Generali Profesional — Daily-Benefit / Self-Employed Incapacity Policy Conditions (English Translation)

Preliminary — Information clause ↑ top

This information is issued under Article 96 of Law 20/2015 and Article 122 of Royal Decree 1060/2015, on the insurer's duty to inform the policyholder and the insured. Insurer: GENERALI España de Seguros y Reaseguros S.A. (the Company / Generali / the Insurer). Registered office: Pl. de Manuel Gómez-Moreno, 5, 28020 Madrid. NIF: A48037642. Madrid Commercial Registry, sheet M-377257. Supervisory authority: the Directorate-General for Insurance and Pension Funds (DGSFP). Complaints: via Generali's Complaints and Claims Service (Pl. de Manuel Gómez-Moreno 5, Madrid; reclamaciones.es@generali.com), which must resolve within two months; thereafter the DGSFP Claims Service (Paseo de la Castellana 44, Madrid; www.dgsfp.meh.es/reclamaciones), without prejudice to the courts. Applicable law: Law 50/1980 on the Insurance Contract (not mandatory where this is treated as a large risk under Art. 11 of Law 20/2015), Law 20/2015, RD 1060/2015 and developing rules, plus the Conditions, the application and the risk questionnaire signed by the policyholder.

Article 1 — Definitions ↑ top

• Sum insured (Capital Asegurado): the amount in the Particular Conditions for each guarantee contracted.
• Policy: the legal document governing the parties' relationship — the General and Specific General Conditions, the Particular Conditions, the application and any later supplements.
• Premium: the price of the insurance (the receipt also includes legally chargeable taxes and surcharges).
• Pathology / pathological process: an alteration of health, of common or accidental cause, confirmed by a legally recognised doctor and requiring medical care.
• Illness: an alteration of health of common, non-accidental cause, confirmed by a doctor and requiring medical care.
• Accident: bodily injury from a violent, sudden, external cause beyond the insured's will.
• Waiting period (plazo de carencia): a period from the effective date of each guarantee during which that guarantee is not yet in force.
• Loss event (siniestro): any event whose consequences are covered by a guarantee.
• Hospitalisation: the insured's stay in a health centre, clinic or hospital for more than 24 hours as a patient.
• Health centre / clinic / hospital: a legally constituted establishment with the medical services and 24-hour nursing and instruments needed to diagnose and operate. Spas, rest homes, asylums and geriatric homes do not count.
• Excess (Franquicia): a period after the loss occurs during which no guarantee is in force and no indemnity is payable; its length is set in the Particular Conditions.

Article 2 — Persons in the contract ↑ top

Policyholder: the person who, with the Insurer, signs the contract and holds its rights and obligations (save those that by nature fall to the Insured). Insured: the named person on whom the insurance is established. Company / Insurer: the legal person assuming the risk. Beneficiary: the person(s) entitled to receive the sums insured when the contingency occurs.

Article 3 — Object of the insurance ↑ top

This contract guarantees cash benefits, within the limits of the guarantees contracted, regardless of the cost of any medical care the insured may need — which is in no case guaranteed by this policy. The right to the sum insured is independent of the rulings of the Social Security or other public/private bodies; the Insurer is not bound by their valuations.

Article 4 — The guarantees ↑ top

4.1. Daily indemnity for illness and accident — the core difference between Plus and Baremado

Profesional Plus: during the Indemnity Period set in the Particular Conditions, the Insurer pays the daily sum insured when illness or accident causes a total interruption of the insured's usual work or profession requiring medical care. The sum accrues for each day the loss lasts, up to the Indemnity Period, after deducting the contracted excess (franquicia). The right ceases the moment the insured can resume work partially or totally — even if not fully recovered or still signed off by the Social Security; leaving home against a prescribed home-rest order also ends it; the discharge day counts as a working day (no sum). The daily sum is paid for calendar days (including weekends and holidays). Acute processes are payable while they cause total work interruption; chronic non-operable processes are payable during flare-ups; operable ones only from hospital admission for surgery. Pregnancy/childbirth: maximum 20 days for the whole gestation/birth/post-partum process.

