Generali Dental 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 de Seguros y Reaseguros S.A., registered office 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), under the Ministry of Economy. Complaints: Generali's Claims & Complaints Service (rules at www.generali.es; Pl. de Manuel Gómez-Moreno 5, 28020 Madrid; reclamaciones.es@generali.com) resolves with reasons within a maximum of two months; you may then escalate to the DGSFP Complaints Service (Paseo de la Castellana 44, 28046 Madrid) or go to the courts. Applicable law: Law 50/1980 on Insurance Contracts, Law 20/2015 and RD 1060/2015, plus the terms of the contract, its annexes, the application and the risk questionnaire.

Article 1 — Definitions & Article 2 — The parties ↑ top

1. Definitions

• Accident (1.1): bodily injury from a violent, sudden, external cause beyond the Insured's control.
• Sum insured (1.2): the amount in the Particular Conditions for each contracted guarantee.
• Health centre, clinic or hospital (1.3): a legally constituted establishment to treat people as patients, with proper medical services, 24-hour nursing and the instruments for diagnosis and surgery of any kind. Spas, rest homes, asylums and care/geriatric homes are not hospitals.
• Illness (1.4): a non-accidental alteration of health, confirmed by a legally-recognised doctor, requiring medical care.
• Excess / co-pay (Franquicia) (1.5): the part of a claim's cost the Insured bears. The dental co-pays per act are set in Generali's Guía Dental.
• Hospitalisation (1.6): a stay as a patient in a health centre, clinic or hospital for more than 24 hours.
• Pathology / pathological process (1.7): a health alteration from illness or accident, confirmed by a doctor and requiring care.
• Waiting period (1.8): the period after each guarantee's effective date during which that guarantee is not yet in force.
• Policy (1.9): the legal document governing the relationship — the General and Specific General Conditions, the Particular Conditions, the application, the Guía Dental and any later supplements.
• Premium (1.10): the price of the insurance, plus legally-applicable taxes and surcharges.
• Claim (1.11): any event whose consequences are covered by one of the policy's guarantees.

2. The parties

Policyholder (Tomador): the person who, with the insurer, takes out the contract and holds its rights and obligations (except those that by nature fall to the Insured). Insured (Asegurado): the person on whom the insurance is established, named in the Particular Conditions. Insurer (Compañía): the legal person assuming the agreed risk.

Article 3 — Object of the insurance ↑ top

This contract guarantees a daily indemnity for hospitalisation due to illness and accident, and access — through the professionals in the Guía Dental — to the dental and stomatological care the Insured needs, within the limits of the contracted guarantees. This is independent of the cost of any healthcare the Insured might need, which is only covered where expressly stated in the Conditions. The sum insured is that set for each contracted guarantee in the Particular Conditions.

Article 4.1 — Dental assistance ↑ top

This guarantee gives access in Spain to the services in the Particular Conditions and in the “Coded Dento-Stomatological Medical Services” section of the Guía Dental. The coded services are provided only at the network providers listed in the Guía Dental. No cash indemnity is paid in place of the dental service, but the Insured may freely choose any dentist among the network professionals. The Insured identifies themselves with the insurer's card at network providers — in their own province or any other where the insurer has a published Guía Dental.

Acts provided at the insurer's charge (no co-pay)

Oral diagnosis: initial oral exam & diagnosis (0110), estimate (0120), emergency exam (0130), professional consultation (0140), check-ups (0150).

X-rays: periapical (0210), occlusal (0212), bitewing (0214), orthopantomography (0220), lateral / teleradiography (0222), TMJ (0224), periodontal series (0250).

Preventive & dental aesthetics: scaling / annual mouth cleaning (1110), oral-hygiene education (1120), brushing-technique teaching (1130), caries-control diet planning (1140), plaque staining & index (1150), topical fluoride per session — 2 a year (1210).

Paediatric dentistry (children up to 14, deciduous teeth): deciduous-tooth extraction (2440).

Child dental plan (permanent dentition only, per the Guía Dental rules): pit & fissure sealing of 1st/2nd permanent molar (2310), filling (2410), reconstruction (2412), prefabricated stainless-steel crown (2420), indirect pulp capping (2430), pulpotomy (2432), apexification visit (2434), pulp opening & drainage (2436), deciduous-tooth extraction (2440).

Space maintainers: fixed unilateral (2510), removable acrylic (2520), re-cementing (2550).

Oral surgery: simple extraction (7110), complicated extraction and/or suture (7120), surgical extraction of semi-impacted wisdom tooth (7210), extraction of a tooth retained in bone — with odontosection and/or osteotomy (7220), abscess opening & drainage (7310), frenectomy (7320), cystectomy with or without extraction (7330), minor soft-tissue surgery (7350), pre-prosthetic surgery (7410).

