Generali Salud Opción Premium 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. (“Generali”, the Company or the Insurer), 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) acknowledges and 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 (LOSSEAR) and RD 1060/2015, together with the policy conditions and the risk questionnaire signed by the policyholder.

Article 4 — 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.
• Care for social reasons: care not arising from objective treatable medical conditions or from illnesses of old age (not covered).
• Illness: a health alteration of common or accidental cause, confirmed by a legally recognised doctor and requiring care.
• Congenital illness/defect: existing at birth from hereditary factors or conditions acquired during gestation (may show at birth or be discovered 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. Medical / Psychiatric / Surgical hospitalisation are defined by the type of treatment received.
• Members of the family unit: family members living at the habitual residence named in the Particular Conditions and listed in the policy.
• Premature birth: before 37 completed weeks of gestation 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 or appliance replacing an organ, part of 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).
• Co-payment (Copago): the Insured's share of the cost of a medical act, by service used, at the network providers.
• Infertility treatment: techniques to overcome diagnosed primary or secondary infertility in the couple, by female or male factor.

Article 9 — How the policy works (object of the insurance) ↑ top

Salud Opción Premium is Generali's top-tier network health policy (Seguro de Protección Médica Familiar). The insurer provides access to its widest panel of doctors, specialists, clinics and hospitals — the Cuadro Médico Premium. In a claim you freely choose the provider from the panel and the insurer settles the cost directly (no cash to you). The up-to-date panel by specialty, with addresses and phone numbers, is kept on Generali's website.

If the reimbursement guarantee (10.5) is contracted, the insurer also reimburses reasonable and customary fees for primary care and for obstetrics & gynaecology when you use a doctor outside the panel. The insurer does not reimburse where you used a network provider. In all cases (Art. 103 of the Insurance Contract Law) the insurer assumes necessary urgent care.

Co-payment — and the sin-copago option ↑ top

The policy can be taken two ways, and this is the key choice:

• With co-payment (con copago) — using the network providers carries a small additional cost on top of the premium, which depends on the co-payment level contracted (set in the Particular Conditions).
• Without co-payment (sin copago) — the policy can be taken out with no co-payment, in which case no additional cost is charged beyond the premium. The wording states this expressly. This is the version used for Spanish residence visas.

Using it for a visa (NLV & DNV) ↑ top

Spanish consulates require private health insurance with full cover, from a Spanish (DGS-registered) insurer, with no co-payments and no annual cap, for at least one year. Salud Opción Premium taken sin copago meets all of this, and Generali issues the official certificate consulates accept. It is the policy for the non-lucrative visa and the digital nomad visa; see also the NLV guide and DNV guide.

Article 10 — What is covered ↑ top

Cover is grouped into seven guarantees, in three blocks — Concerted medical care: 1. Primary care · 2. Medical & surgical specialties · 3. Travel assistance · 4. Preventive medicine. Reimbursement of medical fees in Spain: 5. Reimbursement of primary care / obstetrics & gynaecology. Complementary family cover: 6. Daily hospital cash for illness & accident · 7. Dental.

10.1 Primary care ↑ top

General medicine; paediatrics (to age 14); qualified nurse (ATS/DUE); podology (max 6 sessions/year unless foot pathology); home emergency medical service; and psychology — individual sessions prescribed only by a psychiatrist for psychological treatment, simple diagnosis or psychometric tests (forms at the Insured's cost), max 4 sessions/month and 20/year. Psychoanalysis, psychoanalytic therapy, hypnosis, narcolepsy and psychosocial/neuropsychiatric rehabilitation are excluded.

10.2 Medical & surgical specialties ↑ top

The full range of specialties — allergology; clinical, anatomopathological and biochemical analysis (diagnostic only); anaesthesia & resuscitation; angiology & vascular surgery; digestive; cardiology; cardiovascular, general & digestive, maxillofacial, paediatric, plastic-reconstructive and thoracic surgery; dermatology & venereology; endocrinology & nutrition; stomatology (cures & extractions only — fillings, endodontics, prosthetics, orthodontics and periodontics excluded); geriatrics (excluding care for social reasons); haematology & haemotherapy; internal medicine; nuclear medicine; nephrology; neonatology; pneumology; neurosurgery; clinical neurophysiology; neurology; obstetrics & gynaecology (incl. pregnancy monitoring, midwife-assisted childbirth and epidural anaesthesia); ophthalmology (incl. photocoagulation laser and intra-ocular surgery, not refractive defects); medical and radiotherapy oncology (cobalt therapy, radiotherapy); ENT; psychiatry; radiodiagnosis (X-ray, tomography, urography and special surgical-technique studies); rheumatology; traumatology & orthopaedics; urology (incl. renal lithotripsy).

