Private Healthcare Insurance

Transcription

1 Private Healthcare Insurance Insurance with Comprehensive health declaration General terms and conditions, 1 January 2012 Joint insurance terms and conditions for: Lifeline Basic Lifeline Access Lifeline Plus Lifeline Excellent How to contact Skandia For questions regarding insurance agreements and risk assessment: Tel.: Tel.: (from abroad): privatvard@skandia.se Skandia Document Handling R812 SE Stockholm, Sweden For planning and booking of care in Sweden, and questions on claims settlement: Tel.: Tel.: (from abroad): Fax (Skandia Healthcare Planning): When booking more extensive care abroad, contact shall always be made with: SOS International, skandia.se Lifeline Basic Options: Referral requirement Health examination Healthcare advice Healthcare planning Healthcare guarantee Private physician's care Operations and in-patient hospital care Aftercare/rehabilitation Patient copayments Physiotherapy/naprapathy/chiropractic care, 10 visits per claim & year Dietician, 5 visits per claim Medical devices Travel and lodging Lifeline Access Options: Referral requirement Health examination Psychologist/psychotherapist, 10 visits per claim Medicines Post-operative home care Second opinion Healthcare advice Healthcare planning Healthcare guarantee Private physician's care Operations and in-patient hospital care Aftercare/rehabilitation Patient copayments Physiotherapy/naprapathy/chiropractic care, 10 visits per claim & year Dietician, 5 visits per claim Medical devices Travel and lodging Lifeline Plus Options: Health examination Healthcare when residing abroad Healthcare coach Speech therapist, 10 visits per claim Weight programme Healthcare during temporary travel abroad Eye examinations Vaccinations Psychologist/psychotherapist, 10 visits per claim Medicines Post-operative home care Second opinion Healthcare advice Healthcare planning Healthcare guarantee Private physician's care Operations and in-patient hospital care Aftercare/rehabilitation Patient copayments Physiotherapy/naprapathy/chiropractic care, 10 visits per claim & year Dietician, 5 visits per claim Medical devices Travel and lodging Lifeline Excellent Options: Healthcare when residing abroad Health examination Vaccinations prior to travel abroad Travel service for operation abroad Added costs for in-patient hospital care Substance abuse treatment Healthcare coach Speech therapist, 10 visits per claim Weight programme Healthcare during temporary travel abroad Eye examinations Vaccinations Psychologist/psychotherapist, 10 visits per claim Medicines Post-operative home care Second opinion Healthcare advice Healthcare planning Healthcare guarantee Private physician's care Operations and in-patient hospital care Aftercare/rehabilitation Patient copayments Physiotherapy/naprapathy/chiropractic care, 10 visits per claim & year Dietician, 5 visits per claim Medical devices Travel and lodging

2 SKANDIA'S PRIVATE HEALTHCARE INSURANCE What is the insurance protection? What does the insurance cover? LIFELINE BAS LIFELINE ACCESS LIFELINE PLUS LIFELINE EXCELLENT What options are available? Referral requirement Health examination Healthcare when residing abroad What doesn't the insurance cover? Pre-existing illness or accidental injury Certain illnesses and accidental injuries Certain care and certain treatment, etc Doctors' certificates Missed or late cancellation of appointments, treatments or operations Treatment by unlicensed care providers and treatments that are not based on scientific grounds Prescription glasses, medical devices, contraceptives Costs covered by other means Senior care Worsening of injury Are there other limitations? HOW DO I USE THE INSURANCE? What do I do when in need of care? For illness or accidental injury in Sweden For illness or accidental injury during temporary travel abroad For illness or accidental injury when the insurance applies with the complementary cover Healthcare when residing abroad How do I report an illness or accidental injury? GENERAL CONTRACT STIPULATIONS Who can be a policyholder? Who is insured? Is any health examination required? Who can be insured? How is proof of insurance notified? When does the insurance come into force? Where is the insurance valid? Is Skandia's liability limited to a specific amount? Is there any deductible? How long is the liability period? The insurance contract When do premiums need to be paid? Cancellation due to delinquent premium payment Reinstatement The policyholder's and insured's disclosure obligation Reservation for changes in the validity and scope of the insurance, and obligation of the policyholder to notify Skandia about changes in conditions regarding the insured Skandia's right to prematurely cancel or amend the insurance Date for payment of claims and interest stipulations Statute of limitations Definitions Information Contesting decisions on insurance matters Information on the handling of personal data

3 Who is the insurance provider? The insurance provider is Skandia Insurance Company Ltd (publ), referred to in these terms and conditions as Skandia. Skandia's address can be found on the first page of these terms and conditions. SKANDIA'S PRIVATE HEALTHCARE INSURANCE For definitions, see page What is the insurance protection? The insurance provides private healthcare in accordance with point 2 for illness or accidental injury ("insurance events") that take place during the term of the insurance. 2 What does the insurance cover? The insurance statement of policy states which of the following types of insurance the insured is covered by: Lifeline Basic Lifeline Access Lifeline Plus Lifeline Excellent The insurance can be purchased with different options, according to point 3. The choice of insurance affects the scope of the insurance elements described below. 2.1 LIFELINE BASIC Lifeline Basic Options: Referral requirement Health examination Healthcare advice Healthcare planning Healthcare guarantee Private physician's care Operations and in-patient hospital care Aftercare/rehabilitation Patient copayments Physiotherapy/naprapathy/chiropractic care, 10 visits per claim & year Dietician, 5 visits per claim Medical devices Travel and lodging Healthcare advice The insurance gives the insured and the insured's children the right to healthcare advice by phone, 24 hours a day, from a registered nurse referred by Skandia Healthcare planning The insured has access to healthcare planning. By healthcare planning is meant that a registered nurse provides assistance in planning and booking of healthcare within Skandia's network of private healthcare providers Healthcare guarantee The insurance gives the insured the right to a healthcare guarantee. By healthcare guarantee is meant that, in the event of an indemnifiable insurance event that requires an operation or admission to a hospital for in-patient hospital care, the insured has the right to be admitted to a hospital in Skandia's network of private healthcare providers within 20 days. If the healthcare guarantee is not met, from the 21st day the insured will receive SEK 300 per day until the day of admission for operation or in-patient hospital care. Compensation will be paid for a maximum of 30 weekdays per insurance event. If the insured is admitted by a healthcare provider on several occasions prior to an operation or for in-patient hospital care, the healthcare guarantee applies only for the first occasion on which the insured was admitted. The term of the healthcare guarantee begins from the date when Skandia has received complete medical documentation, when the right to operation or in-patient hospital care was acquired, and 3

