ExtraAdeslas

guide book

Reimbursement Policy

4

4

4

5

6

6

8

12

14

15

18

introduction

Presentation

Documentation Received by the Insured

Customer Service

usage norms

Expense Reimbursement Modality

Healthcare Modality. Services Catalogue Usage

Combined Services Usage

international travel health insurance

what should i do?

provincial office directory

3

table of contents

Presentation

Healthcare specialist Adeslas SegurCaixa has designed the Adeslas Extra policy, which offers you the possibility of choosing healthcare anywhere in the world.

Adeslas Extra is a combined service policy comprised of expense reimbursement (for medical services used outside of the Services Catalogue and healthcare service (pro-vided in accordance with a previously established services catalogue) making it pos-sible to choose healthcare service in three ways:

1 Expense reimbursement modality

As the Insured you can have access to any healthcare service not included in our services catalogue, both in Spanish territory and abroad. In this case, the company will reimburse you for any invoices you have paid, provided that the healthcare service received is covered under the policy conditions and within the limits specified therein.

2 Healthcare modalityAs the Insured, you receive medical service, completely cost-free, through the healthcare professionals and clinics included in our extensive services catalogue, throughout the territory of Spain.

3 Combined healthcare serviceThis service consists of the combined use of the two preceding modalities: serv-ices through the company services catalogue or choice of services outside of the services catalogue anywhere in the world. Use of the combined services allows you to freely alternate both systems, previously agreed to services or reimburse-ment, in the same medical process.

Documentation received by the insured

With the Adeslas Extra policy you have taken out, you receive the following docu-mentation:

4

Presentación

Adeslas SegurCaixa, especialista en seguros de salud, ha diseñado la póliza Adeslas Extra, que le ofrece la posibilidad de elegir asistencia sanitaria en cualquier parte del mundo.

Adeslas Extra es un seguro mixto de servicio, reembolso de gastos (para los servicios médicos utilizados fuera del cuadro) y asistencia sanitaria (facilitada con un cuadro médico concertado), permitiéndole a usted la posibilidad de elegir la prestación asistencial de tres formas:

1 Modalidad de reembolso de gastos

Usted como asegurado puede acceder a cualquier servicio asistencial, no incluido en nuestros cuadros médicos, tanto en territorio nacional como en el extranjero. En este caso, la compañía le indemnizará al asegurado las facturas que haya pagado, siempre y cuando el servicio asistencial recibido esté cubierto en las condiciones de la póliza y con los límites que están especificados en la misma.

2 Modalidad de asistencia sanitariaUsted como asegurado recibe un servicio médico, sin coste alguno, a través de los facultativos y clínicas incluidas en nuestros amplios cuadros médicos, concertados en todo el territorio nacional.

3 Asistencia combinadaConsiste en la utilización combinada de las dos modalidades anteriores: servicios concertados a través del cuadro médico de la compañía o elección fuera del cuadro en todo el mundo. La utilización combinada de servicios le permite a usted alternar libremente ambos sistemas, concertado o reembolso, dentro de un mismo proceso médico.

Documentación que recibe el asegurado

Con la póliza Adeslas Extra que usted ha contratado recibe la siguiente documentación:

introducciónintroducción

4

introduction

General terms and conditions, special terms and conditions, specific terms and conditions of the policy and an additional health insurance policy when traveling abroad.

A Services Catalogue listing the services provided in the province where the policy was taken out. You can request information at any Adeslas SegurCaixa office regarding the services provided in the province where you wish to receive the service. This information is also available in the 24-hour customer service phone number 902 200 200.

An Adeslas SegurCaixa Healthcare Card for all Insured individuals.

Expense reimbursement forms.

A Policy Usage Guide, the document you’re reading now.

Customer service

Adeslas SegurCaixa officesAdeslas SegurCaixa has an extensive network of offices throughout Spain aimed at providing the Insured with the following services:

Processing of authorizations for services so requiring.

Consultancy, when requested by the Insured, for the use of services contained in the services catalogue or not at the national level.

Claims management and reimbursement for services obtained outside of the services catalogue.

Procedures to be followed in order to obtain reimbursement authorizations and management.

Authorization for diagnostic tests and rehabilitation treatments.

