Insurance Terms and Conditions

Transcription

1 Insurance Terms and Conditions CZ Zorgkeuze Policy (Reimbursement Healthcare Insurance) and Additional Insurance Valid from 1 January 2012

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3 Insurance Terms and Conditions Healthcare Insurance and Additional Insurance Valid from 1 January 2012 The previous insurance terms and conditions have expired Page 1

4 INDEX ALPHABETICAL LIST OF REIMBURSEMENTS... 4 EXCEPTIONAL MEDICAL EXPENSES ACT (AWBZ)... 8 HOW TO USE THIS BOOKLET... 8 ===================================================================... 9 CHAPTER A... 9 GENERAL TERMS AND CONDITIONS OF GENERAL AND ADDITIONAL INSURANCE... 9 ===================================================================... 9 A.0. INTRODUCTION... 9 A.1. DEFINITIONS A.2. BASIS OF YOUR HEALTHCARE INSURANCE A.3. CONTENT AND SCOPE OF YOUR INSURANCE A.4. START AND DURATION OF YOUR INSURANCE A.5. WHEN CAN YOU CANCEL OR AMEND? A.6. WHEN DO WE CANCEL THE INSURANCE? A.7. LEVEL OF PREMIUM AND COSTS A.8. PAYMENT OF PREMIUM AND COSTS A.9. PAYMENT ARREARS A.10. PREMIUM AND COSTS AFTER TERMINATION A.11. CHANGE IN BASIC PREMIUM A.12. COMPULSORY DEDUCTIBLE A.13. VOLUNTARY DEDUCTIBLE A.14. GENERAL OBLIGATIONS A.15. PASSING ON INFORMATION A.16. REGISTRATION AND CHECKS A.17. HEALTHCARE PROVIDERS A.18. CARE ADVICE AND AUTHORISATION A.19. BILLS A.20. GENERAL EXCLUSIONS A.21. DISPUTES A.22. COMPLAINTS A.23. NETHERLANDS LAW A.24. WHAT HAPPENS IF A SITUATION IS NOT RESOLVED? =============================== CHAPTER B DESCRIPTION OF CARE UNDER GENERAL INSURANCE =============================== B.0. INTRODUCTION B.1. RIGHT TO OTHER CARE B.2. CARE ABROAD B.3. GP CARE B.4. SPECIALIST MEDICAL CARE B.5. CARE FOR CHILDBIRTH B.6. CARE DURING DELIVERY B.7. POSTNATAL CARE B.8. PHYSIOTHERAPY AND CESAR/MENSENDIEK EXCERCISE THERAPY B.9. OCCUPATIONAL THERAPY B.10. SPEECH THERAPY B.11. CHAIN CARE B.12. DENTAL CARE FOR INSURED PERSONS OF ALL AGES B.13. DENTAL CARE FOR INSURED PERSONS YOUNGER THAN 18 YEARS B.14. DENTAL CARE FOR INSURED PERSONS AGED 18 YEARS AND OVER B.15. MEDICINES B.16. DIETARY PREPARATIONS Page 2

5 B.17. MEDICAL DEVICES CARE B.18. PATIENT TRANSPORT B.19. MENTAL HEALTH CARE B.20. DYSLEXIA CARE B.21. PREVENTION B.22. PROVISIONAL CARE =============================== CHAPTER C GENERAL TERMS AND CONDITIONS OF NON-HEALTHCARE AND ADDITIONAL INSURANCE. 67 =============================== C.0. INTRODUCTION C.1. DEFINITIONS C.2. BASIS OF YOUR ADDITIONAL INSURANCE AND NON-HEALTHCARE INSURANCE C.3. NATURE, CONTENT AND SCOPE OF YOUR ADDITIONAL INSURANCE C.4. START AND DURATION OF THE ADDITIONAL INSURANCE C.5. REFERRAL C.6. TERMINATION OR AMENDMENT C.7. LEVEL OF PREMIUM AND COSTS C.8. PREMIUM AND COSTS AFTER CANCELLATION C.9. REIMBURSEMENT C.10. GENERAL EXCLUSIONS C.11. DEVIATING CONDITIONS =============================== CHAPTER D DESCRIPTION OF CARE UNDER ADDITIONAL INSURANCE =============================== D.0. INTRODUCTION D.1. SPECIALIST MEDICAL CARE D.2. PREVENTION D.3. MEDICINES D.4. MEDICAL DEVICES CARE D.5. STUTTER THERAPY D.6. MENTAL HEALTH CARE D.7. ALTERNATIVE CARE D.8. DENTAL CARE FOR INSURED PERSONS OF ALL AGES D.9. HEALTH SPA TREATMENT D.10. SKIN THERAPIES D.11. OBESITY TREATMENT D.12. PATIENT TRANSPORT D.13. HOSPITALISATION D.14. CARE ABROAD D.15. FOOT TREATMENT D.16. PHYSIOTHERAPY AND CESAR/MENSENDIECK EXERCISE THERAPY D.17. OCCUPATIONAL THERAPY D.18. DIETARY ADVICE D.19. PRENATAL CARE D.20. CARE DURING DELIVERY D.21. POSTNATAL CARE D.22. EXERCISE PROGRAMMES D.23. HOME CARE / HOME HELP ANNEX 116 Page 3

