Generali Salud Opción Family Policy Conditions (English Translation)

Information Clause ↑ top

This information is issued under Articles 96.1, 96.2, 96.4 and 96.6 of Law 20/2015 (Regulation, Supervision and Solvency of Insurers) and Article 122 of Royal Decree 1060/2015.

Insurer. GENERALI ESPAÑA, S.A. DE SEGUROS Y REASEGUROS (referred to as the Company, Generali, the Insurer or the Insurance Entity), registered office Pl. de Manuel Gómez-Moreno, 5, 28020 Madrid; C.I.F. A-28007268 (Madrid Mercantile Register, sheet M-54.202).

Supervisory body. The Directorate-General of Insurance and Pension Funds (DGSFP), under the Ministry of Economy, controls insurance activity in Spain.

Complaints. A Complaints and Claims Service (an autonomous, independent department) is available; its rules can be consulted at www.generali.es. Submit written complaints — with your personal details, signature, address, policy or claim number and the facts — to the Servicio de Quejas y Reclamaciones, Generali España, Pl. de Manuel Gómez-Moreno, 5, 28020 Madrid, or by e-mail to reclamaciones.es@generali.com. It must reply, with reasons, within a maximum of two months. Thereafter, or if the request is rejected, you may complain to the DGSFP Claims Service (Pº de la Castellana, 44, 28046 Madrid), without prejudice to your right to take the matter to the competent courts.

Applicable law. The contract is governed by Law 50/1980 of 8 October on the Insurance Contract, Law 20/2015, Royal Decree 1060/2015 and the agreed conditions, together with the insurance application and risk-assessment questionnaire signed by the policyholder, which is a fundamental document for the insurer's consent.

Article 1 — Parties to the contract ↑ top

• Policyholder (Tomador): the natural or legal person who signs the contract with the insurer and holds the resulting rights and obligations, except those that by nature fall to the Insured.
• Insured / Beneficiary: the person on whom the insurance is established and named in the Particular Conditions. The Insured may, if they wish, fulfil the policyholder's duties.
• Company / Insurer: the legal person who assumes the agreed risk.

Article 2 — Policy documents ↑ top

The “policy” is the set of documents recording the terms of the contract. It comprises: (2.1) these General Conditions, governing the birth, life and extinction of the contract and the scope of each type of cover; (2.2) the Particular Conditions, recording the individual agreements and any clauses that complete, replace or modify the general conditions as permitted by law; and (2.3) later numbered, signed appendices. The insurer also issues an identification card for each Insured. The “Cuadro Médico Óptimo” (the panel of contracted doctors and services by specialty, with addresses and telephone numbers) is kept permanently up to date on Generali's website.

Article 3 — Governing law ↑ top

The contract is subject to Law 50/1980 and Law 20/2015 (LOSSEAR) and to the applicable regulations and the Particular Conditions. Clauses that limit the Insured's rights are only valid if specifically accepted in writing; mere transcriptions of, or references to, mandatory legal provisions do not need such acceptance. The insurer drew up the policy on the basis of the policyholder's application and the answers given in the prior questionnaire and the Insured's health declarations — the only data known to the insurer, hence the importance of an exact and correct declaration.

Article 4 — Definitions (incl. co-payment) ↑ top

Key terms used in the contract:

