Terms and conditions of insurance

Transcription

Terms and conditions
of insurance
Healthcare Insurance
and Additional Insurance
from 1 January 2014
Valid from 1 January 2014
Terms and Conditions of Insurance for Health Insurance and Additional Insurance Packages as
per 1 January 2014
______________________________________________________________________________________
Terms and Conditions of Insurance
Health Insurance
and
Additional Insurance Packages
valid from 1 January 2014
This supersedes the previous terms and conditions of insurance
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page 1
per 1 January 2014
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How does your insurance work?
Based on the "occupational therapy" example, we will show how you can use this booklet so that you know
what your insurance covers. After all, this booklet applies to everyone we insure, but not all of the Articles
apply to you.
1. Alphabetical list of reimbursements
In the "Alphabetical list of reimbursements" (starting on page 6) you look up Occupational therapy, under
"o" (see arrow 1 in the illustration below):
1
2
3
Health insurance
Reimbursement
Occupational therapy, general
Occupational therapy, instructions for volunteer
carers
…
Article
B.9.
page
54
Additional insurance
package
Article
page
D.17.1.
123
D.17.2.
123
2. Health insurance
The 2nd column (see arrow 2) shows the Article number and the page on which the coverage of the
health insurance can be found. Article B.9 tells you that you are entitled to reimbursement for a maximum
of 10 treatment hours per year. You can also see the terms and conditions that have to be met and what,
if anything, is not included in this reimbursement.
3. Additional insurance package
In the 3rd column (see arrow 3) you will see the Article number and the page where you will find the cover
under the additional insurance package. Article D.17.1. tells you what you are entitled to, and what the
terms and conditions are. You will also read that your Reimbursements Overview will show you the
amount for that reimbursement.
4. Reimbursements Overview
You check your Reimbursements Overview to see whether Article D.17.1. is included in your additional
insurance package and the amount of the reimbursement. Can't find Occupational Therapy, Article
D.17.1. in your Reimbursements overview? Then your are not entitled to additional reimbursement (therefore, only the reimbursement in the health insurance).
The illustration below shows part of the Reimbursements Overview. This may show that you are insured
for Occupational Therapy (see arrow 4). The Reimbursements Overview therefore contains the actual information about the healthcare that you are insured for and the amount of the reimbursement. The number in the Terms and conditions column refers to the Article number in this booklet.
4
What will you be reimbursed
How much will you be reimbursed Terms and
conditions
Occupational Therapy
D.17.
Occupational therapy for insured personsup to 18 years
maximum
2 hours per year over and
above insurance in the general
insurance
D.17.1.
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per 1 January 2014
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Instructions and assistance for volunteer carers
maximum 2 hours per year
for insured persons undergoing occupationaltherapy
D.17.2
5. Terms and Conditions of Insurance
This terms and conditions of insurance booklet is divided into 4 chapters:
o Chapter A contains the general terms and conditions that apply for the health insurance and additional
insurance package;
o Chapter B describes the healthcare that is insured under your health insurance;
o Chapter C shows the different conditions or additional general conditions that only apply to the additional insurance packages and the medical expenses insurances;
o Chapter D describes the healthcare that you are entitled to by virtue of your additional insurance
packages. In your Reimbursements Overview you can read whether you are insured for this and the
extent to which you are entitled to reimbursement.
Chapters A and B therefore apply to all health insurances. Chapters A, C and D apply to the additional insurance packages.
6. Internet
Our website contains more information such as:
o Healthcare search ('Zorgzoeker'): here you can find all kinds of information about healthcare providers, such as who can provide specific healthcare and which healthcare providers are contracted or recognised;
o "List of disorders for physiotherapy and/or exercise therapy": this document tells you whether you are
entitled to reimbursements (and the amount) from the health insurance for physiotherapy and/or exercise therapy. If you are not entitled to reimbursement by virtue of the health insurance, the treatments
immediately become eligible for reimbursement from your additional insurance package;
o various enclosures that are part of your insurance, such as an enclosure showing premiums and reimbursement rates;
you can use your password or DigiD to visit your personal page. Here you can view you policy document, bills you have submitted or reimbursements and pass on changes at any time of the day.
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TABLE OF CONTENTS
TOC
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per 1 January 2014
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Alphabetical list of reimbursements
Reimbursement
'Basis'
insurance
Additional
Article
page
Article
Insurance
Package
page
Acne treatment
D.10.3.
117
ADL (general daily vital functions) medical aids
D.4.11.
107
Adoption, maternity care
D.21.8.
131
Adoption, medical screening
D.2.4.
99
Alarm (personal)
D.4.16.
109
Alarm (epilepsy)
D.4.20.
109
70 D.4.19.
D.7.1.
109
Non-allergenic shoes
B.17.
Alternative care and psychosocial care
Alternative medicines
113
103
Contraceptives (contraception)
B.15.1.
65 D.3.5.
Audiological care
B.4.13.
52
Ventilation, mechanical
B.4.9.
50
Treatment for snoring
Pelvic physiotherapy
D.1.8.
B.8.2.
112
D.7.2.
96
57
Circumcision
D.1.5.
94
Monitor (home)
D.4.10.
107
Exercise programmes, general
D.22.1.
132
Exercise programmes for certain disorders
D.22.2.
132
Visiting costs
D.12.3.
119
Breast prosthesis, replacement
B.4.5.
Upper eyelid correction
46 D.1.9.
D.1.6.
97
95
Braces and bandages
D.4.18.
109
Spectacles and contact lenses
D.4.7.
106
B.2.
42 D.14.
D.2.3.
124
Healthcare abroad, non-urgent
B.2.
42
Healthcare abroad, urgent
B.2.
42 D.14.1.
D.10.4.
Healthcare abroad
Healthcare abroad, vaccinations and pills
Camouflage therapy
98
124
117
Circumcision
D.1.5.
94
Condoms
D.4.17.
109
Consultations for women
D.2.5.
99
Patients' association contribution
D.2.9.
101
Correction of the upper eyelids
D.1.6.
95
Ear protrusion correction (elephant ears)
D.1.3.
94
Cosmetic treatments
D.1.7.
96
Incubator care
D.21.5.
131
Courses
D.2.8.
100
Courses relating to the birth
D.19.2.
128
Diabetes, test strips
D.4.15.
108
Diabetes, foot care
B.23.
81
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Reimbursement
'Basis'
insurance
Additional
Article
page
Article
Dialysis, without hospitalisation
B.4.8.
50
Dietary advice
B.11.
59 D.18.
Dietary advice for some chronic indications
B.11.1.
59
Dietary advice in other cases
B.11.2.
60
Dietary preparations (liquid diet and gavage)
B.16.
69
Dyslexia care
B.20.
79
Ultrasonography
B.5.2.
54
Personal contribution, medicines
B.15.1.
65
Personal contribution, hospice
Personal contribution, medical aids
B.17.3.
Personal contribution, postnatal care
B.7.
Personal contribution, outpatient childbirth
B.6.
Epilepsy alarm
Hereditary disease investigation and advice
B.4.12.
B.9.
Occupational therapy, instructions for volunteer
carers
Extra postnatal care
128
102
D.13.7.
123
70 D.4.1.
56 D.21.2.
104
55 D.20.1.
D.4.20.
129
130
109
51
Extra postnatal care
Occupational therapy, general
D.3.2.
Insurance
Package
page
D.21.4.
130
58 D.17.1.
D.17.2.
127
127
D.21.4.
Pharmaceutical care (see medicines also)
B.15.
Physiotherapy and/or exercise therapy
B.8.
64 D.3.1.
57 D.16.
Mental healthcare (GGZ), 'Basis' GGZ
B.19.1.
74 D.6.
Mental healthcare (GGZ), specialist mental healthcare
Mental healthcare, open homes
B.19.2.
76
Hearing aid
B.17.
Medicines, general
B.15.(1.)
Medicines, contraceptive
130
102
127
1110
D.6.3.
111
70 D.4.5.
65 D.3.1.
105
B.15.1.
65 D.3.5.
D.3.3.
103
Medicines prepared by the pharmacy
B.15.4.
68
Medicines, personal contribution
B.15.1.
65 D.3.2.
Medicines, medication assessment
B.15.2.
67
Medicines for erectile dysfunction
Medicines, other
102
102
102
D.3.4.
103
Medicines, self-care medicines and
antacids
Geriatric rehabilitation
B.15.3.
B.4.6.2.
68
Visual aids
B.17.
70 D.4.7.
D.1.4.
106
Health courses
D.2.8.
100
Health courses for childbirth
D.19.2.
128
Visual acuity treatments (laser eye surgery)
Hairpieces
B.17.
Recuperation & Balance
Convalescent home
Hearing aid
48
70 D.4.4.
D.6.1.
D.13.6.
B.17.
70 D.4.5.
94
105
110
123
105
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per 1 January 2014
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Reimbursement
'Basis'
insurance
Additional
Article
page
Article
Insurance
Package
page
Hospice, personal contribution
D.13.7.
123
Skin therapies
D.10.
116
Domestic care/home nursing
D.23.
133
ADL medical aids
D.4.11.
107
Foot care medical aids
D.4.9.
107
70 D.4.
70 D.4.1.
104
D.6.3.
111
Camp, therapeutic
D.13.1.
120
Class nursing
D.13.3.
121
D.13.8.
123
GP care
B.3.
Medical aids, general
B.17.(1.)
Medical aids, personal contribution
B.17.3.
43
Open homes
Registration and intake, postnatal care
B.5.4.
54
IVF (In Vitro Fertilisation)/ICSI
B.4.14.
52
Multidisciplinary care
B.1.2.
41
Childcare
Postnatal care/Healthcare following childbirth
B.7.
56 D.21.(2.)
D.21.8.
123
B.7.
56 D.21.2.
D.21.4.
130
B.5.4.
54
Maternity care for adoption
Postnatal care, personal contribution
Postnatal care, extra
Postnatal care, registration and intake
104
131
130
Postnatal care following hospital admission
D.21.6.
131
Postnatal care allowance
D.21.3.
130
Spa treatment
D.9.
116
Lactation consultant care
D.21.1.
129
Light therapy, UV-B
D.10.1.
116
Light therapy for seasonal affective disorder
D.6.4.
111
In-patient accommodation allowance/compensation/additional
costs
Accommodation expenses
D.13.4.
122
D.13.2.
Speech therapy
B.10.
59
Mechanical ventilation
B.4.9.
50
Medication assessment for chronic use
B.15.2.
67
Medical specialist care, general
B.4.1.
44 D.1.
Medical specialist care with hospitalisation
B.4.2.
45
Medical specialist care without hospitalisation
B.4.3.
46
Medical screening for adoption
Oral care, all ages (general)
D.2.4.
B.12.
Oral care, all ages (dentures and implantology)
60 D.8.(1.)
D.8.3.
120
93
99
113
114
Oral care, all ages (crowns, bridges, inlays)
D.8.2.
114
Oral care, all ages (orthodontics)
D.8.5.
115
Oral care, all ages (other)
D.8.4.
114
Oral care, insured persons up to 18 years
B.13.
62
Oral care, insured persons from 18 years
B.14.
63
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Reimbursement
'Basis'
insurance
Additional
Article
page
Article
Obesity treatment
Exercise therapy, Cesar/Mensendieck
D.11.
B.8.
57 D.16.
D.13.8.
Examination, hereditariness
B.4.12.
51
Investigation of paediatric cancer
B.4.10.
51
Support for home situation
Insurance
Package
page
118
127
123
Investigation, preventive
D.2.2.
98
Reversing sterilisation
D.1.2.
93
Hair removal
D.10.2.
117
Laser eye treatment
D.1.4.
94
B.4.5.
46 D.1.6.
D.1.3.
95
Organ transplantation
B.4.7.
48
Orthodontics
B.12.3.
115
Orthopaedic shoes and modified shoes
B.17.
61 D.8.5.
70 D.4.2.
D.2.9.
101
Eyelid correction
Ear correction (elephant ears)
Patients' association, contribution
Chiropody treatment, for certain disorders
B.23.
Personal alarm
Plastic surgery
B.4.5.
81 D.15.3.
D.4.16.
94
105
126
109
46
Bedwetting alarm
D.4.6.
105
Therapeutic soles
D.4.9.
107
81 D.15.1./2.
55 D.20.1.
125
Podotherapy/podiatry (see foot care also)
B.23.
Outpatient childbirth/care during the birth
B.6.
Prevention
B.21.
129
80 D.2.
D.2.3.
97
Preventive vaccinations
D.2.1.
97
Preventive investigations
D.2.2.
98
Prevention for trips abroad
Prenatal screening
B.5.3.
Hairpiece (or other head cover)
B.17.
54 D.19.1.
70 D.4.4.
Psychological care (see mental healthcare)
98
128
105
D.6.
B.19.
74
110
Psychosocial care (see alternative care and
psychosocial care)
Redression helmet
D.7.1.
D.4.21.
110
Travelling expenses, parents
D.12.2.
119
109
112
Rehabilitation (care)
B.4.6.(1.)
47
Rehabilitation (care), geriatric
B.4.6.2.
48
Shoes, non-allergenic
B.17.
Shoes, modified and orthopaedic
B.17.
70 D.4.19.
70 D.4.2.
Second opinion
B.4.15.
53
Snoring, treatment for
Specialist care (see medical specialist care also)
Medical sports advice (sports doctor, physical for
participation in sport)
Sterilisation
B.4.
105
D.1.8.
96
44 D.1.
D.2.6.
93
99
D.1.1.
93
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Reimbursement
'Basis'
insurance
Additional
Article
page
Article
Insurance
Package
page
Sterilisation, reversal
D.1.2.
93
Support pessary
D.4.14.
108
Support soles
D.4.8.
106
Stammer therapy
B.10.
Dentist (see oral care)
B.12. through
B.14.
58 D.5.
D.8.
110
60
113
TENS for birth
D.20.2.
130
Test strips, diabetes patients
D.4.15.
108
Therapy camp
D.13.1.
120
Home monitor
D.4.10.
107
Home nursing/domestic care
D.23.
133
Home care products
D.4.12.
108
D.6.5.
111
UV-B light equipment
D.10.1.
116
Fall prevention
D.2.10.
101
D.13.
120
D.23.
133
97
Transplantation (organ)
B.4.7.
48
Coping with trauma
Thrombosis service
Bandage shoes
B.4.11.
B.17.
51
70
Stay
Obstetric care
B.5.1.
53
Nursing without hospitalisation
B.4.4.
46
Nursing/care (home)
Breast prosthesis replacement
B.4.5.
Transport (see patient transport)
B.18.
46 D.1.9.
72 D.12.(1.).
Insured healthcare
B.1.
41
118
Care products (home)
D.4.12.
108
Dietary advice
D.2.7.
100
Foot care, general
D.15.(1.)
125
B.23.
81 D.15.2./15.3.
D.4.9.
126
B.22.
80
Foot care, for certain disorders
Foot care, medical aids
Conditional care
Women, consultation
Fertility related care (IVF/ICSI)
B.4.14.
D.2.5.
99
D.6.4.
111
D.13.3.
121
52
Seasonal affective disorder, light treatment
'ZBC' (Independent Treatment Centre) (see medical specialist care)
Self-care medicines and antacids
107
B.4.
44
B.15.3.
67
Hospital nursing in a higher class
Hospital care (see medical specialist care)
B.4.
44
Patient transport
B.18.
72 D.12.(1.)
Patient transport by ambulance
B.18.1.
72
Patient transport by car, public transport or taxi
B.18.2.
Postnatal care
B.7.
73 D.12.1.
56 D.21.
118
118
129
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Reimbursement
'Basis'
insurance
Additional
Article
page
Article
Care during childbirth
B.6.
Prenatal care
B.5.
Insurance
Package
page
55 D.20.
53 D.19.
129
128
Exceptional Medical Expenses Act (AWBZ)
Exceptional Medical Expenses Act
Do you need home care, nursing care and nursing home care, disability care or long-term non-medical psychiatric care? This is care that is paid for by the AWBZ. These types of care are arranged by care administration offices that are part of the various health insurers. You are automatically registered as AWBZ insured if
you have health insurance.
Do you require care under the AWBZ?
You have to have a referral if you require care from the AWBZ. You can request this referral from:
• 'Centrum Indicatiestelling Zorg' (CIZ); you can find more information about this on the www.ciz.nl website
(information in Dutch) or
• 'Bureau Jeugdzorg' for children up to 18 years with a psychiatric disorder; see the
www.bureaujeugdzorg.info website for information (in Dutch).
AWBZ Premium and Personal Contribution
The AWBZ is a national insurance scheme for everyone in the Netherlands. Everyone who has income in the
Netherlands pays the premium automatically. If you make use of AWBZ care you also pay a personal contribution that depends on your income. You can find more information about this at www.hetcak.nl (information
in Dutch)
More Information about AWBZ
You can find all kinds of information about the range of care, advice for finding care that suits you, care in
kind,
personal
budget
(PGB),
care
administration
offices,
brochures
etc.
at
the
www.zn.nl/branche/zorgkantoren/ website (information in Dutch).
Which health insurances and additional insurance packages?
We can provide one or more of the following health insurances:
• a 'Zorgverzekering Restitutie';
• a 'Zorgverzekering Natura';
• a 'Zorgverzekering Natura Direct';
• a 'Zorgverzekering Natura Select'; or
• another health insurance, which is based on one of the health insurances mentioned above.
In addition to this, you can choose from the various additional insurance packages that we provide.
Your health insurance is health insurance within the meaning of the Health Insurance Act.
If you have a 'Natura', a 'Zorgverzekering Natura Direct' or a 'Zorgverzekering Natura Select'
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health insurance then you are entitled to care ("in kind"). If you have a 'Zorgverzekering
Restitutie' you are entitled to reimbursement (refund) of the costs of healthcare.
Check you policy document to see which health insurance you have and whether you have an additional
insurance package also.
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AND CONDITIONS
A.1. Explanation of terms
In this Article we explain the meaning of the terms
that you will come across in the terms and conditions of insurance.
Additional insurance package
An insurance contract, the subject of which is the
reimbursement of healthcare and which is geared
to and forms an addition to a health insurance.
You can take out one additional insurance package or a combination of a number of additional
insurance packages with us. Where "additional
insurance package" is mentioned from now on this
could also be a combination of additional insurance packages.
Statement of approval
The written statement that we give you in response to your request for a care recommendation. This statement shows:
• that we consider this healthcare to be healthcare that is covered by your (additional)
(healthcare) insurance;
• that in your situation you are reasonably entitled to that healthcare; and
• that you are entitled to that healthcare in accordance with the terms and conditions of insurance.
This statement is issued by our Medical Assessments department.
CHAPTER A
GENERAL HEALTH
INSURANCE AND ADDITIONAL INSURANCE
PACKAGE TERMS
Dispensing
A general practitioner or pharmacy that has a
permit to supply medicines in accordance with the
Medicines Act.
General insurance
An insurance contract, the subject of which is the
reimbursement of healthcare and which you can
enter into, and which provides independent cover
without being an addition to another insurance. A
general insurance is the same as a health insurance. These terms may be used interchangeably.
Company Medical Officer
A doctor who is registered as a Company Medical
Officer in the register of the 'Koninklijke Nederlandsche Maatschappij tot Bevordering der Geneeskunst'. This register has been set up by the
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CHAPTER A
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'Sociaal-Geneeskundigen Registratie Commissie'
(SGRC).
Treatment
The (physical) contact with one or more healthcare providers where you are provided with
healthcare or receive advice. Treatment is not
understood to mean courses. We use the date of
treatment, not the invoice date, for reimbursement.
Pelvic physiotherapist
A physiotherapist who is registered as a pelvic
physiotherapist in the 'Centraal Kwaliteitsregister
Fysiotherapie'.
Foreign country
All countries apart from the Netherlands. What if
you don't live in the Netherlands? Then we understand "foreign country" to mean all countries other
than your country of residence.
'Bureau Jeugdzorg'
A bureau as described in Article 4 of the Youth
Care Act. This is an independent bureau in your
Province which provides access to all youth care
facilities. As an independent body, this bureau
assesses your request for assistance and refers
you on.
Centre for specialist dentistry
A centre that provides dentistry in special cases in
accordance with the "the centre referral" (de centrumindicatie) document, with associated specifications. The treatments are provided by teams
and/or require special expertise. A centre or establishment for oral care is not a centre for specialist dentistry.
Consultation A consultation with a healthcare
provider. This could involve a referral, a discussion, physical examination, patient's medical history, the formulation of a diagnosis or an additional examination/diagnosis if this is a medical
necessity.
Outpatient treatment
A form of nursing that takes a number of hours in
an establishment for specialist medical care in a
department set up for outpatient treatment, or an
establishment for rehabilitation designed for medical examination and/or medical treatment which
does not involve hospitalisation. It must involve
care that is generally foreseeable.
DBC: Diagnosis Treatment Combination
A DBC describes the entire course of medical
specialist healthcare or specialist psychiatric
healthcare. The healthcare request, the healthcare type, the diagnosis and the treatment are
described in the DBC. A DBC performance code
is assigned to the DBC. This code is determined
by the 'Nederlandse Zorgautoriteit' (NZa). The
DBC course commences as soon as you report
with a healthcare request (so-called opening of
the DBC) and concludes at the end of the treatment. If your treatment lasts longer than 365 days,
the DBC course is closed, claimed and a new
DBC course is opened. The rate is an average
price for that form of providing healthcare. One
instance of healthcare provision may last longer
than another instance. See the term "DBC on the
way to transparency (DOT)" also.
Healthcare providers for medical specialist care or
specialist psychiatric care must claim the DBC
course using DOT healthcare product codes (see
"DOT" below). Certain expensive care (such as
intensive care healthcare, expensive medicines
and blood products) are not claimed using a DOT
healthcare product code but are claimed separately as an OZP (Other Healthcare Product).
Dietician
Someone who has the "quality registered" status
as a dietician in the 'Kwaliteitsregister Paramedici'.
DOT: DBC on the way to Transparency
DOT is an improved claim system for medical
specialist healthcare that came into effect on 1
January 2012. This system should lead to simplification of the DBC system, the starting points being more transparency and greater medical identifiability. The diagnosis-treatment combinations
that are used in the DOT system are called DOT
healthcare products.
Sonographer
Someone who has completed (para) medical
training to a minimum of HBO (higher professional
eduction) level and is registered in the 'KNOV'
register
for
ultrasonography
or
in
the
'Beroepsvereniging Echoscopisten Nederland'
(BEN) register.
Primary care (primary healthcare)
Initial point of contact for people requiring healthcare.
Primary care psychologist
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CHAPTER A
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A healthcare psychologist who works in a practice, dealing with the primary care of mental
healthcare.
Personal contribution
Healthcare costs that are covered by the health
insurance, but for which have to make a contribution. Personal contributions are legally determined. The personal contribution could be a fixed
amount per treatment or a specific percentage of
the costs for the healthcare. A personal contribution is not the same as a deductible. Deductibles
and personal contributions can both apply simultaneously to the insured healthcare.
Deductible
Costs for healthcare that is covered by the health
insurance, but which you must pay yourself. Deductible is legally determined. A deductible is not
the same as a personal contribution. Deductibles
and personal contributions can both apply simultaneously to the insured healthcare. See Articles
A.12. and A.13. for deductible.
Occupational therapist
An occupational therapist has the quality registered status in the 'Kwaliteitsregister Paramedici'.
Physiotherapist
Someone who is registered as a general physiotherapist in the 'Centraal Kwaliteitsregister Fysiotherapie'.
EU state and EEA state
The EU states (European Union) are:
Belgium, Bulgaria, Cyprus (Greek area),
Denmark, Germany, Estonia, Finland, France
(including Guadeloupe, French Guyana, Martinique, St. Barthélemy, St. Martin and La Réunion),
Greece, Hungary, Ireland, Italy, Croatia, Latvia,
Lithuania, Luxembourg, Malta, the Netherlands,
Austria, Poland, Portugal (including Madeira and
the Azores), Romania, Slovenia, Slovakia, Spain
(including Ceuta, Melilla and the Canary Islands),
Czech Republic, United Kingdom (including Gibraltar) and Sweden. Switzerland is equivalent to
this, based on the provisions of treaties. The following are not part of the EU: Andorra, Monaco,
the Channel Islands, Isle of Man, San Marino and
the Vatican City.
The EEA states (European Economic Area) are:
the aforementioned EU states, Lichtenstein, Norway and Iceland.
Birthing centre
An establishment (also known as a birthing hotel
or delivery centre) for obstetric care. Insured persons can give birth here and if necessary remain
here during the postpartum period.
Geriatrics physiotherapist
A physiotherapist who is registered as a geriatrics
Fysiotherapie'.
Specialist mental healthcare
Diagnosis and specialist treatment of complicated
psychological disorders. A specialist (psychiatrist,
clinical psychologist or psychotherapist) is involved in the treatment.
Skin therapist
A skin therapist has the quality registered status in
the 'Kwaliteitsregister Paramedici'.
General Practitioner
A doctor who is registered as a general practitioner
in
the
'Koninklijke
Nederlandsche
Maatschappij tot Bevordering der Geneeskunst'
register of qualified general practitioners. This
register has been compiled by the general practitioner, Specialist geriatric medicine and doctor for
the mentally handicapped 'Registratie Commissie'
(HVRC).
General Practitioner service structure
An organisational partnership of general practitioners. The partnership has a legal personality as
meant in article 29c of the Decree on Extension
and Limitation Scope Healthcare Market Regulation Act. The partnership has been set up to provide urgent general practitioner medical care during the evening, at night, during the weekend and
on public holidays in a specific location known as
the 'huisartsenpost' (After Hours GP Clinic) and
has a legally valid rate.
Establishment for medical specialist care
An establishment for medical specialist care as
meant in the Care Institutions Act (WTZi). This is
a hospital or an independent treatment centre
(ZBC) for example.
• If we only mean a hospital, we write it thus:
hospital (establishment for medical specialist
healthcare). We then mean a general hospital,
categorial hospital (this is a hospital that provides only one, or a couple of, medical specialism such as a burns centre or psychiatric
hospital) or a university hospital.
• If we mean a ZBC only, we write it thus: ZBC
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(establishment for medical specialist healthcare).
• In cases where we mean both, you will see
'establishment for medical specialist healthcare' only.
Year
Calendar year. Except in the case of someone's
age, in which case it does not mean "calendar
year" but year of life.
Youth healthcare physician
A doctor who is registered as a Community and
Health doctor in the registers of the 'Registratiecommissie Geneeskundig Specialisten' (RGS)
and is employed in youth healthcare or a doctor
who is registered with the profile Youth Healthcare
('KNMG' youth healthcare physician) in the registers of the 'Registratiecommissie Geneeskundig
Specialisten' (RGS).
Clinical psychologist
A mental healthcare psychologist who is registered as a clinical psychologist in accordance with
the terms and conditions of Article 14 of the Individual Healthcare Professions Act.
Maternity hotel
An establishment where one can stay during the
maternity period and where one can receive maternity care.
Maternity care
Care during the maternity period and, if necessary, during the birth (partus assistance) which is
supplied by a maternity nurse with the (maternity)
nurse level 3 qualification or equivalent.
Laboratory investigation
Investigation by a legally authorised laboratory
that has a rate arrangement, where the investigation can be claimed up to a maximum price.
Speech therapist
A speech therapist has the quality registered status in the 'Kwaliteitsregister Paramedici'.
Month
Calendar month.
Manual therapist
A physiotherapist who is registered as a manual
therapist in the 'Centraal Kwaliteitsregister Fysiotherapie'.
(Medical) advisor
A doctor, pharmacist, dentist, physiotherapist or
other expert who provides us with advice on
medical, pharmacotherapeutic, dentistry, physiotherapist care or healthcare that relates to his/her
own substantive care area.
Medical specialist
A doctor who is registered as a medical specialist
in the Specialists Register of the 'Koninklijke
Nederlandsche Maatschappij tot Bevordering der
Geneeskunst'. This register has been compiled by
the 'Medisch Specialisten Registratie Commissie'
(MSRC). We also understand medical specialist to
mean the obstetrician who carries out procedures
in the hospital on behalf of the gynaecologist.
Oral hygienist
A self-employed oral hygienist who runs a practice
at their own expense and under their own responsibility.
Oedema physiotherapist
A physiotherapist who is registered as an oedema
Fysiotherapie'.
Cesar/Mensendieck exercise therapist
An exercise therapist who has the quality registered status in the 'Kwaliteitsregister Paramedici'.
Accident
A sudden, involuntary event that is harmful to
health.
Hospitalisation
A period of nursing in an establishment for medical specialist healthcare in a department set up for
nursing, not being an outpatient department, day
case unit or emergency department or in an establishment for rehabilitation intended for medical
examination and/or medical treatment. This stay
starts before 00:00 hours and lasts until at least
07:00 hours on the following day.
Orthodontist
A dentist-specialist, who is registered in the specialist register for Dentomaxillary Orthopaedics of
the 'Nederlandse Maatschappij tot bevordering
der Tandheelkunde'.
Chiropodist
• A person who is registered as a chiropodist
with an annotation 'voetverzorging bij diabetici
(DV)' (foot care for diabetics (DV)) in the
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'Kwaliteitsregister Pedicure' or in the 'Register
Paramedische Voetzorg' is allowed to treat an
insured person with diabetes mellitus.
• A person who registered as a chiropodist with
an annotation 'voetverzorging bij reumapatiënten (RV)' (foot care for rheumatism patients (RV)) in the 'Kwaliteitsregister Pedicure'
or in the 'Register Paramedische Voetzorg' is
allowed to treat an insured person with rheumatoid arthritis.
• A person who is registered as a medical chiropodist in the 'Kwaliteitsregister Pedicure' or
in the 'Register Paramedische Voetzorg'. The
medical chiropodist is a specialised chiropodist
for various, complex foot problems. This chiropodist is allowed to treat an insured person
with diabetes mellitus or rheumatoid arthritis.
• A chiropodist who is registered as a paramedical chiropodist in the 'Register Paramedische
Voetzorg '. The paramedical chiropodist is a
specialist chiropodist for various complex foot
problems. This chiropodist is allowed to treat
an insured person with diabetes mellitus or
rheumatoid arthritis.
The Articles which describe healthcare also state
which of the aforementioned chiropodists is allowed to provide this healthcare.
Policy document
The proof of insurance.
Podotherapist
A podotherapist is a member of the 'Nederlandse
vereniging van Podotherapeuten' (N.V.v.P.).
Prevention
The entirety of activities, individual or as a group,
that are aimed at improving or maintaining your
health (physical or mental).
Psychiatrist
A doctor who is registered as a psychiatrist in the
Specialists Register of the 'Koninklijke Nederlandsche Maatschappij tot Bevordering der Geneeskunst' and who is engaged in the diagnosis
and treatment of disorders in the cognitive functions, the emotional functions, psychomotility,
motivation and behaviour.
Psychotherapist
A healthcare provider who has completed psychotherapist training and is registered as a psychotherapist in accordance with the terms and conditions of Article 14 of the Individual Healthcare
Professions Act.
Rehabilitation
Examination, advice and treatment of a medical
specialist, paramedical, behavioural science and
rehabilitation technology nature. A team of various
types of experts provides the healthcare, under
the leadership of a medical specialist (rehabilitation doctor). The team is affiliated with a rehabilitation establishment.
Written
By means of a physical or digital information carrier where the information itself is intelligible, storable and reproducible. Digital information carrier is
also understood to meant the Internet and e-mail
messages.
Specialist in geriatric medicine
A person who is registered as a specialist in geriatric medicine in the 'Koninklijke Nederlandsche
Maatschappij tot Bevordering der Geneeskunst'
register of qualified geriatric medicine practitioners. This is the new name for the "nursing home
doctor".
Urgent medical care
medically necessary healthcare that cannot reasonably be delayed.
Clinical dental technician
A clinical dental technician who has a diploma in
accordance with the Decree "on training and expertise area clinical dental technician".
Home
The place where you live or have your permanent
residence.
Stay
An hospitalisation that lasts 24 hours or longer.
Treaty country
A treaty country is:
• the following states with which the Netherlands
has concluded a treaty on social security which
includes an arrangement for the provision of
medical healthcare: Australia (for a stay of less
than one year), Bosnia Herzogovina, Cape
Verdi Islands, Macedonia, Morocco, Montenegro, Serbia, Tunisia and Turkey;
• members of the European Union other than the
Netherlands;
• a state that is party to the European Economic
Area Treaty;
• Switzerland.
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Obstetrician
An obstetrician who is included in the quality register of the 'KNOV'.
Insured person
The person for whom healthcare and/or costs for
healthcare are insured. The insured person is
entitled to insured healthcare and/or reimbursement of the insured costs. In the terms and conditions of insurance we refer to the insured person
and the policyholder as "you" and "your". If we
want to refer to the insured person only and not
the policyholder, we speak of "you (the insured
person)" and "your (the insured person's)".
Healthcare group
Organisational partnership of healthcare providers, registered as a legal person. See Article A.17.
also.
Health insurer
An insurance entrepreneur who is authorised as
such and who provides health insurance. The
insurance company to which these terms and
conditions of insurance apply is the insurance
company that is shown in that capacity in the insurance policy. In these terms and conditions of
insurance that insurance company is referred to
as "we" and "us".
Insurance Package
An insurance contract which can comprise one or
more of the following insurances:
• healthcare insurance;
• medical expenses insurance;
• additional insurance package.
If the insurance is a combination of 2 or more of
the aforementioned insurance contracts, then that
combination contains only a single health insurance or medical expenses insurance.
Health insurance
A health insurance within the meaning of the
Health Insurance Act the subject of which is
healthcare or the reimbursement of healthcare. A
health insurance is the same as a general insurance. These terms may be used interchangeably.
Policyholder
The person who concluded the insurance contract
with us. The policy is in his or her name. The
policyholder can be the insured person also. In
the terms and conditions of insurance we refer to
the insured person and the policyholder as "you"
and "your". If we want to refer to the policyholder
only and not the insured person, we speak of "you
(the policyholder)" and "your (the policyholder's)".
A.2.1. General
Independent treatment centre (ZBC)
See under "establishment for medical specialist
healthcare".
Hospital
See under "establishment for medical specialist
healthcare".
Medical expenses insurance
An insurance contract that you can enter into and
which provides independent cover without this
being an addition to another insurance. It is an
insurance that is not general insurance or health
insurance within the meaning of the Health Insurance Act and can only be taken out and be in
force if an insurance obligation does not exist in
accordance with the Health Insurance Act. It is
expressly not an additional insurance package.
A.2. The fundamentals of your
insurance
You have taken out insurance with us. We record
the agreement in the policy document. We send
this to you annually.
A.2.2. Insurance obligation
You can take out health insurance with us if you
have an insurance obligation in accordance with
the Health Insurance Act.
A.2.3. The basis of your insurance
Your insurance is based on:
• these terms and conditions of insurance;
• the application form and the details you entered on it or that a third-party entered on your
behalf;
• the information and the statements that we
obtained when you took out the insurance.
These details were supplied by you or by a
third-party;
• the policy document and policy enclosures;
• any additional or group agreements.
A.2.4. The basis of your health insurance
In addition to Article A.2.3. the health insurance is
also based on:
• the Health Insurance Act;
• the Health Insurance Decree;
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• the Regulation on Healthcare Insurance;
• the explanations of this legislation and regulations;
• interpretations by the 'College voor Zorgverzekeringen' (so-called "opinions").
If there is a difference between these terms and
conditions of insurance and one or more rules
based on the aforementioned law, explanations or
opinions, the law, explanations or opinions take
precedence.
A.2.5. The nature of your health insurance
Your "in kind" health insurance or "refund" health
insurance are health insurances within the meaning of the Health Insurance Act. With 'Zorgverzekering Natura', 'Zorgverzekering Natura Direct'
and 'Zorgverzekering Natura Select' you are entitled to healthcare ("in kind") from healthcare providers with whom we have entered into a healthcare agreement/Internet agreement. Under these
insurances you are entitled to reimbursement of
the costs of your healthcare from healthcare providers with whom we have not entered into a
healthcare agreement/Internet agreement. See
Article A.17. also.
With 'Zorgverzekering Restitutie' you are entitled
to reimbursement (refund) of the costs of healthcare. You can see which health insurance you
have on your policy document.
A.2.6. Information from third-parties
We assume that you are familiar with the information that third-parties provide to us in relation to
your application for insurance. We consider this
information to have been supplied by you.
A.2.7. Contact person
We consider only you (the policyholder) to be our
contact person for insurance. Only the policyholder is allowed to cancel or change it.
A.2.8. Checking the policy document
We assume the details on your application are
yours. You must check the details in the policy
document carefully. If the details in the policy
document are incorrect or incomplete, you must
inform us of this within 30 days of receiving the
policy document. If you do not contact us within
this period we will assume that these details are
correct and complete.
A.2.9. Your pass
Once you have enrolled with us, we will send you
an insurance pass in addition to the policy docu-
ment for your insurance. On production of this
pass you can obtain healthcare from those
healthcare providers with whom we have entered
into an agreement and/or whose care you are
entitled to in accordance with your terms and conditions of insurance.
A.2.10. Valid terms and conditions of insurance
Your policy document shows which terms and
conditions of insurance are applicable. If you believe that a different version of the terms and conditions of insurance, the Reimbursements Overview and/or any addition is applicable or that another text is in force, only the text and content of
the versions that are in force at that time and that
are in our possession are valid at that time.
A.2.11. Other language
In addition to Dutch, we can also publish the
terms and conditions of insurance in one or more
other languages. If there are differences in the
content or explanation between the Dutch version
and the version in another language, then only the
text and content of the Dutch language version
that is in our possession are applicable.
A.2.12. What do we send to you?
When you take out insurance with us for the first
time, or if the terms and conditions of insurance,
premium (fundamentals) and/or entitlement to
healthcare or reimbursement change, we will send
you:
• a new policy document. When doing so we
also state the date from which this new policy
document applies. Your old policy document
ceases to be valid from that date.
• if you ask us to do so, we will also send you
new terms and conditions of insurance and a
new Reimbursements Overview. We will state
the date from which the new terms and conditions of insurance and the new Reimbursements Overview are applicable. This is almost
invariably the time at which the new insurance
starts. Your old terms and conditions of insurance and the old Reimbursements Overview
cease to be valid from that date.
• if you ask us, an addition to your existing terms
and conditions of insurance and the existing
Reimbursements Overview. We will state the
date from which the addition applies. This is
almost invariably the time at which the new insurance starts. From that date, that addition
applies alongside your existing terms and conditions of insurance and the existing Reim-
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bursements Overview.
You can find terms and conditions of insurance
and a Reimbursements Overview on our website.