6 ALPHABETICAL LIST OF REIMBURSEMENTS insurance Additional insurance Reimbursement Clause Page Clause Page Accommodation costs D Acne treatment D ADL devices D Adoption, maternity care D Adoption, medical screening D Alarm (epilepsy) D Alarm (personal) D Alternative medicines D Alternative treatments D Artificial respiration B Artificial respiration B Audiological care B Bed-wetting alarm D Braces and bandages D Breast prosthesis, replacement B b. 39 D Breastfeeding care D Camouflage therapy D Camp, therapeutic D Cancer tests for children B Care abroad B D Care abroad, emergency B D Care abroad, inoculations and tablets D Care abroad, non-emergency B D Care monitor (home) D Care products (home) D Category nursing D Chain care, general B.11.(1) 50 Childbirth B D Childbirth classes D Childbirth classes D Circumcision D Circumcision D Condoms D Consultations for women D Contraceptives B D Contribution to patients associations D Cosmetic treatment D Course D Cures D Day care for children D Dental care, 18 years and over B Dental care, all ages (crowns, bridges, inlays) D Dental care, all ages (dental prostheses) D Dental care, all ages (general) B D Dental care, all ages (orthodontics) D Dental care, all ages (other) D Dental care, younger than 18 years B Depilation D Dialysis without hospitalisation B Page 4

7 insurance Additional insurance Reimbursement Clause Page Clause Page Dietary advice D Dietary advice D Dietary advice for chronic illnesses B Dietary products (fluids and drip feed) B Dyslexia care B Ear correction (protruding ears) D Ear position correction (protruding ears) D Epilepsy alarm D Erectile dysfunction, medicines D Examination, preventive D Exercise programmes, general D Exercise programmes, special circumstances D Exercise therapy, Cesar/Mensendieck B D Eye laser treatment D Eyelid correction B c. 39 D Eyelid, upper, correction B c. 39 D Eyesight devices D Fertility treatments B Foot treatment, general D.15.(1.) 111 Foot treatment, medical devices D Foot treatment, special cases B.3.1.a. / 35, 38 D / 111 B a. D daily vital functions devices D GP care B Health courses D Hearing aid B D Home care / home help D Home care articles D Home help/home care D Home monitor alarm D Home support D Hospice, personal contribution D Hospital nursing in a higher class D Hospitalisation D Incubator care D Inherited disease test and consultation B Inpatient care: see specialist medical care Inpatient payment/compensation/additional costs D IVF (in vitro fertilisation) B Light therapy for winter depression D Light therapy, UV-B D Maternity care / Postnatal care B D Maternity care after a stay in hospital D Maternity care for adoption D Maternity care payment D Maternity care registration and intake B Maternity care, extra D Maternity care, registration and intake B Maternity, extra care D Maternity, personal contribution D Medical devices care, general B D.4.(1.) 88 Medical devices care, rental B D Page 5

8 insurance Additional insurance Reimbursement Clause Page Clause Page Medical devices for foot treatments D Medical examination for adoption D Medication assessment for chronic use B Medicines, contraceptive D Medicines, general B D Medicines, made by pharmacy B Medicines, medicine assessment B Medicines, other D Medicines, personal contribution B D Medicines, registered B Medicines, self-help B Mental health care, primary B.19.(1.) 64 D Mental health care, specialist B Non-allergenic shoes B D Nursing without hospitalisation B Obesity treatment D Obstetric care B Occupational therapy, general B D Occupational therapy, informal carer instructions D Oral care: see dental care Organ transplants B Orthodontics D Orthopaedic and adapted shoes B D Other care B Outpatients clinic / care during childbirth B D Patient organisation, contribution D Patient transport by ambulance B Patient transport by car, public transport or taxi B D Patient transport, general B.18.(1.) 61 D.12.(1.) 102 Pedicure treatment, special cases B.3.1.a. / 35, 38 D B a. Personal alarm D Personal contribution for hospice D Personal contribution for maternity care D Personal contribution for medication B D Personal contribution for outpatient birth D Pharmaceutical care: see medicines Physiotherapy and exercise therapy B D Plastic surgery B Podiatric insoles D Podiatry / foot therapy: see foot treatment Postnatal care B D Prenatal care B D Prenatal screening B D Prevention B D Preventive care for foreign travel D Preventive check-ups D Preventive inoculations D Provisional care B Psychological care, primary B D Psychotherapy B Recovery & Balance D Page 6

9 insurance Additional insurance Reimbursement Clause Page Clause Page Rehabilitation B Rehabilitation centre D Replacement of breast prostheses B b. 39 D Second opinion B Shoes for bandaged feet B D Shoes, adapted and orthopaedic B D Shoes, non-allergenic B D Skin therapies D Snoring, treatment for D Specialist care: specialist medical care Specialist medical care, general B D.1.(0). 78 Specialist medical care, inpatient B Specialist medical care, outpatient B Specialist mental health care B Spectacles and contact lenses D Speech therapy B Sports medical advice (sports doctor, sports examination) D Sterilisation D Sterilisation reversal D Sterilisation, reversal D Stutter therapy D Support pessary D Support soles D TENS during delivery D Test strips for diabetes patients D Therapeutic camp D Thrombosis service B Transplant (organ) B Transport: see patient transport Trauma processing D Travel expenses, healthy mother D Travel expenses, parents D Treatment for snoring D Ultrasound scan B UV-B light equipment D Visiting costs D Visual acuity treatments (laser surgery) D Walk-in centres D Wig (or other head cover) B D Zorg TV D Page 7

