Terms and conditions of insurance. Healthcare Insurance and Additional Insurance from 1 January 2014

Transcription

1 Terms and conditions of insurance Healthcare Insurance and Additional Insurance from 1 January 2014 Valid from 1 January 2014

2 of Insurance for Health Insurance and Additional Insurance Packages as of Insurance Health Insurance and Additional Insurance Packages valid from 1 January 2014 This supersedes the previous terms and conditions of insurance page 1

3 of Insurance for Health Insurance and Additional Insurance Packages as How does your insurance work? Based on the "occupational therapy" example, we will show how you can use this booklet so that you know what your insurance covers. After all, this booklet applies to everyone we insure, but not all of the Articles apply to you. 1. Alphabetical list of reimbursements In the "Alphabetical list of reimbursements" (starting on page 6) you look up Occupational therapy, under "o" (see arrow 1 in the illustration below): Health insurance Additional insurance package Reimbursement Article page Article page Occupational therapy, general B D Occupational therapy, instructions for volunteer D carers 2. Health insurance The 2nd column (see arrow 2) shows the Article number and the page on which the coverage of the health insurance can be found. Article B.9 tells you that you are entitled to reimbursement for a maximum of 10 treatment hours per year. You can also see the terms and conditions that have to be met and what, if anything, is not included in this reimbursement. 3. Additional insurance package In the 3rd column (see arrow 3) you will see the Article number and the page where you will find the cover under the additional insurance package. Article D tells you what you are entitled to, and what the terms and conditions are. You will also read that your Reimbursements Overview will show you the amount for that reimbursement. 4. Reimbursements Overview You check your Reimbursements Overview to see whether Article D is included in your additional insurance package and the amount of the reimbursement. Can't find Occupational Therapy, Article D in your Reimbursements overview? Then your are not entitled to additional reimbursement (therefore, only the reimbursement in the health insurance). The illustration below shows part of the Reimbursements This may show that you are insured for Occupational Therapy (see arrow 4). The Reimbursements Overview therefore contains the actual information about the healthcare that you are insured for and the amount of the reimbursement. The number in the Terms and conditions column refers to the Article number in this booklet. 4 What will you be reimbursed How much will you be reimbursed Terms and conditions Occupational Therapy D.17. Occupational therapy for insured personsup to 18 years maximum 2 hours per year over and above insurance in the general insurance D page 2

4 of Insurance for Health Insurance and Additional Insurance Packages as Instructions and assistance for volunteer carers maximum 2 hours per year D.17.2 for insured persons undergoing occupationaltherapy 5. of Insurance This terms and conditions of insurance booklet is divided into 4 chapters: o Chapter A contains the general terms and conditions that apply for the health insurance and additional insurance package; o Chapter B describes the healthcare that is insured under your health insurance; o Chapter C shows the different conditions or additional general conditions that only apply to the additional insurance packages and the medical expenses insurances; o Chapter D describes the healthcare that you are entitled to by virtue of your additional insurance packages. In your Reimbursements Overview you can read whether you are insured for this and the extent to which you are entitled Chapters A and B therefore apply to all health insurances. Chapters A, C and D apply to the additional insurance packages. 6. Internet Our website contains more information such as: o Healthcare search ('Zorgzoeker'): here you can find all kinds of information about healthcare providers, such as who can provide specific healthcare and which healthcare providers are contracted or recognised; o "List of disorders for physiotherapy and/or exercise therapy": this document tells you whether you are entitled to reimbursements (and the amount) from the health insurance for physiotherapy and/or exercise therapy. If you are not entitled to reimbursement by virtue of the health insurance, the treatments immediately become eligible for reimbursement from your additional insurance package; o various enclosures that are part of your insurance, such as an enclosure showing premiums and reimbursement rates; you can use your password or DigiD to visit your personal page. Here you can view you policy document, bills you have submitted or reimbursements and pass on changes at any time of the day. page 3

5 of Insurance for Health Insurance and Additional Insurance Packages as TABLE OF CONTENTS TOC page 4

