PFA Health Insurance (PFA Helbredssikring ) - group insurance Insurance conditions 1 January 2012

Transcription

1 TRANSLATION: In case of any discrepancy between the Danish text and the English translation, the Danish text shall prevail. PFA Health Insurance (PFA Helbredssikring ) - group insurance Insurance conditions 1 January 2012 Contents: Chapter I Preliminary conditions Chapter II General conditions of cover Chapter III Basic cover Chapter IV Optional cover A - extended cover Chapter V Optional cover B - preventive health examination Chapter VI Optional cover C - children's cover Chapter VII Disbursements Chapter VIII Risk not covered Chapter IX Calculation and payment of premium Chapter X Lapse of cover and continuation Chapter XI Notice of termination and change Chapter XII Notification of the insurance event and claim for disbursement Chapter XIII Other conditions Chapter I Preliminary conditions Terms of agreement 1. These insurance conditions shall apply from 1 January (2) The insurance cover is established as a group insurance. The group insurance is based on an agreement between an association, organisation or company and PFA Pension. (3) The association, organisation or company that has entered into an agreement on a group insurance with PFA Pension shall be referred to as the policyholder. (4) The group insurance shall cover the group members stated in the agreement between the policyholder and PFA Pension. PFA Pension can make agreements with the policyholder on behalf of the group members on all matters relating to the agreement. (5) Group members who enter into the group insurance shall be referred to as the insured. (6) The insurance period shall be the period from the date when the individual insured is covered by the insurance cover and until the lapse of the insurance cover - see the conditions in Clause 21. Spouse s/cohabiting partner s cover 2. The individual insured's spouse/registered partner or cohabiting partner can be covered by the group insurance unless otherwise laid down in the agreement between the policyholder and PFA Pension. (2) A spouse/cohabiting partner shall be the insured person who is covered by the group insurance by virtue of his or her marriage/registered partnership or cohabitation with an insured person who is a member of, organised in or employed with the policyholder. (3) A spouse/cohabiting partner who chooses to be covered by the group insurance shall be covered on equal terms with the other insured who are covered by the group insurance on the as-

2 sumptions and specifications that are laid down in Sub-clauses 4 and 5 and in the conditions of Clauses 12, 18 and 21. The insurance cover for a spouse/cohabiting partner cannot include optional cover C - see Clause 13. also includes any disbursements from PFA Health Insurance to the spouse/cohabiting partner who was comprised by previous pension plans or insurance cover which the insured had in PFA Pension. (4) The insurance cover for a spouse/cohabiting partner presupposes that the spouse/registered partner or cohabiting partner, who is a member of, organised in or employed with the policyholder, is covered by PFA Health Insurance by virtue of the membership or conditions of organisation or employment in question. Please see Clause 21, Sub-clause 1, schedule d, about lapse of cover once the precondition is no longer met. Effective date of the group insurance 3. The group insurance shall take effect from the date stated in the agreement between the policyholder and PFA Pension. Effective date of the insurance cover 4. The insurance cover of the individual insured shall take effect from the date stated in the agreement between the policyholder and PFA Pension. (5) It is a precondition of a cohabiting partner becoming covered by the group insurance that the cohabiting couple shares the same registered address at the time of the cohabiting partner s registration for the group insurance. Furthermore, impediments to marriage must not exist according to the legislation. Each insured group member can only make one cohabiting eligible for cover under the group insurance. (6) If the insurance includes a spouse s/cohabiting partner s cover, it shall be the responsibility of the individual insured and his or her spouse/registered partner or cohabiting partner to inform PFA Pension in the event of divorce, separation or if the cohabitation is discontinued. (7) The spouse/cohabiting partner must pay regular premiums for the insurance directly to PFA Pension. (8) The total disbursements for the spouse/cohabiting partner during the entire insurance period is stated in the policy or the insurance certificate and may be adjusted and may be subject to adjustments. This maximum Misrepresentation or incomplete information 5. Where the policyholder is guilty of misrepresentation or has submitted incomplete information in connection with the establishment of the group insurance, the rules contained in Sections 4 to 10 of the Insurance Contracts Act shall apply. According to these rules, cover under the insurance policy may lapse fully or in part. (2) Where other persons than the policyholder is guilty of misrepresentation or submits insufficient information, this shall have the same effect as if misrepresentation was made by the policyholder. Chapter II General conditions of cover 6. The insurance cover consists of a basic cover that comprises all insured employees. In addition, the group insurance can consist of up to three optional cover types: A. Extended cover, B. Preventive health examination and/or C. Health Insurance for children - see chapters IV - VI. It is stated in the agreement between the policyholder and PFA Pension which optional cover shall be applicable to the individual group. It shall be stated in the policy or the insurance 2 / 12

