These general conditions will help you to fully understand the contract that you sign with HEALTH INSURANCE ISSUER when you accept this insurance policy.
Here we explain most of the questions that can arise when using your insurance policy. In this section, we seek to give answers in a clear and simple way to some of our clients’ most frequently asked questions. We hope you find it useful.
Regarding the contract
What documents comprise the insurance contract?
The insurance contract consists of the application form, the health declaration, the general conditions, the particular conditions, the supplements and appendices, and as applicable, the special conditions.
What are the conditions exactly?
The “general conditions” and “particular conditions”, group together the rights and obligations of HEALTH INSURANCE ISSUER, and those of the insured person or the person that takes out the insurance policy.
What documents do I receive when I take out the insurance policy?
The general and particular conditions, Your Insurance Medical card and information about the medical directory or the corresponding Covered Health Care Network, according to the modality contracted. Please check that your personal data has been correctly copied.
What do I have to do with the documentation?
Sign the particular and general conditions, keep a copy for yourself, and send us the other signed copy. The delivery of the signed copy together with the payment of the initial premium implies their acceptance. Until both requirements are fulfilled, the contract is signed and paid, the policy is not effective, even though a date for such is stipulated in the particular conditions.
If you have any doubts, contact us.
We will be pleased to help you.
Do I need to request the extension of the contract?
The contract is renewed automatically every year; you don’t need to confirm the renewal. However, both you and HEALTH INSURANCE ISSUER can cancel the contract before the expiry date, provided that demonstrable notification is given to the other party. In the case of the policy holder one month’s notice is required and for HEALTH INSURANCE ISSUER, two months’ notice.
What happens to my personal data?
HEALTH INSURANCE ISSUER is specifically authorised to request, handle and give the personal data of the policy holder and/or the insured person to entities of the group. Regarding the health data of the insured person, this may only be given to a third party with the sole aim of administering health care, the plans for prevention and promoting good health and the additional services covered by the policy.
HEALTH INSURANCE ISSUER is also authorised to send the policy holder and/or insured person information about health care, the plans for prevention and promoting good health and the goods and services that could be of interest to them. The policy holder and/or the insured person may contact HEALTH INSURANCE ISSUER to consult this data and update, modify, or delete it in accordance with the Organic Law 15/99 for the Protection of Personal Data.
Insurance Medical card
Can a doctor of the corresponding Covered Health Care Network according to the modality contracted ask me for my Insurance Medical card besides the authorisation of certain services?
Yes. The card INSURANCE Medical card is the means by which you are identified as a client of the corresponding Covered Health Care Network according to the modality contracted, and you will be asked to show it.
How much do I have to pay for each visit?
The preset amount for each medical act is stipulated in the “Table of groups of medical acts and contributions” of the particular and/or special conditions of the policy.
What should I do if I lose my Insurance Medical card?
Contact HEALTH INSURANCE ISSUER so that we can send you a new one.
Authorisations
What tests or services in the Covered Health Care Network need an authorisation according to the modality contracted?
Complex diagnostic tests, transfers by ambulance, prostheses, and surgical implants, psychotherapy sessions, preventative programmes or check-ups, medical or surgical treatment as well as hospital admissions. If you have any doubts, please consult the web page and/or medical directory or the Covered Health Care Network for the current year, Chapter 2 “Advice for Use”, to see the list of diagnostic and therapeutic acts that do not require prior authorisation from HEALTH INSURANCE ISSUER.
Payment
Do I pay the same every month?
No. Some months you will also receive the surcharge for the contributions towards the medical acts received.
What do you mean by a yearly contract, if I pay monthly?
The duration of the contract stipulated in the policy is annual and can be extended by calendar years, which is compatible with the monthly payment of the premium. You can also opt for a quarterly, six monthly, or annual payment. The instalments scheme selected does not release the policy holder from his obligation to pay the annual premium in full. In the event of the receipts being returned or left unpaid, HEALTH INSURANCE ISSUER is entitled to claim the amount corresponding to the outstanding balance.