6 of Insurance for Health Insurance and Additional Insurance Packages as Alphabetical list of reimbursements Reimbursement 'Basis' insurance Additional Insurance Package Article page Article page Acne treatment D ADL (general daily vital functions) medical aids D Adoption, maternity care D Adoption, medical screening D Alarm (personal) D Alarm (epilepsy) D Non-allergenic shoes B D Alternative care and psychosocial care D Alternative medicines D Contraceptives (contraception) B D Audiological care B Ventilation, mechanical B Treatment for snoring D Pelvic physiotherapy B Circumcision D Monitor (home) D Exercise programmes, general D Exercise programmes for certain disorders D Visiting costs D Breast prosthesis, replacement B D Upper eyelid correction D Braces and bandages D Spectacles and contact lenses D Healthcare abroad B D Healthcare abroad, vaccinations and pills D Healthcare abroad, non-urgent B Healthcare abroad, urgent B D Camouflage therapy D Circumcision D Condoms D Consultations for women D Patients' association contribution D Correction of the upper eyelids D Ear protrusion correction (elephant ears) D Cosmetic treatments D Incubator care D Courses D Courses relating to the birth D Diabetes, test strips D Diabetes, foot care B page 5

7 of Insurance for Health Insurance and Additional Insurance Packages as Reimbursement 'Basis' insurance Additional Insurance Package Article page Article page Dialysis, without hospitalisation B Dietary advice B D Dietary advice for some chronic indications B Dietary advice in other cases B Dietary preparations (liquid diet and gavage) B Dyslexia care B Ultrasonography B Personal contribution, medicines B D Personal contribution, hospice D Personal contribution, medical aids B D Personal contribution, postnatal care B D Personal contribution, outpatient childbirth B D Epilepsy alarm D Hereditary disease investigation and advice B Extra postnatal care D Occupational therapy, general B D Occupational therapy, instructions for volunteer carers D Extra postnatal care D Pharmaceutical care (see medicines also) B D Physiotherapy and/or exercise therapy B D Mental healthcare (GGZ), 'Basis' GGZ B D Mental healthcare (GGZ), specialist mental healthcare B Mental healthcare, open homes D Hearing aid B D Medicines, general B.15.(1.) 65 D Medicines, contraceptive B D Medicines for erectile dysfunction D Medicines prepared by the pharmacy B Medicines, personal contribution B D Medicines, medication assessment B Medicines, other D Medicines, self-care medicines and antacids B Geriatric rehabilitation B Visual aids B D Visual acuity treatments (laser eye surgery) D Health courses D Health courses for childbirth D Hairpieces B D Recuperation & Balance D Convalescent home D Hearing aid B D page 6

8 of Insurance for Health Insurance and Additional Insurance Packages as Reimbursement 'Basis' insurance Additional Insurance Package Article page Article page Hospice, personal contribution D Skin therapies D GP care B Domestic care/home nursing D ADL medical aids D Foot care medical aids D Medical aids, general B.17.(1.) 70 D Medical aids, personal contribution B D Open homes D Registration and intake, postnatal care B IVF (In Vitro Fertilisation)/ICSI B Camp, therapeutic D Class nursing D Multidisciplinary care B Childcare D Postnatal care/healthcare following childbirth B D.21.(2.) 123 Maternity care for adoption D Postnatal care, personal contribution B D Postnatal care, extra D Postnatal care, registration and intake B Postnatal care following hospital admission D Postnatal care allowance D Spa treatment D Lactation consultant care D Light therapy, UV-B D Light therapy for seasonal affective disorder D In-patient accommodation allowance/compensation/additional costs D Accommodation expenses D Speech therapy B Mechanical ventilation B Medication assessment for chronic use B Medical specialist care, general B D Medical specialist care with hospitalisation B Medical specialist care without hospitalisation B Medical screening for adoption D Oral care, all ages (general) B D.8.(1.) 113 Oral care, all ages (dentures and implantology) D Oral care, all ages (crowns, bridges, inlays) D Oral care, all ages (orthodontics) D Oral care, all ages (other) D Oral care, insured persons up to 18 years B Oral care, insured persons from 18 years B page 7

9 of Insurance for Health Insurance and Additional Insurance Packages as Reimbursement 'Basis' insurance Additional Insurance Package Article page Article page Obesity treatment D Exercise therapy, Cesar/Mensendieck B D Support for home situation D Examination, hereditariness B Investigation of paediatric cancer B Investigation, preventive D Reversing sterilisation D Hair removal D Laser eye treatment D Eyelid correction B D Ear correction (elephant ears) D Organ transplantation B Orthodontics B D Orthopaedic shoes and modified shoes B D Patients' association, contribution D Chiropody treatment, for certain disorders B D Personal alarm D Plastic surgery B Bedwetting alarm D Therapeutic soles D Podotherapy/podiatry (see foot care also) B D.15.1./ Outpatient childbirth/care during the birth B D Prevention B D Prevention for trips abroad D Preventive vaccinations D Preventive investigations D Prenatal screening B D Hairpiece (or other head cover) B D Psychological care (see mental healthcare) B.19. D Psychosocial care (see alternative care and psychosocial care) D Redression helmet D Travelling expenses, parents D Rehabilitation (care) B.4.6.(1.) 47 Rehabilitation (care), geriatric B Shoes, non-allergenic B D Shoes, modified and orthopaedic B D Second opinion B Snoring, treatment for D Specialist care (see medical specialist care also) B D Medical sports advice (sports doctor, physical for participation in sport) D Sterilisation D page 8

