Aon s Global Health Complete Policy Terms and Conditions

Transcription

1 Aon s Global Health Complete 2012 Policy Terms and s

2 Table of contents Chapter 1 contains the general terms and conditions that apply to the insurances described in chapters 2, 3 and 4. The policy schedule indicates which supplementary insurances are included. You are therefore advised to first consult your policy schedule in order to find out which chapters are applicable to your insurance. Important notice emergency assistance organisations 3 Chapter 1 General terms and conditions of insurances 5 Art. 1 Description of terms 5 Art. 2 Basis of the insurance 10 Art. 3 Commencement date, duration and end of insurance 10 Art. 4 Obligations of the insured 11 Art. 5 Premium, premium payment and suspension 12 Art. 6 Change to premium and/or terms and conditions 13 Art. 7 Payment of claims 13 Art. 8 Deductible 13 Art. 9 General exclusions 14 Art. 10 Notification regarding relevant incidents 14 Art. 11 Children 14 Art. 12 Fraud 15 Art. 13 Liability of the healthcare insurer 15 Art. 14 Other terms and conditions 15 Art. 15 Registration of personal information 16 Art. 16 Disputes 16 Chapter 2 Aon s GlobalHealth Complete 17 Art. 1 Coverage 17 A Coverage area 17 B Scope of the coverage 18 C Supplementary reimbursements 33 D Repatriation and evacuation 44 Art. 2 Special exclusions 48 Chapter 3 Supplementary insurance: Comfort Class 48 Chapter 4 Supplementary insurance: Dental Expenses 48 Art. 1 Coverage 49 2

3 Important In the case of hospital admission anywhere in the world except the United States, you must first contact: Aon alarmcentre Tel: +31(0) In the event you need to visit a healthcare provider in the United States, you must first contact: GMMI (24 hours/7 days) Tel: (free within the U.S.) Fax: Billing address: GMMI 1300 Concord terrace, Suite 300 Sunrise, Florida USA Please have the following information on hand when you call: - Patient s name - Employer s name - Patient s policy number - Patient s contact information - Hospital contact information Failing to contact the aforementioned emergency assistance organisation can result in whole or partial refusal to cover the costs. 3

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5 Chapter 1 General terms and conditions of insurances Art. 1 Description of terms In these terms and conditions, the following terms are defined as follows: 1 Ambulance A vehicle intended to transport the sick and victims of accidents. 2 Pharmacy A pharmacy is understood to include (internet) pharmacies, chain pharmacies, hospital pharmacies, outpatient facility pharmacies and dispensing physicians. 3 Doctor A doctor recognised by the competent authorities. 4 Company doctor A doctor recognised by the competent authorities who acts on behalf of the employer or the Occupational Health and Safety Service with which the employer is affiliated. 5 Centre for special dentistry A university centre or equivalent facility for providing dental care in special cases, in which treatment requires a team approach and/or special expertise. 6 Genetic advice centre An institution recognised by the competent authorities for the application of clinical-genetic research and genetic advising. 7 Day treatment Foreseeable care provided in a hospital for less than 24 hours, required to undergo examination or treatment on the same day by a medical specialist or dental surgeon. 8 Dyslexia (serious) A reading and spelling disorder resulting from a neurological impairment that is genetically determined and can be distinguished from other reading and spelling problems. 9 Occupational therapist An occupational therapist recognised by the competent authorities. 10 EU or EEA state This includes the Netherlands and the following EU countries: Belgium, Bulgaria, Cyprus (Greek), Denmark, Germany, Estonia, Finland, France, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Austria, Poland, Portugal, Romania, Slovenia, Slovakia, Spain, Czech Republic, United Kingdom and Sweden. 5

6 Switzerland is equated with this on grounds of treaty provisions. The EEA states (states that are party to the Agreement concerning the European Economic Area) are Lichtenstein, Norway and Iceland. 11 Evacuation and repatriation Evacuation involves transport to the nearest medical facility that is equipped to provide the necessary care. Repatriation is transport to one s home country. 12 Pharmaceutical care The dispensation of medications recognised and registered by the competent authorities, dispensed on prescription from the treating GP or medical by a pharmacy. 13 Physical therapist A physical therapist recognised by the competent authorities. 14 Guesthouse accommodation A facility that is part of a hospital complex and provides accommodation for children and their parents while the child undergoes outpatient treatment at that hospital. 15 Healthcare psychologist A healthcare psychologist recognised by the competent authorities. 16 Authorised agent Jacobs & Brom B.V., the authorized agent given power of attorney by the healthcare insurer within the meaning of section 1 under o of the Financial Services Act (Wfd) for the provision of healthcare insurance. 17 Emergency Assistance Organisation An organization that is contracted by us and that is specialised in providing assistance in the event of hospital admission, etc. 18 Aon Alarmcentre The emergency assistance organisation appointed by Aon Hewitt which provides medical advice and assistance and takes care of repatriation and evacuation 24 hours per day, 7 days a week worldwide except for the United States of America. 19 GMMI The emergency assistance organisation GMMI which provides medical advice and assistance and takes care of repatriation and evacuation 24 hours per day, 7 days a week, in the United States. 20 Skin therapist A skin therapist recognised by the competent authorities. 21 GP (General Practitioner) A doctor who is recognised as GP by the competent authorities, or who functions as such in places where the term GP is not used. 6