Health care
Can I go to the doctor the day after taking out the health policy?
Yes, from the first day that the policy becomes effective, except for some services that have a period of grace (see Section 6, Periods of grace).
Do I need to request an authorisation to go to a medical or surgical specialist’s consultations?
No. Consultations for medical or surgical specialities have free access in the corresponding Covered Health Care Network according to the modality contracted.
Do I need authorisation for clinical psychiatry?
Yes. You need to request the corresponding authorisation to use this, non-medical, speciality in the corresponding Covered Health Care Network according to the modality contracted.
Do I need an authorisation to have a mammogram or orthopantomogram?
No, you don’t need an authorisation for these. Only the written prescription of a doctor in the Covered Health Care Network is required.
When can I request service at home?
When, due to the sick person’s state, going to a consultation or hospital centre is medically inadvisable. Also, the visits of a nursing assistant can be made at home if a doctor of the corresponding Covered Health Care Network according to the modality contracted prescribes them.
Are illnesses previous to contracting the policy covered?
Due to the nature of the contract, previous illnesses are not covered, but it is possible to include them by paying an extra premium in some cases, for example allergic asthma.
What does the dental speciality cover?
It covers consultations, extractions, stomatological treatment, fluoridations, dental cleans and dental x-rays associated with this treatment. It also includes fissure sealers and obturations (fillings) up to 14 years of age. Other dental treatment that is not covered by the policy can be provided, with a contribution from the insured person through the dental service. (see “Additional services”).
How many dental cleans does the policy cover a year?
Those necessary, whenever they are requested by a doctor of the corresponding Covered Health Care Network according to the modality contracted.
Does “Insurance Policy” include medications?
Only in the case of hospital admission, with the exception of biological medication and medicalised biomaterials not specified in section 4.7 “Surgical Prostheses”.
Is the epidural anesthesia for childbirth covered?
Yes, and also for any other surgery where required.
Does “Insurance Policy” cover laser surgery for myopia?
HEALTH INSURANCE ISSUER offers you access to laser surgery for myopia through a network of opticians’ centres, associated to the company, anywhere in Spain.
Does “Insurance Policy” include clinical psychology?
Yes, it is only included 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 provided it is 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 illnesses: 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.
Should further sessions be required, HEALTH INSURANCE ISSUER offers you the possibility of continuing the sessions at a subsidised rate, with prior application to HEALTH INSURANCE ISSUER.
And family planning?
Yes. Both the fitting of the IUD (except for the cost of the intra-uterine device) and tubal ligature, hysteroscopic tubal occlusion and vasectomy are included in the policy. In these last three cases, as they are considered to be surgery or require a prosthesis, there is a period of grace of six months.
If I break something while playing sports, is it covered by the policy?
Yes, as long as it is not a professional activity, an official competition or that the sport in question is defined as a high risk sport.
What happens if I can’t get a certain test done in my area?
HEALTH INSURANCE ISSUER will provide you with access to the service in the area that you choose where suitable means to carry it out are available.
Is health care included while I’m abroad?
Only in the event of an emergency or an accident through a complementary travel assistance coverage, which guarantees the provision of health care abroad up to a maximum of 180 days per trip. (See Appendix I).
What should I do if I am admitted to hospital, with prior notice?
The admission should be requested by the corresponding doctor of the Covered Health Care Network according to the modality contracted and should be authorised beforehand by HEALTH INSURANCE ISSUER. (Please refer to the section ‘AUTHORISATIONS’ of ‘Frequently asked questions and answers’. To do so the written application of a doctor stating the motive for admission is required.
In the event of an emergency, what should I do if there is not an associated hospital in the area?
You can go to any hospital, but you must inform HEALTH INSURANCE ISSUER in the 72 hours following admission. As long as there is no medical reason for not doing so, HEALTH INSURANCE ISSUER may provide the hospital care in an associated hospital, providing the opportune transfer means.
In the event of an emergency, the individual room with a companion’s bed is included in the coverage of the policy, except in the cases of ICU incubator and psychiatric hospital care.
