Generali Salud Total 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”), 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) is autonomous, acknowledges receipt and resolves with reasons within a maximum of two months; its decisions bind the insurer. After two months, or on a rejection, you may escalate to the DGSFP Complaints Service (Paseo de la Castellana 44, 28046 Madrid), without prejudice to recourse to the courts at any time. Applicable law: Law 50/1980 on Insurance Contracts, Law 20/2015 and RD 1060/2015, the Conditions of the contract and the risk-assessment questionnaire signed by the policyholder.

Definitions ↑ top

• You: the Policyholder and/or the Insured. We / Generali: the insurer assuming the risk.
• Insured: the natural person(s) meeting the policy conditions and on whom the risk is assumed. Beneficiary: the named Insured-Holder, entitled to receive the reimbursement of the covered family group's expenses and any indemnities.
• Policy: these General & Specific General Conditions, the Particular Conditions (which individualise the risk), supplements/appendices, the insurance application and the premium receipts.
• Premium: the price of the insurance plus surcharges and taxes, fixed on the declared risk.
• Insurance year: the period between the effective date and the policy expiry, and between each subsequent annual renewal.
• Sum insured / contracted capital: the total maximum limit for the reimbursable or directly-payable expenses for each Insured, both per insurance year and for the whole of a single illness or accident across several years.
• Excess (Franquicia): a percentage of the reimbursable expenses always borne by you, within the policy limits.
• Waiting period (Carencia): the time from the effective date (or a new Insured's inclusion) during which a cover is not yet in force.
• Illness: any alteration of health, including injuries from an accident, diagnosed and confirmed by a doctor. Lesions, after-effects and conditions from the same or related causes count as one and the same illness (a continuation, not a new illness).
• Accident: bodily injury from a violent, sudden, external cause beyond the Insured's intent.
• Pre-existing illness/accident: one already diagnosed, treated, consulted or showing first symptoms before the Insured joined the policy.
• Doctor: a person legally qualified and authorised to treat the illness medically or surgically where they practise.
• Out-patient care: care given in surgeries, at home, or in hospital without an overnight stay.
• Hospitalisation: being registered as an in-patient for a minimum of 24 hours, or registered in a day hospital for surgery. A re-admission for the same cause counts as a continuation of the previous one unless 90 days have passed since the previous discharge (relevant to the 180-day cap).
• Hospital: a public or private establishment legally authorised for medical treatment, with adequate facilities and staff for diagnosis and surgery and attended by doctors 24 hours a day. Asylums, residences, rest/convalescent homes, spas and neuro-psychiatric clinics are not hospitals for this policy, nor facilities for the elderly, disabled, chronic, mental, drug- or alcohol-dependent.
• Surgical operation: any operation by incision or other internal approach, for purposes other than diagnosis, performed in a hospital by a surgeon, normally needing an operating theatre. Day hospital is a centre equipped for day-case surgery.
• Claim (Siniestro): any act of care given under a contracted guarantee.
• Necessary medical/surgical care: care prescribed and necessary for diagnosis or treatment on generally accepted medical practice. Reasonable & customary expenses: costs not exceeding the usual level charged by that provider or similar providers in the same area for a comparable service.
• Pregnancy: from fertilisation to the birth or caesarean, including a “difficult pregnancy” (spotting, morning sickness, hyperemesis, etc.). Complications of pregnancy are conditions needing hospitalisation with a distinct diagnosis (acute nephritis, cardiac decompensation, miscarriage, ectopic pregnancy, puerperal infection, eclampsia, toxaemia, and similar).
• Emergency (Urgencia): care whose delay could gravely endanger life or physical integrity, needing treatment within 24 hours.
• Prosthesis: a permanent artificial device replacing all or part of a limb, organ, tissue or its function. Osteosynthesis material: pieces used to join the ends of a fractured bone or weld articular ends.