3 certificate which optional cover shall apply to the individual insured. (2) Illness shall be understood as a state or condition which requires a medically-backed treatment, without considering if the need came into existence during working hours or off-duty hours. (3) Treatment shall be understood as treatment which according to an ordinary medical evaluation is fair and necessary to initiate as a result of a diagnosed illness which according to an ordinary medical evaluation is to be expected to cure the illness or improve the condition considerably or permanently. Treatment etc. shall be understood as all the conditions that this group insurance covers. (4) An insurance event shall be understood as a need for treatment etc. which relates to an illness. If a treatment paid by this insurance has not resulted in the expected improvement of the insured s condition, the same illness cannot be regarded as a new insurance event. Where the treatment has resulted in the expected improvement of the insured's condition but where the illness recurs, this may be regarded as a new insurance event. However, a minimum of six months without symptoms and treatment must have elapsed since the treatment was finalised before the same illness can be considered as a new insurance event - however, in case of surgery, a minimum of six months without symptoms and treatment must have elapsed since the final control. (5) The insurance event shall be present (meaning the need for treatment etc. is present) and treatment etc. shall take place during the insurance period see Clause 1, Sub-clause 6. If the insurance event has been notified to PFA Pension during the insurance period, and if the necessary doctor s referrals etc. are available as described below during the insurance period, treatment etc. may continue for three months after the insurance cover has ceased, unless other limitations are stated in the individual conditions. (6) Treatment etc. shall be conditional upon a referral or approval from the insured s general practitioner. The doctor's referral or approval must be available before treatment etc. can be initiated. As far as treatment of abuse of alcohol, medicine and other intoxicants is concerned, cover is conditional on a written medical certificate stating that the insured is in need of treatment. If the group insurance covers treatment by a chiropractor, see Clause 11, Sub-clause 1, schedule a, the doctor's referral can be replaced by a written declaration from a chiropractor that the insured is in need of treatment. These requirements do not apply if otherwise is stated in the individual condition. (7) PFA Pension must approve the treatment etc. before it is initiated. PFA Pension can refer the insured to both private and public health services if the waiting period and the duration of the treatment etc. are estimated to be at the same level in the public health services as at the private medical practitioners, therapists and treatment facilities. (8) Treatment etc. shall take place in Denmark, unless otherwise is agreed with PFA Pension - see Sub-clause 9. (9) However, the insured can choose treatment etc. outside Denmark in consultation with PFA Pension. The total expenses for treatment etc. outside Denmark may not exceed the total expenses for similar treatment etc. at a private hospital/clinic etc. in Denmark by more than 30 per cent, based on an estimate. The estimation shall be made by PFA Pension. 3 / 12

