General Insurance Provisions (GIP)

Transcription

1 Group Supplementary Insurance Pursuant to the Swiss Federal Law on Insurance Contracts (VVG) General Insurance Provisions (GIP) Edition January 2005 (Version 2007) Sanitas Privatversicherungen AG with its Registered Office in Zurich

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3 1 Basis of Contract 1 This contract is based on the group contract of the insured company with Sanitas Privatversicherungen AG (hereinafter referred to as Sanitas ), all written declarations submitted by the insured company, the insured (applicants and/or insured persons) or their representatives in the application and any other documents, as well as medical reports. 2 The rights and obligations of the contracting parties are set out in the group contract, the General Insurance Provisions (GIP), the Additional Insurance Provisions (AIP) and any Special Insurance Provisions (SIP). 3 If a matter is not explicitly agreed in these documents, the Swiss Federal Law on Insurance Contracts (VVG) applies. 4 Compulsory health insurance pursuant to the Swiss Federal Law on Health Insurance (KVG) cannot be taken out in isolation under this group insurance contract. 5 Any masculine terms used in these GIP also apply to women. 2 Scope of Insurance 1 Sanitas insures the financial consequences of illness, maternity and accident. Accident coverage is only provided if this is explicitly included in the policy. 2 The insurance covers the costs that exceed the benefits under the compulsory health insurance pursuant to the KVG, the compulsory accident insurance pursuant to the Swiss Federal Law on Accident Insurance (UVG), the federal disability insurance (IV) and the federal military insurance (MV). 3 Insured Benefits 1 The insured can choose between the following benefit categories and additional insurance options. All insurance products on offer are listed in the group contract with the insured company. Switzerland BASIC COMFORT PRIVATE ROYAL Abroad ROYAL ABROAD PRIVATE INTERNATIONAL 2 The benefits pertain to the costs that are not covered. The obligation of Sanitas to provide benefits is based on the date of treatment or the date on which the insured service is provided by the service provider. 3 Benefits for illness, maternity and accident cannot be cumulated. 4 Eligibility for maternity benefits begins 9 months after receipt of the application by Sanitas. 5 Cross border commuters and their family members are also covered in the border regions of Switzerland and its neighboring countries. 6 Sanitas may check whether the measures that were implemented are effective, expedient and economical. The invoiced services are also compared to local standards and the benefit amount is adjusted accordingly. In this case Sanitas succeeds to the rights of the insured. 7 If the costs are not itemized, Sanitas will allocate them at its own discretion. 4 Definitions 1 Illness is deemed to be a physical, mental, or psychological health condition that is not the consequence of an accident and which requires medical examination or treatment or prevents the insured from working. A congenital defect is a condition suffered by the insured since birth. 2 Maternity includes the pregnancy, childbirth, and the post partum recovery period. 3 An accident is defined as the sudden, unintentionally harmful influence of an exceptional external force on the human body, resulting in the impairment of physical, mental, or psychological health, or death. Occupational illnesses and events similar to an accident are treated in the same manner as an accident. The provisions of the Swiss Federal Law on Accident Insurance (UVG) apply. 4 Employees are persons with whom the insured company has a relationship governed by labor law. 5 Family members are the spouses or partners of employees and their children, provided that they live in the same household. 6 Insured are persons who have an insurance relationship with Sanitas. 3