Profesional Baremado: the Insurer pays the daily sum × the number of days assigned to the diagnosis in the “daily-indemnity-by-diagnosis” scale (baremo), when illness or accident alters the insured's health requiring medical care. Payment is limited to the baremo days for the condition, regardless of whether the insured has fully recovered; a diagnosis the baremo rates at zero days pays nothing. The yearly maximum is the daily sum × the maximum Indemnity Period, regardless of the number of claims. Chronic processes and their flare-ups are NOT indemnifiable. Operable conditions accrue from hospital admission for surgery. At least 90 days must pass since the previous payment before a successive claim for the same or an equivalent diagnosis qualifies; concurrent ailments do not accumulate — the diagnosis with the most baremo days is paid. Pregnancy/childbirth: maximum 15 days.

Under both versions, the right to the daily sum ceases on unemployment, permanent disability of any kind, or cessation of the usual work/profession for any cause (a person is in permanent disability where, despite treatment, serious objectively-determinable and presumably permanent anatomical/functional reductions disable them from the fundamental tasks of their usual work).

4.2. Complementary pre-surgery indemnity (Profesional Plus)

Where illness or accident requires surgical treatment, the Insurer pays the daily sum from the moment surgery is needed to cure the injury until the insured is admitted for that surgery, up to the Indemnity Period — provided there is a scheduled surgery date or the insured is on the Social Security waiting list. The right ceases when the insured can resume work partially or totally; the admission day pays no sum. This guarantee is incompatible with the daily illness/accident indemnity (4.1) for the same period, and ends on unemployment/permanent disability/cessation of activity.

4.3. Hospitalisation for illness and accident

During the Indemnity Period, if illness or accident requires hospitalisation, the Insurer pays the daily sum for each day of uninterrupted stay in a health centre, accrued in complete 24-hour periods from admission. An additional daily sum is paid for uninterrupted stay in intensive care (ICU/UVI). Successive hospitalisations for the same cause count as one period; no sum is paid for stays under 24 hours.

4.4. Death or absolute & permanent disability by accident

If an accident causes the insured's death or absolute & permanent disability during the policy's full force, the Insurer pays the capital in the Particular Conditions to the insured or designated beneficiary. Payment for absolute & permanent disability by accident automatically extinguishes the policy. Absolute & permanent disability by accident = the irreversible physical state rendering the insured totally and permanently unfit for any paid work (employed or self-employed) and for normal daily activities, certified by the Insurer's Medical Service. This guarantee is incompatible with the daily-indemnity and pre-surgery guarantees. Disputes over the cause of death/disability are resolved by medical experts under Articles 38–39 of Law 50/1980.

4.5. Surgical-operation indemnity

The Insurer pays the sum resulting from multiplying the Base Capital in the Particular Conditions by the percentage in the Surgical-Operations Baremo (annex) for the operation performed on the insured (whether day-case or as an inpatient) due to a covered illness or accident. Where several operations are performed in one session for expressly differentiated processes, the Insurer pays the full indemnity for the highest-value operation and 50% of each of the others (except abdominal surgery on different organs through the same approach, where only the highest is paid). An operation not in the baremo is indemnified by analogy with a similar listed one.

4.6. Mental-Health Programme (support only — no cash indemnity)

This service gives access to professional psychological support: an initial questionnaire, an assigned psychologist acting as a personal coach (changeable on request), up to 10 consultations a year by phone or video (max 4 a month), an asynchronous messaging chat (reply within 24 working hours), and digital well-being resources — accessed via the Generali app/portal, confidentially. It is orientation and support only, non-urgent, and does NOT involve any cash indemnity for mental illness; high-risk situations are directed to specialist in-person care.

Article 5 — Risks not covered ↑ top

The following are outside cover and give no right to indemnity:

• a) accidents/illnesses from scientific expeditions or practising any sport professionally, air sports, motorised sports, boxing, climbing, martial arts, bobsleigh, bullfighting, running of bulls, and other manifestly dangerous activities;
• b) all illnesses (chronic or not), injuries, constitutional/physical defects and accidents pre-existing at the date the affected insured joined the policy (even without a concrete diagnosis), and their consequences/sequelae — “pre-existing” meaning those causing evident symptoms or reasonable suspicion before each guarantee's effective date;
• c) losses caused directly by any contagious disease classified by the WHO as a Phase 5 or higher pandemic;
• d) consequences of war, public disorder, officially-declared extraordinary/catastrophic events, and nuclear atomic energy (save where from a medical treatment based on it);
• e) pathological processes whose sole manifestation is pain, aches or vertigo, unverified/not objectifiable by diagnostic tests;
• f) accidents/illnesses caused wilfully by the policyholder/insured entailing grave health risk, and interruption/omission of treatment and other self-inflicted harm;
• g) illnesses/accidents from alcohol intoxication, drugs or narcotics, brawls, challenges or attempted suicide;
• h) medical examinations, check-ups and stays in spas, rest homes, asylums or geriatric homes;
• i) voluntary medical/surgical acts not arising from accident or illness, such as fertility and purely cosmetic treatments (save reparative surgery after an accident or burn during the policy);
• j) neurological illnesses unverified/not objectifiable by diagnostic tests;
• k) psychoses, neuroses, psychopathies, personality disorders, depression or stress, and all organic manifestations of a mental illness known as psychosomatic illnesses;
• l) immunodeficiency illnesses;
• m) accidents from driving vehicles without the required licence;
• n) death and disability resulting directly from a surgical operation;
• o) losses occurring during the waiting period, even if they extend beyond it;
• p) the process from diagnosing and treating fibromyalgia.