7 22 Dental surgeon A dental specialist recognised by the competent authorities. 23 Calendar year The period that runs from 1 January through 31 December. 24 Maternity centre An institution that provides obstetric care and/or maternity care and which is recognised by the competent authorities. 25 Maternity care The care provided by a certified maternity carer or a nurse working as such. 26 Speech therapist A speech therapist recognised by the competent authorities. 27 Manual therapist A physical therapist specialised as a manual therapist and recognised as such by the competent authorities. 28 Medical adviser The doctor who advises us on medical matters. 29 Medical specialist A doctor recognised by the competent authorities, who is not a dentist, and who has devoted himself to specialist treatment. 30 Medical necessity The need for nursing, examination or treatment according to generally accepted scientific medical reasons. 31 Dental hygienist A dental hygienist recognised as such by the competent authorities. 32 Multidisciplinary cooperation Integrated (chain) care that is provided in cohesion by several healthcare providers from different disciplinary backgrounds and which requires coordination in order to provide the care process for the insured. 33 Oedema therapist An oedema therapist recognised as such by the competent authorities. 34 Remedial therapist (Cesar or Mensendieck) A remedial therapist (Cesar or Mensendieck) recognised as such by the competent authorities. 7

8 35 Accident The sudden impact of violence on the body of the insured, of external origin and outside his will, which causes medically demonstrable bodily injury. 36 Admission Admission to a (psychiatric) hospital, psychiatric ward of a hospital or rehabilitation facility, while and as long as medical nursing, examination or treatment can exclusively be provided in a hospital or rehabilitation facility. 37 Orthodontist A dentist or dental orthopaedic specialist recognised by the competent authorities. 38 Podiatrist A podiatrist recognised by the competent authorities. 39 Policy schedule The healthcare policy (contract) that contains the insurance concluded between you (the policyholder) and us (the health insurer) 40 Psychologist A psychologist recognised by the competent authorities 41 Psychiatrist/neurologist A psychiatrist/neurologist recognised by the competent authorities. 42 Rehabilitation Examination, advice and treatment of specialist medical, paramedical, behavioural and rehabilitative nature. This care is provided by a multidisciplinary team of experts led by a medical specialist, affiliated with a rehabilitation facility accredited in accordance with regulations laid down by law. 43 Location/country of residence The country where the insured has established the centre of his activities. 44 Dentist A dentist recognised by the competent authorities. 45 Dental prosthetician A dental prosthetician recognised by the competent authorities. 46 Terrorism Damage caused by terrorism, malevolent contamination and/or preventive measures and actions or conduct in preparation for terrorism 8

9 47 Home country The insured s country of birth and/or the country where the insured has established the centre of his life interests and to which insured will return after the period of secondment/ stay in the country of residence. 48 Permission The written permission granted by us. 49 You/your The insured persons. These persons are named on the certificate of health insurance. You (policyholder) means the party who took out the insurance. 50 Midwife A midwife recognised by the competent authorities. 51 Insured Anyone designated as such on the policy, schedule, the endorsement, or the insurance certificate. 52 Policyholder The party who entered into the insurance agreement with us. 53 We/us The authorized agent as described in art. 1 (description of terms) point Independent treatment centre A centre for specialist medical care (examinations and treatment) recognised as such by the competent authorities. 55 Hospital An institution for nursing, examining and treating sick people which has been accredited as a hospital in accordance with regulations drawn up by, or pursuant to, the law. 56 Hospital care Admittance to hospital for more than 24 hours, when and as long as, on medical grounds, care, examination and treatment can only be provided in a hospital while constant treatment by a medical specialist or dental surgeon is necessary. 57 Healthcare provider The healthcare provider or healthcare institution that provides care. 58 Healthcare insurer The principal(s) that is/are listed as such on the policy. 9