Information and contracting of new policy modalities.

General information which will prove useful to you.

5

902 200 200 is a permanent telephone customer service hotline, aimed at

providing information on the AdeslasCaixa healthcare services throughout Spain: healthcare professionals, hospitals and

emergency services.

Customer Service 24 hours a day

902 200 200 www.adeslassegurcaixa.es

As a customer you have access to the highest quality healthcare in the world, since you can go to any doctor or hospital in Spain as well as abroad, and receive the healthcare services covered by the policy.

Expense reimbursement

Healthcare servicesYou can go to any healthcare professional or medical center in the world in order to receive the services covered by the policy. If the physician or center is not listed in the services catalogue of the insurer, the insurer will reimburse you for expenses in accordance with the special terms and conditions.

As a private patient, you will be required to obtain an invoice for the service received. This document, with the accreditation of payment having been made, will allow you to apply to the company for the corresponding indemnity in ac-cordance with the limits agreed to in the policy.

Remember, you will only be reimbursed for the health-care expenses for medical professionals and centers which are not included in our services catalogue. Con-sult your services catalogue or the company if you have any doubts.

Claims communicationYou are required to notify the insurer, as soon as possible, of any healthcare service received and, in any event, prior to 7 days following the date on which the service was used.

6

usage norms

In the case of admission to hospital, 7 days prior to admission you must notify us of the following: date of admission, name of hospital and reason for admission.

This information may be communicated either in person, by phone or by fax.

If the hospital is included in the services catalogue of the insurer, you must request from the company au-thorization for admission.

Expense reimbursement procedure

In order to be reimbursed for the healthcare services received, you must present

the following documents at any Adeslas SegurCaixa office:

Application for expense reimbursement, filled out following the instructions

printed on the back of the document itself. If you don’t have any application

forms, you can obtain any ones you require at any Adeslas SegurCaixa office.

Original invoices, with accreditation of payment made. These documents

must contain the following information:

- First and last name or corporate name of the individual or legal entity

issuing the invoice.

- Address, telephone number, professional medical association number

and specialized field.

- Tax ID number.

- Detailed itemization of the various healthcare services included in the

invoice: type of medical act and date service was performed.

7

En caso de ingreso hospitalario, deberá comunicarnos con 7 días de antici-pación los datos siguientes: fecha de ingreso, centro hospitalario y motivo del Ingreso.

Esta comunicación la puede realizar en persona, por teléfono o fax.

Si el hospital estuviera incluido en el cuadro médico de la aseguradora, usted debe solicitar autorización de ingreso a la compañía.

Procedimiento para el reembolso de gastos

Para que se le reembolsen los gastos por prestaciones sanitarias, usted debe

presentar en cualquier oficina Adeslas SegurCaixa los documentos siguientes:

Solicitud de reembolso de gastos, cumplimentada siguiendo las instrucciones

impresas en el dorso del propio documento. Si no tiene ningún ejemplar de

este formulario, en la oficina Adeslas SegurCaixa le facilitarán los que

necesite.

Facturas originales, con la acreditación de haber sido pagadas. Estos

documentos deben indicar los datos siguientes:

- Nombre y apellidos o denominación social de la persona física o

jurídica que las emita.

- Domicilio, teléfono, número de colegiado y especialidad.

- N.I.F. o C.I.F.

- Desglose detallado de los diversos conceptos asistenciales incluidos

en la factura: clase de acto médico y fecha de realización.

7

Clinical report, when hospital admission is required.

Original medical prescriptions, when diagnostic tests, special treatments, hos-pitalization or other services (ambulance, oxygen therapy) are required.

You are required to provide the company with an official translation of any documents written in any language other than the official lan-guages of the Spanish State.

All claims filed will be evaluated, and you will be paid the amount which cor-responds to you within 15 business days following receipt of the full documen-tation indicated above.

Payment will be made at all times in Spanish currency. Any invoices which you present in any other currency will be valued at the applicable exchange rate in effect on the date the documentation is received.

Expenses will be paid by bank transfer to the account for which there is a direct debiting order for the payment of premiums or to any other account indicated by you on the expense reimbursement application. Additionally, you will receive a detailed report on the evaluation of the expenses contained in your application. If you should require any information regarding the procedure followed or the amounts paid, do not hesitate to contact the insurer.