Article 1 — How it works (object of the insurance) ↑ top

Salud Total is an international insurance that reimburses the reasonable and customary expenses of hospital and out-patient medical and surgical care needed during the policy through illness, accident, pregnancy and birth/caesarean, plus the Travel Assistance and Second Medical Opinion covers, and pays the indemnities set in each guarantee.

Its defining feature is free choice: the Insured may freely choose the doctor or centre. There are two routes, and you can mix them:

• Free choice (anywhere in the world): use any provider you wish, in Spain or abroad; Generali reimburses the expenses subject to the excess and sub-limits and up to the contracted capital.
• Recommended Medical Network: use a network provider and no excess and no sub-limits apply — Generali pays the provider directly, so you pay nothing.

The three cover levels ↑ top

You choose the annual sum insured (maximum per Insured and insurance year, or per single claim) that best fits your family. The figures below are the main sub-limits from the Cuadro General de Garantías; your Particular Conditions hold the full table and bind. Using the Recommended Network removes all sub-limits and the excess.

Psychology is capped at 20 consultations/year, podology 6 sessions/year, oxygen/aerosol therapy 30 days/year, and preventive medicine at €150 — the €150 cap does not apply if the check-up is done in the Network. Travel Assistance and Second Medical Opinion are included on all three levels.

2.1 Hospital care ↑ top

Covers the costs of admission up to a maximum of 180 days per hospitalisation and insurance year:

• Hospital stay — the Insured's room and board plus a bed for a companion, up to the daily sub-limit.
• Intensive care (ICU/CCU) — no daily sub-limit.
• Medical fees — surgeon, assistants, anaesthetist and specialist consultations, with the per-operation sub-limit by surgical group (see Annex I) and the consultation sub-limit.
• Other hospital costs — theatre fees, medicines and materials, dressings, rehabilitation and other in-patient services.
• Psychiatric hospitalisation — max 60 days per Insured/year or per illness (stay, board, fees, medicines), to the sub-limit.
• Hospital cash (no charge to policy) — if covered hospital costs are not charged to this policy, Generali pays the daily amount set in the Particular Conditions per full day.
• Prostheses — an internal bone, osteosynthesis, cardiac (artificial heart excluded), vascular or ophthalmic prosthesis, abdominal mesh, port-a-cath, and breast prosthesis after radical mastectomy, to the annual sub-limit.
• Ambulance — necessary road transfer, to the sub-limit.
• Haemodialysis — acute/reversible cases and acute flare-ups of chronic processes only, max 15 sessions per process.

A re-admission for the same cause counts as a continuation unless 90 days have passed since the previous discharge. Not covered: plastic/cosmetic surgery (except reconstructive surgery after a covered accident and breast reconstruction after radical mastectomy); rest cures and treatment from alcohol, drugs and gambling addiction; admissions for pre-existing physical defects/deformities, refractive defects or congenital/hereditary anomalies (save the newborn cover); and any prosthesis other than those listed.

2.2 Out-patient care ↑ top

• Consultations — primary care (general medicine, paediatrics, nursing/ATS and physiotherapy, at the surgery or home) and specialist consultations, to the consultation sub-limits.
• Diagnostic tests — clinical analysis, diagnostic imaging, endoscopy and electrophysiology.
• Special treatments — functional rehabilitation (max 60 sessions/year), out-patient surgery (to the surgical-fee sub-limits), chemotherapy, cobalt therapy, radiotherapy and lithotripsy.
• Preventive medicine — the check-ups below, to the sub-limit (sub-limit waived if done in the Network).
• Podology — max 6 sessions/year unless foot pathology.
• Psychology — individual sessions prescribed only by a psychiatrist, max 4/month and 20/year (psychoanalysis, psychoanalytic therapy, hypnosis, narcolepsy and psychosocial/neuropsychiatric rehabilitation excluded; forms at the Insured's cost).
• Oxygen / aerosol therapy — at home, acute/reversible cases and chronic flare-ups only, on prescription; aerosol therapy max 30 days (medication at the Insured's cost).
• Stomatology — cures and extractions in the Network only (fillings, endodontics, prosthetics, orthodontics and periodontics excluded).