4 when the person claiming compensation has fulfilled his/her obligations according to points 5 and 6. The healthcare guarantee does not apply if an operation or in-patient hospital care must be delayed for medical reasons, if the insured does not accept an offered time for an operation or admission for inpatient hospital care, or if the insured chooses another operation or in-patient hospital care alternative. The healthcare guarantee applies only for operations and in-patient hospital care provided by a healthcare provider in Sweden referred by Skandia Private physician's care The insured has access to examinations and treatment performed by a physician at a healthcare clinic within Skandia's network of private healthcare providers. Physician's care must reasonable and necessary, and must always be booked via Skandia Healthcare Planning Operations and in-patient hospital care The insured has access to pre-operative examinations, surgical operations, in-patient hospital care. Pre-operative examinations, surgical operations and in-patient hospital care are provided at any of the hospitals or clinics that are included in Skandia's network of private healthcare providers, or at any other hospital that is more suitable from a therapeutic standpoint. The right to an operation or in-patient hospital care commences when a medical investigation has been completed and the attending physician has issued a referral for an operation or in-patient hospital care. The care must be approved in advance by Skandia Aftercare rehabilitation The insurance gives the insured the right to aftercare and rehabilitation at any of the hospitals or clinics included in Skandia's network of private healthcare providers referred by Skandia in connection with an indemnifiable operation or in-patient hospital care in accordance with point Compensation is paid for a maximum of one aftercare or rehabilitation period for each insurance event, as follows: if the aftercare/rehabilitation pertains to outpatient treatment care, the insurance will pay benefits for a maximum of two months for each insurance event, starting from the date when the aftercare/rehabilitation was begun; if the aftercare/rehabilitation pertains to treatment that includes an overnight stay, the insurance will pay benefits for a maximum of 21 days for each insurance event; if the aftercare/rehabilitation pertains to physiotherapy, the insurance will pay benefits for a maximum of ten treatment sessions for each insurance event above and beyond the treatment provided under point The aftercare and rehabilitation must have been preceded by a medical investigation and referral from the attending physician, and shall be performed at the insured's town/city of residence. If it is urgent from a therapeutic perspective, they can be performed at another location. Compensation will be paid only for costs approved in advance by Skandia Patient copayments The insurance covers costs for publicly financed healthcare according to the compensation elements included in the insurance and that are within the scope of the socalled medical cost ceiling level (högkostnadsskyddet). Compensation is provided up to the medical cost ceiling level. 4

5 2.1.8 Treatment by physiotherapist, naprapath or chiropractor The insurance covers costs for treatment by a physiotherapist, naprapath or chiropractor under referral from an attending physician. The right to compensation requires that such referral is not older than six months. Compensation is paid for a maximum of ten treatment sessions per insurance event and year. A double session is counted as two treatment sessions. Treatment must be provided by any of the physiotherapists, naprapaths or chiropractors referred by Skandia and included in Skandia's network of private healthcare providers Dietician The insurance covers costs for treatment by a dietician under referral from an attending physician. The right to compensation requires that such referral is not older than six months. Compensation is paid for a maximum of five treatment sessions per insurance event. Treatment must be provided by a dietician referred by Skandia and included in Skandia's network of private healthcare providers Medical devices The insurance covers costs for medical devices prescribed by an attending physician that can be considered to be reasonable and necessary for the healing of the illness or accidental injury. No compensation is paid for medical devices intended for permanent use. The cost must be approved in advance by Skandia Travel and lodging The insurance covers necessary and reasonable travel and lodging costs incurred by the insured in connection with an indemnifiable treatment. Compensation is paid for travel that exceeds 50 km. per one-way journey. In such cases, the insurance pays compensation for the entire travel cost. The limit does not apply for travel to and from an operation. In addition, in cases where the insured requires a major operation, the insurance pays compensation for travel and lodging costs incurred by an assistant. Skandia must be contacted for approval prior to the start of any travel. By major operation is meant an operation that is judged by Skandia to be medically complicated and require extensive care. 2.2 LIFELINE ACCESS Lifeline Access Options: Referral requirement Health examination Psychologist/psychotherapist, 10 visits per claim Medicines Post-operative home care Second opinion Healthcare advice Healthcare planning Healthcare guarantee Private physician's care Operations and in-patient hospital care Aftercare/rehabilitation Patient copayments Physiotherapy/naprapathy/chiropractic care, 10 visits per claim & year Dietician, 5 visits per claim Medical devices Travel and lodging Lifeline Access covers, in addition to the cover provided by Lifeline Basic, also the following insurance elements: Treatment by psychologist or psychotherapist The insurance covers costs for treatment by a psychologist or psychotherapist under a referral from an attending physician. The right to compensation requires that the referral is not older than six months. Compensation is paid for a maximum of ten sessions per insurance event with any of the psychologists or psychotherapists referred by Skandia and included in Skandia's network of private healthcare providers Medicines The insurance covers patient copayments for prescription medicines within the scope of the so-called medical cost ceiling level (högkostnadsskyddet) and the insurance. Compensation is provided up to the medical cost ceiling level Post-operative home care The insurance gives the insured the right to a maximum of ten hours (incl. travel time) of necessary and reasonable home care for a period of 14 days after the insured has returned home from an indemnifiable operation. This is subject to the condition that the home care can be obtained from an established firm in the insured's town/city of residence. The right to home care must be approved in advance by Skandia. 5

