Salary group daily benefits insurance (based on KVG/LAMal)

Transcription

1 Salary group daily benefits insurance (based on KVG/LAMal) Group daily benefits insurance pursuant to the Swiss Federal Act on Insurance Contracts (VVG/LCA) General terms of insurance April 2013 edition Insurance carrier: Sanitas Privatversicherungen AG

2 Contents Basis 3 1 Insurance carrier 3 2 Object of the insurance 3 3 Basis of contract 3 4 Definitions Persons covered 3 5 Establishments included in insurance 3 6 Insured persons 3 7 Insured pay 4 8 Geographic coverage 4 Duration of coverage 4 9 Commencement 4 10 Duration 5 11 End 5 12 Claims not yet closed on expiry of coverage 5 13 Transfers to individual insurance plans 5 Benefits 6 14 Qualifications for benefits Notification and obligations in the event of a claim 6 16 Violation of obligations 7 17 Commencement of benefits 7 18 Waiting period 7 19 Benefit period 7 20 Interruptions in benefits Scope of benefits 8 22 Restrictions to insurance coverage 8 23 Third-party benefits 8 24 Maternity 8 25 Parental allowance 9 26 Calculation of daily benefits 9 27 Profit accruing from insurance 9 28 Assignment and pledging of benefits 9 Premiums 9 29 Basis for calculating premiums 9 30 Payment of premiums and due dates 9 31 Billing of premiums 9 32 Refunding of premiums Late payment Surplus share Offsetting premiums against benefits; duty to refund wrongfully drawn benefits Changes to premiums 10 Final provisions Notifications and duty to inform Place of jurisdiction 11 2

3 Basis 1 Insurance carrier The insurance carrier for the group daily benefits insurance pursuant to these General Terms of Insurance is Sanitas Privatversicherungen AG (hereinafter Sanitas ). Sanitas Privatversicherungen AG has authorised Sanitas Grundversicherungen AG to take any action in its name and for its account. person s ability to perform such duties as may reasonably be expected in another profession, trade or area of responsibility will also be taken into account. 4.5 Disability is defined as full or partial incapacity for work that is likely to be permanent or protracted. 4.6 Doctors are defined as doctors or chiropractors with a Swiss federal diploma or equivalent cantonal or non- Swiss vocational diploma who are licensed to exercise the profession. 2 Object of the insurance The group daily benefits insurance (hereinafter the insurance ) provides insurance cover for the economic consequences of incapacity from work resulting from illness and, if contractually agreed, accidents. A parental allowance can also be insured in addition. This translation is provided for the sake of convenience. The wording of the German original shall take precedence. 4.7 Family members are defined as spouses, children, parents, the registered partner pursuant to the Swiss law on registered partnerships, or the life partner living with the policyholder in the same household. 4.8 The policyholder is defined as the natural person or legal entity that has taken out the insurance contract. Persons covered 3 Basis of contract 3.1 The contract consists of the following components: a) the present General Terms of Insurance b) any supplementary terms or special terms c) any written representations made in the application, the report of the examining physician or other documents e) the policy document f) any supplements. 3.2 Supplementary to these terms is the Swiss Federal Act on Insurance Contracts (LCA/VVG). 4 Definitions 4.1 Illness is defined as any impairment to the physical, mental or psychological health that is not the consequence of an accident and which requires a medical examination or treatment. 4.2 An accident is defined as the sudden, unintentional, harmful influence of an exceptional external force on the human body, resulting in the impairment of physical, mental, or psychological health. The occupational ill nesses and accident-like events specified in the Ordinance on Accident Insurance (UVV/OLAA) are deemed to be equivalent to an accident. 4.3 Maternity includes pregnancy and childbirth and the mother s postnatal recovery period. 5 Establishments included in insurance The establishments included in the insurance are deemed to be the principal and auxiliary establishments, branches and subsidiaries specified in the policy document. 6 Insured persons 6.1 The insurance covers persons and groups of persons who work for the insured establishments as employees under the terms of the Swiss Federal Act on Old-Age and Survivor s Pensions (AHVG/LAVS) and who have not yet reached age 70 (subject to the terms of 6.4c below). 6.2 Employers, self-employed people and members of their families working for the insured establishments who are not on the payroll are only insured if they are specified by name in the policy document. 6.3 The following are only insured if a special contractual agreement exists: a) temporary staff with a contract of employment of up to 3 months b) part-time staff who work fewer than eight hours a week c) home workers d) employees who are employed in Switzerland but who on the basis of the agreement on the free movement of persons with the EU or the EFTA Convention are not subject to Swiss social security requirements. 4.4 Incapacity for work is defined as the complete or partial inability to perform such duties as may reasonably be expected in one s previous profession, trade or area of responsibility as a result of physical, mental or psychological health conditions. In protracted cases, the insured 6.4 The following are not insured: a) personnel subcontracted to the policyholder or insured establishment by a third party b) persons working for the insured establishment on contract 3

