VGZ Gezin Package 2014 Supplementary insurance conditions. Manage everything online with My VGZ

Transcription

1 VGZ Gezin Package 2014 Supplementary insurance conditions Manage everything online with My VGZ

2 Welcome to VGZ These policy conditions contain everything you need to know about your supplementary insurance: the VGZ Gezin Package. A detailed explanation of the conditions is presented in the text blocks. More information is available at about your health insurance and supplementary insurance cover. If you have special wishes or suggestions for improvement related to healthcare, you are more than welcome to share them on our online platform: Deel het met VGZ (Tell it to VGZ). We are always looking for new insights to help us improve our service and value your opinion in this. After all, taking care of good care is something best done together. If there is anything you would like to tell us about, don t hesitate to visit Taking care of good care together My VGZ You can make changes to your insurance cover, view your claims and pay your premium contribution at My VGZ. Log in with your DigiD and discover the possibilities! Go to Current news items Would you like to stay up to date about the latest developments in healthcare, health and your insurance? Subscribe to the VGZ newsletter. Important information: You will find a list of telephone numbers and addresses at A list of contracted care providers is available at To request permission Sending invoices Treatment permission applications can be sent to: VGZ Postbus RS Eindhoven Consult these policy conditions to find out in which cases prior permission is required. To submit your claims conveniently online, simply log in at and follow the relevant procedure. You can also send the original invoice, accompanied by a claim form, to: VGZ Postbus RS Eindhoven 2

3 Contents I.General section 5 Article 1. Insured care 5 Article 2. General provisions 7 Article 3. Premium 8 Article 4. Other obligations 9 Article 5. Change in premium and policy conditions 10 Article 6. Commencement, duration and termination of the VGZ Gezin Package 10 Article 7. Complaints and disputes 11 Article 8. Care advice and mediation 11 II. VGZ Gezin Package 12 Article 9. Alternative care 12 Article 10. Movement-related care 12 Article 11. Glasses and contact lenses 13 Article 12. Contraceptives 14 ABROAD 14 Article 13. Urgent care while on holiday and during a temporary stay abroad 14 Article 14. Repatriation 14 Prevention 14 Healthy Lifestyle 14 Article 15. Courses 14 Article 16. Health test 15 Article 17. Weight consultant 15 Advice and Assistance 15 Article 18. Sports medical advice 15 Article 19. Menopause care 15 Vaccinations 15 Article 20. Preventative vaccinations and medicines in connection with a holiday 15 DELIVERY-RELATED CARE 16 Article 21. Obstetric care 16 Article 22. Personal contribution for maternity care 16 Article 23. Deluxe maternity care 16 Article 24. Maternity package 16 Article 25. Reimbursement for adoption 16 Article 26. Electrical breast pump 16 Article 27. Lactation consultation 16 HOME CARe 17 Article 28. Domestic support 17 Article 29. Child care 17 SKIN TREATMENTS 17 Article 30. Acne treatment 17 Article 31. Camouflage therapy 17 Article 32. Hair removal 17 3

4 CARE AIDS 18 Article 33. Audiological care aids 18 Article 34. Breast prosthesis 18 Article 35. Wigs and Mutssja head covers 18 Article 36. Urinary buzzer 18 Article 37. Support pessary 18 SPECIALIST MEDICAL CARE 18 Article 38. Medical circumcision 18 Article 39. Protruding ear correction 18 Article 40. Redression helmet 19 Article 41. Sterilisation 19 PSYCHOLOGICAL CARE 19 Article 42. Cogmed 19 Article 43. Group therapy 19 Article 44. Neurofeedback 19 Article 45. Sexological care 20 FOOT TREATMENTS 20 Article 46. Rheumatoid foot care 20 Article 47. Podotherapy 20 Article 48. Arch supports 20 CARE FOR ONCOLOGICAL PATIENTS 20 Article 49. Herstel en Balans (Recovery and Balance) rehabilitation programme 20 INFORMAL CARE 20 Article 50. Informal care broker 21 Article 51. Substitute informal care 21 INPATIENT CARE 21 Article 52. Convalescent homes and care hotels 21 Article 53. Hospice 21 Article 54. Ronald McDonald House/family house 22 Article 55. Therapeutic holiday camps 22 TRANSPORT 22 Article 56. Transport in connection with an organ transplant 22 DENTAL CARE/ORAL CARE 22 Article 57. Dental care 22 Article 58. Dental prostheses (dentures) 23 Article 59. Crowns required as a result of an accident 23 Article 60. Orthodontic care 23 III. Glossary 24 4

