injections/cures): Services of Health Care Technical Assistant or University Graduate (ATS/ DUE) that will be given in a centre and at home with a prior written prescription from the doctor attending the insured person.
Ambulance service: for cases of urgent need, road transport is included from the place where the insured person is located to the nearest hospital in the corresponding Covered Health Care Network according to the modality contracted where the treatment can be carried out and vice versa, provided that special circumstances impede him from physically using ordinary means of transport (public transport, taxi, private car).
Transport with incubators is included.
The written authorisation of an associated doctor in the corresponding Covered Health Care Network according to the modality contracted together with a report indicating the need for assisted transfer will be required in all cases.
4.2 Emergency care
Permanent Emergency service: To obtain health care in emergency cases you should go to any centre offering this service that appears in the corresponding Covered Health Care Network according to the modality contracted.
In the case of going to a centre not in the corresponding Covered Health Care Network according to the modality contracted for a life threatening emergency the insured person, or person acting on his behalf, should notify HEALTH INSURANCE ISSUER in a demonstrable way within 72 hours following admission. As long as there is no medical reason for not doing so, HEALTH INSURANCE ISSUER may move you to an associated hospital, providing the opportune transfer means.
4.3 Medical specialities and surgery
Allergy & immunology treatment. The vaccines will be at the expense of the insured person.
Anaesthesiology-resuscitation. Includes epidural anaesthesia.
Angiology and cardiovascular surgery.
Cardiology-circulatory system. Includes cardiac rehabilitation after an acute myocardial infarction.
Dermatology (medical & surgical): includes outpatient phototherapy with narrowband (UVB-BE) ultraviolet radiation B for the indications given in Section 4.5 (“therapeutic methods”) of the general conditions. Digestive apparatus. Endocrinology and nutrition. General and gastrointestinal surgery. Includes bariatric surgery for a body mass index of 40 or over (morbid obesity), in national associated centres.
Gynaecology. Includes diagnosis and treatment of women’s illnesses. Coverage includes a yearly gynaecological check-up, family planning, the use of surgical lasers (CO2, Erbium and diode) and fertility and sterility tests. Assisted reproduction treatment is at the client’s expense. (see Additional services)
Haematology & haemotherapy.
Registered nursing assistant (ATS) or qualified nurse (DUE) specialised in providing care during childbirth.
Obstetrics. Including control of pregnancy and childbirth assistance.
Includes “triple screening” EBAScreening (the first trimester combined test) and amniocentesis or Chorion biopsy to obtain the chromosomal karyotype, for the diagnosis of foetal anomalies.
The genetic test of prenatal screening in maternal blood for trisomy 21 (Down) 18 (Edwards) and 13 (Patau) is only covered for high-risk pregnancies, multiple gestation and a history of repeated miscarriages (two or more) of unknown cause, and when the fi rst trimester combined test is positive (with risk of abnormality in the foetus of more than 1/250).
Odontostomatology. Includes consultations, extractions and stomatological cures, dental cleans and associated X-rays. Also, until 14 years of age coverage includes fissure sealers and obturations (fillings). Other dental care requires the client’s participation in the expense through the Dental Service (see Additional services).
Oncology. Includes intra operative molecular diagnosis of the sentinel node for breast cancer at an early stage, without lymphatic extension using the OSNA technique.
Ophthalmology. Includes cross linking or corneal cross linking technique, cornea transplants and use of surgical laser, except for the correction for visual refraction defects (myopia, hypermetropia and astigmatism), and presbyopia, which are at the client’s expense (see Additional services).
Orthopaedic surgery. Includes arthroscopic surgery, percutaneous nucleotomy and chemonucleosis.
Oral and maxillofacial surgery.
Otorhinolaryngology. Includes adenoamigdaloplasty and surgery for nasal turbinates or turbinoplasty by radiofrequency, and the use of laser in the operating theatre except for surgery for snoring, obstructive sleep apnea or uvulopalatopharyngoplasty.
Peripheral vascular surgery. Includes the use of endoluminal laser in the operating theatre for treatment of varicose veins except for that stipulated in section 5.f (“Excluded Coverage”) of the General Conditions.
Plastic and repair surgery. Surgery to repair injuries using plasties and grafts.
Plastic surgery for aesthetic purposes is not included, except for:
- in the case of oncoplastic breast reconstruction after radical surgery, and if required, during the same operation the reconstruction of the healthy contralateral breast (maximum limit of one year after the oncology surgery) Includes the breast prosthesis, skin expanders and coated breast meshes.
- Breast reduction for women over 18 years with gigantomastia (more than 1500 grams or ml. of volume for each breast): a distance from the nipple of more than 32 cm to the suprasternal notch, minimum removal of 1000 gr for each breast, and an index of body mass equal to or less than 30.
Pneumology-respiratory tract: includes home therapy in severe obstructive sleep apnoea/hypopnoea syndrome (OSAHS) (see section 4.5 “Therapeutic methods” of the General Conditions).
Proctology. Includes the use of a surgical laser for the treatment of rectal and haemorrhoidal pathology. Psychiatry. Mainly neuro-biological treatment.
Rehabilitation. Under the direction of a specialist physician who is specifically qualified in this area and assisted by physiotherapists to restore the correct functioning of those parts of the locomotor apparatus injured due to an illness or accident and carried out in a suitably prepared centre. A suitably prepared centre, or specific rehabilitation centre, is one that is duly licensed to carry out such health care activity and is registered in the autonomous community’s Health Care Register of Centres, Services and Establishments.
Thoracic surgery. Includes sympatectomy by hyperhydrosis (treatment for excessive sweating).