10 Art. 2 Basis of the insurance A B C D The completed and signed application form or the completed online application form and written information submitted with it separately, together with the information provided by you in the event of an examination, form the basis of the insurance agreement and constitute a part thereof. The contract is set down on the policy schedule. Answering questions posed by or on behalf of us incompletely or inaccurately or failing to report significant information to us can be grounds for us to limit payment or refrain from payment entirely. We can cancel the agreement in the event of demonstrated intention to mis lead us or if we would not have concluded the agreement at all if we had been aware of the true state of affairs. You may claim the costs of care, excluding personal contributions or deductible, to us on the basis of this insurance, unless direct billing to us takes place. The costs of care claimed by a contracted healthcare provider will be reimbursed by us directly to this healthcare provider or emergency assistance organisation in line with the rate agreed with this contracted health care provider and in accordance with the coverage of this insurance. The content and scope of the claim to care or reimbursement of the costs of healthcare as described in this insurance are determined partly by science and practice, and in the absence of such a criterion, by what applies in the relevant professional area as responsible and adequate care and services. You are only entitled to healthcare insofar as you reasonably depend on it in terms of content and scope. Art. 3 Commencement date, duration and end of insurance A B Commencement date and duration of the insurance The insurance starts on the date reported on the policy schedule as the commencement date and is tacitly renewed each year as of 1 January. End of the insurance 1 You (the policyholder) can cancel the insurance by ensuring that we have received your cancellation in writing or by by 31 October at the latest. The insurance ends as of 1 January of the following year. Once a cancellation has been submitted and effected, it is irrevocable. 2 You (the policyholder) can cancel the insurance on grounds of Chapter 1, articles 6.A and B (change to premium or terms and conditions). The insurance ends on the day on which the change comes into effect. 3 The insurance also terminates: 1 a. if the insured has died. We must be notified within 30 days after the date of death; b. when the insured reaches the age of 67. The insurance terminates as of the first day of the year following the year in which the insured reaches the age of 67. Only with our written approval can the insurance be extended for a limited period; 10

11 c. in the event of definitive residence outside the Netherlands. The insurance is ended on the next contract expiration date following on the date on which the insured has taken up residence permanently outside the Netherlands or on the earlier date on which primary healthcare insurance is taken out locally by the insured. d. if one of the insured persons is/will be no longer seconded and/or employed by an organisation/employer recognised by us; e. If one of the insured persons is required by the Dutch Healthcare Insurance Act to purchase basic health insurance. If you are required to have insurance on grounds of the Healthcare Insurance Act, you are automatically entitled to an equivalent supplementary insurance if the following conditions are satisfied: - the supplementary insurance comes into effect immediately upon termination of this Insurance; - the basic health insurance is also purchased from us. 2 It is emphatically determined that we do not have the right to terminate the insurance, except after suspension as referred to in Chapter 1, article 5 under C. 3 No retroactive force is granted to the cancellation or dissolution of insurance because of failure to pay premiums owed. Art. 4 Obligations of the insured A You are required: 1 Anywhere in the world except for the United States: to always contact the emergency assistance organisation or have this organisation contacted prior to hospital admission abroad or admission to a psychiatric facility outside the Netherlands; United States: except in the case of force majeure, to always contact the emergency assistance organisation or have this organisation contacted prior to visiting a healthcare provider in the United States; 2 to ask the treating doctor or medical specialist to report the reason for admission to the emergency assistance organisation s doctor or to our medical adviser, if the medical adviser so requests; 3 to lend cooperation to us, our medical adviser or those who are charged with control activities in obtaining all the desired information, with due regard for privacy regulations; 4 to be helpful towards us in seeking recourse on a liable third party; 5 as applicable, to submit the original invoices to us within twelve months after the expiration of the calendar year in which treatment took place. The determining factor for the right to reimbursement is the date of treatment and/or the date on which care was provided and not the date on which the invoice was issued. In the event your invoices are submitted to us later than 12 months after the expiration of the calendar year, we reserve the right to grant a lower reimbursement than that to which you would have been entitled according to the reimbursement. On the basis of article 942 of book 7 of the Netherlands Civil Code, invoices that are submitted to us later than 3 years after the treatment date and/or the date of care are not processed. 11

12 B C D E Insureds have an obligation to limit damage. We and the emergency assistance organisations have the right to propose cost-saving alternatives. Insureds are required to lend their cooperation to this within the bounds of reasonableness and fairness. If our interests are damaged by the failure to satisfy the aforementioned obligations, we are not obliged to reimburse any costs. The personal contribution or deductible owed by you and advanced by us and/or uninsured costs owed by you and advanced by us are set off against the next declaration(s), or must be repaid to us at our first written request. You must submit to us original and clearly itemised invoices. They must bear the name of the treating care provider. If the care provider is a legal entity the invoice must bear the name of the natural person who administered the treatment. We do not reimburse provisional invoices. Art. 5 Premium, premium payment and suspension A B C Premium At commencement of the insurance the premium is set according to the rate published for this type of insurance. Adjustment of the premium when the insured enters a new age bracket takes place as of 1 January of the year following that in which the next age bracket is entered. Premium payment 1 You are obliged to pay the premium, as well as amounts stemming from (foreign) legal regulations or provisions, in advance and in the agreed manner, that is to say monthly, quarterly, half-yearly or yearly. In the event the insurance is changed in the course of a month, we are entitled to (re)calculate the premium with effect from the first of the following month. You are not permitted to set off the premiumowed with any reimbursement to be claimed fromus. 2 Payment of premium, personal payments and any other amounts take place preferably by automatic debit. If a payment method other than automatic debit is chosen, we can charge administration costs. 3 In the event of the insured s death, the setoff or restitution of the premium takes place with effect from the day following the date of death. 4 If the insurance is terminated in the interim, premiums that have already been paid will be repaid on a prorated basis. We assume a 30-day month in this respect. We may deduct an amount for administration costs from the premium to be repaid. Suspension in the event premium is not paid on time If you do not satisfy payment of the premium, costs or claims stemming from costs advanced by us for you in a timely manner, once the premium due date has passed we may send you a written demand for payment within a period of 30 days, counted from the day after the demand, with the notification that failure to pay within the set period will result in coverage not being applicable for medical treatment that has taken place after the premium due date. You continue to be liable for the premium payment. The obligation applies as well if the 12