10 EXCEPTIONAL MEDICAL EXPENSES ACT (AWBZ) Exceptional Medical Expenses Act Do you need home care, nursing and nursing home care, handicap care or long-term non-medical psychiatric care? This care is paid for by the AWBZ. These types of care are administered by healthcare offices that are part of different healthcare insurers. You are automatically registered for AWBZ care if you have healthcare insurance. Do you need care under the AWBZ? You require a grading if you need AWBZ care. You can apply for the grading at: 1. Centrum Indicatiestelling Zorg (CIZ); you can read more about this on their website or 2. Bureau Jeugdzorg, for young people up to the age of 18 years with a psychiatric condition; for information see Premium and personal AWBZ contribution The AWBZ is social care insurance for everyone in the Netherlands. Everyone who receives income in the Netherlands automatically pays a premium. If you receive AWBZ care you pay a personal contribution depending on your income. You can find more information about this at More information about AWBZ On the website you will find all kinds of information about the type of care, advice for finding suitable care for your needs, care in kind, individual budget, healthcare offices,brochures, etc. HOW TO USE THIS BOOKLET We will use 'occupational therapy' as an example of how to use this booklet. 1. Alphabetical list of reimbursements Look up occupational therapy under 'o' in the 'Alphabetical list of reimbursements' at the front of this booklet. 2. insurance In the second column you will see the clause number and the page where you will find the cover available under the general insurance. In clause B.9. you will see that you are entitled to reimbursement up to a maximum of 10 treatment hours per year. You will also see the conditions you have to meet and what may not be covered. 3. Additional insurance In the third column you will see the clause number and the page where you will find the cover available under the additional insurance. In clause D you will see what you are entitled to and the conditions. You will also see that you will find the extent of the reimbursement in your Cover Statement. 4. Cover Statement You can check your Cover Statement to see if clause D is included in your additional insurance and the level of the If occupational therapy, clause D.17.1., does not appear on your Cover Statement, you are not entitled to the Except for the reimbursement under the general insurance. Chapters A. and C. contain all the general terms and conditions that apply to the general insurance and/or additional insurance. Page 8

11 =================================================================== CHAPTER A GENERAL TERMS AND CONDITIONS OF GEN- ERAL AND ADDITIONAL INSURANCE =================================================================== A.0. INTRODUCTION We can offer one or more of the following general insurance policies: - Natura healthcare insurance - Restitutie healthcare insurance - Natura direct healthcare insurance, or - a different general insurance policy, based on one of the three above policies. In addition, you may add one of the additional insurance policies that we offer. Your policy document will show you which general insurance you have, and whether you have any additional insurance. Chapters A and B apply to all general insurance policies. Chapters A, C and D apply to the additional insurance policies. There may be special conditions for any of the general insurance and additional insurance policies you have chosen. In the overview below you can see which special conditions apply to you. A.0.1. Types of health insurance Natura / Natura direct Your general insurance is based on the Healthcare Insurance Act and is a so-called insurance in kind ('Natura') policy. This means that you are entitled to healthcare. Natura Natura Restitutie Natura direct Natura direct Add. Ins. Restitutie Your general insurance is based on the Healthcare Insurance Act and is a so-called reimbursement ('Restitutie') policy. This means that you are entitled to reimbursement of the costs of care. Restitutie Additional Insurance The additional insurance policies are so-called reimbursement policies. This means that you are entitled to reimbursement of the costs of care. A.0.2. Level of voluntary deductible (additional with A.13.2.) You can choose from a voluntary deductible of 100, 200, 300, 400, or 500 per year. Natura Restitutie Add. Ins. You can only opt for the voluntary deductible of 500 per year. Natura direct CHAPTER A Page 9

12 The deductible does not apply to the additional insurance policies. A.0.3. Agreements with care providers (extra condition with A.17.3) For a large number of the medical devices, medicines and dietary preparations we have made 'internet agreements on medical devices' and/or 'internet agreement on medicines and dietary preparations' with certain care providers. The care provider may only deliver after ordering through the internet. You will find an overview of care providers with whom we have an 'internet agreement' on our website. You will also find an overview there of the medicines, dietary preparations and aids for which we have made such 'internet agreements'. You can also request this information from us. A.0.4. Agreement with care provider ends during your treatment (extra condition with A.17.) This is the case if you receive treatment from a care provider with whom we had an agreement when your treatment started. For a maximum of 12 months after the start of your treatment by a care provider who no longer has an agreement with us, we will reimburse this care as if the care provider treating you does have an agreement with us. A.0.5. Change of care provider during your treatment (extra condition for A.17.) You retain the right to reimbursement for the care provided by a care provider with whom the previous healthcare insurer had an agreement when you switch to us. This also applies if we do not have an agreement with the care provider, cannot enter into an agreement in time, or we cannot ensure that the care will be provided in time. The costs of such care are reimbursed by us as if the care were provided by a care provider with whom we do have an agreement. A.0.6. Rates The cover statement specifies the level of the reimbursements that you will receive. This is often in terms of a percentage, e.g. 100%. This, however, does not mean that we will fully reimburse your bill. We use different rates for the reimbursement of care. - agreed rate - claimed rate - market rate. In the diagram in the Annex (at the back of this booklet) you will see which rate We reimburse you per situation. Different rates are reimbursed depending on the specific situation: Natura Natura Natura Restitutie Natura direct Natura direct Natura direct Natura direct Add. Ins. Add. Ins. Add. Ins. Add. Ins. a. Agreed rate Are you going to a care provider with whom we have agreed on the rates for that treatment? In this case We reimburse the treatment according to the agreed rate. Contrary to the above, this agreed rate applies to 'medical devices care' where it concerns devices supplied by a care provider with an 'internet agreement' for those aids. If we only have an agreement with the care provider that is not an 'internet agreement' for those aids, b. applies. (see also clause A.0.9.) Natura Restitutie Natura direct Natura direct Add. Ins. b. Reduced rate (75%) Are you going to a care provider with whom we have not agreed CHAPTER A Page 10