Urology. Includes use of Holmium surgical laser for lithiasis endourological, stenotic or tumour surgery and Green Laser Diode (KTP and HPS), Holmium and Thulium for the surgical treatment of benign prostatic hyperplasia in reference centres throughout the country, the rehabilitation of the pelvic floor for urinary incontinence, vasectomy, as well as the study and diagnosis of male sterility and infertility.
4.4 Diagnostic aids
These must be prescribed by a doctor in the corresponding Covered Health Care Network according to the modality contracted indicating the reason for the exploration. Contrast techniques are included.
Clinical, anatomopathological and smear tests.
Radiology: includes the habitual techniques for diagnosis using images such as general X-rays, computerised axial tomography (TAC), magnetic nuclear resonance (RNM) and bone density measuring. Endoscopic capsule: included in the diagnosis of haemorrhage and/ or intestinal bleeding of unknown or hidden origin. Endoscopic examinations: digestive, diagnostic and/or therapeutic. Fibrobroncoscopic: diagnostic and/or therapeutic.
Cardiac diagnosis: Electrocardiograms, strength tests, ultrasound scans, holter, doppler and haemodynamic. It also includes multislice coronary tomography (tc 64) and cardiac spectography (cardiac spect) after an acute heart attack and post-operative heart pathologies.
Neurophysiology: electroencephalograms, electromiograms, etc.
Sleep unit: Polyomonography for pathological processes prescribed beforehand by a specialist.
Surgical radiology or profound vascular exploration.
Tomography by optic coherence (OCT): in ophthalmologic diagnoses according to commonly accepted clinical practices.
High diagnostic technology: In the corresponding Covered Health Care Network, depending on the modality that you have contracted, provided in reference centres throughout the country.
- a) includes computed tomographic (CT angiography) multislice magnetic resonance angiography (MRA) for the diagnosis of arterial vascular disease and cerebral and abdominal venous, the follow up and control of the integrity of the vascular prosthesis, evaluation of arterial dilations or aneurysms, vascular malformations and limitations regardless of their location.
- b) Magnetic resonance arthrography (ArtroRM) for tendon and intraarticular injuries that are diffi cult to diagnose, Magnetic resonance cholangiography CRM) and cholangiopancreatography ERCP) allows threedimensional reconstruction and exclusion of choledocholithiasis in cholecystectomy patients, and oncology in bile and pancreatic ducts.
- c) Tomography by emission of positrons (PET) either solely or combined with computerised tomography (PETTC), Unique Photon Tomography (Spectography -SPECT), Scintigraphy and Spectroscopy by MRI or NMR or high field (3 teslas): in oncologic diagnosis and/or epilepsy resistant to medical treatment according to commonly accepted clinical practices.
- d) Genetic and molecular biology tests covered with a doctor’s prescription provided that they have an effect on the treatment of a current illness, or that are necessary to obtain a different diagnosis that cannot be confirmed by any other means, according to the criteria established by the Health Technology Assessment Agencies. (AETS).
- e) Ecobroncoscopy (EBUS) or endobronchial ultrasound for the detection of oncological pathologies of the bronchi (in lung and mediastinum) that are not accessible by other means, and if necessary, biopsies.
- f) Digestive endoscopic (USE) sectoral or radial in the evaluation of submucosal lesions, location of neuroendocrine tumours, identification of the degree of evolution of digestive and biliopancreatic cancer, and diagnosis of recurrence outside the wall of the digestive tube.
4.5 Therapeutic methods
Aerosol therapy, oxygen therapy and ventilation therapy: In lung or breathing pathologies, only for hospitalisation and care given at home. The medication will be at the insured person’s expense.
Analgesic and pain killing treatment: covers techniques employed by specialised units in these techniques, with limitations for out patients’ medication as stipulated in the General Conditions. (see section 5.X. “Excluded coverage”).
Narrow-band ultraviolet B phototherapy: in associated centres of reference in the “Covered Health Care Network” on a national level, for the treatment of extensive psoriasis (affecting more than 20% of the body surface area) and Chronic inflammatory dermatosis (trunk and limbs), when drug treatment has not been effective. There is an annual maximum limit of 35 sessions per insured person.
Home therapy for severe Apnoea – Hypopnea (SAHS) by means of CPAP/ BiPAP devices for supplying air at a continuous preset positive pressure, up to a maximum of 10 sessions per insured person / year if the Apnoea Hypopnea Index per hour (AHI) is over 30. Includes polysomnography of dose titration to adjust the device and obtain the appropriate level of treatment.
Radiotherapy: includes linear particle accelerator, cobalt therapy, radio neurosurgical stereotactic and intensitymodulated radiotherapy (IMRT) and radioactive isotopes whose diagnostic or therapeutic use is endorsed by the EMA (European Medicines Agency) and the NICE clinical guidelines.
3D image-guided radiotherapy is also covered in real time (IGRT) and the helical TomoTherapy (THel) in paediatric tumours, in prostate, lung, spine, head and neck.
Brachytherapy: for the treatment of prostrate, gynaecological, genital and breast cancer.
Dialysis & haemodialysis: this service is offered to both out patients and hospitalised patients, exclusively for treatment during the precise days of acute renal insufficiencies. Chronic disorders are expressly excluded.
Chiropody: Chiropody treatment.
Transplants: cornea, heart, liver, bone marrow and kidney. All costs arising from the implant are covered as well as matching tests. Extraction, transport and conservation of the organ for the operation are not included, except for cornea which is fully covered.
Grafts: includes bone and skin autografts and bone, tendon and ligament allograft obtained from bone and tissue banks. Blood and plasma transfusions, in hospitals.