5 I. General section Article 1. Insured care 1.1. Content and extent of the insured care Your VGZ Gezin Package entitles you to care and the reimbursement of costs associated with that care as described in these policy conditions Medical necessity You are entitled to care and the reimbursement of costs associated with that care as described in these policy conditions if you reasonably depend on the type of care in question in terms of its content and extent, and if the type of care provided is appropriate and effective. The content and extent of the type of care are partly determined by what the care providers concerned are in the habit of providing in terms of care. The content and extent of the type of care are also determined by the latest scientific knowledge and practical know-how. This is determined using the Evidence-Based Medicine (EBM) method. If information in this regard is lacking, the content and type of care are determined according to what is considered to be responsible and adequate care within the field of specialisation concerned Parties authorised to provide the care Your care provider must meet certain criteria. For many care providers these criteria are set out in law; titles for medical professions are protected. This applies, for instance, to general practitioners, medical specialists, dentists, physiotherapists and health psychologists. See the relevant care article for the requirements that must be met by care providers for which these criteria are not set out in law or for which we have imposed additional conditions. We have made arrangements with contracted, designated or accredited care providers for specific types of care. This means that in those cases you will be entitled to only partial reimbursement, or no reimbursement at all, if you use non-contracted, non-designated or non-accredited care providers. The applicable restrictions are clearly explained under the relevant Care Articles. You are free to choose your own care provider, on condition that the other requirements set out in these policy conditions have been met. You will find a comprehensive list of our contracted an designated care providers on our website. The accredited care providers are specified in the relevant care article. We have made specific agreements with some suppliers. These are our preferred suppliers. Where we have a preferred supplier, this is stated in the relevant care article. The articles that address the types of care supplied by contracted, designated or accredited care providers are: Article 9. Alternative care Article 10. Care relating to movement Article 28. Domestic support Article 29. Child care Article 30. Acne treatment Article 31. Camouflage therapy Article 32. Hair removal Article 42. Cogmed Article 43. Group therapy Article 50. Informal care broker Article 51. Substitute informal care Article 52. Convalescent homes and care hotels Article 53. Hospice Article 56. Transport in connection with an organ transplant 1.4. Reimbursement of the costs of care You are entitled to reimbursement of the costs of care up to a maximum of the Healthcare (Market Regulation) Act (WMG) rates current in the Netherlands. If WMG rates do not apply, we will reimburse the costs up to a maximum of the reasonable market price current in the Netherlands. If you receive treatment from a care provider contracted by us, we will reimburse the costs of care based on the rate agreed with the care provider concerned. If you are not using the services of one of our contracted care providers, you may have to pay a portion of the costs, or all the costs, yourself. See the relevant care article for further details. The maximum reimbursement rates can be found in the 2014 VGZ Natura List of Maximum Reimbursements for Non-Contracted Care Providers. This list can be consulted on our website. Does a budget apply to the relevant type of care? If so, the total reimbursement will never exceed the maximum amount of the budget referred to in the relevant article Submitting invoices Many care providers send invoices directly to us. If you have personally received an invoice, you can complete a claim form and send it to us, together with the original invoice. Please do not send us any copies or payment demands. We only process original invoices. It is important that the invoice specifies the name and birth date of the insured person, the treatment, the date of treatment and the invoice amount, and features the initials of the care provider. Invoices must be itemised in such a way as to preclude the need for further queries to determine the reimbursement we are obliged to pay. We use the historical rates on XE.com to convert the currency amount of foreign invoices into euros, based on the exchange rates that applied on the day the treatment was given. We are authorised to refrain from paying the invoice until you have provided sufficient evidence that the costs have been paid. VGZ GEZIN PACKAGE 2014 Supplementary Insurance Policy Conditions 5

6 You can submit invoices up to a maximum of three years after the start of the treatment in question. Claiming costs online If you would like to make use of our online claim service, go to After you have submitted your claim we request that you retain your original invoice for a year. We may be required to ask you to provide the original invoice for inspection purposes. If you are unable to produce the invoice, we may be required to reclaim the amounts paid out to you or settle these against amount owed to you. Some invoices, such as foreign invoices, cannot be claimed online. Please send us the original invoice together with a fully completed claim form. We recommend making a copy for your own administration. Please use the return envelopes provided with our business reply number for claims. If you did not receive such envelopes, you may send your claim to the address listed at the beginning of these policy conditions Direct payment We are authorised to pay the costs of care directly to the care provider. In such a case, your entitlement to reimbursement will lapse Settlement of costs If we pay the care provider directly and reimburse more than we owe you under these conditions or if the costs of care are otherwise payable by you, as a policyholder you will owe the costs to us. We will charge these amounts to you at a later stage. You are obliged to pay these amounts. We are authorised to offset these any amounts against amounts owed to you Referral, prescription or permission For certain types of care you require a referral, prescription and/or prior written permission to prove that you depend on that care. This is specified in the relevant care article. Referral or prescription If the care article specifies that you need a referral or prescription, you can ask for this from the care provider listed in that article. In many cases, that care provider is the general practitioner. Permission Some types of treatment require our prior written permission. We also refer to this permission as an authorisation. If you failed to obtain prior written permission, you will not be entitled to this care or to reimbursement of the costs. If you are using the services of one of our contracted care providers, you will not need to apply to us for prior permission. Your care provider will, in this case, determine whether you satisfy the conditions and/or will apply for permission from us on your behalf. You may, for reasons of privacy, prefer to apply directly to us for prior written permission. In such cases you can send your application to us directly if you wish. You will find the correspondence address in the insurance conditions. If you are not using the services of one of our contracted care providers, you will need to apply to us directly for permission Derived right You are entitled to care and the reimbursement of associated costs if the treatment or supply occurs during the term of the VGZ Gezin Package. If you receive a particular treatment during two calendar years and the care provider is entitled to charge a single amount for it (Diagnosis Treatment Combination), we will reimburse the costs in question if the treatment began within the term of the VGZ Gezin Package insurance cover. Where these policy conditions refer to a year or calendar year, the actual treatment date or date of supply specified by the care provider is decisive for determining the year or calendar year to which the costs claimed must be allocated Exclusions You are not entitled to: - reimbursement of costs incurred because you failed to attend an appointment with a care provider; - reimbursement of costs of written statements, mediation costs charged by third parties without our prior written agreement, administrative costs or costs incurred due to a failure to pay invoices of care providers on time; - reimbursement of personal contributions or excess owed pursuant to any other insurance unless determined otherwise in these policy conditions; - care and the reimbursement of associated costs that could be claimed pursuant to the Exceptional Medical Expenses Act (AWBZ) if you were insured under this Act; - care and the reimbursement of associated costs that could be claimed pursuant to the Healthcare Insurance Act (Zvw) if you were a person obliged to take out insurance within the meaning of that Act; - care and the reimbursement of associated costs that can or could be claimed pursuant to the AWBZ, the Zvw or another Act, provision or insurance, whether or not from an earlier date, if the supplementary insurance with us did not exist. In that case, the VGZ Gezin Package will be the last to apply and, pursuant to these policy conditions, only the amount in damages that exceeds the amount that you could claim elsewhere will be eligible for reimbursement. We apply the Convenant samenloop reisverzekeringen en aanvullende ziektekostenverzekeringen (Concurrence of Travel Insurances and Supplementary Health Insurances Agreement), which is available on our website; - reimbursement for damage that is an indirect consequence of acts or omissions on our part; - care and the reimbursement of associated costs made necessary by armed conflict, civil war, insurrection, internal civil commotion, riots and mutiny taking place in the Netherlands as provided in Section 3.38 of the Financial Supervision Act (Wft); 6 General section