Services catalogue usage modality

Healthcare servicesIn this modality you can have cost-free access to all healthcare services through-out Spanish territory, regardless of the geographical area in which you have taken out the policy, or regardless of your place of residence.

The services contracted from the company are detailed in the services catalogue which, as the Insured, you will receive when you contract the policy; if you so wish, you may have access to information on healthcare services throughout Spain.

8

usage norms

Form of access

You can receive healthcare services by means of the following:

Doctor’s office visit: by appointment, calling the number indicated for each

professional in the services catalogue.

House calls: your general practitioner, pediatrician or nurse (ATS) will make house calls when you are unable to go to the doctor’s office for reasons of health. House calls must be requested prior to 10 am in order to be made that same day.

Emergencies: emergency services are clearly identified in the services catalogue provided by the company. This section lists the addresses and telephone numbers to be contacted in order to request emergency home assistance.

Diagnostic tests, hospitalization and other services: when a physician prescribes any of these services, you must consult the services catalogue in order to verify whether or not advance authorization is required.

Services requiring advance authorization The following services require advance authorization by the company:

• Consultations and hospitalization:

a) Consultant specialist visit.

b) Ambulatory surgery.

c) Hospital admission.

d) Out-patient hospital.

9

• Special diagnostic techniques performed on an out-patient basis and not performed at the hospital center:

a) Special clinical analyses: karyotypes, genotypes, immunohistochemistry, molecular biology.

b) Specialized radiology: angiography, digital angiography, interventional radiology, bone density, MRI, CAT scan, PET scan.

c) Circulatory system: ergometrics, vascular hemodynamics, holter monitord) Nuclear medicinee) Fibroendoscopy: all typesf) Neurophysiology: sleep studiesg) Gynaecology: amniocentesis and amnioscopyh) Ophthalmology: fluorescein angiographyi) Urology: urodynamics

• Special surgical treatments and techniques:a) Oncology: chemotherapy, immunotherapy, cobalt therapy,

radiation therapy and radioactive isotopes. b) Rehabilitation: all techniquesc) Oxygen therapy: ventilation therapy and aerosol therapy in the

homed) Arthroscopic surgerye) Renal lithotripsy f) Laser therapyg) Peritoneal dialysis and hemodialysish) Pain management uniti) Psychotherapy

• Inter-city ambulance service and other special means of transport for

periodical treatments.

10

usage norms

Obtainment of authorizationAuthorization may be obtained in the following manners:

a) By telephone: 902 200 200 b) By internet: www.adeslassegurcaixa.esc) By fax, sending the medical prescription to 902 205 205. In this case, you

should include the following information:• Number of the Insured.• Patient first and last name. • Professional prescribing the service and center or physician performing the service.• Fax number to which the authorization is to be sent.• Contact telephone number for possible clarifications.

d) In person, at the Adeslas SegurCaixa offices, presenting your Adeslas SegurCaixa Card and the physician’s prescription.

Documents to be Handed in to Healthcare Professionals or centers

Whenever you receive healthcare service you will be required to present your Adeslas SegurCaixa Card to the healthcare professional and to sign the corre-sponding receipt for the service provided.

In cases of admission to hospital, you will also have to present your Adeslas SegurCaixa Card.

Whenever you receive healthcare service requiring authorization in advance, hand in the authorization issued by the company to the healthcare professional or center.

Remember, you will not be reimbursed for expenses incurred as the result of healthcare services received from the professionals or centers included in the com-pany services catalogue. In this case, the healthcare services are paid for directly by the company, and all you have to do is present your Adeslas SegurCaixa Card and sign the receipt corresponding to the service provided.

11

Combined services usage

Healthcare services

Adeslas Extra can be used in combination form, alternating the two modalities:

expense reimbursement or healthcare with an established services catalogue.

In each case you will have to follow the procedure for access and use of the services

as described for each modality.

Expense Reimbursement Limits

The expense limits established in the policy are only applicable to expense reim-

bursement, not to the services provided for in the services catalogue, which are

paid for directly by the company.

