expatriate Health Insurance

Transcription

1 expatriate Health Insurance CONDITIONS AND REIMBURSEMENTS INDIVIDUAL INSURANCE 2015

2 About these conditions These are the policy conditions of your expatriate Health Insurance (XHI). XHI offers two comprehensive health insurance policies: and. The insurance you have taken out is specified on your policy certificate. You can take out XHI if you are not required to take out basic health insurance in the Netherlands. This will apply if, for example, you are working or residing abroad for a prolonged period. Two sections: conditions and reimbursements These policy conditions list the conditions under which insurance is provided and what is, and is not, reimbursed by the insurance. These policy conditions are divided into two sections: 1. the general conditions that apply to all insurance policies are set out on pages 5 to the reimbursements to which you are entitled are listed from page 14 onwards. The level of reimbursement provided by each XHI policy is listed for each form of care covered by the insurance together with the specific conditions for reimbursement of that form of care and details of what is not reimbursed. Do you need permission? To qualify for certain reimbursements you must request permission from us (XHI) in advance. You can do this by telephone, post or . Our contact details are as follows: Telephone: +31 (0) servicedesk@xhi.nl Address: Serviceteam XHI PO Box AB LEIDEN The Netherlands Permission from Eurocross Assistance Do you need to request permission from our emergency assistance provider Eurocross Assistance? Then please contact them. Eurocross Assistance can be contacted on +31 (0) , 24 hours a day, 365 days a year.

3 CONTENTS ABOUT THESE CONDITIONS 2 PART 1: XHI GENERAL CONDITIONS 5 1 How do you apply for the insurance? 5 2 When does the insurance commence? 5 3 How do you alter your insurance? 5 4 How do you cancel your insurance? 5 5 In what situations will we cancel your insurance? 6 6 What are your obligations? 6 7 What is reimbursed? And how is reimbursement arranged? 6 8 What is not insured (exclusions)? 8 9 Is there a deductible excess? 8 10 What will you have to pay? 9 11 What if your premium and/or conditions alter? 9 12 Do you have a complaint? What do we do with your personal details? What are the consequences of fraud? Definitions 11 PART 2: CONDITIONS FOR REIMBURSEMENT 14 MAXIMUM REIMBURSEMENT 14 1 Maximum total reimbursement provided by XHI 14 HOSPITAL CARE 14 2 Specialist medical care (outpatient) 14 3 Hospital care and day treatment at a hospital 14 4 Independent treatment centre 14 5 Specialist medical rehabilitation 15 6 Plastic surgery 15 7 Second opinions (including Best Doctors) 16 8 Dialysis 16 9 Organ transplantation 16 CARE OUTSIDE OF A HOSPITAL General practitioner care Nursing outside of a hospital (home care) Physiotherapy and remedial therapy Psychological care and psychiatric care 18 (primary care) 14 Complementary and alternative treatments, 18 therapies and medicines 15 Psoriasis treatment 18 ACCIDENT COVER FOR DENTAL CARE Dental care required as a result of an accident for insured persons aged 18 or older 19 CHILD AND FAMILY In vitro fertilisation (IVF), other fertility-enhancing treatments, sperm and oocyte cryopreservation Prenatal screening Childbirth and obstetric or midwifery care Childbirth allowance Vaccination of children and infants Hearing and eye tests for children Speech therapy Stutter therapy Oncological examination of children Accommodation expenses for one parent 22 CARE OUTSIDE YOUR COUNTRY OF RESIDENCE Urgent medical treatment outside your country of residence Transport of the insured person and mortal remains (repatriation) Travel escort for the insured person (during repatriation) 22 MEDICINES AND MEDICAL DEVICES Vaccinations and preventive medicines Medicines and dietary preparations Contraceptives Medical devices 23 PREVENTIVE CARE AND MEDICAL INFORMATION Annual medical assessment Preventive examinations Genetic research and advice Dietary advice 24 DENTAL CARE Implants Full set of removable dentures (false teeth) Orthodontics Dental care up to the age of Dental care in exceptional cases Dental care for insured persons with a handicap 26 TRANSPORT Patient transport Patient transport and travel and accommodation expenses 27 (not to your country of residence) REIMBURSEMENTS PROVIDED BY XHI DENTAL INSURANCE 28 3

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5 PART 1 XHI GENERAL CONDITIONS 1 HOW DO YOU APPLY FOR THE INSURANCE? 1.1 You (the policyholder) apply for the insurance by completing the application form on our website. Or by completing and signing the application form and sending it to us. You (the policyholder) must fill out the application form completely and truthfully. The application form, and the results of a medical assessment if an assessment is required, form part of the insurance contract. We may reject the application on this basis. 1.2 If you deliberately fail to provide information or provide inaccurate information Did you (the policyholder) deliberately conceal certain information during the application procedure? Or did you (the policyholder) deliberately provide incorrect or incomplete answers to our questions? And would we have rejected your application had we known the actual situation? Then we can cancel the insurance contract with immediate effect within two months of discovering this. In all cases you are no longer entitled to reimbursements. For more information about this see Article If the information you provide is incorrect Did you (the policyholder) fail to comply with the obligation to disclose information in a manner other than that described in Article 1.2? Then we will notify you (the policyholder) to this effect within two months of discovering this. In our letter we will inform you (the policyholder) of the fact that you (the policyholder) failed to comply with the requirements of the insurance and advise you of the consequences. Are the facts that you did not (accurately) disclose important in enabling us to assess the risk? Or would we have set a higher premium had we been aware of this information? In that case we may reclaim (part of) a reimbursement that you (the policyholder) have received. Any reimbursements that are still pending will not be issued. 1.4 Add your child(ren) to your policy within two months of birth or adoption You (the policyholder) do not need to complete an application form for children who are born or legally adopted during the period covered by the insurance contract. However, you do need to add them to your policy within two months of birth or adoption. Your child(ren) will then be added to your insurance policy from the date on which they were born or adopted. Are you (the policyholder) adopting a child from another country? In that case the child will be added to your policy from the date on which they are adopted abroad. If you (the policyholder) adopt a child, you (the policyholder) need the following documents to add the child to your policy: If you adopt a Dutch child: official proof of inclusion in the family or transfer of the child. If you adopt a child from another country: proof of transfer issued by a foreign court. If the documents are drawn up in a language other than English, German, French or Spanish, we will need a translation by a certified translator. 1.5 We can only insure you if the Dutch Health Insurance Act does not apply You (the policyholder) are obliged to take out the same insurance for all family members. Once you (the policyholder) have taken out the policy, it applies for all family members. This does not apply if you and/or your family members are required to take out statutory basic insurance under the Dutch Health Insurance Act (Zorgverzekeringswet). In other words, you (the policyholder) cannot take out an individual XHI policy in addition to the Dutch basic health insurance. 1.6 Family members do not have to be added to a supplementary dental insurance policy Have you (the policyholder) taken out supplementary dental insurance? In that case you (the policyholder) are not obliged to add all family members to the policy. 2 WHEN DOES THE INSURANCE COMMENCE? 2.1 The date on which the insurance commences, is stated on the policy certificate. 2.2 How long is the insurance valid? Your XHI policy is valid for a period of 1 calendar year. Will your insurance commence after 1 January? In that case your XHI policy is valid through to 31 December of the same calendar year. 2.3 What happens at the end of that calendar year? The insurance is automatically renewed for a further calendar year from 1 January of the following year. 3 HOW DO YOU ALTER YOUR INSURANCE? 3.1 Do you want to alter your insurance? You can do this as of 1 January of the following calendar year. We must agree to the alteration in writing. You may be required to undergo a preliminary medical assessment. 3.2 Do you want to add supplementary dental insurance to your policy? You can do this as of 1 January of the following calendar year. We must agree to this in writing. You may be required to undergo a preliminary medical assessment. 4 HOW DO YOU CANCEL YOUR INSURANCE? 4.1 You (the policyholder) can notify us that you wish to cancel your insurance by post or . We must receive notice of cancellation by 1 December at the latest. Your insurance will then terminate on 1 January of the following calendar year. Have you (the policyholder) notified us that you wish to cancel your insurance with us? In that case the cancellation is irrevocable. 5