6 2.2.4 Second opinion The insurance gives the insured the right to a second opinion, entailing that an insured who is facing a difficult medically related decision has the right in some cases to seek a second medical opinion from a specialist physician. The insured can have the right to a second opinion in the following situations: for a life-threatening or especially serious illness or injury, or if the insured is facing the decision of subjecting him-/herself to an especially high-risk treatment, i.e., if the treatment itself could be life-threatening or cause permanent pain and suffering in addition to the disease/condition being treated. Skandia must approve the right to seek a second opinion in advance. 2.3 LIFELINE PLUS Lifeline Plus Options: Health examination Healthcare when residing abroad Healthcare coach Speech therapist, 10 visits per claim Weight programme Healthcare during temporary travel abroad Eye examinations Vaccinations Psychologist/psychotherapist, 10 visits per claim Medicines Post-operative home care Second opinion Healthcare advice Healthcare planning Healthcare guarantee Private physician's care Operations and in-patient hospital care Aftercare/rehabilitation Patient copayments Physiotherapy/naprapathy/chiropractic care, 10 visits per claim & year Dietician, 5 visits per claim Medical devices Travel and lodging Lifeline Plus covers, in addition to the cover provided by Lifeline Basic and Lifeline Access, also the following insurance elements: Healthcare coach The insurance gives the insured the right to a healthcare coach. By healthcare coach is meant that the insured has contact with a registered nurse at Skandia Healthcare Planning who monitors the course of events surrounding the insured's illness or accidental injury. The aim of a healthcare coach is to help the insured have greater participation in and understanding for his/her illness and its consequences, and to gain insight into how the healthcare process works. The right to a healthcare coach exists: when several care providers in different healthcare areas are involved in the medical investigation and treatment, when several diagnoses have been made, for life-threatening or particularly serious illnesses or injuries, for a diagnosis that is unclear or not yet identified and requires an extended investigation. By healthcare coach is not meant medical care. Skandia determines if the insured has the right to a healthcare coach Treatment by a speech therapist The insurance gives the right to treatment by a speech therapist under a referral from an attending physician. The right to compensation requires that such referral is not older than six months. Compensation is paid for a maximum of ten treatment sessions per insurance event. Treatment is provided by any of the speech therapists referred by Skandia and included in Skandia s network of private healthcare providers Weight programme The insurance gives the insured the right to treatment for weight problems if the insured has a BMI (Body Mass Index) higher than 35 or lower than 18.5, under a referral from an attending physician. The right to compensation requires that such referral is not older than six months. Treatment is provided by any of the private healthcare providers referred by Skandia and included in Skandia s network of private healthcare providers. The insurance pays compensation only for one treatment period that has been started regardless of diagnosis until the insured reached the final age for the insurance. 6

7 Compensation is paid for one of the following alternatives for a BMI above 35: surgical treatment with follow-up for two years, or a weight reduction programme with follow-up for one year, or psychologist care (20 treatment sessions), physiotherapy (10 treatment sessions) and dietician (10 treatment sessions). Compensation is paid for one of the following alternatives for a BMI under 18.5: in-patient care, or psychologist care (20 treatment sessions), physiotherapy (10 treatment sessions) and dietician (10 treatment sessions) Care for temporary travel abroad The insurance is valid during the first 45 days starting from the date of departure if the insured suffers an acute illness or accidental injury during a temporary stay outside of the zone stipulated in the insurance statement of policy. The insurance covers necessary and reasonable costs for emergency care by a doctor or hospital. In addition, the insurance covers costs for prescription medicines and necessary and reasonable travel to and from the care provider at the place of visit. If it is not possible to travel home for medical reasons, the insurance is valid until the insured's condition has improved to such a degree that the insured can travel home. In such case, a certificate is required from the attending physician. The insurance does not cover costs for travel home in connection with an illness or accident during a stay abroad. For treatment of an illness or accidental injury abroad, the insurance amount is limited to SEK 3,000,000 per insurance event. The same applies when the care and treatment of such illness or accidental injury continues in Sweden and the insured is de-registered from Försäkringskassan Eye examinations The insurance covers one eye examination per insurance year by a licensed optometrist. The insured shall book and pay for the cost of the eye examination him-/herself. Skandia will reimburse the cost of the eye examination after a claim and original receipt have been sent to Skandia. The cost for travel in connection with an eye examination is not covered by the insurance Vaccinations The insurance covers the following vaccinations: seasonal influenza TBE (tick-borne encephalitis). The insured shall book and pay for the cost of the vaccination him-/herself. Skandia will reimburse the cost of the vaccination after a claim and original receipt have been sent to Skandia. The cost for travel in connection with vaccinations is not covered by the insurance. 7