What preventive medicine covers

• General check-up (men & women from 45): a network check-up or reimbursement to the sub-limit, every two years from the second insurance year to age 59, then yearly to 70 — full physical, blood test (count, ESR, glucose, cholesterol, uric acid, GOT/GPT transaminases), urine test, resting ECG, and (on the examiner's prescription) a chest X-ray; a biennial colonoscopy may be done on prescription.
• Gynaecological check-up (women from 20): a network check-up or reimbursement to the sub-limit, yearly from the second insurance year between ages 20 and 70 — full gynaecological exam incl. breast exam, cytology (Pap); a bilateral mammogram from 40 on the examiner's prescription.

Not covered: dietary treatments, slimming cures, hair-process treatment (e.g. alopecia) and aesthetic-medicine treatments.

2.3 Pregnancy & treatment of the newborn ↑ top

• Pregnancy and birth, and pregnancy and caesarean (incl. the processes in the pregnancy definition); after the birth this entitles the newborn cover.
• Treatment of the newborn — for a birth during the policy, Generali covers the newborn's medical and hospital costs, incl. neonatal hearing screening, provided you request the baby's inclusion within 15 days of birth. If accepted and a congenital illness appears in the first year, there is additional cover to the newborn sub-limit until the first birthday; if inclusion is declined for congenital defects, the newborn cover still applies to the sub-limit for the first year (you may submit updated reports before the first birthday for re-assessment).
• Antenatal classes — included up to €120 per pregnancy.

Sub-limits: if the whole pregnancy and birth/caesarean is done exclusively through the Recommended Network (doctors, tests and hospitals), the excess and reimbursement sub-limits are removed; if you mix reimbursement with the Network, the Particular-Conditions sub-limits apply.

Not covered: non-spontaneous abortions and sterilisations, infertility diagnosis and treatment, and contraception.

2.4–2.6 Travel assistance, second opinion & dental ↑ top

• Travel Assistance (Annex II) — 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.
• Second Medical Opinion (Annex III) — information and a second diagnosis on serious illnesses, through prestigious specialist medical bodies; available to all Insureds on the policy.
• Dental — access to the coded dental services in the Guía Dental, provided only at its listed providers (no cash indemnity; free choice among them; show the ID document).

Article 3 — Using the cover & the excess cap ↑ top

Reimbursement (free choice)

If you choose your own doctor or centre, Generali reimburses the proved expenses less the excess, up to the applicable sub-limit. In any one insurance year the total excess you bear can never exceed €1,500; once you pass that figure, Generali reimburses 100% of further expenses up to the applicable sub-limit.

Using the Network

Generali gives an ID card per Insured; the network of hospitals, clinics and doctors and the home-emergency numbers are kept up to date on Generali's website. For hospitalisation, choose a network hospital and request authorisation at least 72 hours beforehand (in an urgency the medical order or admission report suffices, notified as soon as possible). For out-patient care, attend directly with your card; authorisation is only needed for invasive diagnostic tests in a hospital, special treatments (except rehabilitation) and preventive medicine. For pregnancy, request authorisation as above.

Advantages of the Network

Using the Network exclusively removes the economic sub-limits (except the rehabilitation-session limit and the preventive-medicine check-up frequency) — Generali pays directly, with no payment and no excess for you, provided you identify yourself and/or obtain prior approval; otherwise it is treated as a normal reimbursement subject to limits and excess. The sum insured is the total maximum per Insured/year and for a single illness/accident across years.

Waiting periods (carencias) ↑ top

• 3 months — any surgery or hospitalisation (Hospital-care guarantee).
• 3 months — high-technology diagnostic tests (catheterisation, arthroscopy, laparoscopy, amniocentesis), special treatments (lithotripsy, radiotherapy, cobalt therapy, chemotherapy) and out-patient surgery (Out-patient guarantee; preventive medicine has no waiting period).
• 8 months — pregnancy/birth or caesarean, complications of pregnancy, and the newborn cover (the birth must occur after the mother has been 8 months on the policy).