4 5 Territorial Validity 1 Insurance coverage applies worldwide. However, outside of Switzerland the insurance only covers illness or accidents requiring emergency treatment suffered during a temporary stay abroad for a maximum of 12 months. Any deviations from this provision are defined in the Additional Insurance Provisions. 2 Insured who reside abroad temporarily for over 12 months or who relinquished their Swiss residence and are no longer subject to the insurance obligation pursuant to the Swiss Federal Law on Health Insurance (KVG) may take out PRIVATE INTERNATIONAL insurance coverage. Insured who remain subject to the insurance obligation pursuant to the KVG may continue their insurance coverage in the ROYAL ABROAD insurance category for a maximum of 6 years. The residence abroad is treated in the same manner as residence in Switzerland. 3 The following applies to employees who are assigned to work abroad and their family members (subject to any agreements to the contrary with the insured company): Transfer abroad for up to 8months: COMFORT, PRIVATE or ROYAL Transfer abroad for up to 12 months: PRIVATE or ROYAL Transfer abroad for longer than 12 months ROYAL ABROAD (if subject to compulsory insurance coverage pursuant to the KVG) PRIVATE INTERNATIONAL (not subject to compulsory insurance coverage pursuant to the KVG) 4 The place of domicile or residence is deemed to be the place around which the insured s professional and social life is centered. Interventions to remedy or improve physical defects and disfiguration, unless made necessary by an insured event Treatment aimed at self-fulfillment, self-development or personality development or other purposes that do not involve the treatment of an illness Weight-reduction programs, dietary advice, revitalization therapy, cellular therapy Dental treatment, except for compulsory benefits under the compulsory health insurance pursuant to the KVG Measures ordered by ajudge or the administrative authorities (therapy instead of imprisonment, alcohol tests, etc.) Consequences of riots, terrorist acts, crimes or offences of any type and measures implemented to counteract these, unless the insured can prove that he did not actively participate on the side of the perpetrators or incite them to further violence Treatment during foreign military service and/or followup treatment Illness and accidents as aconsequence of acts of war in Switzerland in another country, unless the illness or accident occurs within a period of 14 days from the first outbreak of warlike activities in the country in which the insured is staying and he was surprised by the outbreak of warlike activities while staying there for expatriates and insured who are working abroad for a short period (max. 12 months) on behalf of the employer, the insurance also covers accidents as a result of acts of war, provided that the insured did not actively participate in these activities or incite the perpetrators to further violence and did not intentionally travel to the war zone. 6 Gross Negligence Sanitas waives its right to reduce insurance benefits in the event of gross negligence. However, insured are not entitled to compensation for benefit reductions from other insurance companies. Restrictions to Insurance Coverage Sanitas may temporarily or permanently cancel this supplementary coverage for some countries, but must announce its intention to do so 14 days in advance. 8 Multiple Insurance If costs or loss of earnings are insured with more than one insurance company, the total costs/loss of earnings are only repaid once. In this case Sanitas only pays benefits on a pro rata basis. 7 Benefit Exclusions Subject to provisions to the contrary in the Additional Insurance Provisions (AIP), no benefits for medical expenses or daily benefits are paid in the following cases: Contributions to costs and benefit reductions under other insurance policies Health conditions existing prior to the effective date of the contract Treatment and measures that are not effective, expedient or economical, whereby effectiveness must be scientifically proven 9 Third-Party Benefits 1 The insured must inform Sanitas without delay of all benefits provided by third parties as well as of any agreements regarding lump sum settlements if Sanitas is liable to pay benefits for the same insurance claim. 4

5 2 If Sanitas pays benefits on behalf of a third party, the insured must assign his claims to Sanitas to the extent of the latter s obligation to provide benefits. 3 Agreements between insured and third parties are not binding on Sanitas. Obligations and Establishment of Claims 10 General Obligations Insured are obliged to comply with the instructions of their doctor or other service providers. 11 Establishment of Claims 1 Detailed original invoices and documents must be submitted to Sanitas when benefits are claimed. 2 If benefits are paid by another insurer (e.g. the compulsory health insurance or accident insurance), copies of the invoices and detailed statements from these insurers must be submitted to Sanitas. 3 The accident report form must be submitted to Sanitas when accident benefits are claimed. 12 Foreign Invoices 1 Foreign invoices and documents must be submitted in German, French, Italian, English, or Spanish. Invoices and documents in any other language must be accompanied by an acceptable translation. 2 Invoice amounts are converted at the exchange rate on the invoice date or the credit card debit date. 13 Violation of Obligations If the insured violates his obligations toward Sanitas in the event of a claim, benefits may be reduced or refused. Beginning and End of Insurance Coverage 14 Provisions on Acceptance 1 Bysubmitting an application for insurance coverage, the applicant authorizes all doctors, previous insurers and other insurance carriers to disclose information to Sanitas or its medical officers. 3 Sanitas may refuse an application or impose provisos without providing any reasons. 4 If at the time the contract was concluded the insured provided misleading information or concealed significant information on a condition (existing or earlier illnesses and/or accident sequelae) of which he was aware or should have been aware and on which he was questioned in writing, Sanitas may terminate the contract within 4 weeks of becoming aware of the breach of the disclosure obligation. Insurance coverage ends on the last day of the month in which the insured received written notice of termination. Benefits already paid out that are affected by the failure to disclose or the inaccurate disclosure of this significant fact must be repaid by the insured in full. 5 The upper age limit for acceptance into the supplementary health insurance is 55, while the maximum age for acceptance into the supplementary accident insurance is Beginning of Insurance Coverage Insurance coverage begins on the date indicated in the policy or the letter of acceptance of the application. The earliest possible effective date of insurance coverage is the date on which the insured starts working for the company (this applies mutatis mutandis to the insured s family members). 16 Contract Term The contract is indefinitely binding. 17 Contract Amendments by Insured 1 In principle, contracts may be amended with effect from the first day of the following month. 2 Insured wishing to switch to a higher insurance category must submit a new application. The upper age limit for switching to a higher insurance category is 55 (or 65 for the supplementary accident insurance). 3 Insured may submit a request to switch to a lower insurance category in writing (without having to submit a new application). Such notification must indicate the requested insurance coverage and requested effective date, and must be dated and signed by the insured. 4 The provisions of art. 14 of these General Insurance Provisions apply. 2 Sanitas may order a medical examination at the expense of the applicant. Sanitas may be involved in the decision regarding which doctor is to carry out the medical examination. 5