A.3. Content and scope of your
insurance
A.3.1. Healthcare mediation
You are entitled to care recommendation and
healthcare mediation. For example, if it is expected that the necessary healthcare cannot be
provided or cannot be provided on time also. Not
being able to provide the healthcare or not being
able to provide it on time is also understood to
mean that the healthcare can only be provided at
a long distance from your place of residence or
cannot be provided in a qualitatively responsible
manner in the vicinity of the insured person's
place of residence.
information that is available.
The healthcare must also be effective. In other
words, it must be the proper healthcare for your
situation. For example, there must be medical
grounds for the healthcare and it must not be unnecessarily expensive. Healthcare that is too expensive in your situation is therefore not proper
healthcare. This healthcare is therefore not covered by your insurance. Not even if you pay for
part of it yourself.
A.3.3. Conditional care
nd
rd
Contrary to Article A.3.2. 2 and 3 bullet points,
the cover also includes the healthcare and the
services that are provided for a specific period
under the Regulation on Healthcare Insurance.
The conditions stipulated there (see Article B.23.)
apply for that healthcare.
A.3.4. Coverage area
A.3.2. Content and scope of healthcare
You insurance(s) include(s) worldwide coverage.
The content of your health insurance is determined by the government. We determine the content of the medical expenses insurance and the
additional insurance packages.
These terms and conditions of insurance show the
cover that you are entitled to. This cover comprises healthcare that must meet the following
requirements:
• the content and scope of the healthcare is
determined by the state of science and practice or by what applies as responsible and
proper healthcare and services in the field of
expertise concerned; and
• it is healthcare such as is customarily provided
by healthcare providers of the professional
group concerned in accordance with their
standards and norms and considered to be acceptable healthcare; and
• the healthcare is named as insured healthcare
in the Reimbursements Overview for your insurance and elaborated and described in chapters B or D of these terms and conditions of insurance; and
• you are - taking account of your indication reasonably entitled to that healthcare in regard
to content and scope. The healthcare to be
provided must be effective.
For example:
You are on holiday in France and while there you
buy prescription spectacles. You have an additional insurance package that includes a reimbursement of € 100.00 per 2 years for visual aids.
This reimbursement also applies for spectacles
that you buy abroad.
The terms and conditions associated with the
Article concerned also apply to foreign countries
and the healthcare provider must meet the requirements, laws and rules that are stipulated for
that country.
Explanation:
There must be sufficient (good) evidence clearly
indicating that the healthcare is safe and proper
(in the long term). Here we consider all scientific
A.4. Start and duration of your
insurance
A.4.1. Start date
The insurance starts on the date on which we
received your application take out insurance with
us. When applying you should state your address
as known in the municipal personal records database. If you are still insured by another health
insurer at this time and you state in your application that you want the insurance to start at a later
date, the insurance will start on that later date.
Your policy document shows the start date for
your insurance.
A.4.2. Request for change
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We also consider your application to take out insurance with us to be a request to cancel any
similar insurance you currently have with us.
If you apply to take out health insurance with a
different health insurer, then from the time that we
receive a copy of that application we consider that
same application as your request to cancel the
health insurance that you currently have with us.
A.4.3. Insured with retrospective effect
There are situations in which we will enrol you
with retrospective effect:
• if your health insurance starts within 4 months
after the insurance obligation arose. In that
case, the day on which the insurance obligation arose applies as the start date.
• if you take out the insurance with us within one
month after cancelling your insurance with another health insurer because they changed the
terms and conditions of insurance, or because
it was the end of the year. Your (additional)
(healthcare) insurance (package) starts with us
on the 1st day after your old insurance was
cancelled.
A.4.4. Duration of insurance
Your insurance is for one complete year. We extend the insurance from year to year. We will inform you of this every year, together with the
changes, before the extension starts. This gives
you the opportunity to change or cancel your insurance.
A.5. When can you cancel or
make changes?
A.5.1. Revoking your new insurance
You (the policyholder) can cancel your newly
taken out insurance without cost and without reason by revoking it. The following conditions apply
for doing this:
• You must submit the revocation in writing.
When doing so clearly state your name, address, place of residence and which insurance
you want to revoke.
• We must receive the revocation within 14 days
of the start of your new insurance. If the insurance has not yet started we must receive the
revocation within 14 days of you having received the policy document.
If you do not comply with these terms and conditions your new insurance will not be cancelled by
revocation.
We cancel your newly taken out insurance with
retrospective effect up to and including the day on
which the insurance started. If you have already
paid us the premium for this insurance, we will
repay it within thirty days of receiving the revocation.
If you have incurred costs between the insurance
start date and the revocation date and had them
reimbursed, you have to repay us within thirty
days after you receive a specification from us.
A.5.2. At the start of a new year
You (the policyholder) can cancel or change your
insurance every year. In that case, we must receive your cancellation or change in writing no
later than 31 December. If we receive it later, then
your current insurance remains valid for one year
and then ends on 1 January. This Article does not
apply to health insurance that the 'College voor
Zorgverzekeringen' has taken out for you; see
Article A.5.7.
In the event of change, you take out another, replacement insurance with us - after we have
agreed the change. Your current insurance then
ends on the following 1 January.
A.5.3. On change of the terms and conditions of insurance
We reserve the right to change the terms and
conditions of insurance. If the change is to your
disadvantage, then you (the policyholder) have
the right to cancel or change the insurance. You
must cancel in writing. In any event, you have a
period of 30 days to do this after we have informed you of the change. Your insurance ends
on the day that the change take effect.
Your right to cancel or change the insurance does
not apply if the change to the terms and conditions of insurance are the result of a change in the
law.
A.5.4. On change of the base premium
If we change the base premium, we will notify you
at least 6 weeks in advance. If we increase the
base premium you (the policyholder) have the
right to cancel or change your insurance from the
day on which notify you of this until the day on
which the increase comes into effect. You must
cancel in writing. Your insurance ends on the day
that the increase of the premium takes effect.
A.5.5. On change of employer
What if you (the policyholder) are group insured
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through an employer and you then enter the employment of another employer who has taken out
another group insurance? You (the policyholder)
can then cancel the group insurance through your
old employer in the course of the year. You (the
policyholder) can cancel the old group insurance
in writing from the day that your old period of employment ends up to thirty days after your new
period of employment starts. Your new group
insurance starts on the day you commenced employment with the new employer if this is the 1st
day of the calendar month, otherwise it starts on
the 1st day of the month after your employment
commenced. Your old group insurance ends on
that same day, as does the premium discount and
other group agreements that are associated with
the old group insurance.
A.5.6. At the end of the insurance for
someone else
If you (the policyholder) have insured someone
else, then you can also cancel the insurance for
that insured person during the course of the year
or take out another insurance with us, if this person is insured through another insurance:
• If you (the policyholder) cancel the insurance in
writing before the new insurance starts, the insurance ends on the day on which the new insurance starts.
• If you (the policyholder) cancel the insurance in
writing after the new insurance has started,
then the insurance ends at the end of a full
month.
A.5.7. At the end of the health insurance
taken out by the 'College voor Zorgverzekeringen'
If you are obliged to take out insurance under the
terms of the Health Insurance Act, there is a
possibility that you were, nonetheless, not insured
and that the 'College voor Zorgverzekeringen'
took out insurance for you with us.
• You can cancel this health insurance with
retrospective effect during a period of 2 weeks
from the time that the 'College' notified you of
this, if you demonstrate to that 'College' and to
us that you have already taken out a different
health insurance within 3 months after the 'College' notified you that you were wrongfully not
insured.
• You cannot cancel this health insurance during
the first twelve months that it is in effect.
A.5.8. When can you not cancel and make
changes?
The opportunities to cancel and make changes
that we previously described in Articles A.5.2.,
A.5.5., and A.5.6. do not apply in the following
situations:
• You (the policyholder) have not paid the premium that you should pay us on time: and
• We sent you a reminder about this to pay the
premium to us within a maximum of 14 days:
and
• We have not (yet) suspended the insurance
cover; and
• We have not indicated that we agree the cancellation within 14 days.
From the time that you (the policyholder) have
nonetheless paid the premium and any collection
fees to us, you (the policyholder) can still use
these cancellation and change options.
A.6. When do we cancel the insurance
A.6.1. Statutory cancellation of your insurance
We are legally obliged to cancel your insurance in
certain situations. If this is the case, we will inform
you (the policyholder) of this as quickly as possible. The cancellation date is the day after:
• our permit to operate the insurance company
changes or is withdrawn and as a result we are
no longer allowed to offer or operate insurances. We will inform you of this no later than 2
months in advance;
• you (the insured person) die. We must have
been notified of this within thirty days of the
date of death.
A.6.2. Statutory cancellation of your health
insurance
In additional to the stipulation in Article A.6.1. we
are also legally obliged to cancel your health insurance in certain other situations. If this is the
case, we will inform you (the policyholder) of this.
The cancellation date is the day after:
• we have changed the area in which we provide
health insurance (the working area) and you
(the insured) come to live outside of our working area as a result of this change. We will inform you of this no later than 2 months in advance;
• your (the insured person's) insurance obligation ends because you are no longer insured
on the basis of the AWBZ or you have entered
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into military service. You (the policyholder)
must inform us of this.
count.
We do not consider collection fees that we incur if
you pay late or do not pay to be costs.
A.6.3. Wrongfully enrolled
If it turns out that you (the policyholder) have
taken out insurance with us while you do not have
an insurance obligation, then we will cancel this
health insurance with retrospective effect from the
time that you took it out. We will offset the premium that you have paid against the healthcare
that we have reimbursed and will repay the difference to you, or invoice you the difference.
A.6.4. Fraud
If you are guilty of (attempting to) commit a criminal act against us, commit an offence against us,
swindle us, mislead us, defraud us, coerce us or
threaten us, we have the right:
• to cancel your insurance immediately;
• to reclaim any reimbursements;
• to claim the costs of the investigation from you;
• to report the matter to the police;
• to register you in the common warning system
between financial institutions.
A.6.5. Error
We will claim an error, if you are insured with us
through the 'College voor Zorgverzekeringen'
because this 'College' was of the opinion that you
had an insurance obligation based on the Health
Insurance Act, but it turns out that you did not
have an insurance obligation at that time. We will
then cancel your health insurance with retrospective effect.
A.7. Amount of premium and
costs
A.7.1. Costs
You (the policyholder) must pay us the following
costs for the insurance:
• the premium;
• the amounts due to/remaining for your account
based on legislation (such as deductible, personal contributions, exceeding the fixed maximum reimbursements);
• amounts for insured healthcare that we have
advanced to your healthcare provider on your
behalf by means of direct payment.
• any surcharges and other costs. This includes
an amount that we will additionally bill you (the
policyholder) if the costs that you should pay
us are not paid by direct debit from you ac-
A.7.2. Setting the costs
We set the amount of the costs in Dutch legal
tender (euros) as well as the circumstances under
which and when you (the policyholder) have to
pay them. Your current age and the type of insurance that you (the policyholder) have taken out
are important here.
For example:
For health insurance see Article A.7.4. and for the
additional insurance packages see Article C.11.5.
A.7.3. Premium amount
The premium that is stated in Article A.7.1. under
st
the 1 bullet point and that you (the policyholder)
must pay to us, is the same as the base premium
(the gross premium) minus the following discounts
if they are applicable:
• discount if you have opted for voluntary deductible;
• group discount;
• discount if you pay your premium in advance
for a period longer than one month (payment
period discount).
A.7.4. Up to 18 years
For an insured person with health insurance, the
premium is € 0.00 up to the 1st day of the month
that they reach the age of 18 years.
A.7.5. While in custody or during imprisonment
If you are in custody or are imprisoned, you do not
owe us any costs for your insurance.
A.7.6. If your insurance changes
If your insurance changes during the course of the
month, we recalculate the amount of the costs.
These new amounts then apply on the day on
which the changes come into effect. If an insured
person dies, we repay the amounts pro rata from
the date of death or we will offset them pro rata.
A.7.7. Application for new insured person
If you (the policyholder) apply for insurance for a
new insured person during the course of a payment period, you only pay the remaining part of
this payment period for that insured person.
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A.7.8. If you are wrongfully not insured
You are not (yet) insured but should be insured
under the terms of the Health Insurance Act. We
must have received all documents within 4
months after you are obliged to take out insurance
or within one month after your previous health
insurance was cancelled. If the documents are
received too late, the health insurance starts at
the time that we received your application to take
out health insurance and any details and/or
documents.
For the period that you are not insured, we can
fine you on behalf of the 'College voor Zorgverzekeringen'. The amount of this fine is 130% of
the premium owed for the period that you were
wrongfully not insured, with a maximum of 5
years.
A.8. Payment of premium and
costs
A.8.1. Who pays the premium?
You (the policyholder) are responsible for the full
and timely payment of all costs owed.
A.8.2. Payment in advance
You (the policyholder) must pay the costs owed in
advance. We have agreed the period for which
you pay these costs in advance with you (the
policyholder). We call that period the 'payment
period'. The payment period can be one month,
one quarter, one six-month period, or one year.
We must have received the total amount that you
owe us before the 1st day of the payment period.
A.8.3. Payment method
You (the policyholder) have agreed with us the
way in which you will pay all costs owed. This
could be by direct debit, a Giro payment form
(paper or e-mail), bank portal or a premium invoice. If you have agreed to communicate digitally, then only direct debit, Giro payment form by
e-mail or, in certain circumstances payment via
bank portal are possible. In the case of 'Natura
direct' health insurance only direct debit payment
is possible.
If we collect the costs owed from your bank account by direct debit you remain responsible for
the timely and full payment.
You pay the personal contribution and/or deductible in the same way as your premium. When it
involves an amount that is higher than € 1,500.00
you will always receive a Giro payment form (on
paper or by e-mail), even if you issued an authorisation for direct debit. You will receive advance
notification before the amount is deducted from
the bank account.
A.8.4. Offsetting
• You (the policyholder) cannot offset debts
against amounts that we still owe you (the
policyholder and insured person).
• We can offset your (the policyholder's) debts
against amounts that you (the policyholder and
insured person) are entitled to based on insurances that you have taken out with us. When
doing so we cannot offset debts from your
general insurance against reimbursements that
you are entitled to from your additional insurance package or vice versa.
A.9. Arrears of payment
A.9.1. Reminders and suspension
If you (the policyholder) do not meet your payment
obligations, we will send you a reminder. If you do
not pay within 14 days, we will then take the following steps in successively:
• we will offset your (the policy holder's) debts
against amounts that you (the policyholder and
insured person) are entitled to. If any part of
your debt still remains, you will still have to pay
it. You will only be entitled to cover again from
the day after all amounts that you should pay
us have been received.
• we will call in a bailiff (see Article A.9.2.).
• we will cancel your additional insurance package(s).
• after 6 months we will report your arrears of
payment for your health insurance to the 'College voor Zorgverzekeringen' . You will then
have to pay an administrative premium for
health insurance to the 'College voor Zorgverzekeringen' every month instead of the premium that you should pay to us. The amount of
this administrative premium for your health insurance is determined by the Government. In
principle, the 'Zorginstituut Nederland' collects
this administrative premium until you have paid
all of the amounts owed for your health insurance. This is a legal arrangement.
• You are no longer obliged to pay the administrative premium to the 'Zorginstituut Nederland'
from the 1st day of the month following the
month in which:
o there is no longer an arrears of payment, or
o a judge has declared the natural persons
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debt rescheduling arrangement of the
Bankruptcy Act to be applicable to you (the
policyholder), or
o you (the policyholder) are about to participate in a debt (rescheduling) arrangement.
This has come about due to the intervention
of a professional debt counsellor and at
least we are participating in it, or
o we have made a payment arrangement with
you.
Your (the policyholder's) obligation to pay your
normal costs to us starts again on the 1st day of
the month following the month in which one of the
situations above became applicable.
is.
You are once again obliged to pay the administrative premium from the 1st day of the month following the month:
• in which the applicability of the natural persons debt rescheduling arrangement ended on
the grounds of Article 350, third paragraph,
part c, d, e, f, g, of the Bankruptcy Act, or
• in which you, according to a report to the 'College voor Zorgverzekeringen' withdrew from
participation in an agreement or arrangement,
as meant above, which applied to you before
you had fully discharged your obligations to us
as laid down in the agreement or arrangement
concerned.
A.9.2. Statutory interest and collection
fees
If you (the policyholder) have an arrears of payment, you also pay us the statutory interest on the
costs that are owed and claimable. In addition,
you must pay collection fees.
A.9.3. Lapse of payment period discount
If you (the policyholder) have agreed to pay us in
advance for a period that is longer than one
month you receive a payment period discount for
this. If you have accrued arrears of payment, we
convert the payment period for the insurances for
which you are the policyholder to one month and
you loose your payment period discount. The loss
of this discount does not give you the right to cancel your insurance.
A.9.4. Debt settlement
What if you (the policyholder) have arrears of
payment? Then with each amount that we receive
from you, you settle (some of) your debt:
• You always settle the debt from the costs of
your health insurance and the costs of you additional insurance package(s) first, then the
oldest claim. For an explanation of "costs"
please see Article A.7.1. also.
• First, you settle the part of your debt that has
been outstanding longest. What if the outstanding debt comprises amounts from a number of periods, because you have not paid for
an extended period? Then you cannot split the
debt by, for instance, first paying the outstanding premium only, and then settling any other
debts. The debt must be paid in its entirety.
A.10. Premium and costs after
cancellation
A.10.1. Debt for cancelled insurance
If you still have to pay us premium and costs for
an insurance that has been cancelled in the
meanwhile, and you take out a new insurance
policy with us, we have the right to:
• offset the costs of the healthcare that we reimburse you from your new insurance against the
old, outstanding debt;
• postpone our obligations until the time that you
(the policyholder) have paid all unpaid and
claimable premiums and costs. We will not reimburse any bills until you (the policyholder)
have paid all unpaid premiums and costs to us,
including those from the old, cancelled insurance.
A.10.2. Overpaid premium
• If your insurance ends in a payment period for
which you (the policyholder) have paid in advance, then you (the policyholder) will be repaid some of the amount paid for the number
of days remaining. After all, we will reduce the
amount that is to be repaid by the amount of
the administrative costs.
• If your insurance changes during a payment
period for which you (the policyholder) have
paid in advance, then we will offset the overpaid premium for the days remaining in that
payment period against the premium you will
have to pay for the new insurance(s).
• In a payment period that you (the policyholder)
have paid in advance, we can cancel your insurance because you are guilty of (attempting
to) commit a criminal act against us, commit an
offence against us, swindle us, mislead us, defraud us, coerce us or threaten us. In these
cases, you (the policyholder) will not receive
any repayment of the amount paid for the re-
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maining part of that payment period.
A.11. Change in the base premium
We can change the base premium. The amount of
the premium also increases in that case. We will
inform you (the policyholder) of this change at
least 6 weeks before it comes into effect. You can
see the cancellation options that apply in this case
in Articles A5.4. and A.5.7.
A.12. Compulsory deductible
A.12.1. Deductible amount
If you are 18 or older, your health insurance has a
compulsory deductible of € 360.00 for a full year.
The compulsory deductible is lower in the year
that the insurance starts or ends or in which you
become 18 years of age. See Articles A.12.6. and
A.12.7. in this regard also.
Compulsory deductible means that you will have
to pay the first € 360.00 of costs that you would
have had reimbursed by your health insurance,
yourself. We will only reimburse the other costs
that are covered by your health insurance after
you have done this.
A deductible is not the same as a personal contribution. Deductible and personal contribution can
both apply simultaneously to the insured healthcare.
A.12.2. Offsetting deductible
The costs of healthcare are offset against the
compulsory deductible for the year in which the
healthcare was enjoyed.
If the healthcare is enjoyed in 2 successive years
and billed as a single amount in a single bill, then
the costs of this healthcare are offset against the
compulsory deductible for the first year.
However, the costs of a DOT healthcare product
code - apart from the primary care DOT healthcare product codes - only count towards the compulsory deductible for the year in which a DOT
healthcare product code commenced (opening of
the DOT healthcare product code). This does not
apply to OZPs (Other Healthcare Products) for
medical specialist or specialist psychiatric care.
A.12.3. No deductible
Some costs do not count toward the compulsory
deductible. We will, of course, reimburse you
those costs, even if you have not yet paid your
compulsory deductible of € 360.00. The following
costs do not count toward the compulsory deductible:
• The costs of GP care. The compulsory deductible does apply again to the costs of investigations that are related to the GP care but are
carried out somewhere else and are billed
separately. This care must then be carried out
by a person or establishment that is allowed to
request a rate that has been determined by the
'NZa'.
For example:
• In one year you incur costs of € 110.00 that are
covered by your health insurance. This involves costs of € 80.00 for a medical specialist
in a hospital. These costs count toward the
compulsory deductible. In addition the costs
involve € 30.00 for a consultation with the general practitioner. These costs do not count toward the compulsory deductible. You must
then pay € 80.00 yourself. We pay the € 30.00
for the general practitioner consultation.
• The costs for obstetric care and postnatal care
(Articles B.5., B.6. and B.7.). The compulsory
deductible will apply for costs that could be associated with this, but are included in another
Article, such as IVF, ambulance transport,
medicines, medical aids and (laboratory) investigation that is not carried out by the general
practitioner and is not billed by the general
practitioner either.
• The cost of follow-up checks for you as a
donor after the period as meant in Article
B.4.7.2.a. has elapsed.
• The costs of registering with a general practitioner or with an establishment that provides
GP care. Registration costs include:
o an amount for registering as a patient. We
reimburse a maximum of the rate that has
bee determined based on the Healthcare
Marketing Regulation Act (taking account of
fiscal legislation);
o cost that are involved in:
- the way in which the medical healthcare is
provided in the GP practice or the establishment;
- the characteristics of the patient file;
- the location of the practice or establishment.
We must have concluded a healthcare
agreement with the general practitioner or
establishment for this. In this healthcare
agreement we must also have agreed that
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they are allowed to bill for the costs of your
registration;
• The costs of healthcare and other services
may fall fully or partly outside of the compulsory deductible, if:
o to obtain that care or those services you
visited a healthcare provider that we designated this, or
o you have followed a programme for diabetes, depression, cardiovascular diseases or
obesity, that we designated.
We have not designated any healthcare providers or health programmes for this. If there
any changes to this we will place a notice on
our website;
• The costs for multidisciplinary care (see Article
B.1.2. also for "multidisciplinary care");
• Medical aids that we loan to you. No costs are
owed for this. This is why the compulsory deductible does not apply here. The compulsory
deductible does apply again for the costs for
the consumables and the usage costs involved
with the medical aid that we lend you.
In addition, the compulsory deductible does not
apply (not even the voluntary deductible) for the
care that is covered by reimbursement in your
additional insurance package(s).
A.12.4. Costs for own account
Costs that you have to pay yourself based on the
terms and conditions of insurance do not count
toward the compulsory deductible that you have to
pay. This could be (statutory) personal contributions for example.
A.12.5. Payment to healthcare provider
and deductible
If a healthcare provider (who has a payment
agreement with us) claims directly from us, we
can reimburse your costs directly to the healthcare provider. If you are still liable to pay (part of)
the deductible, we will claim this amount back
from you, or offset it for you.
If you send us the bill yourself (or if the healthcare
provider does not have a payment agreement with
us) we will make payment to you if (part) of the
deductible is still outstanding. In that case you will
receive from us the amount that you are entitled
to, minus the outstanding deductible. You yourself must make payment in full to the healthcare
provider.
A.12.6. If the health insurance starts, ends
or changes during the course of the year
If your health insurance starts or ends during the
course of the year you will pay a pro rata amount
of the compulsory deductible for the part of the
year that the health insurance was in effect,
rounded up to full euros.
We count the number of days in the year that the
health insurance is in effect and divide this by the
total number of days in that year (this is usually
365 days, apart from leap years). We multiply the
result of this by € 360.00. The result is rounded to
full euros.
For example:
You health insurance starts on 23 September
2014. From 23 September 2014 up to and including 31 December 2014 is 100 days. Your deductible is then:
• € 360.00 : 365 = € 0.986 deductible per day
• € 0.986 x 100 days = € 98.63 deductible that
year (not rounded)
• We round off € 98.63. The result is € 99.00.
This is your deductible for that year.
Please note!
If you have a number of consecutive health insurances with the same health insurer within one
year with different voluntary deductibles, the pro
rata calculated deductible amounts for this year
have to be added together.
For example:
You first health insurance runs from 01 January
2014 up to and including 30 June 2014 (this is
181 days). In this case you only have the compulsory deductible of € 360.00.
nd
You 2 health insurance runs from 01 July 2014
up to and including 31 December 2014 (this is 184
days). You then opt to have a voluntary deductible
of € 300.00 in addition to the compulsory deductible.
Your deductible for the first health insurance is
then:
• € 360.00 : 365 = €0.986 deductible per day
• € 0.986 x 181 days = € 178.52 deductible;
which rounds off to € 179.00. .
nd
The deductible for your 2 health insurance is
then:
• € 360.00 + € 360.00 = € 660.00
• € 660.00 : 365 = €1.808 deductible per day
• € 1.808 x 184 days = € 332.71 deductible;
which rounds off to € 333.00.
We add together the deductible amounts for these
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2 periods: € 179.00 + € 333.00 = € 512.00. This is
your deductible for the full year.
A.12.7. If you turn 18
Up until 18 years of age the compulsory deductible is € 0.00. From 18 years of age this is
€ 360.00 for a full year. If the amount of your
compulsory deductible changes during the course
of the year and had insurance with us immediately
prior to the change, a pro rata amount, rounded to
full euros applies as the compulsory deductible.
The amount of the compulsory deductible is then
calculated as follows:
• We multiply the amount of the compulsory
deductible by the number of days of the year
for which this compulsory deductible is to apply;
• We divide the result of this by the total number
of days in that year (this is usually 365 days,
apart from leap years);
• We round that amount off to full euros.
For example:
You have taken out health insurance for your son.
Your son turns 18 on 5 November 2014. Prior to 5
November 2014 he did not have a compulsory
deductible (€ 0.00) and from 5 November 2014 he
has a compulsory deductible of € 360.00. From 5
November there are 57 days remaining in that
year. The deductible for your son in that year is
then:
• € 360.00 : 365 days = € 0.986 deductible per
day.
• € 0.986 x 57 days = € 56.22 deductible; which
rounds off to € 56.00. This is then the remaining portion of the deductible for that year, applicable from the moment your son turned 18.
A.12.8. First compulsory deductible then
voluntary deductible
The costs that are covered by the health insurance are first used to cover the compulsory deductible. Once this has been paid, the costs are
used to cover any voluntary deductible that you
have chosen. When this is also reduced to € 0.00
we will actually reimburse the costs that you incur
and which are covered by your health insurance
from that time onwards.
A.12.9. Payment in instalments
You (the policyholder) can pay the compulsory
deductible in instalments.
When can you participate?
• You have health insurance with us on 1 January;
• Your health insurance only has a compulsory
deductible; you have not, therefore, opted for a
voluntary deductible;
• You are 18 years or older on 1 January;
• We must have received your application to
make payments in instalments before 1 January of the year that the compulsory deductible
relates to;
• You determine which insured persons, named
in your policy document, you want to register
for this scheme. You register these participating insured persons simultaneously in the application;
• You pay in 10 instalments from the 1st quarter
of the year of participation.
Terms and conditions during participation
• Participation can be renewed, except if you
state that you want to stop this payment
scheme, and which insured persons you want
to stop it for, before 1 January of the following
year.
• You will receive a final bill in the 1st quarter of
the following year. If you have overpaid compulsory deductible then we will pay the (remaining) amount back to you not later than that
same quarter. If we receive bills after this,
which have to be offset against your compulsory deductible for the last year, then we will
claim that amount back from you directly.
End of the participation
• If you want to cancel your participation in the
interim, then this cancellation applies to all participating insured persons in your policy document.
• We can cancel the participation if:
o the terms and conditions above are no
longer being met;
o you fail to pay on time;
o you insurance situation changes, where the
policyholder or the number of participants
changes.
• If participation in this payment scheme ends
during the course of the year, you will receive a
final bill immediately. We will repay any compulsory deductible that you have overpaid. If
you still owe any compulsory deductible you
will pay this immediately in a single payment. If
we receive bills after this, which have to be offset against your compulsory deductible then
we will claim that amount back from you directly.
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A.13. Voluntarily chosen deductible
A.13.1. Terms and conditions for voluntary
deductible
Articles A.12.2. through A.12.8. relating to the
compulsory deductible also apply to the voluntary
deductible in your health insurance. In addition to
this, the following terms and conditions of insurance apply to the voluntary deductible.
A.13.2. Lower premium
If you are 18 years or older, you may also opt for
a voluntary deductible for you health insurance in
addition to the compulsory deductible. The higher
this voluntary deductible is, the lower the premium
that you (the policyholder) will pay for your health
insurance. You can opt for a voluntary deductible
of € 100.00, € 200.00, € 300.00, € 400.00 or
€ 500.00 per year.
With 'Zorgverzekering Natura Direct' and
'Zorgverzekering Natura Select' you can only opt
for a voluntary deductible of € 500.00 per year.
Deductible does not apply to additional insurance
packages.
A.13.3. If you turn 18
th
Not later than the month prior to your 18 birthday
we will ask you the amount you want to choose for
th
the voluntary deductible from your 18 birthday. If
you do not respond to this question, or respond
too late, we will calculate the premium for your
health insurance without voluntary deductible.
A.14. General obligations
A.14.1. If you do not meet your obligations
You have certain general obligations to us. These
obligations are stated in this Article. If you damage our interests, because you do not meet these
obligations, you are not entitled to healthcare
cover. We can also reclaim the reimbursements
that you have previously received from us and we
will no longer be required to provide the healthcare or the reimbursements that you have yet to
receive from us for bills that have been submitted.
A.14.2. General obligations
You are obliged to:
• be able to prove that you are who you say you
are if you call for healthcare from an establishment for medical specialist care or at an
outpatients department;
• ask the doctor in attendance or the medical
specialist to make the reason for hospitalisation known to our medical advisor if he/she requests it;
• assist us, our medical advisor, consultant dentist, auditor or the healthcare provider with
whom we have concluded an agreement, in
obtaining all the information required;
• report to us within thirty days that you are in
custody or imprisoned or have been sentenced
to imprisonment;
• report to us within thirty days that your custody
or imprisonment has ended;
• inform us who the new policyholder(s) is (are)
or will be within thirty days on the death of the
policyholder or when the policyholder is no
longer competent of handling their own affairs.
A.14.3. Assigning liability to another party
Assignment: transferring claims to us
Sometimes, we can assign liability for costs or
healthcare that we have reimbursed from your
insurance(s) to a third-party. From the moment
that your insurance becomes valid, you transfer
any claims that obtain on a third-party to us. This
involves claims that it may be possible to consider
as falling under the cover of the insurance(s).
Cooperation in liability of
other parties (third-parties)
Situations may arise, events or accidents occur
where you may have to obtain healthcare immediately or later, or where the costs are covered
by one or more of your insurance(s). If we are
able to make others liable for these costs, you
must report this to us not later than within 14
days. You are obliged to cooperate with us if we
try to recover these costs.
No agreements with third-parties
You must not come to an understanding or make
agreements with third-parties (including insurers)
who we may be able to hold liable. This does not
apply if we have given you a written statement of
approval for this in advance.
Consequences of failure to cooperate
We can assign liability for all losses and costs that
arise to you if you do not assist us in recovering
them.
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A.15. Forwarding of information
A.15.1. Providing the correct information
You are obliged to provide us with correct information and to assist us in obtaining all necessary
information. If you misrepresent matters to us,
provide us with false or misleading documents,
provide an untruthful statement or refuse to cooperate with us, we then have the following options:
• We cancel your insurance and you therefore
have no further entitlement whatsoever to
healthcare cover;
• We reclaim all amounts that you have received
from us up until the date that you misled us;
• You have to pay the costs for the investigation
into deliberately misleading us;
• We register you in our incident register;
• We register you in the alert system that is recognised between insurers;
• We report the matter to the police;
• We will refuse any new request from you for
insurance for a period of 5 years.
The same applies if someone else carries out the
aforementioned actions on your behalf.
A.15.2. Significant events
You are obliged to report events that are important in allowing us to operate the health insurance
properly within 30 days. These are events such
as:
• moving house or change of address as recorded in the municipal personal records database;
• change of postal address or other communications address (such as e-mail address);
• birth or adoption;
• death;
• divorce;
• start and end of custody/period of imprisonment;
• start and end of participation in a group
agreement;
• change to composition of family.
If you do this on time, the modification becomes
effective at the time of the change. If you fail to do
this on time, the modification to the insurance
becomes effective at a time that we will determine.
A.15.3. Current address
We assume that you receive messages that we
send to the last postal or e-mail address that we
hold for you. We cannot be held liable for any loss
you incur if you receive messages from us too late
or do not receive them at all because you have
not made us aware of your most current postal or
e-mail address.
A.16. Registration and verification
A.16.1. Privacy
We store the personal details that you provide to
us when you apply for insurance or later in our
personal data files. We only use this data for the
purposes that are stated in the terms and conditions of insurance or are mentioned in the applicable privacy legislation and which we have reported to the 'College Bescherming Persoonsgegevens'.
The 'Gedragscode Verwerking Persoonsgegevens
Zorgverzekeraars' (Code of Conduct for the Processing of Personal Data by Health Insurers) is
applicable.
A.16.2. Processing of personal details
We process the personal details that we hold in
our records to:
• evaluate and accept insured persons, for taking out and operating insurances and for completing the payments;
• use personal details for statistical and scientific
purposes;
• carry out (targeted) marketing activities to establish a relationship, to maintain it or to expand it. We do not use personal details about
your health to do so;
• guarantee the safety and integrity of the sector.
This includes combating, preventing and detecting (attempted) (criminal) behaviour targeting our sector of industry, and the use of and
participation in alert systems;
• comply with legal obligations.
In the event of unlawful behaviour we may record
your details in the External Reference Register.
We are able to check this register via the 'Stichting
CIS'
central
database.
Visit
www.stichtingcis.nlfor more information (in Dutch).
A.16.3. Provision of information and registration
From the moment that the insurance commences
we can:
• provide or request information from/to third-
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•
•
•
•
parties (including healthcare providers) if we
feel this is necessary for compliance with our
obligations arising from the health insurance;
provide or request information to/from thirdparties (including healthcare providers) to allow
us to operate your insurance more effectively;
negotiate costs with healthcare providers and
take legal action against them if necessary (at
our own expense);
include your personal details that we require to
operate your insurance(s) in our records;
use your personal details, supply them to thirdparties or use them in litigation if this is necessary to protect our interests.
Explanation:
your insurance is operated more quickly and
easily if we receive bills directly from healthcare
providers and pay them. To do this, it may be
necessary for the healthcare provider who treated
you to know how you are insured. This is why the
healthcare providers can view your address and
policy details with us in a secure manner. The
healthcare providers are only allowed to view
these details if they actually do treat you. If there
are imperative reasons why healthcare providers
should not be able to view your address details
you can inform us of this. We can then hide your
address details.
A.16.4. Material verification
We are allowed to carry out verification in regard
to content and fraud investigation in relation to
handling your insurance and your details in our
records. We do this in accordance with the Health
Insurance Act, the national 'Protocol materiële
controle' (Material Verification Protocol) and the
national 'Protocol Incidentenwaarschuwingssystemen Financiële Instellingen' (Financial Institutions Incident Warning System Protocol). You are
obliged to provide your cooperation in this.
A.17. Healthcare providers
A.17.1. Healthcare provider
This is the person who is authorised to provide or
supply the insured healthcare. A healthcare provider can provide you with healthcare and/or supply goods/resources. We therefore understand
"zorgaanbieder" (healthcare provider) to mean the
same as "zorgverlener" (care provider). A healthcare provider can be:
• a person; or
• an establishment for the provision of care; or
• a healthcare group (see Article A.17.2.).
Insured healthcare is, for example, medical,
paramedical, dental or nursing care. Supply involves medicines or medical aids and any services associated with this.
A.17.2. Healthcare group
A healthcare group is a healthcare provider as
meant in Article A.17.1. In addition, a healthcare
group has the following characteristics:
• the healthcare group is a partnership of a
number of healthcare providers from different
disciplines, a general practitioner and a dietician for example. The partnership is a legal
person or is based on one or more partnership
agreements.
• the healthcare group provides multidisciplinary
care (see Article B.1.2.).
• the healthcare group is responsible for supervising the maintenance of the quality requirements for the multidisciplinary care.
• claims for the healthcare supplied go through
the healthcare group, not via the individual,
participating healthcare providers, unless there
is a so-called "koptarief" (top rate).
• a healthcare group is a healthcare provider
with a healthcare agreement (see Article
A.17.4.).
A.17.3. Terms and conditions for healthcare providers
Healthcare is covered by the insurance if:
• a healthcare provider type is shown for the
healthcare provider concerned in the terms
and conditions of insurance or expressly mentioned in the Reimbursements Overview under
the heading "zorgaanbieder" (healthcare provider). Types of healthcare providers that we
do not mention under the heading 'zorgaanbieder' (healthcare provider) in the healthcare
concerned cannot then provide that healthcare
at our expense nor can they claim it from us.
You are not, therefore, covered for healthcare
from types of healthcare providers that are not
named, even if you are insured for that healthcare; and
• that healthcare provider provides this healthcare themselves. Healthcare can also be provided by someone else, even a type of healthcare provider that is not named. He or she
must act under the responsibility of the healthcare provider that we have expressly mentioned under that particular Article, unless
there is an express statement to the contrary in
the Article concerned; and
• that healthcare provider claims the healthcare
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under their own name. It is also possible for an
establishment, another healthcare provider or
a third-party to claim the healthcare, stating the
name of the healthcare provider responsible;
and
• a healthcare provider in the Netherlands complies with the requirements, legislation and
regulations that have been stipulated for
his/her profession and company and the operation thereof and in this way is authorised to
provide their healthcare. Healthcare providers
established in the Netherlands must, amongst
other things, comply with the requirements of
the Individual Healthcare Professions Act ('Wet
BIG'):
o doctors, dentists, pharmacists, mental
health psychologists, psychotherapists,
physiotherapists, obstetricians and nurses
must be included in the national 'BIGregisters' (Individual Healthcare Professions
Registers) or another register that we consider to be equivalent (for example, registration as a clinical chemistry laboratory
specialist with the 'Nederlandse Vereniging
voor Klinische Chemie en Laboratoriumgeneeskunde' (NVCK);
o we only reimburse healthcare other than
from these healthcare providers if it involves healthcare providers who have
undertaken designated training on the basis
of Article 34 of the 'Wet BIG' (Individual
Healthcare Professions Act) and who legitimately bear the title or insignia associated with that training; and
• a healthcare provider in a foreign country complies with the requirements, legislation and
regulations that are laid down for their profession in that country.
