Generali Salud Clinic 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, registered office Pl. de Manuel Gómez-Moreno 5, 28020 Madrid; NIF A48037642; Madrid Mercantile Registry, sheet M-54.202. (Referred to throughout as the Company, Generali, the Insurer or the Insurance Entity.) Supervisor: the Directorate-General for Insurance and Pension Funds (DGSFP). Complaints: Generali's Claims & Complaints Service (rules at www.generali.es; reclamaciones.es@generali.com) acknowledges and resolves with reasons within a maximum of two months; its decisions bind the insurer. You may then escalate to the DGSFP Claims Service (Paseo de la Castellana 44, 28046 Madrid) or go to the courts. Applicable law: Law 50/1980 on Insurance Contracts, Law 20/2015 (LOSSEAR) and RD 1060/2015, together with the policy conditions and the risk questionnaire signed by the policyholder.

Articles 1–3 — The parties & documents ↑ top

Policyholder: the individual or company that, with the insurer, takes out the contract and holds its rights and obligations (save those that by nature fall to the Insured). Insured/Beneficiary: the person on whom the insurance is set, named in the Particular Conditions; may fulfil the policyholder's duties if they wish. Insurer (Generali): the company that assumes the agreed risk.

The policy = these General & Specific General Conditions + the Particular Conditions (the individual pacts and any clauses that complete, replace or modify the general ones) + later numbered appendices. The insurer also provides an ID card per Insured and a medical panel (Cuadro Médico) listing the hospitals, clinics, doctors and home-emergency phone numbers, kept up to date on Generali's website. The contract is governed by Law 50/1980 and Law 20/2015; limitative clauses are only valid if specifically accepted by the Insured. The policy was issued on the basis of the policyholder's application and the prior health questionnaire/interview/medical examination — hence the importance of accurate declarations.

Articles 4–5 — Communications, perfection, duration & premiums ↑ top

Communications (Art. 4)

All communications must be in writing (telephone only where law permits and where recorded with prior consent). The insurer may write by post, burofax, fax, email or SMS to the address/number in the policy; you must write to the registered office or any branch. Communications take effect on receipt (postal/burofax on the first delivery attempt). A communication to the broker/agent who mediated the contract has the same effect as one made directly.

Perfection, duration & premiums (Art. 5)

The contract is perfected by both parties' consent and signature, with cover starting on the date in the Particular Conditions once the first premium is paid. It renews automatically each year; either party may oppose renewal by written notice — two months by the insurer, one month by the policyholder. For each Insured, cover ends on moving abroad or not residing at least 180 days a year in Spain, or on death. Premiums are annual (payable in instalments by agreement). The first is due on perfection; if unpaid the insurer may extinguish the contract or claim it, and is released from any claim arising before payment. Successive premiums have a one-month grace period, after which cover is suspended; the insurer may claim within six months of the due date, failing which the contract is extinguished. Taxes are borne by the policyholder/Insured.

Article 6 — Waiting periods (carencias) ↑ top

All cover is provided from the policy's effective date, except the following waiting periods, counted from the Insured's join date:

• Three months — surgery (with or without hospitalisation) and non-surgical hospitalisation.
• Three months — complementary diagnostic means (except simple analysis, simple radiology and abdominal/gynaecological ultrasound), i.e. radioactive isotopes, CT scanner, scintigraphy, EEG, endoscopy, arthroscopy and similar.
• Three months — any special treatment (radiotherapy, chemotherapy, cobalt therapy, oxygen therapy, physiotherapy, functional rehabilitation, haemotherapy and similar).

Waiting periods do not apply in a vital emergency or where the claim results from a covered accident.