4 c) persons who have reached AHV/AVS retirement age at the moment they commenced work or on commencement of the insurance d) hourly staff who do not have fixed, regular working hours of at least 8 hours a week with the establishment e) persons whose hourly wages include a loss of earnings component. Duration of coverage 9 Commencement 9.1 The insurance commences on the date specified in the policy document or on a date specified by Sanitas in a written acceptance of the application. 7 Insured pay 7.1 The following applies to the indemnity insurance: The insured pay for employees is the percentage of the actual salary for AHV/AVS purposes stipulated in the policy document, subject to other contractual agreements. Daily benefits are calculated on the basis of the last salary for AHV/AVS purposes drawn from the insured establishment before the commencement of illness. In the event of irregular earnings, benefits will be calculated on the basis of a reasonable average pay per day since the person was hired, but not going back further than the last 12 months. Pay increases during a period when daily benefits were being drawn are not counted, unless the increase was absolutely necessary on the basis of a collective labour agreement. The maximum insured annual pay is specified in the policy document. 7.2 The following applies to the fixed-sum insurance: The maximum insured pay for employers and self-employed people and members of their families working for the insured establishment who are not on the payroll is the fixed annual pay specified in the policy document. 8 Geographic coverage 8.1 Coverage is worldwide for insured persons resident in Switzerland or the Principality of Liechtenstein and crossborder commuters with the relevant permit. 8.2 The insurance covers insured persons on secondment for a maximum of 24 consecutive months abroad. Insured persons on secondment are defined as those who continue to work for the employer based in Switzerland, who are entitled to pay from this employer, and who are subject to the requirements of the AHVG/LAVS. 8.3 Benefits will only be paid for sojourns outside EU/EFTA states if acute inpatient hospitalisation is necessary, and only for as long as a return to the place of residence is not possible. This restriction does not apply to the persons specified in 8.2 above. 9.2 In principle, neither applications nor health examinations are required for persons who are not named but who belong to a group of persons specified in the contract; the insurance automatically covers such persons. 9.3 Insurance must be applied for on an individual basis for employers and self-employed people and members of their families working for the insured establishment if these persons are not on the payroll. The insurance commences only once Sanitas has accepted the application in writing. 9.4 If in taking out the insurance the policyholder or insured person has withheld or misrepresented a material fact about which they knew or should have known, in particular illnesses or conditions resulting from an accident which existed at the time the insurance was applied for or from which they have recovered, Sanitas is entitled to terminate in writing the part of the contract affected within 4 weeks of becoming aware of the breach of the disclosure obligation. This termination shall be effective from the moment it is delivered to the policyholder. 9.5 Insurance for newly joining employees commences on the date they commence work. Persons who on commencement of their employment contract and/or commencement of insurance are unfit for work or only partially fit for work as the result of an illness, accident, defect or handicap are insured only once they are again fully fit for work within the scope of their employment contract. 9.6 Partially disabled or handicapped employees who as a result of their health impairment work only part time for the insured establishment must be fully fit to work the agreed part-time job on the date they commence work and/or their insurance commences. The insurance does not cover a temporary or partial deterioration in the condition that led to their partial disability. 9.7 If insured persons are entitled to more favourable conditions on the basis of agreements on the transfer of cover, these conditions shall apply. 4