10 of Insurance for Health Insurance and Additional Insurance Packages as Reimbursement 'Basis' insurance Additional Insurance Package Article page Article page Sterilisation, reversal D Support pessary D Support soles D Stammer therapy B D Dentist (see oral care) B.12. through B.14. D TENS for birth D Test strips, diabetes patients D Therapy camp D Home monitor D Home nursing/domestic care D Home care products D Transplantation (organ) B Coping with trauma D Thrombosis service B UV-B light equipment D Fall prevention D Bandage shoes B Stay D Obstetric care B Nursing without hospitalisation B Nursing/care (home) D Breast prosthesis replacement B D Transport (see patient transport) B D.12.(1.). 118 Insured healthcare B Care products (home) D Dietary advice D Foot care, general D.15.(1.) 125 Foot care, for certain disorders B D.15.2./ Foot care, medical aids D Conditional care B Women, consultation D Fertility related care (IVF/ICSI) B Seasonal affective disorder, light treatment D 'ZBC' (Independent Treatment Centre) (see medical B.4. specialist care) 44 Self-care medicines and antacids B Hospital nursing in a higher class D Hospital care (see medical specialist care) B Patient transport B D.12.(1.) 118 Patient transport by ambulance B Patient transport by car, public transport or taxi B D Postnatal care B D page 9

11 of Insurance for Health Insurance and Additional Insurance Packages as Reimbursement 'Basis' insurance Additional Insurance Package Article page Article page Care during childbirth B D Prenatal care B D Exceptional Medical Expenses Act (AWBZ) Exceptional Medical Expenses Act Do you need home care, nursing care and nursing home care, disability care or long-term non-medical psychiatric care? This is care that is paid for by the AWBZ. These types of care are arranged by care administration offices that are part of the various health insurers. You are automatically registered as AWBZ insured if you have health insurance. Do you require care under the AWBZ? You have to have a referral if you require care from the AWBZ. You can request this referral from: 'Centrum Indicatiestelling Zorg' (CIZ); you can find more information about this on the website (information in Dutch) or 'Bureau Jeugdzorg' for children up to 18 years with a psychiatric disorder; see the website for information (in Dutch). AWBZ Premium and Personal Contribution The AWBZ is a national insurance scheme for everyone in the Netherlands. Everyone who has income in the Netherlands pays the premium automatically. If you make use of AWBZ care you also pay a personal contribution that depends on your income. You can find more information about this at (information in Dutch) More Information about AWBZ You can find all kinds of information about the range of care, advice for finding care that suits you, care in kind, personal budget (PGB), care administration offices, brochures etc. at the website (information in Dutch). Which health insurances and additional insurance packages? We can provide one or more of the following health insurances: a 'Zorgverzekering Restitutie'; a 'Zorgverzekering Natura'; a 'Zorgverzekering Natura Direct'; a 'Zorgverzekering Natura Select'; or another health insurance, which is based on one of the health insurances mentioned above. In addition to this, you can choose from the various additional insurance packages that we provide. Your health insurance is health insurance within the meaning of the Health Insurance Act. If you have a 'Natura', a 'Zorgverzekering Natura Direct' or a 'Zorgverzekering Natura Select' page 10

12 of Insurance for Health Insurance and Additional Insurance Packages as health insurance then you are entitled to care ("in kind"). If you have a 'Zorgverzekering Restitutie' you are entitled to reimbursement (refund) of the costs of healthcare. Check you policy document to see which health insurance you have and whether you have an additional insurance package also. page 11