Article 7 — Basis of the contract & your declarations ↑ top

The contract is based on the policyholder's declarations in the application and the health questionnaire, which determine the insurer's acceptance of the risk. Before signing, you must declare every circumstance known to you that affects the risk. During the policy you must declare aggravations of the risk (the insurer may then propose a change within two months or rescind) and may declare reductions (entitling a premium reduction). If undeclared reserve/inaccuracy or aggravation comes to light at a claim, the insurer's payment is reduced in proportion to the unpaid premium — or, in bad faith, the insurer is released. You must also declare any other insurance covering the same risks and facilitate the insurer's subrogation.

Article 8 — Definitions ↑ top

• Accident: bodily injury during the policy from a violent, sudden, external cause beyond the Insured's intent.
• Calendar year: 1 January to 31 December.
• Social-type care: care not directly from objective, treatable medical pathology, or arising from old-age illness.
• Illness: a health alteration of common or accidental cause, confirmed by a doctor and requiring care.
• Congenital illness/defect: existing at birth from hereditary factors or conditions acquired during gestation (may show at birth or later).
• Pre-existing illness: a health alteration giving evident symptoms or reasonable suspicion before the Insured's join date.
• Excess (Franquicia): a percentage of the reimbursable expenses borne by the Insured, within the policy limits.
• Day hospital: an area of a hospital/clinic where medical or surgical care is given without admission, for no more than 24 hours.
• Hospitalisation: a stay over 24 hours for diagnosis or treatment. Medical hospitalisation = admission for medical (non-surgical) treatment; Surgical hospitalisation = admission for treatment by surgery.
• Family-unit members: related persons living at the habitual residence in the Particular Conditions and listed as Insureds.
• Waiting period: the time from the join date during which a cover is not yet in force.
• Prosthesis: any part/appliance replacing an organ, part of it, or its function.
• Claim (Siniestro): any event whose consequences a guarantee covers.
• Vital emergency: an acute situation needing immediate care because the patient's life is imminently at risk (not the same as a serious illness).

Article 9 — How the policy works & the cover windows ↑ top

Salud Clinic is a hospital-and-surgery plan. It is built around a hospital or surgical episode, with defined windows of out-patient care around it. The insurer covers, within the policy limits:

• 9.1 Hospital and/or surgical care the Insured needs to treat a covered illness or accident, in the specialties of Art. 10, choosing the provider from the medical panel — for an annual period of up to 180 days.
• 9.2 Pre-hospitalisation care — out-patient care in the 60 days before a covered operation/hospitalisation, needed to diagnose the condition leading to it.
• 9.3 Post-hospitalisation care — out-patient care in the 90 days after a covered operation/hospitalisation, needed as a consequence of it.
• 9.4 Oncology treatments by chemotherapy, radiotherapy and brachytherapy in the 540 days after diagnosis of a covered cancer (or after the treatment start date, if later).
• 9.5 Reimbursement of reasonable and customary medical fees: surgeons', assistants' and anaesthetists' fees per the surgical-group scale in Art. 10.3; pre-operative consultations and diagnostic tests in the 60-day window; specialist consultations in the 90-day window — all up to the Art. 10.3 limits.

The policy also includes 9.6 Travel assistance, 9.7 Dental and 9.8 a 24-hour medical teleconsultation service.

Article 10 — What is covered ↑ top

The guarantees are: (a) hospital/surgical care, (b) pre-hospital care, (c) post-hospital care, (d) oncology treatments, (e) medical-expense reimbursement, (f) travel assistance, (g) dental and (h) 24h teleconsultation. Guarantees (a)–(e) are provided through the primary care and medical/surgical specialties below.

10.2(a) Primary care

General medicine; paediatrics (to age 14); qualified nurse (ATS/DUE); podiatry (foot pathology only).

