Generali Daily Benefit (Profesional) Insurance Policy Conditions (English Translation)

Information Clause ↑ top

This clause fulfils the insurer's duty to inform under Article 96 of Law 20/2015 and Article 122 of Royal Decree 1060/2015. Insurer: GENERALI España S.A. de Seguros y Reaseguros, Pl. de Manuel Gómez-Moreno 5, 28020 Madrid (NIF A48037642; Madrid Mercantile Registry, sheet M-377257). Supervisor: the Directorate-General for Insurance and Pension Funds (DGSFP). Complaints: Generali's Claims & Complaints Service (reclamaciones.es@generali.com), then the DGSFP. Applicable law: Law 50/1980 on Insurance Contracts and related rules.

Key concepts & definitions ↑ top

• Illness (Enfermedad): a change in health of a common, non-accidental cause, confirmed by a legally recognised doctor and needing medical care.
• Accident (Accidente): a bodily injury from a violent, sudden, external cause beyond the Insured's control.
• Sum insured (Capital Asegurado): the daily amount chosen in the Particular Conditions, on which the benefit is based.
• Excess period (Franquicia): the period from the start of the claim during which no benefit is payable — the benefit is paid only for the days after it. Its length is set in the Particular Conditions.
• Waiting period (Plazo de carencia): a period from the policy's effective date during which a given guarantee is not yet in force. Claims arising during it are not covered, even if they continue afterwards.
• Indemnity period (Período de Indemnización): the maximum number of days the benefit can be paid for a claim (set in the Particular Conditions).
• Hospitalisation (Hospitalización): a stay of more than 24 hours as a patient in a proper hospital or clinic (spas, rest homes, care homes and geriatric centres do not count).

Object of the insurance ↑ top

Within the limits in your Particular Conditions, the insurer pays the agreed cash benefit when your health is affected by an illness or accident that requires medical care. The two policies differ in the trigger and calculation of the main guarantee (set out below), and each guarantee applies only when it is expressly contracted. Each guarantee also has its own conditions and exclusions, in addition to the general exclusions.

Profesional Plus — temporary-incapacity cover ↑ top

Daily benefit for illness & accident (the main cover)

The insurer pays the daily sum insured for each day that an illness or accident causes the total interruption of your usual work or professional activity — for the duration of the claim, up to the indemnity period, after deducting the contracted excess period. The benefit stops as soon as you can resume your work, even partially, even if you are not fully recovered and even if you remain signed off by Social Security. If a doctor has prescribed that you stay at home, leaving home ends the benefit. The day of hospital admission is not paid under this guarantee.

Complementary pre-surgery benefit

A complementary indemnity in connection with a scheduled surgical operation, payable on the terms in the Particular Conditions (you provide the medical report with the admission date, or proof you are on the surgery waiting list).

Hospitalisation benefit

A daily sum for each day you are hospitalised (a stay over 24 hours) due to a covered illness or accident, notified within 7 days of admission.

Death or absolute permanent disability by accident

If an accident during the policy causes the Insured's death or absolute & permanent disability (total, irreversible inability to do any paid work or normal daily activities, certified by the insurer's medical service), the capital in the Particular Conditions is paid. Paying the disability capital ends the policy. This guarantee cannot be combined with the daily illness/accident or pre-surgery benefits for the same event.

Surgery indemnity

For an operation in theatre (as a day case or inpatient) due to a covered illness or accident, the insurer pays the base capital multiplied by the percentage in the Surgery Scale (Baremo de Intervenciones Quirúrgicas) for that procedure. For several operations in one session, it pays the highest in full plus 50% of each of the others (with an abdominal-surgery exception). Operations not listed are paid by analogy.

Mental-health programme

Where contracted, a psychological support service (not a cash benefit): up to 10 consultations a year (maximum 4 a month) with an assigned psychologist by phone or video, an asynchronous chat with a 24-working-hour response, and digital wellbeing resources, via the Generali app/portal. It is supportive and non-urgent and does not pay any cash indemnity for mental-health conditions.