8 2.4 LIFELINE EXCELLENT Lifeline Excellent Options: Healthcare when residing abroad Health examination Vaccinations prior to travel abroad Travel service for operation abroad Added costs for in-patient hospital care Substance abuse treatment Healthcare coach Speech therapist, 10 visits per claim Weight programme Healthcare during temporary travel abroad Eye examinations Vaccinations Psychologist/psychotherapist, 10 visits per claim Medicines Post-operative home care Second opinion Healthcare advice Healthcare planning Healthcare guarantee Private physician's care Operations and in-patient hospital care Aftercare/rehabilitation Patient copayments Physiotherapy/naprapathy/chiropractic care, 10 visits per claim & year Dietician, 5 visits per claim Medical devices Travel and lodging Lifeline Excellent covers, in addition to the cover provided by Lifeline Basic, Lifeline Access and Lifeline Plus, also the following insurance elements: Health examination The insurance covers the cost of a health examination every other year. The first examination is conducted during the second insurance year; thereafter, an examination can be conducted every other year. The insured receives a letter entitling him or her to the health examination during the current insurance year. If the insured does not use the opportunity to undergo a health examination, no compensation will be paid and no premium will be refunded. The date of the health examination cannot be moved to another insurance year. By health examination is meant lab tests taken by a nurse and a doctor's examination entailing a review of the test results. If the insured is enrolled in zone 2 or 3, the health examination can be conducted abroad. The insurance pays compensation for a maximum of SEK 2,500 for a health examination, verified by original receipt. The cost for travel to and from a health examination is not covered by the insurance Vaccinations prior to travel abroad The insurance covers vaccinations prior to travel abroad. The vaccination must be medically necessary for the travel destination. The insured shall book and pay for the cost of the vaccination him-/herself. Skandia will reimburse the cost of the vaccination after a claim and original receipt have been sent to Skandia. The cost for travel in connection with vaccinations is not covered by the insurance Travel service for operation abroad The insurance gives the insured the right to travel service in association with an operation abroad. By travel service is meant that Skandia will provide assistance in booking flights and hotel accommodations for the insured and an accompanying assistant. The cost must be approved by Skandia in advance Added costs for in-patient hospital care The insurance covers added costs for indemnifiable in-patient hospital care in an amount of SEK 100 per day if the insured is admitted to a hospital overnight. Compensation will be paid for a maximum of 100 days per insurance event Substance abuse treatment The insurance covers costs for an uninterrupted treatment period for diagnosed abuse of alcohol, narcotics, medicine or for gaming addiction, under the condition that the treatment is medically motivated. The treatment must be referred and approved by Skandia in advance, and must be performed in Sweden. The insurance does not cover costs that arise within one year from the date that the insurance first came into force. The insurance covers only one treatment period, regardless of diagnosis, until the insured reaches the maximum age stipulated for the insurance. 8

9 3 What options are available? 3.1 Referral requirement The policyholder can choose Referral requirement upon purchase of Lifeline Basic and Lifeline Access insurance. The insurance statement of policy specifies if the insurance is contracted with Referral requirement. Referral requirement entails that the insurance does not cover any costs for care until a referral has been issued to a physician in specialist care. When in need of care, the insured shall always turn to a primary care physician. The primary care physician shall perform a basic medical examination and/or treatment as incumbent upon him/her as the attending physician. What is included in a basic medical examination/treatment depends on the illness at hand and can include, e.g., lab tests, radiological exams, treatment or other examination. If the care responsibility is to be transferred to specialist care, the attending physician in primary care thereafter issues a referral to a physician in specialist care. When a referral to a specialist physician has been issued, the insurance covers treatment by any of the specialist physicians referred by Skandia and included in Skandia's network of private healthcare providers. The insured shall contact Skandia Healthcare Planning, who will provide assistance in planning and booking the care. The specialist physician shall thereafter, where necessary, issue further referrals, such as to a physiotherapist, naprapath, chiropractor, psychologist, operation or in-patient hospital care. The insurance does not cover costs for the basic medical examination. 3.2 Health examination The policyholder can choose to complement Lifeline Basic, Lifeline Access and Lifeline Plus insurance with Comprehensive or Standard health examination Comprehensive health examination The insurance covers the cost of a comprehensive health examination every other year. The first examination is conducted during the second insurance year; thereafter, an examination can be conducted every other year. The insured receives a letter entitling him or her to the health examination during the current insurance year. If the insured does not use the opportunity to undergo a health examination, no compensation will be paid and no premium will be refunded. The date of the health examination cannot be moved to another insurance year. By comprehensive health examination is meant lab tests taken by a nurse and a doctor's examination entailing a review of the test results. The health examination shall be referred by Skandia and can only be performed in Sweden. The cost for travel to and from a health examination is not covered by the insurance Standard health examination The insurance covers the cost of a standard health examination every other year. The first examination is conducted during the second insurance year; thereafter, an examination can be conducted every other year. The insured receives a letter entitling him or her to the health examination during the current insurance year. If the insured does not use the opportunity to undergo a health examination, no compensation will be paid and no premium will be refunded. The date of the health examination cannot be moved to another insurance year. 9