Also covered: ambulance (urgent transfer to the nearest centre, or home-to-surgery when prescribed; not for rehab/physio, outpatient diagnostics or dialysis); haemodialysis (acute/reversible cases only, max 15 sessions); complementary diagnostics (ECG, audiometry, EEG, endoscopy, kidney/liver function tests, ultrasound, CT, scintigraphy, MRI); oxygen therapy and aerosol/ventilation therapy (acute/reversible, max 30 days; medication at the Insured's cost); prostheses — only the listed internal items: osteosynthesis material, heart valves, pacemakers, hip prosthesis, abdominal mesh, port-a-cath, vascular bypass, internal traumatological prostheses, the intra-ocular lens for cataract surgery and the breast prosthesis after radical mastectomy; chemotherapy (hospital or outpatient, incl. authorised cytostatic drugs); blood transfusions (for admitted patients); rehabilitation (outpatient, functional — maintenance rehab excluded; only for illnesses arising after joining); phoniatrics (speech rehabilitation after surgery/oncology); permanent emergency centre.

Hospitalisation: medical, surgical, paediatric (incl. the newborn), and ICU/UVI hospitalisation; psychiatric hospitalisation capped at 60 days per Insured per year; in-clinic companion lodging (room only, where available; excluded for psychiatric, ICU and newborn admissions); in-clinic medication outside theatre during the stay.

10.2 Infertility treatment of the couple ↑ top

Covered if both partners are insured, each with at least 24 months in the policy, there is a diagnosis of primary or secondary infertility, and the woman is no older than 42 at the start of treatment. Maximum 3 artificial-insemination attempts (homologous or donor) and 2 full IVF cycles (incl. ICSI and the relevant freezing). This is a lifetime, non-renewable limit regardless of how many times the policy renews.

Each attempt includes the relevant gynaecology consultations, diagnostic scans/analysis, ovulation stimulation, semen preparation/donor semen and the procedure (IVF adds ovarian puncture, embryo culture and transfer, ICSI, testicular biopsy/TESE and up to 2 years' embryo freezing/maintenance). Failure of two ovulation-stimulation attempts ends cover for the rest of the treatment; embryo maintenance beyond the second year is at the Insured's cost. Excluded: treatment where infertility is voluntary or the natural end of the reproductive period, and the medication used. Treatment requires the insurer's prior express authorisation. Via free choice/reimbursement (no excess): up to €600 per insemination attempt and €4,000 per IVF attempt; paid within 20 days of full documentation.

10.3 Travel assistance abroad (Europ Assistance) ↑ top

Valid throughout Spanish territory beyond your province (more than 10 km from home 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 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). Amounts for the different areas are not additional.
• 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; dispatch of medicines abroad; forgotten/personal-objects dispatch (max 10 kg).
• Family member to accompany an Insured hospitalised >5 days (travel + €200/day stay, max 10 days; companion-stay extension €60/day, max 10 days); return on death or serious hospitalisation (>5 days) of a close relative; escort of accompanied minors/dependants under 14.
• Fund advance up to €5,000; criminal bail advance abroad up to €12,000; legal-assistance fees abroad (road accident) up to €600; advance to hospitals up to €6,000 (advances repayable within 30 days); telephone interpreter; card-cancellation information; digital-legacy management.
• Search & rescue up to €1,500 (mountain/sea/desert rescue excluded); checked-baggage loss/theft up to €1,000 (cash, jewellery, electronics and documents excluded); 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) and a range of at-home services — health staff, companion, cleaning, catering, telepharmacy (fees/medicines at the Insured's cost), home-security guard (max 24h after burglary/fire), plus a 24h legal-advice, lawyer-network, consumer-defence and contract-review service (free choice of lawyer; arbitration available).