13 rates? And in your situation could you have received timely care from a care provider with whom we do have an agreement? We will then reduce the reimbursement by 25%. We will therefore reimburse 75% of the legally determined fixed rate ( rate based on points ). If no legal fixed rate has been determined we reimburse 75% of the market rate. Natura Natura direct The reduced rate above applies to 'medical devices care', where it concerns devices that can be provided by a care provider with an 'internet agreement', also where it concerns a care provider with whom we have made an agreement, but not an 'internet agreement' (see also clause A.0.9.) Natura direct c. Full rate (100%) If you go to a care provider with whom we have not agreed rates, We reimburse the full fixed statutory rate, (the so-called 'point rate'). If no legal fixed rate has been determined, we reimburse the full market rate. This full rate only applies contrary to b. if: 1) you cannot obtain the care you need, or cannot obtain it in time, from a care provider with whom we have an agreement. What is meant by the timely provision of care depends on the waiting time that is considered by society to be medically responsible and acceptable; or 2) you can only obtain the care you need at a considerable distance from your home town, from a care provider with whom we have an agreement; or 3) the care that you need is not offered in a qualitatively responsible manner in the vicinity of your home town; or 4) you require acute care that cannot be postponed. You must tell us about this acute care as soon as possible. Referral is not a requirement for acute care; or 5) you have received authorisation in writing from us for the care provided by a specific care provider with which we do not have an agreement. Natura Natura Restitutie Natura direct Natura Direct Add. Ins. d. Claimed rate Are you going to a care provider with whom we have not agreed rates? And we don't have agreements with other care providers for the type of care you will be receiving (or have received)? And there is no statutory rate and the market rate is difficult or impossible to determine? Then We reimburse the claimed rate. We never reimburse more than the costs you were actually charged. A.0.7. Internet agreement on medicines (extra condition for B.15.1.) a. s with an 'internet agreement'. You are entitled to medicines and dietary preparations that you order from nationally operating care providers with whom we have an 'internet agreement'. This ensures you do not have to pay a part yourself (apart from any statutory personal contribution). b. s with an agreement that is not an 'internet agreement'. In this case you will be reimbursed on the basis of the rate we have agreed with these care providers based on the standard purchase agreement. Natura Restitutie Natura direct Natura direct Add. Ins. CHAPTER A Page 11

14 c. s without an agreement. You can read in under b, c and d how much we reimburse in that case. The requirements under this clause do not apply to medicines that are imported from abroad as referred to in clause B b. A.0.8. (extra condition for B , B and B ) If delivery takes place by a care provider with whom we have an 'internet agreement', delivery can only be to your home address. The requirements under this clause do not apply to medicines that are imported from abroad as referred to in clause B b. A.0.9. Internet agreement on medical devices (extra condition for B.17.) a. s with an 'internet agreement'. A large number of devices can best be ordered from the small group of nationally operating care providers with whom we have concluded an 'internet agreement'. This ensures you do not have to pay a part yourself (apart from any statutory personal contribution). Natura direct Natura direct b. s with an agreement that is not an 'internet agreement' 1. A number of medical devices cannot be provided by care providers with an 'internet agreement'. For these devices you can go to one of the many care providers with whom we have an agreement that is not an 'internet agreement'. In this case you do not have to pay part of the costs yourself with these care providers (apart from any statutory personal contribution). 2. If a device can be provided by a care provider with an internet agreement, but you go to a care provider with whom we have an agreement but not an 'internet agreement', the same applies as under c. c. s without an agreement You can read in how much we reimburse in that case. A Arrangement of insurance terms and conditions These insurance terms and conditions are divided into 4 chapters: - Chapter A contains the general terms and conditions that apply to the general insurance and additional insurance; - Chapter B describes the healthcare that is insured under your general insurance; - Chapter C contains the non-standard or additional general terms and conditions that only apply to additional insurance and the general insurance that are not healthcare insurance; - Chapter D describes the healthcare you may be entitled to under your additional insurance. Your cover statement shows whether you are insured for this and to what extent you are entitled to Apart from these insurance terms and conditions, the cover statement applies as follows: - for the general insurance the cover statement is a summary of the cover of the Healthcare Insurance; - for your additional insurance, the cover statement shows which care you are insured for and the level of A.1. DEFINITIONS This clause explains the meaning of the concepts used in the insurance terms and conditions. Additional insurance An insurance contract concerning a reimbursement for healthcare that is geared to and supplements a general insurance. You can take out one or a combination of several additional insurances with us. When we use the term 'additional insurance' below this can also mean a combination of CHAPTER A Page 12