A.17.4. Healthcare agreement, Internet
agreement and payment agreement
a. Healthcare providers with a healthcare
agreement
We have entered into agreements about the
healthcare or resources that healthcare providers
supply. In those agreements we have come to an
understanding about the price (rates), the quality
and effectiveness of the healthcare and the terms
and conditions under which they provide that
healthcare and the costs that they can claim from
us for it. We have prepared a list of the healthcare
providers. You can find it on our website or request it from us.
If we have an agreement with a healthcare provider, this does not necessarily mean that we
have done this for all of the (healthcare) services
they provide.
b. Healthcare providers with an 'Internet
agreement'
For the 'Zorgverzekering Natura Direct' we have
entered into "internetovereenkomsten hulpmiddelen" (Internet agreements for medical aids) and/or
an "internetovereenkomst geneesmiddelen en
dieetpreparaten" (Internet agreement for medicines and dietary preparations) for the supply of
the majority of the medical aids, medicines and
dietary preparations. Here, the healthcare provider is only allowed to supply after ordering via
the Internet. We enter into similar agreements (on
rates, quality, effectiveness and the method of
claiming) as for a healthcare agreement. You can
find further terms and conditions for these "Internet agreements" in the relevant Articles, if applicable.
You can find an overview of these healthcare
providers on our website. You can also find an
overview of the medicines, dietary preparations
and medical aids for which we have entered into
such "Internet agreements" there.
c. Healthcare providers without a healthcare
agreement and/or Internet agreement
What if you use a healthcare provider with whom
we have not entered into a healthcare agreement
and/or Internet agreement? We will then give you
a (partial) reimbursement of the costs for the
healthcare if the terms and conditions in Article
A.17.3. have been met. And if the terms and conditions for the healthcare concerned have been
met. This is known as “restitutie” (refunding).
d. Healthcare providers with a payment
agreement
If you use a healthcare provider with a payment
agreement, the costs of the healthcare that is
provided is not claimed by you; it is claimed directly from us. We then pay the costs of the insured healthcare directly to the healthcare provider. See Articles A.19.3. and A.19.4. in this regard.
Healthcare providers may have entered into a
number of the aforementioned agreements with
us.
Healthcare providers with a healthcare agreement
and/or Internet agreement always have a payment
agreement with us. The reverse does not apply.
Healthcare providers with a payment agreement
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do not always have to have a healthcare agreement and/or Internet agreement.
In Article A.20. we show how much we reimburse
if you use a healthcare provider who does or does
not have a healthcare agreement and/or Internet
agreement.
A.17.5. End of agreement with healthcare
provider ("uitbehandeling" (completion of
treatment))
• What if the agreement that we have entered
into with your healthcare provider ends after
you have started undergoing treatment with
this healthcare provider? We will then reimburse this healthcare during your treatment.
• What if you switch to us from another health
insurer during your treatment? In that case you
retain the right to (reimbursement for) insured
healthcare that you continue with the healthcare provider with whom your previous health
insurer had entered into an agreement. This
also applies if we have not entered into an
agreement with this healthcare provider, or if
we cannot, as yet, enter into an agreement in
time, or if we cannot ensure that the healthcare
is provided on time.
The healthcare will then be reimbursed as if it had
been provided by a healthcare provider with
whom we had entered into an agreement.
A.18. Care recommendation and
approval
A.18.1. Care recommendation and approval
You are entitled to care recommendation from us.
Then you will know the extent to which certain
healthcare or healthcare providers are covered by
your insurance. Not only that, you will also know
which healthcare providers we have entered into
an agreement with. You request this care recommendation and the statement of approval from our
Medical Assessments department. The healthcare
description in Chapter B and/or D also shows
whether a care recommendation and a statement
of approval are required or mandatory for that
healthcare. If there is nothing mentioned alongside a type of healthcare, then a care recommendation and a statement of approval are not mandatory. Care recommendation and approval can
be voluntary or mandatory:
• voluntary care recommendation and approval:
we recommend that you make use of this if you
are in any doubt. You can do this for any
healthcare, but this is not shown as a condition
in the healthcare description in Chapter B
and/or D. It is not mandatory for you to do this.
You retain the right to the healthcare in the
way it is covered by your insurance.
• mandatory care recommendation and approval: it is mandatory for you to use this before undergoing healthcare. This is stated as a
condition in the healthcare description in Chapter B and/or D. If you follow our care recommendation, we will guarantee that the healthcare is fully or partly covered by your insurance.
A.18.2. Statement of approval, referral or
prescription on change of health insurer
nd
If the situation in the 2 bullet point of Article
A.17.5 arises, the approval, the referral or the
prescription remain valid as if you were still insured by that other health insurer. The statement
of approval expires on the date that was indicated
by the other health insurer in the approval. The
referral or the prescription expires on the date that
was indicated by the other health insurer in the
approval .
A.18.3. Announcements and undertakings
Announcements we make and undertakings we
give to you only bind us to that which has been
confirmed in writing. We assume that you have
received notifications sent to the last postal or email address known to us. We cannot be held
liable for any loss you incur if you receive messages from us too late or do not receive them at
all because you have not made us aware of your
most current postal or e-mail address.
A.18.4. Period of validity
If the terms and conditions of insurance state that
a statement of approval in advance is mandatory,
it must not be older than 365 days. Our statement
of approval is therefore valid for a maximum of
365 day, unless we expressly determine otherwise.
Please note!
The statement of approval is issued based on the
applicable legislation and regulations and the
terms and conditions of insurance.
The statement of approval is no longer valid if the
legislation or regulations concerned changes or if
your insurance has changed or cancelled (unless
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the start date of the DOT healthcare product code
lies within the duration of your insurance).
A.19. Bills
A.19.1. Who receives the bill?
Certain healthcare providers can submit bills directly to us. If you use other healthcare providers,
you will receive the bill from them. You then submit it to us.
A.19.2. Submitting bills
You can use our free 'NotaApp' to submit bills.
You can also use your personal page on our website to submit bills. You can also send bills to us
on paper.
We process bills in accordance with the terms and
conditions of insurance of the insurance(s) that
you have taken out if they meet certain requirements:
• Bills must:
o be original (not a copy); or
o be on computer-readable data carriers (e.g.
CD-ROMs, DVDs or BluRays); or
o arrive with use by means of electronic data
exchange. You must make claims in this
way for certain types of insurance. You
were informed of this when you took out the
insurance(s);
• If you have received healthcare abroad, you
may be entitled to reimbursement of (some
part of) bills that you have previously submitted
in your country of residence.
In that case we will process a copy of the original, foreign bills. You should submit these
copies together with a statement from the
executive body of the social or statutory insurance of your country of residence, showing:
o that (part of) the costs have not been eligible for reimbursement; and
o the amount that remains for for you to pay.
• Bills relate to treatment that has actually taken
place and healthcare or medical aids that have
been supplied.
• We received the bill within 36 months from the
date on which the healthcare was provided. If
we receive your bill later than this, it will no
longer be considered for reimbursement;
• Bills come from you, the healthcare provider or
healthcare establishment;
• Bills must be specified and translated in such a
way that we can process them in accordance
with the terms and conditions of insurance
without translation, follow-up questions or fur-
ther investigation. We base specification of
bills on the same requirements as the tax
authority. This is why a bill must show, for example, the name and address of the healthcare provider, your name, the content, number/period and the amount of the healthcare
that has been provided. If the 'NZa' has set
specific requirements for a certain type of
healthcare, these requirements apply over and
above those of the tax authority.
Please note!
• Quotations and advance bills will not be reimbursed.
• We will not return bills, enclosures and documents that you have submitted to us, not even
if you have only been reimbursed in part, there
has been offsetting against the deductible or
even if you have not been reimbursed. You
can request a certified copy from us.
A.19.3. Direct payment to the healthcare
provider
By taking out your insurance you gave us permission to enter into a payment agreement with
healthcare providers. Amongst other things, we
can agree that they submit all or certain bills to us
and that we will pay these bills directly to them.
Your cooperation in this is mandatory. If we receive a bill which is eligible for reimbursement
from this kind of healthcare provider, you are
therefore considered to have given us permission
to pay that bill directly to that healthcare provider.
If we pay the bill to the healthcare provider, this
discharges our obligation to reimburse you for the
costs. Payment of the bill to the healthcare provider/healthcare establishment can also occur by
compensation with advances that we have issued
to the healthcare provider/healthcare establishment.
A.19.4. Healthcare provider overreimbursed
If we pay the healthcare provider more than we
should reimburse them in accordance with your
insurance(s) then we assume that you have
granted us a collection mandate for the amount
that we have overpaid the healthcare provider. If
you are not entitled to healthcare based on these
terms and conditions of insurance, or are entitled
to less healthcare or a smaller reimbursement
than the amount that we have paid to the healthcare provider, you are obliged to pay us the difference. This could occur if, for instance, you have a
personal contribution or a deductible or if a (statu-
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tory) maximum reimbursement applies.
A.19.5. Verification of original bill
If you have submitted bills to us via the Internet,
you must keep the paper, original bills for a minimum of 2 years because we could request these
bills for verification purposes.
A.20. Rates
A.20.1. Description of the rates
The Articles in Chapter B and on your Reimbursements Overview show what healthcare you
are entitled to and the amount of the reimbursement that you receive. A percentage, 100% for
example, is often shown there. But that does not
always mean that we will accept all of your bill for
our account. We use various rates:
1. Agreed rate
The rate that we have specified in a healthcare
agreement and/or Internet agreement with the
healthcare provider.
2. Fixed, statutory (set point) rate
The fixed rate that is specified for certain healthcare based on the Healthcare Marketing Regulation Act. These are rates where no margin (leeway) is specified. The rate used by a healthcare
provider must not, therefore, be higher, but must
not be lower either. These rates are also known
as set point rates. They are therefore never higher
than the maximum agreements in your insurance.
3. Market rate applicable in the Netherlands
This is the rate that is customary for certain
healthcare in the Netherlands and is proportional
with the price of similar care from similar healthcare providers. We mean an amount that is the
same as the rate that we have specified for that
healthcare in healthcare agreements and/or Internet agreements with healthcare providers. If we
have agreed a number of different rates then we
use the average of those rates. What if we have
not agreed rates for that healthcare? In that case,
we use the the prices that are customary for the
Dutch market conditions and/or standards as a
basis. You will find the 'Tarievenlijst' (List of
Rates) for various types of healthcare on our
website.
4. Claimed rate
The rate shown on the invoice.
A.20.2. Rate amount
a. Agreed rate
o 'Zorgverzekering Natura', 'Zorgverzekering
Natura Select', 'Zorgverzekering Natura Direct', 'Zorgverzekering Restitutie' and additional insurance packages:
What if you use a healthcare provider with
whom we have entered into a healthcare
agreement for that treatment/healthcare?
You are then entitled to the treatment in accordance with the agreed rate.
o 'Zorgverzekering Natura Direct':
1. for medical aids you are only entitled to
the agreed rate if the medical aid is supplied by a healthcare provider with an Internet agreement. What if the medical
aid can be supplied by a supplier with an
Internet agreement but you nonetheless
use a supplier with an ordinary healthcare agreement? You are then entitled
in accordance with the reduced rate, see
b. (refer to Article A.17.4. Internet
agreement).
2. for medicines and dietary preparations
you are entitled to the agreed rate in accordance with the Internet agreement.
What if you use a healthcare provider
with an ordinary healthcare agreement
instead of an Internet agreement? You
are then entitled in accordance with the
agreed rate for the ordinary healthcare
agreement.
b. Reduced rate for the fixed or market rates
applicable in the Netherlands
Natura Select' and 'Zorgverzekering Natura
Direct' and the components of the additional
insurance packages that contain care in
kind:
whom we have not entered into a healthcare
agreement
for
that
treatment/healthcare? And what if, in your situation, you had been able to obtain suitable
healthcare in good time from a healthcare
provider with whom we have entered into a
healthcare agreement? You are therefore
not using contracted healthcare. In this
case you are entitled to a reduced reimbursement. We will then reimburse a certain percentage (part) of the legally determined, fixed rate (the so-called "punttarief"
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(set point rate)). If there is no set point rate,
we will then reimburse that percentage of
the market rates applicable in the Netherlands. If the amount invoiced is less than
the market rate applicable in the Netherlands, we use this lower, invoiced amount
for this calculation. You can find the level of
that reimbursement percentage in the
'Premies en vergoedingstarieven' (Premiums and reimbursement rates) enclosure. In the case of the additional insurance
packages you will find it in your Reimbursements Overview.
o 'Zorgverzekering Natura Direct':
In the case of medical aids this reduced
rate also applies if it involves a healthcare
provider with whom we have entered into a
healthcare agreement but not an Internet
agreement. (refer to Article A.17.4. Internet
agreement).
o 'Zorgverzekering Restitutie' and refund reimbursements in additional insurance packages:
We do not reduce the rate if you use a
healthcare provider with whom we have not
entered into a healthcare agreement. With
these insurances we reimburse the full rate
(100%), stated under c.
c. Full rate (100%) of the fixed or market rate
applicable in the Netherlands
o 'Zorgverzekering Restitutie' and the components of the additional insurance packages the contain reimbursements on a refund bases and do not contain care in kind:
agreement
for
that
treatment/healthcare? In that case, we reimburse the full, legally determined, fixed rate
(the so-called "punttarief" (set point rate))
for the 'Zorgverzekering Restitutie' and the
components of the additional insurance
packages that include reimbursement on a
refund basis. If there is no set point rate, we
will then reimburse the full (100%) of the
market rate applicable in the Netherlands. If
the amount invoiced is less than the market
rate applicable in the Netherlands we reimburse this lower, invoiced amount.
Natura Select', 'Zorgverzekering Natura Direct' and the components of the additional
insurance packages that contain care in
kind:
We only reimburse the full rate stated under
c. if:
- you cannot obtain the healthcare or
cannot obtain it in good time from a
healthcare provider with whom we have
entered into a healthcare agreement or
an Internet agreement. What comprises
timely provision of healthcare depends
on what is considered intrinsically safe
from a medical standpoint and what is
generally acceptable to the public; or
- you can only obtain the healthcare a
long distance from your place of residence from a healthcare provider with
agreement; or
- you require acute (urgent) care, which
cannot be delayed.
d. Claimed rate
o All types of insurances:
agreement
for
that
treatment/healthcare? And we have not entered
into a healthcare agreement and/or Internet
agreement with other healthcare providers
for the type of treatment/healthcare? And
there is no statutory rate and the market
rate applicable in the Netherlands cannot
be determined or is almost impossible to
determine? We will then reimburse the
claimed rate. We will reimburse this to a
maximum of the amount that you are entitled to under your insurance. The reimbursement is never higher than the costs
that you have actually incurred for the
healthcare.
The flowchart on the next pages shows which reimbursement rate we use in each situation.
Explanation of terms:
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* Healthcare provider
This could be a person, but it could also be a supplier, healthcare group or establishment. See Article A.17.
** Healthcare agreement/Internet agreement
An agreement in which we have made arrangements in relation to price (rates) and quality, amongst other
things. In Article A.20.2.a. you can see whether this should involve a healthcare agreement or an Internet
agreement.
*** Reduced rate
A certain percentage (part) of the fixed or market rate applicable in the Netherlands. You can see the level of
that part in your 'Premies en vergoedingstarieven' (Premiums and reimbursement rates) enclosure.
This reduced rate applies for 'Zorgverzekering Natura', 'Zorgverzekering Natura Select', 'Zorgverzekering
Natura Direct' and the components of the additional insurance packages that include care in kind. The reduced rate does not apply for 'Zorgverzekering Restitutie' and the components of the additional insurance
packages that include healthcare on a refund basis.
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Rates Flowchart
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Examples:
• If you have a 'Natura' policy, when do you receive a reimbursement at a lower rate than the
fixed rate or market rate applicable in the
Netherlands?
Example
You visit a physiotherapist. You found the
healthcare provider on our 'Zorgzoeker'
(Healthcare Search) website and you saw that
the physiotherapist that you want to use does
not have a healthcare agreement with us. You
see on our 'Zorgzoeker' (Healthcare Search)
website that there are other physiotherapists
who do have a healthcare agreement, but you
would prefer to use the physiotherapist of your
own choosing.
There is no fixed, statutory rate for physiotherapy. There is a market rate applicable in the
Netherlands, because we have rate agreements with the other healthcare providers.
Your reimbursement is therefore a reduced
rate of the market rates applicable in the
Netherlands. The level of this percentage is
shown on the 'Premies en vergoedingstarieven' (Premiums and reimbursement
rates) enclosure to your insurance.
For example:
The 'Premies en vergoedingstarieven' (Premiums and reimbursement rates) enclosure to
your health insurance shows that the reimbursement percentage is 50%. Your physiotherapist charges € 28.10 for a treatment. We
have agreed a rate of € 28.10 with the physiotherapists. Your reimbursement is: 50% of
€ 28.10 = € 14.05.
• If you have a 'Natura' policy, when do you receive a reimbursement of 100% of the market
rate applicable in the Netherlands?
For example:
You require treatment for an inguinal hernia. In
the Netherlands you will be placed on an unacceptably long waiting list. The healthcare required is not available to you locally within a
reasonable period of time. You therefore apply
to us to have treatment abroad. After assessment, we give you a statement of approval, but
we do not have a healthcare agreement with
the healthcare provider who treats you. There
is no fixed, statutory rate for this treatment. We
have entered into agreements for this treatment with the other healthcare providers in the
Netherlands, so there is a market rate applicable in the Netherlands. The market rate applicable in the Netherlands is, for example,
€ 100.00. The healthcare provider that you use
charges € 150.00 for the treatment. You will be
reimbursed 100% of the market rate applicable
in the Netherlands. You are therefore reimbursed 100% of € 100.00 = € 100.00.
• If you have an additional insurance package,
when will you be reimbursed the claimed rate
up to maximum amount?
For example:
You visit an acupuncturist. The treatment costs
€ 60.00. The acupuncturist is recognised in accordance with the terms and conditions. We do
not have healthcare agreements with alternative healthcare providers. Alternative healthcare providers are allowed do determine the
cost of a treatment themselves. Therefore,
there is no fixed, statutory rate for alternative
healthcare and the market rate applicable in
the Netherlands cannot be determined or is
almost impossible to determine. The maximum
that you will be reimbursed is the claimed rate.
If you have an additional insurance package in
which, for example, a maximum of € 40.00 is
reimbursed per treatment you will then be reimbursed € 40.00 (if you have not yet used-up
you maximum reimbursement per year).
A.20.3. Turnover tax
If a healthcare provider who is legally obliged to
do so charges turnover tax on the amount for the
healthcare provided and invoices you for it, this
turnover tax falls under the reimbursement also.
A.21. General exclusions
A.21.1. General
You are not entitled to the (costs of) the following
treatments:
1. The costs of appointments with healthcare
providers that you fail to attend;
2. Costs related to obtaining a copy of or access
to medical details;
3. Treatments for medical pedagogical issues,
dyslexia (with the exception of dyslexia care
based on the health insurance), language test-
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ing, spelling testing, intelligence testing, nonnative speaker or treatments with an educational aim;
4. Costs for exchanging and paying in a foreign
currency;
5. Cost for payment in, to or from bank notes
from outside the Netherlands;
6. Costs for the late payment of invoices sent
directly to you by the healthcare provider;
7. Costs that are charged by means of an advance bill;
8. The personal contribution that you pay in accordance with the AWBZ and/or the Social
Support Act (WMO);
9. Attestations, vaccinations or physicals (appointment physicals or physicals for your driving licence or pilot's licence). We will accept
these costs for our account if this has been so
stipulated in or pursuant to the Health Insurance Act;
10. Additional costs, such as administrative costs,
invoicing costs and shipping costs;
11. More than one treatment of the same type in
one day, unless expressly indicated otherwise
in these terms and conditions of insurance or
on you Reimbursements Overview. We understand "type of treatment" to mean the healthcare that is described per Article; 1 Article is 1
type of healthcare.
12. A treatment that is not generally medically
recognised in accordance with the medical
standards that are applicable in the Netherlands or is still in a scientific or experimental
stage;
13 A treatment which, in our opinion, is not intended to counteract the illness or symptoms
or to prevent exacerbation of the illness;
14. A treatment that cannot be considered to be
responsible and suitable healthcare;
15. A treatment for which there is no medical or
dental necessity;
16. Healthcare that does not take place within the
period that your insurance is valid. The date of
treatment is determinative therefore, not the
date on which the invoice was written.
Is the invoice for a DOT healthcare product
code? If the start date for a DOT healthcare
product code falls outside of the period of your
insurance, then all costs that are related to this
entire DOT healthcare product code are not
covered;
17. Healthcare that is not named or described in
our insurance;
18. A treatment that has been given not in the form
of personal (physical) contact but by telephone
or via electronic/digital traffic (e-mail and/or Internet). This is when this type of non-physical
treatment is reasonably impossible or where
the expectation is that it will not produce the
expected results.
For example: manual therapy or inserting a
filling under oral care is not possible by phone,
whereas mental healthcare (GGZ) is possible
digitally (via the Internet). This is indicated in
the terms and conditions for the healthcare
concerned where necessary;
19. Screening;
20. Cost that are involved in:
a. sports massage;
b. occupational therapy and/or recreational
therapy;
c. emergency response training courses.
A.21.2. War risk and terrorism
You are not entitled to the (costs of) the following
treatments:
• Losses that are caused by or arise from an
armed conflict, civil war, insurrection, internal
disorder, civil commotion, revolt and mutiny, as
indicated in Article 3:38 of the Act on Financial
Supervision. We base this on the explanation
of terms for this that the 'Verbond van Verzekeraars' had laid down in a text.
• Terrorism, malicious infection, preventive
measures or preparatory actions and conduct
(collectively we call this "terrorismerisico" (terrorism risk)). We base this on the explanation
of terms that the NHT has laid down in the latest, applicable 'polisblad terrorismedekking'
(terrorism risk policy document) issued by the
NHT.
We will reimburse the costs as a result of these
events (which may take place both in the
Netherlands and abroad) insofar as we are
able to pay them from the amount that we receive from the 'Nederlandse Herverzekeringsmaatschappij voor Terrorismeschaden N.V.'.
(NHT) in Amsterdam.
Insured persons living outside of the Netherlands are not covered by this reinsurance and
therefore cannot receive any reimbursement.
If, after a terrorist action, an additional amount
is made available on the grounds of Article 33
of the Health Insurance Act, the insured person
is entitled to an additional reimbursement to
the level of an amount to be determined based
on that Article.
Explanation:
The NHT describes 'Terrorisme, kwaadwillige
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besmetting en preventieve maatregelen' (Terrorism, malicious infection and preventive measures)
as follows:
Terrorism:
"violent acts and/or conduct - undertaken outside
of the scope of one of the 6 forms of war risk
named in Article 64 section 2 of the Insurance
Supervision Act 1993 - in the form of an attack or
a series of attacks similar in terms of time and
nature as a consequence of which injury and/or
adverse health effects, whether or not leading to
death, and/or damage to property arise or economic interests are otherwise harmed, where it is
plausible that this attack has been planned and/or
perpetrated - whether or not with any organisational cohesion - with the intention of achieving
specific political and/or religious and/or ideological
aims".
Malicious infection:
"the spreading - outside of the scope of one of the
6 forms of war risk named in Article 64 section 2
of the Insurance Supervision Act 1993 - of pathogens and/or substances (or causing them to be
spread) which as a result of their (in)direct physical, biological, radioactive or chemical effects can
cause injury and adverse health effects, whether
or not leading to death, in humans or in animals
and/or can cause damage to or otherwise harm
the economic interests, where it is plausible that
the spreading (or causing to be spread) has been
planned and/or perpetrated - whether or not with
any organisational cohesion - with the intention of
achieving specific political and/or religious and/or
ideological aims".
Preventive measures:
"measures taken by the Government and/or insured persons and/or third parties to avert the
gespecialiseerde GGZimminent threat of terrorism
and/or malicious infection or - if this danger has
materialised - to limit the consequences of it".
Reinsurance by the NHT.
The reinsurance by the NHT covers the costs of
terrorism risk to a maximum of 1 billion euros per
year. This amount can be adjusted from year to
year and applies to all insurers who are associated with the NHT. If there is an adjustment, the
NHT will announce this in 3 national newspapers.
Terrorism policy document
Almost all insurers use the reinsurance provided
by the NHT. A national 'polisblad Terrorisme' (Ter-
rorism Policy Document) has also been published.
You can find more information about this (in
Dutch) on the www.terrorismeverzekerd.nl website.
A.21.3. Nuclear reactions
You are not entitled to (the costs of) treatments
that are the result of nuclear reactions.
If the costs are caused by radioactive material that
finds its way outside of the nuclear facility you are
then entitled if the following conditions are met:
• The national government has granted a permit
for placing the nuclides;
• The location of this material is not in contravention of the Nuclear Incidents (Third-party
Liability) Act;
• A third-party is not liable for the losses incurred
in accordance with Dutch or foreign legislation.
A.21.4. Custody or imprisonment
During the period that you are in custody or are
imprisoned you are not entitled to healthcare or to
reimbursement of the costs for healthcare. Even if
the healthcare that you receive is covered by the
insurance. This applies to both imprisonment/custody in the Netherlands and abroad.
During this period you are reliant on the medical
care that is provided by or on behalf of the establishment where you are detained. In the Netherlands this is provided by the 'Ministerie van Justitie'.
A.22. Disputes
A.22.1. Request for reconsideration
If you do not agree with a decision we have made
relating to the implementation of your health insurance, you can submit a written request for
reconsideration of the decision to our 'Juridische
Zaken' (Legal Affairs) department.
A.22.2. Judge or Arbitration Service
What if you do not agree with the result of the
reconsideration? You can then choose one of the
following options:
• You have recourse to the competent courts if
we do not respond to your request for reconsideration within 4 weeks. You can also do this
if we indicate that we stand by our decision
(and why).
• You can also put your dispute before the
'Geschillencommissie Zorgverzekeringen' (Arbitration Service) of the 'Stichting Klachten en
Geschillen Zorgverzekeringen' (SKGZ), Post-
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bus 291, 3700 AG Zeist (www.skgz.nl (information in Dutch)). The Health Insurance Ombudsman works for this foundation. This Ombudsmen tries to resolve the complaint though
mediation. If this fails, the SKGZ can issue
binding advice.
Once you have chosen one option you can no
longer choose the other option.
A.22.3. E-Court
If you fail to pay us your costs (this includes premium) on time, we can resort to arbitral proceedings using the 'Stichting e-Court' arbitration to
collect this debt. The legal rules for this and the
Arbitration Regulations found on the www.ecourt.nl website are applicable.
A.23. Complaints
A.23.1. Complaint
courts;
• You can put your complaint to the 'Stichting
Klachten en Geschillen Zorgverzekeringen'
(SKGZ). The Health Insurance Ombudsman
works for this foundation. This Ombudsmen
tries to resolve the complaint though mediation. If this fails, the SKGZ can issue binding
advice.
Once you have chosen one option you can no
longer choose the other option.
A.23.3. Complaint about standard forms
If you, healthcare providers or other health insurers find our forms to be too complicated or superfluous, you can submit a complaint about this to
the NZa. The NZa will then issue judgement on
this. This judgement is binding.
A.24. Dutch Law
If you have a complaint that does not relate to the
implementation of your health insurance, please
let us know. You can do this in writing or by
phone. We will make a decision on your complaint
and inform you of the outcome. Dutch law applies to your insurance(s).
A.23.2. Do not agree with the decision
In all cases not provided for in these terms and
conditions of insurance the Management Board or
the Board of Directors will decide how we will
proceed.
What if you do not agree with our decision and
your complaint has not been reasonably resolved? You now have the following options:
• You can take your complaint to the competent
A.25. What if the situation has
not been provided for?
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HEALTH INSURANCE
B.1. Insured healthcare
B.1.1. Classification of insured care
This chapter, B, shows what healthcare is covered
by the health insurance:
• The insured healthcare is described per Article.
For instance, GP care is described in Article
B.3. or the various components of medical
specialist care are described in B.4.1. through
B.4.15.
• The insured healthcare can also comprise
"multidisciplinary care", see Article B.1.2.
• The insured healthcare can also comprise
healthcare other than described in this Chapter, B. We call this "andere zorg" (other care),
see Article B.1.3.
B.1.2. Multidisciplinary care
CHAPTER B
HEALTHCARE IN
Multidisciplinary care is when:
• the insured healthcare is provided in case of:
o Diabetes Mellitus Type II (DM Type II) for
insured persons of 18 years and older;
o Vascular Risk Management (VRM) for cardiovascular diseases;
o the chronic lung complaint, Chronic Obstructive Pulmonary Disease (COPD); and
therefore is provided in accordance with the
healthcare standards applicable to the
aforementioned disorders; and
• the insured healthcare comprises a combination of multiple types of healthcare described
individually in this chapter. Multiple disciplines
are involved such as a general practitioner or
dietician. They work together like links in a
chain; and
• the healthcare is in the form of a total healthcare programme, tailored to your situation and
circumstances; and
• the healthcare provided is organised and coordinated by a healthcare group; and
• The insured healthcare is provided by healthcare providers who are members of a healthcare group or who are separately contracted
by the main treatment provider; and
• the insured healthcare is claimed:
o via this healthcare group as an entirety. In
that case the "Integral costing for the provision of multidisciplinary healthcare for
chronic disorders (DM type 2, VRM,
COPD)" policy guideline of the 'Nederlandse Zorgautoriteit' (NZa), drawn up on
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the basis of the Healthcare Marketing
Regulation Act, applies;
o via the main treatment provider for organisational and coordination costs only, where
organisation and coordination of separately
contracted healthcare providers is involved.
Individual healthcare providers must not claim
multidisciplinary care.
B.1.3. 'Andere zorg' (Other care)
The following conditions apply for "andere zorg"
(other care) mentioned in Article B.1.1.:
• the generally accepted perception is that other
care leads to a comparable result; and
• other care is not legally excluded; and
• we have issued you a statement of approval
for the other care in advance.
B.1.4. Hospitalisation in a class different
to the insured class
If you are admitted to a hospital (establishment for
medical specialist care) and while there are put in
a class that is different to the class that you are
insured for, the rate for the healthcare in the lowest class is applicable.
B.1.5. Start and end of entitlement to
healthcare
You are only entitled to (the reimbursement) of
healthcare that you are entitled to under the terms
and conditions of insurance if you have had that
healthcare in the period that this health insurance
is valid. If you claim for a DOT healthcare product
code that started before the end date for your
insurance, then we assume that the costs for this
have been incurred during the period in which
your health insurance was valid.
B.2. Healthcare abroad
Check your policy document to see if you are entitled to
healthcare (you have 'natura', 'natura direct' or 'natura select'
health insurance) or to reimbursement of healthcare (you have
a 'restitutie' health insurance): see Article A.2.5. also.
B.2.1. Living or staying in Treaty Country
and healthcare in a (different) Treaty
Country
Healthcare: what are you entitled to?
If you live or stay in a Treaty Country and you
obtain healthcare there, or if you temporarily stay
in another Treaty Country (this could also be the
Netherlands!) and obtain healthcare there, you
can choose between:
• healthcare in accordance with the statutory
scheme that applies in that Treaty Country
based on the stipulations of the EU social
regulations or the treaty concerned; or
• (reimbursement of) insured healthcare in accordance with the healthcare that you have
taken out and as described in Article B.2.2.
Please note!
See article A.21. for general exclusions.
B.2.2. Healthcare outside of your country
of residence
What if you use a healthcare provider with whom
we have not entered into an agreement outside of
your country of residence? We will then give you
the same reimbursement as if you had used a
healthcare provider with whom have not entered
into an agreement in the Netherlands. See Article
A.20. for details.
The same terms and conditions apply here as
apply to the healthcare concerned in the Netherlands. We recommend you request advice
beforehand. In this way you will be aware of the
financial consequences of using this foreign
healthcare provider. We do need more information
than found as standard on a referral or prescription to be able to asses the application properly.
This can differ per disorder or treatment.
For example:
You want to consult a medical specialist in a foreign country. If you ask us for a care recommendation beforehand we can tell you:
• whether this is healthcare that is covered by
your insurance;
• if you are reasonably entitled to that healthcare
in your situation;
• whether we can find healthcare providers for
this care in the Netherlands or abroad with
whom we have (indeed) entered into an
agreement;
• if you have to pay some of the cost for this
healthcare yourself. The rates that are allowed
to be used abroad could be higher than in the
Netherlands. And we may not have an agreement with this healthcare provider. There is a
possibility that you may have to pay a higher
rate for the treatment than for a comparable
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treatment in the Netherlands. In addition to
this, you must also take account of any personal contribution based on the social security
system in that country.
Tip:
Are you temporarily abroad, but within Europe or
Australia? In that case you can apply for an EHIC
(European Health Insurance Card, a European
healthcare pass). This pass allows you to obtain
healthcare in countries within the EU, Macedonia,
Norway, Iceland, Lichtenstein, Switzerland and
Australia. So that you don't have to pay anything
in advance. Healthcare providers abroad know
that we will pay their invoices. You may have to
pay a personal contribution because of the social
security system in the country. You may be able
to have this reimbursed under your additional
insurance package.
Please note!
• See article A.21. for general exclusions.
• This healthcare could be insured (additionally)
in an additional insurance package. Your Reimbursements Overview will show whether or
not this is the case.
• Hospitals abroad are familiar with the EHIC but
this is not the case for all general practitioners,
pharmacists and other healthcare providers.
The pass is meant for medically necessary
healthcare that cannot reasonably be delayed
until return to you country of residence, for insured persons who go on holiday or stay
abroad temporarily (to work or study for example). The application for the pass is free of
charge. You can apply via www.ehic.nl (information in Dutch). If you live in a foreign country, you can apply for the pass through the
'College voor Zorgverzekeringen' website:
www.cvz.nl (information in Dutch).
B.3. GP care
B.3.1. Advice, investigation and assistance
comprises, amongst other things:
• healthcare advice;
• treatment;
• laboratory investigation carried out by and in
the GP practice;
• preconception care. This comprises advice on,
amongst other things, the field of:
o healthy diet;
o taking vitamins;
o (brief) advice about, for example, stopping
smoking and alcohol and drugs use;
o the use of medicines;
o infectious diseases and vaccinations;
o diseases and pregnancy complications.
Please note!
The healthcare does not include:
• an MRI scan on request of a general practitioner if referral is for an indication that is not
contained in the guidelines and standards for
general practitioners;
• screening;
• laboratory investigation carried out by a hospital or independent laboratory, even if this is
done at the request of the general practitioner.
This investigation is not GP care and falls
under the deductible.
Terms and Conditions
Healthcare provider
The healthcare is provided by a general practitioner or a healthcare provider within the GP practice, GP services structure or healthcare provider
(such as a practice assistant, nurse or physician
associate).
The healthcare provider within the GP practice,
GP services structure or healthcare groups works
under the final responsibility of the general practitioner.
Rates
We use various rates. The level of the rate depends on the healthcare provider that you use.
See Article A.20. for details.
Location
You receive the healthcare at a GP practice or
After Hours GP Clinic, at your home or at your
temporary residence. In this case we do not
understand temporary residence to mean a establishment for medical specialist care or nursing
home.
The healthcare comprises GP care such as is
customarily provided by general practitioners and
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B.3.2. GP care in a medical specialist field
This relates to healthcare that borders on family
medicine and for which we have entered into a
healthcare agreement with your general practitioner.
This care comprises, amongst other things:
• (minor) surgical procedures;
• audiometry (hearing testing);
• ECG diagnosis (heart tracing);
• doppler testing (blood vessel investigation);
• spirometry (lung function measurement).
See Article B.3.1. The following terms and conditions apply in addition to these terms and conditions:
• The healthcare can also be supplied via the
Internet through a programme that we have
granted recognition.
• The results of an exploratory examination form
and a diagnostic consultation are required to
determine whether or not you can be treated
by a general practitioner.
Healthcare provider
Preferably, a general practitioner will be supported
by the 'POH GGZ' (Practice Assistant GP Mental
Healthcare) if he/she provides healthcare for mild
psychiatric complains.
Please note!
See Article B.3.1.
B.3.3. GP care in the GGZ (mental healthcare) field
GP care also includes healthcare in the field of
GGZ (mental healthcare) and comprises:
• healthcare for minor psychological disorders
(depression for example), if you do not (yet)
have a psychological disorder that requires
treatment under Basic Mental Healthcare (see
Article B.19.1.) or under Specialist Mental
Healthcare (see Article B.19.2.);
• Preventive healthcare for complaints in the
field of depressive disorders, a panic disorder
or problem alcohol use.
• healthcare for a suspected minor psychiatric
disorder. The disorder is not complex, is low
risk and the symptoms are short duration;
• healthcare and support for a stable chronic
situation for a mental healthcare problem with
a low risk and is not crisis prone;
Please note!
The healthcare does not include a psychological
or psychiatric disorder for which treatment is required in the Basic Mental Healthcare (see Article
B.19.1.) or Specialist Mental Healthcare (see Article B.19.2.). The general practitioner can refer
these cases on.
General
B.4. Medical specialist care
B.4.1. Medical specialist care general
The whole of Article B.4. describes medical specialist care. Here you are entitled to medical
healthcare such as is customarily provided by
medical specialists. The specialist mental healthcare also falls under this, but it is described in
Article B.19.2.
This Article also contains oral care by a oral surgeon. The other terms and conditions that apply to
this healthcare are shown in Articles B.12., B.13.
and B.14.
Within the medical specialist care we distinguish
between:
• Medical specialist care with hospitalisation
(see Article B.4.2.);
• Medical specialist care without hospitalisation
(without stay/non-clinical) (see Article B.4.3.);
• Nursing without hospitalisation (see Article
B.4.4.);
• Plastic surgery (see Article B.4.5.);
• Rehabilitation (see Article B.4.6.);
• Organ transplantation (see Article B.4.7);
• Dialysis without hospitalisation (see Article
B.4.8.);
• Mechanical ventilation (see Article B.4.9.);
• Investigation of paediatric cancer (see Article
B.4.10.);
• Thrombosis service (see Article B.4.11);
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• Hereditary disease investigation and advice
(see Article B.4.12.);
• Audiological care (see Article B.4.13);
• Treatments to improve fertility (see Article
B.4.14.)
• Second opinion (see Article B.4.15.).
• Conditional care (see Article B.22)
Please note!
