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Sanitas Health Plan Complete. General Conditions:
X. DISPUTES AND APPEALS
1. In the case of a dispute about the nature of an illness or the amount of benefit payable, each Party shall appoint an expert, who shall accept in writing the terms outlined below. If one of the parties has not selected an expert, they may be required to do so eight days following a request to so do, failure to do so shall mean that the advice of the other party's expert shall be considered binding.
2. In the case that the Experts reach an agreement, they shall make a report containing the causes of the Claim Event, the valuation or the Benefits, and the other surrounding circumstances affecting the payment of Benefits and the suggested amount of any reimbursement.
3. If the experts do not agree, both parties will appoint a third expert by consent, if no agreement is reached about the third expert, the expert will be decided by a Judge of First Instance according to the Civil Law of Arbitration. In this case the experts opinion will be delivered in a way specified by the parties, failing agreement within 30 days of the appointment of the third expert.4. The Experts opinion, whether unanimous or by a majority will be notified to the parties immediately and will be binding on the parties unless judicially challenged by either of the parties within 30 days in the case of the Insurer and 180 days in the case of the Insured, both periods shall be calculated from the date of notification. If neither party takes the aforementioned actions within these time limits the experts' decision shall become final.
5. If the decision of the experts is not appealed, the Insurer must make the payment indicated by the experts within five days.
6. If the Insurer fails to pay the amount stipulated, the Insured should apply for legal judgement, the corresponding payment shall be increased at the annual rate legally specified and will be calculated from the time that the experts decision became final, and in any case the Insurer shall pay the costs incurred by the Insured in obtaining judgement.
7. Each party will pay the costs of their own expert. The third experts cost and any further expenses that the experts deliberations have incurred shall be split between the Insurer and the Insured. Should the need for the expert's decision have been due to a clearly inaccurate valuation of the claim then these costs shall be the sole responsibility of that party
| Fax: | (00 34) 91 8032484 |
| 'phone: | (00 34) 609 522 300 |
| Also more information on.. | www.e-healthinsuranceservices.com |
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