Services not included in the services catalogue:

In this case, the company will indemnify you in accordance with the conditions

agreed to in the policy.

Services included in the services catalogue:

The company directly pays the healthcare professional or center, and you do not

have to pay any amount whatsoever. These expenses are not computed for the

purposes of reimbursement limits.

12

usage norms

Efficient Use of Combined Services

Remember that you will be repaid part of the expense you incur, in accordance

with the limits agreed to in the policy. Therefore, we recommend that you follow

the following steps in cases involving high-cost healthcare:

1. Obtain from the chosen healthcare provider(s) not included in our services

catalogue an estimate for all of the expenses which you will incur: medical

fees, diagnostic tests and hospital expenses.

2. Request information from the company regarding the amounts which will be

reimbursed to you in accordance with your policy.

3. Consult the company about the optimal combination of providers (included in

and outside of the services catalogue) which will cause you the least expense.

You can avoid deductibles and not have any limits on quantity, by using the es-

tablished services for doctors’ office visits, diagnostic tests, hospitals and special

treatments. Consult the section “Healthcare Modality. Services Catalogue Usage”

of this document in order to verify whether or not you require authorization in

advance from the company.

13

Adeslas Extra includes an additional health insurance policy covering Travel Abroad for travel of less than 90 days.

• Healthcare expenses up to 12,000 €/year.

For illness or accident occurring during your stay abroad.

• Emergency dental expenses

• Expenses for prolonged hotel stay

• Healthcare repatriation for the wounded or ill.

• Repatriation of deceased and accompanying insured persons.

These services, as well as additional services and the use thereof are detailed in the general terms and conditions of Adeslas Asistencia which you re-ceived together with the policy documentation.

14

international travel health insurance

Should I go to the Adeslas SegurCaixa offices to request authorization for an X-ray?

No, all you need is a prescription from your physician, since this type of diagnostic

test does not require authorization. When you are in doubt as to the need for

company authorization in order to receive a given healthcare service, you can

consult the services catalogue, call the Adeslas SegurCaixa offices or the 24-hour

customer service number: 902 200 200.

How can I request emergency services?

Call the emergency centers listed in the services catalogue.

How can I have access to healthcare services in another province?

You can request information on healthcare services in any province at the Adeslas

SegurCaixa offices, or by calling the 24-hour customer service number:

902 200 200.

What do I need to do prior to hospital admission?

If you are going to be admitted to a hospital listed in the services catalogue, you

must obtain authorization from the company.

If the hospital is not listed in the services catalogue, you must notify the company

of the date of admission, the name of the hospital and the reason for hospitaliza-

tion seven days in advance.

15

what should i do?

When I go to a doctor’s office or use services which are not included in the company services catalogue, what amount of the expenses incurred will I be reimbursed?

In accordance with the conditions of the policy, the company will reimburse you

between 80% and 90% of the expenses you incur. We recommend that you consult

the document “Special terms and conditions”, which you received with the policy

documentation, and in which are listed the maximum amounts to be received as

indemnity in accordance with the type of healthcare service you receive.

How can I minimize payments not reimbursed by the company?

By alternating the two modalities: expense reimbursement or healthcare service

using the established services catalogue. Consult the section “Combined Services

Usage” in this guide.

For instance, you can use the services from the company services catalogue for

diagnostic tests and treatments prescribed to you by professionals not listed in the

services catalogue, without the need to pay any amount whatsoever.

16

what should i do?

Where can I file an application for expense reimbursement?

At the offices of Adeslas SegurCaixa. Consult the office directory in this usage

guide or call the 24-hour customer service number: 902 200 200.

The documents you are required to present are indicated on the back of expense

reimbursement application.

How and when will I receive payment of the expenses submitted to the company?

Payment for expenses settled by the company will be made to you by bank

transfer, to the current account for which there is a direct debiting order for the

payment of premiums, in the term of no longer than 15 business days as from the

date of presentation of the invoices to the company.

17

Listed below are the Adeslas SegurCaixa offices located in each provincial capital. You can hand in expense reimbursement applications at these offices (except those marked with *). For additional places where these applications can be presented, call the direct customer service number: 902 200 200.

