Generali Salud Elección Health 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). Complaints: Generali's Claims & Complaints Service (rules at www.generali.es; reclamaciones.es@generali.com) resolves with reasons within a maximum of two months; you may then escalate to the DGSFP (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.

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.
• 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 where care (medical or surgical) is given without admission, for no more than 24 hours.
• Hospitalisation: a stay in a clinic/hospital over 24 hours for diagnosis or treatment. Medical / Psychiatric / Surgical hospitalisation are defined by the type of treatment received.
• Premature birth: before 37 completed weeks and after 22.
• Waiting period: the time from the Insured's join date during which a cover is not yet in force.
• Prosthesis: any part/appliance replacing an organ 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 (object of the insurance) ↑ top

Salud Elección gives you two ways to use the cover:

• Network (Cuadro Médico Premium): the insurer provides access to its panel of doctors, specialists and hospitals; you choose the provider from the panel and the insurer pays them directly (no cash to you). The up-to-date panel by specialty is on Generali's website.
• Free choice with reimbursement: you may use any doctor/centre outside the panel and claim back the reasonable and customary medical, surgical and hospital costs, up to the maximum sum insured and the reimbursement percentage in your Particular & Special Conditions (see the reimbursement section). The insurer does not reimburse where you used the network panel.

In all cases (Art. 103 of the Insurance Contract Law) the insurer assumes necessary urgent care.

Article 10 — What is covered ↑ top

Cover is grouped into seven guarantees: 1. Primary care · 2. Medical & surgical specialties · 3. Travel assistance · 4. Preventive medicine · 5. Medical-expense reimbursement · 6. Daily hospital cash · 7. Dental.

10.1 Primary care

General medicine; paediatrics (to age 14); qualified nurse (ATS/DUE); podiatry (max 6 sessions/year unless foot pathology); home emergency medical service; psychology — individual sessions prescribed only by a psychiatrist, max 4/month and 20/year (psychoanalysis, hypnosis and psychosocial rehabilitation excluded).

10.2 Medical & surgical specialties

The full range of specialties — allergology; clinical analysis; anaesthesia; vascular; digestive; cardiology; permanent emergency centre; cardiovascular, general, maxillofacial, paediatric, plastic-reconstructive and thoracic surgery; dermatology; endocrinology; stomatology (cures & extractions only — fillings, endodontics, prosthetics, orthodontics and periodontics excluded); geriatrics; haematology; internal medicine; nuclear medicine; nephrology; neonatology; pneumology; neurosurgery; neurophysiology; neurology; obstetrics & gynaecology (incl. pregnancy monitoring, childbirth, antenatal classes and epidural); ophthalmology (incl. photocoagulation laser and intra-ocular surgery, not refractive defects); medical and radiotherapy oncology; ENT; psychiatry; radiodiagnosis; rheumatology; traumatology & orthopaedics; urology (incl. lithotripsy); ambulance; haemodialysis (acute/reversible, max 15 sessions); complementary diagnostics (ECG, EEG, endoscopy, ultrasound, CT, scintigraphy, MRI); oxygen/aerosol therapy (acute, max 30 days; medication at the Insured's cost); prostheses (only the listed internal items: heart valves, pacemakers, hip, vascular bypass, internal traumatological, abdominal mesh, port-a-cath, intra-ocular lens for cataract, breast prosthesis after radical mastectomy); chemotherapy; blood transfusions; rehabilitation (functional, not maintenance); phoniatrics (speech rehab after surgery/oncology); medical, surgical, paediatric, ICU and psychiatric hospitalisation (psychiatric capped at 60 days/year); companion lodging in clinic; in-clinic medication.

Infertility treatment of the couple (both insured, each ≥24 months in policy, diagnosed infertility, woman ≤42): max 3 artificial-insemination attempts and 2 full IVF cycles (this is a lifetime, non-renewable limit). Via free choice/reimbursement: up to €600 per insemination attempt and €4,000 per IVF attempt, no excess. Failure of two ovulation-stimulation attempts ends the cover; medication is the Insured's cost.