5 10 Duration 10.1 The contract is concluded for the term specified in the policy document. On expiry, the contract shall be tacitly extended by another year if neither of the contracting parties has terminated it. To be valid, termination must be received by the other contracting party at least three months before the contract expires After any illness for which an indemnity is due, the policyholder may terminate the contract within 14 days of becoming aware of the payment. The contract expires at the moment Sanitas receives this notification. Insurance coverage ends at the moment Sanitas receives notice of termination The policyholder many terminate the insurance any time there is a change in the premium tariff. The period of notice specified in 36.1 below applies Sanitas may waive its right of termination in the event of a claim. 11 End 11.1 Insurance coverage for all insured persons ends when the contract expires The contract expires a) if it is terminated in accordance with the stipulated period of notice b) if the policyholder petitions bankruptcy c) if the place of business is moved abroad d) if the establishment ceases doing business. 12 Claims not yet closed on expiry of coverage Insured persons who are unfit for work or unfit to earn a living at the moment the insurance expires continue to be entitled to benefits under the ongoing claim within the terms of the contract (continued payment of benefits). If the insured person transfers to individual insurance, the terms specified in 13 below apply. There is no entitlement to continued payment of benefits in the event of transfer of cover as per 13.8b below, nor is there entitlement to continued payment of parental allowance if the insured person leaves the insured establishment earlier than 8 weeks before giving birth. 13 Transfers to individual insurance plans Insured persons resident in Switzerland are entitled to transfer to Sanitas individual insurance if a) they leave the group of insured persons b) the contract expires c) they are deemed to be unemployed under the terms of Art. 10 of the Swiss Federal Law on Obligatory Unemployment Insurance and Compensation in Cases of Insolvency (AVIG/LACI) The insured person must exercise their right to transfer within three months. This period begins at the moment they leave the insurance, but not later than the moment they receive written notification as per 13.4 below drawing their attention to their right to transfer. If the insured person continues to be paid benefits as per 12 above, the period begins once the obligation to pay benefits ceases. In this case, they will receive written notification from Sanitas Insurance cover for individual insured persons ends a) with the expiry or termination of the contract b 31 days after the insured person leaves the insured group of persons and/or the employ of the policyholder, provided that no other insurance cover exists on the basis of agreements on the transfer of cover. This subsequent cover expires once the insured person moves their residence abroad c) once the insured person reaches AHV/AVS retirement age, or once insured persons with continued cover under the terms of 6.1 above reach age 70 d) once another insurer undertakes to continue cover on the basis of agreements on the transfer of cover e) if a stay abroad continues for more than 24 consecutive months f) once the agreed maximum benefit period has been reached g) on the death of the insured person If the insured person is deemed to be unemployed under the terms of the AVIG/LACI, they must exercise their right to transfer within three months of receiving written notification as per 13.4 below The policyholder must notify the leaving insured person in writing of their right to transfer and the deadline for transferring to individual insurance on leaving the insured establishment. If the policyholder fails to meet this duty to notify, the insured person remains in the group insurance. In this case the policyholder shall be liable for any resulting damages Persons transferring to Sanitas individual insurance are entitled to insurance cover equivalent to their previous cover. However, the amount of their daily benefits will be limited to their current pay or unemployment (ALV/ AC) benefits, up to a maximum of the previously insured bene fits or the maximum insurable daily benefit under the individual insurance plan. The new contract shall be subject to the terms and tariffs of the individual insurance plan. Unemployed persons under the terms of Art. 10 of the AVIG/LACI shall also be subject to the provisions of Art. 100 Para 2 of the Swiss Federal Act on Insurance Contracts (VVG/LCA). 5