18

provincial office directory

Álava*IQUIMESA Seguros de Salud, S.A.

Plaza Amárica, 3 bajo01005 Vitoria Gasteiz Tel.: 945 23 09 58Fax: 945 14 47 65

Central Office*Juan Gris, 20-2808014 BarcelonaTel.: 93 227 87 00

Asturias*Igualatorio Médico Quirúrgico y deEspecialidades de Asturias, S.A. de Seguros

Matemático Pedrayes, 15-17 bajo D 33005 Oviedo Tel.: 98 525 49 00Fax: 98 524 12 46

AlmeríaPlaza Barcelona,Edf. Brisas, 1 bajo04004 AlmeríaTel.: 950 23 34 97Fax: 950 23 09 17

AlbaceteCaba, 17 02001 Albacete Tel.: 967 50 18 18Fax: 967 22 31 20

ÁvilaPadre Victoriano, 4 05005 Ávila Tel.: 920 22 44 08 Fax: 920 22 17 57

AlicanteBenito Pérez Galdós, 2 03004 Alicante Tel.: 96 514 33 78Fax: 96 520 01 37

BadajozAvda. de Colón, 19-1º 06005 Badajoz Tel.: 924 20 77 90Fax: 924 24 70 98

19

Cantabria*Igualatorio Médico Quirúrgico Colegial,S.A. de Seguros

Juan de Herrera, 24 entresuelo39001 SantanderTel.: 942 22 96 00Fax: 942 24 55 27

CeutaPlaza Teniente Ruiz, 3-1º51701 CeutaTel.: 956 51 31 27Fax: 956 51 49 71

CastellónPoeta Guimerá, 5, 2ª12001 CastellónTel.: 964 25 32 32Fax: 964 25 23 21

A CoruñaAvda. Linares Rivas, 9 bajo 15005 A CoruñaTel.: 981 12 20 67Fax: 981 12 27 05

CuencaPlaza Constitución, 6-2º C 16001 CuencaTel.: 969 23 08 43Fax: 969 22 45 51

BarcelonaPaseo de Gracia, 85 08008 Barcelona Tel.: 93 216 22 00 Fax: 93 216 22 67

Baleares31 de Diciembre, 15 bajo07003 Palma de Mallorca Tel.: 971 49 80 60Fax: 971 75 68 34

Ciudad RealRonda de Ciruela, 14-1613004 Ciudad RealTel.: 926 21 50 39Fax: 926 27 28 45

CórdobaPaseo de la Victoria, 31 14004 Córdoba Tel.: 957 29 09 11 Fax: 957 29 93 16

CáceresAvda. de la Virgen deGuadalupe, 12 bajo 10001 CáceresTel.: 927 22 44 77 927 24 74 08Fax: 927 21 41 03

CádizAvda. Andalucia, 34 bajo 11008 Cádiz Tel.: 956 27 48 08Fax: 956 26 38 38

BurgosAvda. de la Paz, 11 bajo 09004 Burgos Tel.: 947 24 14 00Fax: 947 24 13 99

20

provincial office directory

Guipúzcoa*Iquimesa Seguros de Salud, S.A.

Paseo Ramón María Lili, 3-4 20002 San Sebastián Tel.: 945 23 09 58Fax: 945 14 47 65

GranadaAvda. Constitución, 4 bajo 18012 Granada Tel.: 958 20 93 80Fax: 985 20 93 52

GuadalajaraJuan Diges Antón, 21esquina calle Sigüenza19003 GuadalajaraTel.: 949 23 42 70Fax: 949 22 96 25

HuelvaFernando el Católico, 1-3 bajo 21003 HuelvaTels.: 959 25 02 21

959 24 13 89Fax: 959 24 13 89

HuescaAlcoraz, 822002 HuescaTel.: 974 21 50 26Fax: 974 21 50 63

LugoDinán, 5-7 bajo 27002 LugoTel.: 982 25 00 22Fax: 982 24 11 07

LleidaValcalent, 1º 2-1Edif. Trading Balmes 25006 Lleida Tel.: 973 27 83 83Fax: 973 27 13 41

LeónGran Vía de San Marcos, 19 1º A 24002 León Tel.: 987 24 59 15Fax: 987 24 50 58