Profesional Baremado — scale-based indemnity ↑ top

Daily indemnity by diagnosis (the main cover)

Instead of paying for the actual days you are off, this policy pays the daily sum insured multiplied by the fixed number of days the scale (Baremo de indemnización diaria según diagnóstico) assigns to your diagnosis — regardless of whether you have fully recovered. If the scale assigns zero days to a diagnosis, nothing is payable. Key rules:

• The yearly maximum is the daily sum × the indemnity period, whatever the number of claims.
• Pregnancy and childbirth (and any complications) are capped at 15 days in total.
• Chronic processes and their flare-ups are not indemnified.
• For the same or an equivalent diagnosis, at least 90 days must pass between successive paid claims.
• Several ailments at once cannot be added together — the diagnosis with the most scale-days is paid.
• Permanent disability, unemployment or otherwise ceasing your declared work ends the right to the benefit.

Hospitalisation, death/disability, surgery & mental health

Profesional Baremado also offers a hospitalisation benefit, death or absolute permanent disability by accident cover, a surgery indemnity (base capital × the percentage in the Surgery Scale, with the same multiple-operation rules as above), and the same mental-health support programme (support only, no cash indemnity) — each as described in Part 2 and subject to your Particular Conditions.

The scales (annexes)

Two annexes set the amounts: Annex I — Daily-indemnity scale by diagnosis (the number of days payable for each listed illness or accident) and Annex II — Surgery scale (the percentage of base capital payable for each listed operation). Ask us for the scale that applies to your policy.

Cover common to both policies ↑ top

Both policies share the same definitions, the same general exclusions, the same Consorcio clause and the same claims rules. Both are designed for the self-employed (autónomos) and professionals who lose income when they cannot work, and both pay independently of any Social Security determination — the insurer is not bound by Social-Security or other bodies' rulings on incapacity.

Exclusions (risks not covered) ↑ top

The policies do not give any right to indemnity for, among others:

• Pre-existing conditions — any illness (chronic or not), injury or physical/constitutional defect, and accidents, existing before the Insured joined the policy (even without a firm diagnosis), and their consequences.
• Professional sport and dangerous activities — air sports, motor-sport, boxing, climbing, martial arts, bobsleigh, bullfighting and running of bulls, scientific expeditions, and other clearly hazardous pursuits.
• Mental and certain unverifiable conditions — psychosis, neurosis, psychopathy, personality disorders, depression or stress and psychosomatic illness; neurological conditions not objectively verifiable; conditions whose only sign is pain or vertigo not confirmed by tests; and fibromyalgia.
• Wilful or self-caused injury, interruption of treatment, and accidents/illness from alcohol, drugs, brawls, duels or attempted suicide.
• Voluntary medical/surgical acts not caused by accident or illness — fertility and purely cosmetic treatments (except reconstructive surgery after an accident or burn during the policy).
• Contagious disease declared a WHO Phase 5+ pandemic; immunodeficiency diseases.
• War, public disorder, officially declared extraordinary/catastrophic events, and nuclear energy (except as part of medical treatment).
• Medical exams and check-ups, and stays in spas, rest homes, care homes or geriatric centres.
• Driving without the required licence; death or disability directly resulting from a surgical operation; and claims arising during the waiting period.

Extraordinary risks (Consorcio de Compensación de Seguros) ↑ top

As a personal-insurance policy, losses from extraordinary events are indemnified by the public Consorcio de Compensación de Seguros, funded by a surcharge collected with your premium, under Royal Legislative Decree 7/2004 and RD 300/2004. Cover applies to events in Spain — and abroad where the insured is resident in Spain — for natural phenomena (earthquakes, tsunamis, extraordinary floods, volcanic eruptions, atypical cyclonic storm with gusts over 120 km/h and tornadoes, and falling meteorites), terrorism, rebellion, riot and popular tumult, and acts of the Armed or Security Forces in peacetime. Claims can be reported to the Consorcio directly (900 222 665).

How to claim & how it is paid ↑ top

Notify a claim within seven days (Article 16, Law 50/1980). For the daily illness/accident benefit you provide a doctor's Declaración de Siniestro and your work-life report (VILATRA), plus the sick-note (baja), weekly follow-up notes and the discharge note (alta) showing the exact dates. For surgery, a medical report with the operation date; for hospitalisation, notice of admission within 7 days. The insurer's medical service may review your condition and arrange visits, and may consult the doctors treating you. The benefit is paid once the claim is verified, and the insurer may make payments on account where a claim lasts more than 40 days. The right to the benefit is independent of any Social-Security ruling.