10.2(b) Medical & surgical specialties

Allergology; clinical/biochemical analysis (diagnostic only); anaesthesia & resuscitation; angiology & vascular surgery; digestive system; cardiology; cardiovascular, general & digestive, maxillofacial, paediatric, plastic-reconstructive and thoracic surgery; medical-surgical dermatology & venereology; endocrinology & nutrition; geriatrics (excluding social-type care); haematology; internal medicine; nuclear medicine; nephrology; pneumology; neurosurgery; clinical neurophysiology; neurology; gynaecology; ophthalmology (incl. photocoagulation laser and intra-ocular surgery, not refractive defects); medical oncology; radiotherapy oncology (cobalt therapy, radiotherapy); ENT; radiodiagnosis (X-ray, tomography, urography, etc. and special surgical imaging); rheumatology; traumatology & orthopaedics; urology (incl. renal lithotripsy); ambulance (urgent transfer to the nearest centre, or home-to-theatre on prescription); haemodialysis (acute/reversible only, max 15 sessions); other diagnostics (ECG, audiometry, EEG, endoscopy, kidney/liver function tests, ultrasound, CT, scintigraphy, MRI); oxygen/ventilation therapy (acute/reversible); aerosol therapy (acute/reversible, max 30 days; medication at the Insured's cost).

Prostheses (only the listed items): internal osteosynthesis material, heart valves, pacemakers, hip prosthesis, vascular bypass, internal traumatological prostheses, abdominal mesh, port-a-cath, the intra-ocular lens in cataract surgery and the breast prosthesis after radical mastectomy. Also: chemotherapy (in-patient or out-patient, incl. authorised cytostatic drugs); blood transfusions (the act, plus blood/plasma, for in-patients); rehabilitation (functional, not maintenance; incl. laser); phoniatrics (speech rehab after surgery/oncology); medical, surgical, paediatric and ICU/UVI hospitalisation; companion lodging in clinic (where available; excludes intensive-care units); and in-clinic medication outside theatre during admission.

10.2(c) Specialties NOT covered

Psychiatry; obstetrics; out-patient emergencies; aesthetic medicine & surgery; odontology/stomatology; neonatology — and any specialty not expressly listed in 10.2(b).

Article 10.3 — Reimbursement of medical expenses (limits) ↑ top

The insurer reimburses the reasonable and customary costs for the care in 9.1–9.3, based on the amount you actually paid and proved, up to these limits:

Hospital care

Hospital costs (stay, ICU, theatre, medication, in-stay tests, rehabilitation and any other in-stay medical cost), and prostheses and ambulance, are covered only through the medical panel. Surgeons' fees by surgical intervention follow the OMC group scale (January 1992):

• Group 0: €800 · Group 1: €1,200 · Group 2: €2,000 · Group 3: €2,200
• Group 4: €3,000 · Group 5: €3,600 · Group 6: €4,600 · Group 7: €5,000 · Group 8: €8,000

Pre-hospital care

• Specialist consultations: €300 per insured and claim.
• Diagnostic tests: €600 per insured and claim.
• Pre-operative tests: €300 per insured and intervention.

Post-hospital care

Specialist consultations: €300 per insured and claim; any other covered care is provided through the medical panel.

Oncology

The oncology treatments of Art. 9.4 are provided only through the medical panel.

Article 9.5(d) — €150-a-day cash if you use the public system ↑ top

If a covered hospitalisation is dealt with some other way — for example through the public health system — so the medical/hospital care in 9.1–9.5 is not provided under this policy, the insurer pays a daily cash indemnity of €150 for each day the Insured is hospitalised for a covered condition, up to a maximum of 180 days per insured and claim.