• Co-payment (copago): the Insured's share in the cost of a medical act, or series of acts, depending on the service used, when received from professionals or centres contracted in the “Guía Médica Óptimo”. This is a co-payment policy: the Insured pays a set amount per act, with the amounts shown in the Particular Conditions.
• Accident: bodily injury during the policy term from a violent, sudden, external cause beyond the Insured's intent.
• Calendar year: 1 January to the following 31 December.
• Illness: an alteration of health of common or accidental cause, confirmed by a legally recognised doctor and requiring medical care.
• Congenital illness/defect: one existing at birth from hereditary factors or conditions acquired in gestation, whether recognised at birth or discovered later.
• Pre-existing illness: an alteration of health with evident symptoms or reasonable suspicion before the affected Insured joined the policy.
• Excess (franquicia): a percentage of the total reimbursable cost borne by the Insured, up to the maximums set in the policy.
• Day hospital: care without admission, never exceeding 24 hours, medical or surgical. Hospitalisation: a stay of over 24 hours for diagnosis or treatment (medical, surgical or psychiatric).
• Family unit members: persons with family ties living at the habitual residence named in the Particular Conditions and listed as Insureds.
• Premature birth: before 37 complete weeks of gestation and after 22.
• Waiting period: a period from the Insured's join date during which a given cover does not take effect.
• Prosthesis: any piece (auto-, homo-, hetero- or alloplastic) or device replacing an organ, part or its function. Operating theatre (quirófano): a suitably equipped, accredited room. Claim (siniestro): any event whose consequences are covered.
• Vital emergency: an acute situation requiring immediate care because the patient's life is imminently at risk — not to be confused with a serious illness, which does not necessarily imply a vital emergency.
• Compassionate use of medicines: use of investigational, off-label or non-Spain-authorised medicines under the regulatory definitions.

Article 5 — Perfection, commencement, duration & premiums ↑ top

The contract is perfected by both parties' consent and signature; cover begins on the date shown in the Particular Conditions once the first premium (or agreed fraction) is paid. Duration is as specified; unless agreed otherwise it renews automatically each year. Either party may oppose renewal in writing — the policyholder with at least one month's notice, the insurer with two months' notice; the insurer must also give two months' notice of any contract change. For each Insured the cover ends on: (a) moving abroad or not residing at least 180 days a year in Spain; or (b) death.

Premiums are annual (unless contracted for a shorter period) and may be paid in fractions, all of which must be paid. The first premium is due on perfection; if unpaid through the policyholder's fault the insurer may treat the contract as extinguished or claim it by enforcement, and is released from all obligation if a claim occurs before the first premium is paid. For successive annual premiums (or fractions) a one-month grace period applies; afterwards cover is suspended until 24 hours after payment is made. If the insurer does not claim payment within six months of the due date, the contract is extinguished. Premiums are paid at the Company's address (or as stated), and may be set up by bank direct debit. Legally chargeable taxes are borne by the policyholder or Insured.

Article 6 — Waiting periods ↑ top

Cover applies from the policy's formalisation or effective date. As an exception, and unless agreed otherwise, the following waiting periods run from the Insured's join date:

• Three months — surgery (with or without hospitalisation) and non-surgical hospitalisations.
• Three months — complementary diagnostic methods, except tests, simple radiology and abdominal or obstetric-gynaecological ultrasound (which have none). The wait applies to CT, scintigraphy, EEG, endoscopy, arthroscopy, radioactive isotopes, etc.
• Three months — special treatments (radiotherapy, chemotherapy, cobalt therapy, physiotherapy, functional rehabilitation, haemotherapy, etc.).
• Eight months — any service relating to pregnancy and childbirth, from the pregnant Insured's join date. No waiting period applies to obstetric/delivery services in vital-emergency dystocic births or premature births.
• Three months — preventive medicine, except child prevention, which has no waiting period.

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

Article 7 — Basis of contract; declarations ↑ top

The contract is based on the policyholder's declarations in the application/proposal and the completed questionnaire. If the policy differs from the proposal, the policyholder may demand correction within one month of delivery. Before signing, the policyholder must declare all known circumstances affecting the insurer's risk assessment, answering the questionnaire fully.

During the term, the policyholder must declare circumstances that aggravate the risk; the insurer may then propose a change within two months (the policyholder has 15 days to accept or reject), or rescind within one month of learning of the aggravation. If a reservation, inaccuracy or aggravation is not declared before a claim, the benefit is reduced in proportion (acting in good faith); in bad faith the insurer is released. Circumstances that reduce the risk entitle the policyholder to a proportionate premium reduction or to terminate. The policyholder must notify other policies covering the same risks and must facilitate subrogation in the insurer's favour.