10 By standard health examination is meant lab tests taken by a nurse. A doctor compiles the results, which are conveyed to the insured in writing. The health examination shall be referred by Skandia and can only be performed in Sweden. The cost for travel to and from a health examination is not covered by the insurance. 3.3 Healthcare when residing abroad The policyholder can choose Healthcare when residing abroad for Lifeline Plus and Lifeline Excellent insurance. Healthcare when residing abroad is valid in Europe (zone 2) or worldwide (zone 3). If the insurance is contracted with Healthcare when residing abroad, the insurance covers emergency and planned care in accordance with the respective benefits provided by Lifeline Plus or Lifeline Excellent in the applicable zone. In addition, the insurance covers costs for prescription medicines, and necessary and reasonable travel to and from the care provider in the city/town of residence. The insurance does not cover costs for travel to Sweden in connection with an illness or accident while residing abroad. For treatment of an illness or accidental injury abroad, the insurance amount is limited to SEK 3,000,000 per insurance event. The same applies when the care and treatment of such illness or accidental injury continues in Sweden and the insured is de-registered from Försäkringskassan. Persons eligible to apply for insurance with the option Healthcare when residing abroad are defined in points What doesn't the insurance cover? The following limitations apply for all forms of Private Healthcare insurance. 4.1 Pre-existing illness or accidental injury The insurance does not cover illness or accidental injury that the insured had symptoms of or received care for or medication for before the insurance came into force. 4.2 Certain illnesses and accidental injuries The insurance does not cover: accidental injury caused by the insured's use of alcohol, other intoxicants, sleeping medication or narcotic substances, illness or accidental injury caused by the insured's participation in sports or a sporting event, so-called multisport or training at a level that is not to be regarded as exercise or recreational activity of a normal extent and intensity, e.g., participation in sports at division II or higher, at a sports-oriented secondary school or other education with a sport orientation, illness or accidental injury sustained from participation in motor sports and adventure sports, such as kite sailing, skydiving, bungee-jumping, river rafting/kayaking, mountain climbing, diving and off-piste skiing, illness or accidental injury sustained from participation in wrestling, boxing or other martial art in which punching/kicking or similar occur, illnesses covered by the Communicable Diseases Act, injury sustained from a nuclear explosion or radioactive radiation, healthcare, operation or other compensation for obesity or inanition, and consequences resulting from such, with the exception of point Dietician and point Weight programme, eating disorders and consequences from such, with the exception of points and

11 4.3 Certain care and certain treatment, etc. The insurance does not cover: emergency care. However, the insurance covers patient copayments within the limit of the medical cost ceiling level (högkostnadskyddet) for emergency care under the condition that the insurance was not purchased with the option Referral requirement, emergency care during temporary travel abroad for Lifeline Plus and Lifeline Excellent, and emergency care if the insurance includes complementary Healthcare when residing abroad, certain, special forms of treatment that cannot be offered by private healthcare providers in Sweden. However, the insurance pays compensation for patient copayments within the medical cost ceiling level, care for such deterioration of health condition which, according to medical experience, is due to various forms of abuse, such as abuse of alcohol, narcotic substances, medicines, doping agents, or gaming addiction or similar, except for Substance abuse treatment according to point 2.4.5, care for dementia-related diseases, i.e., pathological changes in brain tissue, organ transplants and consequences of such, dialysis treatment, dental treatment, treatment of dental diseases or dental injury, regardless of cause, surgical procedures including laser surgery designed to correct vision, treatment of snoring, unless examination shows that the insured suffers from moderate to severe sleep apnoea, treatment of, and complications in connection with or after pregnancy, childbirth, abortion or fertility examinations, and treatment of infertility, cosmetic treatments and operations or consequences of such, massage, preventive care, actions and check-ups, except for vaccination and health examinations in accordance with points 2.3.6, 2.4.1, and Doctors' certificates The insurance does not cover: costs for doctors' certificates that have not been requested by Skandia. 4.5 Missed or late cancellation of appointments, treatments or operations The insurance does not cover: care costs that arise when the insured misses a booked appointment, treatment or operation. In such cases the cost shall be paid for by the insured. The same also applies if the insured cancels a booked appointment, treatment or operation less than 24 hours prior to the contracted time, unless otherwise stated by any confirmation from the care provider. 4.6 Treatment by unlicensed care providers and treatments that are not based on scientific grounds The insurance does not cover: treatments performed by unlicensed care providers, alternative forms of therapy that are not based on scientific grounds and tested experience and that are not under the supervision of the National Swedish Board of Health and Welfare. 4.7 Prescription glasses, medical devices, contraceptives The insurance does not cover: prescription glasses and contact lenses, contraceptives, including measures, check-ups and the consequences of such, hearing aids, 11

12 more than one pair of orthotic shoe inlays, other medical devices intended for permanent use. 4.8 Costs covered by other means The insurance does not cover: costs that can be covered by medical malpractice insurance or pharmaceutical insurance, or where there is a care provider or pharmaceutical liability. Nor is Skandia otherwise liable for injury incurred in connection with health or medical care, e.g. in connection with an examination, treatment, advice, nursing or medicines, costs compensated by other means according to law, statute, convention or collective agreement. 4.9 Senior care The insurance does not cover: senior care, i.e., care aimed at providing senior citizens with financial security, housing, medical devices and personal nursing, e.g., home care, "home Samaritans", home healthcare and assisted living Worsening of injury The insurance does not cover: care or costs attributable to a deterioration in the insured's health status, or an injury that could not heal/be treated because the insured did not follow the care provider's instructions or because of the insured's actions in general Are there other limitations? Force majeure Skandia is not liable for loss that may arise in the event there is a delay in the investigation of an insurance event or in the payment of benefits as a result of war, political unrest, legal statute, action of authorities or labour conflict War and political unrest The insurance does not apply for illnesses that are discovered within one year after staying in a country in which there is a state of war or unrest and that can be considered to be attributable to such war or unrest. If war or unrest should break out while the insured is staying in the area, the insurance applies during the first month under the condition that he/she does not participate in such war or unrest Compensation for legal counsel No compensation is paid for costs for legal counsel Compensation for interpreter No compensation is paid for costs for interpreters Double insurance If an interest covered by this insurance is insured for the same risk under another insurance, Skandia does not have any indemnification responsibility for an insurance event that has occurred. If the other insurance has a corresponding exclusion, a situation arises where a similar exclusion applies for both insurances. In such case the indemnification responsibility is split between the two insurances. 12