6 13.6 Any claim pending when the insured person transfers to the individual insurance plan will be settled via the previous group insurance until the claim is closed If, after transferring to the individual insurance plan, the insured person suffers a relapse as per 19.2 below, and if this relapse is connected with illnesses or accidents that occurred during the term of insurance under the present contract, the resulting claims will be settled via the previous group insurance Insured persons are not entitled to transfer to the individual insurance plan a) if they change jobs and transfer to another employer s daily benefits insurance plan b) if the present contract expires and is continued for the same group of persons with another insurer, provided the new insurer must guarantee to continue the insurance cover (transfer of cover) c) if they have reached AHV/AVS retirement age or take early retirement d) if they live abroad (subject to the terms of the agreements on the free movement of persons) e) if they have a temporary, fixed-term contract of employment; unemployed persons under the terms of Art. 10 of the AVIG/LACI are subject to the provisions of Art. 100 Para 2 of the Swiss Federal Act on Insurance Contracts (VVG/LCA) f) if the benefits under the contract have been completely exhausted Absences from work resulting from spa treatments are covered only if the spa treatment is necessary on medical grounds and Sanitas approves the treatment on the basis of an application received 14 days before the treatment commences No benefits will be paid if the insured person goes abroad for treatment, care or childbirth. 15 Notification and obligations in the event of a claim 15.1 The policyholder must report incapacity for work no later than 10 days after incapacity for work commences. This notification must be accompanied by an incapacity certificate from the doctor providing treatment. If notification is late with no excuse, there is no entitlement to insured benefits until notification has been received Sanitas must be notified immediately of any change in the degree of incapacity for work during an illness or accident-related condition. In the event of protracted incapacity, the insured person must submit confirmation of their incapacity every four weeks. Sanitas must be sent confirmation of the degree and duration of incapacity immediately once a period of incapacity has ended Insured persons must do everything in their power to aid their recovery and refrain from anything that might hinder their recovery. In particular, they must follow the instructions of medical personnel. Benefits 14 Qualifications for benefits 14.1 Once any applicable waiting period has expired, daily benefits will be paid for the duration of the incapacity for work certified by the doctor In the event of partial incapacity to work, the amount of daily benefits is determined in accordance with the degree of incapacity; there is no entitlement if the degree of incapacity is below 50% If the insured person is deemed to be unemployed under the terms of the AVIG/LACI, Sanitas will pay daily benefits subject to the following terms: a) half daily benefits for a degree of incapacity of 50% b) full daily benefits for degrees of incapacity of more than 50% If an insured person is likely to remain permanently or partially unfit to work in their customary trade or profession, they are obliged to exercise any remaining capacity to earn a living, even if this means changing trade or profession. Sanitas will require that the insured person change trade or profession and will make them aware of the consequences as per 16 below The insured person is obliged to cooperate in the execution of this insurance. In particular they must supply Sanitas with any information it requires to clarify their entitlement to benefits and the amount of benefits The insured person must go for regular medical treatments or check-ups. The insured person is also obliged to undergo, at Sanitas s expense, any medical examinations deemed by Sanitas to be necessary. Sanitas is entitled to have the insured person additionally examined by a doctor appointed by Sanitas, and to visit the insured person to check their compliance with the instructions of medical personnel For the purposes of these terms, partially disabled or handicapped insured persons are deemed to be fully fit for work if they are fully fit for work in terms of their agreed working hours. Their incapacity for work is calculated on the basis of their degree of incapacity to continue doing their previous work If the insured person fails to attend a medical examination arranged by Sanitas without excuse, Sanitas reserves the right to bill the insured person for the fee for the missed consultation The insured person must release the doctors providing them with treatment from their obligation to maintain 6