• The following care is not medical specialist
care as described in Article B.4.:
o treatment of the upper eyelids that are
paralysed or weakened or are overhanging
resulting in a surplus of skin, where there is
no birth defect or chronic disorder present
at birth;
o stomach liposuction;
o inserting or replacing a breast prosthesis
during an operation if you have not had a
complete or partial mastectomy;
o removing a breast prosthesis during an operation without there being a medical necessity for this;
o treatment for snoring with uvuloplasty;
o sterilisation treatments;
o treatments to reverse sterilisation;
o a circumcision;
o ear protrusion correction (elephant ears);
o periodontal surgical care during oral surgery where this takes place outside of a
hospital (establishment for medical specialist care);
o treatment with a redression helmet in case
of plagiocephaly and brachycephaly without
craniosynotosis.
Please note!
The following excluded healthcare can be insured
in an additional insurance package. Your Reimbursements Overview will show whether or not
this is the case. This relates to:
• Sterilisation;
• Reversing sterilisation;
• Ear protrusion correction;
• Visual acuity treatments (laser eye surgery);
• Circumcision;
• Corrections of the upper eyelids;
• Cosmetic treatments;
• Treatment for snoring;
• Breast prosthesis replacement;
• Treatment with a redression helmet.
B.4.2. Medical specialist care with hospitalisation
The healthcare comprises:
• medical specialist treatment;
• hospitalisation in the lowest class of an establishment for medical specialist care for a
maximum of 365 days (after 365 the costs are
for the account of the AWBZ);
• stay, nursing and care;
• paramedical care (for example, physiotherapy,
exercise therapy, occupational therapy, speech
therapy, the medicines, medical aids and
dressing materials associated with the treatment;
• laboratory investigation.
Please note!
• Treatments of a plastic surgery nature not
covered by this Article but by Article B.4.5.
• Laboratory investigation at the request of an
alternative healthcare provider is not covered
by your health insurance.
General
The following rules apply to counting the 365
days:
• if your hospitalisation is interrupted for a period
of less than 31 days then the days that the interruption lasts do not count towards the 365
days. The count continues after the interruption;
• if your hospitalisation is interrupted for more
than 30 days then we start the count anew and
you are therefore entitled to (reimbursement
of) healthcare for 365 days;
• if your hospitalisation is interrupted for weekend and holiday leave, then these days of interruption count towards the 365 days.
Healthcare provider
The healthcare is provided by an establishment
for medical specialist care, a medical specialist or
an oral surgeon.
Referral
• Prior to the start of the treatment you have
been referred by a general practitioner, doctor
for the mentally handicapped, specialist in
geriatric medicine, medical specialist, nursing
specialist, youth healthcare physician or company medical officer.
• If it involves the insertion of dental implants,
you have been referred by a dentist prior to the
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start of the treatment.
• If it involves healthcare in relation to pregnancy
and/or a birth, an obstetrician may have referred you prior to the start of the treatment.
• It it involves an eye disorder, you may be referred by an optometrist.
Care recommendation and approval
You must have requested a care recommendation
from us in advance and have received a statement of approval from us if it concerns medical
specialist care which comprises the insertion of
dental implants, osteotomy and the removal of
teeth and molars under anaesthesia. We may
stipulate additional conditions in the statement of
approval.
Rates
Location
The healthcare takes place in hospital (establishment for medical specialist care).
The healthcare is provided by a medical specialist.
Referral
been referred by a general practitioner, obstetrician, doctor for the mentally handicapped,
specialist in geriatric medicine, youth healthcare physician or company medical officer.
• It it involves an eye disorder, you may be referred by an optometrist prior to the start of the
treatment.
Rates
Location
The healthcare takes place in an establishment
for medical specialist care or in the practice of a
medical specialist.
B.4.4. Nursing without hospitalisation
B.4.3. Medical specialist care without hospitalisation
The healthcare comprises medical specialist care
without hospitalisation. This healthcare comprises,
amongst other things:
• treatments that take place without hospitalisation, such as ophthalmology care,
• applying plaster(cast);
• ECG testing.
Healthcare or resources that could form part of
the treatment:
• the nursing;
• the medicines;
• the medical aids;
• the dressing materials;
• laboratory investigation.
Please note!
• Treatments of a plastic surgery nature are not
covered by this Article but by Article B.4.5.
• Laboratory investigation at the request of an
alternative healthcare provider is not covered
Healthcare provider
The care comprises nursing care such as is customarily provided by nurses, without this care
being paired with a stay, and which is required in
connection with the medical specialist care.
Please note!
• The healthcare does not include:
o nursing that is necessary in connection with
the care in the last period prior to death
(palliative terminal care);
o nursing that is required in connection with
mechanical ventilation.
Healthcare provider
The healthcare is provided by a nurse under the
responsibility of a medical specialist. The nurse
must be BIG registered and this must be in relation to the disorder which requires the healthcare,
must have sufficient expertise (for example, by
periodic (refresher) training and instructional sessions). The nurse guarantees the continuity of the
healthcare required.
Referral
You have been referred by a medical specialist or
nurse prior to the start of the treatment.
Rates
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Location
The healthcare takes place in your own home.
B.4.5. Plastic surgery with or without hospitalisation
The healthcare comprises treatments of a plastic
surgery nature in accordance with the standards
of plastic surgeons. It may involve healthcare with
or without hospitalisation. It involves correction to:
• abnormalities in your appearance that cause
demonstrable physical functional disorders.
This involves physical complaints where the
investigation has determined (objectively) that
they have arisen because of the physical abnormality that is to be corrected. A example of
this is: untreatable, continuously present blemished areas in the skin fold with a severely
overhanging stomach.
• mutilation that has occurred as a result of illness, an accident or a medical procedure (an
operation for example). This is the case where
it involves a serious deformation that is immediately obvious in daily life, for example: deformation as a result of burns and amputated
(cut off) legs, arms or breasts;
• upper eyelids that are paralysed or weak or are
overhanging resulting in a surplus of skin,
where there is a birth defect or a chronic disorder already present at birth. In the case of
paralysed, weak or overhanging upper eyelids
as a result of ageing you are not entitled to
plastic surgery treatment to correct the upper
eyelids. You may be entitled to reimbursement
under an additional insurance package;
• primary facial characteristics when transsexuality has been determined;
• the following congenital deformities:
o cleft lip, jaw or palate;
o deformity of the bony face;
o benign uncontrolled growth of blood vessels, lymphatic vessels or connective tissue;
o birthmarks;
o deformities of the urinary tract and sex organs.
o The corrections must be in accordance with
VAGZ (Association of Doctors, Dentists and
Pharmacists Working for Healthcare Insurers) working methods.
Examples of when plastic surgery is insured
healthcare:
• Breast reduction:
you are entitled to a breast reduction if your
cup size is DD/E or bigger (or D cup if you are
smaller than 1.60 metres) with associated,
demonstrable physical complaints. This involves complaints that are caused by the
weight of your breasts and which severely restrict you. Other treatments or therapies have
not alleviated your complaints here. You must
not be overweight and your weight must be
stable. After all, operations on people who are
overweight have a greater risk of complications
and the likelihood of a good outcome is
smaller.
• Correction of uneven breasts in cases other
than following mastectomy:
you are entitled to a reduction if one of your
breasts differs from the other by 2 or more cup
sizes. This can, after all, be seen as deformity.
The entitlement is to a single-sided reduction
only.
• Laser treatment:
this treatment of blood vessels, pigment marks
or other irregularities or skin complaints is covered by health insurance. There must be (noticeable) disfiguration or a demonstrable physical functional disorder. In most case these abnormalities are not seen as such.
• Nose correction:
you are only entitled to a nose correction if
there is a severely restrictive obstruction problem that cannot be treated in another way. Entitlement to correction due to disfiguration or a
congenital deformity is rare.
Please note!
Healthcare provider
Referral
Prior to the start of the treatment you have been
referred by a general practitioner, doctor for the
mentally handicapped, specialist in geriatric medicine, medical specialist, nursing specialist, youth
healthcare physician or company medical officer.
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from us in advance and received a statement of
approval from us if it involves a treatment that
appears on the latest, national list of procedures.
This 'Limitatieve lijst machtigingen medisch specialistische zorg ZN' (Dutch healthcare insurers
exhaustive list of authorisations for medical specialist care) is on our website and available from
us on request. We may stipulate additional conditions in the statement of approval.
Rates
Location
medical specialist.
types of experts (multidisciplinary team) under the
leadership of a medical specialist or rehabilitation
doctor.
Referral
mentally handicapped, specialist in geriatric medicine, company medical officer, medical specialist
or nursing specialist.
Rates
Location
The healthcare takes place in a rehabilitation establishment.
B.4.6.2. Geriatric rehabilitation
B.4.6. Rehabilitation care
B.4.6.1. Rehabilitation
Rehabilitation comprises the healthcare that is the
best method for preventing, reducing or mastering
your handicap. This healthcare comprises:
• stay: this involves rehabilitation for which you
are hospitalised for a number of days. The
multiple day hospitalisation takes place if it is
expected that this would achieve better results
than rehabilitation without hospitalisation;
• part-time or day treatment: this involves rehabilitation without a stay.
Please note!
General
This involves a handicap that is the result of:
• disorders or limitations of the movement capacity;
• a disorder of the central nervous system that
leads to limitations in communication, mental
capacity or behaviour.
As a result of the rehabilitation you can achieve or
maintain a specific degree of independence that is
possible in relation to your limitations.
Healthcare provider
The healthcare is provided by a team of various
Geriatric rehabilitation comprises integral and
multidisciplinary rehabilitation care such as is
customarily provided by specialists in geriatric
medicine in connection with:
• vulnerability;
• complex multi-morbidity; and
• reduced learning capacity and trainability.
The healthcare is aimed at reducing your functional limitations so that you are able to return
home. The healthcare lasts a maximum of 6
months.
Please note!
General
• The geriatric rehabilitation immediately follows
a hospitalisation and stay in an establishment
for medical specialist care as meant in Article
B.4.2.; and
• initially, the geriatric rehabilitation is paired with
a stay as meant in Article B.4.2.; and
• prior to this there has not been a stay and
treatment in an AWBZ establishment for cohesive care. This latter comprises personal care,
nursing, supervision/treatment for an insured
person with a somatic, psychogeriatric or psychiatric disorder/limitation or a mental, physical
or sensory handicap if the insured person is reliant on a protected living environment, a
therapeutic social climate or permanent supervision (Articles 8 and 9 of the Decision Care
Entitlements EMEA ('Besluit zorgaanspraken
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AWBZ')).
Healthcare provider
The healthcare is provided by a team of various
types of experts (multidisciplinary team) under the
leadership of a medical specialist, specialist in
geriatric medicine, or rehabilitation doctor.
Referral
referred by a doctor for the mentally handicapped,
specialist in geriatric medicine or nursing specialist.
If (in exceptional cases) the geriatric rehabilitation
takes longer than 6 months, you must have requested a care recommendation from us advance
and have received a statement of approval from
us.
Rates
Location
The healthcare takes place in a geriatric rehabilitation establishment.
B.4.7. Organ transplantation
B.4.7.1. Care for the recipient of an organ
transplant
For you, the insured person and recipient of an
organ, the healthcare comprises:
• The transplantation of tissues and organs;
• the medical specialist care that is involved in
the implantation in you (the recipient) of the
transplant material from the donor.
• the investigation, the removal, the storage and
the transportation of the transplant material following the death in connection with transplantation. This could involve live donation.
Please note!
General
• The transplant takes placed based upon a
medical grounds that are acceptable for that
type of transplant in accordance with the state
of science and practice.
• The transplantation of tissues and organs is
carried out in:
o a member state of the European Union;
o a state that is party to the European Economic Area Treaty;
o another state if the donor is resident in that
state and is the husband/wife, the registered partner or a 1st, 2nd or 3rd degree
blood relative of the insured person.
Healthcare provider
The healthcare provider must:
• comply with the legally stipulated minimum
requirements for tissue and organ transplantation; and
• be affiliated with a legally authorised and recognised transplant centre.
Referral
mentally handicapped, specialist in geriatric medicine, medical specialist or nursing specialist.
Rates
Location
The healthcare takes place in a recognised transplant centre.
B.4.7.2. Care for the donor of an organ
transplant
In an organ transplant, the care for donor (the
person who donates an organ/tissue to the recipient) comprises:
• hospitalisation and specialist medical care for
the selection or removal of the transplant material up to a maximum of 13 weeks after the
end of this hospitalisation. A maximum of 6
months applies for this in the case of liver
donors.
• transport within the Netherlands based on the
lowest class of public transport. The donor requires this in connection with the selection, the
admission to and the discharge from a hospital
(establishment for medical specialist care).
This transport lasts a maximum of 13 weeks
after the end of the hospitalisation that this is
related to. A maximum of 6 months applies for
this is the case of liver donors,
• if transport is a medical necessity, transport by
car or taxi is also possible instead of by public
transport.
• transport from and to the Netherlands if the
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donor lives abroad and it involves the transplantation of a kidney, liver or bone marrow in
an insured person in the Netherlands.
• costs incurred by the donor in relation to the
transplantation if these costs are related to the
fact that the donor lives abroad. Here we mean
cost that are related to the fact that the screening and the selection of donors takes place
abroad. This involves, for instance, travel costs
abroad to an establishment where the screening takes place and the selection and transport
costs for blood samples. This does not cover
the accommodation costs and any lost income
for the donor living abroad.
The healthcare on behalf of the donor in this section is covered by the insurance for you as the
recipient of the transplanted organs or the organs
to be transplanted. The donor is regarded as the
insured person exclusively for this healthcare.
Please note!
o the accommodation costs in the Netherlands for a donor who is living abroad;
o any income lost by a donor.
See Article B.4.7.1.
B.4.8. Dialysis, without hospitalisation
• haemocatharsis in connection with kidney
problems (haemodyalisis) and stomach lavage
(peritoneal dialysis) without hospitalisation;
• medical specialist care that is related to this
and comprises:
o investigation, treatment and nursing that is
paired with the dialysis;
o and the medicines needed for the treatment;
o your psychosocial supervision.
If the dialysis takes place at your home, then in
addition to the dialysis you are also entitled to:
• training by a dialysis centre for the individuals
who carry out the home dialysis or who assist
in it;
• loan, regular inspection and maintenance (including replacement) of the dialysis equipment
and accessories;
• the chemicals and liquid required for performing the dialysis;
• the necessary expert assistance from the dialysis centre during the dialysis;
• psychosocial supervision of the individuals who
assist in performing the dialysis at home;
• other consumables which may reasonably be
required for the home dialysis.
Based on Article B.17. Medical aids, you are also
entitled to the following healthcare. Please see
our Medical Aids Regulations for details:
• the reasonably expected modifications in and
to the dwelling and restoration to the original
state, insofar as this is not provided for in other
statutory schemes;
• other costs directly related to the home dialysis
that may be considered reasonable, insofar as
they are not provided for in other statutory
schemes.
Please note!
Healthcare provider
The healthcare is provided by or under the final
responsibility of a medical specialist who is an
expert in the field of dialysis.
Referral
nursing specialist prior to the start of the treatment.
from us in advance and have received a statement of approval from us if the dialysis takes
place at your home. We may stipulate additional
conditions in the statement of approval.
Rates
Location
The healthcare takes place is an establishment for
kidney dialysis, at the practice address of the
internist who specialises in kidney diseases
(nephrologist) or at your home.
B.4.9. Mechanical ventilation
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• the necessary mechanical ventilation or the
provision of the equipment required for this, so
that you can use it immediately during any
treatment;
• the relevant medical specialist care;
• the medicines that are involved in the mechanical ventilation.
Please note!
• The healthcare does not include the nursing in
connection with the ventilation at your home,
which is required in connection with the medical specialist care as described in this Article.
Healthcare provider
The healthcare is provided by or under the final
responsibility of a respiratory centre.
Proposed treatment
A medical specialist or nursing specialist has determined that the healthcare is a medical necessity.
Rates
Location
The healthcare takes place in a respiratory centre
or at your home.
B.4.10. Investigation of paediatric cancer
The healthcare for your child comprises the central (referral) diagnosis (determining the medical
cause of the problem), the coordination and registration of the bodily sample that is sent in.
Please note!
Healthcare provider
The healthcare is provided by 'Stichting Kinderoncologie Nederland' (Skion).
Rates
B.4.11. Thrombosis service
The healthcare comprised healthcare for the
thrombosis service and comprises:
• regularly taking blood samples from you;
• the laboratory investigations needed to determine the clotting time of your blood. These investigations are carried out by or under the responsibility of the thrombosis service;
• the equipment with accessories with which you
can check the clotting time of your own blood.
The thrombosis service will make this equipment available to you;
• the training during which you learn how to
handle the equipment which will allow you to
measure the clotting time of your own blood
and the supervision that you are given when
taking these measurements;
• the advice from the thrombosis service about
the use of medicines which could affect blood
clotting.
Please note!
Healthcare provider
The healthcare is provided by a recognised and
authorised thrombosis service.
Proposed treatment
A general practitioner, doctor for the mentally
handicapped, a specialist in geriatric medicine,
your attending medical specialist, nursing specialist or a thrombosis doctor who is affiliated to a
recognised thrombosis service has determined
that the healthcare is a medical necessity.
Rates
Location
The healthcare takes place at a recognised
thrombosis service, at the attending healthcare
provider's practice location or at your home.
B.4.12. Hereditary disease investigation
and advice
The healthcare comprises hereditary disease
investigation and advice comprising the central
(referral) diagnosis (determining the medical
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cause of the problem) coordination and registration of the blood and bone marrow preparations.
This healthcare comprises:
• the investigation of hereditary abnormalities by
means of family-tree investigation, chromosome investigations, biochemical diagnosis,
ultrasound investigation and DNA testing;
• advice on heredity;
• the psychosocial supervision of those involved
in the care;
• investigation of individuals other than yourself
if this is necessary to advise you. These individuals may then receive advice also.
Please note!
Healthcare provider
The healthcare is provided by a clinical geneticist.
Referral
You have been referred by a doctor, medical specialist or nursing specialist prior to the start of the
treatment.
Rates
Location
The healthcare takes place in a legally recognised
and authorised Clinical Genetics Centre, a centre
for advice on heredity. This is an establishment
that has been authorised and holds a permit for
the use of clinical genetic investigation and providing advice on heredity.
B.4.13. Audiological care
Audiological care comprises healthcare that is
related to problems with hearing/the hearing function. Here you are entitled to:
• the investigation of the hearing function;
• the advice relating to the hearing aid that is to
be acquired;
• information about the use of the device;
• the psychosocial care in relation to the problems with the impaired hearing function if necessary;
• the assistance in formulating a diagnosis of
speech and language disorders in children.
Please note!
Healthcare provider
The healthcare is provided by a healthcare provider who meets the legally stipulated minimum
requirements for this healthcare and who is also
affiliated to an establishment for medical specialist
care or an audiology centre.
Referral
mentally handicapped, specialist in geriatric medicine, youth healthcare physician, medical specialist, nursing specialist or company medical
officer.
Rates
Location
The healthcare takes place in the legally recognised and authorised establishment for medical
specialist care or the audiology centre.
B.4.14. Fertility related care
• the 1st, 2nd and 3rd attempt using the in vitro
fertilisation method (IVF), per achieved pregnancy and
• the medicines used for this in accordance with
the Medicines Reimbursement System (GVS)
(see Article B.15.).
An ICSI treatment (intra-cytoplastic sperm injection) is equivalent to IVF. National criteria apply
for the reimbursement of egg cell donation.
Please note!
o fertility related care if you are older than 43
years, except:
- if you were 43 years or older on 31
December 2012 and an IVF attempt at
was started no later than on that date; or
- if you were younger than 43 years at the
start of an IVF attempt;
o you are then entitled to completion of that
attempt at our expense;
o the 1st and 2nd IVF attempt per pregnancy
to be achieved if more than 1 embryo is implanted and you are younger than 38 years;
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o the 4th or subsequent IVF attempt per
pregnancy to be achieved;
o treatment of the donor of the egg cell and
donation of the egg cell in case of egg cell
donation treatment.
• An achieved pregnancy means:
o a pregnancy of at least 10 weeks, calculated from the time of follicle puncture; or
o A pregnancy of at least 9 weeks and 3 days
calculated from the implantation in the case
of re-implantation of cryopreserved (frozen)
embryos;
o a pregnancy of at least 12 weeks calculated
from the 1st day of the last menstruation in
case of a spontaneously originated (physiological) pregnancy.
• An IVF attempt consists of 4 phases:
o Phase 1: Hormone treatment that stimulates the maturation of the egg cells;
o Phase 2: Follicle puncture (obtaining the
mature egg cells);
o Phase 3: Fertilisation of the egg cells and
growing the embryos in the laboratory;
o Phase 4: One or more implants of 1 or 2
embryos into the womb.
A success is when phase 2 (the follicle puncture) is successful. Replacement of previously
obtained (frozen) embryos forms part of the attempt in which the embryos are obtained.
Examples:
• You have a 3rd attempt. In this attempt a follicle puncture is carried out. After a couple of
weeks things go wrong. A subsequent (4th) attempt is not covered by your health insurance.
• You have a 3rd attempt. In this attempt a follicle puncture is carried out. After a couple of
weeks things go wrong, but there are still some
frozen embryos. The replacement of one or
more is permitted. This is still part of the 3rd attempt. If it were the 1st or 2nd attempt, then
only one embryo would be allowed to be replaced at one time.
• You have a 3rd attempt. In this attempt a follicle puncture is carried out. After 14 weeks
things go wrong. You are then entitled to 3 new
attempts because a pregnancy was achieved.
• You have had 3 attempts without result. After a
while, you become pregnant without medical
intervention. You are then entitled to 3 new attempts.
Healthcare provider
The treatment is provided by a gynaecologist.
Referral
nurse prior to the start of the treatment.
Rates
Location
The healthcare takes place in a establishment that
holds a permit for this.
B.4.15. Second opinion
The healthcare comprises a second opinion. We
understand this to mean a consultation about a
diagnosis that has been made or a proposed
nd
treatment with a 2 , independent medical specialist who is working in the same specialism or
field of expertise as the healthcare provider who
was consulted 1st.
Please note!
General
• The second opinion relates to your medical
care;
• You return to the original healthcare provider
with the second opinion; they retain control of
your treatment.
Healthcare provider
The healthcare is provided by a medical specialist
or oral surgeon.
Referral
A separate referral from the general practitioner,
medical specialist or nursing specialist who is
treating you is required prior to the start of the
treatment for a second opinion.
Rates
Location
medical specialist.
B.5. Prenatal care
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B.5.1. Obstetric care
• obstetric care such as obstetricians and general practitioners or
• medical specialist care such as medical specialists
customarily provide during the pregnancy.
Please note!
Healthcare provider
The supervision of the pregnancy without medical
necessity is provided by an obstetrician or a general practitioner. The supervision of the pregnancy
with medical necessity is provided by a medical
specialist.
Referral
A referral by a general practitioner or obstetrician
is required prior to start of the treatment if a medical specialist or nursing specialist provides the
healthcare.
Rates
Location
The supervision of the pregnancy without medical
necessity takes place in an obstetrician's practice,
a general practitioner's practice or at your home.
The supervision of the pregnancy with medical
necessity takes place in an establishment for
medical specialist care.
B.5.2. Ultrasonography
Healthcare provider
The ultrasonography is carried out by a medical
specialist, general practitioner, obstetrician or
sonographer.
Referral
is required prior to start of the treatment if a medical specialist, nursing specialist, or sonographer
provides the healthcare. A referral is not required
if the obstetric care is provided by a specialist.
Rates
Location
for medical specialist care, in the practice of the
medical specialist, general practitioner or obstetrician, in an ultrasound centre/prenatal screening
centre or in a general practitioners' laboratory.
B.5.3. Prenatal screening
The healthcare comprises prenatal screening.
This prenatal screening comprises:
• counselling for pregnant women of all ages.
During the counselling you will receive an explanation of the prenatal screening;
• the Structural Ultrasound Scan (SEO) for
pregnant women of all ages (also know as the
'20-wekenecho' (20-week scan));
• the combined test for pregnant women 36
years and older. The combined test comprises
the NT measurement (also known as the 'nekplooimeting' (nuchal fold measurement)) and
serum test (blood test);
• the combination test for pregnant women
younger than 36 years if there are medical
grounds.
Please note!
The healthcare comprises ultrasonography.
Please note!
Healthcare provider
The ultrasonography is performed by a medical
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sonographer who:
• has a permit for this pursuant to the Population
Screening Act (WBO) or
• has a collaboration agreement with a 'Regionaal Centrum voor Prenatale Screening'
(Regional Prenatal Screening Centre) which
has a permit pursuant to the Population
Screening Act (WBO).
Referral
is required prior to start of the treatment if a medical specialist, nursing specialist, or sonographer
provides the healthcare. A referral is not required
if the obstetric care is provided by a specialist.
Rates
Location
medical specialist or obstetrician, in an ultrasound
centre/prenatal screening centre or in a general
practitioners' laboratory.
B.5.4. Registration and intake for postnatal care
The healthcare comprises registration and intake
for postnatal care. The intake comprises discussing the postnatal care (both the content and the
number of hours) that you will received after the
birth.
Please note!
• The registration and intake are covered by
your health insurance only once per pregnancy.
• The costs for any registration at a birthing
centre are not reimbursed.
Healthcare provider
The registration and intake is done by a maternity
centre.
Rates
Location
The registration and intake can take place at your
home or by telephone.
B.6. Care during childbirth
• obstetric care such as is customarily provided
by obstetricians or
• medical specialist care such as is customarily
provided by medical specialists
during the birth (including pre and post care). The
healthcare can take place with or without medical
necessity.
During the healthcare the assistance of an nurse
or maternity nurse should also be provided during
the birth (parturition assistance) based on the
"Inhoudelijk Kader Partusassistentie" (Substantive
Framework Parturition) to the maximum number
of hours as determined by the obstetrician in accordance with the "Kraamzorg, Landelijk Indicatieprotocol" (National Maternity Care Indication
Protocol).
You can request this Framework and Indication
Protocol from us or find it on our website.
We understand birth to mean the end of the pregnancy after the 18th week.
Please note!
• You pay a personal contribution. In the event
of an outpatient childbirth or birth in a birthing
centre without medical necessity, you must pay
a sum of € 16.50 per person per day yourself
for mother and child(ren).
• If more than € 116.50 per person per day is
requested, you must pay the amount above the
€ 116.50 yourself.
• The maximum reimbursement per day and the
personal contribution per day remains the
same regardless of whether there is 1 child or
a multiple birth.
Examples:
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• Suppose that the establishment requires
€ 130.00 per person per day. We have made
the following agreement with the establishment:
o We refund all of this amount to the establishment;
o We will invoice you the personal contribution of € 16.50 per day for mother and
€ 16.50 per day for the child.
o We will also invoice you the amount above
the € 116.50 per person per day. In this
case that is € 130.00 minus € 116.50 =
€ 13.50 per person per day. So you have to
pay this yourself, and you also have to pay
the fixed personal contribution.
• Imagine, you give birth in a hospital or birthing
centre without medical necessity, without hospitalisation. We therefore reimburse 2x
€ 116.50 per day for mother and child. The
total reimbursement is € 233.00 for this birth
but we deduct € 16.50 each for personal contribution; this is € 33.00. You therefore receive
€ 233.00 minus € 33.00 = € 200.00 per day
from us.
Healthcare provider
The medically necessary birthing is provided by a
medical specialist.
A birthing without medical grounds can also be
provided by an obstetrician or a general practitioner.
Referral
is required prior to the start of the treatment for a
birth on medical grounds.
Rates
Location
The medically necessary delivery takes place in
an establishment for medical specialist care. In
the case of a birth without medical grounds the
healthcare can also be provided in a birthing
centre with which we have an agreement, or in
your home.
B.7. Healthcare following childbirth
• postnatal care for mother and child(ren) such
as is customarily provided by maternity nurses;
• obstetrician and medical specialist care (the
latter if there is a medical necessity) and any
stay in an establishment after the birth for
mother and child such as is customarily provided by obstetricians and medical specialists
respectively;
• during the period of hospitalisation, medicine
and dressing materials that are associated with
the specialist care.
The postnatal care follows immediately after the
mother has given birth. The postnatal care is only
meant for the biological mother of the born child or
born children. Postnatal care at home normally
lasts 8 days. Your number of days postnatal care
and your number of hours per day are determined
by the obstetrician or medical specialist in accordance with national indication agreements. These
agreements can be found in the National Maternity Care Indication Protocol. You can request this
Protocol from us or find it on our website.
A further 2 days can be added to this on medical
grounds. The additional number of days and the
number of hours/days postnatal care elsewhere
depends on the judgement of the obstetrician or
medical specialist. They discuss this with the establishment that is to provide the postnatal care.
In the case of medical grounds you are then also
entitled to stay and obstetric and medical specialist are in an establishment for medical specialist care from the day after the birth. You postnatal care is included in this stay. The number of
remaining hours/days postnatal care is determined based on the number of days hospitalisation/days that you stay.
Please note!
• In the following cases, a personal contribution
applies to postnatal care:
o in the maternity hotel or at home, a personal contribution of € 4.10 per hour applies;
o for postnatal care without medical necessity
in an establishment for medical specialist
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care, a birthing centre or in a maternity hotel, you must pay a sum of € 16.50 per person per day yourself (personal contribution)
for mother and child(ren);
o if the establishment requests more than
€ 116.50 per person per day you must pay
the amount above the € 116.50 yourself.
Healthcare provider
The postnatal obstetric care (maternity bed
checks) during the maternity period is provided by
an obstetrician or medical specialist.
The postnatal care is provided by:
• a maternity nurse:
o in the service of a contracted establishment
that organises the postnatal care,
o holds all the necessary diplomas, and
o works in accordance with the National Indication Protocol; or
• a birthing centre of maternity hotel; or
• and independently operating maternity nurse
or a maternity nurse employed by a noncontracted establishment:
o has all necessary diplomas, and
o works in accordance with the National Indication Protocol and
o is registered in the Quality Register of Maternity Nurses of the 'Kenniscentrum
Kraamzorg'.
During the stay on medical grounds in an establishment for medical specialist care the postnatal
care is included in the nursing and care. The
medical specialist care is provided by a medical
specialist or obstetrician.
Referral
If the stay and care for the mother and/or
child(ren) on medical grounds takes place in an
establishment for medical specialist care, then
prior to the start of the treatment a referral by the
obstetrician, general practitioner, medical specialist or nursing specialist is required for this in
advance.
You must contact our Postnatal Care Service
department before the twentieth week or in the 4th
month of your pregnancy so that we can organise
postnatal care for you.
Rates
We use various rates. The level of the rate de-
pends on the healthcare provider that you use.
Location
The healthcare on medical ground takes place in
an establishment for medical specialist care. The
remaining postnatal care is provided in an establishment that is legally recognised (birthing centre,
maternity hotel or at your (temporary) residence or
own home.
B.8. Physiotherapy and/or Cesar/Mensendieck exercise
therapy
B.8.1. Physiotherapy and/or
therapy from 18 years of age
exercise
If you are 18 years or older you are only entitled to
physiotherapy and/or exercise therapy is you have
limitations from a disorder that appears on the
'Lijst met aandoeningen voor fysiotherapie en/of
oefentherapie' (List of disorders for physiotherapy
and/or exercise therapy).
You can find this list (Enclosure 1 to the Health
Insurance Decree) on our website or can request
it from us.
Per disorder (named on the list) the healthcare
comprises the necessary physiotherapy and/or
exercise therapy treatment from the 21st treatment (so not treatments 1 through 20).
If you are treated for a disorder for which a maximum period is shown on the list, you are entitled
to treatments up to no later than the end of this
period.
Please note!
• Please see Article B.8.3. for the terms and
conditions.
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B.8.2. Pelvic physiotherapy from the age
of 18
If you are 18 years or older, the healthcare comprises a maximum of 9 pelvic physiotherapy
treatments in connection with urine incontinence.
Please note!
conditions.
B.8.3. Physiotherapy and/or
therapy up to 18 years of age
exercise
If you are younger than 18 years, the healthcare
comprises physiotherapy and/or exercise therapy
if you have limitations from a disorders:
• which appears on the 'Lijst met aandoeningen
voor fysiotherapie en/of oefentherapie'.
You can find this list (Enclosure 1 to the Health
Insurance Decree) on our website or can request it from us.
You are entitled to the necessary treatments
from the 1st treatment. If you are treated for a
disorder for which a maximum period is shown
on the list, you are entitled to treatments up to
no later than the end of this period;
• which appears on the 'Lijst met aandoeningen
voor fysiotherapie en/of oefentherapie'.
You are entitled to 9 treatments per year per
disorder. If you are still suffering from this disorder after 9 treatments, you are entitled to a
maximum of 9 additional treatments for this
disorder; the total therefore comes to 18 treatments.
Please note!
Terms and conditions (B.8.1., B.8.2. and
B.8.3.)
General
• These terms and conditions apply to insured
persons of all ages.
• Physiotherapy is healthcare such as is customarily provided by physiotherapists.
• Cesar or Mensendieck exercise therapy is
exercise therapists.
• This section 'physiotherapy and/or exercise
therapy' also covers, for example, therapies offered by a paediatric (physio or exercise)
therapist, manual therapist, pelvic therapist,
geriatrics physiotherapist and oedema physiotherapist.
Healthcare provider
• A physiotherapist provides physiotherapy.
• A manual therapist provides the physical
therapy.
• A pelvic physiotherapist provides the pelvic
physiotherapy.
• A paediatric physiotherapist provides the paediatric physiotherapy. That is a physiotherapist
who is registered as an paediatric physiotherapist in the 'Centraal Kwaliteitsregister Fysiotherapie'.
• A geriatrics physiotherapist provides the geriatrics physiotherapy.
• An oedema physiotherapist or skin therapist
provides the oedema physiotherapy.
• A Cesar or Mensendieck exercise therapist
provides the exercise therapy.
• A Cesar or Mensendieck paediatric therapist
provides the paediatric exercise therapy. That
is a exercise therapist who is registered as a
paediatric physiotherapist in the 'Kwaliteitsregister Paramedici'.
Referral
Prior to the start of the treatment a statement is
required from a general practitioner, doctor for the
mentally handicapped, specialist in geriatric medicine, youth healthcare physician, dentist, company medical officer or medical specialist if it involves a disorder that appears on the list (Enclosure 1 to the Healthcare Decree) or if involves
pelvic physiotherapy in connection with urine incontinence.
• You do not need to request a statement of
approval from us if you use a physiotherapist
or exercise therapist with whom we have entered into a healthcare agreement. You can
find those healthcare providers on our website.
On our behalf, the physiotherapist will assess
whether your disorder appears on the "Lijst
met aandoeningen voor fysiotherapie en/of oefentherapie" (List of disorders for physiotherapy and/or exercise therapy) or whether it involves pelvic physiotherapy in connection with
urine incontinence.
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• If you are not sure if your disorder falls under
one of these disorders, we recommend that
you request a care recommendation from us
beforehand.
• If you need both physiotherapy and exercise
therapy at one specific time or if you are
treated by 2 different physiotherapists or by 2
different exercise therapists for a specific period, you must then request a statement of approval from us in advance.
Rates
Location
The healthcare takes place:
• in the practice of the attending healthcare provider or
• at the physiotherapy or exercise therapy department of an establishment as meant under
the Care Institutions Act where physiotherapy
and exercise therapy is given to patients without there being any hospitalisation, or
• at your own home if this is a medical necessity.
B.9. Occupational therapy
The healthcare comprises occupational therapy
such as is customarily provided by occupational
therapists for a maximum of 10 treatments per
year. This comprises, advice, instruction, training
or treatment with the aim of stimulating or restoring your ability to care for yourself and your ability
to live independently .
Please note!
Healthcare provider
The healthcare is provided by an occupational
therapist.
Referral
Rates
Location
• in the practice of the attending occupational
therapist or
• at the occupational therapy department of an
establishment as meant under the Care Institutions Act where occupational therapy is given
to patients without there being any hospitalisation, or
B.10. Speech therapy
The healthcare comprises speech therapy such
as is customarily provided by speech therapists.
The speech therapy has a medical aim and leads
to an improvement in or restoration of the speech
function or the speech capacity.
Speech therapy also includes individual stammer
therapy treatments.
Please note!
o treatment with an educational aim;
o treatments for speech development disorders in connection with dialect and being
a non-native speaker;
o dyslexia care (see Article B.20. for details);
o group stammer therapy using the Del Ferro,
BOMA or INS method (see Article D.5. for
details).
Healthcare provider
The healthcare is provided by a speech therapist.
Referral
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mentally handicapped, specialist in geriatric medicine, youth healthcare physician, company medical officer, dentist, medical specialist or nursing
specialist.
Rates
Location
• in the practice of the attending speech therapist or
• at the speech therapy department of an establishment as meant under the Care Institutions
Act where speech therapy is given to patients
without there being any hospitalisation, or
B.11. Dietary advice
B.11.1. Dietary advice for chronic indications
The healthcare comprises dietary advice in the
fields of nutrition and eating habits such as is customarily provided by dieticians. This comprises
information and advice in the case of one or more
of these chronic indications:
• Diabetes Mellitus Type II (DM Type II) for insured persons of 18 years and older;
• increased Vascular Risk (VRM);
• chronic lung disorder, Chronic Obstructive
Pulmonary Disease (COPD).
The healthcare is provided:
• in the form of multidisciplinary care (see Article
B.1.2. also for "multidisciplinary care") and is
provided by a healthcare group. A healthcare
group always has a healthcare agreement or
Internet agreement with us. This healthcare is
reimbursed in full;
• by a coordinated, multidisciplinary partnership.
This is not a healthcare group. You are entitled
to 3 hours of treatment per year.
Please note!
Healthcare provider
Multidisciplinary care is provided by a healthcare
provider who specialises in Diabetes, COPD
and/or vascular risk management and who is a
member of:
• a healthcare group; or
• a multidisciplinary partnership (not being a
healthcare group) of healthcare providers who
provide coordinated treatments for the specified disorders.
In the case of a healthcare group, the healthcare
group submits claims as such. Individual healthcare providers do not submit claims, not even if
they are members of the healthcare group.
In a multidisciplinary partnership, the individual
(member) healthcare providers submit claims.
Referral
You have been referred by a general practitioner
prior to the start of the treatment.
Proposed treatment
A general practitioner has determined that the
healthcare is a medical necessity.
Rates
Location
The healthcare is provided at the location where a
healthcare provider works, at your residential address or at another suitable location that you
agree with the healthcare provider.
B.11.2. Dietary advice in other cases
The healthcare comprises dietary advice in the
fields of nutrition and eating habits such as is customarily provided by dieticians. This comprises
information and advice without there being one or
more chronic indications which are named in Article B.11.1. You are entitled to 3 hours of treatment per year.
Please note!
• You are entitled to reimbursement of dietary
advice if you already receive dietary advice on
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the grounds of Article B.11.1. from a healthcare group contracted by us.
General
There must be a medical necessity for the dietary
advice.