4 (10) The group insurance shall only cover expenses approved by the National Health Service in relation to the public health service. (11) The group insurance shall not cover all medical treatment unless it takes place during hospitalisation. (12) All expenses related to treatment etc. must be deemed reasonable and necessary by PFA Pension in relation to the expected result of the treatment. (13) The total disbursements for the insured and children during the entire insurance period is stated in the policy or the insurance certificate. The disbursements may be adjusted. This maximum also includes any disbursements from PFA Health Insurance to the insured and any children which formed part of previous pension plans or insurance cover which the insured had in PFA Pension. Danish national registered address 7. The insured must have a registered address in Denmark, as provided by the Danish Act on the Civil Registration System. The requirement of a registered address in Denmark shall not apply to international commuters who have a permanent address either in Sweden or Germany as stipulated in the Tax at Source Act. (2) Cover shall lapse if the insured does no longer comply with these requirements. An insured, who is stationed abroad by the employer, can choose to remain covered by the insurance for the period of expatriate service. Geographic conditions 8. In these insurance conditions, Denmark shall not include Greenland and the Faeroe Islands. Authorisation of medical practitioners and therapists 9. The general practitioners (including psychiatrists), psychologists, physiotherapists, chiropractors and other therapists who carry out treatments covered by this group insurance must be in possession of an authorisation according to Danish legislation, unless that conditions is specifically dispensed with in these terms and conditions of pension see the Clause 11, Sub-clause 1, schedule e. If these general practitioners and therapists have establishments abroad, they must have similar qualifications. Chapter III Basic cover 10. The group insurance covers the expenses for: a. Treatment at doctor and/or nurse at a private hospital/clinic, however, see schedule d b. Other treatment during hospitalisation at a private hospital or clinic. c. Consultation or treatment at a specialist (however not a specialist in ordinary medicine), however, see schedule d. d. Examination of and treatment for mental illness by a psychiatrist is covered by up to and not more than 12 consultations of 60 minutes duration per insurance event and not more than 12 consultations of 60 minutes duration per calendar year. Limitations include preliminary examinations under schedule e. e. Preliminary examinations that are necessary for making a diagnosis, and/or reexamination of a treatment, for instance, X- ray, laboratory tests etc. f. Expenses for medicine and board, when the insured is hospitalised in a private hospital/clinic. g. Prescribed prostheses and other aids prescribed by a doctor that are necessary for 4 / 12

5 the treatment that is in progress. The insurance shall cover expenses related to these for a period of six months, at a maximum. h. Treatment of abuse of alcohol, medicine and other intoxicants. Total expenses for treatment cannot exceed the agreed amount. The amount, which can be adjusted, shall be stated in the policy or insurance certificate. i. Second opinion. When the insured is facing a difficult decision the insured can have the expenses covered for one further evaluation by a doctor in the following cases: In the event of a life-threatening or particularly serious disease If the insured is facing the choice of undergoing particularly risky treatment If the choice has particularly great importance to the insured's quality of life PFA Pension shall decide whether the insured can have expenses covered in relation to a second opinion. j. Examination and diagnosis at a private hospital or clinic in Denmark due to a reasonable suspicion of cancer, which has arisen during the insurance period. In connection with treatment of cancer, where public health services offer a package deal, the public offer must be accepted. In consultation with PFA Pension s medical consultants, treatment may under certain circumstances be offered at private hospitals in Denmark, the Northern countries and Germany. k. In connection with treatment of heart disorders, where public health services offer a heart disorder package deal, the public offer must be accepted. In this connection, PFA Pension may offer advise see Clause 6, Sub-clause 7. Chapter IV Optional cover A - extended cover 11. Group insurance that includes optional cover A shall cover the expenses for: a. Treatment at physiotherapist or chiropractor. PFA Pension may require that the physiotherapist is covered under a collective agreement with the National Health Service in Denmark (provider ID number). In case of treatment by a physiotherapist who is not covered by a collective agreement with the National Health Service in Denmark (provider ID number), PFA Pension shall cover no more than an amount equal to the patient s share according to the rate for general physiotherapy. The insurance shall cover up to and not more than 12 treatments per insurance event and not more than 12 treatments per calendar year by a physiotherapist and chiropractor altogether. b. Examination and treatment at psychologist, including emergency counselling. PFA Pension may require that the psychologist is covered under an agreement with the National Health Service in Denmark (provider ID number). The insurance shall cover up to and not more than 12 consultations of 60 minutes duration per insurance event and not more than 12 consultations of 60 minutes duration per calendar year. Limitations include preliminary examinations and emergency counselling. PFA Pension shall cover no more than the rates set out in the collective agreement between the Danish Psychological Association (Dansk Psykolog Forening) and the National Health Service in Denmark. c. Treatment at chiropodist. The insurance shall cover up to and not more than 12 treatments per insurance event and not more than 12 treatments per calendar year. d. Medically reasoned consultation at clinical dietician if the insured s BMI (Body Mass Index) exceeds 30. The insurance shall cover up to and not more than 12 consultations per insurance event and not more than 12 consultations per calendar year. 5 / 12