Article 8 — Communications between the parties ↑ top

Communications must be in writing; exceptionally, the insurer's telephone communications are valid where recorded on a durable medium with the recipient's prior consent. The insurer may use postal mail, burofax, fax, e-mail or SMS to the address/number/e-mail in the policy (or later notified). Communications take effect when received; postal/burofax communications take effect from the first attempted delivery, and e-mail/SMS from the date received, regardless of whether opened. Communications made through the mediating agent or broker have the same effect as if made directly.

Article 9 — Object of the insurance & co-payment ↑ top

Within the policy's limits and on payment of the premium and the corresponding co-payment, the insurer covers the medical, surgical and hospital care needed for the illnesses and injuries within the specialties and modalities of Article 10, making available a range of healthcare providers in the Cuadro Médico Óptimo. In a claim, the Insured freely chooses the provider from those in the panel. As required by Article 103 of the Insurance Contract Act, the insurer assumes the necessary urgent care. The cover is grouped into: Contracted Medical Care (1. Primary care; 2. Medical & surgical specialties; 3. Travel assistance; 4. Preventive medicine) and Complementary Family Care (5. Basic dental).

Article 10.1 — Primary care, paediatrics & podiatry ↑ top

• General & family medicine — general consultation services.
• Paediatrics — diagnosis and treatment of children up to 14 years.
• Nursing (A.T.S./D.E.) — on medical prescription.
• Podiatry — limited to six sessions a year, except foot pathology.
• Home emergency doctor — for emergencies, only where the insurer has contracted the service.

Article 10.2 — Medical & surgical specialties ↑ top

Consultations, study, treatment and (where stated) surgery in the following specialties, all through the network panel:

• Allergology & immunology — vaccines/auto-vaccines are at the Insured's cost.
• Clinical, pathological, biological & biochemical analyses — for diagnosis only, not predictive/preventive; food-intolerance tests excluded.
• Anaesthesia & resuscitation — all prescribed anaesthesia.
• Angiology & vascular surgery — therapeutic aim must be confirmed by diagnostic tests.
• Digestive system — biliary lithotripsy excluded.
• Cardiology and cardiovascular / cardiac surgery (heart and great vessels).
• General & digestive surgery — including laparoscopic technique where proven effective.
• Maxillofacial surgery — excludes stomatology, odontology and the scaled dental cover.
• Paediatric surgery — for under-14s.
• Reconstructive plastic surgery — only to repair injury from accident or illness during the term; breast reconstruction is limited to prosthesis implantation after radical mastectomy; any breast reduction is excluded, even on psychological or traumatological grounds.
• Thoracic surgery; dermatology & venereology (excludes scalp treatments, actinic-lesion treatment and dermo-cosmetic laser).
• Endocrinology & nutrition — includes morbid-obesity treatment; excludes dietary treatments and slimming cures.
• Geriatrics — excludes social-type assistance and residence-stay costs.
• Haematology; internal medicine.
• Nuclear medicine — scintigraphy and radioactive-isotope treatment; PET, PET-CT and SPECT for oncological/neurological study.
• Nephrology — chronic dialysis excluded; haemodialysis only in acute, reversible cases or chronic flare-ups, maximum 15 sessions.
• Pulmonology; neurosurgery; clinical neurophysiology (EEG, EMG, evoked potentials, polysomnography); neurology.
• Ophthalmology — includes laser photocoagulation and intraocular surgery for conditions other than refractive/accommodation defects.
• Medical oncology — chemotherapy (in-patient and outpatient); cost of authorised antitumour cytostatic medicines applied in a care centre, plus implantable infusion reservoir where applicable; other medicines excluded.
• Radiotherapy oncology — cobalt therapy, radiotherapy, linear accelerator, radio-neurosurgery.
• Otorhinolaryngology (ear/larynx/nasal passages) — hearing prostheses excluded.
• Psychiatry — mental/nervous illness on prescription; excludes detox cures (drugs, alcohol, tobacco or any dependence), sleep cures, psychotherapy and psychoanalysis.
• Radiodiagnosis — general/digestive radiology and orthopantomography (at radiology centres), ultrasound, mammography, CT, MRI, special radiology (cystography, pyelography, urography), angiography, bone densitometry and interventional radiology; includes contrast media supplied by the centre. Virtual colonoscopy and full-body check-up excluded.
• Rheumatology; traumatology & orthopaedics (incl. arthroscopic surgery); urology (incl. renal lithotripsy).