Healthcare provider
The healthcare is provided by a dietician.
Referral
mentally handicapped, specialist in geriatric medicine, youth healthcare physician, dentist, company medical officer, dentist medical specialist or
nursing specialist.
Rates
Location
• in the practice of the attending dietician or
• at the dietary advice department of an establishment as meant under the Care Institutions
Act where dietary advice is given to patients
without there being any hospitalisation, or
B.12. Oral care for all ages
B.12.1. Oral care in special circumstances.
The comprises oral care such as is customarily
provided by dentists. This oral care in special
circumstances is necessary because:
• You have a serious development disorder,
growth disorder or acquired disorder of the
teeth-jaw-mouth; and
• you have a non-dental, physical or mental
disorder; and
• you receive a medical treatment which has
delivered demonstrably inadequate results
without dental care. This dental care generally
involves making the mouth infection-free by,
for example, a periodontal treatment, the ex-
traction of (one or more) teeth and/or (one or
more) molars, of by administering antibiotics.
Without this oral care your teeth cannot maintain
or obtain the normal function that they would have
had without the disorder.
For example:
This involves people with the following disorders:
• heart disorders;
• diabetes mellitus;
• lichen planus (skin disorder in the mouth);
• multiple sclerosis;
• lung infection.
It may involve people who are treated using the
following therapies:
• radiotherapy in the head-neck area;
• chemotherapy;
• intravenous bisphosphonates (medicines that
are injected into the arteries to counteract the
breakdown of bone tissue);
• calcium antagonists (agent that is used for
certain heart complaints);
• phenytoin-like preparations (agent that can be
used for, amongst others, epilepsy).
In addition, it may be necessary to make the
mouth infection-free:
• in oncology patients in whom the immune system is in danger of being compromised;
• in the case of periodontitis (severe gum infection) as a complication of immune, blood or
metabolic diseases;
• within the scope of preventing systemic complications in endocarditis (infection of the inner
wall of the heart), heart-valve disorders, stem
cell transplantation, kidney failure and organ
transplantation.
Please note!
• If you are 18 years or older, and you receive
oral care when one of the aforementioned indications has not been diagnosed, then this oral
care will not be reimbursed under Article
B.12.1.
conditions.
B.12.2. Dental implants
This healthcare involves the insertion of a dental
implant and the attachment of the fixed part of
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superstructure (the click-system):
• in the case of a very seriously shrunken, toothless jaw to which the removable prosthesis can
be fixed; and
• if you have a serious development disorder,
growth disorder or acquired abnormality of the
teeth-jaw-mouth, such as named under B.12.1.
and your teeth cannot maintain or obtain their
normal function, which they would have had
without that disorder, without that dental care.
Please note!
• A personal contribution of € 125.00 per jaw
applies for the full set of dentures that is fixed
to a dental implant.
conditions.
B.12.3. Orthodontics
Orthodontics is covered by your health insurance
if:
• you meet the requirements mentioned in Article B.12.1.; and
• there is a very serious development or growth
disorder of the teeth-jaw-mouth where joint diagnosis or joint treatment by disciplines other
than dental medicine is required.
Please note!
Terms and conditions (B.12.1., B.12.2. and
B.12.3.)
General
If prosthetic follow-up treatment is required during
combined orthodontics and oral surgery treatment, a multidisciplinary treatment plan must be
drawn up by all of the healthcare providers involved.
Healthcare provider
• The healthcare under B.12.1. is provided by a
dentist, oral hygienist, oral surgeon, orthodontist or an authorised oral healthcare provider
who is affiliated with an oral healthcare centre
or Centre for Special Dentistry (CBT).
• The healthcare under B.12.2. is provided by a
dentist, oral surgeon or an authorised oral
healthcare provider who is affiliated with an
oral healthcare centre or Centre for Special
Dentistry (CBT);
• The healthcare under B.12.3 is provided by a
registered orthodontist;
• In the case of a dentistry treatment under general anaesthesia or nitrous oxide sedation this
is provided:
o in a Centre for Special Dentistry (CBT) recognised by COBIJT ('Centraal Overleg Bijzondere Tandheelkunde') or
o by a healthcare provider with whom we
have entered into written agreements for
this treatment.
Referral
If it involves the insertion of dental implants you
need to have a referral from a dentist, orthodontist
or dentist-implantologist prior to the start of the
treatment.
• You must have requested a care recommendation from us in advance and have received a
statement of approval from us for the healthcare under B.12.1. We may stipulate additional
• At the start there is a written justification from
the dentist and a treatment plan in writing. We
can also withdraw our approval if:
o the oral care is no longer necessary;
o you seriously neglect your oral hygiene;
o you do not follow the instructions of the
• You request a care recommendation and
statement of approval from us before the insertion of a dental implant and the fixed part of the
superstructure (to which the removable part of
the dentures can be affixed to the jaw). You
must have a seriously shrunken jaw for this.
You must also forward a treatment plan justified in writing along with the healthcare request.
Rates
Location
• in the establishment for medical specialist
care;
• in a dental practice;
• in a oral care centre;
• In a Centre for Special Dentistry (CBT),
• in the practice of the orthodontist, or
• at the location where you are staying (so in a
place other than where the healthcare provider
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has his/her practice); you require a written recommendation from the general practitioner or
the specialist for this.
B.13. Oral care up to 18 years
The healthcare comprises care such as is customarily provided by dentists. In addition to the
healthcare described in Article B.12. this care
comprises:
a. one periodic, preventive dental examination
per year, more often if this is deemed to be a
dental necessity;
b. incidental dental consultation;
c. removal of tartar;
d. the application of fluoride a maximum of 2
times per year on children from the cutting of
the permanent teeth elements (so not the milk
teeth);
e. the application of a protective layer of lacquer
on the top of the molars (fissure sealant lacquer);
f. treatment of the supporting tissue for teeth and
molars, such as the gums (periodontal aid);
g. anaesthesia (local anaesthesia);
j. tooth nerve treatment (endodontic care);
i. restoration of (filling) teeth or molars with plastic materials;
j. treating the jaw joint (gnathological care);
k. removable dentures;
l. replacing teeth with non-plastic materials and
the insertion of dental implants, which are
needed to replace one or more missing, permanent incisors or canines which have not
grown, or which are missing as a direct result
of a recent accident;
m. surgical dental care, with the exception of inserting dental implants;
n. x-ray examination, with the exception of x-ray
examination for orthodontic care.
Please note!
o crowns, bridges and implants, except where
there is oral care in special cases (see Article B.12.1) or if front teeth, incisors or ca-
nines are missing as the direct result of an
accident or because they have not grown);
o orthodontic care and the associated x-rays,
except in the case of oral care in special
cases (see Article B.12.1);
o mouthpiece or gum shield (indicated by the
code M61) or care and the associated xrays except in the case of oral care in special cases (see Article B.12.1);
o external whitening of teeth (indicated by
code E97 or E98);
General
You are younger than 18 years.
Healthcare provider
The healthcare is provided by a dentist, oral surgeon or authorised healthcare provider affiliated
with a oral care centre, Centre for Special Dentistry (CBT), an establishment for youth dental
care or an establishment for medical specialist
care.
Healthcare in Article B.13.a through f and i (insofar as authorised for this) can also be provided by
an oral hygienist.
• You must have requested a care recommendation from us in advance and have received a
statement of approval from us if it involves:
o the replacement and/or restoration of teeth
and/or molars with non-plastic materials;
o the insertion of dental implants, which are
needed to replace one or more missing,
permanent incisors or canines which are
missing as a direct result of a recent accident;
o the insertion of dental implants, for elements that have not grown in the case of
oligodontia for the restoration of the function.
• The healthcare request includes a written justification from the dentist and a treatment plan in
writing.
We can withdraw our approval if:
o the oral care is no longer necessary,
o you do not follow the instructions of the
healthcare provider, or
o you seriously neglect your oral hygiene.
• You must also have a statement of approval
from us for the following healthcare by a den-
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tist-specialist oral diseases and oral surgeon:
o treatment of the supporting tissue for teeth
and molars, such as the gums (periodontal
care);
o extracting teeth or molars under general
anaesthesia or nitrous oxide sedation;
o jaw surgery (osteotomy);
o inserting a dental implant.
We may stipulate additional conditions in the
statement of approval.
• Our approval is also required if you obtain oral
care in a Centre for Special Dentistry (CBT).
Rates
B.14. Oral care from 18 years
In addition to the healthcare described in Article
B.12., the healthcare comprises:
a. medical specialist care: this comprises oral
care for oral, jaw and facial surgery such as is
customarily provided by medical specialists.
This oral care comprises:
o specialist surgical oral care;
o the x-ray examination associated with this;
o hospitalisation in the lowest class of a hospital (establishment for medical specialist
care) and during the period of hospitalisation the medical specialist treatment, the
accommodation, the nursing and the care,
the paramedical care, the medicines, medical aids and dressing materials associated
with the treatment for a maximum of 365
days.
b. removable full set of dentures: this comprises
oral care to the standards of dentists and comprises:
o a reimbursement of 75% of the costs of
making and fitting:
- a removable full set of dentures; or
- a temporary, removable (immediate) full
set of dentures; or
- a removable full replacement prosthesis;
or
- a removable, full overdenture for the
upper and/or lower jaw;
o a reimbursement of 100% of the costs of
repairing and/or rebasing:
- an existing, removable full set of dentures; or
- an existing, removable full overdenture,
not on implants.
Please note!
o periodontal surgery by an oral surgeon
(surgery on the supporting tissues of the
teeth and molars, such as the gums);
o the insertion of a dental implant;
o uncomplicated extractions;
• You do not have a higher entitlement than we
have issued a statement of approval for.
General
A hospitalisation must be a medical necessity in
connection with the specialist surgical oral care.
The following rules apply to counting the 365 days
on hospitalisation in a hospital:
• if your hospitalisation is interrupted for a period
of less than 31 days then the days that the interruption lasts do not count towards the 365
days. The count continues after the interruption;
• if your hospitalisation is interrupted for more
you are therefore entitled to (reimbursement
of) healthcare for 365 days;
• if your hospitalisation is interrupted for weekend and holiday leave, then these days of interruption count towards the 365 days.
Healthcare provider
• The medical specialist oral care as mentioned
in Article B.14.a. is provided by an oral surgeon.
• The oral care relating to the removable, full
dentures as mentioned in Article B.14.b. is
provided by:
o a dentist, or
o a clinical dental technician, or
o an authorised healthcare provider affiliated
to an oral care centre or Centre for Special
Dentistry (CBT), or
o a clinical dental technician if it involves:
- making and supplying a new, removable
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full set of dentures for upper and/or
lower jaw, not on implants or on natural
elements (own teeth or molars);
- making a removable full set of dentures
for upper and/or lower jaw, not on implants or on natural elements (own teeth
or molars) fit again (rebasing) or repairing them.
• A dentist, clinical dental technician, oral care
centre or Centre of Special Dentistry must
submit the costs of the removable full set of
dentures named in Article B.14.b.
Referral
referred by a dentist, orthodontist or general practitioner if you require oral care from an oral surgeon.
from us in advance and have received a statement of approval from us if:
• it involves the following healthcare from an oral
surgeon:
o treatment of the supporting tissue for teeth
and molars, such as the gums (periodontal
care);
o the extraction of teeth or molars under general anaesthesia or nitrous oxide sedation;
o jaw surgery (osteotomy).
• the total costs (including technology costs) of
the full upper and lower prosthesis that is
made and fitted by a dentist is more than
€ 650.00 per jaw;
• the total costs (including technology costs) of
the full upper and lower prosthesis that is
made and fitted by a clinical dental technician
is more than € 550.00 per jaw;
• the full upper and/or lower prosthesis is replaced within 5 years of acquisition. This does
not apply to a temporary, removable full set of
dentures (immediate denture).
Rates
Location
• The specialist oral care as mentioned in Article
B.14.a. takes place in a establishment for
medical specialist care;
• The oral care relating to the removable, full
denture as mentioned in Article B.14.b. takes
place in a dental practice, oral care centre,
Centre for Special Dentistry (CBT) or in the
practice of a clinical dental technician.
B.15. Medicines
We use the following classifications:
• General terms and conditions (Article B.15.1.);
• Medication assessment for chronic use (Article
B.15.2);
• Self-care medicines and antacids (Article
B.15.3.);
• Medicines prepared by the pharmacy (Article
B.15.4.).
B.15.1. Medicines, general
The healthcare comprises (the dispensation of
and advice on) medicines that are included in the
Medicines Reimbursement System (GVS). This
involves enclosures 1 and 2 to the Regulation on
Healthcare Insurance.
The Pharmacy Regulations form part of these
terms and conditions. These Regulations contain
the following lists:
• Medicines in Enclosure 2 to the Regulation on
Healthcare Insurance;
• List of Medicines Transferred to the Hospital;
• List of Preferred Medicines.
You can find the Pharmacy Regulations on our
website or request them from us by phone.
B.15.1.a. Medicines
The Minister for Health, Welfare and Sport (VWS)
has drawn up the Medicines Reimbursement System (GVS). This is a list containing all registered
medicines (Enclosure 1) that you may be entitled
to. Occasionally, further conditions are stipulated
in relation to, for example, the indication (Enclosure 2), see the Pharmacy Regulations also. You
can find Enclosures 1 and 2 on www.wetten.nl
(information in Dutch).
The Medicines Reimbursement System (GVS)
stipulates whether a medicine is reimbursed in full
or if a personal contribution applies.
You may also be entitled to non-registered medi-
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cines, a pharmacy preparation (magistral preparation) for example. This must then be rational
pharmacotherapy. Rational pharmacotherapy is
the treatment, prevention or diagnosis of a disorder using a medicine in the form that is suitable
for you. Scientific research must have proven that
the agent is active, effective and the most economical. (See B.15.4 also)
Additional conditions apply for non-registered
allergens (these are agents that are use in a desensitisation cure, a specific treatment for an allergy). These are shown in Article 3.4 of the
Pharmacy Regulations.
"Non-registered allergens".
Please note!
• Some medicine in the Medicines Reimbursement System (GVS) are not fully covered by
your health insurance because a personal contribution applies to them.
1. alternative (homoeopathic and anthroposophic) medicines;
2. medicines that are preventive or to prevent
a disease for a trip abroad;
3. medicines that are (almost) equivalent to a
registered medicine that is not in the Medicines Reimbursement System (GVS);
4. self-care medicines, insofar as they are not
covered by your health insurance in accordance with the Regulation on Healthcare
Insurance;
5. medicines for research or experimental use;
medicines as meant in Article 40, section 3
under f of the Medicines Act;
6. medicines falling under the AWBZ, government financing or subsidy;
7. medicines for which we do not have a preference. The medicines for which we do
have a preference are shown in the "Lijst
voorkeursgeneesmiddelen" (List of Preferred Medicines) in the Pharmacy Regulations. Your health insurance only covers
these preferred medicines;
8. medicines that are used for indications
other than those stated in Enclosure 2 to
the Regulation on Healthcare Insurance, or
if the additional terms and conditions are
not met. See under "Terms and conditions",
"Care recommendation and statement of
approval", "a. Further terms and conditions";
9. care products and cosmetic products such
as toothpastes, soaps, disinfectants, shampoos, bath oils, balsams, lotions, hair
growth preparations and Vichy products;
10,additional costs, such as administrative
costs, import costs and/or shipping costs;
11,vitamins and dietary supplements;
12.medicines where a claim can be made
under manufacturer's warranty or other
compensation schemes following the failure
of the administration method (related to an
aid or consumable).
Please note!
This care can be insured (additionally) in an additional insurance package. Your Reimbursements
Overview will show whether or not this is the case.
B.15.1.b. Supply of medicines and
provision of advice
The healthcare comprises handing over (the dispensation) of the medicines and the provision of
advice that is associated with the handing over,
such as is customarily provided by pharmacists.
The following rules apply to supplying medicines:
• They must only be supplied to the insured
person for whom the medicine is intended,
his/her carer or the healthcare provider who is
responsible for administering them;
• If the medicine is not collected after the prescription has been handed over, the pharmacist can invoice delivery costs;
• If a medicine is prescribed for an extended
period of time, partial deliveries per week are
possible. This only applies if there is a medical
necessity for this and no one can take on the
management of the medicines on your behalf.
The associated provision of advice comprises at
least:
• additional support on a 1st and 2nd issue of a
medicine or if you have not used a medicine
for more than 12 months;
• explanation if you use a medicine for which a
medical aid is also required;
• pharmaceutical support when visiting an outpatients department, hospitalisation or discharge
from hospital;
• a written record of you current medicine use
and your medicine use on discharge after hospitalisation.
You can find more information about provision of
advice in the Pharmacy Regulations on our website.
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Please note!
This healthcare does not include:
• information and advice for:
o self-care medicines (that are not reimbursed in accordance with Article B.15.3.)
and
o medicines to prevent diseases when travelling abroad;
• supply of and instruction on medical aids if the
associated medicine is for the expense of the
hospital;
• instruction on medical aids:
o if the associated medicines are for a
chronic treatment under the responsibility of
your general practitioner;
o that are required with the medicines, if
these medical aids are supplied by someone other than a pharmacist or dispensing
general practitioner;
• the additional costs for submitting prescriptions
and collecting medicines outside of normal
opening hours. These are only covered by your
health insurance in case of urgency.
Preferred medicines
Within the group of mutually interchangeable
medicines (see Pharmacy Regulations, Chapter
3) we designate one or more medicines as preferred medicine based on the lowest price. You
are then only entitled to that preferred medicine
within this group.
There is always at least one medicine available to
you with the prescribed active ingredient, in the
desired strength and administration route. After 15
days of use it may prove that the preferred medicine is not suitable for you from a medical point of
view. This is understood to mean that the treatment using the medicine that we have designated
is not sound. Your general practitioner or medical
specialist and pharmacist together determine if
there is a medical necessity for you to use another
medicine from the Medicines Reimbursement
System (GVS) instead of the preferred medicine.
This is described in the Regulation on Healthcare
Insurance. You are then entitled to that other
medicine with the same active ingredient, strength
and administration method.
Our preferred medicines are shown in the "Lijst
Voorkeursgeneesmiddelen" (List of Preferred
Medicines) in the Pharmacy Regulations. We can
change this list in the interim. If we do make
changes, we will place a notice on our website.
Healthcare provider
The medicines are supplied by or under the responsibility of a pharmacist or dispensing general
practitioner.
This could be abroad also. The following applies
here:
• the active ingredient, dose and form of administration for the medicine must be included in
the Dutch Medicines Reimbursement System
(GVS).
• the reimbursement takes place in accordance
with the reimbursement limit that has been arranged in the Netherlands. (See Pharmacy
Regulations, Chapter 3);
• the further terms and conditions as mentioned
in this Article B.15.1 are applicable.
Proposed treatment
General
The medicines are prescribed by a general practitioner, doctor for the mentally handicapped, specialist in geriatric medicine, a doctor specialising
in infectious diseases who is affiliated to the
Municipal Health Service (GGD), medical specialist, dentist, oral surgeon or obstetrician (taking
account of their powers to prescribe).
We may stipulate additional conditions for the type
of prescriber. As an example of this, for dimethyl
fumarate: the 1st prescription must be issued by a
dermatologist or an internist.
Please note!
Medicines are not reimbursed if they are prescribed by a medical doctor, alternative doctor or
alternative healer.
By exception
Certain medicines in the Medicines Reimbursement System (GVS) are so specialist that the
Minister has decided that these medicines can
only be paid to the hospital (see Article B.4. Medical specialist care). You can find these medicines
under the "Lijst met geneesmiddelen die zijn
overgeheveld naar het ziekenhuis" (List of Medicines Transferred to the Hospital) in the Pharmacy
Regulations.
What is the period for which the medicine can
be supplied?
The healthcare exclusively comprises the supply
of medicines under the proposed treatment/on
prescription. A prescription applies for a specific
period. How long this period is can differ per
medicine. The supply periods that apply per pro-
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posed treatment/prescription are:
• 15 days or the smallest manual package for a
medicine that is new for you;
• 15 days for a medicine to combat acute disorders using antibiotics or chemotherapy;
• 30 days for hypnotics (soporifics) and for
medicines that reduce anxiety and agitation
(anxiolytics);
• 3 months for medicine to treat a chronic illness;
• 12 months for the 'pill' (oral contraceptives);
• 1 month when the costs of the medicine per
month exceed € 1,000.00.
• 1 month in all other cases.
If a medicine falls under a number of groups, the
shortest period applies.
No repeat prescription
For:
• "the pill" (oral contraceptives) and
• insulin to treat diabetes ("diabetes mellitus")
there is no maximum period of validity per prescription. You only to have these medicines prescribed once and a repeat prescription is not required. Your health insurance covers no more
than what is required for 12 months use per year.
If the medicine, the strength and/or the use of the
medicine changes, you will need a new prescription.
in a form that is suitable for you; and
• the efficaciousness and effectiveness must
have been proven in scientific literature; and
• the treatment is the most economical for you
and the health insurance.
Rates
Location
The medicines are delivered to the practice of a
dispensing general practitioner or to a government
recognised (hospital) pharmacy or to your residential address.
Further terms and conditions
Additional terms and conditions apply for some
medicines in the Medicines Reimbursement System (GVS). These terms and conditions are in
Enclosure 2 to the Regulation on Healthcare Insurance. You will find the "Lijst geneesmiddelen
met toetsing vooraf" (List of medicines with verification in advance) in our Pharmacy Regulations.
We, or the healthcare provider on our behalf, will
verify whether you meet the terms and conditions
in advance. The Minister can change the list in the
Regulations in the interim. If changes are made,
we will place new Regulations with the amended
List on the Internet.
Medicines imported from abroad
In accordance with Article 2.8 section 1 under b of
the Healthcare Decree, the prescriber must request a statement of approval from us in advance
for these medicines, with the following conditions:
• they must be intended for a patient who has an
illness that occurs very infrequently in the
Netherlands; and
• no treatment is possible with a medicine registered in the Netherlands or a magistral preparation; and
• the treatment, prevention or diagnosis is used
Please note!
B.15.2. Medication assessment for chronic
use
This healthcare comprises a medically and pharmaceutically necessary, periodic evaluation for
multiple chronic medicine use, a so-called medication assessment, once every 2 years. You will
find further clarification in the Pharmacy Regulations.
General
The terms and conditions and that we have specified in Article 1.4. of the Pharmacy Regulations
are met.
Healthcare provider
The healthcare is provided exclusively by a pharmacist or dispensing general practitioner who has
successfully completed a supplementary training
course that we consider sufficient for carrying out
a medication assessment.
Proposed treatment
A pharmacist, (dispensing) general practitioner,
doctor for the mentally handicapped, specialist in
geriatric medicine, medical specialist, nursing
specialist and/or other healthcare provider involved in the treatment has determined that the
medical assessment is medically and pharmaceutically necessary.
This is only required if you need a medication
assessment for other medical or pharmaceutical
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reasons but the general terms and conditions and
conditions above are not met.
Rates
Location
The healthcare is provided in the practice of a
dispensing general practitioner or in a government
recognised (hospital) pharmacy or at your residential address.
B.15.3. Self-care medicines and antacids
The healthcare comprises the following medicines
for chronic use. A number of these medicines are
also available without a prescription:
Self-care medicines
These are medicines that fall into one of the following groups:
• laxatives;
• calcium tablets;
• allergy medicines;
• medicines for diarrhoea;
• medicines for evacuating the stomach;
• artificial tears;
Antacids
This involves antacids including medicines which
contain an antacid.
Please note!
• The healthcare does not comprised the (selfcare) medicines and antacids that you use during the first 15 days.
General
• The terms and conditions mentioned in Article
B.15.1. apply to (self-care) medicines;
• The (self-care) medicine and the antacid is
included in Enclosure 1 and 2 to the Regulation on Healthcare Insurance and in the G
standard of the Z index (the national medicines
file);
• You will have to use the (self-care) medicine
longer than 6 months to treat a chronic illness.
The prescriber states on the prescription that
they are prescribing the medicine for chronic
use.
Proposed treatment
handicapped, specialist in geriatric medicine,
medical specialist, nursing specialist, dentist, oral
surgeon or obstetrician has determined that the
(self-care) medications are medically necessary
for chronic use.
(self-care) medicines and antacids are medicines
for which additional terms and conditions apply,
see Article B.15.1. under Care recommendation
and statement of approval, a. "further terms and
conditions". We may stipulate additional conditions for this.
Rates
B.15.4. Medicines prepared by the pharmacy
The healthcare comprises medicines that are
made on a small scale by or on behalf of a pharmacist (magistral preparations).
Please note!
• The healthcare does not comprise magistral
preparations that are equivalent to or near enough equivalent to a medicine that is included
in the Medicines Reimbursement System
(GVS).
• A personal contribution applies if the magistral
preparation contains a medicine with personal
contribution.
General
• The terms and conditions mentioned in Article
B.15.1. apply to medicines;
• It involves rational pharmacotherapy.
• The preparation does not equate to Commodity Act products.
Rates
B.16. Dietary preparations
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The healthcare comprises the provision of (polymer, oligomer, monomer and modular) dietary
preparations that can be used for liquid diets
and/or for tube-feeding.
Please note!
o dietary supplements and vitamin preparations that are available without a prescription;
o slimming products, not even if they are registered as a dietary preparation;
o modified foods such as lactose-free
cheese, gluten-free bread, goat or horse
milk and suchlike;
o food that is administered via the bloodstream; this is reimbursed under Article
B.15.1.
General
The following terms and conditions apply to dietary preparations:
• The dietary preparation that you are prescribed
is registered as a dietary preparation and included as such in G standard of the Z index
(the national medicines file);
• The terms and conditions for dietary preparations that are described in Enclosure 2 to the
Regulation on Healthcare Insurance (see Article B.15.1 under Care recommendation and
statement of approval, further terms and conditions also) are being met;
• Modified, normal food does not suit you;
• Other products in special food do not suit you
and;:
o you are suffering from a metabolic disorder;
o you are suffering from a food allergy;
o you are suffering from a reabsorption disorder;
o you are suffering from illness related malnutrition or at risk of suffering from it (measured using an officially determined method);
• You are reliant on dietary preparations in accordance with the guidelines of the relevant
professional group in the Netherlands.
Healthcare provider
The dietary preparations are supplied by a recognised healthcare provider. Only certain specialist
companies (medical aids suppliers) are allowed to
supply food for gavage.
Proposed treatment
medical specialist, nursing specialist, or dietician
has determined that the dietary preparations are
medically necessary.
The healthcare provider who prescribes you the
dietary preparation completes the national doctor's certificate. We, or a recognised supplier use
this certificate to test whether you fulfil the terms
and conditions in advance. We may stipulate
additional conditions in the statement of approval.
Rates
Location
• The dietary preparations are supplied at the
location where the healthcare provider works,
at your residential address or at another suitable location that you agree with the healthcare provider.
• If the supply is via a healthcare provider with
whom we have entered into an "Internet
agreement", they can only supply to your residential address.
B.17. Medical aids
B.17.1. General
The healthcare comprises issuing, for ownership
or loan, replacing, adjusting or repairing functioning medical aids and instruction on and supervision of their use.
This relates to medical aids that are meant and/or
named in the Regulation on Healthcare Insurance.
A number of medical aids are specifically named
in the Regulation on Healthcare Insurance. Other
medical aids are not named.
The entitlement to the medical aid has a function
oriented description here: you are entitled to a
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functioning medical aid to compensate the stated
functional limitation.
The medical aid must meet the "state of science
of practice" criterion, which means that the medical aid must be proven to be effective for the aim
for which it is used.
Please note!
o costs for normal use of the medical aid. It
involves, for example, the costs of energy
consumption and replacement of accumulators and batteries. These costs are covered
by your health insurance if this is indicated
in the Medical Aids Regulations;
o medical aids that fall under the agreements
in the WMO (Social Support Act);
o medical aids and dressing materials that
are supplied and form part of a hospitalisation or medical specialist treatment (see Article B.4. for details);
o medical aids that do not meet the "state of
science and practice" criterion;
o medical aids or adjustments to medical aids
if they are used exclusively or predominantly in the working or teaching environment, unless stated otherwise in the
Medical Aids Regulations.
Tip
• A number of medical aids are also insured in
an additional insurance package. Your Reimbursements Overview will show whether or not
this is the case.
• Some medical aids that are covered by your
health insurance are not reimbursed in full.
There is, for example, a statutory personal
contribution or statutory maximum reimbursement. This is the following medical aids:
o orthopaedic shoes;
o bandage shoes;
o hairpieces;
o hearing aids;
o visual aids;
o non-allergenic shoes.
You can find more information about this in the
Medical Aids Regulations and/or in Chapter
D.4.
• The following medical aids are not covered by
your health insurance (under certain terms and
conditions). They cannot be insured in an additional insurance package either. This involves:
o Bedwetting alarm;
Visual aids;
Support soles;
Foot care medical aids;
Home monitor;
ADL (general daily vital functions) medical
aids;
o Home care products;
o Hire of medical aids;
o Support pessary;
o Test strips, diabetes patients;
o Personal alarm;
o Condoms;
o Braces and bandages;
o Epilepsy alarm;
o Redression helmet.
You can find more information about this in
Chapter D.4.
o
o
o
o
o
B.17.2. Medical Aids Regulations
The medical aids meant in Article B.17.1 are included in our Medical Aids Regulations. These
Regulations form part of this health insurance.
The Regulations also include:
• the terms and conditions that must be met to
be entitled to the medical aids mentioned;
• whether or not a statement of approval should
be requested from us;
• the requirements we stipulate for the medical
aids and/or the healthcare provider;
• the amount of any personal contribution or
maximum reimbursement.
You can view the Regulations on our website or
request them from us.
B.17.3. Personal contribution or maximum
reimbursement
A statutory personal contribution or statutory
maximum reimbursement applies to certain medical aids. The medical aids that this applies to are
shown in the Medical Aids Regulations. If you
obtain the medical aid from a healthcare provider
with whom we have entered into a healthcare or
Internet agreement, we pay the healthcare provider and settle this personal contribution with
you, unless the Regulations stipulate otherwise for
that medical aid.
Please note!
This personal contribution and/or additional reimbursement on maximum amounts may be covered
in an additional insurance package. Your Reimbursements Overview will show whether or not
this is the case.
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B.17.4. Care for the medical aid
You are responsible for the care of the medical
aid that you have taken ownership of or have on
loan. You do this, in any case, in accordance with
the manufacturer's and/or healthcare provider's
guidelines and/or the warranty conditions.
Damage to a medical aid that we have supplied to
you (on loan) and which arises as a result of negligence attributable to you, is not covered by your
health insurance.
In the event of the medical aid being stolen, you
report this to the Police and report the theft to us
and to the healthcare provider.
General
• You comply with the terms and conditions that
we have stipulated for that medical aid in the
terms and conditions of insurance and in Medical Aids Regulations. The medical aid meets
the requirements that we stipulate for that
medical aid in the Medical Aids Regulations.
• Taking account of your need and from the
standpoint of the effective provision of healthcare, you are reasonably, in regard to content,
nature and scope, reliant on the medical aid
concerned.
• The aid is necessary for you, is effective and
not superfluous, unnecessarily expensive or
unnecessarily complicated. We and/or the
healthcare provider with whom we have entered into a healthcare agreement and/or Internet agreement will ensure this.
• There must be specific medical grounds for
every medical aid. If these medical grounds
are statutory, this is also shown in the Regulations per medical aid.
Healthcare provider
The following situations may exist for the
'Zorgverzekering Natura Direct':
• Healthcare provider with an "Internet agreement":
a large number of medical aids are best ordered from the small group of healthcare providers operating nationally with whom we have
entered into an "Internet agreement". After all,
in that case you do not have to pay some of
the costs yourself (except any statutory personal contribution).
• Healthcare provider with a healthcare agreement, not being an "Internet agreement":
the healthcare providers with an "Internet
agreement" cannot supply a number of medical aids. You can use one of the many healthcare providers with whom we have entered into
a healthcare agreement, not being an "Internet
agreement" for these medical aids. In that case
you do not have to pay some of the costs
yourself either (except any statutory personal
contribution).
If a medical aid can be supplied by a healthcare provider with an "Internet agreement", but
you still use a healthcare provider with whom
we do have a healthcare agreement, but not
an "Internet agreement", the same applies as
for a Healthcare provider without agreement;
• Healthcare provider without agreement:
you can read how much we will reimburse you
in this case under b, c and d of Article A.20.
Proposed treatment
Prior to the start of the treatment you have a referral and/or a prescription for the use of the medical
aid from a doctor or other healthcare provider
authorised for this. For each medical aid, the
Medical Aids Regulations show who the authorised referrers/prescribers are.
• The Medical Aids Regulations show whether or
not a statement of approval is required in advance per medical aid.
• We may amend our policy for statement of
approval for a medical aid. In that case, the
terms and conditions in our Medical Aids
Regulations will change. We will also place a
notice on our website. If you request a statement of approval for the supply of a medical
aid, the terms and conditions that are applicable on the date that you submit the application are always applicable.
Rates
Location
If the supply is via a healthcare provider with
whom we have entered into an "Internet agreement", they can only supply to a your residential
address.
B.17.5. Lapsed.
B.18. Patient transport
B.18.1. Patient transport by ambulance
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• patient transport by ambulance as meant in
Article 1, 1st section, of the Ambulance Act,
over a maximum distance of 200 kilometres
single journey, unless you have a statement of
approval from us for journeys over a longer
distance.
The Ambulance Act understands ambulance to
mean "a motor vehicle, vessel or helicopter,
equipped for the transport of patients or the injured";
• patient transport using another means of
transport, if transport by ambulance is not possible and if you have received a statement of
approval for that other means of transport from
us in advance.
For example:
In the case of an accident at sea, inside or outside
of Dutch territorial waters, helicopter transport is
also covered by your health insurance, if you are
transported to the nearest land (at home or
abroad). Whether you are a professional diver,
sports diver, employee on a drilling rig or (professional) fisherman is irrelevant.
In case of emergency
Helpline/Help service.
always
contact
the
Please note!
• The healthcare does not comprise patient
transport by ambulance within the scope of
supervision or treatment on the grounds of Articles 6 and 8 of the Decision Care Entitlements EMEA ('Besluit zorgaanspraken AWBZ')
for treatment or observation for part of a day. If
the patient transport is a medical necessity,
that entitlement falls under the AWBZ in accordance with Article 10 of the Decision Care
Entitlements ('Besluit zorgaanspraken').
General
We understand patient transport to mean:
• Patient transport in the Netherlands or - if you
live abroad - in your country of residence:
• The transport of an insured person by ambulance between:
o the location of the legal residential address
or the location of the accident or sudden illness; and
o the nearest location for treatment and nurs-
ing.
• Patient transport during a temporary stay
abroad.
The patient transport by ambulance is a medical
necessity, because another method of patient
transport (by car, public transport or taxi) is not
justified on medical grounds.
Healthcare provider
The ambulance service has a recognised permit.
Proposed treatment
medical specialist or nursing specialist has determined that the patient transport by ambulance is a
medically necessary. This does not apply in the
case of acute ambulance transport, so if urgency
is required.
These are not required, except when:
• you travel further than 200 kilometres single
journey; or
• you want to use a different means of transport
because patient transport by ambulance is not
possible.
If you have doubts about the insurance, we recommend that you request a care recommendation
from us beforehand.
Rates
Location
The patient transport takes place:
• From:
o your legal residential address;
o you temporary accommodation address;
o the location where you are being treated;
o the location of your accident or sudden illness;
To:
o a healthcare provider or establishment. You
must be fully or partly covered for the health
insurance that you will receive there on the
grounds of your health insurance;
o an establishment where you will remain.
Your stay must be covered in full or in part
under the AWBZ.
• From:
o an establishment where you are staying
and where this stay is covered in full or in
part under the AWBZ;
To:
o a healthcare provider or establishment
where you will undergo an examination or
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receive treatment. The treatment or the
examination must be covered in full or in
o a healthcare provider for measuring and fitting a prosthesis. This prosthesis must be
covered in full or in part under the AWBZ.
• From:
o a healthcare provider. You must be fully or
partly covered for the health insurance that
you will receive there on the grounds of
your health insurance;
o an establishment where you are going to
remain. Your stay must be covered in full or
in part under the AWBZ;
o a healthcare provider or establishment
where you will undergo an examination or
receive treatment. The treatment or the
examination must be covered in full or in
o a healthcare provider for measuring and fitting a prosthesis. This prosthesis must be
covered in full or in part under the AWBZ;
To:
o your home or another residence, if you unable to reasonably obtain the care in your
own home.
B.18.2. Seated patient transport (patient
transport by car, public transport or taxi)
• the seated patient transport:
o by car
o in lowest class of public transport or
o taxi
over a maximum distance of 200 kilometres
single journey, unless you have a statement of
approval from us for journeys over a longer
distance;
• patient transport using another means of
transport, if seated patient transport by car,
public transport (in the lowest class) or a taxi is
not possible and if you have received a statement of approval for that other means of transport from us in advance;
• the transport of a escort and, in exceptional
cases, 2 escorts. This escorting must, in that
case, be necessary or the insured person who
is being escorted must be younger than 16
years. We also understand escort to mean assistance dogs or guide dogs for the blind.
The Minister has stipulated a reimbursement of
€ 0.31 per kilometre for seated patient transport
by own car or hire car.
The length of journey is determined using the
most recent version of the Routenet route planner
(free to use on the Internet), based on the quickest route. We reimburse on the basis of full kilometres; we use the customary rounding-off
method.
Please note!
• The healthcare includes personal contributions
or has exclusions:
o You have a personal contribution of € 96.00
per year for seated patient transport;
o You are not entitled to seated patient transport within the scope of supervision or
treatment based on Articles 6 and 8 of the
Decision Care Entitlements EMEA ('Besluit
zorgaanspraken AWBZ') if you receive
healthcare for part of a day. If the patient
transport is a medical necessity, that entitlement falls under the AWBZ in accordance with Article 10 of the Decision Care
Entitlements ('Besluit zorgaanspraken').
o You are not entitled to seated patient transport if you receive healthcare that is reimbursed under your additional insurance
package;
o Rental costs for a hire car are not covered
General
We understand patient transport to mean:
• Patient transport in the Netherlands or - if you
live abroad - in your country of residence:
• The transport of an insured person by car,
public transport or taxi to:
o A healthcare provider or establishment
where you will be treated and/or nursed;
and
o Then back to your home at your legal residential address or another address if you
cannot obtain that nursing at your legal
residential address
• Patient transport during a temporary stay
abroad within the scope of treatment.