13 HOW DO I USE THE INSURANCE? 5 What do I do when in need of care? 5.1 For illness or accidental injury in Sweden In the event of an illness or accidental injury, the insured shall contact Skandia Healthcare Planning. If the insurance applies with Referral requirement, the insured shall always seek care from a physician in primary care. See description under point 3.l For illness or accidental injury during temporary travel abroad Care for temporary travel abroad applies only for Lifeline Plus and Lifeline Excellent. In the event of an acute illness or accidental injury, the insured shall book the care him- /herself with the care provider that is nearest to the insured's place of visit. The insured shall pay the cost of the doctor's visit, prescription medicine and reasonable travel to and from the care provider at the insured's place of visit. If the costs are covered by the insurance, Skandia will reimburse the costs when a claim and original receipts have been received by Skandia. For more extensive care that entails higher costs, such as in-patient hospital care or an operation, the insurer shall always contact SOS International in Copenhagen, phone In such case, care can only be provided by a care provider referred by SOS International. The limitations under point 4 also apply for temporary travel abroad, except for the limitation regarding emergency care. 5.3 For illness or accidental injury when the insurance applies with the complementary cover Healthcare when residing abroad In the event of an illness or accidental injury, the insured shall book the care him-/herself with the closest care provider in the insured's city/town of residence. The insured shall pay the cost of the doctor's visit, prescription medicine and reasonable travel to and from the care provider in the insured's city/town of residence abroad. If the costs are covered by the insurance, Skandia will reimburse the costs when a claim and original receipts have been received by Skandia. For more extensive care that entails higher costs, such as in-patient hospital care or an operation, the insurer shall always contact SOS International in Copenhagen, phone In such case, care can only be provided by a care provider referred by SOS International. The limitations under point 4 also apply for the option Healthcare when residing abroad, except for the limitation regarding emergency care. 6 How do I report an illness or accidental injury? A claim for illness or accidental injury shall always be made with Skandia as soon as possible. The condition for the right to compensation is that a claim has been filed and that the insurance claim has been approved by Skandia. The insured shall provide the information and certificates that Skandia requests and which Skandia deems necessary to determine the right to compensation and continued treatment. Skandia will reimburse the cost for certificates and examinations requested by Skandia. However, the insurance does not cover translation of documents to Swedish. Claims for compensation shall be verified with original receipts, which shall be sent to Skandia together with the claim. Skandia shall have referred and approved the care in advance. Approved costs can be invoiced to Skandia directly by the care provider. 13

14 If the insurance has lapsed and an insurance event occurred when the insurance was still valid, a claim shall be filed with Skandia as soon as possible. If treatment has been approved or begun before the insurance has lapsed, costs for the treatment will be compensated for, however, not longer than the point in time specified in point 16. At Skandia's request, the insured shall provide his or her consent for Skandia to obtain information from e.g., care providers, hospitals, Försäkringskassan or other insurance institution. GENERAL CONTRACT STIPULATIONS 7 Who can be a policyholder? An employer that is registered and has its operations in Sweden can be a policyholder. Such a policyholder does not have the right to access information about the insured's health status and insurance-related medical evaluation concerning the insured. A private person who is a resident of Sweden and registered with a Swedish social insurance office can be a policyholder. 8 Who is insured? The insurance applies for the person or persons stated on insurance statement of policy. 9 Is any health examination required? The insurance can only be contracted with Comprehensive health declaration. The health declaration shall be submitted by the person applying for the insurance. 10 Who can be insured? A person who has turned 16 but not 70 years of age has the right to apply for insurance. For persons under 18 years of age, written consent from a guardian is required. The premium is based on the insured's age on his or her next birthday. The insurance can be renewed annually for lifetime cover, however, the scope of the insurance cannot be expanded after the insured turns 70 years of age Employee An employee of an employer that is registered in Sweden and has its operations in Sweden can be insured. By employee is also meant part owners of partnerships (handelsbolag), limited partnerships (kommanditbolag), and owners of a registered sole proprietorship (enskild firma). By employee is also meant board members of limited liability companies (aktiebolag). The employee must be a resident of Sweden or Denmark and registered with a Swedish or Danish social insurance office. The employee must work in Sweden Coinsureds of an employee An employee's spouse/cohabitant and children can be insured during the time that the employee was covered by the insurance in accordance with point The coinsureds must be residents of Sweden and registered with a Swedish social insurance office Private persons A private person can be insured. The private person must be a resident of Sweden and registered with a Swedish social insurance office. 14

15 10.4 An employee who is not registered with Försäkringskassan An employee who is a resident of Sweden, but not registered with a Swedish social insurance office (försäkringskassa), can be insured with Lifeline Plus or Lifeline Excellent. The employee must be employed by an employer that is registered in Sweden and has its operations in Sweden. In such case, the application shall be complemented with a doctor's examination that is performed in Sweden. Skandia will reimburse the cost of such doctor's examination that serves as documentation for consideration of the insurance application Coinsureds of an employee who is not registered with Försäkringskassan A spouse/cohabitant and children of an employee who is not registered with Försäkringskassan can be insured with Lifeline Plus or Lifeline Excellent during the time that the employee is covered by the insurance in accordance with point The coinsureds must be residents of Sweden. In such case, the application shall be complemented with a doctor's examination that is performed in Sweden. Skandia will reimburse the cost of such doctor's examination that serves as documentation for consideration of the insurance application An employee who is a foreign citizen An employee who is stationed abroad can be insured with Lifeline Plus or Lifeline Excellent. By stationed abroad is meant an employed person who works abroad for an employer that is registered in Sweden, or a foreign employer that is a subsidiary that is owned by as Swedish company that is registered in Sweden. The employee must be a Swedish citizen with residence in Sweden and registered with a Swedish social insurance office at the time the stationing abroad began. For stationing abroad longer than 45 days in a row, the insurance must be expanded to apply in zone 2 or zone Coinsureds of an employee who is a foreign citizen The spouse/cohabitant and children of an employee who is stationed abroad can be insured with Lifeline Plus or Lifeline Excellent as long as the employee is covered by the insurance in accordance with point The coinsureds must be Swedish citizens with residence in Sweden and registered with a Swedish social insurance at the time the stationing abroad began. For stationing abroad longer than 45 days in a row, the insurance must be expanded to apply in zone 2 or zone Private persons residing outside Sweden A private person who is a Swedish citizen and who resides abroad can be insured with Lifeline Plus or Lifeline Excellent. By residence abroad is meant that the person lives at a permanent address abroad. The person must be a resident of Sweden and registered with a Swedish social insurance office at the time residence was taken up abroad. In cases of residence outside Sweden, the insurance must be expanded to apply in zone 2 or zone How is proof of insurance notified? The policyholder receives an insurance statement of policy that describes the scope of the insurance. The insured receives a confirmation of insurance that states the scope of the insurance. The insured also receives a personal card and information on how the insurance works. The card is sent to the insured after the premium has been paid. 15