Articles 6–11 — Contract, premiums & communications ↑ top

Art. 6 — Formation: the contract is perfected by both parties' consent and signature, the guarantees taking effect on the date in the Particular Conditions once the first premium is paid.

Art. 7 — Duration: for the period in the Particular Conditions, then tacitly renewed yearly; either party may oppose renewal in writing (one month's notice for the policyholder, two for the insurer). Any insured who turns 70 or retires automatically ceases to be insured at the end of that insurance year.

Art. 8 — Premiums: annual (payable in instalments by agreement). The first premium is due on formation; non-payment lets the Insurer terminate or enforce, and unpaid before a loss releases the Insurer. Successive premiums have a one-month grace period, after which cover is suspended; if the Insurer does not claim within six months, the contract is extinguished; while suspended only the current period's premium may be demanded.

Art. 9 — Basis of contract: the policyholder's declarations and the risk questionnaire are the basis; divergences between policy and proposal may be corrected within one month of delivery.

Art. 10 — Duties of the policyholder/insured: to declare all risk-relevant circumstances before signing and any aggravation during the contract (the Insurer may then propose a modification or, on rejection/silence, cancel); a decrease of risk entitles a premium reduction. The insured must notify any change of professional situation — change of profession, Social Security regime, becoming unemployed or permanently disabled, or ceasing the usual activity. On unemployment / permanent disability / cessation of the activity, the contract is automatically cancelled (premium for the current year refunded); a loss occurring in such a state is not indemnified. The insured must also notify address changes, other insurances covering the same risk, facilitate subrogation, and use all means to lessen the loss (seek treatment, follow prescriptions).

Art. 11 — Communications: all communications must be in writing (telephone valid only if recorded with consent). The insurer may use post, burofax, fax, e-mail or SMS to the addresses/numbers in the policy; communications take effect on receipt (postal on first delivery attempt; e-mail/SMS on reaching the destination); communications via the mediator have the same effect as if made directly.

Article 12 — Insurable persons ↑ top

Save agreement to the contrary, persons aged between 16 and 64 inclusive who carry on a usual paid work or profession may be insured at the date they join the policy.

Article 13 — Handling a claim ↑ top

a) Expert procedure

If a party disagrees with the Insurer's determination of the cause and circumstances affecting the indemnity, it must notify the Insurer in writing within 48 hours; the attending doctor and the Insurer's doctor then try to resolve it as experts. Failing agreement, the Article 38 (Law 50/1980) procedure applies: each party appoints an expert (a party failing to appoint within eight days of being required is bound by the other's expert); if they agree, a joint report is made; if not, a third expert is appointed (by agreement or via the Voluntary Jurisdiction Act / notary). The opinion is binding unless judicially challenged within thirty days (Insurer) or one hundred and eighty days (Insured); if challenged, the Insurer pays the minimum it may owe, otherwise the experts' amount within five days. Each pays its own expert; the third and other costs are shared equally (unless one party forced it by a manifestly disproportionate valuation).

b) Monitoring

The Insurer may make visits to check the insured's state (refusing a visit releases the Insurer from paying, save the attending doctor's justified, written objection). The insured consents to the Insurer consulting the attending doctors (confidentially). The Insurer is not bound by other bodies' valuations, and may end the accrual where the insured breaches a condition or its doctor finds the loss is being artificially prolonged. If the insured is away from home and cannot return after the accident/illness, the daily sum is still payable provided all the guarantee's requirements are met and the circumstantial address is reported.