Physiotherapy: requires the written prescription of rehabilitating doctor, traumatologist, rheumalogist, or neurologist and will be carried out by a qualified physiotherapist to restore recoverable functions of the locomotor apparatus in a suitable rehabilitation centre that complies with the requirements stipulated in section 4.3, of Rehabilitation.
Laser therapy and magnetotherapy: as rehabilitation techniques. Renal and vesicular extracorporeal shock wave lithotripsy (ESWL). Muscle-skeletal lithotripsy (maximum of 3 sessions per process) in Covered Health Care Network associated centres of national reference for pseudoarthrosis, osteonecrosis and chronic insertion tendinitis (over 3 months) of the shoulder, elbow, knee, heel and sole of the foot, when the medical and/or rehabilitative treatment has failed.
High therapeutic technology: Through the corresponding Covered Health Care Network, according to the modality taken out. Available in national reference centres.
- a) Carto (3D) navigation or mapping system or nonfluoroscopic electroanatomical mapping atrial radiofrequency ablation for the following treatments:
> Circumferencial pulmonary vein isolation for highly symptomatic paroxysmal atrial fi brillation (with three or more episodes a year) and the insured person is under 70 years of age.
> Recurrent symptomatic atrial fibrillation (more than one year) refractory to antiarrhythmic drugs (2 or more antiarrhythmic drugs, including amiodarone), provided there is no Comorbidity (eg. arterial hypertension, sdm. Sleep apnea …) and the size of the left auricle is less than 5 centimetres.
> Ventricular or atrial arrhythmias associated with congenital heart disease.
> Complex atrial fi brillation without structural heart disease, when at least two previous ablation treatments guided by conventional radiographic systems have failed.
- b) Cross-linking corneal therapy: to treat keratoconus in its early stages and degenerative or traumatic corneal ectasia, except as a consequence of corrective laser surgery for vision defects. (Excluded from the coverage of the policy).
- c) Intracranial and spinal tumour surgery assisted by (3D) neuronavigators. Computerized system of digitised images to guide the surgeon in real time in complex or high risk neurological interventions.
- d) Intraoperative neurophysiological monitoring (MNI) of the nervous system in intracranial surgery and fusion or arthrodesis of 3 levels or more of the spine. Surveillance system improves surgical safety for the patient and facilitates the work of neurosurgeons
Logopaedics & Phoniatrics: treatment for speech disorders caused by conditions of organic origin.
Oncology chemotherapy: cytostatic anti tumour medication that the patient requires will be provided, and if applicable the implanted port for intravenous perfusion, both for out-patients, day patients and during hospitalisation, providing that it is prescribed by the specialist physician who is in charge of the care of the patient.
With reference to medication, HEALTH INSURANCE ISSUER will only cover expenses for specific cytostatic pharmaceutical products that are sold on the national market and which are duly authorised by the Ministry of Health as detailed in “Cytostatic” in section 2 of Basic Concepts- Definitions, as well as the intravenous BCG (Bacilo de Calmette y Guerin) drip feeds and palliative medications without antitumoral effect that are administered in a simultaneous way in the same treatment session together with cytostatic medications, to avoid their adverse or side effects and/or to control the symptoms of the illness.
4.6 Hospital care
Hospital care will be given in hospitals or clinics, previously prescribed in writing by a doctor of the corresponding Covered Health Care Network according to the modality contracted with the corresponding authorisation. Includes the expenses derived from a stay in a hospital centre and the medical or surgical fees corresponding to the treatment received: In addition, it specifically includes:
> Oncology treatment: radiotherapy, brachytherapy and chemotherapy.
> OSNA technique or method: intra operative molecular diagnosis of the sentinel node for breast cancer at an early stage, without lymphatic extension.
> Renal and vesicular and muscle skeletal lithotripsy.
> Dialysis and haemodialysis.
> Surgery of the Groups II to VIII of the OMC carried out exclusively in a hospital centre.
> Major out-patient surgery.
> Surgical radiology or profound vascular exploration.
> Family planning techniques: tubal ligature and vasectomy. Tubal occlusion hysteroscopy
> Intracranial stereotactic radio neurosurgery.
> Arthroscopic surgery.
> Turbinate surgery or turbinoplasty and adenoamigdaloplasty by radiofrequency.
> Surgical laser in gynaecology, ophthalmology, proctology, peripheral vascular surgery and otorrinolaringology.
> Endourologic holmium laser and green laser (ktp and hps), diode and thulium for the surgical treatment of benign prostatic hiperplasia.
> Percutaneous nucleotomy and chemonucleosis.
> High therapeutic technology: Carto system for radiofrequency ablation and corneal cross-linking, therapy and surgery assisted by intracranial and spinal tumour neuronavigators and monitoring neurophysiological intraoperative in intracranial surgery and fusion or arthrodesis of the column of three or more levels.
> Surgical prostheses.
> Daily compensation for hospital care.
Hospital admission includes the use of an individual room with toilet and bed for a companion (except for psychiatric hospital care, in ICU and incubator) the patient’s maintenance, general nursing expenses, special care unit, complementary means of diagnosis, treatments, material, surgical expenses and delivery room, anaesthetic products and medications and implants of biological medication and medicalised biomaterials for therapeutic purposes specified in section 4.7 “Surgical Prostheses” of the general conditions. Biological medication and medicalised biomaterials not stipulated in section 4.7 and the therapies in Section 5. r “Excluded Coverage” are expressly excluded. Similarly, according to the kind of hospital care received:
- Medical hospital care (without surgical intervention). Includes the different medical specialities for the diagnosis and/or treatment of the medical pathologies susceptible for admission for adults over 14 years of age.
- Surgical hospital care. Includes the surgical specialities for the treatment of pathologies that require it, pre-operative or pre-anaesthetic study (consultation, analysis and electrocardiogram), immediate post operative visits and treatment (up to 2 months after surgery), major out-patient surgery and, if required, prosthesis.