7 - care and the reimbursement of associated costs made necessary by wilful misconduct or gross negligence; - reimbursement if the costs are charged by you, your partner, child, parent or other family member living as part of the household unless we have granted permission in advance Entitlement to care and other services as a result of acts of terrorism Do you need care as a result of one or more acts of terrorism? If so, the following rule applies. If the total damages to be claimed in a year from non-life, life or funeral with in-kind benefits insurers (including health insurers) according to the Nederlandse Herverzekeringsmaatschappij voor Terrorismeschaden N.V. (Dutch Terrorism Risk Reinsurance Company, NHT) exceeds the maximum amount reinsured per year by this company, you will only be entitled to a specific percentage of the costs or value of the care. The NHT determines this percentage. This applies to life, non-life and funeral insurers (including health insurers) that fall within the scope of the Financial Supervision Act. The exact definitions and provisions for the entitlement referred to above are set out in the NHT s Clausuleblad terrorismedekking (Terrorism Cover Clauses Sheet). Guaranteed payment in the event of claims due to terrorism Following the attacks that took place in the US on 11 September 2001 it became clear how much damage terrorist attacks can actually cause. A large-scale attack in the Netherlands could mean that the number of claims for compensation is so high that they cannot all be paid. To be able to guarantee that you will receive a payment in the event of a claim due to terrorism, almost all insurance companies in the Netherlands came together to set up the Nederlandse Herverzekeringsmaatschappij voor Terrorismeschaden (NHT). We are also affiliated with this company. The NHT has set up a scheme to ensure that you will always receive at least part of your claim. The NHT has imposed a maximum on the total amount to be paid out in the event of an act of terrorism. The maximum, which is one billion euros per year, applies to all insured persons as a group. If the total damages exceed this amount, each insured person who has suffered damages will receive the same percentage of the maximum amount. In practice, this can therefore mean that you will receive less than the actual value of the damages. However, it also means that you are always guaranteed to receive at least part of your claim. Article 2. General provisions 2.1. Basis of the insurance The insurance contract is concluded on the basis of the details provided by you on the application form or forwarded to us by you in writing VGZ Gezin Package supplementary insurance The insurance contract applies to the supplementary insurance or insurances stated on the policy schedule or confirmed to you in writing in another way. These policy conditions form part of the insurance contract and apply to the VGZ Gezin Package supplementary insurance. The general conditions are set out in Articles 1 to 8 inclusive (Chapter I, General section). Articles 9 to 60 inclusive describe the care and reimbursement of associated costs to which you are entitled. The Definitions can be found in Chapter III. If you have MiX Aanvullende Verzekering cover pursuant to the group contract concluded between your employer and VGZ, then you are entitled to the care and reimbursement of movement-related care and prevention under the MiX Aanvullende Verzekering insurance policies. In that case, you will not be entitled to reimbursement of these costs under the VGZ Gezin Package Accompanying documents These policy conditions make reference to the following documents, which form part of the present policy conditions insofar as applicable: - Appendix 1 of the Healthcare Insurance Decree; - Healthcare Regulations; - Terrorism Cover Clauses Sheet; - Overview of Contracted and Designated Care Providers; - Protocol governing referral to a lactation expert of the Dutch Association of Lactation Experts (NVL). These documents can be consulted on our website Fraud Actual inspection and fraud investigation are carried out in accordance with the provisions laid down for health insurance under or pursuant to the Healthcare Insurance Act. If you commit fraud, your entitlement to care and the reimbursement of associated costs will lapse. We will reclaim any reimbursements paid to you. You will also be obliged to pay any costs incurred by us that arise from the fraud investigation. Upon detection of fraud, we will enter your personal data and the personal data of the accessory or co-perpetrator in our Incidents Register. This Incidents Register is registered with the Dutch Data Protection Authority (CBP) and is administered by our Security Affairs Department. Your personal data and the personal data of the accessory or co-perpetrator can also be registered: - at the Centre for Combating Insurance Fraud of the Dutch Association of Insurers; - in the external reference register of the CIS Foundation. In addition, we may report the fraud to the police, judicial authorities and/or the Fiscal Intelligence and Investigation VGZ GEZIN PACKAGE 2014 Supplementary Insurance Policy Conditions 7

