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Sanitas Health Plan Complete. General Conditions:
A) PROVISION OF SERVICES
A.1 In Spain
A.1.2. Inpatient, Day case and Out patient treatment in Spain but outside the Insurer network.
When Treatment is received in Spain but outside the insurer Network, Treatment costs will be reimbursed according to the Co-Insurance shown in the Table of Benefits. Any costs not covered shall be the responsibility of the Insured.
In order to make a Claim the Insured must take the following steps:
1. The Insured or someone acting on behalf of the Insured must notify the claim to the Insurer within the following time limits
(a) In an Emergency, within 5 working days of the Treatment being received
(b) In the case of Surgery or planned Hospitalisation, at least 7 working days before the date of Treatment
(c) The above mentioned time limits shall not contravene article 16 of the Spanish Insurance Law that states "The insured or the beneficiary should notify the insurer of any claim within 7 days of becoming aware of the claim unless the Policy states a longer time limit."
2. For claims involving Surgery, Hospitalisation, diagnostic tests and other Treatments together with the notification of the Claim Event the Insured will send to the Insurer medical information that specifies the diagnosis and type of illness, the name of the place where Treatment was received, the date of admission, the probable duration of the Treatment and its likely nature.
3. The Insured should follow closely the advice of their Doctor and should give the Insurer any information requested regarding the Claim Event and its consequences.
4. The Policy Holder, the Insured or the Insured's family should permit a doctor appointed by the Insurer to examine the Insured in order to verify any issue regarding the Insured's state of health.
5. The Policy Holder or the Insured should notify the Insurer of the end of any period of Hospitalisation.
6. The Policy Holder or the Insured should present the Insurer with the following documents:
6.1 A fully completed claim form
6.2 Receipts and original invoices of any costs inclurred by the Insured, duly separated and accompanied by the following information.
a) the patient's name
b) Details, dates and costs of the Treatment
c) Identification of the person or entity providing the Treatment with their name, surname, address, tax number (NIF) and practice identification number
6.3 Original receipts
6.4 Original medical prescriptions for the Treatment received by the Insured, save that for Consultations where such prescriptions are not necessary.
6.5 Original medical report explaining the Treatment provided to the Insured, the development of the illness, with a prognosis and assessment of future Treatment.
Failure to comply with paragraphs 1 to 6 above shall be grounds for denial of a claim, unless such failure to comply was due to circumstances beyond the Policy Holder, Insured or their families' control.
Should the Insured suffer any of the illnesses noted in these General Conditions that is eligible for reimbursement, the Insurer will pay the Policy Holder or the Insured the appropriate sum by the method detailed below.
Once all the required documentation has been received, and the appropriate checks have been made regarding the Claim Event, the insurer within ten working days will reimburse or make the appropriate payment according to the circumstances.
Should the Claim Event last for longer than three months, the Policy Holder or the insured should send to the Insurer the invoices for the costs incurred in the previous three months.
If the Insurer has, without cause, failed to reimburse the claim three months after the Claim Event, the amount to be reimbursed by the Insurer shall increase at 50% the current Spanish basic rate of interest. This shall be calculated daily and without need for a court judgement. Two years after the claim has been made, the annual interest cannot be less than 20% (article 20 of the Spanish Insurance Act).
Reimbursement for Treatment received in Spain outside the Insurer Network will be paid in Euros only by bank transfer to the Spanish bank account of the Insured or the Policy-holder.
| A.1.1 Inpatient, Day Case and Out Patient treatment in the Insurer Network |
A.2. In the second European country of cover
| Fax: | (00 34) 91 8032484 |
| 'phone: | (00 34) 609 522 300 |
| Also more information on.. | www.e-healthinsuranceservices.com |
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