- Obstetric hospital care. Includes treatment given by gynecological obstetrician and/or midwife during pregnancy and birth; cot and/or incubator for the new born baby during admission, up to a maximum of 28 days.
- Paediatric hospital care. (For under 14 year olds.) Includes care given by paediatrician both in conventional hospital care and in the incubator.
- Psychiatric hospital care. Includes care given by psychiatrist. Only covered in the event of acute outbreaks. The stay is limited to a maximum period of 60 days per natural year.
- Hospital care in Intensive Care. Includes the care given by a specialist in intensive care.
- Hospital care for Dialysis and artifi cial Kidney. Includes the care given by nephrologist or an internist. Exclusively for the treatment of acute renal inadequacies during the necessary days.
4.7 Complementary coverage
Preventive medicine. Includes the following specific programmes according to commonly accepted protocol:
- Programme of infant health.
> Exercise classes and psychoprophylactic preparation for birth, with practical and theoretical classes in child care and the preventive rehabilitation of the pelvic floor following birth in associated reference centers of the “Covered Health Care Network “that corresponds to him, with a maximum limit of three sessions covered per process and insured person.
> Checkup of the new born baby, including metabolic screening tests (phenylketonuria and primary congenital hypothyroidism), otoacoustic emission (OAE) or neonatal auditory screening for the early detection of hypoacusis, visual acuity test and neonatal ultrasound.
> The programme of child vaccination which is compulsory in Spain in associated centres, provided that are authorised by the autonomous communities.
> Health control at key stages during the child’s development during the first four years.
- Programme for the advance detection of gynaecological cancer in women.
> Periodic examinations for the early diagnosis of tumours in the breast and uterine neck.
> Annual gynaecological checkup, which includes checkup consultation, colposcopy, cytology, gynaecological ultrasound scan, and mammography according to commonly accepted protocol.
HPV TEST (ADN-HPV) to detect a Human papillomavirus (HPV) infection in women with cervical-vaginal cytology (Bethesda Classification) and after conisation and to identify and treat cervical lesions with a high risk of developing a cervical carcinoma at an early stage.
3. Programme for the prevention of heart disease.
> Basic annual medical or cardiac checkup which includes the checkup consultation, basic analyses of blood and urine, thorax X-ray and electrocardiogram.
> Complete cardiac check up every three years, in national associated centres, includes clinical history, physical cardiac exploration, specific and preventive analysis of the atheromatous (cell blood count, ionogram, cholesterol, triglycerides, homocysteine, glycaemia, uraemia, uricaemia, calcemia, prothrombin rate and platelets) rest and stress electrocardiogram and an echocardiogram.
- Prevention of skin cancer programme.
> Consultations and revision of changes in size, colour and shape of the dysplastic or atypical nevus.
> Digitized epiluminescence microscopy or dermatoscopy for the early diagnosis of the melanoma:
- In high risk patients with atypical multiple nevus (>100) or family dysplastic nevus syndrome, personal or family (first and second degree) history of melanoma and/or carriers of genetic mutations associated with its development.
- In dermatological check up every three years: for the control and follow-up of congenital, pigmented lesions or cutaneous risk.
- Programme for the prevention of colorectal cancer in risk group with a history Includes:
> Medical consultation and physical examination.
> Specific tests to detect hidden blood in faeces.
> Colonoscopy, if required.
- Programme for the prevention of prostate cancer for men over 45. Includes:
> Medical consultation and physical examination.
> Analyses of blood and urine to determine specific prostatic antigen.
> Transrectal ultrasound scan and/or prostatic biopsy, if required.
- Programme of dental health. From infancy for the prevention of caries, periodontal illness and problems of bad dental positioning or occlusion.
> Dental consultation and exploration of state of dental health.
> Correction of eating habits.
> Taking up appropriate dental hygiene.
> External fluorisation.
> Fissure sealers and obturations (fillings) up to the age of 14.
> Tartrectomies or dental cleans, as required. Clinical psychology. Includes psychotherapy sessions on an individual basis as Out-patient treatment with the prior prescription of a psychiatrist or paediatrician of the corresponding Covered Health Care Network according to the modality contracted given by an associate psychologist and with the authorisation of HEALTH INSURANCE ISSUER.
Insured clients can access this service for the following pathologies susceptible to psychological intervention, on paying the contribution stipulated in the “Table of groups of medical acts and contributions” of the particular and/ or special conditions of the policy up to a maximum limit of 20 sessions per person, per natural year, except for eating disorders (Anorexia and Bulimia) whose annual limit is 40 sessions.
> Psychiatric illness: Depression, Schizophrenia and Psychotic Disorders.
> Behavioural disorders: Neurosis, Anxiety, Personality, and Obsessive Compulsions.
> Eating disorders: Anorexia and Bulimia.
> Sleep disorders: Enuresis, Insomnia, Somnambulism, Night Fears.
> Adjustment Disorders: Work Related and Post Traumatic stress, Bereavement, Divorce, Adolescence: Post Vacation Syndrome, etc.
> Learning disorders: Hyperactivity and school failure. Family planning. Includes the following services:
> fitting of the IUD. The cost of the intra-uterine device is at the insured person’s expense.
> Tubal ligature.
> Tubal occlusion hysteroscopy with the limits for the coverage of prosthetic material as stipulated in these General Conditions (See “Surgical Prostheses”).