8 Service and Economic Investigation Service (FIOD-ECD). Fraud in relation to an insurance policy with us may result in the termination of your VGZ Gezin Package insurance and you will not be permitted to take out supplementary insurance policies with any company that is a member of the Coöperatie VGZ U.A. (the VGZ U.A. Cooperative) for a period of eight years Protection of personal data Your privacy is a serious matter to us. Your personal data is necessary to conclude and execute insurance contracts and is included in our register of personal data. We use your personal and other data: - to enter into and execute your insurance contract or financial service; - for the administration of any relationships arising from these; - for activities aimed at increasing our customer base; - to conduct surveys amongst insured persons to ascertain whether the care was indeed provided; - to conduct surveys amongst insured persons to establish the perceived quality of the care provided; - for the purpose of statistical analysis; - to comply with statutory obligations; - within the framework of safety and integrity of the financial sector (to prevent and combat fraud). The registration of that data is governed by the Gedragscode Verwerking Persoonsgegevens Zorgverzekeraars (Code of Conduct for the Processing of Personal Data by Health Insurers). This code of conduct can be consulted on our website. We may need to consult your personal details at the Stichting CIS (Netherlands Central Information System Foundation) in Zeist in the interests of the safety and integrity of the financial sector. From the inception date of the supplementary insurance, we will be authorised to: - request information from and provide information to third parties such as care providers and suppliers if we believe this is necessary to fulfil the obligations arising from the supplementary insurance or insurances; - include your citizen service number (BSN) in our administrative records. Care providers are legally obliged to use your citizen service number in every form of communication. We will use your citizen service number in communications with your care providers. In doing so, we will comply with legislation governing privacy. Use of personal data by care providers If we receive your invoices directly from your care providers and pay the amounts owed directly to them, your VGZ Gezin Package will be effected in a faster and more convenient manner. To that end, it may be necessary for a care provider to know how you are insured. For this reason, care providers can inspect your address and policy details as well as citizen service number in a secure manner. They may only do so if they are actually treating you. If it is necessary for an urgent reason to prevent care providers from inspecting your address details, please let us know and we will ensure that these details remain inaccessible Communications Communications sent to your last address known to us are deemed to have reached you. If you prefer to contact us by , we will also contact you by in the future. Wherever reference is made in these policy conditions to communication in writing, this will extend to communication by . In such a situation the term address will be taken to mean address Membership of the Cooperative By taking out the VGZ Gezin Package, you will also become a member of the Coöperatie VGZ U.A. (the VGZ U.A. Cooperative) as an insured person unless you indicate in writing or by that you do not wish to become a member. The Cooperative represents the interests of its members in the area of health and other insurances. Membership can be terminated at any time with due observance of a notice period of one month. Membership will in any case end at the moment at which the insurance contract ends Period for reflection When entering into a VGZ Gezin Package contract, as a policyholder you will be granted a period for reflection of 14 days. You will be authorised to cancel the VGZ Gezin Package in writing within 14 days of having concluded the contract or, if this occurs later, within 14 days of having received the policy conditions. The insurance contract will then be deemed not to have been concluded Dutch law The VGZ Gezin Package is governed by Dutch law. Article 3. Premium 3.1. Premium owed The policyholder is required to pay a premium. No premium is owed for an insured person until the first day of the month following his or her 18 th birthday. With respect to death, premium is owed up to and including the date of death. In the event of a change in the supplementary insurance we will recalculate the premium owed from the inception date of the change. Example: A person who turns 18 on 1 July will owe premium from 1 August. 8 General section