13 of Insurance for Health Insurance and Additional Insurance Packages as AND CONDITIONS A.1. Explanation of terms In this Article we explain the meaning of the terms that you will come across in the terms and conditions of insurance. Additional insurance package An insurance contract, the subject of which is the reimbursement of healthcare and which is geared to and forms an addition to a health insurance. You can take out one additional insurance package or a combination of a number of additional insurance packages with us. Where "additional insurance package" is mentioned from now on this could also be a combination of additional insurance packages. Statement of approval The written statement that we give you in response to your request for a care recommendation. This statement shows: that we consider this healthcare to be healthcare that is covered by your (additional) (healthcare) insurance; that in your situation you are reasonably entitled to that healthcare; and that you are entitled to that healthcare in accordance with the terms and conditions of insurance. This statement is issued by our Medical Assessments department. CHAPTER A GENERAL HEALTH INSURANCE AND AD- DITIONAL INSURANCE PACKAGE TERMS Dispensing A general practitioner or pharmacy that has a permit to supply medicines in accordance with the Medicines Act. insurance An insurance contract, the subject of which is the reimbursement of healthcare and which you can enter into, and which provides independent cover without being an addition to another insurance. A general insurance is the same as a health insurance. These terms may be used interchangeably. Company Medical Officer A doctor who is registered as a Company Medical Officer in the register of the 'Koninklijke Nederlandsche Maatschappij tot Bevordering der Geneeskunst'. This register has been set up by the CHAPTER A page 12

14 of Insurance for Health Insurance and Additional Insurance Packages as 'Sociaal-Geneeskundigen Registratie Commissie' (SGRC). Treatment The (physical) contact with one or more healthcare providers where you are provided with healthcare or receive advice. Treatment is not understood to mean courses. We use the date of treatment, not the invoice date, for reimbursement. Pelvic physiotherapist A physiotherapist who is registered as a pelvic physiotherapist in the 'Centraal Kwaliteitsregister Fysiotherapie'. Foreign country All countries apart from the Netherlands. What if you don't live in the Netherlands? Then we understand "foreign country" to mean all countries other than your country of residence. 'Bureau Jeugdzorg' A bureau as described in Article 4 of the Youth Care Act. This is an independent bureau in your Province which provides access to all youth care facilities. As an independent body, this bureau assesses your request for assistance and refers you on. Centre for specialist dentistry A centre that provides dentistry in special cases in accordance with the "the centre referral" (de centrumindicatie) document, with associated specifications. The treatments are provided by teams and/or require special expertise. A centre or establishment for oral care is not a centre for specialist dentistry. Consultation A consultation with a healthcare provider. This could involve a referral, a discussion, physical examination, patient's medical history, the formulation of a diagnosis or an additional examination/diagnosis if this is a medical necessity. Outpatient treatment A form of nursing that takes a number of hours in an establishment for specialist medical care in a department set up for outpatient treatment, or an establishment for rehabilitation designed for medical examination and/or medical treatment which does not involve hospitalisation. It must involve care that is generally foreseeable. DBC: Diagnosis Treatment Combination A DBC describes the entire course of medical specialist healthcare or specialist psychiatric healthcare. The healthcare request, the healthcare type, the diagnosis and the treatment are described in the DBC. A DBC performance code is assigned to the DBC. This code is determined by the 'Nederlandse Zorgautoriteit' (NZa). The DBC course commences as soon as you report with a healthcare request (so-called opening of the DBC) and concludes at the end of the treatment. If your treatment lasts longer than 365 days, the DBC course is closed, claimed and a new DBC course is opened. The rate is an average price for that form of providing healthcare. One instance of healthcare provision may last longer than another instance. See the term "DBC on the way to transparency (DOT)" also. s for medical specialist care or specialist psychiatric care must claim the DBC course using DOT healthcare product codes (see "DOT" below). Certain expensive care (such as intensive care healthcare, expensive medicines and blood products) are not claimed using a DOT healthcare product code but are claimed separately as an OZP (Other Healthcare Product). Dietician Someone who has the "quality registered" status as a dietician in the 'Kwaliteitsregister Paramedici'. DOT: DBC on the way to Transparency DOT is an improved claim system for medical specialist healthcare that came into effect on 1 January This system should lead to simplification of the DBC system, the starting points being more transparency and greater medical identifiability. The diagnosis-treatment combinations that are used in the DOT system are called DOT healthcare products. Sonographer Someone who has completed (para) medical training to a minimum of HBO (higher professional eduction) level and is registered in the 'KNOV' register for ultrasonography or in the 'Beroepsvereniging Echoscopisten Nederland' (BEN) register. Primary care (primary healthcare) Initial point of contact for people requiring healthcare. Primary care psychologist CHAPTER A page 13