Surgical Prostheses: includes the prescription and fitting of articular, (shoulder, hip, knee, ankle and foot), vascular and heart prostheses (heart valves, bypass vascular, stent, temporary and permanent pacemakers, automatic desfibrilator), “Essure” helical tubal prosthesis, internal orthopaedic prostheses (internally fitted metal plates and screws) and intersomatic cages or spacers in spinal fusion or arthrodesis of the spine, as well as biological and/ or biomaterial implants for therapeutic purposes as detailed below:
> Sealants, biological glues or bioglues in oncologic surgery.
> Antiadhesive or nonstick barrier gel in back surgery and in reoperations of other specialties.
> Substitutes of bone grafts: cements and regenerative demineralised bone matrix in back and joint surgery: hip, knee and foot).
> Biological plasties. Biomatrix or resorbable mesh in substitution of the dura in intracranial surgery or spinal tumour, and the pericardium in heart surgery.
> Joint anchors: Includes highly resistant biomaterials (PPLA AND PEEK) for ligament fixation in major joints (shoulder, knee, hip, elbow and ankle) in minimally invasive arthroscopic surgery of extremities.
Also includes ostheosynthesis material, surgical meshes for the repair of defects of the abdominal wall, tension free suburethral bands and mesh for containing the pelvic floor and prolapse of the pelvic organs, valves for hydrocephalus, external extra-skeletal braces, neutral monofocal intraocular lens (without added visual correction) in the cataract, testicular prosthesis for orchidectomy after oncological process or an accident, skin expander, breast prosthesis and mesh covering only in reconstruction after radical surgery. The maximum limit of the coverage for prosthetic material and implantology as stipulated above is 12.000 euros per insured person, per year.
Daily compensation for Hospital Care. A compensation of 50 EUR is included from the third day of hospitalisation (i.e. first two days are not compensated) and up to a maximum of 1.500 EUR per insured person per year. Provided that two conditions are met:
> The hospital care is covered by the policy.
> None of the costs derived from the hospital care has been paid by HEALTH INSURANCE ISSUER.
4.8 Exclusive coverage
Only the contracting of the insurance policy for complete medical care in its individual modality grants the insured person access to the following additional guarantee:
- Refund of health care expenses abroad for serious illnesses.
- Refund of expenses for family care and/or dependence, in the event of being awarded Dependence grade
- due to an accident. The description of this exclusive coverage, its modality, territorial scope, object, form of access, coverage limitations and excluded risks are stipulated in Appendix II (Exclusive coverage of Insurance Policy in its individual modality) and in the sections of the general conditions that define the coverage of the insurance policy: 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”.
4.9 Optional coverage
Only the contracting of “Insurance Policy” for full medical care in its individual modality grants the insured person access to the following optional coverage:
> Appendix for reimbursement of expenses in gynaecology, obstetrics and paediatrics. This complementary refund guarantee is optional and allows the insured person to consult a gynaecologist, obstetrician or paediatrician anywhere in Spain and the world , provided that they are not included in the “Health Care Services Network“ associated to HEALTH INSURANCE ISSUER, and reimburses a percentage of the health care costs generated, taking into account the exclusion period and the maximum reimbursement, partial limits (for therapeutic act, care for the newborn) and totals (per insured person and calendar year, or proportional part) set out in the Table of coverage and limits in the appendix to the particular conditions.
The definition of this optional coverage, its description, form of access, period of grace, limits and exclusions of risk, are laid down in special conditions which are issued separately with the contracting of this optional module by the insured person. For all the provisions not expressly stipulated in that appendix, that set out in the sections of the general conditions that delimit the insurance coverage will apply: Section 2 “Basic concepts. Definitions”, section 3 ”Modality and extension of insurance”, 4”Description of coverage”, Section 5 ”Excluded coverage”, and section 6 “Periods of grace”.
4.10 Travel assistance
For temporary trips abroad, the insurance policy has a world-wide Travel Assistance coverage for a maximum of 180 days per trip and whose coverage is detailed in Appendix I of these general conditions.
Excluded from the general coverage of this insurance policy are:
- a) The coverage of all kinds of preexistent illnesses, injuries, ailments, states or medical conditions (for example pregnancy) and their consequences, as well as the congenital, constitutional or physical defects and those that are a result of accidents or illnesses and their consequences suffered previously to the date of inclusion of each insured person in the policy. The policy holder, acting on his behalf and that of the beneficiaries is obliged to state at the moment of taking out the policy, any type of injury, congenital pathology, illnesses diagnostic tests, treatments and even the symptoms that could be considered as the beginning of a pathology.
In the event of concealment, the condition will be excluded from the coverage of the insurance contract. If they were declared pre-existent and/or congenital illnesses, HEALTH INSURANCE ISSUER reserves the right to accept or to reject the insurance application. In the event of accepting them HEALTH INSURANCE ISSUER may include the corresponding exclusion clause for this coverage, or as appropriate apply an excess premium for the coverage of the same. For illnesses neither known nor suspected by the insured person or policy holder in the absence of symptoms prior to contracting, the contract will be considered indisputable after a period of a year starting from the perfection of the contract or the inclusion of an insured person in the contract except for the fraudulent conduct of the policy holder.
- b) All those diagnostic and therapeutic procedures whose clinical security and effectiveness have not been scientifically proven and/ or have not been ratified by the of Health Technologies Assessment Agencies or have been clearly substituted by other available ones.
- c) Physical damage that is a consequence of wars, mutinies, revolutions and terrorism; that caused by officially declared epidemics; that which is directly or indirectly related to radiation or nuclear reaction and that which results from cataclysms (earthquakes, floods and other seismic or meteorological phenomena).