6 4.2 In the event of death If you (the policyholder) die, the other members of your family covered by the policy can cancel the insurance within 2 months of your death. Have you notified us that you wish to cancel your insurance? In that case we will send you (the policyholder) confirmation. The date on which the insurance terminates will be specified in the confirmation. 5 IN WHAT SITUATIONS WILL WE CANCEL YOUR INSURANCE? We will cancel your insurance: a) if it subsequently transpires that you failed to complete the application form correctly and in full, or if it subsequently transpires that you failed to disclose circumstances that are important to us. b) if a premium payable by you (the policyholder) is 2 months overdue, in which case we will terminate your insurance on a date to be determined by us. c) in the event of proven fraud as described in Article 14 of these general conditions. d) if we withdraw an insurance product from the market for reasons that are important to us, we are entitled to unilaterally terminate your policy for that product on a date to be determined by us. Are we planning to terminate your insurance? In that case we will notify you (the policyholder) to this effect. The reason for the termination of your insurance and the date on which the insurance terminates will be specified in our letter. 6 WHAT ARE YOUR OBLIGATIONS? The obligations you are required to meet if you have taken out insurance with us are listed below. Have you harmed our interests by failing to fulfil these obligations? In that case, you are not entitled to reimbursement of the costs of care. 6.1 You are required to cooperate if we need more information about your treatment Does our medical advisor want to know why you were admitted? In that case you must ask your doctor or medical specialist to inform our medical advisor. You must provide all the information we need and cooperate in our efforts to obtain this information. This is for our medical advisors or for people responsible for monitoring or investigation. Naturally, we always comply with the requirements of privacy legislation. Medical information should preferably be written in Dutch, French, German, English or Spanish. If we consider it necessary, we may ask you to arrange for the information to be translated by a certified translator. We do not reimburse translation costs. 6.2 You must cooperate if we want to recover costs from an accountable third party You may not enter into an arrangement that is prejudicial to our rights. You may only enter into an arrangement with a third party, or their insurer, or a person acting on their behalf, if you have received written permission from us. 6.3 You must notify us of changes in your situation within 2 months Has there been a change in your personal situation? Or in the situation of one of the other persons covered by your policy? Then you (the policyholder) must notify us of the change within 2 months. This applies to any information that may be relevant in enabling the provision of your insurance. Obvious examples include a change of address, residence in a country other than your country of residence for a period of more than six months per calendar year, acquisition of the right to the basic insurance provided in the Netherlands, the birth of a child, or the addition of a step, foster or adopted child to your family, death, divorce or termination of a cohabitation agreement, and a change in your international bank account number (IBAN) and/or bank identifier code (BIC). What if you do not notify us of changes in your situation within 2 months? In that case, rather than applying retroactively from the date on which it occurred, the change will apply from the date on which we receive your notification. If we write to you (the policyholder) at your last-known address, we are entitled to assume that the letter reached you (the policyholder). 7 WHAT IS REIMBURSED? AND HOW IS REIMBURSEMENT ARRANGED? Reimbursement of the costs of care, as described in this insurance, is also determined, in terms of the nature and extent of care, by current scientific knowledge and practice. What if no such criteria exist? In that case, the standard is whatever the professional field involved regards as responsible and adequate care and services You only have a right to care if you are reasonably reliant on care of that nature and to that extent We only reimburse costs incurred during the period covered by the insurance In the event of proven fraud, all right to reimbursement of the costs of care covered by the insurance ceases to apply. This also applies to situations in which true statements were made and/or the facts were represented correctly. Furthermore, proven fraud may mean that we reclaim reimbursements that have already been made and (investigation) costs incurred Reimbursements of the costs of care are issued to you (the policyholder) in euros. We base the reimbursement on the daily exchange rate published by the Dutch Central Bank. We use the exchange rate that applied on the date on which care was provided. 6

7 7.1.6 Do you receive invoices from a care provider or institution? In that case send us the original and clearly specified invoices (keep a copy for your own files). You can also scan the original invoices and send them to us electronically via your personal page on our website. We do not accept copies of invoices, reminders, pro-forma invoices, (cost) estimates or any other such documents. We will only be able to reimburse your costs if we have an original and clearly specified invoice Do you (the policyholder) submit invoices electronically? Then you (the policyholder) are obliged to keep the original invoices for a period of 1 year after we receive them. We may ask you to submit these original invoices The care provider who treats you must issue invoices in their own name. Is the care provider a legal person (such as a foundation, a practice or a limited company)? In that case the name of the doctor or specialist who treated you must be stated on the invoice. Reimbursements to which you (the policyholder) are entitled are always paid into the bank account known to us. Any claim you have on us may not be transferred to a third party We do not reimburse down payment invoices (provisional estimate invoices) You can claim your medical expenses via your personal page on our website You are required to submit claims within a specified period. Be sure to submit your invoices to us as soon as possible. In any event, you must do this within 12 months of the end of the year in which you were treated. Please note! The date of treatment and/or the supply date noted on an invoice is decisive in determining whether you are entitled to reimbursement of the costs of care. In other words, the date on which the invoice was drawn up is not the determining factor. Will treatment be invoiced in the form of a diagnosistreatment-combination (diagnose-behandelcombinatie, DBC)? In that case the moment at which the treatment started determines the right to reimbursement. You must be insured with us on the date on which treatment starts. Do you want to know what applies in your case? Then please contact us. Are you submitting invoices more than 12 months after the year in which you were treated? In that case you may receive a lower reimbursement than the reimbursement to which you were otherwise entitled. We do not process invoices submitted more than 3 years after the date of treatment and/or the date on which care was provided. This is pursuant to Article 942, Book 7 of the Dutch Civil Code We reimburse the costs of care up to the maximum tariff set by the legislation in the country of residence. If no statutory (maximum) tariff has been set in the country of residence, we reimburse the standard market rate in the country of residence We only reimburse the costs of treatments that are medically necessary. This does not apply if an article explicitly states that we reimburse non-medically necessary treatments. 7.2 How we arrange reimbursement We reimburse you (the policyholder) directly In some cases we settle the bill directly with the care provider. Is part of your deductible excess still payable? In that case the amount will be deducted from your deductible excess or you will be invoiced for this amount. What if you (the policyholder) do not pay your deductible excess without delay? In that case we will only reimburse your medical expenses once you (the policyholder) have paid your deductible excess in full. We are only obliged to reimburse expenses incurred after your deductible excess has been paid in full. If payment of your deductible excess is overdue, an administration fee and interest will be added to the outstanding amount. If we need to take steps to recover the deductible excess, you will be required to cover the costs. These costs are set at a minimum of 15% of the outstanding amount. 7.3 What we do and do not pay when reimbursing medical expenses abroad All amounts are calculated in euros. Are your medical expenses incurred abroad? In that case reimbursement of these expenses is still issued in euros. The reimbursement is calculated in euros using the exchange rate that applied on the date on which care was provided. This is the date of treatment noted on the invoice. For the 40 most commonly used currencies, we use the weekly exchange rate published by the Dutch Central Bank. For other currencies, we use the monthly exchange rates published by OANDA. We do not reimburse costs incurred as a result of exchange rate differences. We do reimburse transaction fees when transferring payments to a foreign bank account. Does a foreign bank charge you other fees in addition to this? In that case we do not reimburse these fees. 7.4 Sequential application of insurance policies Do you have several insurance policies with us? Then we will reimburse the bills you submit by applying the policies in the following order: XHI; XHI Dental (supplementary dental insurance). 7.5 Reimbursement of expenses outside the country of residence or country of origin Do you want to receive medical treatment in a country other than your country of residence or country of origin? In that case we only reimburse the costs of the treatment if we have issued permission in writing in advance. 7