9 3.2. Premium discount by virtue of a group contract The premiums and conditions as agreed in the group contract apply from the date that you become a participant in the group contract From the date that you are no longer able to participate in the group contract, the premium discount and terms and conditions as agreed in the group contract will lapse. The VGZ Gezin Package will be continued on an individual basis from that date You can only participate in one group contract at a time Payment of premium, statutory contributions and costs You are obliged to pay the premium and national or foreign statutory contributions owed for all insured persons on a monthly basis in advance unless agreed otherwise. If you pay the premium on an annual basis in advance, you will receive a discount on the premium owed. The amount of the discount is stated on the policy schedule You are obliged to pay the premium according to the agreed payment method. We charge 1.50 administration costs for payment by giro collection form. Payment methods that are free of charge a. You can authorise us to deduct the amounts owed by direct debit. b. You can also download an invoice via My VGZ. In that case you must ensure we receive payment in time. If you wish you can pay directly via ideal. c. Your employer deducts the premium from your salary and pays it directly to us. This payment method can only be used for the payment of premium contributions. These payment methods are free of charge. Costs associated with paper giro collection forms (for premium payments) If you prefer not to use the payment methods that are free of charge, you will receive a paper giro collection form. An administrative fee of 1.50 applies to payments with a giro collection form to cover the costs of maintaining, drawing up, sending and processing these forms. You will also be sent a paper giro collection form if we are unable to collect your premium payment through direct debit. In this case you will also be charged the applicable fee of Your direct debit authorisation applies to the payment of premiums, personal contributions and erroneous reimbursements. A direct debit authorisation will also grant your bank a standing authorisation to deduct a specific amount in accordance with our instructions. The authorisation will be valid for the term of the insurance agreement and may continue to apply after its termination, if necessary. We will inform you at least three days before the amount will be debited, stating the amount and the date on which it will be deducted. If you are not in agreement with a direct debit collection you can request to have the entry reversed. Please note that you must contact your bank about this within eight weeks of the debit date. The amount to be deducted by direct debit for the personal contributions and erroneous reimbursements is capped at 220 per month. We will send a giro collection form for amounts above 220. If we choose to send you a giro collection form we will not charge you for administrative costs arising from this Offsetting You may not offset amounts owed against an amount to be received from us Overdue payment If you fail to pay the premium, statutory contributions and personal contributions and to pay back erroneous reimbursements on time, we will send you a demand for payment. If you do not pay within the term of at least 14 days specified in the demand for payment, we will be authorised to suspend the insurance cover. In that case, there will be no entitlement to care and the reimbursement of associated costs from the last premium due date prior to the demand for payment. You will remain obliged to pay the premium even in the event of suspension of the insurance cover. Entitlement to care and the reimbursement of associated costs will resume on the date subsequent to the one on which we have received the amount and any costs owed. In the event of overdue payment, we will be authorised to terminate the VGZ Gezin Package. In the event of termination of the insurance contract, the VGZ Gezin Package can again be applied for after payment of the amount and any costs owed. If we accept your application, the VGZ Gezin Package will commence on 1 January of the subsequent calendar year We are authorised to charge collection costs and statutory interest to you If a demand for payment has already been sent to you with respect to overdue payment of premiums, statutory contributions, excess, personal contributions or the return of erroneous reimbursements, we will not be required to send you a separate, written demand for payment in the event of a failure to pay a subsequent invoice on time We are authorised to offset overdue premium and costs against any costs of care claimed by you or other amounts to be received from us If we terminate the VGZ Gezin Package due to a failure to effect timely payment of the premium owed, we will be authorised to refuse to conclude any insurance contract with you for a period of five years. Article 4. Other obligations You are obliged: - to ask the care provider to inform our medical adviser about the reason for admission; - to cooperate with our medical adviser or employees VGZ GEZIN PACKAGE 2014 Supplementary Insurance Policy Conditions 9

10 tasked with verification in order to ensure that all information required to effect the VGZ Gezin Package is made available to these parties; - to inform us about facts that enable or could enable costs to be recovered from liable or potentially liable third parties, and to provide all necessary information to us in that regard. You may not come to any arrangement whatsoever with a third party without our prior written agreement. You must furthermore refrain from acts that may harm our interests; - to inform us as soon as possible about facts and circumstances pertinent to the proper execution of the VGZ Gezin Package. Among other things, these facts and circumstances include the start and end of a period of detention, separation or divorce, a birth, adoption or change in bank or giro account number. We will bear no risk whatsoever for a failure to comply with the foregoing provisions. If you fail to meet your obligations and our interests are harmed as a result, we will be authorised to suspend your entitlement to care and the reimbursement of associated costs. Article 5. Change in premium and policy conditions 5.1. Change in premium and policy conditions We are authorised at all times to change the policy conditions and premium of the VGZ Gezin Package. We will inform you, the policyholder, accordingly in writing. Such a change will come into effect on a date set by us Right of termination If we change the policy conditions and/or premium of the VGZ Gezin Package to your detriment, you will be authorised as a policyholder to terminate the insurance contract from the date on which the change enters into force. You will in any case be authorised to terminate the contract within a period of one month after the change has been reported to you. This right of termination will not apply if a change in the policy conditions is a direct result of an amendment to statutory measures, regulations or provisions. Article 6. Commencement, duration and termination of the VGZ Gezin Package 6.1. Commencement and duration The insurance contract comes into effect on the date on which VGZ s health insurance commences or on 1 January of a calendar year. If you apply to us for health insurance, you give us permission to cancel your old policy with a Dutch health insurer. This permission also applies to supplementary health insurance policies. Please notify us on the application form if you do not wish us to cancel any of the supplementary insurance policies. The VGZ Gezin Package is concluded for the calendar year in which the supplementary insurance is effected. After the end of this term, the insurance is tacitly renewed each year for a period of one calendar year Acceptance for the VGZ Gezin Package Health insurance You may take out the VGZ Gezin Package to augment your VGZ health insurance but you are not obliged to do so. No medical selection applies to the VGZ Gezin Package Family insurance cover All insured persons aged 18 and older specified on your policy schedule may take out supplementary insurance according to choice. If one of the insured parents and/or caregivers specified on the policy schedule has taken out VGZ Gezin Package cover, children under the age of 18 will likewise be accorded VGZ Gezin Package cover Changing supplementary insurance You may change your supplementary insurance. The provisions set out in will apply in this regard. As a policyholder, you must report the change to us by 31 December at the latest. The change will come into effect on 1 January of the subsequent calendar year. For care subject to reimbursement terms of longer than a calendar year, these terms will continue in the event of a change of supplementary insurance within VGZ. This means that reimbursements previously paid out by us pursuant to your previous supplementary insurance cover will be carried over to the new supplementary insurance. These previous reimbursements will count towards calculating the reimbursement amount to which you are entitled Termination by operation of law The VGZ Gezin Package will end by operation of law on the date subsequent to the one on which: - due to a change in or the withdrawal of its licence to act as a non-life insurer, VGZ is no longer authorised to offer or effect health insurances. We will inform you of this no later than two months before this date; - the insured person dies; - VGZ ceases to offer and effect the VGZ Gezin Package supplementary insurance. We will inform you of this no later than three months before this date. As a policyholder, you are obliged to inform us as soon as possible about the death of an insured person or about other facts and circumstances concerning the insured person that led or that could lead to termination of the VGZ Gezin Package. If we establish that the VGZ Gezin Package cover has ended or will end, we will send you a statement to that effect as soon as possible. 10 General section