Rehabilitation & speech therapy

Rehabilitation is outpatient, to restore the functional state held before the illness where medically possible (maintenance rehabilitation excluded); includes laser and shockwaves for musculoskeletal rehabilitation, and lymphatic drainage/pressotherapy only for oedema from oncological complications. Limit: 20 sessions per Insured per year. Phoniatrics — only as speech rehabilitation after larynx/vocal-cord surgery or oncological processes — limit 15 sessions per Insured per year.

Maternity, obstetrics, gynaecology & neonatology ↑ top

Obstetrics & gynaecology — diagnosis, treatment and surgery of the female genital organs, including laparoscopic gynaecological surgery. It covers pregnancy monitoring by an obstetrician and delivery attended by the obstetrician with a midwife, and includes the cost of the epidural anaesthesia. (An eight-month waiting period applies to pregnancy and childbirth — see Art. 6 — waived for vital-emergency dystocic or premature births.)

Neonatology — diagnosis and treatment of the newborn's illnesses during the hospital stay, provided the birth was covered by the policy.

Hospitalisation & surgery ↑ top

• Permanent emergency centre — emergency care at the panel centres where contracted.
• Medical hospitalisation — at panel centres; includes the Insured's room and meals (not the companion's meals).
• Surgical hospitalisation — doctors' and assistants' fees, anaesthetist, nursing, theatre use, medication and any other medical service during the stay or operation.
• Paediatric hospitalisation — the child or neonate's admission.
• ICU hospitalisation (U.V.I./U.C.I.) — stay in intensive-care units.
• Psychiatric hospitalisation — limit 60 days per Insured per year.
• Companion in clinic — accommodation only, where the room offers it; excluded for psychiatric hospitalisation, intensive-care units and neonate hospitalisation.
• Medication in clinic — during hospitalisation and surgery.

Never included: telephone, television, cafeteria, the companion's meals or anything not directly related to treating the illness or accident.

Prostheses, ambulance, transfusions & sub-limits ↑ top

• Ambulance — only for urgent transfer to the nearest centre, or from home to the surgical centre on prescription; excludes transfers for rehabilitation/physiotherapy, outpatient diagnostics, outpatient consultations, day-hospital treatments and dialysis.
• Haemodialysis — acute, reversible cases and chronic flare-ups only, max 15 sessions.
• Prostheses — only the cost of: cardiac valves, pacemakers, vascular prostheses (coronary stent / by-pass), internal traumatological prostheses, osteosynthesis material, breast prostheses after a covered total mastectomy, monofocal intraocular lenses (cataract surgery) and abdominal meshes. Excluded: orthopaedic material, artificial heart, any defibrillator, aortic vascular prostheses, valved conduits, ENT prostheses and any prosthesis not listed. Access is by reimbursement only, with a maximum capital of €6,000 per Insured per year and the sub-limits in the Particular Conditions.
• Blood transfusions — the transfusion act and the blood/plasma for in-patients; excludes donor-bank costs and “growth factor” blood-product treatments.