15 additional policies. Authorisation The written authorisation we give you following your request for care advice. This authorisation provides the following information: a. that the relevant care is covered by your (additional) (healthcare) insurance; b. that in your situation you are reasonably entitled to such care; and c. that you are entitled to such care under the conditions of insurance. The authorisation is issued by our Medical Assessment and Healthcare Service department. Dispenser A GP or pharmacist who has a licence under the Medicines Act to supply medicines. insurance An insurance contract that can be taken out and that guarantees independent cover without it being a supplement to another insurance. A general insurance can be healthcare insurance but also an insurance that is not a healthcare insurance in the sense of the Healthcare Insurance Act, a socalled 'non-healthcare insurance'. Company doctor The doctor is listed as a company doctor in the register of the Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst. The register was set up by the Sociaal- Geneeskundigen Registratie Commissie (SGRC). Treatment The (physical) contact with one or more care providers when you receive care or are given advice. With treatment we do not mean courses. We reimburse a maximum of one treatment of the same type per day unless specifically stated otherwise in these insurance terms and conditions or your cover statement. We take the date of treatment, not the date of billing into account when reimbursing. Pelvic physiotherapist A person registered as a physiotherapist in accordance with Section 3 of the Individual Healthcare Professions Act (BIG) and who is also listed as a pelvic physiotherapist in the Register for Specialist Physiotherapists of the Register Verbijzonderde Fysiotherapeuten of the Koninklijk Nederlands Genootschap voor Fysiotherapie. Abroad Every country outside the Netherlands. Bureau Jeugdzorg An agency as described under Section 4 of the Youth Care Act. This is an independent agency in your province which provides access to all youth care facilities. This agency assesses your request for help as an independent institution and refers you. Special dentistry centre A centre for special dental care. where treatment is provided by a team and/or requires special expertise. Outpatient treatment A stay in an institution for specialist care or in an institution for rehabilitation intended for medical examination and/or medical treatment, without intention of admission. DBC: Diagnosis Treatment Combination ('DBC') A DBC describes the complete course of specialist medical care or specialist psychiatric care. as well as the need for care, the type of care, the diagnosis and the treatment. The DBC is allocated a DBC performance code. The code is determined by the Nederlandse Zorgautoriteit (NZa). The DBC process starts when you request care (the start of the DBC) and is concluded at the end of the treatment, or after 365 days if your treatment lasts longer than 365 days. The rate is an average price. See also the concept 'DBC on the way to transparency (DOT)'. Dietician The dietician has the status 'quality registered' in the Paramedics Quality Register. DOT: DBC On the way to Transparency DOT is an improved declaration system for specialist medical care that will come into effect on 1 January This system should lead to a simplification of the DBC system, with greater transparency and medical identifiability as starting points. The diagnosis treatment combinations used in the DOT system are called DOT care products. Echographist Someone who has completed a (para)medic training at higher vocational level and is working or involved in medical imagery/ultrasound scanning. Primary healthcare CHAPTER A Page 13

16 First point of contact for people requiring care. Primary psychologist A healthcare psychologist who practices in the primary mental health care sector. Personal contribution Healthcare expenses covered by the general insurance but which you pay in part yourself. Personal contributions are required by law. The personal contribution may be a fixed amount per treatment or a certain percentage of the costs of the care. The personal contribution is not the same as the deductible. The deductible and the personal contributions may both apply to the insured care. Occupational therapist The occupational therapist has the status 'quality registered' in the Paramedics Quality Register. EU and EEA states The EU (European Union) states are: Austria, Belgium, Bulgaria, Cyprus (Greek part), Czech Republic, Denmark, Germany, Estonia, Finland, France (including Guadeloupe, French Guinea, Martinique, St. Barthélemy, St. Martin en La Réunion, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal (including Madeira and the Azores), Romania, Slovenia, Slovakia, Spain (including Ceuta, Melilla and the Canary Islands), Sweden and United Kingdom (including Gibraltar). Switzerland is ranked with these countries under a treaty. Countries that are not in the EU are: Andorra, Channel Islands, Isle of Man, Monaco, San Marino and Vatican City. The EEA (European Economic Area) states are: Liechtenstein, Norway and Iceland. Geriatric physiotherapist The physiotherapist registered as a geriatric physiotherapist in the Register for Specialist Physiotherapists of the Royal Dutch Physiotherapists Association (Register Verbijzonderde Fysiotherapeuten van het Koninklijk Nederlands Genootschap voor Fysiotherapeuten). Skin therapist The skin therapist has the status of quality registered in the Paramedics Quality Register. Practitioner A doctor listed as a general care provider in the register of approved general practitioners of the Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst. The register was set up by the GP, Specialist Ouderengeneeskunde en arts voor verstandelijk gehandicapten Registratie Commissie (HVRC). practitioner service structure An association of GPs. The association has a legal personality as referred to in Section 29c of the Decree on extension and limitation of the working sphere of the Healthcare Market Regulations Act. The association was set up to provide urgent GP care in the evenings, at night, at weekends and on public holidays at a particular place called 'GP Post' and applies a legally valid rate. Organisation for medical specialist healthcare An institution for specialist medical care as provided in the Care Institutions Accreditation Act. This could be for instance a hospital or an independent treatment centre (ZBC). - If we only mean a hospital, we will write it like this: hospital (institution for specialist medical care). In this case we mean a general hospital, specialist hospital (this is a hospital that only provides treatment for one or a few medical specialisations, such as a burns unit or a psychiatric hospital) or a university hospital. - If we only mean an independent treatment centre we write this as follows: Z.B.C. (institution for medical specialist healthcare). - In cases where we mean both, it will only say 'institution for specialist medical care'. Annual Calendar year, unless it concerns a person s age, when years refers to age, and not the 'calendar years. Youth doctor A doctor working in the youth healthcare sector who is registered as a Maatschappij en Gezondheid doctor or as a doctor with the profile Jeugdgezondheidszorg in the registers of the Koninklijke Nederlandsche Maatschappij tot Bevordering der Geneeskunst established by the Sociaal Geneeskundigen Registratie Commissie (SGRC). Paediatric therapist The physiotherapist registered as a paediatric physiotherapist in the Register for Specialist Physiotherapists of the Royal Dutch Physiotherapists Association (Register Verbijzonderde Fysiotherapeuten van het Koninklijk Nederlands Genootschap voor Fysiotherapeuten). Child exercise therapist CHAPTER A Page 14