The seated patient transport is necessary be-
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cause:
• you have to undergo kidney dialysis;
• you have to undergo cancer treatment with
chemotherapy or radiotherapy;
• you are only mobile in a wheelchair and therefore not with specially adapted patient transport. The healthcare that you receive at the
healthcare provider or the establishment you
are transported to must be covered by this
health insurance;
• your sight is impaired to such an extent that as
a result you cannot move without an escort.
The healthcare that you receive at the healthcare provider or the establishment you are
transported to must be covered by this health
insurance.
Hardship clause
The so-called "hardship clause" applies in certain
cases. Specifically, if in your case it is extremely
unreasonable that you do not receive patient
transport for treatment of a prolonged illness or
disorder other than those aforementioned.
Explanation:
We use a formula and other information to determine if you are entitled to seated patient transport
in accordance with the "hardship clause". A
statement from the attending doctor must be enclosed with the application that you submit for this.
The healthcare that you receive at the healthcare
provider or the establishment you are transported
to must be covered by this health insurance or the
AWBZ.
We use the following formula on an annual basis
to determine if you are entitled to seated patient
transport on the basis of the "hardship clause":
number of months treatment x number of treatments per week x 52/12 (this is the number of
weeks on an annual basis) x (number km single
journey) x 0.25 (this is the weighting factor).
If the result is 250 or more, you are then entitled
to seated patient transport. The length of journey
is determined using the most recent version of the
Routenet route planner (free to use on the Internet), based on the quickest route. We reimburse
on the basis of full kilometres; we use the customary rounding-off method.
For example:
5 (number of months' treatment) x 2 (number of
treatments per week) x 52/12 x 26 (distance in
kilometres) x 0.25 (weighting factor) = 281.67.
This result is higher than 250 and means you are
entitled to reimbursement of the seated patient
transport.
You must notify us as quickly as possible if this
situation changes.
Healthcare provider
If the seated patient transport is by taxi, the taxi
operator must be a recognised (Taxi Quality Mark
/ TX quality mark) and have the correct permit.
Proposed treatment
medical specialist or nursing specialist has determined that the seated patient transport is a medically necessary.
from us in advance and have received a statement of approval from us. This also applies if you
travel more than 200 kilometres single journey or
for transport using a means of transport other than
a car, in the lowest class of public transport or taxi
(such as a boat). We may stipulate additional
conditions in the statement of approval. Because
the healthcare involved must be effective, we
assess whether or not you can use public transport, own transport or taxi transport.
Rates
Location
The same terms and conditions apply for this as
apply for "location" in Article B.18.1. If you use
seated patient transport because you have to
undergo kidney dialysis, treatments with chemotherapy or radiotherapy for cancer, then you are
only entitled to seated patient transport to and
from the location where you undergo the kidney
dialysis, chemotherapy or radiotherapy for cancer.
B.19. Mental healthcare (GGZ)
B.19.1. 'Basis GGZ'
There are 2 definitions that are important for a
clear understanding of this Article:
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Main treatment provider 'Generalistische Basis
GGZ'
The main treatment provider for 'Generalistische
Basis GGZ' has final responsibility for formulating
the diagnosis and for specifying and implementing
the treatment plan. The main treatment provider is
a healthcare psychologist ('GZ-psycholoog') or
psychotherapist.
Support staff 'Generalistische Basis GGZ'
In a establishment for 'Generalistische Basis GGZ'
support staff may be use where there is course of
treatment for BGGZ chronic healthcare.
Support staff are qualified to carry out some of the
treatment (under the supervision of the main
treatment provider). Only healthcare providers
included in the 'DBC-GGZ' professions table of
the 'CONO' professions structure can be support
staff. This is a social psychiatric nurse for example.
The healthcare must not be provided by others,
unless we have agreed otherwise in a healthcare
agreement with the healthcare provider concerned.
The healthcare comprises 'Generalistische Basis
GGZ' such as is customarily provided by clinical
psychologists.
This healthcare is classified into various performances:
• Short
• Medium
• Intensive
• Chronic.
Please note!
o an intelligence test;
o dyslexia treatment (see Article B.20. in this
regard);
o school psychological care;
o supervision of a non mental health nature,
such as training and courses;
o orthopedagogical care;
o assistance in work and relationship problems;
o supervision of children with a development
disorder or learning disorder;
o diagnosis only without the intention that
mental health treatment takes place based
on a diagnosis in accordance with internationally recognised standards (the DSM IV);
o treatment of adjustment disorders.
General
The healthcare can also be supplied via the Internet through a programme that we have granted
recognition.
Healthcare provider
• 'Generalistische Basis GGZ' for Short, Medium
or Intensive performances:
The healthcare is provided by a mental healthcare psychologist or psychotherapist.
• 'Generalistische Basis GGZ' for the Chronic
performance:
The healthcare is provided by a mental healthcare psychologist or a psychotherapist from
and claimed by an establishment for 'Generalistische Basis GGZ'. Some of the healthcare
may also be provided by 'Generalistische
Basis GGZ' support staff.
Healthcare must not be provided by others, unless
we have agreed otherwise in a healthcare agreement with the healthcare provider concerned.
If the healthcare is provided via the Internet, we
have made express agreements with the healthcare provider about this in the healthcare agreement.
Referral
been referred by a company medical officer or
by a general practitioner (preferably supported
by a Practice Assistant GP Mental Healthcare
(POH-GGZ)).
• The referral is based a diagnostic consultation
with an exploratory examination. This exploratory examination has shown that there is a
psychiatric disorder that requires treatment
within the 'Generalistische Basis GGZ'. The result of this exploratory examination is part of
the referral and must be present with both the
general practitioner and the healthcare provider.
Proposed treatment
The main treatment provider for ''Generalistische
Basis GGZ' checks if the healthcare falls within
the 'Generalistische Basis GGZ' and records the
referral in a treatment plan.
Rates
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Location
• in the practice of the attending healthcare provider; or
• in a 'Generalistische Basis GGZ' establishment
with there being hospitalisation.
B.19.2. Specialist mental healthcare
There are 2 definitions that are important for a
clear understanding of this Article:
Main treatment provider of Specialist Mental
Healthcare
The main treatment provider of Specialist Mental
Healthcare has final responsibility for formulating
the diagnosis and for specifying and implementing
the treatment plan. The main treatment provider is
a psychiatrist, psychotherapist or clinical psychologist. The main treatment provider is in an
establishment or is self-employed.
Specialist Mental Healthcare Support Staff
Support staff may be used in an establishment for
Specialist Mental Healthcare. Support staff are
qualified to carry out some of the treatment (under
the supervision of the main treatment provider).
Only healthcare providers included in the 'DBCGGZ' professions table of the 'CONO' professions
structure can be support staff. This a social psychiatric nurse or an addiction doctor for example.
The healthcare must not be provided by others,
unless we have agreed otherwise in a healthcare
agreement with the healthcare provider concerned.
B.19.2.1. Specialist Mental Healthcare with
hospitalisation
The healthcare comprises Specialist Mental
Healthcare such as is customarily provided by
psychiatrists and clinical psychologists in combination with hospitalisation:
• in a psychiatric hospital (establishment for
specialist psychiatric care); or
• in a psychiatric department in a hospital (establishment for medical specialist care).
We understand this Specialist Mental Healthcare
to mean;
• diagnosis (identifying the disorder) and
• specialist treatment of complicated (complex)
psychological disorders.
For a maximum of 365 days the healthcare also
comprises:
• the specialist psychiatric treatment and the
accommodation;
• the nursing and care associated with this;
• the paramedical care (for example, physiotherapy, exercise therapy, occupational therapy,
speech therapy or dietary advice with a medical necessity);
• the nursing, medicines, medical aids and
dressing materials associated with the treatment during this hospitalisation.
After these 365 days you may still be entitled to
this healthcare on the grounds of the AWBZ.
The following rules apply to counting the 365
days:
• If your hospitalisation is interrupted for a period
of less than 31 days then the days that the interruption last do not count towards the 365
days. The count continues after the interruption.
• If your hospitalisation is interrupted for more
you are therefore once again entitled to (reimbursement of) healthcare for 365 days.
• If your hospitalisation is interrupted for weekend and holiday leave, then these days of interruption count towards the 365 days.
Please note!
• See article A.21. for general exclusions. For
the sake of clarity, the following point repeats a
number of exceptions.
• The healthcare does not comprise the following in any case:
o neurofeedback;
o psychoanalysis;
o treatment of adjustment disorders;
o intelligence testing;
o medicals, for driving ability for example;
regard);
o psychological care at school;
o medical psychological care (see Article B.4
in this regard);
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such as training, courses and parenting
help;
o orthopedagogical care;
disorder or learning disorder.
Healthcare provider
• The healthcare is provided by a hospital (establishment for medical specialist care) or an
establishment for Specialist Mental Healthcare.
• An establishment that provides the healthcare
complies with the terms and conditions stipulated by the WTZi (Care Institutions Act). The
medical director bears final responsibility for
the quality of the healthcare that is provided.
The criteria for the quality of the healthcare is
described in a clear, quality handbook. The division of responsibilities of the experts involved
is described in a protocol.
• In this establishment, the diagnosis and the
treatment indication should be determined by a
'BIG' registered main treatment provider of
Specialist Mental Healthcare. On request, the
establishment provides us with a list of all
social workers, including 'BIG' registration
numbers.
• You can find the establishments that fulfil these
requirements on our website.
Referral
been referred by a company medical officer or
by a general practitioner (preferably supported
by a Practice Assistant GP Mental Healthcare
(POH-GGZ)), doctor for the mentally handicapped, specialist in geriatric medicine, youth
healthcare physician, psychiatrist or 'Bureau
Jeugdzorg' as meant in the Youth Care Act. A
company medical officer can make a referral
for psychotherapy except where there is (longterm) psychoanalytical psychotherapy.
within the Specialist Mental Healthcare. The
result of this exploratory examination is part of
• In the case of youths, as meant in the Youth
Care Act, an indication decision from a 'Bureau
Jeugdzorg' as meant in the Youth Care Act or
a referral by a doctor or other healthcare provider named in Article 10 of the Youth Care Act
Implementation Decree is required if the
healthcare proceeds as described in Article 9b,
5th section of the AWBZ.
Proposed treatment
A main treatment provider of Specialist Mental
Healthcare has determined that the healthcare
falls within the Specialist Mental Healthcare (the
main treatment provider checks the referral); the
treatment instruction is described in a treatment
plan.
Rates
Location
The healthcare is provided in a hospital (establishment for medical specialist care).
B.19.2.2. Specialist Mental
without hospitalisation
Healthcare
The healthcare comprises 'Specialist Mental
Healthcare such as is customarily provided by
psychiatrists and clinical psychologists without
hospitalisation.
We understand this Specialist Mental Healthcare
to mean:
• diagnosis (identifying the disorder) and
• specialist treatment of complicated (complex)
psychological disorders:
o the psychotherapy, including (long-term)
psychoanalytical psychotherapy;
o other Specialist Mental Healthcare without
hospitalisation;
o the nursing, medicines, medical aids and
dressing materials associated with the
treatment.
Please note!
• See article A.21. for general exclusions. For
the sake of clarity, the following point repeats a
number of exceptions.
o neurofeedback;
o psychoanalysis;
o treatment of adjustment disorders;
o intelligence testing;
o medicals, for driving ability for example;
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regard);
o school psychological care;
o medical psychological care (see Article B.4
in this regard);
such as training, courses and parenting
help;
disorder or learning disorder.
There are different terms and conditions to be
eligible for the healthcare for:
• psychotherapy, including (long-term) psychoanalytical
psychotherapy
(see
Article
B.19.2.2.a.) and
• other Specialist Mental Healthcare without
hospitalisation (not psychotherapy and not
(long-term) psychoanalytical psychotherapy)
(see Article B.19.2.2.b.).
The terms and conditions which must be met to
be entitled to the healthcare are stated below per
category.
B.19.2.2.a. Psychotherapy, including (longterm) psychoanalytical psychotherapy
Healthcare provider
• The healthcare is provided by a self-employed
psychiatrist, psychotherapist, clinical psychologist, establishment for Specialist Mental
Healthcare or hospital (establishment for medical specialist care) .
numbers.
Referral
been referred by a general practitioner (preferably supported by a Practice Assistant GP
Mental Healthcare (POH-GGZ)), doctor for the
mentally handicapped, specialist in geriatric
medicine, youth healthcare physician, psychiatrist or 'Bureau Jeugdzorg' as meant in the
Youth Care Act. A company medical officer
can make a referral for psychotherapy except
where there is (long-term) psychoanalytical
psychotherapy.
with an exploratory examination ('gevalideerde
screener GGZ' (accredited mental health
screener)). This exploratory examination has
shown that there is a psychiatric disorder that
requires treatment within the Specialist Mental
Healthcare. The result of this exploratory
examination is part of the referral and must be
present with both the general practitioner and
the healthcare provider.
Proposed treatment
plan.
from us in advance and have received a statement of approval from us if (long-term) psychoanalytical psychotherapy is involved. We may
stipulate additional conditions in the statement of
approval.
Rates
Location
The healthcare is provided in an establishment for
specialist psychiatric care or in a hospital (establishment for medical specialist care). This includes
a psychiatric hospital.
Psychotherapy, insofar as it is not (long-term)
psychoanalytical psychotherapy, can also take
place in the practice of the self-employed healthcare provider or at your home. If you are treated
at home, there must be medical grounds for this.
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B.19.2.2.b. Other Specialist Mental Healthcare
without hospitalisation
Healthcare provider
• The healthcare is provided by a self-employed
psychiatrist, psychotherapist, clinical psychologist, establishment for Specialist Mental
Healthcare or hospital (establishment for medical specialist care) .
numbers.
Referral
been referred by a general practitioner (preferably supported by a Practice Assistant GP
Mental Healthcare (POH-GGZ)), company
medical officer, doctor for the mentally handicapped, specialist in geriatric medicine, youth
healthcare physician, psychiatrist, company
medical officer or 'Bureau Jeugdzorg' as meant
in the Youth Care Act.
within the Specialist Mental Healthcare. The
result of this exploratory examination is part of
Proposed treatment
plan.
Rates
Location
for specialist psychiatric care or in a hospital (establishment for medical specialist care). This includes a psychiatric hospital. The healthcare can
also take place in the practice of the selfemployed healthcare provider or in your home. If
you are treated at home, there must be medical
grounds for this.
B.20. Dyslexia care
The healthcare comprises examination if there is
a suspicion of severe, simple dyslexia, and you
are entitled to treatment if the examination/diagnosis shows that there is severe dyslexia.
We understand severe dyslexia to mean a specific
reading and spelling disorder as a result of a neurobiological function disorder which has been
determined to be hereditary. This is a disorder or
the brain, where certain nerve stimuli are not
passed on correctly. This disorder can be distinguished from other reading and spelling problems.
It relates to healthcare for children of 7 years and
older who are in primary eduction. This care must
not start in 2014 and subsequent years after the
child has turned 14.
Please note!
• The healthcare does not comprise remedial
teaching.
General
• Determining the cause (diagnosis) is carried
out using measuring instruments that meet the
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requirements for psychodiagnositic tests
(COTAN: 'Commissie Testaangelegenheden
Nederland' of the NIP).
• Treatment takes place with a team of various
experts (multidisciplinary), where the healthcare provider mentioned here under the heading "healthcare provider" bears final responsibility in accordance with a treatment plan and
subsequent evaluation;
• This involves healthcare that takes place in
accordance with the 'Protocol Dyslexie Diagnostiek en Behandeling' (Dyslexia Diagnosis
and Treatment Protocol) (Blomert 2006). You
can request this Protocol from us or view it on
our website;
• Before a child becomes eligible for diagnosis,
the school must have drawn up a patient history report which shows that the school has
done everything that the school should do in
accordance with the Reading Problems and
Dyslexia Protocol.
Healthcare provider
The healthcare is provided by a psychologist or
orthopedagogician. This healthcare provider must:
• be registered as a mental health psychologist;
and
• have and additional specialisation in the diagnosis and treatment of dyslexia; and
• be affiliated to the 'Kwaliteitsinstituut Dyslexie'
(KD) or the 'Nationaal Referentiecentrum Dyslexie' (NRD).
Referral
The school, through a qualified and expert official
with associated expertise as described in the 'Protocol Dyslexie Diagnostiek en Behandeling' (Dyslexia Diagnosis and Treatment Protocol) (Blomert
2006), must make the referral before the start of
the treatment. You can request this Protocol from
us or view it on our website.
Rates
Location
The healthcare takes place in the practice of the
attending healthcare provider.
B.21. Prevention
The healthcare comprises preventive care for
people with (a high risk of) a complaint and/or
disorders designated by the'College voor Zorgverzekeringen'. This then involves healthcare such as
is customarily provided by general practitioners,
obstetricians, clinical psychologists, and medical
specialists.
The aim of the healthcare is to improve behaviour
and to maintain healthy behaviour in daily life.
The healthcare can take place on a consultation
basis, via the Internet and in group sessions.
This care targets:
• problematic use of alcohol;
• depressive complaints and panic complaints;
• providing advice and stimulating healthy behaviour in case of overweight and obesity;
• stopping smoking. This programme can be
followed once per year and can be supported
by medicines if there is reason for this in the
individual circumstances.
Please note!
o treatment for being overweight and/or
obesity;
o day treatment and/or stay;
o medicines in the medicine reimbursement
system (see Article B.15.1.) if it involves the
"stoppen met roken" (stopping smoking)
intervention.
Healthcare provider
The healthcare is provided by:
• a general practitioner;
• a medical specialist;
• an obstetrician, unless the care is for depressive complaints;
• a healthcare psychologist;
• a healthcare provider or organisation with
whom we have entered into an agreement for
that prevention.
Referral
mentally handicapped, medical specialist, nursing
specialist or company medical officer. A referral is
not necessary for the stopping smoking health-
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care programme.
Rates
B.22. Conditional care
The healthcare comprises the following healthcare
and the services that are conditionally designated
for a specific period under the Regulation on
Healthcare Insurance:
• up until 01 January 2016, the treatment of
chronic, aspecific lower back complaints with
the use of anaesthesiological pain alleviation
techniques, if you are participating in the research that is being financed by 'ZonMw';
o transitional rule: if you are already receiving
healthcare in accordance with this provision
on 31 December 2013 then up until 01
January 2016 the healthcare comprises the
treatment of chronic, aspecific lower back
complaints with the use of radiofrequency
denervation, if the indication and treatments
are in accordance with the terms and conditions that are included in the research proposal that is being financed by 'ZonMw';
therapy-resistant hypertension with the use of
percutaneous renal denervation if you are participating in the research that is financed by
'ZonMw';
treatment of therapy-resistant hypertension
with the use of percutaneous renal denervation, if the indication and treatment are in
accordance with the terms and conditions
that are included in the research proposal
that is being financed by 'ZonMw';
• up until 01 January 2017 treatment of a cerebral infarction with the use of intra-arterial
thrombolysis if you are participating in the randomized, multi-centre study 'Multicenter Randomized Clinical trial of Endovascular treat-
ment for Acute ischemic stroke in the Netherlands. (MR CLEAN)';
treatment of therapy-resistant hypertension
with the use of percutaneous renal denervation, if the indication and treatment are in
accordance with the terms and conditions
that are included in randomised multi-centre
study 'Multicenter Randomized Clinical trial
of Endovascular treatment for Acute
ischemic stroke in the Netherlands. (MR
CLEAN);
infected pancreatic necrosis using a Transluminal endoscopic step-up approach if you
are participating in the research that is being
financed by 'ZonMw';
therapy refractory patients with Crohn's disease using autologous stem cell transplantation if you are participating in the research that
is being financed by 'ZonMw'.
Hospitalisation may be a medical necessity.
Please note!
Healthcare provider
The healthcare is provided by a healthcare provider that we have granted recognition.
Rates
B.23. Foot care
The healthcare comprises foot care such as is
customarily provided by general practitioners or
medical specialists to insured persons with:
• Diabetes Mellitus Type I (DM Type I) or
• Diabetes Mellitus Type II (DM Type II).
In the case of Diabetes Mellitus Type II the
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healthcare can be provided in the form of multidisciplinary care. See Article B.1.2. for more information about multidisciplinary care.
There is an annual foot inspection and examination for Diabetes Mellitus. When doing so, the
severity of the foot problems are indicated in socalled Simm's classifications. The Simm's classification is used as the basis for determining
whether you are entitled to treatment for skin and
nail problems and foot shape and position abnormalities (treatment).
What the classification in Simm's entails and what
healthcare is insured in that case are is shown
below:
• Simm's 0: no increased risk of infections, there
are no abnormalities, no loss of feeling and no
blood vessel problems. You are not entitled to
treatment;
• Simm's 1: moderately increased risk of infections, blood vessel problems or loss of feeling,
no sign of increased pressure locally. You are
only entitled to treatment if you are not capable
of self-management.
• Simm's 2: high risk of infections, blood vessel
problems in combination with loss of feeling
and/or signs of increased pressure locally. You
are entitled to treatment.
• Simm's 3: infections present, or had amputation and/or infections previously. You are entitled to the treatment.
In addition, the insured foot care comprises:
• information and stimulation of lifestyle change
as part of the treatment and
• Advice on suitable footwear.
Please note!
• the deductible applies if the healthcare is not
provided by a healthcare group or general
practitioner.
• The healthcare does not comprise personal
care such as the removal of hard skin for care
reasons or general nail care.
• Preventive foot care can also be insured in an
additional insurance package. Your Reimbursements Overview will show whether or not
this is the case.
General
• The healthcare is provided to an insured person with Diabetes Mellitus (DM Type I or DM
Type II).
• The following must be stated on the bill:
o the Simm's classification;
o what foot care you have been given;
o whether or not the foot care has been provided within the scope of multidisciplinary
care by a healthcare group / multidisciplinary partnership.
Healthcare provider
Coordinated healthcare provided by a healthcare
provider who specialises in Diabetes and is part
of:
• a healthcare group; or
• a multidisciplinary partnership of healthcare
providers who provide coordinated treatments
for the specified disorders.
If you do not receive diabetes care from a healthcare group the healthcare can also be provided
by:
• a medical specialist.
• a general practitioner or a healthcare provider
within the GP practice or GP services structure
or healthcare provider (such as a practice assistant, nurse or physician associate) provides
the healthcare. The healthcare provider within
the GP practice or GP services structure works
under the final responsibility of the general
practitioner.
• a chiropodist with a valid certificate or diploma
from an additional training course for treating
diabetes patients (chiropodist who is registered
as a chiropodist with the DV (diabetic foot)
specialism in the 'Kwaliteitsregister Pedicure',
see www.ProCerrt.nl (information in Dutch)).
We have granted recognition to that training.
The chiropodist runs a practice as a chiropodist for diabetes patients, amongst other
things.
• a medical chiropodist. This chiropodist is registered as a medical chiropodist in the
'Kwaliteitsregister
Pedicure',
see
www.ProCert.nl (information in Dutch). This
chiropodist runs a practice as a chiropodist for
patients with diabetes mellitus or rheumatoid
arthritis, amongst other things.
• a podotherapist.
If you choose multidisciplinary care provided by a
healthcare group, not healthcare provided by individual healthcare providers, the healthcare group
submits the claim for the healthcare provided, not
the individual healthcare providers.
Rates
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Referral
A referral by a general practitioner, medical specialist or nursing specialist is required prior to the
start of the treatment if the healthcare is not provided by a general practitioner, medical specialist
or nursing specialist themselves.
Proposed treatment
A general practitioner, medical specialist or nursing specialist has determined that the healthcare
is a medical necessity.
Location
The healthcare is provided:
• at the location where a healthcare provider
who is a member of the healthcare group or
the multidisciplinary partnership works;
• at a GP practice or After Hours GP Clinic;
• in the practice of the podotherapist;
• in the practice of the chiropodist with the DV
(diabetic foot) specialism;
• in the practice of the medical chiropodist;
• at your own home;
• at your temporary residence. In this case we
do not understand temporary residence to
mean a establishment for medical specialist
care or a nursing home;
• in an establishment for medical specialist care
or in the practice of a medical specialist;
• Consultations can also take place via the Internet.
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PACAKGES
C.1. Explanation of terms
In this Article we explain the meaning of the terms
that appear in Chapters C and D (Terms and
Conditions of Insurance for Additional Insurance
Packages) that we did not explain previously in
Chapter A.
Exercise programme
An exercise programme is aimed at influencing
and activating movement behaviour and developing an active and healthy lifestyle. The duration of
exercise programme is fixed in advance. Within
the programme the aim is to achieve a change in
behaviour. We do not understand this to mean
exercise programmes aimed at improving fitness.
Additional costs
Costs that an establishment may invoice in addition to the current nursing rate. This is regulated in
the Healthcare Marketing Regulation Act.
When we mention 'additional costs' we mean, for
example, the costs for using the operating theatre,
dressing materials and the medicines in an establishment for medical specialist care.
CHAPTER C
GENERAL TERMS AND
CONDITONS FOR ADDITIONAL INSURANCE
Family or family members
We understand family or family members to mean
those individuals we consider to be each others
sole life partners, running a common household
and living at the same address. We also understand those individuals to include:
• children up to 18 years;
• children with a legal entitlement to student
finance;
• children who are studying up to and including
the age of 27, even if they do not live at the
same address as you (the policyholder) and do
not, therefore, run a common household with
you;
• adopted children;
• foster children;
• someone who the company or the establishment which has entered into the group agreement has designated as a family member.
We must have accepted family members as insured persons and have mentioned them in the
policy document.
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Health course
A complete (theory) learning programme that
takes place within a specific time. Increasing your
knowledge of a healthy lifestyle stands central to
the learning programme. The course or programme teaches you skills through personal contact and/or provides information that leads to a
change in behaviour. The aim is that you learn
how you are personally capable of maintaining
and/or improving your (physical or mental) health.
Recuperation & Balance
A national treatment programme for patients with
a good life expectancy following treatment for
cancer. Recuperation & Balance provides a reactivation programme (rehabilitation) of 3 months.
There are various components to this programme.
Vaccination
The entire healthcare, comprising:
• supply of the vaccine and/or medicines;
• the injection materials;
• administration by means of one or more injections;
• the associated registration/administration;
• (any) associated (blood) tests to determine the
vaccine; and
• the invoiced consultation.
Patients' association
An association that represents the interests of
patients and consumers in healthcare and which
is affiliated as a (candidate) member of:
• NPCF ('Nederlandse Patiënten Consumenten
Federatie');
• CG-Raad ('Chronisch zieken en Gehandicapten Raad Nederland');
• Platform VG ('Platform Verstandelijk Gehandicapten');
• LPGGz
('Landelijk
Platform
Geestelijke
Gezondheidszorg').
Podiatrist
A podiatrist is a member of an association for
podiatrists which we have granted recognition and
who runs a practice as a podiatrist.
Home care organisation
An institution with which we have entered into a
healthcare agreement on the supply of home care
as meant in the AWBZ or of comparable care.
Residing
The situation that is central to your life and your
social activities entirely or almost entirely in one
specific place or one specific country.
If this is not the case, but if you are staying in that
place for longer than 365 days without a break,
we also assume that you are residing there. However, if you stay in that place for less than 365
days we consider this to be a temporary stay and
you are not residing there.
Country of residence
The country where you live, apart from the
Netherlands. We also understand country of residence to mean the country where you are detached for your work and where you and your
family members are living.
Z-index
The Z-index collects, verifies, manages and distributes details of all products that are available from
the public pharmacy in the so-called G-Standard.
We use this G-Standard to see if a medicine is
registered, for example, and what the rate is for
that medicine.
C.2. Fundamentals of your additional insurance packages and
non-statutory health insurance
C.2.1. Basis
Further to Article A.2 the additional insurance
package and/or the non-statutory health insurance
can be based on:
• a Reimbursements Overview for you insurances;
• the health statement that you or a third party (a
health statement for example) have completed;
• reports from any medicals;
C.2.2. Nature of your additional insurance
packages and non-statutory health insurance
The non-statutory health insurance is a "restitutieverzekering" (refund insurance). In other words,
you are entitled to reimbursement of the costs for
the healthcare.
Additional insurance packages are also refund
insurances. An additional insurance package is,
however, a "gemengde verzekering" (mixed insurance). In other words, for at least one reimbursement (Article) you are entitled to reimburse-
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ment of the costs of the healthcare (refund) and
for at least one reimbursement (Article) your are
entitled to the healthcare itself (in-kind).
Your additional insurance package is always a
refund insurance except when the Introduction to
your Reimbursements Overview for that additional
insurance package states that it is a mixed insurance.
C.2.3. Content of your non-statutory
health insurance
The terms and conditions, content and the scope
of cover in the non-statutory health insurance are
the same as that in the health insurance.
C.2.4. Differences that may apply
For one or more Articles in these terms and conditions of insurance there may be differences in:
• the Reimbursements Overview;
• an additional or group agreement;
• the terms and conditions that differ are described in Article C.11.
C.2.5. References in the Reimbursements
Overview
You are only entitled to reimbursement of healthcare named in those Articles that are mentioned in
your Reimbursement Overview(s). If not all of the
reimbursement Article is mentioned but only part
of it is, then the description of that healthcare, the
exceptions (see "Please note!") and the terms and
conditions that are described in that Article also
apply.
C.3. Nature, content and scope of
your additional insurance package
C.3.1. Various additional insurance packages
You (the policyholder) can take out various types
of additional insurance packages, for yourself and
for others. You are not allowed to have certain
additional insurance packages at the same time. If
you would like to know which please ask us.
C.3.2. Per family member
You (the policyholder) can select from the various
additional insurance packages that we offer for
the insured persons on your (family) policy. These
can differ per insured person.
C.3.3. Children up to 18 years
a. The additional insurance package for a child
must be the same as that of (one of) the parents. If the child has multiple additional insurance packages then at least one of the parents
must have the same combination of additional
insurance packages.
b. If each of the parents has a different combination of additional insurance packages, you can
specify which combination the child concerned
should be insured under.
c. in deviation to the preceding, you can take out
one or more different additional insurance
packages for your child that are different to
those of their parents. The additional insurance
packages for child are then no longer free. Not
even those additional insurance packages that
are the same as one of the additional insurance packages of one of both parents, as long
as your child has one additional insurance
package that their parents do not have. The
premium from 18 years of age will then apply
for your child.
C.4. Start and duration of your
additional insurance package
C.4.1. Start and duration
If the additional insurance package starts on 1
January, the additional insurance package is in
effect for one full year. If the additional insurance
package starts after 1 January, that additional
insurance package is in effect for the current year,
plus the full year subsequent to this.
C.4.2. Including family members
In the case of family members who are included in
your insurance during the period that your additional insurance package is in effect, their additional insurance package runs for the same period
as yours.
C.5. Concealment
C.5.1. Questions
Before we accept you, we may want to ask you or
third parties (such as your healthcare provider) a
number of questions. You must answer these fully
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and truthfully.
C.5.2. Cancellation by us
If the answers prove to be inaccurate or incomplete, we will draw your attention to this. You then
have 14 days to respond. We can cancel the additional insurance package or the non-statutory
health insurance immediately within 2 months of
discovery.
C.5.3. Cancellation by the policy holder
Form the moment that we have notified you of the
inaccuracy or incompleteness, you have 2 months
in which you may cancel your additional insurance
package with immediate effect.
C.6. Cancellation or change
C.6.1. From group insurance to individual
insurance
We will convert the group additional insurance
package and group non-statutory health insurance
for you (the policy holder) and your family members into an individual insurance in the following
cases:
• If you (the policyholder) have taken out the
group insurance(s) via your employer and you
can no longer be considered to be employed
by that employer. If we are informed within 30
days of your no longer being an employee,
then you can remain a member of the group
until 01 January of the following year. If you inform us later, we will determine when the
membership ends.
• If you (the policyholder) have taken out the
group insurance(s) via legal person who represents your interests. We will do this as per the
date on which you can no longer be considered to be a person whose interests are
represented by that legal person.
The group discount lapses at the time that
membership of the group ends. After cancellation
of membership of the group the group insurance(s) will be continued on the basis of the terms
and conditions that apply for an individual insurance and which most closely resemble the previous group terms and conditions. From that moment on, you must start paying the premium for
an individual insurance.
C.6.2. Cancellation for all insured persons
If the information that you gave us when taking
out an additional insurance package and/or nonstatutory health insurance turns out to be inaccurate or incomplete, we can cancel the insurance
concerned with immediate effect within 60 days of
this discovery. We will claim back all reimbursements that we have paid you from the day that we
were misled.
C.6.3. Cancellation for one insured person
We cancel the additional insurance package and
non-statutory health insurance for one insured
person at the moment that (one of) the following
situations arise:
• The insured person is de facto no longer part
of your (the policyholder's) family;
• Your (the policy holder's) stay abroad can no
longer be considered temporary under these
terms and conditions of insurance and we have
not given you express permission to retain
your additional insurance package.
You must notify us in writing if (one of) the aforementioned situation(s) arises. We must have received this notification within 30 days of the situation concerned arising.
C.6.4. No cancellation
You cannot cancel your additional insurance
package if it involves a change of:
• the terms and conditions of insurance as a
result of which you do not have fewer rights or
more obligations;
• the premium, if this changes because you have
reached a certain age and therefore fall under
a different age category;
• the terms and conditions of insurance or the
premium which does not concern the additional
insurance package that you (the policyholder)
have taken out;
• the terms and conditions of insurance as a
result of government policy or a statutory legislation.
C.7. Amount of premium and
costs
In addition to the costs that we mentioned in
Chapter A you (the policyholder) must also pay
these costs:
• a surcharge on the premium for each child
younger than 18 years for whom you take out
an additional insurance package. We will only
invoice this surcharge if the parents have not
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taken out an additional insurance package (or
have taken out another range). We will invoice
the surcharge to you (the policyholder);
• a surcharge on the premium for every insured
person for whom you have taken out an additional insurance package with us, but for whom
no health insurance has been taken out. We
will invoice this surcharge to you (the policyholder);
• a surcharge on the premium because you have
reached a certain age during the additional insurance package;
• taxes that we must pay to certain bodies in
accordance with the law or a treaty.
If a surcharge is applicable, this is included in the
premium on your policy document.
C.8. Premium and costs after
cancellation
The situation could arise where you still have to
pay us premium and costs for an additional insurance package or a non-statutory health insurance
that has been cancelled in the meantime. If you
then take out a new insurance policy with us, we
then have the right:
• to offset the costs of the healthcare that we
reimburse you from your new additional insurance package or new non-statutory health insurance against the old, outstanding debt;
• postpone our obligations until the time that you
(the policyholder) have paid all unpaid and
claimable premiums and costs.
C.9. Reimbursement
C.9.1. Reimbursement sequence
We will process bills in the order we receive them.
We have a specific sequence for determining the
(amount of) reimbursement of bills:
• first the AWBZ;
• then the health insurance;
• then the general additional insurance package;
• finally, a specific additional insurance package;
this is an additional insurance package which
provides reimbursement for only a single type
of healthcare.
For oral care for instance or for a deluxe arrangement in a hospital.
C.9.2. Maximum reimbursement if you are
not insured for the full year
We reimburse certain treatments to certain maximum amount per year. If your insurance starts or
ends during the course of the year we will not
reduce this maximum amount.
C.9.3. Maximum reimbursement on
change of additional insurance package
Suppose that you obtain treatment that is reimbursed on the grounds of your additional insurance package, but not in full. You then take out an
additional insurance package which also reimburses that treatment, but not in full. After, all this
new additional insurance package reimburses that
treatment to a certain amount or to a certain number of treatments in a period longer than one year.
Then:
• the amount that you have been reimbursed
from your previous additional insurance package with us counts towards the maximum
amount of your new additional insurance package;
• the number of treatments that you obtained
under your previous additional insurance
package with us counts towards the maximum
number of treatments in you new additional insurance package;
• the period in which you are entitled to a limited
reimbursement continues on in your new additional insurance package.
The counting toward the maximum reimbursement
also applies if we change the reimbursement
amount or number of reimbursements in you additional insurance package. Reimbursements that
have been allocated previously also continue to
count.
Please note!
This Article does not apply to the reimbursement
of orthodontics in Article D.8.5.
C.9.4. Continuous reimbursements
The AWBZ and your health insurance do not reimburse all healthcare (in full). The healthcare that
you are not reimbursed, could be covered by the
reimbursement in your additional insurance package. This applies:
• if the costs relate to treatments that are included in your health insurance or the AWBZ;
and
• if the healthcare is not rejected in accordance
with the guidelines for your health insurance or
the AWBZ; and
• if the healthcare is reimbursed in part from the
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AWBZ or your health insurance; and
• if the reimbursement is included in your additional insurance package; and
• if you comply with the terms and conditions
that are stated for the treatments concerned in
these Terms and Conditions for Additional Insurance Packages; and
• if we have received an original, written statement from the AWBZ or the (health) insurer for
the health insurance. This statement must declare that the bill that you submit to us for an
additional reimbursement has already been
submitted and processed there. This statement
also contains information on how it was
finalised. The reason for non reimbursement
must also be stated.
• Costs:
o that are involved in urgent treatment
abroad; and
o that are covered by the reimbursement from
(travel) insurance taken out separately, including a reimbursement for medical expenses abroad or which the travel insurer
has paid or advanced on other grounds;
and
o that the (travel) insurer, with whom you took
out the (travel) insurance separately, claims
from us.
• Cost for healthcare, which you could possibly
have also been reimbursed on the grounds of
another scheme or insurance but where you
have not informed us of the name of the insurer concerned.
C.10. General exclusions
C.10.3. Personal contribution, deductible
and lower rate
C.10.1. Existing illness on application
What if you require healthcare as the result of an
illness or abnormality, for which requested a
medical or dental assessment from you when you
applied? In that case we do not reimburse this
healthcare if you already knew about this illness
or abnormality or if was already causing symptoms when you applied for your additional insurance package. You or the healthcare provider
making the statement did not report it to us (when
we specifically requested this). We do reimburse
healthcare that is not related to the concealed
illness or abnormality.
C.10.2. Other scheme or insurance
We do not reimburse the following costs of
healthcare:
• Costs which you - if the additional insurance
package had not existed - could have been reimbursed or for which you would have been
entitled to treatment on the grounds of:
o a (Dutch or foreign) national insurance
scheme, social security act or other statutory scheme, such as your health insurance
and the AWBZ; or
o a (Dutch or foreign) government scheme or
a subsidy scheme such as government
vaccination programmes; or
o an EU Regulation, the EU Treaty, the EEA
treaty or a bilateral social security treaty
that the Netherlands has entered into; or
o another agreement, regardless of whether it
was entered into before or after your additional insurance package).
We do not reimburse the following costs, unless
we explicitly state that we will reimburse these
costs in these terms and conditions of insurance
or the Reimbursements Overview that apply to
you:
• the statutory personal contribution that you
must pay in accordance with the AWBZ or the
Health Insurance Act;
• costs that are settled against the voluntary or
compulsory deductible in the health insurance;
• costs for treatments that relate to psychoanalysis;
• costs for treatments of a plastic surgery nature.