6 e. Acupuncture or reflexology. Acupuncture must be performed by a doctor, midwife, nurse, physiotherapist or chiropractor. Reflexology must be performed by a therapist who is officially registered as an alternative therapist in Denmark (RAB). The insurance shall cover up to and not more than 12 treatments per insurance event and not more than 12 treatments per calendar year by an acupuncturist and reflexologist altogether. f. Medicine prescribed by a doctor in continuation of treatment justifying cover which is necessary for the treatment that is in progress however see Clause 6, Sub-clause 11. Expenses for medicine shall be covered until and for no longer than six months per insurance event from the first treatment day. Where the insured has been hospitalised in connection with treatment, the six months shall be calculated as from the discharge. g. Rehabilitation prescribed by a doctor, when the rehabilitation is necessary for the treatment which has been initiated through this insurance and paid by PFA Pension. Expenses for rehabilitation shall be covered until and no longer than six months per insurance event from the commencement of the rehabilitation. h. Recuperation stays prescribed by a doctor, where the insured will be under permanent supervision by medical personnel, where the recuperation stay is necessary for the treatment initiated through this insurance and paid by PFA Pension. Recuperation stays after other treatments shall not be covered. The expenses shall be covered until and no longer than three months per insurance event in immediate continuation of terminated treatment. i. Professional and/or authorised temporary home help and visiting nurse in immediate continuation of treatment initiated through this insurance and paid by PFA Pension, and provided the home help and/or the visiting nurse is necessary for the treatment according to a medical evaluation. Expenses for home help and/or a visiting nurse shall be covered until and no longer than three months per insurance event from the commencement of the home help and/or the visiting nurse. j. Transportation. In Denmark, the costs of transporting patients to an from hospitalisation or surgical operation at a private hospital covered by this insurance and paid for by PFA Pension are covered, provided that a relevant medical specialist has assessed that the insured is unable to drive a car or use public transportation for health reasons. Transportation is arranged with PFA Pension. (2) For Sub-clause 1, schedules a e, it shall apply that PFA Pension may condition the insured's continued treatment etc. - even if the insured has not yet had 12 treatments - on the insured being examined by a psychologist, chiropractor, physiotherapist, doctor or psychiatrist appointed by PFA Pension who can confirm the diagnosis made and/or the (continued) relevance of the treatment. Chapter V Optional cover B - preventive health examination 12. Group insurance plans that include optional cover B shall cover expenses for preventive health examinations. At least two years must have elapsed from the last preventive health examination covered by PFA Pension. (2) From the time when the insured is included by the group insurance, at least six months must elapse before the first preventive health examination can be made. 6 / 12

7 (3) A group insurance shall not cover preventive health examinations for an insured who is no longer a member of, organised in or employed with the policyholder. If the insured is a spouse/cohabiting partner, the group insurance shall not cover preventive health examinations after the following maturity date where the insured's spouse/registered partner or cohabiting partner is no longer a member of, organised in or employed with the policyholder or is no longer covered by PFA Health Insurance by virtue of this membership or condition of organisation or employment. (4) The preventive health examination must be performed by medical personnel - for instance by the general practitioner or at a medical test centre. The preventive health examination shall not be conditional upon a doctor's referral. (5) The maximum expense for the preventive health examination cannot exceed the amount agreed upon, in force at any time. The amount, which can be adjusted, shall be stated in the policy or insurance certificate. stepchildren and the insured s cohabiting partner s biologic children, adopted children and stepchildren, provided they are living at home and have attained one year of age but have not yet attained the age of 21. Children living at home shall in this context be the child that shares the same national registered address as the insured. (3) The insured s stepchildren shall be understood as the insured s present or former spouse s/registered partner s biological children and adopted children. The insured s cohabiting partner s stepchildren shall be understood as the insured s cohabiting partner s former spouse s/registered partner s biological children and adopted children. (4) A cohabiting partner shall in this context mean a person who shares the same national registered address as the insured on the date of the insurance event, and where impediments to marriage do not exist according to legislation. An insured can only make one cohabiting partner's children eligible for cover at a time. (6) The group insurance shall not cover preventive health examinations of children - see Clause 13. Chapter VI Optional cover C - children's cover 13. Group insurance plans that include optional cover C shall cover the insured s children on equal terms with the insured, with the exceptions that are a result of Clauses 12, 19 and 22. Children s cover shall lapse at the same time as the insured s cover lapses - see Clause 21. (2) Children shall be the insured s biological children and adopted children who have attained one year but have not yet attained the age of 21. Furthermore, children shall be the insured s Chapter VII Disbursements 14. PFA Pension shall cover and settle expenses directly with the hospital, clinic, other provider of treatment etc. according to invoice submitted. (2) If the insured has paid documented expenses covered by the insurance policy, PFA Pension shall refund the amount against submission of the original invoice. (3) Any expenses for medical examinations etc. and certificates which PFA Pension requests shall be paid by PFA Pension. Taxation 15. Taxes, which PFA Pension must withhold and settle according to legislation, shall be deducted 7 / 12