17 The exercise therapist who is registered as a child exercise therapist and registered in the Register of Specialised Exercise Therapists of the Association of Cesar and Mensendieck Exercise Therapists. Clinical psychologist A healthcare psychologist registered as a clinical psychologist in accordance with the provisions of Section 14 of the Individual Healthcare Professions Act (BIG). Laboratory tests Examination by a legally permitted laboratory that has a rate decision, whereby the examination can be declared up to a particular maximum price. Speech therapist The speech therapist has the status of quality registered in the Paramedics Quality Register. Month Calendar month. Manual therapist A physiotherapist registered as a manual physiotherapist in the Register for Specialist Physiotherapists of the Royal Dutch Physiotherapists Association (Register Verbijzonderde Fysiotherapeuten van het Koninklijk Nederlands Genootschap voor Fysiotherapeuten). (Medical) consultant The doctor, physiotherapist or other specialist who provide advice to us with regard to medical, physiotherapy and other issues. Medical specialist A doctor listed in the Specialist register of the Koninklijke Nederlandsche Maatschappij tot Bevordering der Geneeskunst. This register was instituted by the Medisch Specialisten Registratie Commissie (MSRC). A midwife who gives care in a hospital on behalf of the gynaecologist is also a medical specialist. Dental hygienist An independent oral hygienist who practises for his/her own account and under his/her own responsibility. Non-healthcare insurance A general insurance that is not healthcare insurance in the sense of the Healthcare Insurance Act and can only be taken out and be applicable if there is no insurance obligation under the Healthcare Insurance Act. Oedema physiotherapist A physiotherapist registered as an oedema physiotherapist in the Register for Specialist Physiotherapists of the Royal Dutch Physiotherapists Association (Register Verbijzonderde Fysiotherapeuten van het Koninklijk Nederlands Genootschap voor Fysiotherapeuten). Cesar/Mensendieck exercise therapist The exercise therapist has the status of quality registered in the Paramedics Quality Register. Accident A sudden, involuntary effect of violence on the body that is harmful to health. Admission A stay in an institution for specialist care or in an institution for rehabilitation intended for medical examination and/or medical treatment. The stay starts before 8pm and lasts until at least 10am the following day. Outpatient treatment does not constitute admission to hospital. Orthodontist A dental specialist listed in the specialists register for orthodontics of the Nederlandse Maatschappij tot bevordering der Tandheelkunde. Pedicurist - A person registered in the Pedicure Quality Register as a pedicurist with an endorsement for 'foot care for diabetic people' who may treat insured with diabetes mellitus. - A person registered in the Pedicure Quality Register as a pedicurist with an endorsement for 'foot care for rheumatism patients' who may treat insured with rheumatoid arthritis. - A person registered in the Pedicure Quality Register as a medical pedicurist. The medical pedicurist is a specialised pedicurist for different complex foot problems. This pedicurist may treat insured with diabetes mellitus or rheumatoid arthritis. The clauses where care is described also state which of the relevant pedicures such care should provide. Policy Proof of insurance. Podiatrist CHAPTER A Page 15