We do not reimburse the following costs under
any circumstances whatsoever:
• costs that remain for your own account in accordance with your health insurance because
the healthcare is provided by a healthcare provider or healthcare establishment with whom
we have not entered into a healthcare or Internet agreement;
• costs that remain for your own account in accordance with your health insurance because
the health insurance was provided at a higher
rate than for which you receive reimbursement
in your health insurance.
C.10.4. Blame, criminal act, offence or
fraud
We do not reimburse (the costs of) the following
treatments:
• Costs for which you are to blame. These are
costs which have arisen:
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o as a result or your serious misconduct, your
(intentional or unintentional) recklessness,
as a result of your (conditional) intent or
with your agreement;
o as a result of your serious negligence in
adhering to the instructions of the attending
doctor or therapist;
o because you seriously hinder or delay the
healing process through your own behaviour.
• Costs resulting from a criminal act, offence or
fraud. These are costs that relate to or are the
result of you committing (or participating in the
commission of), being an accessory to or causing or attempting to commit a criminal act, offence or fraud. This condition not only applies if
you yourself commit a criminal act, offence or
fraud, but also if it is committed by someone
else who has an interest in the reimbursement
or the insurance contract (a healthcare provider for example).
• In these cases we will reduce the reimbursement proportionally. This reduction only takes
place if we would have set a higher premium
has we known the truth.
• Fraud may also result in us:
o reporting the matter to the police;
o cancelling the insurance contract(s);
o making a record in the alert systems used
by insurers;
o claiming back reimbursements that have
been made and costs incurred (in any investigation).
C.11. Different terms and conditions
Terms and conditions may apply to your additional
insurance package that differ from the terms and
conditions that have been described above or
those that supplement the terms and conditions of
insurance. These different terms and conditions
may also apply to your non-statutory health insurance.
Your Reimbursements Overview shows whether
one of the following different or additional conditions apply in your case.
C.11.1. Non-statutory health insurance
Check your Reimbursements Overview to see if an Different
Condition applies in your case.
C.11.1.1. Description
You can only take out non-statutory health insurance if you do not have an obligation to be insured in accordance with the Health Insurance
Act. This is the case is you not a Dutch resident.
C.11.1.2. End of non-statutory health insurance
Your non-statutory health insurance ends:
• if you are obliged to take out insurance in accordance with the Health Insurance Act;
• if you move to another country;
• if you live in an EU member state other than
the Netherlands, an EEA member state or a
Treaty country with whom the Netherlands has
entered into a bilateral social security treaty. If
you do, you are entitled to healthcare or reimbursement of the costs on the grounds of that
treaty or on the grounds of the European
Social Security Regulation no. 1408/71 or
883/04. This healthcare or reimbursement is
for the account of the Netherlands, EEA member state or that Treaty country.
You must furnish us with a copy of your proof of
registration with the executive body of the insurer
for the social or statutory insurance in that EU
member state, EEA member state or that Treaty
country.
C.11.1.3. Deductible
The following rules apply to you in regard to deductible:
• Articles A.12.1., A.12.3., A.12.7., A.12.8.,
A.12.9. and A.13. are not applicable;
• You can choose different deductible amounts
per insured person per year. You can find the
level of the deductible amount that applies to
you in the policy document;
• All members of your family choose the same
deductible amount;
• The family deductible is a maximum of 2x the
deductible that you have chosen per insured
person.
• Deductible means that, in a single year, you
will first have to pay the costs that you would
have been reimbursed through your nonstatutory health insurance yourself. We will
only reimburse the other costs that we cover
after you have done this.
• A deductible is not the same as a personal
contribution. Deductible and personal contribution can both apply simultaneously to the insured healthcare.
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C.11.1.4. Rate for bills from your country
of residence
If you live abroad, we use the market rates applicable in that country for settling bills from your
country of residence. This is the rate that we have
agreed for that healthcare with other healthcare
providers in your country of residence or that is
customary there. If the market rates applicable in
your country of residence differ from comparable
healthcare market rates applicable in the Netherlands, then we reimburse the costs of the insured
healthcare up to the highest rate.
C.11.1.5. Legal procedure
The second bullet point of Article A.22.2. and the
second bullet point of Article A.23.2 do not apply
to your non-statutory health insurance. You can
resort to the civil courts for legal procedures.
C.11.2. Treaty policy
C.11.2.1. Start, duration and end
You can only take out the Treaty Policy for yourself and your (notional) co-insured if you are treaty
insured. You are treaty insured if you are a Dutch
resident who is entitled to medical care at the
expense of a Treaty country.
We understand (notional) co-insured to mean the
husband, wife, partner or child up to 18 years of
the treaty insured person.
This husband, wife, partner or child does not have
their own income in the Netherlands. If they do,
you must inform us.
The Treaty policy and your additional insurance
package end if:
• you or your (notional) co-insured are no longer
entitled to medical care at the expense of a
member state of EU/EEA in accordance with
Regulation (EEC) No. 883/04;
entitled to medical care at the expense of Switzerland in accordance with Regulation (EEC)
No. 1408/71 or No. 883/04; or
entitled to medical care at the expense of a
country with which the Netherlands has entered into a bilateral agreement on social security with a medical expenses paragraph.
C.11.2.2. No reimbursement
The Treaty policy does not entitle you to reimbursement of costs for the healthcare which, due
to measures taken by the Government, fall to the
expense of the healthcare, the social or statutory
insurance of the country from which you receive
income.
C.11.3. Start, duration and end of your
additional insurance package
C.11.3.1.
You can only take out this additional insurance
package if:
• you are not obliged to be insured in accordance with the Health Insurance Act; and
• you live in an EU member state (other than the
Netherlands), an EEA member state or a
Treaty country with whom the Netherlands has
entered into a bilateral social security treaty;
and
• you are entitled to healthcare or reimbursement of the costs on the grounds of that treaty
or on the grounds of European Social Security
Regulation no. 1408/71 or 883/04. This healthcare or reimbursement is for the account of the
Netherlands, EU member state, EEA member
state or that Treaty country; and
• you have furnished us with a copy of your
proof of registration with the executive body of
the insurer for the social or statutory insurance
in that EU member state, EEA member state or
that Treaty country.
C.11.3.2.
Your additional insurance package ends if you are
obliged to take out insurance in accordance with
the Health Insurance Act.
C.11.3.3.
Your additional insurance package ends:
a. if you move to a different country than the
one you were living in when the additional
insurance package came into force; or
b. at the moment you no longer have an insurance obligation in the sense of the
Health Insurance Act.
C.11.3.4.
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package if:
• you are obliged to take out insurance in accordance with the Health Insurance Act; and
• you have taken out 'Zorgverzekering Natura' or
'Zorgverzekering Natura Select' with us with
the highest voluntary deductible (€ 500.00 per
insured person per year); and
• you are a member of a group agreement on
the basis of which you were able to take out
this additional insurance package; and
• you have not taken out any other additional
insurance package.
This additional insurance package ends if you no
longer fulfil all of these terms and conditions.
C.11.3.5.
package if:
• you and your family members are obliged to
take out insurance in accordance with the
Health Insurance Act; and
• you are registered with a 'Gemeentelijke
Sociale Dienst' (GSD) of the 'Nederlandse
Gemeenten' which has entered into a group
agreement with us. This registration is based
on an entitlement to benefits. This entitlement
to benefits is named in the group agreement or
is deemed equivalent to it on the grounds of
that group agreement.
longer fulfil all of these terms and conditions.
C.11.3.6.
package if:
• you and your family members are obliged to
take out insurance in accordance with the
Health Insurance Act; and
• the 'Collectieve Arbeids Overeenkomst' (Collective Bargaining Agreement) (CAO) for the
Hospital Services or Residential Homes for the
Elderly applies to you.
longer fulfil these terms and conditions.
C.11.3.7.
package if you are staying, at the expense of the
AWBZ, in an establishment for the handicapped
with which we have entered into a group agreement for a health insurance.
longer fulfil this condition.
C.11.3.8. 'Meegroeiservice'
You can change your additional insurance package in a number of cases. For example: pregnancy, adoption, divorce, marriage, living together, loss of employment, death, moving house,
retirement or if your children leave home. You can
do this a maximum of once per year; you can
request the change by phone. The new additional
insurance package then starts on the first day of
the month following your request for the changed.
You can also have the new additional insurance
package start later.
C.11.4. Healthcare and (no) reimbursement of costs
C.11.4.1.
Your additional insurance package gives you additional cover of the healthcare and the costs that
you are reimbursed from the healthcare or the
social or statutory insurance in your country of
residence.
Costs that you are not reimbursed or not reimbursed in full by your country of residence but
which would fall under the health insurance in the
Netherlands, will be reimbursed from your additional insurance package.
The healthcare, the social or statutory insurance
in your country of residence, together with this
additional insurance package provide cover of the
costs in your country of residence. This makes the
scope the same as the cover from the health insurance if you had incurred the same costs in the
Netherlands.
C.11.4.2.
If you live outside of the Netherlands but within
Europe, your additional insurance package will
provide the same reimbursement as it does to
insured persons who live in the Netherlands. We
understand Europe to mean the collectivity of
countries with national sovereignty who belong to
the European continent, including the Russian
Federation (up to the Urals) and the countries in
or bordering the Mediterranean Sea.
C.11.4.3.
If you are missionary, your additional insurance
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package does not entitle you to reimbursement of
costs during your stay and activities abroad.
C.11.4.4.
Your additional insurance package does not include any entitlement to reimbursement of costs
for:
• healthcare that is purely work related or work
relevant;
• purely cosmetic or aesthetic surgery;
• removal of excess body fat.
C.11.4.5. Rate for bills from your country
of residence
If you live abroad, we use the market rates applicable in that country for processing bills from your
country of residence. These bills could relate to
healthcare that is covered by the social or statutory insurance in your country of residence. These
bills could also relate to healthcare that is not
covered by this, but which is covered by the
Health Insurance Act in the Netherlands.
The market rates applicable in that country, is the
rate that we have agreed for that healthcare with
other healthcare providers in your country of residence or that is customary there.
C.11.4.6. Non-urgent medical care in an
EU/EEA member state
You are entitled to reimbursement of healthcare
outside of your country of residence provided this
healthcare takes place in an EU member state or
an EEA member state. This reimbursement
amounts to a maximum of 200% of the market
rates applicable to which you are entitled in the
Netherlands or in your country of residence. We
never reimburse more than the claimed rate.
It must involve healthcare that would also be re-
imbursed on the grounds of your additional insurance package as if it had taken place in the
Netherlands or in your country of residence. You
are only entitled to healthcare or costs from this
Article that are stated in the Reimbursements
Overview for your additional (dental) insurance
package(s). The terms and conditions that are
stipulated for the individual reimbursements (Articles) in the additional insurance package remain
in force.
C.11.5. Premium
C.11.5.1.
We will adjust the premium on your additional
insurance package if you are a certain age or if
you reach a certain age. You can find the age(s)
involved on your Reimbursements Overview. The
premium change comes into effect on the 1st day
of the month following the month in which you
reach the age.
C.11.5.2.
You do not pay any premium for the additional
insurance package for your children up to 18
years and any other family members if:
• you are an employee of the group that this
Article applies to; and
• you and your family members have applied for
the same additional insurance packages within
the group; and
• your family members fall under the so-called
Transition Rule 2006.
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D.1. Medical specialist care
D.1.1. Sterilisation
Check your Reimbursements Overview to see if you are entitled to reimbursement.
We will reimburse a sterilisation.
The amount we reimburse is shown in your Reimbursements Overview.
Please note!
See articles A.21. and C.10. for general exclusions.
General
An establishment for medical specialist care invoices for the costs using the correct DOT healthcare product code.
Healthcare provider
The treatment is carried out by or under the responsibility of a medical specialist or general practitioner.
Referral
referred by a general practitioner or doctor for the
mentally handicapped.
Rates
Location
The sterilisation takes place in:
• an establishment for medical specialist care;
• the practice of a medical specialist or general
practitioner;
• another establishment that we have granted
recognition for the provision of this healthcare.
CHAPTER D
D.1.2. Reversing sterilisation
HEALTHCARE IN ADDITIONAL INSURANCE
PACKAGES
We reimburse the reversal of a sterilisation.
Please note!
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General
Healthcare provider
The treatment is carried out by or under the responsibility of a medical specialist.
Referral
referred by a general practitioner or doctor for the
mentally handicapped.
Rates
Location
for medical specialist care.
D.1.3. Ear protrusion correction (elephant
ears)
We reimburse an ear protrusion correction (elephant ears).
Please note!
General
Healthcare provider
The treatment is carried out by or under the responsibility of a medical specialist.
Referral
mentally handicapped or youth healthcare doctor.
Rates
Location
D.1.4. Visual acuity treatments (laser eye
surgery)
We reimburse visual acuity treatments to the
standards of medical specialists using laser eye
treatment. We do this to a specific amount in a
specific period.
You can find the level of the reimbursement
amount and how long the period lasts in your Reimbursements Overview.
Please note!
General
• The treatment is not reimbursed from your
health insurance.
• You have not yet reached the maximum reimbursement within the period for which this
maximum applies.
Healthcare provider
A medical specialist (ophthalmologist) performs
the treatment.
Rates
Location
The treatment takes place in:
D.1.5. Circumcision
If the insured person is male we reimburse:
a. a medically necessary circumcision;
g. a circumcision that is not a medical necessity,
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The amount and what we will reimburse is shown
in your Reimbursements Overview.
Please note!
General
Healthcare provider
• A medically necessary circumcision is performed by or under the responsibility of a
medical specialist;
• A circumcision that is not a medical necessity
is performed:
o by or under the responsibility of a medical
specialist, or;
o by a general practitioner qualified to do so,
or;
o by another establishment that we have
granted recognition for providing this
healthcare, for example, branches of 'Besnijdenis Centrum Nederland', 'Besnijdenis
Kliniek Nederland', 'Stichting Al Gitaan' and
'Besnijdenis Centrum Amsterdam'.
Care recommendation and statement of approval
These are not required. A medically necessary
circumcision is reported to us by the attending
medical specialist (urologist). The reimbursement
for a medically necessary circumcision will be
granted based on this report. If we do not receive
a report, reimbursement will be based on a circumcision that takes place for other reasons. You
must, of course, be insured for a circumcision for
other reasons in this case. If you have doubts
about the reimbursement, we recommend that
you request a care recommendation from us
beforehand.
Rates
Location
The circumcision takes place in or at:
• the location of the practice of the general practitioner who performs the circumcision.
D.1.6. Correction of the upper eyelids
Correction of the upper eyelids involves:
• Treatment by a healthcare provider with whom
we have a healthcare agreement for upper
eyelid corrections (see Article D.1.6.1.).
• Corrections of the upper eyelids - general.
Treatment can be provided by a healthcare
provider with whom we have a healthcare
agreement for upper eyelid corrections, but it
can also be provided by other healthcare providers (see Article D.1.6.2.);
Check your Reimbursements Overview to see
which rule applies in your case.
D.1.6.1. Correction of the upper eyelids by
a healthcare provider with a healthcare
agreement for upper eyelid corrections
We reimburse a correction of the upper eyelids if
they are paralysed, weak or overhanging.
Please note!
• See articles A.21. and C.10. for general exclusions.
• You are not entitled to reimbursement if you
use a healthcare provider with whom we have
not entered into a healthcare agreement for
upper eyelid corrections.
General
All of the following conditions must have been
met:
• one or both upper eyelids are paralysed, weak
or overhanging where there is excess skin; and
• the upper eyelid that you applying to have
corrected covers at least half of your pupil
while you are looking straight ahead. As a result of this there is serious impairment of the
field of vision; and
• the medical specialist at the establishment for
medical specialist care assesses whether you
meet the medical grounds as described above;
and
• the establishment for medical specialist care
invoices for the costs using the correct DOT
healthcare product code.
Healthcare provider
The treatment is carried out by an ophthalmologist
or plastic surgeon in an establishment for medical
specialist care with whom we have entered into a
healthcare agreement for upper eyelid correction.
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Location
The correction of the upper eyelids takes place in
an establishment for medical specialist care with
whom we have entered into a healthcare agreement for upper eyelid correction. You can find the
most up-to-date list of healthcare providers on our
website.
D.1.6.2. Corrections of the upper eyelids general
tional conditions in the statement of approval.
Rates
Location
The correction of the upper eyelids takes place in:
D.1.7. Cosmetic treatments
We reimburse a correction of the upper eyelids if
they are paralysed, weak or overhanging. The
amount we reimburse is shown in your Reimbursements Overview.
Please note!
• We do not reimburse the costs of the photographs that you have to submit to us together
with your request for a care recommendation.
General
• One or both upper eyelids are paralysed, weak
or overhanging where there is excess skin; and
• The upper eyelid that you applying to have
corrected covers at least half of your pupil
while you are looking straight ahead. As a result of this there is serious impairment of the
field of vision; and
• An establishment for medical specialist care
healthcare product code; and
• We have received an application from your
attending medical specialist or nursing specialist. This contains a description of and justification for the treatment; and
• You send us a recent colour photograph where
the abnormality is clearly visible. You have
taken this photograph yourself or it was taken
by an establishment for medical specialist
care.
Healthcare provider
The treatment is carried out by an ophthalmologist
or plastic surgeon.
from us in advance and have received a statement of approval from us. We may stipulate addi-
We only reimburse cosmetic treatments that are
exclusively intended to beautify your appearance.
Please note!
• We do not reimburse laser eye treatment
under this Article, but under Article D.1.4.
(visual acuity treatments); check your Reimbursements Overview to see if you are covered
for this.
General
• The maximum reimbursement applies over the
entire period that you have an additional insurance package with us that contains this reimbursement.
• The maximum reimbursement applies for all
cosmetic treatments together.
invoices for the costs using a bill showing the
correct DOT healthcare product code.
Healthcare provider
from us in advance and have received a statement of approval from us. We may stipulate additional conditions in the statement of approval.
Rates
Location
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D.1.8. Treatment for snoring
We reimburse a treatment for snoring. The
Please note!
• We do not reimburse the costs of (prescribed)
medical aids to prevent snoring.
General
Healthcare provider
Rates
Location
D.1.9. Breast prosthesis replacement
We reimburse medical specialist care (plastic
surgery) where one or both breast prostheses are
replaced.
Please note!
General
• What if it involves the removal of one or more
breast prostheses that have been implanted in
circumstances other than following mastectomy? In this case, one of the situations described in Article B.4.5. must exist. If it involves
the replacement of a breast prosthesis that has
been implanted following a mastectomy, this is
reimbursed from the health insurance.
healthcare product code.
Healthcare provider
The healthcare is provided by an establishment
for medical specialist care or a medical specialist.
Rates
Location
D.2. Prevention
D.2.1. Preventive vaccinations
We reimburse preventive vaccinations for the
prevention of:
a. flu (influenza);
b. meningococcus.
Please note!
• We do not reimburse vaccinations that have
been given or which should have been given
on the grounds of the Public Health (Preventive Measures) Act and Government vaccination programmes.
Healthcare provider
The vaccine for the preventive vaccinations is
supplied by a pharmacy, Municipal Health Service
(GGD) or supplier with whom we have entered
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into a healthcare agreement and/or Internet
agreement.
Proposed treatment
A doctor has determined the medical necessity for
preventive medicines or preventive vaccinations
and states them.
Rates
D.2.2. Preventive investigations
qualified healthcare provider or employee
within the GP practice who works under the
final responsibility of the general practitioner.
• The preventive investigation in Article D.2.2.b
is carried out by a healthcare provider or
healthcare establishment with whom we have
entered into a healthcare agreement. We do
not reimburse investigations if they are carried
out by a healthcare provider with whom we
have not entered into a healthcare agreement
Rates
We reimburse the following investigations:
a. preventive investigation of risk factors for
cardiovascular disorders;
b. investigation into risk factors for disorders
that hinder or limit the ability to work.
Please note!
• We do not reimburse:
o self tests;
o (preventive) investigation within the scope
of prevention programmes;
o (preventive) investigations for which a permit is required on the grounds of the Population Screening Act (WBO);
o imaging diagnostics (Total Body Scan in
particular);
o physicals that are statutorily mandated or
are based on a collective bargaining
agreement (CAO).
• We do not reimburse (preventive) examinations, tests and treatments of a sports medicine nature under this Article, but under Article
D.2.6. "Sports medicine advice".
• We do not reimburse laboratory investigations
under this Article, but under Article B.3. "GP
care".
General
The preventive investigation is aimed at (risk factors for) disorders for which an effective and efficient treatment is possible;
Healthcare provider
• The preventive investigation in Article D.2.2.a.
is carried out by your general practitioner or a
D.2.3. Prevention for trips abroad
We reimburse preventive measures for a trip
abroad to a country with a heightened risk of infectious diseases and parasitic disorders.
If an inoculation book or vaccination book is an
official certificate for this healthcare, we reimburse
this too.
The healthcare and the amount we reimburse up
to is shown in your Reimbursements Overview.
We reimburse the following for the prevention of
infectious diseases and parasitic disorders:
a. pills to prevent:
o malaria;
o typhoid.
b. an inoculation or examination for:
o diphtheria;
o tetanus;
o polio;
o mumps, measles, rubella (MMR);
o hepatitis A;
o hepatitis A/B (Twinrix combi-vaccine);
o hepatitis B;
o blood tests in connection with Hepatitis B;
o yellow fever;
o typhoid.
c. the following inoculation or test:
o an inoculation to prevent tuberculosis;
o Mantoux test in connection with possible
tuberculosis;
o an inoculation to prevent meningitis;
o an inoculation to prevent Japanese encephalitis;
o an inoculation to prevent tick-borne encephalitis;
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o an inoculation to prevent rabies (canine
madness).
d. (lapsed).
e. preventive inoculations and preventive medicines due to a (holiday) trip to a country with a
heightened risk.
Please note!
• We do not reimburse vaccinations that have
been given or which should have been given
on the grounds of the Public Health (Preventive Measures) Act and Government vaccination programmes.
General
You go on a trip to a country with a heightened
risk of illnesses for which preventive inoculations,
medicines or tests are prescribed.
Healthcare provider
The vaccine for the preventive inoculations is
provided by a pharmacy, a Municipal Health Service (GGD) or a supplier to whom we have
Proposed treatment
A (company) medical officer or establishment that
is affiliated with the 'Landelijk Coördinatiecentrum
Reizigersadvisering' (L.C.R), (such as a GGD)
has determined a medical necessity for the preventive medicines, inoculations or tests and states
them.
Rates
D.2.4. Medical screening for adoption
What are you entitled to?
We reimburse preventive investigation (medical
screening) for an adopted child coming from
abroad.
Please note!
• A preventive investigation of your adopted
child must be claimed by an establishment for
medical specialist care using the DOT healthcare product code intended for this.
General
• This involves adoption by one or more individuals who have taken out an additional insurance package with us;
• You register the child that is to be adopted with
us as an insured person;
• The adoption takes place in accordance with
Dutch law;
• The preventive examination (medical screening) is connected to the adoption process.
Healthcare provider
A paediatrician carries out the preventive examination.
Rates
Location
for medical specialist care in the Netherlands.
D.2.5. Consultations for women
We reimburse the costs of consultations for
women. The consultations involve or are aimed at:
a. the menopause;
b. young women;
c. pregnancy;
d. a desire to have children;
e. cancer prevention.
Please note!
Healthcare provider
• The menopause consultations are given by:
o a menopause consultant who is affiliated to
Care for Women or VVOC ('Vereniging
Verpleegkundig Overgangs Consulenten');
o an establishment that specialises in menopause consultations.
• The other consultations for female insured
persons are given by an obstetrician or a con-
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sultant who is affiliated with Care for Women.
Rates
D.2.6. Sports medicine advice
We reimburse:
a. sports medicine treatments;
b. sports physicals;
c. x-ray and laboratory investigations;
d. sports medicine consultations and sports
medicine examination.
Please note!
General
X-ray and laboratory investigation takes place for
a physical.
Healthcare provider
• The sports doctor:
o is included in the register of doctors of
social medicine in accordance with the Individual Healthcare Professions Act and
works in a Sports Medicine Advice Centre
(SMA) or sports medicine establishment
(SMI), which is affiliated with the 'Federatie
van Sportmedische Instellingen' (FSMI); or
o is registered as a certified sport diving doctor C or D in the 'Nederlandse Vereniging
voor Duikgeneeskunde' register. He/she
carries out a sports-medicine physical in
accordance with the scientifically specified
requirements of the 'Nederlandse Vereniging voor Duikgeneeskunde'.
• The therapist working under the responsibility
of a sports medicine doctor works in a Sports
Medicine Advice Centre or sports medicine establishment, which is affiliated with the 'Federatie van Sportmedische Instellingen'.
Rates
D.2.7. Dietary advice
We reimburse the costs of the dietary advice. This
comprises advice and support during weight control.
Please note!
• Similar healthcare may already be covered in
the health insurance. You can see if you are
entitled to this in Article B.11 or B.21. If you
are, that healthcare takes precedence over reimbursement under this additional insurance
package.
General
• You can receive treatment and support if you
are healthy and if you are overweight (BMI between 25 and 30) or, as an exception, in case
of obesity (BMI above 30);
• The healthcare is aimed at weight control.
Healthcare provider
• a certified weight consultant who is affiliated
with the 'Beroepsvereniging Gewichtsconsulenten Nederland' (BGN);
• a dietician.
Rates
D.2.8. Health courses
We reimburse health courses aimed at preventing
illnesses and/or improving your health or in which
you learn how to deal with your illness. This will
allow you to maintain and/or improve your health
(physical or mental).
Please note!
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o occupational therapy and/or recreational
therapy;
o exercise programmes; which are covered
by Article D.22. check your Reimbursements Overview to see if you are covered
for this.
o emergency response training, including
First Aid for children courses for registration
as a child minder in the sense of the Childcare Act.
General
• You must suffer from diabetes to qualify or the
additional reimbursementfor diabetes patient
courses. Your general practitioner must be
aware of this also. The course must be related
to diabetes mellitus.
• You have an additional insurance package
which includes entitlement to the reimbursement of a health course during the entire period that you attend a health course.
• We also understand a health course to mean:
o a First Aid course if you complete that
course with an examination and are
awarded a valid and registered certificate/diploma;
o a First Aid refresher course if this extends
the validity of a certificate/diploma you have
already been awarded;
o individual First Aid modules;
o membership fee, if this is for First Aid refresher training.
• On completion of the First Aid course/First Aid
module, you must enclose a copy of the certificate/diploma you have been awarded with the
bill.
Healthcare provider
The health course is provided by:
• a home care organisation;
• a Municipal Health Service (GGD);
• a national or regional patients' association;
• (an outpatients department of) a hospital (establishment for medical specialist care);
• an organisation or association that is the qualitative equivalent of the 'Oranje Kruis' or Red
Cross, if the health course relates to a First Aid
course. This healthcare provider provides courses
for insured persons who are not taking this course
to practice a profession or for commercial use. You
can find a list of professional organisations on our
website;
• a healthcare group with whom we have entered into agreements on the specified health
course;
• an institution other than one of the aforementioned institutions, with whom we have entered
into a healthcare agreement for this healthcare.
Rates
D.2.9. Patients' association contribution
We reimburse the membership fee and/or registration fee for:
a. one or more patients' associations;
b. a Cross society or home care establishment.
Which healthcare, the number of societies and the
amount of the membership fee or registration fee
can be found in your Reimbursements Overview.
Please note!
• We do not reimburse membership fees for
exercise programmes that have a (joint) aim of
improving your fitness.
Healthcare provider
The membership fee and/or registration fee relates to:
• a Cross society or home care establishment
that can operate or is organised regionally or
nationally.
Rates
D.2.10. Fall prevention
We reimburse programmes that are aimed reducing your risk of falling.
Please note!
• See articles A.21. and C.10. for general exclu-
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sions.
• We do not reimburse programmes other than
those programmes specifically named.
General
• You have participated in a programmed that
has been designated "proven effective" by the
'Centrum Gezond Leven'. These are the ‘In
Balans’ (In Balance), ‘Zicht op Evenwicht’ (An
Eye on Balance) and ‘Vallen Verleden Tijd’
(Falling, A Thing of the Past) programmes.
which includes entitlement to the reimbursement of a fall prevention programme during the
entire period that you attend a fall prevention
programme.
• On completion of the programme you send us
proof of participation together with a claim
form.
Rates
D.3. Medicines
D.3.1. Medicines, general
Article B.15.1. contains the general terms and
conditions as applicable to your entitlement to
medicines on the grounds of the health insurance.
The terms and conditions in Article B.15.1. also
apply to the medicines that are eligible for reimbursement in Articles D.3.1. through D.3.5.
Please note!
• We do not reimburse the following costs, not
even from one of the other components of your
additional insurance package:
o medicines that we have not designated
(preferred medicines);
o tonics, slimming preparations, dietary supplements (apart from a few registered supplements) dietary preparations and vitamin
preparations;
o care products such as soaps, shampoos,
bath oils, balsams, lotions and/or hair
growth preparations;
o medicines to treat nicotine dependency.
• We do not reimburse the costs mentioned
below, except if you are expressly insured for
the relevant section of Article D.3. in your Reimbursements Overview:
o alternative (homoeopathic and anthroposophic) medicines;
o personal contribution for medicines covered
by the health insurance;
o medicines not covered by the health insurance, because they are not included in the
Medicines Reimbursement System (GVS);
o medicines that do not meet the conditions
in Enclosure 2 (medicines) to the Regulation on Healthcare Insurance;
o medicines that are preventive or prevent a
disease for a trip abroad;
o certain registered dietary supplements.
D.3.2. Personal contribution, medicines
We reimburse the personal contribution that you
have to pay in accordance with the Medicines
Reimbursement System (GVS) for:
a. contraceptive medicines;
b. medicines other than contraceptive medicines.
Please note!
• Check Article D.3.1. to see the medicines we
do not reimburse.
See Article D.3.1. The following terms and conditions are supplementary to them, or differ from
them.
General
On the grounds of the health insurance you receive partial reimbursement for the medicines
where a Medicines Reimbursement System
(GVS) personal contribution is applicable.
Healthcare provider
The medicines are supplied by or under the responsibility of a pharmacist, dispensing general
practitioner, Internet pharmacy or pharmacy with
an "Internet agreement".
Proposed treatment
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medical specialist, nursing specialist, dentist or
obstetrician has determined the medical necessity
for the medicines
Rates
Location
The medicines are obtained from the practice of a
dispensing general practitioner, a government
dential address.
D.3.3. Medicines for erectile dysfunction
Please note!
• Check Article D.3.1. to see the medicines we
do not reimburse.
• Under this Article we do not reimburse medicines that are covered by one of the other Articles in D.3.
We reimburse the costs for medicines for erectile
dysfunction (e.g. Viagra®, Cialis®, Levitra®, Androskat® and Muse®).
Please note!
them.
General
• The medicines are registered on the grounds
of the Medicines Act;
• The medicines are included in the G standard
of the Z index.
Healthcare provider
practitioner or Internet pharmacy.
Proposed treatment
The medicines have been prescribed by a general
practitioner, medical specialist or nursing specialist.
Rates
Location
recognised (hospital) pharmacy or at your resi-
D.3.4. Other medicines
We reimburse registered medicines that are not
reimbursed in accordance with the health insurance.
them.
General
It involves certain medicines or dietary supplements that have a European registration in an EU
or EEA member state, recognisable by an EU
number, and which also have an RVG number.
Medicines and dietary supplements that are
proven to be effective, are safe and registered in
the Netherlands are given this number.
You can find out if a product is registered at
www.cbg-med.nl: from "Geneesmiddelen voor
mensen" (Human Medicines) you can click the link
for "Geneesmiddeleninformatiebank" (Database
Human Medicine).
For example:
• registered Glucosamine for joint complaints;
• registered Melatonin for children with ADHD.
Healthcare provider
Proposed treatment
medical specialist, nursing specialist, dentist or
obstetrician has determined that the medicines
are medically necessary.
Rates
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Location
D.3.5. Contraceptives
We reimburse contraceptive medicines and contraceptive medical aids that are reimbursed up to
a specific age in accordance with the health insurance.
The amount and the age at which we reimburse
are shown in your Reimbursements Overview.
Please note!
See Article D.3.1. for the terms and conditions for
the contraceptive medicines; see Article D.4.1 for
the terms and conditions for the contraceptive
medical aids. The following terms and conditions
are supplementary to them, or differ from them.
General
• The contraceptive medicine or medical aid is
reimbursed up to a specific age in accordance
with the health insurance.
• You are not reimbursed for the contraceptive
medicines and medical aids on the grounds of
the health insurance because your age does
not meet the conditions stipulated for this.
Healthcare provider
• The contraceptive medicine is supplied by or
under the responsibility of a pharmacist, dispensing general practitioner or Internet pharmacy.
• The contraceptive medical aid is supplied by a
healthcare provider that we have designated.
Proposed treatment
handicapped, medical specialist, nursing specialist or obstetrician has determined that the contraceptive medicine or contraceptive medical aid
Rates
Location
You receive the contraceptive medicine from the
practice of a dispensing general practitioner, a
government recognised (hospital) pharmacy or at
your residential address.
The contraceptive medical aid is delivered:
• to the location of the healthcare provider that
we have designated for the delivery of that
medical aid;
• to your residential address;
• to another location agreed between you and
the healthcare provider and which can reasonably be considered as reasonably fitting in line
with the Dutch market conditions.
D.4. Medical aids
This healthcare may already be covered (in part)
in the health insurance. You can see if you are
entitled to this in Article B.
D.4.1. Personal contribution for medical
aids
Under the health insurance you are entitled to the
supply of functioning medical aids. These are
described in our Medical Aids Regulations and the
Regulation on Healthcare Insurance.
A statutory personal contribution and/or statutory
maximum reimbursement apply to a number of
medical aids.
We reimburse (some of) the statutory personal
contribution and/or statutory maximum amounts
that apply to these medical aids.
Please note!
• The exclusions in Article B.17.1. apply here
also.
• Additional costs for a medical aid (such as
deluxe model) are not reimbursed.
General
See Article B.17. for the terms and conditions for
Medical Aids and the terms and conditions of the
Medical Aids Regulations. The following terms
and conditions or your Reimbursements Overview
are supplementary to them, or differ from them.
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Healthcare provider
The medical aid is supplied by a healthcare provider that we have designated. This may differ per
medical aid.
Proposed treatment
If you require a prescription we state this for the
medical aid concerned.
We show whether we need to give you a statement of approval in advance per medical aid. We
may stipulate further conditions in the statement
of approval. If we have issued a statement of approval for a medical aid on the grounds of your
health insurance, then this also effective for an
additional insurance package.
Location
The medical aid is delivered:
• to the location of the healthcare provider that
we have designated for the delivery of that
medical aid;
• to you residential address;
• to another location agreed between you and
the healthcare provider and which can reasonably be considered as reasonably fitting in line
with the Dutch market conditions.
D.4.2. Orthopaedic shoes and modifications to ready-to-wear shoes
We reimburse (part of) the personal contribution
that you yourself have to pay in accordance with
the health insurance for:
a. orthopaedic shoes or modifications to them,
and/or
b. modifications to ready-to-wear shoes.
Please note!
them.
General
Your are reimbursed fully or in part from the
health insurance for custom orthopaedic shoes or
the modifications to the ready-to-wear shoes.
D.4.3. Lapsed
D.4.4. Hairpiece or other head cover
We reimburse (part of):
a. the personal contribution that you must personally pay for a hairpiece in accordance
with the health insurance; or
b. another form of head cover.
Please note!
them.
General
The terms and conditions of Article D.4.1. apply
for another form of head cover as meant in Article
D.4.4.b. as if it were a hairpiece and therefore the
terms and conditions for the functioning medical
aid in Medical Aids Regulations apply.
from us in advance and have received a statement of approval from us.
D.4.5. Hearing aids
that you have to pay personally for one or more
heading aids in accordance with the health insurance.
Please note!
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tled to reimbursement.
Explanation
If you receive a partial reimbursement from the
health insurance for a sound masker then you can
also use the additional reimbursement for the
sound masker.
See Article D.4.1.
D.4.6. Bedwetting alarm
We reimburse a bedwetting alarm with the necessary accessories on:
a. purchase or
b. rental.
The amount we reimburse is shown in your Reimbursements Overview. The reimbursement is onetime only during the entire period that you are
insured with us.
Please note!
• We do not reimburse rental costs if we have
already reimbursed the purchase costs and
vice versa.
• The associated pants are only reimbursed on
the initial purchase or rental; we assume a
maximum of 3 sets of pants.
them.
Healthcare provider
You buy or hire the bedwetting alarm from a specialist medical company, home care shop or
pharmacy.
Proposed treatment
A general practitioner, general practice facility,
Municipal Health Service doctor, doctor for the
mentally handicapped, specialist in geriatric medicine, medical specialist or nursing specialist has
determined that the healthcare is a medical necessity.
D.4.7. Visual aids
Check your Reimbursements Overview to see if you are enti-
We reimburse the following visual aids:
a. contact lenses (day and/or night lenses);
b. spectacle lenses;
c. spectacle frames that you purchase at the
same time as spectacle lenses.
Tip:
If you received a reimbursement from your health
insurance for a visual aid, but a personal contribution still applies, this personal contribution can be
reimbursed in accordance with this Article.
The amount we reimburse is shown in your Reimbursements Overview. This shows the maximum
amount up to which we reimburse in a specific
period.
For example:
Suppose: you have an additional insurance package in which we reimburse a maximum of
€ 100.00 for spectacle lenses and contact lenses
within a period of 2 years (these are calendar
years).
You order spectacles with lenses costing
€ 230.00. You are going to pick them on 07 June
2014. You then submit the bill to us. The period in
which reimbursement takes places runs from 01
January 2014 to 01 January 2016. We pay
€ 100.00 of the bill. On 15 November 2015 you
pick up new spectacles. We do not reimburse this
bill because you have received the maximum
reimbursement from us within a period of 2 years
(running from 01 January 2014 to 01 January
2016).
This example also applies when a period is not
calendar years but a couple of months. The difference is, however, that with an additional insurance package in which we reimburse spectacles
and contact lenses to a maximum of € 200.00 in
24 calendar months, for example, the following
situation arises:
For example, with the purchase of spectacles on
07 June 2014, the period in which the reimbursement takes place runs from 01 June 2014 to 01
June 2016. So from 01 June 2016 you are once
again entitled to reimbursement of € 200.00.
In some additional insurance packages visual
acuity treatments (Article D.1.4) can fall under the
same maximum reimbursement as visual aids.