8 from the payments received and the disbursements made. Chapter VIII Risk not covered 16. The group insurance does not cover expenses for: a. Consultation or treatment at general practitioners or specialists in general medicine or doctors overseas, who can be compared thereto, when the expenses for the consultation in Denmark would normally be covered by the Danish National Health Service's health insurance group 1. b. Emergency treatment (for instance in relation to situations that require ambulance, doctors from the emergency service and casualty ward and other areas of diagnosis which are defined as an emergency by the public services). c. Treatment of illnesses caused by epidemics. d. Alternative treatment, which is not recognised as treatment of the illness in question according to a general medical evaluation. e. Treatment of any condition which is a result of the insured being HIV-positive or suffering from a similar immunodeficiency. f. Consequences of pregnancy and childbirth as well as treatment in connection therewith. g. Treatment against childlessness. h. Dental treatments and dental surgery. i. Cosmetic operations unless they are performed in connection with an accident or an illness that has occurred during the insurance period and which has resulted in extensive bodily changes. PFA Pension shall make this evaluation. Forehead lifts and drooping eyelids are in this connection regarded as cosmetic operations. j. Additional treatment as a result of cosmetic implants. Additional treatment shall mean a more extensive treatment than what is necessary in connection with the illness justifying cover. k. Treatment as a result of defective cosmetic implants or wear and tear of the implants. l. Treatment of infections and other complications caused by piercing or tattooing. m. Glasses or contact lenses and/or eye tests as well as hearing aids and audition tests. n. Organ transplant. o. Chronic dialysis treatment. p. Obesity treatment and surgery (for instance gastric bypass) and any consequences hereof without considering any temporary or permanent change for the better in connection with other illnesses which may be the consequence hereof however see Clause 11, schedule d. q. Corrective operation of short- and longsightedness as well as structural defects of the eye. r. Replacement of prostheses and implants which can be carried out at publicly financed hospitals within a reasonable period of time. s. Treatment of compulsive gambling, pathological passion for gambling or similar gambling addictions, shopaholic treatment and other treatment of compulsive shopping disorders, treatment of sex addiction and any other dependencies and abuse treatments that are not covered by these insurance conditions see Clause 10, schedule h. t. Treatment of fear of flying, fear of heights, fear of dentists and phobia of reptiles. Other phobias are also excluded from cover, unless the insured's own general practitioner refers the insured to examination and treatment of mental illness - see the Clause 10, schedule d - or for treatment by a psychologist - see the Clause 11, Sub-clause 1, schedule b. u. Preventive or maintenance examinations or treatment see Clause 6, Sub-clause 3. v. Cosmetic treatments, not including reconstructive treatment due to treatment initiated through this insurance and paid by PFA Pension. 8 / 12

