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A. In order to file a claim for expenses partially covered by this Policy (percentage refund of expenses specified in the Particular Conditions of the Policy), the following rules must be observed:

1. The Member or any other individual on his or her behalf shall have to notify the Insurer of the claim within the following deadlines:

a) In the event of emergency health care, within five (5) working days after the date on which the medical care is administered, surgery is performed or hospitalisation takes place

b) In the event of surgery or hospitalisation, within seven (7) working days immediately prior to the date of such surgery or hospitalisation

c) The above deadlines shall be understood to be without prejudice to the provisions of article 16 of the Insurance Contract Act, which stipulates that: "The Policyholder, Member or Beneficiary shall notify the Insurer of the claim no later than seven (7) days after it came to their knowledge, unless a longer term has been established in the Policy".

2. Apart from notifying the illness or accident, the Policyholder or Member shall, in the event of surgery, hospitalisation, diagnostic test and therapy, forward a medical report to the Insurer specifying the diagnosis/es and nature of the illness/es, as well as the healthcare institution, date of hospitalisation, probable duration and nature of treatment, if applicable.

3. The Member shall also have to scrupulously follow all the orders of the physician in charge of his or her case and must provide the Insurer with all kinds of information on the circumstances or consequences of the claim.

4. The Policyholder or Member or his or her relations shall allow the physicians designated by the Insurer to visit the Member as often as the Insurer sees fit, and shall acquiesce to any inquiry or examination that the Insurer deems necessary about their state of health.

5. In the event of hospitalisation, the Policyholder or Member shall notify the Insurer of discharge, as well as the duration of in-patient care.

6. The Policyholder or, as appropriate, Member, shall furnish the Insurer with the following documents:

6.1 Application for refund on duly completed form.

6.2 Duly itemised original voucher/s or invoice/s of expenses actually incurred by the Member for each of the items stated on the invoice/s, showing:

a) The person to whom medical or hospital care was administered.

b) The nature of the care administered (visit, diagnostic tests, therapy, surgery, etc) and the respective dates and sums.

c) Identity of the natural or legal person who administered the care (physician or SEN or SRN, clinic or hospital, etc), indicating, as appropriate, surname and first name or business name, address, medical association member number and taxpayer code.

6.3 Original receipt or proof of the Member having paid the invoice/s

6.4 Original copy of medical prescription for the medical and/or hospital services received by the Member, except in the event of podiatrist's services, for which no such original prescriptions need be submitted.

6.5 Original medical report explaining the medical and/or hospital services received by the Member and the disease process and its development, as well as the medical or hospital discharge, indicating, as appropriate, whether further care will be needed.

Failure to comply with the rules established in the six preceding paragraphs shall entail express waiver of entitlement to refund, unless the Member or their relations are unable to observe such for reasons beyond their control.

B. In order to file a claim covered by this Policy ... (more)

C. In order to file a claim for accidents or illness covered by this Policy ... (more)

Return to Index (English Conditions)

For more information your English Sanitas agent is: David Harris

Mobile / cell: (00 34) 609 522 300

email: saniprof@wanadoo.es

Any questions or comments to saniprof@mail.ddnet.es - thanks.

(Free messenger service - I cover the whole of Spain (click here...))

Preliminary clause Definitions I. Purpose of the insurance

II. Excluded risks III. Grounds for contract IV. Excess

V. Waiting periods VI. Claims procedure VII. Refunds of expenses

VIII. Term of insurance policy IX. Insurance premiums X. Other obligations and duties of policyholders and / or members

XI. Rights of policyholders and / or members XII. Other obligations of the insurer XIII. Disputes

XIV. Duplicate copies of policy XV. Subrogation XVI. Prescription

XVII. Notifications XVIII. Claims-control and procedure XIX. Others

Apartado (PO Box) 19

28760 Tres Cantos Madrid

Tlf: ( 00 34) 91 804 3802 Fax: (00 34) 91 803 2484

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Mainly health plans S.L CIF: B19250372 Inscrito en el Registro Mercantil de Guadalajara: Documento: 1/2007/1.655,0 Diario: 14 Asiento: 779 Tomo 495 Libro: 0 Folio: 71 Hoja: GU-6611.

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