15 of Insurance for Health Insurance and Additional Insurance Packages as A healthcare psychologist who works in a practice, dealing with the primary care of mental healthcare. Personal contribution Healthcare costs that are covered by the health insurance, but for which have to make a contribution. Personal contributions are legally determined. The personal contribution could be a fixed amount per treatment or a specific percentage of the costs for the healthcare. A personal contribution is not the same as a deductible. Deductibles and personal contributions can both apply simultaneously to the insured healthcare. Deductible Costs for healthcare that is covered by the health insurance, but which you must pay yourself. Deductible is legally determined. A deductible is not the same as a personal contribution. Deductibles and personal contributions can both apply simultaneously to the insured healthcare. See Articles A.12. and A.13. for deductible. Occupational therapist An occupational therapist has the quality registered status in the 'Kwaliteitsregister Paramedici'. Physiotherapist Someone who is registered as a general physiotherapist in the 'Centraal Kwaliteitsregister Fysiotherapie'. EU state and EEA state The EU states (European Union) are: Belgium, Bulgaria, Cyprus (Greek area), Denmark, Germany, Estonia, Finland, France (including Guadeloupe, French Guyana, Martinique, St. Barthélemy, St. Martin and La Réunion), Greece, Hungary, Ireland, Italy, Croatia, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Austria, Poland, Portugal (including Madeira and the Azores), Romania, Slovenia, Slovakia, Spain (including Ceuta, Melilla and the Canary Islands), Czech Republic, United Kingdom (including Gibraltar) and Sweden. Switzerland is equivalent to this, based on the provisions of treaties. The following are not part of the EU: Andorra, Monaco, the Channel Islands, Isle of Man, San Marino and the Vatican City. The EEA states (European Economic Area) are: the aforementioned EU states, Lichtenstein, Norway and Iceland. Birthing centre An establishment (also known as a birthing hotel or delivery centre) for obstetric care. Insured persons can give birth here and if necessary remain here during the postpartum period. Geriatrics physiotherapist A physiotherapist who is registered as a geriatrics physiotherapist in the 'Centraal Kwaliteitsregister Fysiotherapie'. Specialist mental healthcare Diagnosis and specialist treatment of complicated psychological disorders. A specialist (psychiatrist, clinical psychologist or psychotherapist) is involved in the treatment. Skin therapist A skin therapist has the quality registered status in the 'Kwaliteitsregister Paramedici'. Practitioner A doctor who is registered as a general practitioner in the 'Koninklijke Nederlandsche Maatschappij tot Bevordering der Geneeskunst' register of qualified general practitioners. This register has been compiled by the general practitioner, Specialist geriatric medicine and doctor for the mentally handicapped 'Registratie Commissie' (HVRC). Practitioner service structure An organisational partnership of general practitioners. The partnership has a legal personality as meant in article 29c of the Decree on Extension and Limitation Scope Healthcare Market Regulation Act. The partnership has been set up to provide urgent general practitioner medical care during the evening, at night, during the weekend and on public holidays in a specific location known as the 'huisartsenpost' (After Hours GP Clinic) and has a legally valid rate. Establishment for medical specialist care An establishment for medical specialist care as meant in the Care Institutions Act (WTZi). This is a hospital or an independent treatment centre (ZBC) for example. If we only mean a hospital, we write it thus: hospital (establishment for medical specialist healthcare). We then mean a general hospital, categorial hospital (this is a hospital that provides only one, or a couple of, medical specialism such as a burns centre or psychiatric hospital) or a university hospital. If we mean a ZBC only, we write it thus: ZBC CHAPTER A page 14