10.6 Daily hospital cash (illness & accident)

The insurer pays the daily sum insured (per the Particular Conditions) for each day of uninterrupted hospitalisation, accruing per complete 24h from admission; an additional sum for ICU. Successive stays for the same cause = one period; never paid for stays under 24h; no Insured may accrue beyond the indemnity period per process/diagnosis. For Insureds under 5 or over 65, this is limited to surgical hospitalisation.

10.7 Dental

Access to the coded acts in the Guía Dental, provided only at network providers (no cash; free choice among them).

Article 6 — Waiting periods ↑ top

From the Insured's join date, unless agreed otherwise:

• Three months — surgery (with or without hospitalisation) and non-surgical hospitalisation.
• Three months — complementary diagnostic means (except simple analysis/radiology and abdominal/gynaecological ultrasound), i.e. isotopes, CT, scintigraphy, EEG, endoscopy, arthroscopy and similar.
• Three months — special treatments (radiotherapy, chemotherapy, oxygen therapy, physiotherapy, functional rehabilitation, etc.) and the daily-hospital-cash guarantee.
• Eight months — anything related to pregnancy and birth (no waiting period for urgent dystocic or premature births).
• Three months — preventive-medicine services (no waiting period for child prevention).

All waiting periods are automatically waived in a vital emergency or where the claim results from an accident.

Article 10.3 — Travel assistance abroad (Europ Assistance) ↑ top

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

• Medical expenses abroad up to €35,000 (illness/accident arising unexpectedly on a trip outside your country of residence); in country of residence up to €2,000; emergency dental up to €2,000 (endodontics, cosmetic, prosthetics, crowns and implants excluded).
• Hotel-stay extension by illness/accident (€200/day, max 10 days); medical transfer of the sick/injured (air ambulance within Europe/Mediterranean); repatriation of mortal remains to Spain; return of accompanying insureds; trip resumption.
• Family member to accompany a hospitalised Insured (travel + €200/day stay, max 10 days; companion-stay extension €60/day max 10 days); return on death/hospitalisation of a close relative; escort of minors/dependants.
• 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 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 excluded).
• 24h information services (health, leisure, travel, motoring, pets), at-home health staff/companion/cleaning services (fees at the Insured's cost), telepharmacy, home-security guard (max 24h after burglary/fire), and a 24h legal-advice + lawyer-network + consumer-defence service (free choice of lawyer; arbitration available).

Travel exclusions include: pre-existing/chronic conditions; mental illness, check-ups, spa cures, cosmetic surgery and trips taken to obtain treatment; pregnancy diagnosis/follow-up/birth (except urgent, before the 6th month); bets, brawls, self-harm and suicide; competition or dangerous sports (boxing, martial arts, glacier climbing, diving, caving, air/adventure sports); rescue in mountain/sea/desert; alcohol/drugs; sudden epidemics; war, terrorism, nuclear and natural catastrophes; and theft/loss of cash, jewellery and documents. Cover ceases on return home or after repatriation. Authorisation from Europ Assistance is required.

Article 10.5 — Medical-expense reimbursement ↑ top

The insurer reimburses the reasonable and customary medical, surgical and hospital costs for cover under primary care (10.1), specialties (10.2) and preventive medicine (10.4), based on the amount you actually paid and proved. “Reasonable and customary” means costs not exceeding the usual level charged by that provider or similar providers in the same area for a comparable service. The reimbursement ceiling and percentage are set in the Condiciones Especiales de Reembolso in your Particular Conditions. No reimbursement applies where you used the network panel. Reimbursement is paid within 20 days of receiving the full documentation (non-EU services converted to euros at the official rate of the payment date; translation of non-Spanish/English documents at the Insured's cost).

Preventive medicine (10.4) covers child prevention (paediatric reviews, official vaccinations, vision/hearing/dental checks, neonatal hearing screening), adult prevention 14–65 (periodic GP review, general blood test, obesity/hypertension/lipid and coronary prevention, annual gynaecological review + mammography from 45, amniocentesis from 35, family planning, dental check, audiometry, vision/tonometry, antenatal classes) and geriatric prevention over 64 (annual GP review, blood/urine, gynaecology, flu & tetanus vaccines, dental, breast/colon/cervical screening).