- d) Illnesses or injuries resulting from the professional practice of any sport, the participation in bets and competitions and the practice, as an amateur or professional, of high risk activities like bullfighting and enclosing of wild stock, the practice of dangerous sports, such as diving, bobsleigh, boxing, martial arts, rock climbing, motor vehicles races, rugby, quad, speleology, paragliding, aerial activities not authorised for the public transportation of passengers, sailing activities, or in rough waters, bungee jumping, gully climbing, including training and any other professedly dangerous practice.
- e) Health care for the treatment of chronic alcoholism and/or the addiction to drugs of any type, as well as their complications and consequences, and health care for injuries due to intoxication, aggression, fighting, attempted suicide or self-injury, as well as for illnesses or accidents due to the deceit, negligence or lack of care of the insured person.
- f) Aesthetic surgery and any other treatment, infiltration or act that has an aesthetic and/or cosmetic purpose, unless referring to a functional defect of the affected part of the body (purely psychological reasons not being valid), treatments of varicose veins for aesthetic aims, weight loss methods both for outpatients and hospitalised patients and skin treatments, in general, including capillary treatments.
Also excluded the surgical correction of myopia, astigmatism and hypermetropia and presbyopia, as well as orthokeratology. In addition to the consequences and complications resulting from all the exclusions included in this section.
- g) Alternative medicines, naturopathy, homeopathy, acupuncture, chiromassage, lymphatic drainage, mesotherapy, gymnastics, osteopathy, hydrotherapy, three phase oxygen therapy, presotherapy, ozonetherapy, the modalities of phototherapy and its indications not detailed in section 4.5,and other similar services or specialities not officially recognised. Also exempt are medical – surgical treatments with radiofrequency techniques except for adenoamigdaloplasty and turbinate surgery or turbinoplasty.
- h) The stays, visits to and treatments in non-hospital centres such as hotels, spas and spa centres, asylums, residences, rest homes, of diagnosis and similar, although they may be prescribed by doctors, as well as admission to centres dedicated to activities related to leisure, rest and dietary treatments. Hospital care for psychiatric reasons, except in the case of severe attacks, or social or family reasons is also excluded, as well as that which can be substituted for treatment at home or out patient treatment.
Also excluded is health care given in non associated private centres and that given in public hospitals, centres and other establishments that form part of the Spanish National Health System and/or those that depend on the autonomous communities, except for the stipulated cases (see section 3.4 Care via means other than the Covered Health Care Network HEALTH INSURANCE ISSUER reserves the right at all times to claim from the insured person the costs paid to the public health care system for the medical, surgical and hospital care provided.
- i) High medical, diagnostic and/or therapeutic technology, lithotripsy, except for that stipulated in 4.4 Diagnostic Aids and 4.5 Therapeutic Methods of these General Conditions.
- j) The treatment for snoring or apnoea sleep obstruction (except for the ten sessions with CPAP or BiPAP) in addition to the treatment and /or modalities of radiotherapy and their medical indications that are not expressly stated in Section 4.5 “Therapeutic methods” of these general conditions. Also excluded are protontherapy, neutrontherapy, Cyberknife radiosurgery, radiotherapy or intracranial stereotactic radiosurgery and/or adapted to breathing (4D) and radiopharmaceuticals with radioactive isotope not approved by the EMA (European Medicines Agency) and/or not recommended by the NICE clinical guidelines.
- k) Preventive medicine and general check ups, all types of vaccines and the supply of extracts in allergic processes other than those detailed in the specific prevention programmes included in section 4.7 (“Complementary Coverage”) of the general conditions are also excluded.
- l) The voluntary interruption of a pregnancy and selective instrumental embryonic reduction under any circumstances, as well as sterility treatment and assisted fertility techniques, sperm washing techniques and those of assisted reproduction of any kind.
- m) All kinds of prostheses, implants, health devices, anatomical and orthopaedic pieces, except for those detailed in section 4 “Description of the coverage” of the general conditions. Also excluded are artificial heart, column implants, biomaterials and/or biological, synthetic and orthopaedic materials not expressly included in section 4.7, as well as the use of those included for other purposes than those indicated.
- n) Endodontics, periodontics, orthodontics, fissure sealers and obturations or fillings for people over 14 years of age, reconstructions, dental prosthesis, apicectomies, implantology and the diagnostic means necessary to carry out these treatments.
- o) Analysis or other explorations that are necessary for the issuing of certificates, reports and the drafting of any kind of document type that does not have a clear health care function.
- p) With respect to psychiatry and clinical psychology, the following are excluded: consultations, diagnoses techniques and therapies that do not follow neurobiological or pharmacological treatment criteria, such as psychoanalysis, hypnosis, ambulatory narcolepsy, sofrologia, rest or dream cures and anything derived from similar services. Also excluded are pair or group psychotherapy, psychological and psychometrical tests, psycho-social rehabilitation and neuropsychiatry, educative or cognitive conductual therapy in oral and written communication disorders of varied origin, except for that expressly included in article 4.7 (Description of the coverage of Clinical psychology).
- q) Logopaedics & Phoniatrics to correct speech and language defects after anatomical or congenital neurological and psychomotor alterations of diverse origin.
- r) Regenerative and biological medicine, immunotherapy or biological therapy, gene or genetic therapy and those with direct action antivirals, and all of their applications. Also excluded are all types of experimental treatments, those of compassionate use, with orphan drugs, as well as those that are for clinical trials in all their phases or degrees.
- s) Hyperbaric chambers, dialysis and haemodialysis: the treatment of chronic disorders will be excluded.
- t) Health care for viral haemorrhagic fevers, and that derived from the infection of the virus acquired immune deficiency syndrome (HIV), AIDS and the illnesses related to this, as well as its complications and consequences.
- u) Robotic surgery, guided by image or computer assisted (except for neuronavigators and the Carto mapping system as detailed in Section 4.5) and laser treatments which are only covered for the specialities and details as described in section 4 “Description of the Coverage”.