18 The podiatrist is a member of the Netherlands association of Podiatrists (N.V.v.P.) Prevention All activities, individually or within a group, aimed at improving or maintaining your (physical or mental) health. Psychiatrist A doctor registered as a psychiatrist in the register of Specialists of the Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst and who focuses on the diagnosis and treatment of disorders of the cognitive functions, the emotional functions, psychomotility, motivation and behaviour. Rehabilitation Examination, advice from and treatment of a special medical, paramedical, behavioural and rehabilitative nature. A team of different experts provides the care under the management of a medical specialist (rehabilitation specialist). The team is affiliated with a rehabilitation institution. Written By means of a physical or digital medium through which the information itself is understandable, storable and reproducible. By digital information carrier we also mean internet and messages. Specialist mental health care Diagnostic and specialist treatment of complex psychological disorders. A specialist (psychiatrist, clinical psychologist or psychotherapist) will be involved in the treatment. geriatric care provider specialist A person registered as a geriatric care provider specialist in the register of approved geriatric care providers of the Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst. This is the new title of the specialist geriatric general practitioner. Dental prosthesis specialist A dental prosthesis specialist trained in accordance with the Decree on training requirements and specialist area of a dental prosthesis specialist. Hospitalisation Hospitalisation and stay lasting 24 hours or more. Treaty country A treaty country is: a. the following states with which the Netherlands has entered into an agreement on social security incorporating an arrangement for the provision of medical care: Australia (with a stay shorter than one year), Bosnia-Herzegovina, Cape Verde, Croatia, Macedonia, Morocco, Montenegro, Serbia, Tunisia and Turkey; b. member states of the European Union other than the Netherlands; c. a country that is party to the Treaty on the European Economic Area; d. Switzerland. Insured person The person whose care and/or costs of care are insured. The insured person is entitled to insured care and/or reimbursement of the insured costs. In the insurance terms and conditions we refer to the insured person and the policyholder as you and your'. If we are only referring to the insured person, and not the policyholder, we say you (the insured person) and your (the insured person s). Insurance An insurance contract that may consist of one or more of the following policies: a. general insurance; b. additional insurance. If the insurance consists of a combination of two or more of the above-mentioned insurance contracts, this combination only contains one general insurance. Policyholder The person who has entered into the insurance contract with us. and the policy is in his or her name. The policyholder can also be the insured person. In the insurance terms and conditions we refer to the insured person and the policyholder as you and your'. If we are only referring to the policyholder, and not the insured person, we say you (the policyholder) and your (the policyholder s). Independent treatment centre (ZBC) See Institution for specialist medical care. Neurologist A doctor registered as a neurologist in the register of Specialists of the Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst and who focuses on psychiatric disorders that can be considered a brain disorder. Hospital CHAPTER A Page 16

19 See Institution for specialist medical care. Healthcare insurer An insurance company that is acknowledged as such and that offers healthcare insurance. The insurance company to which these insurance terms and conditions apply is the insurance company referred to as such in the policy. In these insurance terms and conditions the insurance company is referred to as we and us. Healthcare insurance insurance approved as healthcare insurance by the NZa in the sense of the Health insurance Act. A.2. BASIS OF YOUR HEALTHCARE INSURANCE A.2.1. Basis You have taken out an insurance policy with us. The agreement is laid down by us in the policy. We send this policy to you once a year. A.2.2. Compulsory insurance You can take out healthcare insurance with us if you are required to be insured under the Dutch Health Insurance Act. A.2.3. Basis of your insurance Your insurance is based on: a. these insurance terms and conditions; b. the application form and the details that you or a third party have filled in; c. the information and statements we received when you took out the insurance with us. You or a third party will have given this information; d. the policy and the policy endorsements; e. any additional or collective contracts, where relevant. A.2.4. Basis of healthcare insurance The health insurance is furthermore based on: a. the Health Insurance Act; b. the Health Insurance Decree; c. the Health Insurance Regulations; d. the clarification of this legislation; e. interpretations by the Board of Health Insurers (CVZ) (so-called 'standpoints'). If these insurance terms and conditions differ from one or more rules on the basis of the law, explanations or interpretations referred to, the law, explanations and interpretations shall take precedence. A.2.5. Information from third parties We assume that the information given to us by a third party about your insurance application is known to you, and we regard the information as being provided by you. A.2.6. Contractual party We only regard you (the policyholder) as our contractual party with an insurance. Only the policy holder may cancel or amend the insurance. A.2.7. Checking the policy We assume that the details on your application originate from you. You must check the details on the policy carefully. If any the details on the policy are incorrect or incomplete then you must tell us within 30 days of receiving the policy. If you do not contact us within this period we will assume that the details are correct and complete. A.2.8. Your pass After you have registered with us, we send you your health insurance policy and a policy card. On presentation of this pass you can be given healthcare by the care providers with whom we have an agreement and/or to whose care you are entitled according to the insurance terms and conditions. A.2.9. Valid insurance terms and conditions Your policy states the insurance terms and conditions that apply. If you are of the opinion that another version of the insurance terms and conditions, the cover statement and/or any supplements are valid or that another text is effective, the rule is that only the text and contents of the versions effective at that time and in our possession apply. A Other languages Apart from Dutch, we can also issue our insurance terms and conditions in one or more other languages. If there are any differences in the content or interpretation between the Dutch version and the one in the other language, only the wording and content of the Dutch versions in our possession apply. A What will we send you? When you take out insurance with us for the first time or when the insurance terms and conditions, the basic premium and/or the reimbursement changes, we will send you: a. the new policy. We will also tell you the date on which the new policy comes into effect. Your old policy will no longer be valid from this date; b. the new insurance terms and conditions and a CHAPTER A Page 17