16 of Insurance for Health Insurance and Additional Insurance Packages as (establishment for medical specialist healthcare). In cases where we mean both, you will see 'establishment for medical specialist healthcare' only. Year Calendar year. Except in the case of someone's age, in which case it does not mean "calendar year" but year of life. Youth healthcare physician A doctor who is registered as a Community and Health doctor in the registers of the 'Registratiecommissie Geneeskundig Specialisten' (RGS) and is employed in youth healthcare or a doctor who is registered with the profile Youth Healthcare ('KNMG' youth healthcare physician) in the registers of the 'Registratiecommissie Geneeskundig Specialisten' (RGS). Clinical psychologist A mental healthcare psychologist who is registered as a clinical psychologist in accordance with the terms and conditions of Article 14 of the Individual Healthcare Professions Act. Maternity hotel An establishment where one can stay during the maternity period and where one can receive maternity care. Maternity care Care during the maternity period and, if necessary, during the birth (partus assistance) which is supplied by a maternity nurse with the (maternity) nurse level 3 qualification or equivalent. Laboratory investigation Investigation by a legally authorised laboratory that has a rate arrangement, where the investigation can be claimed up to a maximum price. Speech therapist A speech therapist has the quality registered status in the 'Kwaliteitsregister Paramedici'. Month Calendar month. Manual therapist A physiotherapist who is registered as a manual therapist in the 'Centraal Kwaliteitsregister Fysiotherapie'. (Medical) advisor A doctor, pharmacist, dentist, physiotherapist or other expert who provides us with advice on medical, pharmacotherapeutic, dentistry, physiotherapist care or healthcare that relates to his/her own substantive care area. Medical specialist A doctor who is registered as a medical specialist in the Specialists Register of the 'Koninklijke Nederlandsche Maatschappij tot Bevordering der Geneeskunst'. This register has been compiled by the 'Medisch Specialisten Registratie Commissie' (MSRC). We also understand medical specialist to mean the obstetrician who carries out procedures in the hospital on behalf of the gynaecologist. Oral hygienist A self-employed oral hygienist who runs a practice at their own expense and under their own responsibility. Oedema physiotherapist A physiotherapist who is registered as an oedema physiotherapist in the 'Centraal Kwaliteitsregister Fysiotherapie'. Cesar/Mensendieck exercise therapist An exercise therapist who has the quality registered status in the 'Kwaliteitsregister Paramedici'. Accident A sudden, involuntary event that is harmful to health. Hospitalisation A period of nursing in an establishment for medical specialist healthcare in a department set up for nursing, not being an outpatient department, day case unit or emergency department or in an establishment for rehabilitation intended for medical examination and/or medical treatment. This stay starts before 00:00 hours and lasts until at least 07:00 hours on the following day. Orthodontist A dentist-specialist, who is registered in the specialist register for Dentomaxillary Orthopaedics of the 'Nederlandse Maatschappij tot bevordering der Tandheelkunde'. Chiropodist A person who is registered as a chiropodist with an annotation 'voetverzorging bij diabetici (DV)' (foot care for diabetics (DV)) in the CHAPTER A page 15

17 of Insurance for Health Insurance and Additional Insurance Packages as 'Kwaliteitsregister Pedicure' or in the 'Register Paramedische Voetzorg' is allowed to treat an insured person with diabetes mellitus. A person who registered as a chiropodist with an annotation 'voetverzorging bij reumapatiënten (RV)' (foot care for rheumatism patients (RV)) in the 'Kwaliteitsregister Pedicure' or in the 'Register Paramedische Voetzorg' is allowed to treat an insured person with rheumatoid arthritis. A person who is registered as a medical chiropodist in the 'Kwaliteitsregister Pedicure' or in the 'Register Paramedische Voetzorg'. The medical chiropodist is a specialised chiropodist for various, complex foot problems. This chiropodist is allowed to treat an insured person with diabetes mellitus or rheumatoid arthritis. A chiropodist who is registered as a paramedical chiropodist in the 'Register Paramedische Voetzorg '. The paramedical chiropodist is a specialist chiropodist for various complex foot problems. This chiropodist is allowed to treat an insured person with diabetes mellitus or rheumatoid arthritis. The Articles which describe healthcare also state which of the aforementioned chiropodists is allowed to provide this healthcare. Policy document The proof of insurance. Podotherapist A podotherapist is a member of the 'Nederlandse vereniging van Podotherapeuten' (N.V.v.P.). Prevention The entirety of activities, individual or as a group, that are aimed at improving or maintaining your health (physical or mental). Psychiatrist A doctor who is registered as a psychiatrist in the Specialists Register of the 'Koninklijke Nederlandsche Maatschappij tot Bevordering der Geneeskunst' and who is engaged in the diagnosis and treatment of disorders in the cognitive functions, the emotional functions, psychomotility, motivation and behaviour. Psychotherapist A healthcare provider who has completed psychotherapist training and is registered as a psychotherapist in accordance with the terms and conditions of Article 14 of the Individual Healthcare Professions Act. Rehabilitation Examination, advice and treatment of a medical specialist, paramedical, behavioural science and rehabilitation technology nature. A team of various types of experts provides the healthcare, under the leadership of a medical specialist (rehabilitation doctor). The team is affiliated with a rehabilitation establishment. Written By means of a physical or digital information carrier where the information itself is intelligible, storable and reproducible. Digital information carrier is also understood to meant the Internet and messages. Specialist in geriatric medicine A person who is registered as a specialist in geriatric medicine in the 'Koninklijke Nederlandsche Maatschappij tot Bevordering der Geneeskunst' register of qualified geriatric medicine practitioners. This is the new name for the "nursing home doctor". Urgent medical care medically necessary healthcare that cannot reasonably be delayed. Clinical dental technician A clinical dental technician who has a diploma in accordance with the Decree "on training and expertise area clinical dental technician". Home The place where you live or have your permanent residence. Stay An hospitalisation that lasts 24 hours or longer. Treaty country A treaty country is: the following states with which the Netherlands has concluded a treaty on social security which includes an arrangement for the provision of medical healthcare: Australia (for a stay of less than one year), Bosnia Herzogovina, Cape Verdi Islands, Macedonia, Morocco, Montenegro, Serbia, Tunisia and Turkey; members of the European Union other than the Netherlands; a state that is party to the European Economic Area Treaty; Switzerland. CHAPTER A page 16