All other acts — fixed co-pay

For every other act in the “Coded Dento-Stomatological Medical Services” section of the Guía Dental (detailed in the Particular Conditions), the Insured pays the dentist directly the fixed co-pay (franquicia) set for that act and for the province where it is performed.

Article 4.2 — Daily hospital cash (illness & accident) ↑ top

If, due to illness or accident, the Insured must be hospitalised, the insurer pays — for the indemnity period set in the Particular Conditions — the sum insured for each day of uninterrupted stay in a health centre, clinic or hospital. The sum accrues for complete 24-hour periods from the date and time of admission.

• Intensive care (ICU): an additional sum insured for each uninterrupted stay in ICU, accruing per complete 24 hours from ICU admission.
• Successive stays for the same cause count as a single hospitalisation period. No sum is ever paid for stays under 24 hours.
• If the Insured has several processes at once, or a new one arising from those declared, the indemnity period runs from the date of the initially-declared process; a new, unrelated process starts a fresh period.
• No Insured may accrue the sum insured for the same process or diagnosis — consecutively or across periods — for longer than the indemnity period.
• For Insureds under 5 or over 69, this cover is limited to hospitalisation for illness and accident only in the case of a surgical operation.

Article 5 — What is not covered ↑ top

Dental assistance: any service not expressly included in the Particular Conditions or in the “Coded Dento-Stomatological Medical Services” section of the Guía Dental.

Daily hospital cash — the following give no right to indemnity:

• Accidents/illness from scientific expeditions or practising any sport professionally; air sports, motor-vehicle sports, boxing, climbing, martial arts, bobsleigh, bullfighting, running of bulls, and other manifestly dangerous activities.
• Pre-existing illnesses (chronic or not), constitutional/physical defects and accidents existing before the Insured joined — even without a specific diagnosis — and their consequences/sequelae (pre-existing = processes/defects causing evident symptoms or reasonable suspicion before each guarantee's effective date).
• Claims caused directly by any contagious disease classed as a WHO Phase 5 or higher pandemic.
• Consequences of war, public-order disturbance, officially-declared extraordinary/catastrophic phenomena, and nuclear atomic energy (unless from a medical treatment based on that energy).
• Pathological processes manifesting only as pain, aches or vertigo, not verifiable/objectifiable by diagnostic tests.
• Accidents/illness wilfully caused by the policyholder or Insured that gravely risk the Insured's health; interruption or omission of treatment; and other self-inflicted harm.
• Illness and accidents from alcohol, drugs or narcotics, brawls, challenges or suicide attempts.
• Medical exams, check-ups and stays in spas, rest homes, asylums or care/geriatric homes.
• Voluntary medical or surgical acts not arising from accident or illness — e.g. infertility treatment and purely cosmetic treatment — except reconstructive surgery after an accident or burn occurring during the policy.
• Neurological illness not verifiable/objectifiable by diagnostic tests.
• Psychosis, neurosis, psychopathy, personality disorders, depression or stress, and psychosomatic illness.
• Immunodeficiency illnesses.
• Claims occurring during the waiting period, even if they continue beyond it.
• The diagnosis and treatment of fibromyalgia.

Article 14 — Waiting periods ↑ top

Unless agreed otherwise, for the Daily Hospital Cash guarantee:

• Three months for surgically-treated illnesses (except urgent medical prescription).
• Twelve months where the Insured declared having received medical treatment in the last twelve months, for that cause.
• Eight months for pregnancy and birth.
• Six months for other illnesses requiring hospitalisation.
• All waiting periods are automatically waived where the claim results from an accident.

Article 13 — How to claim & how it is paid ↑ top

a) Expert procedure

If a party disagrees with the insurer's determination of the claim, it must notify the insurer in writing, with reasons, within 48 hours; the attending doctor and the insurer's doctor then try to resolve it as experts. Failing agreement, the procedure of Art. 38 of the Insurance Contract Law applies: each party appoints an expert; if they disagree, a third expert is appointed (or via the Voluntary Jurisdiction Law / notarial law), giving an opinion within 30 days. The experts' decision (unanimous or majority) is binding unless challenged in court within 30 days (insurer) / 180 days (Insured). The insurer pays at least the minimum due (or the full amount within 5 days if unchallenged); each party pays its own expert, and the third expert's costs are shared — unless one party forced the third expert by a manifestly disproportionate valuation.

b) Follow-up & control

The insurer may make visits to check the Insured's condition; obstructing a visit releases the insurer from paying the relevant sum (except where the attending doctor objects with written reasons). The Insured consents to the insurer consulting their attending doctors on medical data (kept confidential). The insurer is not bound by other bodies' valuations, and may end accrual where the Insured breaches the Conditions or artificially prolongs a claim. If away from home and unable to return after the accident/illness, the Insured still receives the sum insured, provided the requirements are met and the temporary address is given.