13 premium is paid by a third party. If we take measures to collect our claims, all collection costs, both in and out-ofcourt, are at your expense. The coverage takes effect once again on the day following that on which the amounts and costs owed are received by us. Art. 6 Change to premium and/or terms and conditions A B C The premium and/or terms and conditions will be changed en bloc, or in relation to a group, on a date to be decided by us. This general change will be effective for you from this date. We will notify you of this change in writing. If you do not agree with the increase to premium or limitation of the terms and conditions, you must notify us of this in writing within 30 days after we have announced the change. The insurance is in such a case terminated on the day on which the change takes effect. You may not refuse the change if this is the direct result of: - a legal regulation or provision; - a change to the premium with respect to the rate that applies to a higher age bracket; - a lowering of the premium; - an improvement to the terms and conditions. Art. 7 Payment of claims A B The original invoices must be itemised in such a manner that it can be ascertained what reimbursement we are required to pay. They must bear the date of treatment, the names and dates of birth of the patients, nature of the treatment and the name of the referring doctor (if applicable). We reserve the right to require proof of payment. The reimbursement will be paid out in euros subject to the exchange rate on the day on which the insured receives treatment, unless fairness dictates otherwise. Art. 8 Deductible A B C D If a deductible is listed on the policy schedule, this deductible is subtracted from the reimbursements which are eligible according to the insurance terms and conditions. If a maximum amount is reported for a component of the insured package, this maximum continues to apply both for the deductible as well as for any reimbursement. If admission to a hospital does not end in the calendar year in which it started, the deductible, as it applied at the time of admission, shall be subtracted only once for the admission. If the first insurance period is not equal to a calendar year, the deductible amount listed on the policy schedule is reduced for that period by 1/12 for each month of that calendar year 13

14 that has elapsed before the commencement date of the insurance. The amount of the deductible will never be set lower however than the amount reported on the policy schedule. E The deductible will never be reduced in the event of suspension or termination of the insurance. Art. 9 General exclusions A B C You have no claim to reimbursement of costs caused by or arising from armed conflict, civil war, riots or mutiny, as in the Financial Supervision Act (Wft. Medical costs resulting from terrorism are only reimbursed up to the benefit as described in the clauses schedule on terrorism coverage from the Dutch Terrorism Risk Reinsurer (Nederlandse Herverzekeringsmaatschappij voor Terrorismeschaden N.V.). This clauses schedule and the related Protocol constitute part of this policy. The applicable Claims Settlement Protocol and the terrorism coverage clauses sheet can be consulted at We do not reimburse the costs related to treatment administered by you at the expense of your insurance. For treatment by your partner, family member and/or relative once or twice removed (insured) we must give our consent beforehand if you intend to claim reimbursement from us. Art. 10 Notification regarding relevant incidents A B You are required to inform us (or to have us informed) within a month of all incidents that could be significant for proper performance of the insurance, such as a move of house, divorce, birth, death, etc. Notifications to the policyholder sent to his last known address are deemed to have reached you (the policyholder). The policyholder or insured is required to notify us if an insured is taken into custody, within one month after such detention has commenced. Art. 11 Children A B Children born to insureds during the duration of this insurance are included in the insurance with effect from their date of birth, without medical restrictions as long as they are reported to the us within 30 days after their birth. Children may remain insured on the policy of the parent(s) as long as they are a part of the family household and/or are living elsewhere while studying, but only until 1 January following the day on which they reach the age of 27. We are subsequently free to re-evaluate 14

15 whether and under what conditions we are willing to insure the risk by means of a new insurance agreement. Art. 12 Fraud Fraud is the securing of a claim and/or reimbursement from us under false pretences or on spurious grounds and/or by spurious means. Every right to claim and/or reimbursement based on this insurance lapses if the policyholder and/or an insured and/or another stakeholder in the claim and/or reimbursement gives a false representation of the situation, has submitted forged or misleading documents, or has given an inaccurate report related to a submitted claim or has remained silent on facts that could be important to us assessing a submitted claim. In such a case any right to claim and/or reimbursement with regard to the entire claim lapses, also for those matters for which no inaccurate report has been made and/or with respect to which no inaccurate representation of the situation has been given. Fraud may also prompt us to: - file a police report; - terminate the insurance contract(s); - enter the incident in the detection systems used by insurers; - reclaim reimbursement paid out and (investigation) costs incurred. Art. 13 Liability If a healthcare provider or emergency assistance organisation does or fails to do something and as a result the insured suffers damage, we are not liable for this, not even if the healthcare or assistance from that healthcare provider serves as part of the insurance. Art. 14 Other terms and conditions A Notification requirement 1 Before concluding this insurance contract, you (the policyholder) are required to notify us of all facts you know or should know, and which, as you know or should understand, are (or could be) deciding factors in our acceptance decision on whether, and if so, under which terms and conditions we are willing to extend the insurance. 2 If you fail to satisfy the notification requirement, and we would have insisted on a higher premium or lower insured amount had we been aware of the true state of affairs, then the claim to reimbursement is reduced proportionately. If we would have set different terms and conditions, then claim to reimbursement only exists with application of these different terms and conditions. 3 In deviation from paragraph 2, there is no entitlement whatsoever to reimbursement if we 15