9 w. Treatment of corns and warts on feet and hands. x. Examination and treatment of venereal diseases. (2) Furthermore the group insurance does not cover in the event of illness which: a. has intentionally or through gross negligence been caused by the insured. This applies regardless of the insured s mental condition at the time of injury. b. has arisen as a result of self-induced intoxication, the influence of euhoriants, toxins of any type, medicine, drugs and similar substances. Likewise, disbursement shall not be made from PFA Health Insurance due to organ damage or other effects thereof due to abuse of alcohol, medicine, drugs, euphoriants or toxins. However, the insurance shall cover treatment of abuse of alcohol, medicine and other intoxicants - see Clause 10, schedule h. c. has arisen as a consequence of attempted suicide unless the insurance cover has been in effect one year prior to the attempted suicide. d. has arisen as a result of professional exercise of sport both during participation and sport. (3) The group insurance does not cover treatment of illnesses that have arisen as a direct consequence of the release of atomic energy or radioactive forces. (4) The group insurance shall lapse in the event of war, a war-like state or any other increase in danger of a corresponding nature on Danish territory, or if the consequences of an increase of risk afflict Danish territory. War, a war-like state or any other increase in danger of a corresponding nature shall mean armed conflicts or other actions which are due to the use of force between Denmark and foreign powers or foreign powers mutually as well as civil war, rebellion or civil unrest. The date of the occurrence and end of the state of war (the increase of risk) shall be determined by the Industry Association for the Danish insurance and pension companies in consultation with the public authorities in Denmark if necessary. (5) The group insurance shall not cover insurance events, which occur due to participation in war, participation in or fight against rebellion or other civil unrest outside Danish territory, shall not be covered unless the insurance has been in effect without interruptions for one year before the war/conflict. Participation in war, participation in or fight against rebellion or other civil unrest shall mean participation in armed conflicts in the shape of participation in armed forces, including police forces and participation in a peace corps or a observer corps and similar in a war or conflict area, either by order from the Danish government or voluntary participation. Participation in forces of foreign countries shall never be covered. Chronic illnesses 17. The group insurance shall not cover treatment of chronic illnesses that have arisen prior to registration. Chronic illnesses shall be understood as a permanent illness which cannot be expected to be cured according to a general medical evaluation, as well as an illness which has not been cured despite at least three years of treatment. Pain relief or other temporary treatment of the symptoms of a chronic illness, which have arisen after the insured was registered for the insurance, and where pain and symptoms are demonstrably connected with physical injuries, shall be covered for up to six months, as a maximum, even if it shall not be expected to cure the illness or improve the condition considerably and permanently according 9 / 12

10 to a medical evaluation see Clause 6, Subclause 3. The above-mentioned applies solely to treatment etc. which is covered by the individual insured s insurance cover see Clauses 10 and 11. Especially for insured with voluntary registration including spouse s/cohabiting partner s cover 18. It shall apply to group insurance plans with voluntary registration and to spouse'/cohabiting partner's cover that during the first two years of the insurance period the insurance shall not cover illness that has direct or indirect connection with an illness that the insured had before the insured was covered by the insurance. Chronic illness that has arisen prior to registration shall however not be covered after the first two years either - see Clause 17. Particularly for optional cover C, children s cover 19. As for children's cover - see Clause 13 - the following shall also apply: a. The group insurance shall provide cover for the child from the child's attained one year of age, at the earliest. b. Hereditary diseases and illnesses that are caused by birth or other illnesses that are related to these shall not be covered by the group insurance. c. If the group insurance includes optional cover B, preventive health examination - see Clause 12, this cover shall not apply to children. Chapter IX Calculation and payment of premium 20. The premium shall be fixed for one year at a time. The premium shall be calculated on the basis of the tariffs of PFA Pension and the composition of the group as regard to age, claims experience and development of the maximum group term insurance cover in the event of death as reported to the Danish Financial Supervisory Authority. (2) The premium shall fall due for payment on the first day of each premium period agreed upon. (3) Unless the group agreement with the policyholder (employer, association or organisation) states otherwise, the conditions in Sub-clause 4 shall apply. (4) Should the first premium not be paid for the group insurance or for the insurance cover for an insured, the group insurance or the insurance cover, respectively, shall cease seven days after demand. Should a later premium not be paid, PFA Pension shall be entitled to terminate the group insurance or the insurance cover for the insured, respectively, to the effect that it shall lapse if the premium has not been paid within 21 days after the termination. (5) If the group insurance or the insurance cover for an insured is terminated or ceases for other reasons, premium shall be payable until the group insurance or the insurance cover lapses. Chapter X Lapse of cover and continuation 21. The insurance cover shall lapse in the following situations. a. The group insurance lapses as a result of notice of termination, see Clauses 23 and 24. b. In the event of lapse of insurance cover due to resignation of an insured - see Clause 23. c. If payments of premium stop - see Clause 20 d. When the insured is no longer a member of, organised in or employed with the policyholder. If the insured is a spouse/cohabiting partner the insurance cover shall lapse on 10 / 12