Article 10.4 — Travel assistance & services (Europ Assistance) ↑ top

Valid throughout Spain beyond your province (10 km in the Balearics/Canaries) and worldwide while the contract is in force, for trips of up to 90 days, provided you reside in Spain. Key benefits:

• Medical expenses abroad up to €35,000 (unexpected illness/accident on a trip outside your country of residence): fees, first-assistance prescribed medicines, hospitalisation, local ambulance; in country of residence up to €2,000; emergency dental up to €2,000 (endodontics, cosmetic, prosthetics, crowns and implants excluded). Amounts are not additive.
• Hotel-stay extension by illness/accident (€200/day, max 10 days); medical transfer of the sick/injured (air ambulance within Europe/Mediterranean only); repatriation of mortal remains to Spain (embalming, minimum coffin, formalities); return of accompanying insureds; trip resumption.
• Travel + stay of a family member when an Insured is hospitalised over 5 days (€200/day, max 10 days); companion-stay extension €60/day, max 10 days; return on death/hospitalisation (>5 days) of a close relative; escort of minors/dependants (under 14).
• Fund advance up to €5,000; criminal bail advance abroad up to €12,000; legal-assistance costs abroad up to €600; advance to hospitals up to €6,000 (advances repayable within 30 days); medicine dispatch abroad; interpreter; card-cancellation info; digital-legacy management.
• Search & rescue up to €1,500 (mountain/sea/desert rescue excluded); checked-baggage loss/theft up to €1,000; baggage delay (>12h) up to €300; trip delay (>6h) up to €300; missed connection (>6h) up to €300; holiday interruption up to €60/day (€600 total).
• Private civil liability on the trip up to €30,000 (incl. costs and bail; motor/aircraft/boat, professional and dangerous-sport liability and entrusted objects excluded).
• 24h information services (health, leisure, travel, motoring, pets); at-home health staff/companion/special/catering/cleaning services and telepharmacy (fees at the Insured's cost); home-security guard (max 24h after burglary/fire); social orientation; and a 24h legal-help + telephone legal-advice + lawyer-network + consumer-defence + contract-drafting service (free choice of lawyer; arbitration available).

Travel exclusions include: pre-existing/chronic conditions; refusal/voluntary delay of an agreed transfer; mental illness, preventive check-ups, spa cures, cosmetic surgery and trips taken to obtain treatment; pregnancy diagnosis/follow-up/birth (except urgent, before the 6th month); bets, challenges or brawls; competition or dangerous sports (boxing, weightlifting, martial arts, glacier climbing, sledging, diving, caving, ski-jumping, air and adventure sports); suicide and self-harm; mountain/sea/desert rescue; alcohol/drugs; wilful acts; sudden epidemics and infectious diseases; war, terrorism, nuclear reactions and natural catastrophes; and theft/loss of cash, jewellery and documents. The guarantees cease on return home or after repatriation; prior authorisation from Europ Assistance is required.

Articles 10.5–10.6 — Dental & 24h teleconsultation ↑ top

Dental (10.5): the “Generali Dental Básico” cover works on a scale of maximum prices the Insured pays directly to the dentist for the dental care received. The scale is published on the Generali and DENTYRED websites and updated annually; Insureds receive a personalised Dental Card. Care is provided only by the clinics and practitioners in the DENTYRED network listed in the online Guía Dental.

24h medical teleconsultation (10.6): a 24-hour phone line giving access to a doctor for advice on a medical process or illness, information on diet/sport/health, help understanding a doctor's instructions on a medicine, or whether a test needs preparation. The doctor advises only and does not visit you.

Article 11 — Claims & authorisations ↑ top

Using the medical panel

Pre-hospital expenses are covered only when they occur in the 60 days before a hospitalisation and lead to it; once you have the diagnosis you may ask the insurer to authorise pre-operative tests and the anaesthesia/surgery consultations. Post-hospital expenses are covered only in the 90 days after and where needed to treat the condition that caused the admission; the insurer authorises the necessary consultations, tests or rehabilitation in the panel.

Prior authorisation: hospitalisation, surgical acts and special therapies (radiotherapy, chemotherapy, physiotherapy, functional rehabilitation, oxygen therapy, haemotherapy, etc.) must be prescribed by a doctor with a justifying report and confirmed at the insurer's offices; that confirmation binds the insurer economically (unless it states the service is not covered). In urgencies the doctor's order suffices, with confirmation obtained within 72 hours of admission. Only urgent hospital care involving an admission of at least 24 hours is covered.