7 professional confidentiality vis-à-vis Sanitas. Sanitas will treat all medical information in confidence Sanitas will only pay benefits once the case is reported to any other insurance companies affected. Entitlement to benefits will be suspended if the insured person fails to comply with the requirement to notify other insurers. Entitlement will resume once they have reported the case accordingly. The duration of the suspension will be counted towards the total benefit period. On the other hand the insured person will lose their entitlement to benefits if they fail to claim from or withdraw claims made to these other insurers Wage replacement benefits for insured persons subject to tax at source (pay as you earn) will be paid to the policyholder in full. In this case the policyholder must deduct the appropriate tax at source in accordance with the relevant tax legislation and fulfil all the statutory duties incumbent on the party owing the taxable consideration, namely by ensuring timely settlement with the tax authorities responsible. The policyholder is liable for all damages to Sanitas resulting from any failure to meet this obligation, in particular for the timely delivery of tax at source. If the insured person is the recipient of the wage replacement benefits, delivery of the tax at source is incumbent on Sanitas. 16 Violation of obligations Insured benefits may be temporarily or permanently reduced, or in serious cases refused, if the insured person violates the obligations and duties stipulated in these General Terms of Insurance. No legal detriment will be incurred if the violation of the obligations or duties is deemed excusable in the circumstances. 17 Commencement of benefits Liability to pay benefits commences once the waiting period stipulated in the policy document has elapsed. The waiting period commences on the first day of medically determined incapacity for work, but no sooner than three days before medical treatment commences. 18 Waiting period The agreed waiting period is stipulated in the policy document and is applied for each claim, and counted towards the benefit period. Days of partial incapacity for work count as whole days Relapses are defined as illnesses and accident-related conditions that are medically connected with earlier illnesses or accidents. If a relapse occurs within 180 days, the waiting period that has already been applied is waived, and benefits already paid are counted when the maximum benefit period is calculated. The renewed occurrence of an illness or a condition resulting from an accident is deemed to constitute a new claim for the purposes of the benefit and waiting periods if, before the relapse, the insured person has not been unfit for work for at least 180 days as a result of this illness or accident-related condition Daily benefits for insured persons with a fixed-term employment contract will not be paid for longer than the term of the fixed-term employment contract Once the maximum benefit period for a claim has been exhausted, the insured person is disqualified for this claim. Any residual functional capacity is still insured The insured person cannot postpone exhaustion of the benefit period by waiving benefits before incapacity has ended An insured person is entitled to benefits for a further 180 days maximum after they reach AHV/AVS retirement age, but only until they reach age 70. If an insured person is unfit for work at the moment they reach AHV/AVS retirement age, their entitlement to benefits lapses unless it can be demonstrated that their employment would have continued had they been fit for work. 20 Interruptions in benefits 20.1 If the insured person receives unpaid leave from the employer, they continue to be covered by the insurance as long as their employment contract continues, but no long er than 210 days after cessation of entitlement to pay. There is no entitlement to benefits and no premiums are owed for the intended duration of the leave. If the insured person falls ill or has an accident during their unpaid leave, Sanitas will count the days from the commencement of incapacity until the date on which they were originally intended to resume work towards the waiting period and benefit period If work is interrupted without entitlement to pay while an insured person is drawing daily benefits (e.g. prison, investigative custody, etc.), no daily benefits are due for this period. Days for which no benefits are paid are counted towards the benefit period. 19 Benefit period 19.1 Sanitas pays daily benefits for each claim for the benefit period stipulated in the policy document minus the agreed waiting period. Days of partial incapacity for work count as whole days for the purposes of calculating the benefit period. Days where there is no cover because of late payment count fully towards the benefit period If an insured person who is ill and entitled to benefits goes abroad without the prior consent of Sanitas, they are not entitled to benefits while they are abroad. The days spent abroad are counted towards the benefit period. 7

8 21 Scope of benefits 21.1 Benefits paid under the indemnity insurance component are calculated on the basis of the salary for AHV/AVS purposes as per the AHVG/LAVS. The precise amount of benefits is based on the policy document and the General Terms of Insurance In the case of the fixed-sum insurance component, Sanitas grants insured benefits in the event of an eligible claim regardless of proof of a corresponding loss of earnings. The amount of benefits paid is calculated on the basis of the insured amount stipulated in the policy document and the present General Terms of Insurance. The agreed fixed annual salary should correspond as closely as possible to the presumed annual AHV/AVS salary. Sanitas may verify the amount of the payroll and modify the policy in the future Sanitas waives its right to reduce insurance benefits in the event of gross negligence, unless the claim is the result of the abuse of alcohol, medication or drugs. 23 Third-party benefits 23.1 If the insured person is paid benefits by a Swiss social security scheme, a corresponding foreign scheme or another private insurer, once the waiting period has elapsed Sanitas will top up these benefits to the amount of the insured daily benefit specified in the contract The insured person is obliged to notify Sanitas of all social security schemes and private insurers paying benefits in this connection, of liable third parties, and of the benefits paid by them. Sanitas may refuse to pay benefits in the event of a deliberate or negligent failure to do so. 22 Restrictions to insurance coverage 22.1 No insured benefits will be paid in the event of illness, accidents and resulting conditions occurring a) in the course of acts of war in Switzerland in another country, unless the illness or accident occurs within a period of 14 days from the first outbreak of warlike activities in the country in which the insured person is staying and they were taken by surprise by the outbreak of warlike activities while staying there b) in the course of exposure to ionising radiation, except in the event of damage to health resulting from radiation treatment medically prescribed because of an insured illness or accident c) in the course of military service abroad d) in the course of earthquakes e) in the course of scuffles or fights, unless the insured person was an innocent bystander or providing assistance f) as a consequences of riots, terrorist acts and crimes of any type and measures implemented to counteract them, unless the insured person can prove that they did not actively participate on the side of the perpetrators or actively incite them to further violence g) in the course of cosmetic treatment or surgery or treatment or surgery not medically indicated, and the consequences thereof h) in the course of risky activity; risky activity is defined as activity by which a person exposes themself to especial danger without taking or being able to take measures to reduce the risk to a reasonable level. However, attempts to rescue people are covered even though they can be viewed as risky activities in themselves Days where reduced benefits are paid because of entitlement to third-party benefits count in full for the purposes of calculating the waiting period, but only proportionally for the purposes of calculating the benefit period If Sanitas pays benefits instead of a liable third party, the insured person must assign their claims to Sanitas to the amount of the benefits Sanitas has paid The provisions of 23 do not apply if daily benefits are calculated on the basis of fixed amounts of pay as per 21.2 above (fixed-sum insurance). This does not apply to insured persons whose AHV/AVS salary has been limited to a maximum Sanitas can claim benefits paid directly from the liable third party or, in the case of federal disability (IV/AS) insurance, reduce benefits by the amount of any additional upcoming IV/AS benefits Sanitas is no longer liable to pay benefits if the policyholder or insured persons, without the consent of Sanitas, make agreements with third parties liable to pay benefits involving the full or partial waiver of insurance or damage claims. 24 Maternity The liability to pay benefits is suspended for eight weeks following the birth. If the insured person, of their own accord, stays off work until the 16th week after the birth, the liability to pay benefits is suspended until this point. This is subject to the cover for parental allowance as per 25 below If the illness is only a partial cause of incapacity, Sanitas will pay only a corresponding portion of the benefit. 8