16 would not have extended any insurance had we known the true state of affairs, or if actions were undertaken with the intention of misleading us. Moreover, the insurance agreement can then be cancelled with immediate effect within two months after discovery of such circumstances. Art. 15 Registration of personal information A B C D Upon the application for insurance or financial service we ask for personal information. This information is used by us for the entering into and performance of contracts, in order to inform you about relevant products and/or services, to guarantee the security and integrity of the financial sector, for statistical analysis, client management and to satisfy statutory requirements. The ethical guidelines for Processing of Personal Data by Financial Institutions apply to the use of the personal data. For health insurers the Ethical Guidelines for the Processing of Personal Data by Health Insurers also apply. If you (the policyholder) do not wish to receive information on products and/or services, you can notify us of this in writing. As part of a responsible acceptance policy, we may consult data at the Stichting CIS in Zeist. In this context participants of the Stichting CISmay also exchange information with each other. The purpose of this is to manage risks and counter fraud. The privacy regulations of the Stichting CIS apply. More information can be found at From the moment the insurance starts, we may request information from third parties (healthcare providers, emergency assistance organisations, suppliers, etc.) and provide such parties with information insofar as this is necessary to be able to honour the obligations stemming from this insurance. Information is understood in this context to be the insured s address and policy information. If urgent reasons make it necessary to refuse healthcare providers or suppliers access to the address information, you can inform us of this in writing. Art. 16 Disputes A B C Dutch law applies to this agreement. The district court in Haarlem has exclusive jurisdiction. If you do not agree with a decision made by us or you are dissatisfied with the service provided by us, you can submit your complaint to the Central Complaints Office within six months after the decision has been communicated to you. You may submit your complaint by letter, , telephone, internet or fax. After receipt, the complaint is included in our complaints registration system and you will receive confirmation of this. Within three weeks at the latest you will receive a substantive response. If more time is needed to handle the complaint, the handler or the Central 16

17 D E F G Complaints Office will notify you of this. If you do not agree with how the complaint has been handled, you may ask us to reconsider. The request for reconsideration may be submitted to the Central Complaints Office by letter, , telephone, internet or fax. You will receive a confirmation of this and a substantive response no later than within three weeks. If more time is needed to reconsider the complaint, the handler or the Central Complaints Office will notify you of this. In contravention to the above paragraph or if you are not satisfied with the reconsideration, you may put the dispute before the Healthcare Insurance Complaints and Disputes Commission (Stichting Klachten en Geschillen Zorgverzekeringen), P.O. box 291, 3700 AG Zeist ( The Healthcare Insurance Complaints and Disputes Commission may not handle your complaint if the case has already been brought to court or if a court decision has already been made with regard to it. You are always free to go to the civil court, even after the Disputes Commission has issued binding advice. Regardless of the provisions in the other paragraphs of this article, consumers, healthcare providers and health insurers always have the right to submit a complaint to the Netherlands Healthcare Authority regarding forms used by us. Such a complaint concerns forms that the complainant feels are superfluous or overly complicated. A pronouncement from the Netherlands Healthcare Authority provides the healthcare provider, health insurer and consumer with binding advice. For more information about how you can submit a complaint to us, how we subsequently handle complaints and the procedure at the Healthcare Insurance Complaints and Disputes Commission, we refer you to the brochure Klachtenbehandeling bij zorgverzekeringen [Complaints handling with respect to healthcare insurance]. You can request this brochure fromus. Chapter 2 Aon s Global Health Complete Art. 1 Coverage A Coverage area 1 The insurance offers worldwide coverage. 2 Medically necessary healthcare costs in Canada and the United States are only insured if the premium rate for these countries has been charged, unless: - there is an accident or unforeseen case of illness during holiday or business travel in one of the countries mentioned; - there is an evacuation to one of the mentioned countries in connection with medical treatment that is not medically possible in the country of residence and which cannot be postponed and for which there are no medical alternatives at hand. 17