11 the next maturity date where the insured's spouse/registered partner or cohabiting partner is no longer a member of, organised in or employed with the policyholder or is no longer in possession of PFA Health Insurance by virtue of this membership or conditions of organisation or employment. If the insured is a spouse/cohabiting partner the insurance cover shall furthermore lapse at the next maturity date after a possible divorce or separation or after the termination of cohabitation with the person who is a member of, organised in or employed with the policyholder. e. When the maximum insurance sum has been disbursed. f. The insured has been placed in a nursing and residential home or have been permanently placed in a 24-hour care centre, a psychiatric hospital or other residential treatment centre. g. The insured no longer has a national registered address in Denmark, unless this is due to expatriate service or that the insured becomes an international commuter - see the regulations of Clause 7. (2) Irrespective of Sub-clause 1 the insurance cover shall lapse no later than on the date specified in the group insurance. The expiry age is stated in the policy or insurance certificate of the individual insured. Possibilities of continuation of cover 22. If the insurance cover lapses according to Clause 21, schedule d, the insured has the possibility of establishing PFA Health Insurance on individual terms without surrendering health information according to an agreement with PFA Pension with effect from the time of termination of insurance cover. The same shall not apply to any children covered by the insurance. Such insurance must be taken out within three months of the end of cover. Chapter XI. Notice of termination and change Notice of termination 23. The policyholder can terminate the group insurance at three months' written notice for expiry at the first day of any month, unless otherwise stated in the agreement between the policyholder and PFA Pension. (2) PFA Pension can terminate the group insurance at three months written notice for expiry at the first day of any month, unless otherwise stated in the agreement between the policyholder and PFA Pension. (3) The insured can terminate his/her cover in the group insurance at 30 days notice for expiry at the end of a calendar month. This may be prevented in the terms of employment. Change of conditions or tariffs 24. PFA Pension may change the insurance conditions and tariffs at 30 days' notice for expiry on the last day of any calendar month. (2) The policyholder shall be informed in writing about any changes (3) In the event of stricter insurance conditions and in the event of changes to tariffs that lead to a higher premium for the group insurance, the policyholder may terminate the group insurance at 14 days notice, as the termination shall be made within 14 days after the policyholder has been notified about the changes. Chapter XII Notification of the insurance incident of claim for disbursement of insurance benefits Notice of claim 25. The insurance event shall be notified to PFA Pension. Notification can be made by telephone. 11 / 12

12 It is also possible to requisition a claims form for the use of a written notification. (2) The insured shall be liable to submit information as well as permissions to procure the medical information etc. which PFA Pension may deem necessary for the assessment of the liability to pay. (3) On notification of the insurance event, the insured must inform whether insurance has been effected for the same risk in another insurance company. (4) If insurance covering the same risk has been taken out with another insurance company, and if that company has made reservations to the effect that cover shall lapse or be limited, if insurance has been taken out with another insurance company, the same reservations shall apply to PFA Health Insurance to the effect that the expenses for treatment shall be paid proportionately by the companies. Notice of claim for disbursement 26. The original invoice must be forwarded to PFA Pension. (2) At lapse of insurance cover, the claim for disbursement shall be made to PFA Pension within six months after the insurance cover has lapsed see Clause 21. The right to disbursement shall lapse at the expiry of this time limit. (3) Claim for disbursement of an insurance benefit, which has not been notified before the insured s death, shall be considered to have lapsed. Justified claims for refund of expenses which existed when the insured died, can, however, be made against PFA Pension within six months after the insured's death. Chapter XIII Other conditions Right of disposal 27. If the insured leaves the group insurance, the insurance cover will not have accumulated any value. (2) The group insurance and the insurance cover must not be disposed of, pledged or sold or traded in any other way. Applicable law 28. The general provisions of Danish law shall apply to the group insurance unless otherwise has been agreed upon in these insurance conditions or in the insurance agreement between the policyholder and PFA Pension. Complaints 29. PFA Pension is affiliated to the Insurance Complaints Board. (2) This Board deals with complaints from consumers concerning matters relating to insurance. Complaints to the Insurance Complaints Board shall be sent in a special form that may be obtained from PFA Pension, the secretariat of the Insurance Complaints Board or the Danish Consumer Council. (3) When the complaint has been filed, a fee fixed by the Insurance Complaints Board is payable. In the event of the complainant succeeding in his/her complaint, the Insurance Complaints Board shall repay the fee. Administration 30. The group insurance is taken out with PFA Pension, forsikringsaktieselskab, Copenhagen, CVR / 12