6 18 Termination of Employment Relationship If the employment relationship is terminated by notice, the existing insurance policy of the former employee and his family members is continued under an insurance plan for those formerly insured under a group plan ( p care ). 19 Retirement 1 If an employee retires, the existing insurance policy covering him and his family members is continued under the group insurance plan, provided that the premiums are deductable from the pension paid by the pension fund of the former employer. If this is not possible, the insured must transfer to the insurance plan for those formerly insured under a group plan ( p care ). 21 Transfer from Group Insurance to p-care 1 Insured who leave the group insurance plan automatically transfer to the insurance plan for those formerly insured under a group plan ( p care ). 2 The insurance relationship is continued with the same benefits and under the p care conditions, but no medical check up is required. Premiums are adjusted accordingly. Transferring insured may terminate their insurance coverage within 30 days of receipt of the new policy. 3 The benefits received under the group insurance plan are credited to the benefit entitlement under p care, and any provisos imposed by the group insurance plan are continued. 2 Accident coverage can be included in medical treatment policies without the need for a risk assessment within three months from the date of retirement. 3 This is subject to the condition that the insured was previously insured for accidents under a group accident insurance contract and that he was forced to leave this group plan on retirement. 4 No benefits are paid for accidents occurring before the health insurance policy was expanded in scope to include accident coverage. 20 Death The family members of a deceased employee insured under the group plan may continue the insurance relationship as is, provided that the premiums are deductable from the survivors pensions paid by the pension fund of the former employer. If this is not possible, the insured must transfer to the insurance plan for those formerly insured under a group plan ( p care ). 22 Termination of Insurance 1 Sanitas expressly waives its right to terminate the insurance policy in the event of a claim. Sanitas may terminate the contract with immediate effect if the insured attempts or commits insurance fraud. 2 The contract may be terminated at the end of a calendar year with one month s notice. 3 If the compulsory health insurance coverage pursuant to the KVG is terminated, the insured transfers to the insurance plan for those formerly insured under a group plan ( p care ) with commensurately reduced coverage. If all supplementary health insurance contracts in the insured benefit category are terminated, compulsory health insurance coverage pursuant to the KVG is continued under a Sanitas individual insurance contract. 23 Suspension Insurance coverage can be suspended against a reduction in premium if the insured travels abroad or becomes eligible for military insurance coverage (at least 28 consecutive service days). An advance application for suspension must be submitted. The maximum suspension period is 24 months. No benefits are paid for any claims arising during the suspension period. 24 End of Insurance Coverage Insurance coverage ends on the date on which the termination of the contract or the exclusion of insurance coverage takes effect. Insurance benefits are due up to and including this date. 6

7 Premiums 25 Change of Age Group and Place of Residence 1 The premiums are determined by a basic rate plus surcharges according to place of residence, age, and gender. Age dependent premium adjustments are made on January 1ofthe year following the 18th, 25th and 40th birthdays, and every 5 years thereafter. The last agedependent premium adjustment is made on January 1 following the 80th birthday 2 A change in place of residence may involve a premium adjustment. 26 Premium Payment The premiums for the insurance coverage of the employee and his family members are deducted from the employee s monthly salary or pension. Miscellaneous 27 Policy Acceptance If the contents of the insurance policy or the supplements thereto do not coincide with the agreements reached, the insured must ask for a correction within four weeks of receipt of the policy, failing which the contents will be deemed to have been approved by him. 28 Data Capture and Processing 1 Sanitas ensures compliance with the data protection provisions of Swiss law, in particular the Swiss Federal Law on Data Protection. 2 Sanitas may obtain the information required for the provision of insurance coverage, process this information electronically, and forward it to third parties for processing within the limits of the statutory provisions and contractual agreements. 3 Reimbursement of Paid Invoices Invoices must be submitted to Sanitas with reference to the group contract and the personal customer or personnel number. Sanitas transfers its share of the costs to a post office or bank account. If claims must be settled in another manner, Sanitas may demand compensation for the additional costs involved. 30 Changes of Name, Contact Addresses, Address Changes 1 The employee or the employer must inform Sanitas of any changes in name. 2 All insured who are absent from Switzerland for more than 3 months and persons who are insured as cross border commuters must provide Sanitas with a contact address in Switzerland. 3 The employer must report address changes and contact addresses of employees to Sanitas, while the employee himself must provide Sanitas with this information for his family members (if Sanitas receives a change of address regarding the employee, it automatically assumes that the change of address also applies to the family members). Notices sent to the address most recently reported to Sanitas are deemed to have been received. 4 Sanitas must be informed of any changes within 30 days. 31 Place of Performance and Jurisdiction 1 The obligations under this contract must be performed in Switzerland and in Swiss currency. 2 The court at the insured s place of residence in Switzerland or the courts in Zurich have jurisdiction over any disputes if the complaint is filed by the insured; if the complaint is filed by Sanitas, the court at the insured s place of residence in Switzerland has jurisdiction. 29 Payment of Benefits 1 Outpatient Treatment Medical services and medicine prescribed by a doctor are provided on submission of the personal insurance card. 2 Payment of Invoices The person to whom an invoice is addressed must also pay the invoice. The original invoice must be sent to Sanitas when reimbursement of the insured costs is claimed. 7

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