9 25 Parental allowance 25.1 If the insurance includes a parental allowance supplementary to the Swiss Federal Law on Income Compensation for Persons Serving in the Army, Civilian Service and Civil Defence and for Expectant Mothers (Income Compensation Law, EOG/LAPD), the benefits paid by Sanitas are stipulated in the policy document. Liability to pay benefits commences with the payment of maternity benefits in accordance with the Income Compensation Law. Sanitas will not pay benefits if the insured person has been insured for fewer than 270 consecutive days at the moment of birth The benefit period cannot be interrupted, and the insured person cannot be eligible for daily benefits simultaneously. Otherwise the eligibility requirements as per the EOG/ LAPD apply. 26 Calculation of daily benefits 26.1 Daily benefits are calculated by annualising the last salary for AHV/AVS purposes paid before the claim occurred and dividing the insured annual salary by 365. If fixed annual pay has been agreed for persons named in the contract, daily pay is calculated as 1/365 of this salary (fixed-sum insurance). Premiums 29 Basis for calculating premiums Unless other arrangements are stipulated in the contract, premiums are calculated on the basis of the salary subject to AHV/AVS contributions as per the AHVG/LAVS. The AHV/AVS norms are also used for insured persons who are not subject to the AHV/AVS. For persons named in the contract, the agreed fixed annual salary applies. 30 Payment of premiums and due dates 30.1 Premiums for an entire period of insurance are due to Sanitas in advance Payment in instalments can be agreed subject to a pre mium surcharge. Instalments must also be paid in advance During incapacity for work, the liability to pay premiums is reduced by the amount of benefits paid under the group insurance. However, this does not apply to employers, self-employed people and members of their families working for the insured establishment For insured persons on an hourly or daily wage, the daily benefit is one seventh of the average weekly wage. The weekly wage is the gross wage earned in one calendar week If the insured person does not work on a regular basis or their pay is subject to major fluctuation, daily benefits are calculated on the basis of their demonstrated average income for the last twelve months. 27 Profit accruing from insurance Insured persons are entitled to daily benefits only to the extent that they do not earn a profit from the insurance (indemnity insurance). 28 Assignment and pledging of benefits Benefits may not be assigned or pledged to third parties without the consent of Sanitas. 31 Billing of premiums 31.1 At the beginning of the insurance year a provisional premium is billed on the basis of the contractually agreed provisional annual payroll. The definitive premium will be calculated on the basis of information to be provided by the policyholder at the end of the insurance year or following termination of the contract. For this purpose Sanitas provides the policymaker with a payroll declaration form, which must be completed fully and accurately and returned within the stipulated period Sanitas or third parties commissioned by Sanitas are entitled to inspect the policyholder s payroll or request copies of the relevant AHV/AVS statements Once the definitive premium is calculated it is used as the premium to be paid in advance for future billing periods If the policyholder fails to declare the required information, premiums will be fixed on the basis of estimates. The policyholder is entitled to object to the estimated premium, enclosing the documents required to correct the estimate, within thirty days of receiving it. If Sanitas does not receive an objection before the deadline has elapsed, the estimated premium is deemed to have been accepted. If it subsequently emerges that too little pre mium has been paid as a result of this, Sanitas may charge interest on arrears in addition to the difference. 9