20 new cover statement (on request). We will indicate the date on which the new insurance terms and conditions and the new cover statement come into effect. This will almost always be the time your new policy comes into effect. The old insurance terms and conditions and the old cover statement will no longer be valid from that date; c. a supplement to your existing insurance terms and conditions and existing cover statement (on request). We shall tell you the date on which the supplement comes into effect. This will almost always be the time your new policy comes into effect. The supplement will also be valid in addition to your existing insurance terms and conditions and existing cover statement from this date. You will find the insurance terms and conditions and cover statements on our website. A.3. CONTENT AND SCOPE OF YOUR INSURANCE See also clause A.0.1. A.3.1. Healthcare mediation You are entitled to care advice and mediation. Also when the required care is not expected to be provided in time or not at all. Not being able to provide the care in time or at all also means that the care can only be provided at a considerable distance from your place of residence or the care cannot be provided in the vicinity of the insured person's place of residence in a qualitatively suitable manner. A.3.2. Content and amount of care A general insurance can be healthcare insurance but also other insurance (a non-healthcare insurance). The content of your health insurance is determined by the government. We determine the content of the non-healthcare insurance and the additional insurance. The cover you are entitled to is stated in these insurance terms and conditions. This cover comprises healthcare that meets the following requirements: a. the content and scope of this care are determined by the state of the art and practice, or by what the relevant discipline deems to be responsible and adequate care and services; and b. it is care such as the care providers of the relevant professional group strive to provide according to their norms and view as acceptable care; and c. the care is referred to as insured care in the cover statement of your policy and set out and described in Chapters B or D of these insurance terms and conditions; and d. in view of your diagnosis you are reasonably reliant on such care in terms of content and extent. The care to be provided must be appropriate. Example: There must be sufficient (reliable) evidence clearly showing that the healthcare is sound and safe (in the long term). We will consider all available scientific information. The care must also be efficiently targeted. This means that it must concern adequate care for your situation. There must be an indication for the healthcare, and it must not be unduly expensive. A.3.3. Provisional care Contrary to clause A.3.2. parts b. and c. the cover also includes the care and services designated for a specific period under the Healthcare Insurance Regulation. The terms and conditions of the regulation apply to such care. A.4. START AND DURATION OF YOUR INSURANCE A.4.1. Commencement date The insurance commences on the date on which we receive your request for insurance with us. If at this time you are still insured with another healthcare insurer, and you indicate in your request that you want the health insurance to commence at a later date, the insurance will commence at that later date. The commencement date of your insurance is shown on your policy. A.4.2. Request for amendment You request for insurance with us is also regarded as a request to cancel any similar insurance you have with us. If you ask to take out general healthcare insurance with another insurer, we will regard your request as a request to cancel the healthcare insurance you have with us from the time we receive a copy of your request. A.4.3. Insured with retroactive effect There are situations in which we register you with retroactive effect: a. if your health insurance commences not more CHAPTER A Page 18

21 than four calendar months after you were required to be insured, the commencement date will be the day on which you were required to be insured; b. if you take out the insurance with us within one calendar month of having cancelled your insurance with another health insurer because they changed the insurance terms and conditions, or because the year had ended, your (additional) (health) insurance will commence with us on the first day after your old health insurance has ended. A.4.4. Duration of insurance Your insurance is valid for one full calendar year. We will annually extend the insurance automatically. We will notify you annually and specify any changes before the extension comes into effect. That is the time when you can change or cancel your insurance. A.5. WHEN CAN YOU CANCEL OR AMEND? A.5.1. Revocation of your insurance You (the policyholder) can cancel your insurance by revoking it, without incurring costs and without specifying a reason. This is subject to the following conditions: a. you must inform us of the revocation in writing, clearly stating your name, address and the insurance you wish to revoke; b. we must receive the revocation within 14 days of commencement of the insurance. If the insurance has not yet commenced, the revocation must be provided within 14 days of your receipt of the policy. If you do not comply with these insurance terms and conditions, we cannot cancel the health insurance through revocation. We will end the insurance with retroactive effect up to and including the day on which the health insurance commenced. If you have already paid us the premium for the insurance, we will pay you back within thirty days of receipt of your revocation. If you have made any costs and had them reimbursed between the commencement date of the insurance and the date of revocation, you must pay us back within thirty days of receiving our specification. A.5.2. With effect from a new year You (the policyholder) can cancel or amend your insurance each year. We must receive your cancellation or amendment in writing on 31 December at the latest. If we receive it later, the insurance will remain in effect for another year and end on 1 January. In case of an amendment you take out another replacement insurance after our authorisation. Your current insurance will then end as of the following 1 January. A.5.3. Change in the insurance terms and conditions We are entitled to change our insurance terms and conditions. If the change is to your disadvantage, you (the policyholder) are entitled to cancel or amend the insurance. Cancellation should take place in writing. You will in any case have 30 days to do this after we tell you of the change. Your insurance will end on the day the amendment comes into effect. The right to cancel or amend the insurance does not apply if the amendment of the insurance terms and conditions is legally stipulated. A.5.4. Change in the premium If we change the basic premium we will notify you at least six weeks beforehand. If we increase the basic premium, you (the policyholder) are entitled to cancel your insurance from the day we make this announcement to the day on which the increase comes into effect. Cancellation should take place in writing. Your insurance will end on the day the increase in basic premium comes into effect. A.5.5. Change of employer If you (the policyholder) are in a collective insurance scheme with an employer and you start working without interruption for another employer with a different collective insurance scheme, you (the policyholder) can cancel your collective insurance with your old employer during the course of the year. You (the policyholder) can cancel the old collective insurance in writing from the day your old employment ends and up to thirty days after your new employment starts. Your new collective insurance commences on the first day of employment with your new employer if this is the first day of the calendar month, otherwise on the first day of the calendar month following the start of your new employment. Your old collective insurance ends the same day, as does the reduction in premium and other collective agreements that form part of your old collective insurance. A.5.6. End of the insurance for someone else CHAPTER A Page 19