11 6.4. Times at which you may cancel your insurance Annually As a policyholder, you may cancel the VGZ Gezin Package in writing as from 1 January of each year subject, provided that we have received your cancellation no later than 31 December of the previous year. You may cancel your VGZ Gezin Package from 1 January of each year, provided that we have received your cancellation no later than 31 December In the interim period As a policyholder, you may cancel the VGZ Gezin Package in the interim period in writing: - in the event of a change in the premium and/or policy conditions as stated in Article 5.2; - at the same time as cancelling your VGZ health insurance You can also make use of the Dutch health insurer s cancellation service to cancel the VGZ Gezin Package as referred to in Articles and Grounds on which we may cancel, terminate or suspend the VGZ Jong Package cover We may cancel, terminate or suspend the VGZ Gezin Package cover in writing: - in the case of overdue payments as stated in Article 3.5; - in the case of fraud (see Article 2.4); - if you have deliberately withheld information or documents from us, or provided incomplete or inaccurate information or documents to us, as a result of which we are or could be adversely affected; - if you have acted with the deliberate intention of misleading us or if we would not have concluded the supplementary insurance contract had we been aware of the true state of affairs. In those cases, we will be authorised to cancel the VGZ Gezin Package cover with immediate effect within two months following discovery. We will in those cases not owe any payment or may reduce any payment due. In addition, we may offset claims that have arisen against other payments. Article 7. Complaints and disputes 7.1. Our complaints procedure. Submitting complaints to the Complaints Management Department We make every effort to ensure that all matters pertaining to your GZ Gezin Package are properly arranged. Nevertheless, it is possible that you are not entirely satisfied about certain aspects. We are open to your complaints and suggestions. You can submit a complaint online via our website or write to us at: Afdeling Klachtenmanagement, antwoordnummer 9292, 5600 VM Eindhoven (no stamp required). The Complaints Management Department acts on behalf of management. Tips when submitting a complaint: Please describe as accurately as possible what has happened, why you are not satisfied and what, in your view, would be the best solution. Send copies of all relevant documents together with your complaint. Do not send the original documents, as you may still need them. If you are unwilling or unable to submit your complaint yourself, someone else may do so on your behalf. To protect your privacy, however, we require your written permission before we can address your complaint You will receive a response to your complaint from us within 30 days. If you are unsatisfied with the decision or have not received a response within 30 days, you can submit your complaint or dispute to Stichting Klachten en Geschillen Zorgverzekeringen (Health Insurances Complaints and Disputes Foundation, SKGZ), Postbus 291, 3700 AG Zeist, You can also submit a dispute to a competent court Complaints about our forms If you consider a form of the health insurer to be superfluous or unnecessarily complicated, you can submit your complaint about that to us via our website or send a letter to the Complaints Management Department at the following address: Afdeling Klachtenmanagement, antwoordnummer 9292, 5600 VM Eindhoven (no stamp required) You will receive a response to your complaint about our forms within 30 days. If you are unsatisfied with the reply or have not received a response within 30 days, you can submit your complaint to the Dutch Healthcare Authority (Nederlandse Zorgautoriteit, NZa) for the attention of the Informatielijn/het Meldpunt, Postbus 3017, 3502 GA Utrecht, informatielijn@nza.nl. The website of the Dutch Healthcare Authority at indicates how a complaint about forms can be submitted. Article 8. Care advice and mediation You are entitled to mediation for care if an unacceptably long waiting time applies to treatment from a care provider that is permitted to provide the treatment in question in accordance with your supplementary insurance. You can contact our Zorgadvies en bemiddeling (Care Advice and Mediation) department to apply for this mediation service. The Care Advice and Mediation department can be contacted via the website or by telephone on You can also contact this department for general questions about care, such as finding a care provider with specific expertise, or for assistance in finding your way within the care sector. We will help you assess the options available. VGZ GEZIN PACKAGE 2014 Supplementary Insurance Policy Conditions 11