18 Except in the case of force majeure, you must always contact the GMMI emergency assistance organisation, or have this organisation contacted, prior to a visit to a healthcare provider in the United States. B Scope of the coverage 1 Hospital admission a. We reimburse the costs for day treatment or hospital admission for an uninterrupted period of maximum 365 days. Time spent admitted to a hospital or rehabilitation centre for rehabilitation purposes and or to a psychiatric hospital also counts towards the total of 365 days. An interruption of at most thirty days is not seen as interruption and does not count towards the calculation of 365 days. Interruptions because of weekend and holiday leave do count towards the calculation of the 365 days. We reimburse the costs of: - hospital admission, including nursing and care on the basis of a hospital room equipped for more than 2 persons; - specialist medical or dental surgical care; - the paramedic care, medicines, health aids and bandages related to the treatment, during the period of admission. The scope of the care to be provided is limited by what medical specialists undertake to provide. b. Assistance with hospital admission outside of the Netherlands If treatment is medically necessary, and the costs of this treatment are covered, the selection of a hospital will take place according to the criterion of internationally accepted quality of medical care. The emergency assistance organisation has the authority to determine whether a hospital satisfies this quality requirement. The medical adviser of the emergency assistance organisation will assess the situation objectively and subsequently select the right hospital or facility. The emergency assistance organisation will organise the admission to hospital and where necessary, negotiate the costs of that hospital, the costs of the treating physicians and all additional costs. In emergency situations the emergency assistance organisation will actively ensure the provision of adequate medical treatment and monitor the progress of treatment. 2 Independent treatment centre In the event of treatment at an independent treatment centre, we reimburse the costs of; a. nursing and care; b. specialist medical care; c. the paramedic care, medicines, health aids and bandages related to the treatment. The scope of the care to be provided is limited by what medical specialists undertake to provide. s - You must have been referred by a GP or other medical specialist. - We must have provided written permission in advance. - You must authorise the GP or medical specialist to inform the medical adviser of the 18

19 reason for admission. 3 Nursing ( outpatient) Instead of nursing in a residential facility as referred to in Chapter 2 article 1B.1, 1B.2, and 1B.11, you are also entitled to care at home, such as nurses undertake to provide and which is necessary in connection with medical specialist care. This is reserved treatment provided by a medical specialist and activities that are supervised directly by the specialist and/or necessary instruction and explanation directly connected to the medical specialist treatment. s - You must still be being treated by the medical specialist. - We must have given permission in advance. Exclusion We do not reimburse the costs of nursing that is required in connection with artificial respiration at home or that is required in connection with palliative care. 4 Medical specialist care (outpatient) We reimburse the costs of: a. specialist medical or dental surgical care; b. the paramedical care, medicines, health aids and bandages related to the treatment. The scope of the care to be provided is limited by what medical specialists undertake to provide. - The insured must be referred by a GP, doctor for youth healthcare, midwife in the event that maternity care is concerned, or other medical specialist. Exclusion This article does not apply for mental healthcare (art. 11). 5 Specialist medical care (independent professional) We reimburse the costs of treatment by a medical specialist who works as an independent professional. This is a medical specialist who does not work at a hospital or independent treatment centre. We reimburse the following costs: a. specialist medical care; b. the medicines, health aids and bandages related to the treatment. The scope of the care to be provided is limited by what medical specialists undertake to provide. The insured must be referred by a GP, doctor for youth healthcare, midwife in the event that maternity care is concerned, or other medical specialist. Exclusion This article does not apply for mental healthcare (art. 11). 19

20 6 Plastic surgery We reimburse the costs of plastic surgery by a medical specialist if the treatment leads to correction of: a. abnormalities in the appearance that are related to demonstrable problems with physical functioning; b. disfigurements resulting from disease, accident or medical procedures; c. the following congenital defects: cleft lip, jaw or palate, malformations of the facial bone structure, benign growths of blood vessels, lymphatic vessels, or connective tissue, birthmarks or malformations of urinary tract and genitals; d. the position of the ears, if surgery is required because of a congenital defect, personal desire, necessity or circumstance; e. paralysed or slackened upper eye lids resulting from a congenital defect, congenital chronic ailment or in the event of demonstrable physical impairment; f. the stomach wall (abdominal plastic), if there is a case of a mutilation that is comparable in seriousness to a third degree burn, of untreatable blemishes in skin creases, or of a very serious limitation to the freedom of movement (this is the case if the omentum extends down beyond at least one quarter of the upper legs); g. primary sexual characteristics in the case of ascertained transsexuality (including the depilation of the pubic area and beard). We must have provided written permission in advance. Exclusion We do not reimburse the costs of: - The surgical implantation and removal of prosthetic breasts, except as following single or double mastectomy; - The surgical removal of prosthetic breasts without medical necessity; - Liposuction of the stomach. 7 Second opinion We reimburse the costs of a second opinion from a medical specialist other than the treating physician. The opinion or advice can be asked either by you or the treating GP. We only reimburse the costs if the diagnosis or treatment falls under the terms and conditions of this health insurance. 8 Organ transplants We reimburse the costs of: - organ and tissue transplants performed in a hospital if the transplant is performed in a member state of the European Union, in a country that is party to the Agreement on the European Economic Area or in another country if the donor resides in that country and is your spouse, registered partner or a first, second or third-degree blood relative; - the specialist medical care in connection with selecting the donor and in connection with 20