Territory: cover is valid only in Spain (except Travel Assistance). The insurer is released where providing the cover would breach UN/EU/UK/US sanctions. Once you have a doctor's prescription for surgery or hospitalisation you may freely choose the specialist from the panel; with the insurer's authorisation you attend without paying (Generali pays the doctor directly).

Reimbursement claims

If you use a doctor outside the panel, the insurer reimburses your costs within the policy guarantees, up to the Art. 10.3 limits and any excess. Notify the claim within: 48 hours after an urgent hospitalisation, 3 days before a planned one, or 7 days after any other claim. Send the completed reimbursement request, original itemised invoices/receipts (with the provider's name, NIF/CIF, college number and specialty, and the nature, date and amount of the service), original prescriptions, and — for hospitalisation — the hospital discharge report. Reimbursement is paid within 20 days of receiving the full documentation; translation of documents in any language other than Spanish or English is at the Insured's cost.

Article 12 — What is not covered ↑ top

In addition to the limits elsewhere in the Conditions, this insurance excludes:

• Pre-existing conditions with evident prior symptoms at the join date (unless shown as covered in the Particular Conditions).
• Prostheses of any kind, anatomical/orthopaedic pieces, implantable defibrillator and artificial heart — except the listed osteosynthesis material and internal prostheses (heart valves, pacemakers, hip, vascular bypass, internal traumatological, abdominal mesh, port-a-cath, cataract lens, post-radical-mastectomy breast).
• Nuclear/radioactive damage covered by nuclear-liability insurance.
• Claims caused directly by any contagious disease classed as a WHO Phase-5+ pandemic.
• War, riots, revolutions, terrorism and cataclysms (earthquake, flood and other seismic/weather phenomena).
• Diagnosis and non-surgical treatment of obstructive sleep apnoea.
• Psychoanalysis, psychoanalytic therapy, hypnosis, narcolepsy, psychosocial/neuropsychiatric rehabilitation, group therapy, psychological tests, sleep cures, acupuncture, and experimental/unrecognised treatments.
• Purely cosmetic treatment (plastic surgery, varicose sclerosis, cosmetic treatments, slimming/obesity treatment, and refractive surgery for myopia/hypermetropia/astigmatism) — but not reconstructive surgery after accident, burn or radical mastectomy for cancer.
• Transplants of any type.
• Treatment of any drug addiction or substance abuse.
• Care from suicide, attempted suicide or self-inflicted injury.
• Immunodeficiency illnesses.
• Medicines and vaccines (except those supplied during a covered hospital admission).
• Care given by the Insured's spouse or relatives up to the second degree.
• Genetic-map determinations (predisposition or infertility/sterility-cause studies).
• Voluntary medical/surgical acts not arising from accident or illness, and social-type hospital emergencies.
• Dental services not in the Particular Conditions or the coded list of the Guía Dental.
• Occupational diseases, and illness/accident from high-risk professional, sporting or recreational activity (underground/underwater work, climbing, parachuting, bridge/height jumping, hang-gliding, bullfighting, boxing, organised motor/boat/ski racing and professional sport).
• Costs billed by the Social Security or the public health system.
• Home visits.

Articles 13–14 — Other obligations, law & jurisdiction ↑ top

The policyholder/Insured must notify any change of address by certified letter at least seven days before requesting any service (the insurer issues the corresponding appendix), and must request additions and removals of Insureds during the policy as soon as possible.

Applicable law & jurisdiction: unless the Particular Conditions say otherwise, Spanish law applies; the competent court is that of the Insured's domicile in Spain (an Insured living abroad must designate a Spanish domicile; any contrary pact is void).

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, S.A. de Seguros y Reaseguros — Generali Salud Clinic, Seguro de Asistencia Hospitalaria con Reembolso, ref. G50743/GEN, edition G51628 (12/2023).