12 II. VGZ Gezin Package Article 9. Alternative care Alternative care comprises: 1. Treatments and consultations that fall within the following categories: a. acupuncture and other traditional Eastern therapies; b. anthroposophic alternative treatments; c. homeopathy; d. naturopathy; e. psychosocial care. - for the care referred to under a to d inclusive: a doctor listed in the register of the Individual Healthcare Professions Act (BIG) or one of our designated care providers; - for the care referred to under e: one of our designated care providers. You will find a comprehensive list of our designated care providers on our website. If you are not using the services of one of our designated care providers, the cost of treatment will not be reimbursed. 2. Homeopathic or anthroposophic medicines that are registered in accordance with the Medicines Act and homeopathic or anthroposophic medicines that are registered under HA or HM in the Z Index of the Taxe Homeopathie. The medicines and care aids must be prescribed by a doctor listed in the BIG register, a general practitioner, a medical specialist, a dental surgeon or an obstetrician and supplied by a pharmacist or dispensing general practitioner. If you wish to know whether you will be reimbursed for a specific medicine you can request the relevant article number in the Z Index from your care provider and contact us. We will look up this number and inform you about the reimbursement conditions. Your pharmacy or dispensing physician can also find out for you if the product is registered in the Taxe Homeopathie as HA or HM. Total budget for alternative care: A maximum of 300 per calendar year. The reimbursement amount for treatments and consultations is capped at 45 a day. Please note: 1. Alternative care does not include consultations and treatments, in a group context or otherwise, for: - prevention, well-being and/or personal development; - social services and coaching; - problems related to work, parenting and/or school; - aesthetics; - dietary and exercise advice related to obesity (see Article 17). 2. You are not entitled to reimbursement of the costs of diagnostic examination (e.g. laboratory tests, scans, psychological testing at school, intelligence tests and examinations for the purpose of obtaining a personal budget (PGB)). Article 10. Movement-related care Movement-related care consists of: 1. physiotherapy; 2. oedema therapy; 3. Cesar/Mensendieck remedial therapy; 4. occupational therapy. In addition to these regular therapies, you can also make use of alternative movement-related therapies: 5. chiropractic, osteopathy, manual therapy E.S., manual and orthomanual therapy, craniosacral therapy, haptotherapy and Van Dixhoorn breathing and relaxation therapy. 1. Physiotherapy: physiotherapists and specialised physiotherapists listed in the Central Quality Register of the Royal Dutch Association for Physiotherapy (Centraal Kwaliteitsregister (CKR) van het Koninklijk Nederlands Genootschap voor Fysiotherapie, KNGF). Specialised physiotherapists are children s physiotherapists, pelvic physiotherapists, physiotherapists specialised in treating psychosomatic disorders, physiotherapists for the elderly and manual therapists; 2. Oedema therapy: oedema therapists or skin therapists. Oedema therapists must be listed in the Central Quality Register of the Royal Dutch Association for Physiotherapy (Centraal Kwaliteitsregister (CKR) van het Koninklijk Nederlands Genootschap voor Fysiotherapie, KNGF). The skin therapist must be listed in the Paramedics Quality Register (Kwaliteitsregister paramedici); 3. Cesar/Mensendieck remedial therapy: Cesar/ Mensendieck remedial therapists and specialised remedial therapists listed in the Paramedics Quality Register (Kwaliteitsregister paramedici, KP). Specialised remedial therapists are children s remedial therapists and those specialised in treating psychosomatic disorders; 4. Occupational therapy: occupational therapists You will find a comprehensive list of our contracted care providers on our website. 12 Care articles