18 of Insurance for Health Insurance and Additional Insurance Packages as Obstetrician An obstetrician who is included in the quality register of the 'KNOV'. Insured person The person for whom healthcare and/or costs for healthcare are insured. The insured person is entitled to insured healthcare and/or reimbursement of the insured costs. In the terms and conditions of insurance we refer to the insured person and the policyholder as "you" and "your". If we want to refer to the insured person only and not the policyholder, we speak of "you (the insured person)" and "your (the insured person's)". Insurance Package An insurance contract which can comprise one or more of the following insurances: healthcare insurance; medical expenses insurance; additional insurance package. If the insurance is a combination of 2 or more of the aforementioned insurance contracts, then that combination contains only a single health insurance or medical expenses insurance. Policyholder The person who concluded the insurance contract with us. The policy is in his or her name. The policyholder can be the insured person also. In the terms and conditions of insurance we refer to the insured person and the policyholder as "you" and "your". If we want to refer to the policyholder only and not the insured person, we speak of "you (the policyholder)" and "your (the policyholder's)". Independent treatment centre (ZBC) See under "establishment for medical specialist healthcare". Hospital See under "establishment for medical specialist healthcare". Medical expenses insurance An insurance contract that you can enter into and which provides independent cover without this being an addition to another insurance. It is an insurance that is not general insurance or health insurance within the meaning of the Health Insurance Act and can only be taken out and be in force if an insurance obligation does not exist in accordance with the Health Insurance Act. It is expressly not an additional insurance package. Healthcare group Organisational partnership of healthcare providers, registered as a legal person. See Article A.17. also. Health insurer An insurance entrepreneur who is authorised as such and who provides health insurance. The insurance company to which these terms and conditions of insurance apply is the insurance company that is shown in that capacity in the insurance policy. In these terms and conditions of insurance that insurance company is referred to as "we" and "us". Health insurance A health insurance within the meaning of the Health Insurance Act the subject of which is healthcare or the reimbursement of healthcare. A health insurance is the same as a general insurance. These terms may be used interchangeably. A.2. The fundamentals of your insurance A.2.1. You have taken out insurance with us. We record the agreement in the policy document. We send this to you annually. A.2.2. Insurance obligation You can take out health insurance with us if you have an insurance obligation in accordance with the Health Insurance Act. A.2.3. The basis of your insurance Your insurance is based on: these terms and conditions of insurance; the application form and the details you entered on it or that a third-party entered on your behalf; the information and the statements that we obtained when you took out the insurance. These details were supplied by you or by a third-party; the policy document and policy enclosures; any additional or group agreements. A.2.4. The basis of your health insurance In addition to Article A.2.3. the health insurance is also based on: the Health Insurance Act; the Health Insurance Decree; CHAPTER A page 17