All waiting periods are waived for care needed through a covered accident or for a vital emergency from an illness arising and diagnosed after joining.

Articles 4–5 — Territory & the over-74 transformation ↑ top

Territory: the cover applies to care in Spain and abroad. If the Insured resides more than 90 days of an insurance year abroad, the cover reduces to medical expenses incurred in Spain. Generali is released from any obligation where providing the cover would expose it to sanctions or restrictions under UN, EU, UK or US rules.

Transformation at 74: from the annual renewal after an Insured reaches 74, the cover is limited to the Recommended Network — reimbursement (free choice) is then excluded.

Article 6 — General exclusions ↑ top

The insurance does not cover:

• Pre-existing illnesses and accidents (and anything derived from them) before joining — unless declared in the Health Declaration and either two symptom-free years have passed since joining, or cover was expressly accepted by clause.
• Pre-existing physical defects/deformities, refractive defects and congenital/hereditary anomalies (save the newborn cover, 3.3).
• Tests and treatments not recognised by medical science or considered experimental at the policy's effective date (unless expressly approved); acupuncture, homeopathy and organometry.
• Preventive medicine not in 2.4, all preventive treatment, vaccines and medicines (except those given during hospital admission).
• Psychoanalysis, psychoanalytic therapy, hypnosis, narcolepsy, psychosocial/neuropsychiatric rehabilitation, group therapy, psychological tests, sleep cures, and unrecognised/experimental treatments; illnesses or accidents from alcohol, drugs and gambling addiction.
• Immunodeficiency illnesses of any kind.
• Treatment of teeth and gums (save 2.8 and care after a covered accident affecting organs other than the mouth); dental prostheses are never covered.
• Acquisition, hire, maintenance and repair of all prostheses and orthopaedic/therapeutic appliances, and any prosthesis other than those in 1.7; non-surgical treatment of obstructive sleep apnoea.
• Non-artificial organs or tissues (the necessary transplant surgery may be covered).
• Claims caused directly by any contagious disease classed as a WHO Phase-5+ pandemic.
• Self-injury, attempted suicide, and illness/accident from war, terrorism, riots, earthquakes, floods, volcanic eruptions, nuclear damage and catastrophic contamination.
• Occupational illnesses, and illness/accident from highly dangerous professional, sporting or recreational activities (underground/underwater activity, mountaineering and climbing, parachuting, bridge/height jumping, hang-gliding, bullfighting, boxing, organised vehicle/boat/ski racing, and professional sport).
• Care given by the Insured's spouse, siblings, ascendants or descendants.
• Charges from a provider whose reimbursement Generali has reasonably suspended (after notice; not before two months for treatments in progress), and reimbursement where the service was given by a Network provider.
• Genetic-map determinations (disease-predisposition or infertility-cause studies); any act for infertility treatment.
• Purely aesthetic treatment (plastic surgery, varicose sclerosis, cosmetic treatment, slimming/obesity treatment and refractive surgery for myopia/hypermetropia/astigmatism) — but not reconstructive surgery after accident or burn.

Article 7 — Who can join ↑ top

Natural persons named in the Particular Conditions may be insured. Maximum entry age 64 (or as set in the contracting rules). Newborns can join from birth if the mother had been on the policy at least 8 months before; otherwise from discharge from the birth centre, once the application is accepted. The Insured must reside in Spain at least 270 days per insurance year (over 90 days abroad reduces cover to Spain only). An adult (or emancipated minor), their spouse and single financially-dependent children living with them may be insured, normally jointly. Joining requires a signed application with the Health Declaration; Generali may accept, decline or propose modified cover.