13 If you are not using the services of one of our contracted care providers, a lower reimbursement applies per treatment (session). 5. Alternative therapies relating to movement: one of our designated care providers. You can find a list of designated care providers on our website. If your are not using one of our designated care providers, the cost of treatment will not be reimbursed. Treatment locations: Care must be provided at the treatment location of your care provider or in a hospital, nursing home or care home. If your attending care provider considers this medically necessary, this care can also be provided at home. Total budget for movement-related care: A maximum of 600 per calendar year. The reimbursement amount for alternative movement-related therapy is capped at 45 a day. If the care under Description points 1-4 is not provided by one of our contracted care providers, the costs of care per treatment (session) are reimbursed up to a maximum of 80% of the average rates as agreed for the types of care concerned with the care providers involved. For more information, see Article 1.4 of these policy conditions. Please note: Under age 18: 1. Non-chronic disorders: You are entitled to reimbursement of the costs of physiotherapy or children s physiotherapy and Cesar/ Mensendieck remedial therapy or Cesar/Mensendieck remedial therapy for children from the 19th treatment session. The first eighteen treatment sessions are covered by the health insurance; From age 18: 2. Chronic disorders: You are entitled to reimbursement, up to a maximum of your budget, of the costs of the first 20 treatment sessions. You are entitled to reimbursement of the costs under the health insurance cover from the 21 st treatment session. An advance referral from your general practitioner, company doctor or medical specialist and our permission are required for this care. These chronic disorders are established by the Minister of Health, Welfare and Sport (Volksgezondheid, Welzijn en Sport, VWS). They are specified in the List of Disorders for Physical and Remedial Therapy (Appendix 1 of the Health Insurance Decree). 3. Non-chronic disorders: You are entitled to reimbursement, up to a maximum of your budget, of the costs of the treatment. In this case you are not entitled to reimbursement under the health insurance (your disorder is not specified in the List of Disorders for Physical and Remedial Therapy). 4. Pelvic physiotherapy to prevent urine incontinence from age 18: reimbursement of the costs of pelvic physiotherapy to prevent urine incontinence applies from the tenth treatment session. The first nine treatment sessions are charged to the health insurance; 5. Reimbursement of the costs of occupational therapy applies from the 11 th hour. The first ten hours are charged to the health insurance; 6. You are not entitled to any treatment that is not regarded as movement-related care. Examples include: - curative processes within the context of occupational health or reintegration processes; - treatments and treatment programmes aimed at improving an individual s physical condition, such as medical training therapy, physio fitness, physical exercise for the elderly, physical exercise for overweight individuals and cardiovascular training. 7. You are not entitled to reimbursement of the costs of diagnostic examination (e.g. laboratory tests, scans, psychological testing at school, intelligence tests and examinations for the purpose of obtaining a personal budget (PGB)). Article 11. Glasses and contact lenses An allowance with respect to the costs of purchasing contact and/or prescription eyeglass lenses, including the accompanying frames the adjustment and fitting costs. The reimbursement also applies to the statutory personal contribution if the eyeglass lenses or filter lenses were paid for by the health insurance and provided to insured persons under the age of 18. Parties authorised to supply glasses and contact lenses: An optician or optician company. VGZ customers enjoy special benefits. Consult our website for our current special membership offers. A maximum of 150 every three calender years for insured persons up to the age of 18. A maximum of 200 every three calendar years. Please note: The costs of fitting a new pair of glasses or contact lenses are not reimbursed separately. Fitting costs are included in the purchase. VGZ GEZIN PACKAGE 2014 Supplementary Insurance Policy Conditions 13

14 Article 12. Contraceptives Contraceptives for insured persons aged 21 and older that can be provided based on the Healthcare Insurance Regulations, such as the contraceptive pill, birth control implant (Implanon rod), intrauterine contraceptive device (coil), ring or diaphragm. A pharmacist or dispensing general practitioner. Prescription (on the instructions of): A general practitioner or medical specialist for the first prescription of a new contraceptive. A maximum of the amount specified in the Healthcare Insurance Regulations and the Medicine Reimbursement System (geneesmiddelenvergoedingssysteem, GVS) The costs of the insertion and removal of a contraceptive device such as an intrauterine contraceptive device will be reimbursed under the health insurance regardless of your age. For persons under the age of 21: you are entitled to contraceptives such as the contraceptive pill, birth control implant (Implanon rod), intrauterine contraceptive device (coil), ring or diaphragm under your health insurance. ABROAD Article 13. Urgent care while on holiday and during a temporary stay abroad A supplement to the reimbursement of the costs of urgent care that you receive from the health insurance. We only reimburse the costs of transport if it is medically necessary in order to receive care at a location as close as possible to your accommodation or the location of the accident. You will receive the reimbursement if: - the care to be provided is urgent. This is unforeseen care that cannot reasonably be postponed until after your return to the Netherlands; - you did not stay abroad for longer than 365 days; - the costs of care and transport in the Netherlands are eligible for reimbursement. Please note that we pay reimbursement amounts only in euros and to a Dutch bank account. We use the historical rates on XE.com to convert the currency amount of foreign invoices into euros, based on the exchange rates that applied on the day the treatment was given. You can use VGZ Alarmcentrale (VGZ Emergency Service), telephone number +31 (0) (+ = international access number). Doing so is particularly recommended if the care in question entails high costs, such as admission to a hospital, for example. Full amount Article 14. Repatriation Your medically necessary transport or, following death, the transport of your mortal remains to the Netherlands. This includes the following: - the costs of transport by ambulance and/or aircraft, or transport by an undertaker; - the costs of necessary assistance, medical or otherwise; - the necessary costs of communication; - the costs of delivering and/or sending necessary medicines that are not available abroad. The party authorised to organise repatriation: VGZ Alarmcentrale (VGZ Emergency Services) (+= international access number). If the repatriation is not arranged by VGZ Emergency Services, the cost of treatment will not be reimbursed. Full amount Please note: The VGZ Alarmcentrale (VGZ Emergency Services) will determine the medical necessity of your return in consultation with the attending physician abroad. PREVENTION A budget for prevention that you can use for the following types of preventative care: - healthy lifestyle; - advice and assistance; - vaccinations. The following articles describe these types of preventative care. HEALTHY LIFESTYLE Article 15. Courses - Courses during pregnancy to prepare for childbirth organised by a home care organisation, maternity centre, obstetrician or obstetrician practice or provided by a yoga teacher affiliated with the Yoga Teachers Association of the Netherlands (Vereniging Yogaleerkrachten Nederland, VYN); 14 Care articles