Article 10.3 — Travel assistance (Europ Assistance) ↑ top

Valid (a) throughout Spain beyond the provincial limit of the habitual residence — in the Balearics and Canaries, beyond 10 km from home; and (b) worldwide while the contract is in force. The Insured must reside in Spain and not be away more than 90 days per trip. Main benefits, provided by EUROP ASSISTANCE:

• Medical expenses abroad — up to €35,000 per Insured per period (doctors' fees, prescribed medicines for the first care, hospitalisation, local ambulance). Includes emergency dental care up to €2,000 (excludes endodontics, aesthetic reconstruction of prior work, prostheses, crowns, implants).
• Medical expenses in the country of residence — up to €2,000 per Insured per period; excluded where the Insured benefits from Social Security (save urgent transfer to a non-Social-Security hospital). The amounts abroad and in the country of residence are not additive.
• Prolonged hotel stay after illness/accident (no admission needed) — up to €200/day, max 10 days.
• Medical transfer / repatriation of the sick or injured (special air ambulance — only in Europe and Mediterranean-bordering countries — first-class train, medical helicopter, ambulance or scheduled flight) and repatriation of mortal remains (embalming, minimum coffin, formalities; excludes funeral/burial expenses).
• Return of accompanying Insureds; resumption of the trip; dispatch of medicines abroad (Insured repays the price).
• Travel of a companion for hospitalisation over 5 days; companion's hotel stay up to €200/day, max 10 days.
• Return on death of a relative; accompaniment of minors/dependants; accompaniment of mortal remains; return on hospitalisation of a relative (over 5 days); companion's prolonged hotel stay on the Insured's hospitalisation up to €60/day, max 10 days.
• Telephone social orientation; luggage search; legal-aid abroad up to €600; transmission of urgent messages; dispatch of forgotten personal objects (max 10 kg).
• Cash advance up to €5,000; criminal-bail advance abroad up to €12,000 (repayable within 30 days); telephone interpreter; card-cancellation information; advance to hospitals up to €6,000.
• Digital-life management on death; search and rescue up to €1,500 (excludes mountain/sea/desert rescue).
• Lost/damaged/stolen checked luggage up to €1,000 (police report required for theft; cash, jewellery, electronics and documents excluded); luggage delay over 12 hours up to €300; travel delay over 6 hours up to €300; missed connection over 6 hours up to €300.
• Holiday interruption (death, serious illness/accident with overnight hospitalisation, hospitalisation/death of a relative, serious home damage, non-disciplinary dismissal or forced relocation, new job, jury/witness summons) — up to €60/day not enjoyed, max €600 for all Insureds combined.
• Private civil-liability insurance — up to €30,000 for bodily/material damage caused involuntarily to third parties on the trip (Arts. 1,902–1,910 of the Civil Code), including legal costs and bail. Excludes liability from motor vehicles, aircraft, vessels or firearms, professional/political/trade-union activity, fines, dangerous sports and damage to entrusted objects.
• 24-hour information & legal-assistance services — health, leisure, travel and motoring information; home healthcare staff, accompaniment, hairdressing/podiatry, catering, pet information, cleaning staff and telepharmacy services (all at the Insured's cost); home guarding after burglary/fire (max 24h); 24h legal aid; telephone legal advice; access to a lawyers' network (first consultation free); consumer defence; free choice of lawyer/solicitor (in conflicts of interest); arbitration; and drafting/review of certain contracts.

Travel-assistance & legal-defence exclusions ↑ top

The travel guarantees cease once the Insured returns home or is repatriated. Expenses not previously notified to, or authorised by, EUROP ASSISTANCE are excluded. Generally excluded are damage and costs arising from:

• Pre-existing or chronic illnesses manifesting during the trip; voluntary refusal/delay of the agreed medical transfer.
• Mental illness, preventive check-ups, spa cures, cosmetic surgery, trips to receive treatment, alternative medicine and physiotherapy/rehabilitation; pregnancy diagnosis/monitoring, voluntary termination and childbirth (save urgent care before the sixth month).
• Bets, challenges or brawls; competitive or motor-sport practice, and listed dangerous/adventure sports (boxing, weightlifting, wrestling, martial arts, glacier mountaineering, scuba diving, caving, ski-jumping, air sports, rafting, bungee, hydrospeed, canyoning, etc.).
• Suicide or self-injury; mountain/sea/desert rescue; illness/accident from alcohol, drugs or non-prescribed medicines; the policyholder's or Insured's wilful acts.
• Epidemics/infectious diseases of sudden appearance and rapid spread, and pollution; war, riots, terrorism, sabotage, strikes; nuclear reactions; earthquakes, floods, eruptions and catastrophic natural events.
• Petty theft, simple loss, money, jewellery and documents; glasses/contact lenses and prostheses; reimbursement of medical/surgical/pharmaceutical costs (under travel cover).