8 7.6 Expenses not reimbursed by the insurance (nonreimbursement of related expenses) Medical expenses that are covered by law or another plan or insurance (including travel insurance), irrespective of which policy was issued first, or medical expenses that would have been covered by law or another plan or (travel) insurance if this supplementary insurance did not exist, are not covered by this insurance. 8 WHAT IS NOT INSURED (EXCLUSIONS)? 8.1 When you apply for (more comprehensive) insurance with us, you are required to provide the following information on the application form: an existing illness or abnormality of which you are aware; an illness or abnormality that causes you to experience symptoms. What if you fail to provide this information? In that case we do not reimburse the related costs. 8.2 You are not entitled to reimbursement of the costs of care if care is required as a consequence of one of the following situations: armed conflict; civil war; an uprising; civil disturbances; riot and mutiny; nuclear reaction (unless the radioactive substances are used in medical treatment). This is stipulated in Article 3.38 of the Dutch Financial Supervision Act (Wet op het financieel toezicht, Wft). 8.3 We do not reimburse the costs of personal contributions that are legally mandatory in your country of residence. 8.4 We do not reimburse the costs of: cell therapy; chelation therapy; check-ups; flu vaccinations; treatments for snoring (uvulopalatoplasty); treatment with a corrective helmet for plagiocephaly and brachycephaly without craniostenosis; treatments designed to result in sterilisation; treatments designed to reverse sterilisation; the issuing of doctor s statements. In some cases you are entitled to reimbursement of the costs of this care. PLEASE NOTE! For this to apply, the policy conditions must explicitly state that the care is reimbursed. 8.5 We only reimburse the costs of treatments provided by a medical specialist if the treatments fall within the specialist s area of expertise. 8.6 We do not reimburse the costs of missed care appointments. 8.7 Costs of treatment carried out by you or a member of your family You may not treat yourself and claim the costs involved against your own insurance. We do not reimburse the costs of this care. Do you want your partner, a family member and/or a first-degree or second-degree family member to treat you? And do you want to claim the costs of this treatment? In that case we must give you permission in advance. 9 IS THERE A DEDUCTIBLE EXCESS? 9.1 A deductible excess applies for this policy. A deductible excess only applies for the XHI policy. In other words, there is no deductible excess for reimbursements covered by XHI Dental. 9.2 The deductible excess depends on the composition of the family The deductible excess applies for a period of one calendar year and is automatically deducted from the care invoices you submit. Are you the only person named on the policy? In that case the deductible excess is 250. Is/are your partner and/or your children also covered by the policy? In that case the deductible excess is 500. It should be noted that no deductible excess applies for the costs of care provided for children up to the age of 18 also covered by the policy. 9.3 Deductible excess if your insurance commences later or terminates prior to the end of the calendar year Will your insurance commence after 1 January? In that case we calculate your deductible excess based on the number of months you are insured during the calendar year. For example, will your insurance commence on 1 October? In that case we calculate your deductible excess for a period of 3 months. Will your insurance terminate prior to the end of the calendar year? In that case we calculate your deductible excess based on the number of months you are insured during the calendar year. For example, will your insurance terminate on 1 October? In that case we calculate your deductible excess for a period of 9 months. 9.4 Your deductible excess if there are changes in the composition of your family Have you added someone to, or removed someone from, the policy during the course of the calendar year? In that case we will adjust your deductible excess accordingly. 9.5 We reimburse medical expenses that exceed the deductible excess We only reimburse medical expenses that exceed the deductible excess. The deductible excess also applies to capped reimbursements. PLEASE NOTE! Your deductible excess is deducted from the invoices you submit. Once the deductible excess has been exhausted we reimburse medical expenses that exceed the deductible excess. So always submit all of your bills! 8

9 9.6 Adjusting your deductible excess You (the policyholder) can increase or reduce your deductible excess. You then pay a lower or higher premium. Do you want to adjust your deductible excess? In that case you need to let us know before 1 January of the next calendar year. That is the only time that your deductible excess can be adjusted. This cannot be done during the course of a calendar year. 10 WHAT WILL YOU HAVE TO PAY? 10.1 The size of the premium We determine the size of the premium for your insurance. This will depend on: the composition of your family; the amount of the deductible excess; the region and/or country of residence; your age. Do you have to pay a higher premium because you have entered a new age bracket? Then the premium will change on the first day of the month following the month in which you enter the new age bracket The size of the premium for XHI and XHI Dental is specified on your policy certificate Payment of the premium The policyholder is obliged to pay the premium. When used in relation to payment of the premium, the word you should be read as you (the policyholder) You (the policyholder) must pay the premium in advance and in euros Are you several months behind with your premium payments? In that case any payments you make will be offset against the premium(s) that has/have been outstanding longest You may not offset the premium that you (the policyholder) are required to pay against reimbursements of the costs of care Has your insurance been terminated prematurely by you (the policyholder) or by us? Then we will refund any premium overpayment. Have we terminated your insurance due to fraud or deception (see also Article 14 of these general conditions)? In that case we may deduct an administration fee from the premium we have to refund If you do not pay the premium on time Did you (the policyholder) fail to pay your premium on time? In that case your right to reimbursement of medical expenses will automatically cease to apply from the first day of the month following the expiry of the stipulated term of payment. The payment obligation continues to apply. We are only obliged to reimburse unexpected expenses incurred after all overdue premiums have been paid in full If payment of your premium is overdue, an administration fee and interest will be added to the outstanding amount If you (the policyholder) do not pay on time, we may charge you (the policyholder) administration fees, judicial and extrajudicial debt collection costs and statutory interest If we initiate debt collection proceedings, you will be required to cover the costs of recovering the outstanding amounts, including judicial and extrajudicial debt collection costs We reserve the right to terminate the insurance following the expiry of the term of payment specified in the third demand for payment (notice of default). If we intend to terminate your insurance we will notify you to this effect in writing. The payment obligation continues to apply We may terminate your insurance if you (the policyholder) do not pay your premium within the term of payment specified in our third demand for payment (notice of default). Do we intend to cancel your insurance? In that case we will notify you (the policyholder) to this effect. The payment obligation continues to apply What happens to the premium if your insurance is terminated or altered? The premium is never adjusted proportionally for part of a month at the start or end of the policy or if the insurance is altered. You are always required to pay a full monthly premium. 11 WHAT IF YOUR PREMIUM AND/OR CONDITIONS ALTER? 11.1 We have the right to alter the premium for and/or the conditions of our insurance policies for all policyholders or certain groups of policyholders. The change will apply from a date to be determined by us. If we increase the premium or restrict the conditions for reimbursement under the insurance, these changes apply even if you are already insured with us Are you not prepared to pay the higher premium or do you not accept more restrictive terms and conditions? Then please notify us to this effect by sending us a letter or within 30 days of the date on which we announced the change. We will then cancel your insurance on the date on which the new premium and/or new conditions become effective You cannot refuse to accept the change if: you have been insured by us for less than a calendar year; the higher premium and/or more restricted reimbursements are stipulated by statutory regulations; you are required to pay a higher premium because you have entered a new age bracket and/or moved to another region You remain obliged to pay overdue premiums. The payment obligation continues to apply. 9