Article 12 — What is not covered ↑ top

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

• Pre-existing illnesses with evident prior symptoms not declared in the health questionnaire.
• 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-mastectomy breast).
• Nuclear/radioactive damage covered by nuclear-liability insurance.
• Claims caused directly by any disease classed as a WHO Phase-5+ pandemic.
• War, riot, revolution, terrorism and cataclysms (earthquake, flood and other seismic/weather phenomena).
• 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, slimming/obesity treatment, and refractive surgery for myopia/hypermetropia/astigmatism) — but not reconstructive surgery after accident or burn.
• Transplants of any type except heart, liver, kidney, lung, bone marrow and cornea (via reimbursement; the organ cost and its extraction/transport are not included).
• Treatment of any drug addiction or substance abuse (e.g. alcoholism).
• Care from suicide, attempted suicide or self-inflicted injury.
• Immunodeficiency illnesses.
• Medicines and vaccines (except those supplied during hospital admission).
• Reimbursement where the service was given by a network (Guía Médica) provider, or by the Insured's spouse/relatives up to the second degree.
• Genetic-map determinations (predisposition or infertility-cause studies).
• Voluntary medical/surgical acts not arising from accident or illness (except preventive medicine 10.4); medical exams/check-ups and spa/rest-home stays under the daily-hospital-cash guarantee; dental acts outside the Guía Dental coded list.

Claims, contract & renewal (Arts. 1–7, 11, 13–15) ↑ top

The parties & documents (Arts. 1–3)

Policyholder (takes out/pays), Insured/Beneficiary (named in the Particular Conditions), Insurer (Generali). The policy = these General & Specific General Conditions + the Particular Conditions + the reimbursement Special Conditions + later appendices, plus an ID card per Insured and the network panel on Generali's website. The contract is governed by Law 50/1980 and Law 20/2015; limitative clauses are only valid if specifically accepted.

Using the network & authorisations (Art. 11)

The claim is deemed notified when you use a network provider. Home visits are only authorised where illness prevents travel to the surgery; for urgencies you may go directly to the permanent emergency centre. Prior authorisation is needed for special diagnostics, hospitalisation, surgery and special therapies (radiotherapy, chemotherapy, physiotherapy, etc.) — obtained at Generali's offices or website; in urgencies the doctor's order suffices, with confirmation within 72h of admission. You must show your ID card (report loss within 48h) and return it when the contract ends.

Reimbursement & daily-cash claims (Art. 11.2–11.3)

Notify within: 48h after an urgent hospitalisation, 3 days before a planned one, or 7 days after any other claim. For reimbursement, send the claim form, original itemised invoices/receipts (with the provider's details, NIF and college number) and original prescriptions; for hospitalisation, the hospital discharge report. Reimbursement is paid within 20 days. For daily cash, the insurer may make visits, may consult attending doctors (with consent), and pays once the claim is established (payments on account if it lasts over 40 days).

Perfection, duration & premiums (Arts. 4–5, 7)

The contract is perfected by signature and the first premium; it renews automatically each year (opposition: one month's notice by the policyholder, two by the insurer). For each Insured it ends on moving abroad / not residing ≥180 days/year in Spain, or on death. Premiums are annual, payable in advance, with a one-month grace period for successive premiums; non-payment suspends cover, and the contract is extinguished if unclaimed within six months. The contract is based on the policyholder's declarations and the health questionnaire; risk aggravations/reductions must be notified.

Other obligations, indisputability & jurisdiction (Arts. 13–15)

Notify any change of address (7 days' notice) and additions/removals of Insureds; newborn children are included automatically from birth if requested within 15 days (no waiting period beyond the parent's). Indisputability: if a medical exam was done (or full rights recognised) the policy is indisputable as to the Insured's health; otherwise, with a health questionnaire, the insurer may rescind within one month of discovering a reservation/inaccuracy, and the policy becomes indisputable one year after conclusion (save wilful misconduct). Spanish law applies; the competent court is that of the Insured's domicile in Spain.

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 Salud Elección, Seguro de Asistencia Sanitaria con Reembolso, ref. SA161/GEN, edition G51627 (01/2026).