21 the surgical removal of the transplantation material from the selected donor, the testing, preservation, removal and transport of the postmortal transplantation material, in connection with the prospective transplant; - the transplant operation at an independent treatment centre if this is permitted pursuant to legislation and regulation. The donor is entitled to reimbursement of the costs of: - care, to which there is claim on the basis of this policy, for a maximum of 13 weeks, or six months in the event of a liver transplant, after the date of discharge from the hospital, in which the donor was admitted for selection or removal of transplant material and exclusively if the care provided is related to that admission: - transport by public transport, lowest fare class, or if and insofar as medically necessary by car, in connection with the selection, admission and discharge from the hospital and with the care referred to in the previous sentence; - the transport to and from the country where the transplant takes place for a donor that resides abroad, in connection with the transplant of a kidney, bone marrow or liver for an insured. - The other transplant costs insofar as these are related to the donor s living abroad. These costs do not in any event include costs of stay or any lost income. 9 Rehabilitation in a hospital or rehabilitation centre We reimburse the costs of rehabilitation, but exclusively if: a. this care is designated as the most effective for you in order to prevent, reduce or overcome a disability resulting from disorders or limitations in the freedom of movement or a disability resulting from an affliction of the central nervous system leading to limitations in communication, cognition or behaviour; and b. this care will enable you to achieve or retain a measure of independence which, given your limitations, is reasonably possible. Rehabilitation can take place: - in a clinical environment, involving admission of several days, as long as this can be expected to lead quickly to better results than rehabilitation without admission. We reimburse costs in the event of rehabilitation in a clinical environment for an uninterrupted period of 365 days. Other admissions to hospitals or psychiatric hospitals also count towards the 365 days. An interruption of at most 30 days is not regarded as interruption, but the duration of such a disruption is not counted towards the 365 days. Interruptions for weekend and holiday leave do count towards the 365 days; - in an outpatient setting (part-time or day treatment). For the rehabilitation referred to above, reimbursement of costs can only be claimed if our written permission for admissi on and/or treatment is requested in a timely manner by you or on your behalf and if we have provided the facility with a guarantee declaration as evidence of our permission. The request for permission must be accompanied by a properly supported treatment plan from the treating/referring physician. This treatment plan must at least discuss the nature and complexity of the disorder or limitation, the disciplines to be involved in the treatment as well as the envisioned duration and intensity of the treatment. 21

22 10 Dyslexia care We reimburse for children who start receiving care at the age of seven, eight, nine or ten the costs of: - the diagnostic examination to determine whether there is a case of serious dyslexia for which specialised treatment is necessary; - the treatments possibly stemming from the diagnosis by a psychologist or special educati on expert; - the care provided by other professional groups in the context of the multidisciplinary cooperation. We reimburse the costs of the diagnosis only if you are referred by a GP or specialist who suspects there is a case of serious dyslexia without there being other reading or spelling problems. 11 Mental healthcare We reimburse the costs of: a. Psychiatric care Ambulant psychiatric care by a medical specialist. A referral from the GP must be produced with the invoice. b. Psychological care (short-term) by a first-line psychologist. Treatment of the insureds in maximum 11 sessions by a first-line psychologist. It must be acute, short-term help that takes place in the context of the treatment by the GP. A referral from the GP must be produced with the invoice. Of the total costs reported under a) and b) above, a maximum of EUR 2,000.- is reimbursed per insured per calendar year. c. Admission to a psychiatric institution for the duration of maximum 365 days. The scope of the care to be provided is limited by what psychiatrists/neurologists and clinical psychologists undertake to provide 12 Non-clinical haemodialysis and peritoneal dialysis We reimburse the costs of kidney dialysis in a hospital, dialysis centre or at your home, whether or not accompanied by examination, treatment, nursing and pharmaceutical care necessary for the treatment and psychosocial treatment of you, and of the persons that assist in carrying out the dialysis, other than at a dialysis centre. In the case of home dialysis we also reimburse: a. the costs related to the training by the dialysis centre of those who will carry out or assist with the dialysis; b. the costs of lending the dialysis equipment and accessories, the costs of regular checks and maintenance thereof (including replacement) as well as the chemicals and fluids necessary for carrying out the dialysis; c. the costs of adjustments in and to the home and for restoring it to its original state, insofar as we consider these costs reasonable and other legal provisions do not provide for reimbursement; d. other costs that are directly related to the home dialysis insofar as we regard these costs as reasonable and other legal provisions do not provide for reimbursement; 22