For legal-defence services, also excluded are: costs not previously notified; events before the contract; matters of foreign law; bad-faith or deliberate acts; unfounded or disproportionate claims; and the payment of fines, penalties, interest or surcharges.

Article 10.4 — Preventive medicine ↑ top

10.4.1 Child prevention (up to 14)

• General check-up by the paediatrician — monthly in the first quarter of life, two-monthly to 18 months, then annual to 14 years.
• Vaccines under each region's official programme (diphtheria, tetanus, whooping cough, polio, MMR).
• Vision and hearing review at ages 3–4 and 10–11; dental prevention at ages 6 and 10–12.

10.4.2 Adult preventive medicine (14–65)

• General check-up — two-yearly to 35, then annual to 65 (history, blood pressure, height/weight, skin, cardio-respiratory and abdominal exam, health/risk assessment).
• General blood test on medical criteria; prevention of obesity, hypertension and hyperlipidaemia; coronary prevention (baseline ECG in men from 30; stress ECG and cardiology review every 5 years from 35 to 65 by cardiovascular risk).
• Annual gynaecological review with cytology, and annual mammography from 45 (medical criteria); amniocentesis where the pregnant woman is 35 or over.
• Family planning — gynaecologist consultation and IUD fitting (IUD/diaphragm/medication cost excluded), or urologist for men; tubal ligation and vasectomy included.
• Annual dental check and hygiene; tetanus vaccine; hearing study (audiometry); eye prevention (visual acuity at 25 and 35, acuity and tonometry two-yearly from 40); antenatal classes.

10.4.3 Geriatric prevention (over 64, annual)

• General check-up; general blood and urine test; annual gynaecological review with cytology.
• Flu and tetanus vaccines; deafness and eye prevention (ENT and ophthalmology review); breast-cancer prevention (mammography), cytology and faecal occult-blood, all on medical criteria.

Article 10.5 — Basic dental cover (Asistencia Complementaria Familiar) ↑ top

The insurer gives access to the services detailed in the Particular Conditions and in the “Coded Dental Services” section of the Guía Dental, which forms part of the documentation. These coded dental services are provided only through the Guía Dental providers; no cash indemnity may be paid in place of the service, though the Insured freely chooses the contracted professional. The Insured must identify themselves with the card issued by the insurer.

Article 11 — Using the network & processing a claim ↑ top

A claim is deemed notified when you use the services Generali provides through the Guía Médica Óptimo. The insurer provides the panel for the locality in the Particular Conditions, and panels in other localities may also be used within the contracted cover. The insurer is released where providing the service would expose it to sanctions under UN, EU, UK or US rules.

Home visits are authorised only where illness prevents the Insured travelling to the surgery and the service exists locally. Urgencies: go directly to the permanent emergency centre shown in the panel, or call the emergency number. Specialists may be consulted freely, though using the family doctor first is recommended.

Prior authorisation is required for special diagnostic tests, hospitalisation, surgical acts and therapeutic treatments (radiotherapy, chemotherapy, physiotherapy, rehabilitation, haemotherapy, etc.) — prescribed by a panel doctor with a justifying report, confirmed at the insurer's offices; once given, it binds the insurer economically unless it states the service is not covered. In urgencies, the doctor's order suffices, with the insurer's confirmation obtained within 72 hours of admission. You must show your ID card (and D.N.I. if required); report loss within 48 hours, and return cards when the contract ends.

11.2 Reimbursement of prostheses

Once medical authorisation for the surgery is approved, the Insured pays the prosthesis cost; the insurer reimburses, within the policy limits, on receipt of the claim form and the original invoices/receipts identifying the Insured and issued by the provider. Reimbursement is paid within 20 days of receiving all documentation. Claims may also be made through Generali's website (Salud reimbursement section).