10 11.4 Sometimes you do not have the option of cancelling your insurance if we change the premium and/or the conditions In some cases you cannot cancel your insurance prior to the expiry date if we change the premium and/or the conditions. This applies if: the higher premium and/or more restrictive conditions and/or reimbursements is/are stipulated by statutory regulations; you have to pay a higher premium because you have entered a new age bracket; you have to pay a higher premium because you have moved to another region and/or country of residence. In the situations listed above, you can cancel your insurance by following one of the procedures described in Article 4 of these general conditions Payment by direct debit If you have a Dutch bank account, we prefer you (the policyholder) to pay the following amounts by direct debit: the premium; the deductible excess; personal contributions; any other amounts you owe us. We send you (the policyholder) advance notice of collection of payment by direct debit. We endeavour to notify you (the policyholder) 14 days before we collect the payment. We announce collection of the premium by direct debit once a year on the policy certificate we send you. What if you (the policyholder) choose to use a different method of payment? In that case you (the policyholder) may have to pay administration costs. 12 DO YOU HAVE A COMPLAINT? 12.1 Do you disagree with a decision we have made? Or are you dissatisfied with our services? In that case you can submit your complaint to our Central Complaints Coordination Department (afdeling Centrale Klachtencoördinatie). You must do this within 6 months of the date on which we informed you of our decision or provided the service. You can send your complaint to us at XHI/Achmea, Centrale Klachtencoördinatie, Antwoordnummer 2241, 8000 VB Zwolle, The Netherlands, or klachten@xhi.nl, or you can tell us about your complaint by telephone +31 (0) Complaints must be written in Dutch or English. If you submit a complaint in a language other than Dutch or English, you might have to pay translation costs What will we do with your complaint? As soon as we receive your complaint, we enter it in our complaint registration system. You will receive confirmation of receipt. We will then send you a detailed response within 3 weeks. If we need more time to process your complaint, we will let you know Do you disagree with our response? A complaint review is possible Do you disagree with how we dealt with your complaint? In that case you can ask us to review your complaint. You can send your complaint review request to us at XHI/Achmea, Centrale Klachtencoördinatie, Antwoordnummer 2241, 8000 VB Zwolle, The Netherlands, or klachten@xhi.nl, or you can request a complaint review by telephone +31 (0) You will receive confirmation of receipt. We will then send you a detailed response within 3 weeks. If we need more time to process your complaint, we will let you know You can also have your complaint reviewed by SKGZ Are you not interested in having us review your complaint? Or did our review fail to meet your expectations? In that case you can have your complaint reviewed by the Health Insurance Complaints and Disputes Board (SKGZ), PO box 291, 3700 AG Zeist, The Netherlands ( SKGZ cannot review your complaint if a judicial authority is already examining your case, or has already issued a ruling Recourse to a civil court in the Netherlands Instead of approaching SKGZ, you can also take the matter to a civil court. You can also turn to a civil court after SKGZ has issued a ruling. In that case the court will determine whether the way in which the ruling was reached is acceptable. You can also take the matter to a civil court if we fail to comply with the ruling issued by SKGZ This contract is governed by Dutch law. 13 WHAT DO WE DO WITH YOUR PERSONAL DETAILS? 13.1 If you apply for insurance or a financial service, we ask you for personal details. At Achmea we use your details: to enter into and execute contracts; to inform you about and offer you relevant products and/or services provided by companies owned by Achmea BV; to guarantee the safety and integrity of the financial services sector; to perform statistical analysis; to maintain relationships; to comply with statutory obligations. When using your personal data, we are required to comply with the Code of Conduct for the Processing of Personal Data by Health Insurers (Gedragscode Verwerking Persoonsgegevens Zorgverzekeraars). We process your data in accordance with the requirements of the Personal Data Protection Act (Wet bescherming persoonsgegevens). The above-mentioned data processing is registered with the Dutch Data Protection Authority (College Bescherming Persoonsgegevens, CBP). 10

11 13.2 If you do not want to receive information about our products and services Would you prefer not to receive information about our products and/or services? Or do you want to withdraw your permission for us to use your address? In that case you can inform us in one of 3 ways: you can write to us at Serviceteam XHI, PO box 75, 2300 AB Leiden, The Netherlands; you can call us on +31 (0) ; You can us: servicedesk@xhi.nl We refer to the Central Information System when processing applications To ensure responsible acceptance policy, Achmea is permitted to consult the data held on you by the Central Information System (CIS) in Zeist (a foundation that retains insurance data for companies). CIS members can also exchange data with one another. The purpose of this is to manage risks and combat fraud. All information exchange via CIS is governed by the CIS privacy regulations. You can find more information at www. stichtingcis.nl We are allowed to pass on your details to third parties From the moment that your insurance commences, we are allowed to ask for and to pass on your address, insurance and policy details to third parties (including care providers and institutions, suppliers, Vecozo [Health Care Communication Centre], Vektis [National Information Centre of health insurers] and CVZ [Health Care Insurance Board]). We are allowed to do this insofar as is necessary to comply with the obligations of the insurance. Are there urgent reasons why it is imperative that third parties should not have access to your address, insurance and policy details? In that case you can notify us in writing. 14 WHAT ARE THE CONSEQUENCES OF FRAUD? 14.1 Fraud is when someone obtains a reimbursement from an insurer, or an insurance contract with us: a) under false pretences; b) on improper grounds and/or in an improper way. In this contract fraud is specifically defined as one or more of the following activities. You are committing fraud if you and/or someone else who has an interest in the reimbursement have/has: a) misrepresented the facts; b) submitted false or misleading documents; c) made a false statement regarding a claim that has been submitted; d) concealed facts that could be important for us in assessing a claim that has been submitted No reimbursement in the event of fraud In the event of fraud, all right to reimbursement of the costs of care covered by the insurance ceases to apply. This also applies to situations in which true statements were made and/or the facts were represented correctly Other consequences of fraud Furthermore, fraud may form a reason for us to: a) report the matter to the police; b) cancel your insurance contract(s), in which case you will only be able to take out another insurance contract with us after 5 years; c) register you in acknowledged signalling systems between insurers (such as CIS); d) reclaim reimbursements that were paid out and (investigation) costs that were incurred. 15 DEFINITIONS Terms used in this insurance contract are explained below. What do we mean by the following terms? Alternative healer/therapist A person authorised by the law of the country of residence to practice alternative medicine and who is registered as such with the appropriate professional body and who meets the quality criteria regarded as standard practice by the profession in the country of residence. Ambulance A motor vehicle equipped to transport those who are ill or wounded. A dispensing general practitioner or pharmacist A dispensing general practitioner or pharmacist listed in the register of established pharmacists in the country of residence. Or a pharmacist who is assisted in the pharmacy by pharmacists listed in the register. The term dispensing general practitioner or pharmacist also includes legal persons that provide care through pharmacists listed in the above-mentioned register. Doctor A person authorised by the law of the country of residence to practice medicine and who is registered as such with the appropriate professional body. Abroad Any country other than your country of residence. Additional costs Medical expenses directly related to a specialist medical or dental treatment that arise during treatment at a hospital. Typical examples include: costs of X-rays, blood transfusions, laboratory tests, medicines, radiotherapy, anaesthetics, dressings and use of the operating theatre. Any additional costs must be charged by a hospital or laboratory. Exceptional dental care Dental care provided for patients who cannot easily be treated at a normal dental practice due to the severity of their condition or handicap. Day treatment Admission lasting less than 24 hours. 11