23 e. the costs of the necessary expert assistance for the dialysis required from the dialysis centre. In the case of home dialysis you must provide us with an estimate of the costs in advance. 13 In vitro fertilisation (IVF) and other fertility treatments a. IVF: We reimburse the costs of maximum three IVF attempts per prospective clinical pregnancy, including the medications used. An attempt involves, at a maximum, going through the following four phases: - maturation of egg cells through hormone treatment in the woman s body; - follicle puncture (to extract mature egg cells); - fertilisation of egg cells and cultivation of embryos in the laboratory; - the placement of one or two embryos in the uterus in order to achieve pregnancy. An attempt will only count as an attempt if successful follicle puncture has taken place. Only attempts that are discontinued before clinical pregnancy is achieved count towards the number of attempts. A new attempt after a clinical pregnancy counts as a first attempt. The placing of embryos that have been frozen falls under the IVF treatment in which they were created. s - We must have given written permission in advance. - The IVF treatment must take place in a licensed hospital. - IVF treatment is reimbursed for female insureds through the age of 40. After the age of 40 the IVF treatment is eligible for reimbursement as long as the suitability of the treatment has been evaluated and determined for the individual situation. - In the event of physiological (spontaneous) pregnancy, a clinical pregnancy is understood to be a pregnancy of at least twelve weeks counted from the first day after the last pregnancy. - For a pregnancy after IVF treatment, a clinical pregnancy is understood to be a pregnancy of at least ten weeks counted from the follicle punction or, if the IVF took place by means of placing embryos that had been frozen, a pregnancy of at least nine weeks and three days from implantation. - ICSI treatment (intracytoplasmic sperm injection) is equated with an IVF attempt. We do not reimburse more than the costs of a maximum of 3 treatments per prospective pregnancy to a maximum of EUR 7,000.- per prospective pregnancy of at least 12 weeks measured from the first day after the last menstruation. b. Other fertility treatments: We reimburse the costs of other fertility treatments. s - We must have provided advance written permission. 23

24 - We reimburse the costs of fertility treatment for female insureds aged 40 and younger. Fertility treatment for female insureds older than 40 is eligible for reimbursement subject to the effectiveness of the treatment being established in each individual situation. - We only reimburse the costs of the medicines used if you are prescribed the medicines for a different fertility treatment other than the fourth and next IVF treatment. c. We reimburse for male insureds for the duration of this insurance the costs of collecting, freezing and storing sperm as part of specialist medical treatment if this treatment could unintentionally cause infertility. s - The care is part of a specialist medical oncology care process which comprises: - major surgery on/to the genitals; - a chemotherapeutic treatment and/or radiation therapy during which the genitals are in the radiation field; 14 Oncology examination in children We reimburse the central (reference) diagnosis, coordination and registration by Skion (Child Oncology Association of the Netherlands) of physical material submitted. 15 Asthma Centre (the Netherlands) in Davos (Switzerland) We reimburse the costs of treatment in the Dutch Asthma Centre in Davos. s - Similar treatment took place elsewhere without success and we deem the treatment in Davos to be effective. - You must be referred by a lung specialist or paediatrician. - We must have given permission in advance. 16 Mechanical respiration We reimburse the costs of necessary mechanical respiration and the specialist medical care connected with this in a respiration centre. If the respiration takes place at the insured s house by and under the responsibility of a respiration centre, the care consists of: a. preparations by the respiration centre to make the necessary equipment ready for use before each treatment; b. the specialist medical and pharmaceutical care applied related to the mechanical respiration to be provided by or on behalf of the respiration centre. 17 Thrombosis service We reimburse the costs of intensive care for thrombosis patients by the thrombosis service. The care entails: a. regular sampling of your blood; b. performing the necessary laboratory tests or having these performed under the responsibility of the thrombosis service to determine the coagulation time of your; c. providing you with the equipment and accessories for you to measure the coagulation time of your blood; 24

25 d. training you in the use of the equipment indicated in paragraph c as well as guiding you in your measurements; e. advising you on the use of medicines to affect blood coagulation. You must be referred by a GP or medical specialist. 18 Hearing centre We reimburse the costs of care provided by a hearing centre. The care consists of: a. hearing tests; b. advising on hearing aids; c. information on the use of hearing aids; d. psychosocial care where necessary in connection with hearing problems; e. assistance in diagnosing speaking and language disorders in children. The insured must be referred by a GP, paediatrician, nose ear and throat doctor or youth health care doctor. 19 Genetic testing and advising We reimburse the costs of genetic testing and advising in a centre for genetic testing. The care consists of: a. testing for genetic defects by means of family tree research; b. chromosome testing; c. biochemical diagnosis; d. ultrasound and DNA examination; e. genetic advising and the psychosocial counselling related to this care. When necessary in order to advise you, the examination will also include testing of persons other than you; they may also be given advice. You must be referred by the treating physician. 20 GP care We reimburse the costs of medical care provided by a GP or equivalent doctor/care provider who works under the responsibility of a GP. The reimbursement also includes x-ray and laboratory testing at the GP s request. The scope of this care is limited by the care GPs undertake to provide. 21 Pharmaceutical care We reimburse the costs of: a. The medicines registered in the country of residence. With regard to medicines supplied in the Netherlands the reimbursement is given in accordance with the GVS medicine reimbursement system. The personal contribution in accordance with this scheme will also be covered by this insurance. The medicines must have been prescribed by a GP, 25