- v) The expenses for use of a telephone, television, companion’s meals, travelling expenses, except for the ambulance according to the terms stipulated in the “Primary care” and “Emergencies” sections of the general conditions, as well as other unnecessary services for hospital treatment.
- w) The transplants or auto transplants of organs, grafts, or autografts, except for those described in the section “Therapeutic methods” of the general conditions. Also, for transplants the extraction, transport and conservation expenses of the organ are excluded, except for a cornea transplant.
- x) Pharmaceutical products, medications and additional curing aids of any kind, except for those that are administered to the insured person during his admission to hospital (minimum 24 hours). In any event, biological medications or biomaterials not specified in section 4.7 “Surgical prostheses” and the therapies in section 5. r “Excluded Coverage” are also expressly excluded although they may be given during a stay in hospital. Oncological chemotherapy only covers expenses for specific cytostatic pharmaceutical products that are detailed in “Cytostatic” in section 2 of “Basic Concepts- Definitions”.
Expressly excluded from this concept are anti tumour immunotherapy, monoclonal antibodies, genetic therapy, endocrinal and hormonal therapy, enzymatic and/or molecular inhibitors, anti angiogenic pharmaceuticals and sensitisors used in photodynamic and radiation therapy.
- y) Maintenance rehabilitation for irreversible neurological injuries of diverse origin and in chronic injuries of the locomotor apparatus is excluded. Also excluded is premature stimulation, rehabilitation at home or as a reason for hospital care and that carried out in non authorised and/or registered centres of their respective autonomous community.
- z) Genetic advice, paternity or family relationship tests, the obtaining of genetic maps of risk with a preventive or predictive purpose, the massive sequence of genes or molecular karyotype, compared genomic hybridization techniques, and microarrays platforms with automated interpretation of results, as well as any other genetic technique and/or of molecular biology that is requested for a diagnostic purpose, or if this can be obtained by other means, or doesn’t have a therapeutic aim.
- Periods of grace
All services, which by virtue of the Policy, HEALTH INSURANCE ISSUER assumes, will be available for use from the effective date of the Contract. Nevertheless, the following services are not covered by the previous general principle:
1. Surgery and hospital care, including surgical prostheses, for any reason and of any kind, will have a period of grace of six months, except in the cases of a life threatening emergency or as the result of an accident.
2. Treatment for any kind of childbirth (except premature childbirth) or Caesarean operation which have a period of grace of eight months.
3. Transplants have a period of grace of twelve months.
4. Base of the contract
7.1 Perfection of the contract and length of insurance
This contract has been drawn up on the base of the declarations made by the policy holder of the insurance policy and the insured person in the previously supplied questionnaire, which have motivated HEALTH INSURANCE ISSUER to accept the risk and which have enabled them to determine the premium. The insurance contract and its modifications will have no effect until the policy has been signed and the first premium paid, unless otherwise stipulated in the particular conditions. If the content of the policy differs from the insurance application or the agreed clauses, the policy holder will be able to request that HEALTH INSURANCE ISSUER, during a period of one month starting from the issue of the policy, corrects the existent divergence. Once this term has lapsed without the request being made, that stipulated in the policy will be binding. The contract is for the period foreseen in the particular conditions and, unless otherwise stated, the duration of the policy will be adjusted to the natural year. The policy will be continued tacitly by annual periods. HEALTH INSURANCE ISSUER may oppose the extension of the contract by written notice to the policy holder, if they will not renew the policy, or if changes will be made to it, with a minimum notice of two months from the date of conclusion of the current year, also, the policy holder may oppose the renewal of a policy, at least from one month to the due date stipulated in the same, provides he notifies HEALTH INSURANCE ISSUER in a demonstrable way. HEALTH INSURANCE ISSUER will not be able to cancel the policy of the insured persons who have maintained the same policy for three consecutive years. The contract will be automatically continued, with the exception of the suppositions of non fulfilment of obligations on the part of the insured person, as well as the existence of inaccuracy, deceit or fault in the answers contained in the Insurance Application questionnaire.
The renunciation of HEALTH INSURANCE ISSUER of its right to oppose the continuing of the contract depends on the acceptance by the policy holder of the annual variation of future premiums, according to the technical criteria stipulated in section 7.4. of the present contract.
7.2 Other obligations and faculties of the policy holder or the insured person
The policy holder and, if applicable, the insured person, should:
- a) Declare to HEALTH INSURANCE ISSUER with truthfulness, diligence, and without withholding anything, all the circumstances known to him that can influence the evaluation of the risk.
- b) During the period of the contract, inform HEALTH INSURANCE ISSUER as soon as possible of all the circumstances that, according to the questionnaire presented before the perfection of the contract, increase the risk and are of such nature that if they had been known by HEALTH INSURANCE ISSUER at the moment of signing the contract, it would not have been accepted or would have been offered at a different cost.
- c) Use all the means at his disposal to obtain a prompt recovery and to reduce the consequences of the claim. The non fulfilment of this duty with the intention of deceiving or harming HEALTH INSURANCE ISSUER or obtaining an additional lucre, will release the HEALTH INSURANCE ISSUER from all obligations relating to the claim.
- d) Facilitate the surrender of his rights or subrogation to HEALTH INSURANCE ISSUER according to section 3.5. In case the policy holder or insured person is entitled to an indemnity from a third responsible part, such a right passes to HEALTH INSURANCE ISSUER for the amount corresponding to the health care.