12 Dietitian A dietitian who meets the statutory requirements established for the profession in the country of residence. Occupational therapist An occupational therapist who meets the statutory requirements established for the profession in the country of residence. Physiotherapist A physiotherapist who meets the statutory requirements established for the profession in the country of residence. Medicines Medicines prescribed by the attending general practitioner, specialist or dentist and supplied by a pharmacy, dispensing general practitioner or pharmacist. Family One adult, or two people who are married or are cohabiting on a permanent basis, and any unmarried biological, step, foster or adopted children under 28 still living at home. Skin therapist A skin therapist who meets the statutory requirements established for the profession in the country of residence. General practitioner A general practitioner who meets the statutory requirements established for the profession in the country of residence. Medical devices A medical device listed in the Achmea Medical Devices Regulations (Achmea Reglement Hulpmiddelen). Doctor specialised in juvenile health care A doctor authorised by the law of the country of residence to practice medicine and who is registered with the appropriate professional body as a doctor who specialises in juvenile health care. Dental surgeon A dental surgeon who meets the statutory requirements established for the profession in the country of residence. Calendar year The period from 1 January up to and including 31 December. Laboratory A recognised laboratory in the country of residence. Country of origin The country in which a person was born and/or from which a person comes and with which the person has the strongest social (family) ties. Speech therapist A speech therapist who meets the statutory requirements established for the profession in the country of residence. Medical necessity The necessity for examination and treatment in accordance with generally accepted medical-scientific considerations Medical advisor A doctor who advises us on medical matters. Medical specialist A medical specialist, other than a dentist, who meets the statutory requirements established for their profession in the country of residence. Remedial therapist A remedial therapist who meets the statutory requirements established for the profession in the country of residence. Accident A sudden violent impact on the body of the insured person, that is not of their volition and beyond their control, causing medically demonstrable physical injury. Orthodontist A dentist or oral surgery specialist who meets the statutory requirements established for the profession in the country of residence. Policy certificate The official document that specifies the health and dental insurance agreed between you (the policyholder) and us. Psychologist A psychologist who meets the statutory requirements established for the profession in the country of residence. Psychiatrist A psychiatrist who meets the statutory requirements established for the profession in the country of residence. Journey A journey made in connection with (para)medical (clinical or outpatient) hospital treatment covered by these conditions after permission has been granted by us. The journey starts on departure from the home address and ends on return to the home address. Rehabilitation Examination, advice and treatment that involve the provision of specialist medical, paramedic, behavioural and/or rehabilitation care. This care is provided by a multidisciplinary team of experts, under the guidance of a medical specialist, affiliated with an institution authorised to provide rehabilitation care in accordance with the rules laid down by or pursuant to the law in the country of residence. Dentist A dentist who meets the statutory requirements established for the profession in the country of residence. 12

13 Clinical dental technician A clinical dental technician who meets the statutory requirements established for the profession in the country of residence. Home care Nursing care provided at home. You/your The insured person named on the policy certificate. You (the policyholder) means the person who took out the insurance. Stay Admission lasting 24 hours or longer. Obstetrician or midwife An obstetrician or midwife who meets the statutory requirements established for the profession in the country of residence. We/us Achmea Zorgverzekeringen N.V. Country of residence The country where a person resides for the majority of the year. Independent treatment centre A legally recognised specialist medical care institution in the country of residence that provides nursing care, examinations and treatment. This may be a(n exclusive) private clinic or a treatment centre that operates within the general health system in the country of residence. Hospital A legally recognised specialist medical care institution in the country of residence that provides nursing care, examinations and treatment. Health insurance The private health insurance we provide for you which is underwritten by us. 13

14 PART 2 CONDITIONS FOR REIMBURSEMENT MAXIMUM REIMBURSEMENT 1 MAXIMUM TOTAL REIMBURSEMENT PROVIDED BY XHI The total reimbursement provided by XHI is subject to a maximum amount. The maximum total reimbursement is as follows: 1,500,000 per person per calendar year 2,250,000 per person per calendar year HOSPITAL CARE 2 SPECIALIST MEDICAL CARE (OUTPATIENT) Are you receiving specialist medical or oral surgery treatment as an outpatient? In that case we reimburse the costs of: a) specialist medical or oral surgery care; b) paramedical care, medicines, medical devices and dressings that are part of the treatment. The extent of the care provided is limited to the care normally provided by medical specialists and dental surgeons. 1. You must be referred by a general practitioner, an obstetrician or a midwife if obstetric or midwifery care is involved, or another medical specialist. 2. If you are being referred to a dental surgeon, you may also be referred by a dentist. 3 HOSPITAL CARE AND DAY TREATMENT AT A HOSPITAL Do you need day treatment at a hospital? Or will you be staying in hospital for more than a day? In that case we reimburse the costs of: a) your stay, including nursing and care, as follows: second class if you have ; first class if you have ; b) specialist medical or oral surgery care; c) any fee surcharges that may apply for first or second class hospital accommodation; d) during your admission and treatment: paramedical care, medicines, medical devices and dressings that are part of the treatment. The extent of the care provided is limited to the care normally provided by medical specialists and dental surgeons. 1. You must be referred by a general practitioner, an obstetrician or a midwife if obstetric or midwifery care is involved, or another medical specialist. 2. If you are being referred to a dental surgeon, you may also be referred by a dentist. 3. The referring doctor (see under 1 and 2) must inform our medical advisor of the reason for your admission. You must authorise the referring doctor to provide this information. 4. Are you being admitted for plastic surgery? In that case we only reimburse your medical expenses if we have given you permission. You must request our permission at least 3 weeks prior to being admitted to hospital. As proof of our permission, we issue the hospital with a guarantee. 5. If you need to be admitted to hospital, you must request permission from us in advance. 6. If you are admitted to hospital in an emergency, you must notify our emergency assistance provider Eurocross Assistance within 48 hours. Were you or will you be admitted to hospital after 30 June? And will your hospital stay extend into the next calendar year? In that case you are only required to pay the deductible excess once. How many days of admission we reimburse Have you been admitted to hospital? In that case we reimburse your costs for a maximum period of 365 consecutive days at the hospital. The following forms of admission also count: a) admission to a rehabilitation centre or a hospital for the purpose of rehabilitation; b) admission to a psychiatric hospital. An interruption of up to 30 days is not treated as an interruption and these days are not counted when calculating the 365 days. Was your stay at the institution interrupted for a weekend break or a holiday? In that case we count these days in our calculation. PLEASE NOTE! In the case of private clinics, reimbursement is only possible if Eurocross Assistance has issued permission in advance. What if you are not sure if your hospital is regarded as a private clinic? In that case please contact Eurocross Assistance. 4 INDEPENDENT TREATMENT CENTRE Are you being treated in an independent treatment centre? Then we reimburse the costs of: a) your stay, including nursing and care, as follows: second class if you have ; first class if you have ; b) specialist medical or oral surgery care; 14