16 12 When does the insurance come into force? The insurance, i.e., Skandia's liability, comes into force on the day the policyholder has applied for the insurance, under the condition that the application documents are complete, that the insurance, according to the assessment rules applied by Skandia, can be granted with normal terms and conditions, and that it is not stated in the application documents or in some other way that the insurance shall come into force at a later date. If the insurance cannot be granted at normal terms and conditions, but only with special terms and conditions, such as with a higher premium or with certain restrictions, then the insurance does not come into force until the day after Skandia has made an offer for insurance at these special terms and conditions, and the policyholder has accepted the offer. The policyholder is considered to have accepted the offer when the insurance premium is paid. Skandia's liability remains in force until the final day of the insurance period. 13 Where is the insurance valid? The insurance is valid for care in Sweden (zone 1). The insurance statement of policy states if the insurance is valid in another zone. For an employee who works in Sweden, is a resident of Denmark and is registered with a Danish social insurance office, the insurance is also valid for care in Denmark. 14 Is Skandia's liability limited to a specific amount? Skandia's liability is not limited to any specific amount for treatment of illnesses and accidental injuries in Sweden. However, for treatment of an illness or accidental injury abroad, Skandia's liability is limited to an amount of SEK 3,000,000 per insurance event. The same applies when the care and treatment of such illness or accidental injury continues in Sweden and the insured is de-registered from Försäkringskassan. 15 Is there any deductible? The insurance has no deductible. 16 How long is the liability period? The liability period remains in effect as long as the insurance is active. If the insurance lapses during an ongoing insurance event, the liability period is one year from the date of the claim under the condition that no new private healthcare insurance has been purchased from another insurance provider. In such case, the liability period ceases on the final day of insurance's validity. Several illnesses with a medical connection are considered to be a single insurance event. However, this does not apply if the insured has been symptom-free and has not received any care or medication for such illness for a period of more than 12 consecutive months. In such case, a new insurance event is considered to have occurred. 17 The insurance contract The stipulations indicated in the following apply for the insurance contract: the insurance statement of policy, these general insurance terms and conditions, and the provisions of the Insurance Contracts Act and Swedish law in general. The insurance period is one year. If another period has been agreed upon, the insurance period will be stated in the insurance statement of policy. 16

17 If the insurance contract is not cancelled, the contract will be renewed at the terms indicated by Skandia for one year at a time. Skandia thus has the right to change the insurance terms and conditions and premiums. If a change is made, it will apply with effect from the next annual due date. Skandia shall notify about any changes not later than when an invoice demanding payment of premium is sent out. Skandia also has the right in general to amend the terms and conditions of the insurance contract during the insurance period if the conditions for the contract change as a result of changed legislation or other statute, changed application of law or other statute, or by decree of an authority. The same applies if the policyholder or the insured has grossly neglected their obligations or other, special reasons necessitate a change. Such a change takes effect after Skandia has sent notification of the new terms and conditions, or at such point in time as required by law. For insurance purchased by an employer for the benefit of an employee, the employee cannot in any respect be regarded as the policyholder in application of the stipulations of the Insurance Contracts Act on information to the policyholder when an insurance contract has been purchased. Once a year during the insurance period and when the insurance is to be renewed, the policyholder shall provide information to the insured about the scope of the insurance terms, conditions and limitations, as well as about the insurance in general that is of significance for the insured to know about. The insurance cannot be contracted in connection with employment, pursuant to Ch of the Income Tax Act. Any disputes arising in connection with these insurance terms and conditions shall be settled in Swedish court and in accordance with Swedish law When do premiums need to be paid? The initial premium shall be paid not later than 14 days from the day Skandia has sent an invoice demanding payment of the premium. Premiums for subsequent premium periods shall be paid not later than one month from the day Skandia has sent an invoice demanding payment of the premium. However, if the premium period is one month, the premium shall be paid not later than the first day of the insurance period Cancellation due to delinquent premium payment If the premium is not paid on time and if the delay is for a significant period of time, Skandia may cancel the insurance. Such cancellation will take effect 14 days after the day notification of cancellation was sent out, unless the premium is paid during this grace period Reinstatement If a cancellation according to point 17.2 has taken effect and the delay does not pertain to the initial premium for a policy, the policy will be reinstated to its previous scope if the outstanding premium is paid within three months from the expiration of the grace period indicated in point If the insurance is reinstated, Skandia's liability comes into force starting with the day after the day on which the premium was paid The policyholder's and insured's disclosure obligation The policyholder and the insured are obligated, at Skandia's request, to disclose information that may have bearing on whether the insurance will be contracted, expanded or renewed. The policyholder and the insured shall provide truthful and complete answers to Skandia's questions. If any information that is provided is false or incomplete, the stipulations of the Insurance Contracts Act apply. If the insurance is cancelled or amended because Skandia has been found to be free from liability, Skandia has the right to demand recompense from the policyholder or the insured for any benefits paid. 17