Article 8 — What to do in a claim ↑ top

Notice & documents

Notify a reimbursement claim as soon as possible and always within 7 days of the first care received, using the Solicitud de Indemnización form (with a medical report if requested). One form per medical act/claim (repeated acts for the same condition may reference the first). For hospitalisation, attach the attending doctor's report (diagnosis, history, start, cause, course and discharge). Original itemised invoices must show the provider's name, tax number (CIF/NIF), college number, type of act, patient and date. Documentation lacking this is not a valid claim. You must allow Generali's doctors to visit and verify, releasing your doctors and centres from professional secrecy and following the treating doctor's prescriptions; failure (by wilful misconduct or gross negligence) can forfeit the right to reimbursement. Claims may also be filed at www.generali.es (“Trámites de Salud”).

Payment of indemnities

Generali pays once it has the documentation and has determined cover, and may obtain information from any insurer/person. Expenses paid in foreign currency are settled in Spain in euros at the reimbursement-day rate; translation of reports/invoices is at Generali's cost only if in English, French or Portuguese (otherwise at the Insured's cost). Generali may settle invoices directly with centres/professionals; if it does not, you may request advances on justified invoices exceeding €600 (within the policy limits).

Resolving disputes

On disagreement over the origin or nature of the illness or care, each party appoints an expert (a third on disagreement; otherwise via the Voluntary Jurisdiction Act). The experts' decision is notified at once and binds the parties unless challenged in court within 30 days (Generali) or 180 days (you); if unchallenged, Generali pays the assessed reimbursement within 5 days.

Articles 9–11 — Premiums, revaluation & the contract ↑ top

Premiums (Art. 9) & revaluation (Art. 10)

Premiums follow Generali's current tariff and change with family-group/risk variations, age, tariff revisions (notified in writing; you may then cancel at the annual renewal) and the automatic revaluation. Each year the sums insured, sub-limits and premiums on guarantees 1–3 are adjusted by the CPI sub-index for Medical & Similar Services (INE); changes do not apply to treatments already started or to pregnancies/births already occurred.

Bases, effect & duration (Art. 11.1–11.2)

The policy is built on your application and Health Declaration. If the policy differs from your application you have one month to claim correction. Errors/omissions known to you let Generali rescind within one month of learning of them; a claim before that reduces the benefit pro-rata to the unpaid premium (or, with wilful misconduct/gross negligence, releases Generali). Cover takes effect at the date/time in the Particular Conditions once the premium is paid; the contract renews automatically (opposition: one month's notice by the policyholder, two by the insurer; contracts under one year do not renew). On extinction cover ceases, but if Generali declines renewal while you are in known treatment, the treatment expenses continue (to the unused sum insured, max 180 days after extinction; not for Travel Assistance).

Risk changes & premium payment (Art. 11.3–11.4)

Notify any aggravation of risk (e.g. profession, sport) promptly; Generali may then propose modified conditions (15 days to accept) or terminate within one month. A claim without notice releases Generali if you acted in bad faith, else reduces the benefit pro-rata. Risk reductions entitle a premium reduction. Premiums are payable in advance; cover does not start (or is suspended) until paid — though claims in the first month of a renewal are covered if the premium is paid that month. Non-payment of a successive premium suspends cover one month after the due date; if unclaimed within six months the contract is extinguished by law.

Communications, jurisdiction & subrogation (Art. 11.5)

All communications must be in writing (recorded phone calls valid where the law allows and you consent) by post, burofax, fax, email or SMS to the addresses in the policy. They take effect on receipt (postal/burofax on first delivery attempt; email/SMS on reaching the destination). Communications via the mediating agent/broker have the same effect as direct ones. The contract is governed by Spanish law; the competent court is that of the Insured's domicile in Spain (any contrary pact is void). After paying, Generali is subrogated to your rights against the party responsible, up to the amount paid (not against a co-resident spouse/relatives to the third degree, save wilful misconduct or where covered by insurance).

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 Total, Seguro de Reembolso de Gastos con Cuadro Médico Recomendado, ref. 60375/02/GEN, edition G51630 (01/2026).