c) Documentation and notice

The loss must be notified within a maximum of seven days (Art. 16 of Law 50/1980). For the daily-indemnity and pre-surgery guarantees, late notice means the daily sum only starts accruing from the date the Insurer received the notice. The required documentation includes: a completed “Loss Declaration” signed by the attending doctor (or an equivalent signed medical statement), the worker's working-life report (VILATRA), sick-leave and follow-up reports with diagnosis, tests and treatment, and the discharge document with the exact period and discharge date/time; for pre-surgery, the scheduled surgery date or Social Security waiting-list proof; for hospitalisation, the admission declaration and discharge document; for accidental death, the doctor's certificate of cause, any judicial/police record, the literal death certificate, the Last Wills certificate and will (or declaration of heirs), proof of beneficiary status and the Inheritance Tax settlement; for accidental absolute disability, a medical certificate of origin/cause/development; for surgery, the operating surgeon's details and a report of cause and date.

d) Payment

The Insurer pays at the end of the investigations and expert valuations needed to establish the loss; it may make payments on account where the loss lasts more than 40 days.

Article 14 — Waiting periods (carencias) ↑ top

Save agreement to the contrary: 2 months for the daily illness/accident indemnity; 2 months for hospitalisation (or 12 months where the insured declares having received treatment in the last twelve months); 8 months for pregnancy and childbirth (any guarantee); 6 months for the surgical-operation indemnity. All waiting periods are automatically waived where the loss is caused by an accident.

Articles 15–19 — Loss of right, jurisdiction, territory, indexation ↑ top

Art. 15 — Loss of the right to the sum insured also arises from: reservation/inaccuracy in the questionnaire with fraud or gross fault; bad-faith failure to declare risk aggravation; a loss before the first premium; failure (with fraud/gross fault) to provide basic loss data; bad-faith failure to lessen the loss; the insured's bad faith; or a loss predating the policy.

Art. 16 — Jurisdiction: Spanish law; the competent judge is that of the insured's domicile (a Spanish domicile must be designated if abroad); any contrary agreement is void.

Art. 17 — Prescription: actions are time-barred after five years.

Art. 18 — Territorial scope: the guarantees apply worldwide, provided the insured has habitual residence in Spain; indemnities are paid in Spain in euros. A sanctions clause releases the Insurer where providing cover would expose it to UN/EU/UK/US sanctions or trade restrictions.

Art. 19 — Automatic annual indexation: at each renewal the policyholder may have the sums insured (and premium) revalued by a chosen percentage; either party may waive it with two months' notice. The sum insured at the time of the loss applies.

Article 20 — Cover of extraordinary risks (Consorcio) ↑ top

Under the legal Statute of the Consorcio de Compensación de Seguros (CCS, RDL 7/2004), indemnities for losses from extraordinary events in Spain (or abroad where the insured is resident in Spain) are paid by the CCS where the surcharge was paid and the risk is not covered by the policy, or the insurer cannot meet its obligations (insolvency). Extraordinary events: natural phenomena (earthquakes, tidal waves, extraordinary floods incl. sea surges, volcanic eruptions, atypical cyclonic storm incl. winds with gusts over 120 km/h and tornadoes, falls of celestial bodies); violent events from terrorism, rebellion, sedition, riot and civil commotion; and acts of the Armed/Security Forces in peacetime. Excluded: losses not indemnifiable under the Insurance Contract Act; persons insured under contracts where the CCS surcharge is not compulsory; armed conflicts; nuclear energy; other natural phenomena (water-table rise, landslip, etc., save rainwater causing extraordinary flooding); lawful demonstrations/strikes; the insured's bad faith; losses before the first premium or while CCS cover is suspended; and Government-declared “national catastrophe”. For personal insurance, the cover reaches the same persons and sums insured as for ordinary risks. Claims are notified to the CCS (900 222 665 / 952 367 042, www.consorseguros.es), which values and pays by bank transfer.

Annex — Surgical-Operations Baremo (and Baremado diagnosis scale) ↑ top

Both versions include an Annex setting out the Surgical-Operations Baremo — a detailed table assigning each surgical procedure a percentage of the Base Capital (used for guarantee 4.5). The Profesional Baremado version additionally uses a “daily indemnity by diagnosis” baremo — a table assigning each diagnosis a fixed number of indemnity days (used for guarantee 4.1; a zero-day diagnosis pays nothing). These per-procedure and per-diagnosis tables are reproduced in the policy's annex and Particular Conditions; the indemnity mechanics that apply them are translated in full above. Ask us for the specific percentage or day-count for a given procedure or diagnosis.