10 32 Refunding of premiums 32.1 If for legal or contractual reasons the contract is terminated before the agreed term has elapsed, Sanitas will refund any premiums paid for the term of insurance that has not elapsed or will refrain from demanding payment of subsequent instalments. This is subject to any administration costs accruing to Sanitas This arrangement does not apply if the policyholder termin ates the contract in the event of a claim before the first year of insurance has elapsed Premiums and benefits for any parental allowance included in the insurance as per 25 above will not be included in the calculation of the surplus share The surplus share will be recalculated if, after the calculation has been made, cases of illness are reported or further payments are made that belong to the completed calculation period. Sanitas may require repayment of surplus shares that have already been paid out The entitlement to a surplus share elapses if the contract is terminated before the calculation period has elapsed. 33 Late payment 33.1 If the premium has not been paid by the due date, the policyholder will be sent a written reminder, including reference to the consequences of default, to pay the outstanding premium within 14 days of dispatch of the reminder. If there is no reaction to the reminder, liability to pay benefits will be suspended from the moment the reminder period expires Sanitas will not pay benefits for any new claims arising during the suspension of cover. The date of the first occurrence of incapacity for work applies for this purpose. Cover for claims that are already ongoing remains in place Cover resumes one day after all premiums relating to this contract, including interest and costs, are paid in full In the event of default, Sanitas is entitled to charge reminder fees, collection fees, debt enforcement costs, interest on arrears from the due date of the premium, and a charge for inconvenience caused If Sanitas has not collected the outstanding premium, including interest and costs, within two months of the expiry of the reminder period as per 33.1 above, the contract is deemed to have expired. 34 Surplus share 34.1 If the insurance is taken out with a surplus share, after every three full years of insurance the policyholder receives a contractually agreed share of the net surplus accruing from the contract; the cut-off date for the payment will be December 31, with each calculation period running from January 1 to December The calculation will be done 5 months after the end of the calculation period at the earliest. 35 Offsetting premiums against benefits; duty to refund wrongfully drawn benefits 35.1 The policyholder and insured persons are not entitled to offset premiums due against benefits due Benefits drawn wrongfully by the policyholder or insured persons must be refunded to Sanitas. 36 Changes to premiums 36.1 Sanitas may adjust premiums with effect the end of an insurance year on the basis of changes in the structure of insureds (age and sex) and the claims record. Besides the individual claims record for the present contract, the claims record for all contracts concluded on the basis of the present General Terms of Insurance (the insurance portfolio) will be taken into account accordingly. The policyholder will be notified of the new premium no later than 25 days before the end of the insurance year. Thereupon the policyholder is entitled to terminate the contract with effect the end of the current insurance year. To be valid, Sanitas must receive the notice of termination no later than the last day of the insurance year. Failure to terminate the contract shall be deemed as the policyholder s consent to the amendment to the contract Premium rates for employers, self-employed persons and members of their families not on the payroll or insured as employees may be adjusted to the tariff for the corresponding age group The net surplus consists of the total definitive premiums for the calculation period minus any insurance benefits paid during this period and a contractually agreed share of the premiums for reserves, provisions and administrative expenses. Any loss will not be carried forward to the next calculation period. 10

11 Final provisions 37 Notifications and duty to inform 37.1 Notifications to the policyholder All notifications from Sanitas to the policyholder shall be sent to the policyholder s last known address in Switzerland Notifications to insured persons Unless alternative arrangements are explicitly mentioned in the present General Terms of Insurance, all notifications to insured persons shall be made via the policyholder. The policyholder is obliged to inform all insured persons of the material content of the contract Notifications to Sanitas All notifications to Sanitas must be sent directly to the address specified in the policy document in either German, French, Italian or English. Documents in any other language must be accompanied by a notarised translation Sanitas must be notified immediately in writing if the policyholder changes their business domicile, their contact or the type of business in which they are engaged, or if their ownership arrangements change. 38 Place of jurisdiction A policyholder or insured person initiating legal proceedings against Sanitas on the basis of this insurance contract can choose between the courts at their Swiss place of residence, the claimant s Swiss place of residence, or the head office of Sanitas Privatversicherungen AG. 11

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