c) Documentation & deadlines

The claim must be notified within a maximum of seven days (Art. 16 of Law 50/1980). For Dental Assistance, the claim is deemed notified when the service is requested from a network professional. For Daily Hospital Cash, notify the admission within 7 days and provide the “Claim Declaration” completed and signed by the prescribing doctor — or a written notice signed by the attending doctor stating the Insured's details, the doctor's details and college number, the admission date/time and centre, a medical report on the cause and treatment, and the likely discharge date. After discharge, provide a document signed by the doctor and the centre's administration giving the exact admission period (day and time of discharge).

d) Payment

The insurer pays the sum insured once the investigations needed to establish the claim are complete, and may make payments on account where the claim lasts more than 40 days.

Articles 6–12 & 15–19 — Contract terms ↑ top

Perfection & duration (Arts. 6–7)

The contract is perfected by both parties' consent and signature; the guarantees take effect on the date in the Particular Conditions, once the first premium (or agreed fraction) is paid. It runs for the period stated and then renews automatically for one year, and so on. Either party may oppose renewal in writing — the insurer with two months' notice, the policyholder with one month. The insurer must notify any contract change at least two months before the period ends.

Premium payment (Art. 8)

Premiums are annual (or for a shorter contracted term), payable in advance — the first at perfection, the rest at their due dates; fractioned payment may be agreed but the full annual premium must be paid. If the first premium is unpaid, the insurer may treat the contract as extinguished or claim payment; if unpaid before a claim, the insurer is released. For successive premiums there is a one-month grace period; after that, cover is suspended until paid. If the insurer does not claim within six months of the due date, the contract is extinguished.

Bases of the contract (Art. 9)

The contract is based on the policyholder's declarations in the application/questionnaire, which determine the insurer's acceptance of the risk. If the policy differs from the application, the divergence may be corrected within one month of delivery; otherwise the policy prevails.

Obligations of the policyholder/Insured (Art. 10)

Before signing, declare all known circumstances affecting the risk (answering the questionnaire). During the contract, declare aggravations of the risk (the insurer may then propose a modification within two months, or rescind) and any reductions (the premium is then reduced). Where an undeclared inaccuracy or aggravation comes to light at a claim, the benefit is reduced in proportion to the premium difference (provided good faith); with wilful misconduct or bad faith, the insurer is released. Also: notify any change of address (certified post, at least 7 days before requesting a service); declare any other insurance covering the same risks; facilitate subrogation; and use all available means to mitigate the claim's consequences (ensuring the Insured receives treatment and follows medical advice).

Communications between the parties (Art. 11)

All communications must be in writing; exceptionally, telephone communications from the insurer are valid if recorded on a durable medium with prior express consent. The insurer may use post, burofax, fax, email or SMS to the address/number in the policy (or later notified). Postal/burofax communications take effect from the first delivery attempt; email/SMS from receipt, regardless of whether opened. Communications via the mediating agent or broker have the same effect as if made directly.

Insurable persons (Art. 12)

Unless agreed otherwise, persons under 70 years old at the contract date may be insured.

Loss of the right to the sum insured (Art. 15)

Besides the causes elsewhere in these Conditions: reservation or inaccuracy in the questionnaire with wilful misconduct or gross negligence; bad-faith failure to notify a risk aggravation; a claim occurring before the first premium is paid (unless agreed otherwise); failure to provide basic claim data with wilful misconduct or gross negligence; breach of the duty to mitigate with intent to harm or deceive the insurer; and a claim caused by the Insured's bad faith.

Jurisdiction & prescription (Arts. 16–17)

Spanish law applies; the competent court is that of the Insured's domicile (an address in Spain must be designated if theirs is abroad). Actions under the contract prescribe in five years.

Territorial scope (Art. 18)

The Daily Hospital Cash guarantee applies worldwide, provided the Insured's habitual residence is in Spain. The Dental Assistance guarantee applies in Spain. Indemnities are paid in Spain and in euros. The insurer is released from any obligation where providing the cover would expose it to sanctions or restrictions under UN resolutions or EU, UK or US law.

Annual automatic revaluation (Art. 19)

At each renewal the policyholder may have the sums insured revalued by a chosen percentage (with a matching premium increase); either party may waive it with two months' notice. The sum insured is that in force when the claim occurs. For Dental Assistance, the co-pays are revalued in line with the price evolution of the services in the Particular Conditions / the Guía Dental.

These General Conditions have been drafted in simplified form to aid understanding. Please read them carefully and ask your mediator or any Generali branch for any clarification. Source: GENERALI España de Seguros y Reaseguros S.A. — Generali Dental, Seguro de Hospitalización Diaria y Asistencia Dental, ref. SA 154/GEN, edition G51212 (01/2026).