15 c) during your admission and treatment: paramedical care, medicines, medical devices and dressings that are part of the treatment. The extent of the care provided is limited to the care normally provided by medical specialists and dental surgeons. 1. You must be referred by a general practitioner or a medical specialist. 2. If you are being referred to a dental surgeon, you may also be referred by a dentist. 3. The referring doctor (see under 1 and 2) must inform our medical advisor of the reason for your admission. You must authorise the referring doctor to provide this information. 4. If you need to be admitted to an independent treatment centre, you must request permission from us in advance through Eurocross Assistance. As proof of our permission, we issue the independent treatment centre with a guarantee. Are you being admitted for plastic or dental surgery? In that case you must request permission at least 3 weeks prior to treatment. PLEASE NOTE! In the case of private clinics, reimbursement is only possible if Eurocross Assistance has issued permission in advance. What if you are not sure if the independent treatment centre is regarded as a private clinic? In that case please contact Eurocross Assistance. 5 SPECIALIST MEDICAL REHABILITATION Do you need rehabilitation care? In that case we reimburse the costs. You are only entitled to reimbursement of rehabilitation care provided by medical specialists if it is indicated as the most effective method of preventing, reducing or overcoming your handicap. Furthermore, your handicap must be the consequence of: a) disorders or limitations in your ability to move; b) a disorder of the central nervous system that leads to limitations in communication, cognition or behaviour. The rehabilitation care must enable you to achieve or maintain a degree of independence that is reasonably possible given your limitations. You must request our permission in advance. When requesting permission you must submit a copy of the treatment plan. As proof of our approval, we issue the hospital or rehabilitation centre with a guarantee. Clinical and non-clinical rehabilitation care We reimburse the costs of non-clinical (part-time or day-treatment) rehabilitation care. In a number of cases we also reimburse clinical rehabilitation care if you are admitted for several days. We only do this if rehabilitation care provided during a period of admission quickly leads to better results than rehabilitation care that does not involve admission. How many days of clinical admission we reimburse Have you been admitted to a clinic? In that case we reimburse your costs for a maximum period of 365 consecutive days at the clinic. The same applies if you are admitted to a (psychiatric) hospital. An interruption of up to 30 days is not treated as an interruption and these days are not counted when calculating the 365 days. Was your stay at the institution interrupted for a weekend break or a holiday? In that case we count these days in our calculation. 6 PLASTIC SURGERY We reimburse the costs of plastic surgery procedures performed by a medical specialist at a hospital or independent treatment centre if these procedures help to correct: a) abnormalities in personal appearance associated with demonstrable physical dysfunction; b) mutilations that are the result of an illness, an accident or a medical intervention; c) the following congenital deformities: cleft lip, jaw and palate; deformities of the facial bones; benign proliferations of blood vessels, lymphatic vessels or connective tissue; birthmarks or deformities of the urinary tract and genital organs; d) paralysed or weakened upper eyelids that are the consequence of a congenital defect or a chronic disorder present at birth; e) the abdominal wall (abdominoplasty), in the following cases: mutilations the severity of which is comparable with that of third degree burns; untreatable inflammation (intertrigo) in skin folds; an extremely severe limitation in the freedom to move (if your belly covers at least a quarter of your upper legs); f) primary sexual characteristics in cases of confirmed transsexuality (including epilation of the pubic region and beard). 1. You must be referred by a general practitioner or a medical specialist. 2. You must request permission from Eurocross Assistance at least 3 weeks prior to treatment. As proof of our permission, we issue a guarantee. 15

16 What we do not reimburse Some plastic surgery procedures are not covered by your insurance. We do not reimburse the costs of the following interventions: a) surgical placement or replacement of breast implants, unless the surgery is performed following a (partial) mastectomy; b) surgical removal of a breast prosthesis without a medical necessity; c) liposuction of the stomach; d) treatment of upper eyelids that are paralysed or weakened, unless the paralysis or weakening is the result of a congenital defect or a chronic disorder present at birth. 7 SECOND OPINIONS (INCLUDING BEST DOCTORS) Do you want to get a second opinion? In that case we reimburse the costs. Getting a second opinion means having the diagnosis made by your doctor, or treatment proposed by your doctor, reassessed. Your doctor can also request a second opinion. The reassessment is performed by a second, independent doctor. The second doctor must possess the same area of expertise and must practice the same profession as the first doctor. You can also seek a second opinion from Best Doctors. 1. The second opinion must relate to diagnosis or treatment covered by the provisions of the insurance. 2. You must be referred by a general practitioner, a medical specialist, a clinical psychologist or a psychotherapist. 3. The second opinion must relate to medical care that is intended for you and which you have discussed with your first doctor. 4. When obtaining a second opinion, you give a copy of your first doctor s medical file to the second doctor. 5. You must return to the first doctor with the second opinion. This doctor remains in charge of your treatment. SECOND OPINION FROM BEST DOCTORS You can also seek a second opinion from Best Doctors (an international medical organisation). A top international specialist will then give a second opinion based on all of the examinations that you have already undergone, which are detailed in your medical file. In other words, you do not need to travel. You can request a second opinion from Best Doctors through the Eurocross Assistance medical team. 8 DIALYSIS Are you receiving dialysis treatment at a hospital or dialysis centre, or in your own home? In that case we reimburse: a) examinations and tests; b) treatment and nursing; c) pharmaceutical care needed for the treatment; d) psychosocial counselling for you. Are you receiving dialysis treatment at home? In that case we also reimburse: a) psychosocial counselling for persons who help you perform the dialysis; b) costs associated with training provided by the dialysis centre for those who perform or assist with the dialysis; c) the costs of borrowing and using the dialysis machine; d) the costs of regular inspection and maintenance of the dialysis machine (including replacement); e) the chemicals and fluids needed to perform the dialysis; f) the costs of necessary expert assistance with the dialysis provided by the dialysis centre. 1. We must give you written permission in advance via Eurocross Assistance. 2. If you are receiving dialysis treatment at home, you must submit an estimate of the costs involved in advance. 3. We reimburse costs incurred by a donor provided that treatment results directly and exclusively from the transplantation. 9 ORGAN TRANSPLANTATION In the case of an organ transplant, we reimburse the costs of the following treatments: a) transplantation of tissues and organs in a hospital. The transplant procedure must be performed in: a member state of the European Union; a state that is party to the Agreement on the European Economic Area; another state. In that case, the donor must live in that state and must be your spouse, registered partner or a first, second or third degree blood relative; b) transplantation of tissues and organs in an independent treatment centre legally qualified and competent to perform these procedures. In the case of a proposed organ transplant we reimburse specialist medical care associated with: a) the choosing of the donor; b) the surgical removal of the transplant material from the chosen donor; c) examination, preservation, removal and transportation of postmortem transplant tissue. 16