Las PalmasPerojo, 6-8 bajo 35003 Las PalmasTel.: 928 37 07 70Fax. 928 38 09 66

La RiojaPío XII, 3 bajo 26003 Logroño Tel.: 941 25 90 00Fax: 941 25 01 73

JaénAvda. de Madrid, 20 bajo 23003 Jaén Tels.: 953 25 94 21

953 25 94 22Fax: 953 27 00 68

GironaGran Vía Jaime I, 78-80 bajo 17001 GironaTel.: 972 20 65 45Fax: 972 22 28 73

21

Navarra*Igualatorio Médico Quirúrgico y deEspecialidades de Navarra, S.A.

Paulino Caballero, 51 bajo 31003 PamplonaTel.: 948 29 04 00Fax: 948 24 11 66

MadridPríncipe de Vergara, 110 bajo 28002 MadridTel.: 91 564 54 54Fax: 91 564 60 61

PalenciaAvda. Manuel Rivera, 12 bajo34002 Palencia Tel.: 979 72 03 62Fax: 979 73 03 71

MálagaAvda. de Andalucía, 17 29002 MálagaTel.: 95 233 02 00Fax: 95 235 21 20

PontevedraGarcía Barbón, 20 bajo 36201 Vigo Tel.: 986 22 14 97Fax: 986 22 74 84

MelillaAvda. de Carlos Arellano, 18 52004 MelillaTel.: 95 268 21 97Fax: 95 268 44 85

SalamancaArco, 7-9 bajo 37002 Salamanca Tel.: 923 28 09 01Fax: 923 26 29 98

MurciaFrancisco Rabal, 1 bajo Edif. Torreluz30009 MurciaTel.: 968 27 45 65Fax: 968 29 90 55

Sta. Cruz de TenerifeRamón y Cajal, 1 bajoEdif. Salesianos38003 Sta. Cruz de Tenerife Tel.: 922 27 45 16Fax: 922 24 63 40

SegoviaMadrona, 1 1ºB 40002 Segovia Tels.: 921 44 39 00 921 42 05 53Fax: 921 44 41 38

OurenseBedoya, 8 bajo32004 Ourense Tel.: 988 24 15 28Fax: 988 24 46 76

SevillaDiego Riaño, 441004 SevillaTel.: 954 41 80 00Fax: 954 41 84 60

22

provincial office directory

TarragonaRambla Nova, 106 bis bajo43001 TarragonaTel.: 977 23 90 18Fax: 977 21 81 08

TeruelJoaquín Costa, 7-1º. Tozal44001 TeruelTel.: 978 60 53 58Fax: 978 60 38 25

ToledoGeneral Villalba, 3 bis 1ª planta45005 ToledoTel.: 925 25 51 42Fax: 925 21 22 66

ValenciaConvento de San Francisco, 8 bajo46002 ValenciaTel.: 96 310 40 00Fax: 96 394 05 70

ValladolidMiguel Iscar, 1347001 ValladolidTel.: 983 34 05 88 983 34 06 88Fax: 983 34 05 11

ZaragozaPaseo Teruel, 38 bajo50004 ZaragozaTel.: 976 23 99 95Fax: 976 23 85 40

ZamoraAvda. Víctor Gallego, 7 bajo49009 ZamoraTel.: 980 52 26 50Fax: 980 51 35 86

Vizcaya*Igualatorio Médico Quirúrgico, S.A.

Máximo Aguirre, 18 bis48011 BilbaoTel.: 944 42 34 50Fax: 944 42 34 85

SoriaSagunto, 14 42001 SoriaTel.: 975 22 78 00Fax: 975 22 59 90

12

S.R

E.5

6 I/

05

Segu

rCai

xa A

desl

as, S

.A. d

e Se

guro

s y

Reas

egur

os -

Jua

n G

ris 2

0-26

, 080

14 B

arce

lona

(Spa

in).

Regi

ster

ed in

the

Com

mer

cial

Reg

istr

y of

Bar

celo

na, b

ook

2048

1, s

heet

130

, pag

e B-

6492

. VA

T N

o.: A

2801

1864

902 200 200 - www.adeslassegurcaixa.es

24-hour customer service