18 Premiums paid in for the time up until the date on which the insurance lapses or is amended will not be repaid Reservation for changes in the validity and scope of the insurance, and obligation of the policyholder to notify Skandia about changes in conditions regarding the insured Point 10 above stipulates who can be insured. The validity and scope of the insurance are dependent on the conditions being met at any given time for who according to that point can be insured. Skandia reserves the right, as a result of such changes, to entirely cancel the insurance or change the scope of the insurance. It is incumbent upon the policyholder to notify Skandia as soon as possible about any change in conditions stipulated in point 10 above. If such notification is not made, Skandia's liability for an insurance event may be fully or partly limited Skandia's right to prematurely cancel or amend the insurance Pursuant to the Insurance Contracts Act, Skandia retains the right to due to the nature of the insurance or other special circumstance cancel or amend the insurance at the end of the premium period Date for payment of claims and interest stipulations Payment of benefits shall be made not later than one month after the right to compensation arises, and when the person making the claim for benefits has fulfilled his/her obligations in accordance with points 5 and 6. However, if there is reason to investigate if any information that has been provided pursuant to the insurance contract is false or incomplete, payment does not need to be made until one month after such an investigation has been concluded. The investigation shall be performed expediently. If payment is made later than what is said above, Skandia will pay penalty interest in accordance with the Interest Act. Other than this, Skandia is not liable for loss that may arise if an investigation of an insurance event or payment is delayed. Interest is not paid if the combined interest on the level of benefits attributable to one and the same insurance event is less than one-half per cent of the Price Base Amount for the year in which payment is made Statute of limitations A party that wants to make a claim for insurance benefits must commence action against Skandia within three years after gaining knowledge that a claim could be made, and in all cases within ten years from the date that such claim could first be made. Otherwise, the right to benefits expires. If a claim has been made to Skandia within this period of time, the grace period for the first sentence above is always six months from the time Skandia has declared that it has taken a final position with respect to the claim. 18

19 Definitions Accidental injury An accidental injury is a bodily injury sustained by the insured involuntarily as the result of a sudden, external event (external bodily trauma an accident). Basic medical investigation By basic medical investigation is meant, among other things, lab tests, examination, treatment or radiological examination. By basic medical investigation is also meant the lab tests or examinations performed under a referral from a primary care provider, where the primary care provider retains responsibility for the care. Cohabitant A person who, pursuant to the Cohabitees Act (Sambolagen (2003:376)), lives permanently with another person in a joint household in a marriage-like relationship, under the condition that neither of them is married or a registered partner. Date of claim By date of claim is meant the day on which the insured notified Skandia about an illness or accidental injury, under the condition that the illness or accidental injury is thereafter approved as an insurance event by Skandia. Diagnosis Determination of an illness, accident, impairment of body function. Emergency care By emergency care is meant such care that is provided for illness or accidental injury that requires immediate attention. Examples can include sudden chest or abdominal pain, and fractured bones requiring mobilisation or surgery. Healthcare By healthcare is meant in these terms and conditions medical measures that include examination, investigation, treatment, consultation or other care provided by a healthcare provider. Illness By illness is meant a deterioration of health condition that is not to be considered as an accidental injury as defined above. Illness is not considered to include voluntarily inflicted bodily injury. In-patient hospital care By in-patient hospital care is meant care that is provided to a patient when the patient has been admitted to a care facility for at least one night. In-patient hospital care does not include leaves from such facility. Insurance event By insurance event is meant an illness or accidental injury that occurs during the insurance period. An insurance event is considered to have occurred at the point in time at which an accident occurred, or at the point in time at which the insured's mental or physical function deteriorated due to an illness or accidental injury. Insurance period The insurance period is one year from the date of insurance contract's inception, unless otherwise stated in the statement of policy. At the expiration of the insurance period, the insurance contract is renewed for another year unless the contract has been cancelled prior to that. 19

20 Insurance year The insurance year is one year from the annual renewal date of the insurance policy. The annual renewal date is specified in the insurance statement of policy. Insured By insured is meant the person whose health the insurance applies for. The insured is also the person who receives care and other benefits under the insurance. Liability period The liability period is the time during which benefits can be paid for each insurance event. Outpatient care By outpatient care is meant such care that is provided at a clinic or hospital whereby the patient does not spend the night. Policyholder By policyholder is meant the party entering into the insurance contract with Skandia Insurance Company Ltd (publ). Premium period By premium period is meant in these insurance terms and conditions the time for which a premium has been paid. Examples: If the premium is paid monthly, then the premium period is one month. If the premium is paid annually, the premium period is one year. Primary care Public or private health and medical care that is the initial care level and which covers basic medical investigation, treatment, radiological examination and care as well as preventive work and rehabilitation without restriction with respect to illness, age or patient groups. The term primary care also applies to, among others, family doctors' offices, public healthcare centres, company health services, general practitioners in the national health care system or in private practice. Private healthcare By private healthcare is meant care that is not publicly financed via taxes. Referral By referral is meant a document that serves as an order of services or a request to take over care responsibility for a patient, e.g., a referral for additional examination or treatment. A referral may not be older than six months. Skandia's network By Skandia's network is meant the hospitals, clinics and healthcare providers' offices in the private healthcare sector and with which Skandia has co-operation agreements. Specialist care Public or private health and medical care that is the second care level and that covers medical investigation, treatment, and care that requires a more specialised approach and greater technical and human resources than primary care. Specialist care does not refer to company healthcare services or care provided by a physician with specialist expertise as a general practitioner, e.g., a family doctor. Spouse By spouse is meant the person with whom the insured is married. The concept of spouse also includes registered partner. 20