17 For the donor we reimburse the costs of: a) care reimbursed by this policy. The donor is entitled to reimbursement for a maximum of 13 weeks, or 6 months in the case of a liver transplant, from the date of discharge from the hospital. This must be the hospital to which the donor was admitted for the selection or removal of the transplant material. Furthermore, the right to reimbursement only exists if the care provided relates to that admission; b) transport by the cheapest form of public transport, or, if medically necessary, by car. The transport must relate to the selection process, admission to or discharge from hospital, or the care referred to in point a; c) transport of a donor who lives abroad to and from the country of residence or the country of origin. The donor is only entitled to reimbursement if you are undergoing a heart, lung, kidney, bone marrow or liver transplant in the country of residence or the country of origin. The donor also has the right to reimbursement of other transplant-related costs incurred as a result of the fact that the donor lives abroad. Please note! This does not include accommodation costs or loss of income. We must give you permission in advance. CARE OUTSIDE OF A HOSPITAL 10 GENERAL PRACTITIONER CARE We reimburse the costs of medical care provided by a general practitioner. The care can also be provided by a similar doctor or care provider under the supervision of the general practitioner. If requested by a general practitioner, we also reimburse the costs of X-rays and laboratory tests. The extent of the care provided is limited to the care normally provided by general practitioners. The costs of registering with a general practitioner are only reimbursed in the country of residence. We only reimburse these costs if you cannot claim reimbursement under another insurance policy. 11 NURSING OUTSIDE OF A HOSPITAL (HOME CARE) We reimburse the costs of home nursing. 100% up to a maximum of 8 hours per 24 hours. For a maximum of 6 weeks per person per 5 calendar years 100% up to a maximum of 8 hours per 24 hours. For a maximum of 6 weeks per person per 5 calendar years 1. We must give you permission in advance. 2. Home nursing must be provided by a qualified nurse. 3. We only reimburse the costs if home nursing shortens or prevents a medically necessary hospital stay. 12 PHYSIOTHERAPY AND REMEDIAL THERAPY PLEASE NOTE! By chronic conditions we mean conditions on the List of Chronic Disorders compiled by the Dutch government (Annex 1 of the Health Insurance Decree [Besluit Zorgverzekering]). The name of the list implies that all chronic disorders are listed, but this is not always the case! Furthermore, non-chronic conditions are also included in the list. You are welcome to contact us if you have questions. We reimburse the costs of physiotherapy and remedial therapy. The extent of the reimbursement depends on whether your condition is included in the list established by the Dutch Minister of Health, Welfare and Sport (Annex 1 of Article 2.6 of the Health Insurance Decree). The list drawn up by the Minister of Health, Welfare and Sport also specifies a maximum treatment period for a number of disorders. This list can be obtained from us Chronic conditions Do you have a disorder that is included in the list established by the Dutch Minister of Health, Welfare and Sport? In that case we reimburse the costs of all treatments by a physiotherapist or remedial therapist. Do you need manual lymph drainage because you suffer from severe lymphatic oedema? In that case you can also be treated by a skin therapist. The extent of care provided is limited to the care normally provided by physiotherapists, remedial therapists, and when manual lymph drainage is involved skin therapists. You must be referred by a general practitioner, a company doctor or a medical specialist. 17

18 What we do not reimburse We do not reimburse the costs of: a) individual or group treatment if the only purpose of the treatment is to improve your fitness by means of training; b) pregnancy gymnastics, postnatal gymnastics, (medical) fitness, (sports) massage and work and activity therapy; c) surcharges for: appointments outside of regular working hours; missed appointments; simple, brief reports or more complicated, timeconsuming reports; d) bandages and medical devices supplied by your physiotherapist or remedial therapist; e) hydrotherapy that takes place in a swimming pool Non-chronic conditions Do you have a disorder that is not included in the list established by the Dutch Minister of Health, Welfare and Sport? In that case we reimburse the costs of treatment by a physiotherapist or remedial therapist. The extent of care provided is limited to the care normally provided by physiotherapists and remedial therapists. maximum of 1,000 per person per calendar year maximum of 2,000 per person per calendar year You must be referred by a general practitioner, a company doctor or a medical specialist. What we do not reimburse We do not reimburse the costs of: a) individual or group treatment if the only purpose of the treatment is to improve your fitness by means of training; b) pregnancy gymnastics, postnatal gymnastics, (medical) fitness, (sports) massage and work and activity therapy; c) surcharges for: appointments outside of regular working hours; missed appointments; simple, brief reports or more complicated, timeconsuming reports; d) bandages and medical devices supplied by your physiotherapist or remedial therapist; e) hydrotherapy that takes place in a swimming pool Pelvic physiotherapy to treat urinary incontinence Are you 18 or older and do you suffer from urinary incontinence? And would you like to use pelvic physiotherapy to treat it? In that case we reimburse the cost of a pelvic physiotherapist. The extent of care provided is limited to the care normally provided by physiotherapists. the costs of the first 9 treatments (once per medical condition) the costs of the first 9 treatments (once per medical condition) 1. You need a referral issued by a general practitioner, a company doctor or a medical specialist. This referral enables us to determine whether you are entitled to reimbursement of the costs of pelvic physiotherapy under the insurance. 2. The treatment must be provided within the context of medical treatment. What we do not reimburse We do not reimburse the costs of: a) pregnancy gymnastics, postnatal gymnastics, (medical) fitness, (sports) massage, examinations and courses of a social nature, or work and activity therapy; b) surcharges for: appointments outside of regular working hours; missed appointments; simple, brief reports or more complicated, timeconsuming reports; c) bandages and medical devices supplied by your physiotherapist or remedial therapist. 13 PSYCHOLOGICAL CARE AND PSYCHIATRIC CARE (PRIMARY CARE) Do you need psychological care? In that case we reimburse the costs of psychological care and psychiatric treatments provided as primary care services. 75% up to a maximum of 500 per person per calendar year maximum of 1,000 per person per calendar year 1. You must be referred by a general practitioner, a company doctor or a doctor who specialises in juvenile health care. 2. We must give you permission in advance. 3. The treatment must be provided in person. What if your treatment process is interrupted by departure to another country of residence? And the treatment can be continued by , telephone or online contact? In that case we reimburse the treatments described in this article. What we do not reimburse We do not reimburse the costs of examinations and courses of a social nature. 14 COMPLEMENTARY AND ALTERNATIVE TREATMENTS, THERAPIES AND MEDICINES Do you need an alternative treatment or therapy and/or alternative medicines? In that case we reimburse the costs of: 18