Article 12 — Other obligations (incl. newborns) ↑ top

The policyholder/Insured must: (a) notify any change of address by certified letter at least seven days before requesting any service (the insurer issues the supplement); and (b) notify, as soon as possible, additions and removals of Insureds during the term. Newborn children are included automatically from the date of birth — with no waiting period greater than the one still outstanding for the father (or failing him the mother) — provided the addition is requested within 15 calendar days of birth and the mother had the childbirth benefit on the policy.

Article 13 — General exclusions ↑ top

In addition to the exclusions elsewhere, the following are excluded:

• Care for pre-existing conditions that had given evident symptoms before joining.
• Prostheses, anatomical/orthopaedic pieces, implants and therapeutic devices, except those listed in Art. 10.2; any breast reconstruction other than implantation after radical mastectomy, and any breast reduction.
• Damage from nuclear explosions/radiation; claims from any contagious disease classed as pandemic Phase 5 or higher by the WHO; war, riots, revolutions, terrorism and cataclysms (earthquakes, floods, seismic/meteorological events).
• Treatment of snoring/obstructive sleep apnoea; psychoanalysis, psychoanalytic therapy, hypnosis, group therapy, psychological tests, sleep cures, acupuncture and experimental or not-scientifically-endorsed treatments.
• Purely aesthetic treatments (plastic surgery, sclerotherapy of varicose veins, cosmetic treatments, slimming cures, obesity treatment, surgery for myopia/hyperopia/astigmatism) — but not reparative surgery after accident or burn.
• Transplants of any kind; treatment of any addiction (e.g. alcoholism); care arising from suicide, attempted suicide or self-injury.
• Cyberknife radiosurgery, robotic/image-guided/neuronavigator-assisted surgery (except intracranial neurological surgery); care for AIDS/HIV-positive disease.
• Pharmaceuticals, dressings, medicines and vaccines, except those supplied during hospital admission (over 24h); monoclonal antibodies, gene therapy, endocrine/hormonal therapy, inhibitors and antitumour immunotherapy are expressly excluded.
• Genetic counselling, paternity/kinship tests and genetic mapping; infertility/sterility study and treatment for all covers; unproven diagnostic procedures and alternative/holistic medicine (homeopathy, reflexology, osteopathy, chiropractic, etc.).
• Laser treatments except those in Art. 10.2; voluntary medical/surgical acts not from accident or illness (save Art. 10.4 preventive medicine); dental services not expressly in the Particular Conditions or the Guía Dental.
• Techniques not in habitual, scientifically demonstrated and Spanish National Health System–accepted use; experimental and compassionate-use treatments, clinical-trial treatments and palliative care (home or in-patient); new techniques until expressly included.
• Analyses, examinations and consultations needed only to issue certificates or reports with no clear care function; speech/language therapy for congenital anatomical, neurological or psychomotor disorders; any benefit not specifically included.

Article 14 — Indisputability ↑ top

If a medical examination was carried out, or full rights were recognised, the policy is indisputable as to the Insured's health and the insurer cannot deny benefits alleging prior illness, unless a reservation was expressly noted in the Particular Conditions. If no examination was done and the policy was based on the health questionnaire, the insurer may rescind within one month of learning of any reservation or inaccuracy, by written notice. The policy becomes indisputable one year after the contract's conclusion, save wilful misconduct (dolo) by the policyholder.

Article 15 — Applicable law & jurisdiction ↑ top

Unless the Particular Conditions state otherwise, Spanish law applies. The competent court is that of the Insured's domicile in Spain; an Insured domiciled abroad must designate a Spanish domicile, and any contrary agreement 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 clarification. Source: GENERALI España S.A. de Seguros y Reaseguros — Generali Salud Opción Family, Seguro de Protección Médica Familiar, ref. G50954, edition 01/2024.