19 of Insurance for Health Insurance and Additional Insurance Packages as the Regulation on Healthcare Insurance; the explanations of this legislation and regulations; interpretations by the 'College voor Zorgverzekeringen' (so-called "opinions"). If there is a difference between these terms and conditions of insurance and one or more rules based on the aforementioned law, explanations or opinions, the law, explanations or opinions take precedence. A.2.5. The nature of your health insurance Your "in kind" health insurance or "refund" health insurance are health insurances within the meaning of the Health Insurance Act. With 'Zorgverzekering Natura', 'Zorgverzekering Natura Direct' and 'Zorgverzekering Natura Select' you are entitled to healthcare ("in kind") from healthcare providers with whom we have entered into a healthcare agreement/internet agreement. Under these insurances you are entitled to reimbursement of the costs of your healthcare from healthcare providers with whom we have not entered into a healthcare agreement/internet agreement. See Article A.17. also. With 'Zorgverzekering Restitutie' you are entitled to reimbursement (refund) of the costs of healthcare. You can see which health insurance you have on your policy document. A.2.6. Information from third-parties We assume that you are familiar with the information that third-parties provide to us in relation to your application for insurance. We consider this information to have been supplied by you. A.2.7. Contact person We consider only you (the policyholder) to be our contact person for insurance. Only the policyholder is allowed to cancel or change it. A.2.8. Checking the policy document We assume the details on your application are yours. You must check the details in the policy document carefully. If the details in the policy document are incorrect or incomplete, you must inform us of this within 30 days of receiving the policy document. If you do not contact us within this period we will assume that these details are correct and complete. A.2.9. Your pass Once you have enrolled with us, we will send you an insurance pass in addition to the policy document for your insurance. On production of this pass you can obtain healthcare from those healthcare providers with whom we have entered into an agreement and/or whose care you are entitled to in accordance with your terms and conditions of insurance. A Valid terms and conditions of insurance Your policy document shows which terms and conditions of insurance are applicable. If you believe that a different version of the terms and conditions of insurance, the Reimbursements Overview and/or any addition is applicable or that another text is in force, only the text and content of the versions that are in force at that time and that are in our possession are valid at that time. A Other language In addition to Dutch, we can also publish the terms and conditions of insurance in one or more other languages. If there are differences in the content or explanation between the Dutch version and the version in another language, then only the text and content of the Dutch language version that is in our possession are applicable. A What do we send to you? When you take out insurance with us for the first time, or if the terms and conditions of insurance, premium (fundamentals) and/or entitlement to healthcare or reimbursement change, we will send you: a new policy document. When doing so we also state the date from which this new policy document applies. Your old policy document ceases to be valid from that date. if you ask us to do so, we will also send you new terms and conditions of insurance and a new Reimbursements We will state the date from which the new terms and conditions of insurance and the new Reimbursements Overview are applicable. This is almost invariably the time at which the new insurance starts. Your old terms and conditions of insurance and the old Reimbursements Overview cease to be valid from that date. if you ask us, an addition to your existing terms and conditions of insurance and the existing Reimbursements We will state the date from which the addition applies. This is almost invariably the time at which the new insurance starts. From that date, that addition applies alongside your existing terms and conditions of insurance and the existing Reim- CHAPTER A page 18

20 of Insurance for Health Insurance and Additional Insurance Packages as bursements You can find terms and conditions of insurance and a Reimbursements Overview on our website. A.3. Content and scope of your insurance A.3.1. Healthcare mediation You are entitled to care recommendation and healthcare mediation. For example, if it is expected that the necessary healthcare cannot be provided or cannot be provided on time also. Not being able to provide the healthcare or not being able to provide it on time is also understood to mean that the healthcare can only be provided at a long distance from your place of residence or cannot be provided in a qualitatively responsible manner in the vicinity of the insured person's place of residence. A.3.2. Content and scope of healthcare The content of your health insurance is determined by the government. We determine the content of the medical expenses insurance and the additional insurance packages. These terms and conditions of insurance show the cover that you are entitled to. This cover comprises healthcare that must meet the following requirements: the content and scope of the healthcare is determined by the state of science and practice or by what applies as responsible and proper healthcare and services in the field of expertise concerned; and it is healthcare such as is customarily provided by healthcare providers of the professional group concerned in accordance with their standards and norms and considered to be acceptable healthcare; and the healthcare is named as insured healthcare in the Reimbursements Overview for your insurance and elaborated and described in chapters B or D of these terms and conditions of insurance; and you are - taking account of your indication - reasonably entitled to that healthcare in regard to content and scope. The healthcare to be provided must be effective. Explanation: There must be sufficient (good) evidence clearly indicating that the healthcare is safe and proper (in the long term). Here we consider all scientific information that is available. The healthcare must also be effective. In other words, it must be the proper healthcare for your situation. For example, there must be medical grounds for the healthcare and it must not be unnecessarily expensive. Healthcare that is too expensive in your situation is therefore not proper healthcare. This healthcare is therefore not covered by your insurance. Not even if you pay for part of it yourself. A.3.3. Conditional care Contrary to Article A nd and 3 rd bullet points, the cover also includes the healthcare and the services that are provided for a specific period under the Regulation on Healthcare Insurance. The conditions stipulated there (see Article B.23.) apply for that healthcare. A.3.4. Coverage area You insurance(s) include(s) worldwide coverage. For example: You are on holiday in France and while there you buy prescription spectacles. You have an additional insurance package that includes a reimbursement of per 2 years for visual aids. This reimbursement also applies for spectacles that you buy abroad. The terms and conditions associated with the Article concerned also apply to foreign countries and the healthcare provider must meet the requirements, laws and rules that are stipulated for that country. A.4. Start and duration of your insurance A.4.1. Start date The insurance starts on the date on which we received your application take out insurance with us. When applying you should state your address as known in the municipal personal records database. If you are still insured by another health insurer at this time and you state in your application that you want the insurance to start at a later date, the insurance will start on that later date. Your policy document shows the start date for your insurance. A.4.2. Request for change CHAPTER A page 19