19 a) chiropractic treatment; b) osteopathy; c) homeopathic medicines; d) acupuncture. maximum of 450 per person per calendar year maximum of 850 per person per calendar year The treatment or therapy must be provided by an alternative healer or therapist. What we do not reimburse We do not reimburse costs that result directly or indirectly from: a an illness or pathological abnormality suffered by the insured person; b gross negligence or wilful intent on the part of the insured person; c the consumption of alcohol and/or use of drugs by the insured person; d engagement in physical fighting by the insured person other than for the purpose of self-defence. CHILD AND FAMILY 15 PSORIASIS TREATMENT Do you need treatment for psoriasis? In that case we reimburse the costs of treatment of psoriasis by means of UV-B light in your own home or at a psoriasis day treatment centre. 75% up to a maximum of 1,000 per person per calendar year 75% up to a maximum of 1,500 per person per calendar year 1. You must provide us with a diagnosis issued by dermatologist in advance. 2. We must give you permission in advance. ACCIDENT COVER FOR DENTAL CARE 16 DENTAL CARE REQUIRED AS A RESULT OF AN ACCIDENT FOR INSURED PERSONS AGED 18 OR OLDER For insured persons aged 18 or older we reimburse the costs of dental treatment by a dentist or dental surgeon. The treatment must be required as a result of an accident that occurs during the period covered by this insurance. To qualify for reimbursement, the treatment must be performed within 1 year of the accident, unless it is necessary to defer the (definitive) treatment because the jaw is not yet fully formed. Our consultant dentist will assess whether temporary treatment is required because the jaw is not yet fully formed. Cover must be provided by this insurance both when the accident occurs and when treatment is provided. maximum of 10,000 per accident maximum of 10,000 per accident 1. We must give you permission in advance. Before approving your request for treatment we will assess whether the treatment is appropriate and legitimate. 2. A treatment plan and cost estimate prepared by your dentist or oral surgeon must be submitted with your request for approval. PLEASE NOTE! We do not reimburse the costs of care at the following private birth clinics in London (UK): Portland Hospital Chelsea & Westminster Hospital (Kensington Wing) St. Mary s Hospital (Lindo Wing) Reimbursement under the following articles does not apply for the first 10 months after you take out an XHI Comfort or policy: a in vitro fertilisation (IVF) (Article 17.1); b other fertility-enhancing treatments (Article 17.2); c prenatal screening (Article 18); d childbirth and obstetric or midwifery care (Article 19); e childbirth allowance (Article 20). 17 IN VITRO FERTILISATION (IVF), OTHER FERTILITY- ENHANCING TREATMENTS, SPERM AND OOCYTE CRYOPRESERVATION We reimburse the costs of in vitro fertilisation (IVF) (17.1), other fertility-enhancing treatments (17.2), sperm cryopreservation (17.3) and oocyte cryopreservation (17.4) In vitro fertilisation (IVF) Do you want to undergo IVF treatment? And are you under the age of 43? In that case, per ongoing pregnancy achieved, you are entitled to reimbursement of the first, second and third IVF attempts, including any medicines used. maximum of 7,000 (including medicines) per ongoing pregnancy achieved maximum of 10,000 (including medicines) per ongoing pregnancy achieved 1. The treatment must take place in a licensed hospital in the country of residence or country of origin. 2. You need a medical statement from your doctor before submitting your application. 3. We must give you permission in advance. 19

20 What we do not reimburse We do not reimburse the costs of medicines needed for a 4th or subsequent IVF attempts. What is the definition of an IVF attempt to achieve pregnancy? An IVF attempt to achieve pregnancy involves undergoing, at most, the following sequential phases: 1. ripening of oocytes within the woman s body by means of hormonal treatment; 2. retrieval of the ripe oocytes (follicular puncture); 3. oocyte fertilisation and cultivation of embryos in the laboratory; 4. replacement of 1 or 2 of the resulting embryos in the uterus to allow pregnancy to occur. Are you under the age of 38? In that case only 1 embryo may be replaced during the first and second attempts. The process only counts as an attempt if follicular puncture (phase 2) is successful. From then on, we count all attempts that are interrupted before an ongoing pregnancy is achieved. A new attempt after an ongoing pregnancy is treated as a first attempt. The replacement of frozen embryos is regarded as part of the IVF attempt during which they were created. ICSI treatment (intracytoplasmic sperm injection) is the equivalent of an IVF attempt. What is the definition of an ongoing pregnancy A distinction is drawn between 2 different forms of ongoing pregnancy: a) physiological pregnancy: a (spontaneous) pregnancy lasting at least 12 weeks from the first day of the last menstruation. b) IVF-induced pregnancy lasting at least 10 weeks from the follicular puncture after a non-frozen embryo is replaced. Or at least 9 weeks and 3 days after a vitrified embryo is replaced Other fertility-enhancement treatments Are you under the age of 43? In that case we reimburse the costs of fertility-enhancement treatments other than IVF, including any medicines used. maximum of 1,000 (including medicines) per ongoing pregnancy achieved maximum of 1,500 (including medicines) per ongoing pregnancy achieved 1. You need a medical statement from your doctor before submitting your application. 2. We must give you permission in advance. 3. The treatment must take place in a licensed hospital in the country of residence or the country of origin. What we do not reimburse We do not reimburse the costs of medicines needed for a 4th or subsequent IVF attempts Sperm cryopreservation Are you undergoing specialist medical treatment that may result in unintended infertility? In that case we reimburse the costs of the collection, freezing and storage of semen. The freezing of semen must be a part of specialist oncological care or an equivalent non-oncological treatment. This must involve: a) major surgery on or close to your genitals; b) chemotherapy and/or radiotherapy treatment during which your genitals are exposed to radiation Freezing human oocytes and embryos (cryopreservation) Do you want to have human oocytes or embryos cryopreserved? In that case we provide reimbursement if the following medical indications are present: a) you are undergoing chemotherapy which carries the risk of permanent fertility problems. b) you are undergoing radiotherapy treatment during which your ovaries are exposed to radiation and could be permanently damaged as a result. c) you are undergoing surgery during which (large parts of) both of your ovaries will be removed for medical reasons. There are also other medical indications that involve an increased risk of premature infertility. This is the case if you suffer from premature ovarian insufficiency (POI) before you reach the age of 40. In that case you are entitled to cryopreservation. The medical indications involved are those relating to the following aspects of female fertility: a) fragile X syndrome; b) Turner syndrome (XO); c) galactosemia. If these medical indications are present, you are entitled to reimbursement of the following parts of the treatment: a) follicular stimulation; b) oocyte puncture; c) cryopreservation of oocytes. For you to qualify for reimbursement one of the medical indications listed above must be present. 18 PRENATAL SCREENING As a female insured person you are entitled to reimbursement of: a) counselling that explains the procedures involved in prenatal screening; b) a structural echoscopic examination, also known as the 20-week ultrasound scan; c) a medical prenatal test for congenital anomalies. 20