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

10.4 Preventive medicine ↑ top

Child prevention (to age 14): paediatric reviews (monthly in the first quarter, then to 14), official vaccinations (diphtheria, tetanus, whooping cough, polio, MMR), vision and hearing checks at 3–4 and 10–11, dental prevention at 6 and 10–12, and neonatal hearing screening.

Adult prevention (14–65): periodic GP review (general exam, blood pressure, height/weight, skin, cardio-respiratory and abdominal exam), general blood test on medical criteria, obesity/hypertension/lipid prevention, coronary prevention (resting ECG from 30, stress ECG from 35 every 5 years), annual gynaecological review with cytology plus annual mammography from 45, amniocentesis from 35, family planning (incl. IUD fitting, tubal ligation and vasectomy; device/medication cost excluded; basic infertility study), dental check, biennial colonoscopy on prescription, tetanus vaccine, audiometry, vision/tonometry and antenatal classes.

Geriatric prevention (over 64, annual): GP review, blood/urine analysis, gynaecological review with cytology, flu and tetanus vaccines, dental check, biennial colonoscopy on prescription, hearing/eye review (ENT and ophthalmology) and breast/colon/cervical cancer screening on medical criteria.

10.5 Reimbursement of primary care / obstetrics & gynaecology fees ↑ top

If contracted, the insurer reimburses fees for services received in Spain from a freely chosen doctor/centre outside the panel: primary-care consultations (general medicine, paediatrics, nurse, podologist, home emergency, psychiatrist-prescribed psychology — within the 10.1 limits) and obstetrics & gynaecology consultations and the fees of the professionals needed for gynaecological surgery (anaesthetists, midwives). Reimbursement is based on the amount paid, less the 20% excess (franquicia) stated in the Particular Conditions, with the per-act limit and the annual maximum sum insured set there. Surgical fees are classified by the official medical-acts terminology, with the combined fees not exceeding the amount for the procedure performed; for two surgical approaches in one operation, the limit is the higher group plus 60% of the other (max two groups). It does not apply where the service was given by a network provider or by the Insured's spouse/relatives to the second degree, nor to the infertility acts (which sit under 10.2).

10.6 Daily hospital cash (illness & accident) ↑ top

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 equal sum applies for ICU/UVI admission. Successive stays for the same cause count as one period; nothing is paid for stays under 24h; no Insured may accrue beyond the indemnity period for one process/diagnosis. A new illness from a different process starts a new period. For Insureds under 5 or over 65, this guarantee is limited to surgical hospitalisation.

10.7 Dental ↑ top

Access to the coded dental acts in the Guía Dental, provided only at the network dental providers (no cash in lieu; free choice among them). You identify yourself with your insurer card. Anything not listed in the coded services or the Particular Conditions is outside this guarantee.

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; not applicable to couple infertility treatment).
• 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 13 — What is not covered ↑ top

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

• Pre-existing illnesses with evident prior symptoms before the Insured joined.
• 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 contagious 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, cosmetic treatments, slimming/obesity treatment, and refractive surgery for myopia/hypermetropia/astigmatism) — but not reconstructive surgery after accident or burn.
• Transplants of any type.
• 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.
• 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 stays in spas, rest homes, asylums and geriatric centres under the daily-hospital-cash guarantee; dental acts outside the Guía Dental coded list; and (under 10.5) reimbursement of fees from a network provider or from the Insured's spouse/relatives to the second degree.

Claims, contract & renewal (Arts. 1–3, 5, 7, 11–12, 14–15) ↑ 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 + later numbered appendices, plus an ID card per Insured and the Cuadro Médico Premium on Generali's website. It is governed by Law 50/1980 and Law 20/2015; limitative clauses are valid only 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, oxygen/aerosol therapy, 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. For travel assistance, call Europ Assistance from the moment of the event.

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; reimbursement is paid within 20 days (non-EU services converted to euros at the official rate of the payment date; translation costs at the Insured's cost). 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. 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 at least 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. 12, 14–15)

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, where the mother had birth cover). 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 Opción Premium, Seguro de Protección Médica Familiar, ref. SA 190/GEN, edition G51629 (01/2026).