7.3 Other obligations of HEALTH INSURANCE ISSUER
Besides providing the health care contracted according to the modality described in the policy, HEALTH INSURANCE ISSUER will provide the policy holder with a copy of the policy. HEALTH INSURANCE ISSUER will also provide the policy holder with the identifying card of each insured person in the policy and information about the medical directory (the corresponding Covered Health Care Network according to the modality contracted) for his residential area, in which the permanent centre or centres for emergencies and the associated doctors’ timetables and addresses appear.
7.4 Payment of premiums
The policy holder is obliged to settle the payment of the first premium or of the single premium at the moment of accepting the contract. The successive payments will have to be made on the corresponding due dates. The policy holder can request the distribution of the payment of the annual premium in six- monthly, quarterly or monthly instalments. In these cases, the corresponding surcharge will be applied. Payment by instalments does not release the policy holder from the obligation of paying the entire annual premium. If, for the fault of the policy holder, the first instalment, or the single premium has not been paid, HEALTH INSURANCE ISSUER is entitled to cancel the contract or to demand the payment by legal means according to the policy. In any event, and unless otherwise stated in the Particular Condition, if the premium has not been paid before the claim takes place, HEALTH INSURANCE ISSUER will be released from their obligation. In the event of non-payment of the second or successive premiums, or their instalments, HEALTH INSURANCE ISSUER’ coverage will be suspended for one month after the due date. If HEALTH INSURANCE ISSUER does not request the payment in the six months following this date, it will be understood that the contract is extinguished.
If the contract had not been cancelled or extinguished according to the previous conditions, the coverage will become effective twenty-four hours after the day that the policy holder pays the premium. HEALTH INSURANCE ISSUER will assume the premium corresponding to the period during which there was no coverage due to lack of payment. In any case, while the coverage is suspended, HEALTH INSURANCE ISSUER will only be able to claim for the payment of the premium for the current period.
HEALTH INSURANCE ISSUER is only obliged by the receipts issued by HEALTH INSURANCE ISSUER. Unless otherwise stated in the Particular Conditions, the place of payment of the premium will be the one that appears in the standing order issued by the bank. To do so, the policy holder must provide HEALTH INSURANCE ISSUER with his bank account details to which the payment of the receipts of this insurance policy will be charged, authorising the financial entity to settle. If no location is specified in the particular conditions for the payment of the premium, by default this will be the policy holder’s address.
HEALTH INSURANCE ISSUER will be able to modify, with each renewal of the policy, the annual premium and the excess for medical acts taking as a base the technical actuarial calculations based on the modifications of the health care costs of the services and/or the technological medical innovations that are necessary to incorporate, applying the rates that HEALTH INSURANCE ISSUER has in force on the date of renewal. Besides the supposition indicated in the previous paragraph, the premiums due may also vary depending on the age and other personal circumstances of the insured persons.
For policies of a collective modality age groups may be established. Similarly, the premiums may experience modifications due to variations in the structure of the insured collective. When the insured person reaches, during the course of the insurance policy, an actuarial age understood to belong to another group, the corresponding premium for the new age group will be applied in the following annual renewal. HEALTH INSURANCE ISSUER is not subject to any limit regarding the annual variations of the premiums. The amount fixed for the total premium, on summing the corresponding surcharges, will cover the principles of sufficiency and technical balance, according to the rules governing insurance companies. The mentioned calculations will also be applied in the supposition of the Insured person having obtained the right to non-rescission from HEALTH INSURANCE ISSUER for the extension of the policy.
The policy holder will be able to choose between extending the insurance contract or cancelling it on the expiry date of the current period when he receives the notification from HEALTH INSURANCE ISSUER regarding the increase in the premium for the following annuity. In this last case, the policy holder will notify HEALTH INSURANCE ISSUER in writing of his decision to conclude the contractual relationship.
7.5 Loss of rights and cancellation of the contract
The insured person loses the right to the guaranteed benefit:
- a) If, when completing the health questionnaire, the policy holder or the insured person do not respond with truthfulness either hiding in any conscious way relevant circumstances, or not observing due diligence to provide the requested data.
- b) If an increase in the risk has taken place, for the circumstances indicated in section 7.2 b and the policy holder or the insured person has not previously notified HEALTH INSURANCE ISSUER.
- c) If the claim takes place before the initial premium has been paid, unless it has otherwise expressly been agreed to the contrary.
- d) If the claim takes place due to bad faith on the part of the insured person or the policy holder or the beneficiary. In any case, HEALTH INSURANCE ISSUER may cancel the contract within one month of becoming aware in a demonstrable way of the following facts: omission or inaccuracy in the risk declaration on the part of the policy holder or the insured person, or the risk level has increased without the insurer having been informed.
Notifications from the policy holder or the insured person to HEALTH INSURANCE ISSUER should be made to its business address. Nevertheless, demonstrable notifications that are made to the Agent of HEALTH INSURANCE ISSUER that mediated in the policy will also be valid. The notifications made by an insurance broker to HEALTH INSURANCE ISSUER on behalf of the policy holder or the insured person will have the same effects as if they had been made directly to HEALTH INSURANCE ISSUER. However, the notifications made by the policy holder or the insured person to the insurance broker are not considered to have been made to HEALTH INSURANCE ISSUER until they are received by them. The notifications of HEALTH INSURANCE ISSUER to the policy holder or the insured person will be made at the address given in the contract, unless HEALTH INSURANCE ISSUER has been notified of the change of address.
7.7 Special health risks
The policy holder will be able to agree with HEALTH INSURANCE ISSUER the coverage of risks excluded from these general conditions or those that are not specifically contemplated in them. These will be denominated special health risks and so that their coverage is included, they should be duly specified in the particular conditions and an additional premium paid.
7.8 Taxes and surcharges
The taxes and surcharges legally due will be paid by the policy holder and/or insured person.