You can see whether or not this is the case in
your Reimbursements Overview.
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Please note!
o spectacle frames that you do not purchase
at the same time as the spectacle lenses;
o non-optical resources (such as a spectacle
case or lens solution);
o service agreements and insurances;
o optical resources that are not prescription;
o grinding and/or transferring spectacle
lenses;
o additional costs.
them.
General
• This involves prescription visual aids;
• If it involves night lenses, they have a specific
refractive value;
• The maximum reimbursement within the period
for which this maximum applies has not yet
been reached;
• The bill must be properly specified (described).
tered into a healthcare agreement and/or Internet
agreement with us.
Proposed treatment
A doctor has determined that the healthcare is a
medical necessity.
D.4.9. Foot care medical aids
We reimburse the purchase and repair of medical
aids for foot care.
For example:
soles, tape, pressure bandage, nail prostheses
and nail braces.
The amount we reimburse is shown in your Reimbursements Overview. The maximum amount
shown here applies to foot care medical aids and
support soles (see Article D.4.8.) together.
Please note!
D.4.8. Support soles
We reimburse measuring, the purchase and repair
of support soles.
The amount we reimburse is shown in your Reimbursements Overview. The maximum amount
shown here applies to support soles and medical
aids for foot care (see Article D.4.9.) together.
Please note!
them.
General
You are insured with us for the treatment by a
podotherapist, podiatrist or chiropodist, on the
grounds of which the medical aids for foot care
have been prescribed and supplied.
Healthcare provider
The medical aids for foot care are supplied by a
podotherapist, podiatrist or chiropodist.
Proposed treatment
A podotherapist, podiatrist or chiropodist has determined that the medical aid is a medical necessity because they form part of the foot care.
them.
General
It concerns individually made support soles.
Healthcare provider
We have granted recognition to the orthopaedic
shoemaker or the orthopaedic instrument maker
who makes the support soles or they have en-
D.4.10. Home monitor
We provide you with a home monitor on loan for:
a. a period that is stated in the Reimbursements Overview;
b. an extension of this period. The duration of
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the extension period is shown in the Reimbursements Overview.
Please note!
them.
General
There must have been a previous cot death (sudden infant death syndrome) in the family.
Proposed treatment
A paediatrician has determined that a home monitor and any extension of the loan period is a
medical necessity.
D.4.11. ADL (general daily vital functions)
medical aids
We reimburse ADL medical aids. These are medical aids for general daily vital functions.
For example:
Modified cutlery, a sock remover for normal socks,
dressing sticks, a reading stand or a so-called
helping hand. In the case of therapeutic elastic
stockings the aid for putting them on and taking
the off (stocking remover) forms part of the general insurance.
Please note!
them.
General
There is a serious joint complaint or long-term
neurological disorder.
Healthcare provider
The delivery is from one of our recognised suppliers, a specialist medical company or another supplier if they have been recommended by the occupational therapist.
Proposed treatment
An occupational therapist has determined which
ADL medical aid is the most suitable for you.
D.4.12. Home care products
We reimburse home care products.
For example:
Latex gloves, ketone strips (if there is no entitlement under the general insurance) or a Haberman
teat.
Please note!
them.
Proposed treatment
A general practitioner, medical specialist, nursing
specialist, doctor for the mentally handicapped,
specialist in geriatric medicine or company medical officer has determined that the home care
products are a medical necessity.
In the case of the ketone strips only, you must
have requested a care recommendation from us
in advance and have received a statement of approval from us. We may stipulate additional conditions in the statement of approval.
D.4.13. Lapsed
D.4.14. Support pessary
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We reimburse the costs of a support pessary and
for inserting it.
We reimburse a personal alarm system on social
grounds. This comprises an alarm system linked
to a telephone, a land line telephone with integrated alarm function or Domotica personal alarm
device.
The healthcare (rental, loan or purchase) and the
amount we reimburse up to is shown in your Reimbursements Overview.
Please note!
General
them.
The support pessary is necessary in case of a
prolapse.
Healthcare provider
The support pessary is inserted by a general practitioner.
Proposed treatment
A general practitioner has determined that the
support pessary is a medical necessity.
D.4.15. Test strips, diabetes patients
We reimburse diabetes test material in the form of
test strips.
Please note!
them.
General
You are a diabetes sufferer who does not use
insulin.
Healthcare provider
A pharmacy, dispensing general practitioner or
specialist medical shop supplies the test strips.
D.4.16. Personal alarm
Please note!
• We do not reimburse the connection and subscription costs to, for example, an emergency
centre for using the alarm.
them.
Healthcare provider
The loan, purchase or hire takes place via a specialist medical company, home care shop or personal alarm organisation.
D.4.17. Condoms
We reimburse condoms.
Please note!
them.
Healthcare provider
The condoms are supplied by a healthcare provider with whom we have entered into a healthcare agreement and/or Internet agreement. We do
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not reimburse condoms supplied by another
D.4.18. Braces and bandages
Please note!
We reimburse braces and bandages, if they are
not reimbursed under the health insurance.
Please note!
them.
Proposed treatment
A doctor or physiotherapist has determined that
the brace or bandage is a medical necessity.
D.4.19. Non-allergenic shoes
that you yourself have to pay for the nonallergenic shoes in accordance with the health
insurance.
Please note!
See Article D.4.1.
D.4.20. Epilepsy alarm
We reimburse a bed mat that detects serious epileptic (tonic/clonic) attacks and raises the alarm.
The amount we reimburse is shown in your Reim-
them.
Proposed treatment
A neurologist from a specialist epilepsy centre has
determined that there is a degree of epilepsy that
is so severe that the bed mat is indicated.
D.4.21. Redression helmet
We reimburse a redression helmet, if it is not reimbursed under the health insurance.
Please note!
them.
General
You child has plagiocephaly or brachycephaly
without craniosynostosis.
Proposed treatment
A medical specialist has determined that a redression helmet is required for your child's treatment.
from us in advance and have received a statement of approval from us.
D.5. Stammer therapy
We reimburse:
a. stammer therapy in accordance with the:
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o Del Ferro method; or
o BOMA method; or
o INS method.
b. lodging costs.
Please note!
• Treatment for stammering also falls under
speech therapists. Speech therapy is insured
entitled
to
this
in
Article
B.10.
If you are, that healthcare takes precedence
over reimbursement under this additional insurance package.
• We do not reimburse the travel and transport
costs that you incur in connection with stammer therapy.
Please note!
• We do not reimburse the travel costs, transport
costs and accommodation costs that you incur
in connection with the Recuperation & Balance
programme.
General
Lodging costs are only eligible for reimbursement:
• if you are expressly insured for them in accordance with the Reimbursements Overview,
and
• if the stammer therapy itself is also reimbursed, and
• if they are necessary for and directly related to
you stay in lodgings, and
• if and for as long as the stammer therapy is
given internally.
Proposed treatment
A doctor has determined that the stammer therapy
from us in advance for the therapy costs and the
lodging costs, if any, and have received a statement of approval from us. We may stipulate additional conditions in that statement of approval.
Rates
D.6. Mental healthcare (GGZ)
D.6.1. Recuperation & Balance
We reimburse the Recuperation & Balance treatment programme or modular components of it.
Healthcare provider
The 'Stichting Herstel & Balans' has certified the
healthcare provider or hospital (establishment for
medical specialist care), rehabilitation establishment, physiotherapist or psychologist to run the
treatment programme.
Proposed treatment
An oncologist or rehabilitation doctor has determined that the healthcare is a medical necessity.
Rates
D.6.2. Lapsed
D.6.3. Open homes
We reimburse social mental healthcare in an open
home for (former) cancer patients and their partner and family members if necessary.
If this partner and family members are themselves
insured for social mental healthcare, then the
costs of reimbursement are eligible for reimbursement under their own additional insurance
package.
If this partner and family members are not insured
for social mental healthcare themselves, or are
not insured with us at all, then the costs for the
reimbursement become eligible under the additional insurance package of the insured patient
him/herself.
The amount we reimburse is shown in your Reim-
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The health is provided at your own home.
Please note!
D.6.5. Coping with trauma
General
The social mental healthcare that the open home
provides for (former) cancer patients is of a shortterm nature, and extends over a period that is
shorter than twelve months.
Healthcare provider
We have granted recognition to the open home for
(former) cancer patients because we believe that
it guarantees a proper level of quality.
Rates
D.6.4. Light therapy for seasonal affective
disorder
We reimburse the hire or purchase costs for the
equipment that is necessary for light therapy at
your home in connection with seasonal affective
disorder, or you will receive the equipment on
loan.
What we will provide you with and the amount we
reimburse is shown in your Reimbursements
Overview.
Please note!
General
The device is equipped for full light spectrum
therapy at an intensity of 10,000 lux.
Proposed treatment
A psychiatrist or psychotherapist has determined
that the light therapy is a medical necessity in
connection with seasonal affective disorder.
Rates
Location
The healthcare comprises the initial emergency
measures and coping immediately after a traumatic event if you are the victim of or are directly
involved in an attack, hostage taking, aggression
or accident where bodily injury occurs, sudden
death (suicide for example) or inappropriate behaviour.
We reimburse the costs of coping with trauma:
a. for a traumatic work-related event;
b. for a traumatic event that is not related to
your work.
Please note!
General
• The traumatic event must be acute and it must
have temporarily affected you to such a degree
that normal daily functioning is no longer possible;
• In the event of a work-related traumatic event it
must have common ground with performing
your work activities. There is an industrial accident with bodily injury, an attack or sudden
death as the result of suicide;
• The event must be demonstrable;
• The traumatic event must have taken place in
the Netherlands.
Healthcare provider
The healthcare provider is the 'IvP' trauma establishment.
Rates
D.7. Alternative care and
Psychosocial care
D.7.1. Alternative and psychosocial treat-
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ments
We reimburse:
a. treatments based on alternative healthcare;
b. psychosocial treatments.
Please note!
• We do not reimburse the costs of:
o healthcare (treatments and consultations)
that are covered by your health insurance,
AWBZ or under another Article in your additional insurance package(s). Here it does
not matter if you are insured under or from
that other Article or if you are not reimbursed (in full) for that treatment in accordance with that other Article. You cannot
choose which Article the healthcare is reimbursed under. Nor are you reimbursed
twice for healthcare. It is only once it has
been determined that healthcare is not covered by your healthcare, AWBZ or another
Article in your additional insurance package(s) that we determine whether this
healthcare is eligible for reimbursement
under alternative healthcare;
o experimental treatment and treatments that
are still in the research phase;
o laboratory investigations such as in a hospital;
o relaxation exercises such as yoga, Qigong
and Tai Chi and treatments aimed at relaxation, such as massage therapy.
General
The healthcare takes place in accordance with the
aims, treatment protocols and guidelines of the
professional association or the register where the
attending healthcare provider is affiliated.
Healthcare provider
• The alternative treatments are provided exclusively by an alternative healthcare therapist or
a alternative healthcare doctor:
o who is registered as a member of professional association for alternative healthcare
that we have granted recognition, or;
o who is included in a register for alternative
healthcare that we have granted recogni-
tion.
• The psychosocial treatments are provided
exclusively by a psychosocial care therapist or
a psychosocial care doctor:
o who is registered as a member of professional association for psychosocial care
that we have granted recognition, or
o who is included in a register for psychosocial care that we have granted recognition.
You can find a list of professional associations
that we have granted recognition on our website.
Rates
D.7.2. Alternative medicines
We reimburse anthroposophic and homoeopathic
medicines and products.
Please note!
• We do not reimburse self-care medicines
which are not eligible for reimbursement in accordance with the Regulation on Healthcare
Insurance as alternative medicines either.
Article B.15.1. contains the general terms and
conditions as applicable to your entitlement to
medicines on the grounds of the health insurance.
They also apply to this Article D.7.2. The following
terms and conditions are supplementary to them,
or differ from them.
General
• The medicines and products are registered as
homoeopathic and/or anthroposophic medicines in accordance with the Medicines Act;
• The medicines and products are included in
the G standard of the Z index.
Healthcare provider
Proposed treatment
A doctor, dentist, obstetrician or alternative
healthcare provider has determined that the medi-
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cines are a medical necessity. The treatment by
the prescriber is insured in accordance with your
health insurance or additional insurance package.
Rates
Location
recognised (hospital) pharmacy or at your residential address (via an Internet pharmacy).
D.8. Oral care
the treatment within the scope of oral
care for special healthcare groups.
o E97 and E98: costs for the external bleaching of teeth;
o myofunctional (pre) orthodontic trainers.
Healthcare provider
• a dentist;
• an oral hygienist;
• a clinical dental technician;
• a healthcare provider who is affiliated with a
oral care centre.
Proposed treatment
A dentist has determined that the healthcare is a
medical necessity.
Rates
D.8.1. Oral care - general
We reimburse the oral care from Articles D.8.1
through D.8.5. such as is customarily provided by
dentists.
Please note!
• We do not reimburse the following costs:
o Costs of an oral care subscription that is
claimed using performance codes that start
with the letter "Z", because these costs do
not relate to the oral care that actually took
place and was provided;
o Costs for oral care which, due to their nature, form part of the health insurance and
for which a statement of approval must be
issued prior to the start of the treatment.
We name the following performance codes
specifically:
- A20: treatment under general anaesthesia (narcosis);
- B10, B11 and B12: anaesthesia using a
light anaesthetic (nitrous oxide sedation);
- C84: preparatory treatment under general anaesthesia;
- U05 and U10: time rates for supervision
of difficult to treat patients; this relates to
D.8.2. Crowns, bridges and inlays
We reimburse the costs of crowns, bridges and
inlays that are made by a dentist. This is inclusive
of the associated dental performances and materials and technology costs.
Please note!
• We do not reimburse the costs that we do not
reimburse under Article D.8.1 under this Article
either.
them.
General
The healthcare is claimed on the basis of the dental care performances list drawn up by the 'Nederlandse Zorgautoriteit'. This is done using performance codes that start with the letter "R".
Rates
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D.8.3. Dentures and implantology
We reimburse the costs of the following forms of
oral care such as is customarily provided by dentists:
a. removable, temporary dentures;
b. the statutory contributions that you have to pay
personally for removable, full dentures in accordance with your health insurance;
c. implantology that is not reimbursed under Article B.12.2 of the health insurance.
For all of the reimbursements mentioned this involves the dental performances and associated
materials and technology costs.
Please note!
either.
them.
General
The healthcare is claimed on the basis of the dental care performances list drawn up by the 'Nederlandse Zorgautoriteit'. This is done using performance codes that start with the letter "P" or "J".
Healthcare provider
The healthcare is provided by a dentist, a clinical
dental technician or qualified healthcare provider
affiliated with an oral care centre or a Centre for
Special Dentistry.
Referral
Referral by a dentist is necessary if prosthetic
care is provided by a clinical dental technician.
This involves healthcare that is indicated by P
codes and/or J codes for insured persons who still
have their own teeth and/or dental implants.
Rates
Location
The healthcare takes place in a dental practice,
the practice of a clinical dental technician, an oral
care centre or Centre for Special Dentistry.
D.8.4. Other oral care
We reimburse other forms of healthcare such as
is customarily provided by dentists, insofar as it is
not described as healthcare in Articles D.8.2,.
D.8.3. and D.8.5.
Please note!
either.
them.
General
The healthcare is claimed on the basis of the dental care performances list drawn up by the 'Nederlandse Zorgautoriteit'. This is done using performance codes other than those named in Articles
D.8.2., D.8.3 and D.8.5. The oral surgeon uses
the claim codes for which he/she is authorised.
Healthcare provider
• The healthcare is provided by a dentist, an oral
hygienist, clinical dental technician or other
qualified healthcare provider (this can be an
oral surgeon) who is affiliated with an oral care
centre;
• An oral surgeon who is affiliated with an hospital (establishment for medical specialist care)
provides the healthcare in relation to inserting
implants.
Rates
D.8.5. Orthodontics (teeth straightening)
We reimburse orthodontics, including the associated dental performances and materials and technology costs.
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The amount we reimburse is shown in your Reimbursements Overview. One of the following points
applies to this:
• Maximum amount
If the Reimbursements Overview for your additional insurance package shows that we reimburse orthodontics to a maximum amount, then
this maximum amount applies for the entire period
that you have that additional insurance package
with us, unless your Reimbursements Overview
states otherwise.
• Maximum amount and specific age
What if the Reimbursements Overview for your
additional insurance package shows that we reimburse orthodontics to a maximum amount and
up to or from a specific age? Then this maximum
reimbursement applies for the entire period that
you have that additional insurance package with
use and up to the age shown or from the age
shown.
• Maximum amount and increasing reimbursement
If the Reimbursements Overview for your additional insurance package shows that we reimburse orthodontics to a maximum amount that
increases each year, then this maximum amount
applies for the entire period that you have that
additional insurance package with us.
For example:
You have taken out an additional insurance package with us for yourself and your 10 year old
daughter which has an increasing reimbursement
for orthodontics.
This additional insurance package started on 01
January 2010. At that time there is a maximum
reimbursement for orthodontics of € 1,000.00 for
your daughter.
On 01 January 2011 the reimbursement for your
daughter increases for the first time by € 500.00
and in 2011 you are reimbursed a total of €
1,500.00 for your daughter.
Your daughter is given braces and on 17 May
2011 you receive a bill for € 1,150.00. Because
you are entitled to a reimbursement of € 1,500.00
we reimburse this bill in full. A total of € 350.00
remains.
On 01 January 2012 this remaining reimbursement increased for the second time by € 500.00 to a total of € 850.00. On 03 April 2012 you receive another bill for your daughter's orthodontics;
this amounts to € 925.00. We reimburse € 850.00
of this and € 75.00 remains for your account.
On 01 January 2013 the reimbursement for orthodontics increases by € 500.00 for the third and
last time. There was nothing left over from 2012,
so the maximum reimbursement is now € 500.00.
This € 500.00 can still be reimbursed in 2013 or in
the subsequent years as long as you have taken
out this additional insurance package.
Please note!
either.
• Article C.9.3. does not apply to the reimbursement of orthodontics in this Article.
them.
General
The healthcare is claimed on the basis of the
orthodontics care performances list drawn up by
the 'Nederlandse Zorgautoriteit' using
performance codes starting with:
• the letter "F",
• ending with the letter "A" and
• with 3 figures in between.
Example
"F121A" for "1st consultation".
A "*" is added to the aforementioned performance
code(s) for the materials and technology costs
associated with this healthcare.
Healthcare provider
The healthcare is provided by a dentist or an
orthodontist.
Rates
D.9. Spa treatment
We reimburse:
• for a health trip via the organisation:
o your transport to a health resort;
o treatment in a health resort;
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o costs for staying in a health resort. This
comprises overnight costs, breakfast, lunch
and dinner.
• for a health trip you have organised yourself:
o treatment in a health resort;
o costs for staying in a health resort. This
comprises overnight costs, breakfast, lunch
and dinner.
Please note!
• Costs for staying in a health resort exclusively
includes
the
costs
of
the
arrangement/programme offered. Additional costs for
extra drinks, newspapers, magazines, cosmetics and other items and services falling outside
of the arrangement are not covered.
D.10.1. UV-B light equipment
We reimburse the purchase or rental of UV-B light
equipment intended for home use.
If you choose to purchase UV-B light equipment
we can reimburse a higher amount than the
maximum reimbursement in the Reimbursements
Overview. As and additional condition we do then
stipulate that we will not reimburse the purchase
of new light equipment for a number of years.
Please note!
General
• This involves a treatment that has been personalised for you, recorded in writing and
which lasts at least one week.
• You are suffering from a severe form of:
o rheumatoid arthritis; or
o psoriatic arthritis; or
o Bechterew's disease.
Healthcare provider
A doctor should be involved in the treatment.
Proposed treatment
A rheumatologist has determined that the spa
treatment is a medical necessity.
Rates
Location
A health resort that specialises in the treatment of
disorders of the locomotor system, rheumatic
disorders in particular, that we have granted recognition; we do not reimburse other health resorts.
General
You are suffering from severe eczema.
Healthcare provider
The healthcare is provided by a dermatologist.
Proposed treatment
A dermatologist has determined that the treatment
or the use of UV-B light equipment is a medical
necessity.
Rates
D.10. Skin therapies
D.10.2. Hair removal
We reimburse the removal of extreme hair growth
on the face and/or the neck for women. The
Please note!
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• We do not reimburse treatments with resins,
gels, creams and other hair removal products.
Healthcare provider
• a dermatologist;
• a skin therapist;
• a beauty therapist with the specialism "electrical epilation" and/or "epilation techniques" who
is registered with the ANBOS organisation.
Proposed treatment
A doctor has determined that the epilation treatment is a medical necessity.
Rates
D.10.3. Acne treatment
We reimburse the treatment for a severe form of
acne on the face and/or on the neck. The amount
we reimburse is shown in your Reimbursements
Overview.
Please note!
General
This involves a severe form of acne on the face
and/or on the neck.
Healthcare provider
• a beauty specialist with specialism "acne" who
is registered with the ANBOS organisation.
Proposed treatment
A doctor has determined that the acne treatment
Rates
D.10.4. Camouflage therapy
We reimburse:
a. camouflage lessons;
b. the purchase costs for the camouflage products required for the lessons.
Please note!
General
The aim of the camouflage lessons is to camouflage port wine stains, scars and other disfiguring
skin disorders on the face and/or the neck.
Healthcare provider
• a beauty specialist with specialism "camouflage" who is registered with the ANBOS organisation.
Proposed treatment
A doctor has determined that the camouflage
lessons are a medical necessity.
Rates
D.11. Obesity treatment
We reimburse the costs for participation in the
part-time day treatment programme for obese
patients.
Please note!
General
• The part-time day treatment programme is
aimed at behaviour change by means of a nonsurgical, multidisciplinary treatment.
• It must be a matter of so-called morbid obesity.
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This is when your Body Mass Index (BMI) is 40
or more.
• You must have completed the entire programme.
• The reimbursement is one-time only for the
entire period that you have taken out an additional insurance package with us that has this
reimbursement.
Location
The treatment takes place in a treatment centre
that we have granted recognition or with which we
have entered into a healthcare agreement.
Rates
D.12. Patient transport
D.12.1. Seated patient transport (patient
transport by car, public transport or taxi)
In relation to seated patient transport we give:
a. reimbursement of the statutory personal
contribution that you have to pay each year
in accordance with the health insurance for
use of car, public transport or taxi;
b. up to a specific amount per kilometre, an
additional mileage reimbursement over and
above the mileage reimbursement in the
health insurance when using car or taxi;
c. a substitute reimbursement when using a
taxi within the Netherlands or your country
of residence from your home address to a
establishment for medical specialist care or
the practice of a medical specialist and
back;
d. a reimbursement when using a car or public
transport (lowest class) within the Netherlands or your country of residence from
your home address to a establishment for
medical specialist care or the practice of a
medical specialist and back.
The Reimbursements Overview shows whether
the personal contribution is reimbursed and the
amount of the (additional) mileage reimbursement.
Please note!
o the costs of seated patient transport if you
travel to a location (further away) than the
closest location where treatment and nursing is available, while there is no medical
necessity for it at the time;
o the costs of patient transport in connection
with AWBZ care;
o costs for (patient) transport, travel or escorting between your country of residence and
another country, if you undergo medical
treatment in that country.
General
• The reimbursements apply per kilometre travelled;
• The seated patient transport is related to a
medical examination or medical treatment that
is (partly) reimbursed on the grounds of the
health insurance or the additional insurance
package;
• The costs of seated patient transport fall under
the coverage of the additional insurance package if and insofar as they are not reimbursed
under the health insurance.
• The length of journey is determined using the
most recent version of the Routenet route
planner (free to use on the Internet), based on
the quickest route. We reimburse on the basis
of full kilometres; we use the customary rounding-off method.
Additional condition for D.12.1.c.
The attending medical specialist or nursing specialist believes that the use of public transport is
irresponsible on medical grounds.
Healthcare provider
For patient transport mentioned in Article:
• D.12.1.a.: an authorised permit-holding taxi
driver, public transport, your own car or hire
car;
• D.12.1.b.: an authorised permit-holding taxi
driver, public transport, your own car or hire
car;
• D.12.1.c.: an authorised, permit-holding taxi
driver;
• D.12.1.d.: public transport, hire car or own car.
Proposed treatment
handicapped, specialist in geriatric medicine, or
medical specialist has determined that patient
transport is a medical necessity if it involves
seated patient transport mentioned in Article
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D.12.1.a. or b.
Rates
Location
The patient transport takes place from your residential address or (temporary) accommodation
(not being a hospital) to the location where you
will be treated and back.
D.12.2. Travelling expenses, parents
We reimburse the travels costs for you as parents
to a hospital (establishment for medical specialist
care) where your child is hospitalised. We reimburse the travel costs from the 1st day of the hospitalisation.
Please note!
• We do not reimburse the travel costs for a visit
to the Dutch Asthma Centre in Davos (NAD).
General
• Your child who is hospitalised is younger than
18 years and is insured with us;
• You child is hospitalised in an establishment
for medical specialist care away from your
place of residence;
• You child is hospitalised in an establishment
for medical specialist care in your country of
residence. If the country of residence is the
Netherlands, the hospitalisation can also be in
Belgium or Germany;
• The length of journey is determined using the
most recent version of the Routenet route
planner (free to use on the Internet), based on
the quickest route. We reimburse on the basis
of full kilometres; we use the customary rounding-off method.
D.12.3. Visiting costs
We reimburse the travels costs for one visitor to a
care) if you are hospitalised there.
Please note!
• We do not reimburse the travel costs:
o for a visit if you are hospitalised in an establishment for medical specialist care in a
country other than the Netherlands, Belgium, Germany or your country of residence;
o for a visit to the Dutch Asthma Centre in
Davos (NAD).
General
• The person who is hospitalised is you yourself
or is your child;
• We reimburse the travel costs once in a specific period and that applies from the 1st day of
hospitalisation; the length of that period is
shown in your Reimbursements Overview;
• Per visit we reimburse a maximum of the number of kilometres for the there and back journey for one visitor;
• The visitor does not have to be insured with us;
after all, in the first instance we reimburse the
visit costs from the additional insurance package of the person who is hospitalised. If they
are not insured with us for visiting costs, but
the visitor is, then we reimburse the visiting
costs from the visitor's additional insurance
package.
• We base this on the distance between the
legal residential address of the person who is
hospitalised and the hospital (establishment for
medical specialist care). This is at least the
number of kilometres single journey that is
shown in the Reimbursements Overview. The
length of journey is determined using the most
recent version of the Routenet route planner
(free to use on the Internet), based on the
quickest route. We reimburse on the basis of
full kilometres; we use the customary roundingoff method;
• You meet the stipulated minimum consecutive
period of hospitalisation. This period is a
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maximum of 365 days.
• You are hospitalised for medical specialist care
and are nursed in a rehabilitation establishment or (psychiatric) hospital (establishment
for medical specialist care) in:
o you country of residence; or
o Belgium or Germany, if you live in the
Netherlands.
• If your additional insurance package reimburses both accommodation expenses (see
Article D.13.2.) and visiting costs, you must
choose whether you want the accommodation
expenses or the visiting costs reimbursed. If
you choose reimbursement of accommodation
expenses, you will not be reimbursed for visiting costs and vice versa. We regard the first
invoice for visiting costs or accommodation expenses that you submit to be your choice.
If you want to be eligible for reimbursement of
visiting costs during hospitalisation in Belgium or
Germany, you must have requested a care recommendation from us in advance and have received a statement of approval from us for the
hospitalisation in the country concerned.
D.13. Stay
D.13.1. Therapy camp
We reimburse the costs of participation in and
staying at a therapy camp for children up to 18
years that is organised by an establishment that
we have granted recognition.
Please note!
Healthcare provider
One of the following associations or establishments organises the camp:
• Stichting Gezond Gewicht' ('Dikke Vrienden
Kampen');
• 'Stichting De Luchtballon';
• 'Vereniging voor mensen met constitutioneel
eczeem';
• 'Stichting De Ster';
• 'Nederlandse Hartstichting';
• 'Diabetes Vereniging Nederland' ('SugarKidsClub');
• 'Stichting
Kinderoncologische
Vakantiekampen';
• any other associations or establishments that
we have granted recognition.
Rates
D.13.2. Accommodation expenses
We reimburse:
a. overnight accommodation for you or your
child in a room in a guest house;
b. the costs for your child younger than 18
years staying in a 'Mappa Mondo' house.
For example:With guest house we mean, amongst
others, a Ronald McDonald house or stay home at
a general hospital or categoral hospital such as
the 'Dr. Daniel den Hoed Kliniek' or the 'Antoni
van Leeuwenhoek Ziekenhuis'.
Explanation:
You may require a number of outpatient treatments over a short period of time without hospitalisation or nursing being required. You can then
also use the guest house. As long as a total of
only one room is used in the guest house.
It is possible that no places are available in the
guest house or 'Mappa Mondo' house. Following
our approval, you or the guest(s) can overnight in
a hotel or guesthouse nearby and claim those
costs from us as accommodation expenses. We
base the reimbursement on the costs that you
and/or the guest(s) would have incurred in the
guest house or 'Mappa Mondo' house if there had
been space available there. The amount we reimburse is shown in your Reimbursements Overview.
Please note!
o the costs that are reimbursed from the
AWBZ in connection with collaboration with
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home care or which fall under a Personal
Budget (PGB);
o the accommodation expenses that are incurred in connection with visiting an insured
person in the Dutch Asthma Centre in
Davos (NAD).
• We reimburse the accommodation expenses
from the additional insurance package of the
individual who is being treated. If they are not
insured with us for accommodation expenses,
but the guest is, then we reimburse the accommodation expenses from the guest's additional insurance package. The person who is
hospitalised must have at least one insurance
with us. The type of insurance is immaterial.
General
• The overnight accommodation for you and/or a
maximum of 2 guests in a guest house (one
room in total) is reimbursed if you or an insured
family member (child or partner) is being
treated in a hospital (establishment for medical
specialist care). This could, therefore, be an
outpatient treatment for you or your child, or a
clinical treatment for your partner or child.
• If your additional insurance package reimburses both accommodation expenses and
visiting costs (see Article D.12.3.), you must
choose whether you want the accommodation
expenses or the visiting costs reimbursed. If
you choose reimbursement of accommodation
expenses, you will not be reimbursed for visiting costs and vice versa.
Healthcare provider
The care is provided by a guest house or a
'Mappa Mondo' house. The guest house in a noncommercial establishment and has an affiliation
with:
• a hospital (establishment for medical specialist
care) in the Netherlands or in your country of
residence; or
• a hospital (establishment for medical specialist
care) outside of your country of residence with
agreement.
Rates
D.13.3. Hospital nursing in a higher class
We reimburse the additional costs of nursing in a
higher class of a hospital (establishment for medical specialist care).
Please note!
• We do not reimburse the costs of:
o nursing in the lowest class; this is reimbursed from the health insurance.
nd
o nursing in the 2 class for which the establishment charges a rate that is the same as
the rate for the lowest class in the Netherlands.
o nursing in a higher class if you are hospitalised and are nursed in a hospital (establishment for medical specialist care) for
specialist medical mental healthcare.
General
• You are 18 years or older;
• Your insured class is higher than the lowest
class;
• The rate for the higher class is higher than the
rate for the lowest class.
Healthcare provider
A hospital (establishment for medical specialist
care) invoices for the costs using the DOT healthcare product code or the class surcharge.
Proposed treatment
A doctor has determined that the hospitalisation is
a medical necessity.
from us in advance and have received a statement of approval from us for the costs that are
reimbursed from the health insurance, if this is
necessary in accordance with the terms and conditions of the health insurance. We may stipulate
Rates
D.13.4. In-patient accommodation allowance / compensation / additional costs for
hospitalisation
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We pay or reimburse:
a. In-patient accommodation allowance.
We pay a fixed amount per day if you are
hospital and nursed in a hospital (establishment for medical specialist care).
b. Deluxe arrangement / comfort package.
We reimburse the costs of a deluxe arrangement or comfort package if you are
hospitalised and nursed in a hospital (establishment for medical specialist care).
Example
The deluxe arrangement or comfort package can comprise anything that makes your
stay in the hospital more pleasant. For example, television hire, telephone, Internet or
radio, etc. A more luxurious room, wider
menu, newspaper or magazine, continuous
visiting arrangement or tea and/coffee for
the visitors could be offered in addition.
c. Compensation payment.
We pay you a fixed amount per day for the
period that you are hospitalised and are
nursed in a hospital (establishment for
medical specialist care) and where you do
not use or cannot use a deluxe arrangement or comfort package as described in
Article D.13.4.b. This is because, for example, the hospital has no distinction between
standard and more luxurious nursing or
does not have a deluxe package.
d. Partner's travel costs.
We reimburse the costs of 2nd class public
transport, or private transport based on
kilometres travelled via the quickest route.
This is determined using the most recent
version of the Routenet route planner (free
to use on the Internet). We reimburse on
the basis of full kilometres; we use the customary rounding-off method. The insured
person from the age of 18 years is entitled
to reimbursement of travel costs incurred by
his/her partner to and from the hospital in
the Netherlands or the country of residence
where the insured is staying.
What we reimburse and the amount we reimburse
up to is shown in your Reimbursements Overview.
Tip
You must personally submit a request to us for inpatient accommodation allowance, compensation
payment or reimbursement of travel costs using
own transport. You must submit a bill for the de-
luxe arrangement and the travel costs using public
transport.
Please note!
• We do not reimburse the costs for medical
specialist care and the associated, additional
clinical costs under this Article.
• Nor do we reimburse the normal, non-deluxe
costs for hospitalisation/staying in a hospital
(establishment for medical specialist care).
General
• If you have not submitted bills for a deluxe
arrangement that you have enjoyed (Article
D.13.4.b.) before we have received your
claim(s) for your hospitalisation and stay in the
care) we assume that you have chosen payment of the compensation payment (Article
D.13.4.c.).
• If the stay is spread across 2 consecutive
years, the maximum in-patient accommodation
allowance or compensation payment is only
made once.
• Hospitalisation and staying in an establishment
for medical specialist care (hospital) for a
maximum of 365 consecutive days (after 365
days the costs are for the account of the
AWBZ).
Proposed treatment
A doctor has determined that the hospitalisation is
a medical necessity.
D.13.5. Lapsed
D.13.6. Convalescent home
We reimburse the stay in a convalescent home in
connection with recovery from a physical disorder.
Please note!
• We do not reimburse the costs of staying in a
convalescent home:
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o if you are entitled to the same or comparable care under the AWBZ;
o if the stay is spread over 2 consecutive
years and your additional insurance package has already reimbursed the maximum
amount over the 1st year.
Healthcare provider
The healthcare is provided by a convalescent
home selected by us.
Rates
D.13.7. Personal contribution, hospice
We reimburse the personal contribution for a stay
in a hospice. The amount we reimburse is shown
Please note!
• We do not reimburse the personal contribution
for domestic help and nursing which the CAK
invoices to you on the grounds of the AWBZ.
Rates
Location
The personal care and nursing takes place in a
hospice. A hospice where only low-complex care
is provided by volunteers, also known as a
"nearly-home-home".
D.13.8. Support for home situation
We reimburse:
a. 24-hour nursing if there is a chronic case of
illness;
b. care support after a hospital stay, for example, a nanny service, a dog-walking service or assistance for unavoidable domestic
activities;
c. childcare on hospitalisation.
Please note!
General
• For Article D.13.8.a. and b. you must have
insoluble problems at home which require support by means of professional help.
• The following applies for Article D.13.8.c.:
o The childcare relates to your own child(ren)
in your family up to a maximum of the age
of 14 years;
o The parent providing the care is hospitalised in a establishment for medical specialist care;
o The parent providing the care has an additional insurance package with us that has
an entitlement to reimbursement of childcare;
o The reimbursement starts on the day after
hospitalisation of the parent providing the
care;
o The childcare falls outside of the hours that
you have normally arranged, before there
was hospitalisation in an establishment for
medical specialist care.
Healthcare provider
For 24-hour care (a.) and for care support (b.) the
care is provided by a professional organisation.
The childcare (c.) takes place at a registered children's centre or a registered child minder.
In the case of 24-hour care (a.) and care support
(b.) you must have requested a care recommendation from us in advance and have received a
statement of approval from us. We may stipulate
Rates
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D.13.9. Lapsed
D.14. Healthcare abroad
D.14.1. Urgent medical care abroad
This healthcare comprises urgent medical care
during a temporary stay abroad. This healthcare is
a medical necessity that cannot reasonably be
delayed.
We reimburse:
a. healthcare that would also have been reimbursed under your healthcare or additional insurance package if you had incurred these
costs in the Netherlands or in your country of
residence but where part of the costs remain
for your own account due to higher rates
abroad. (Specifically, we reimburse costs in
accordance with the Dutch rates. See Article
A.20. for details) The rates abroad often differ
(higher or lower) from the Dutch rates. If the
rates abroad are higher than the Dutch rates,
then we reimburse these additional costs from
the additional insurance package up to the rate
that is shown in your Reimbursements Overview;
b. a dental treatment by a dentist;
c. repatriation (return) of the sick, insured person.
This is the patient transport from the place
where you are temporarily staying or the location of your accident, sudden illness or your
treatment abroad to an establishment for
medical specialist care in the Netherlands, or if
you do not live there, to an establishment for
medical specialist care in your country of residence.
The repatriation itself must be a medical necessity, because we are of the opinion that:
o the correct medical treatment abroad is not
available in that location or is not a good
feasibility and it is in the country of residence/the Netherlands;
o treatment abroad in that location is medically irresponsible;
o treatment abroad in that location is clearly
much more expensive than treatment in the
country of residence/the Netherlands.
d. the accompaniment by a number of the family
members of an insured person who is repatriated on the grounds of the previous article c.;
e. medical escort by a qualified doctor or nurse for
a sick, insured person who is repatriated on
the grounds of the previous article c.;
f. transport of the human remains:
1. back to the Netherlands of the insured person who has died outside of the Netherlands and who has lived there until their
death, or;
2. back to the country of residence of the insured person who has died outside of their
country of residence.
The reimbursement relates to costs that are
directly related to transporting the human remains from the country of death back to the
Netherlands or to the country of residence.
These costs include the costs for preserving
the human remains, to attend to them and prepare them for transport, costs of the transport
itself and in addition, government costs such
as fees and duties;
g. forwarding the necessary medicines and/or
medical aids;
h. the costs of telecommunication with our emergency services to obtain the necessary healthcare;
i. medical advice from our emergency service's
Medical Team prior to and during your temporary stay abroad.
You can find out if your additional insurance
package provides reimbursement for this healthcare in your Reimbursements Overview. If this
healthcare is reimbursed, then this, together with
the reimbursement under the general insurance,
is to a maximum that is also shown in your Reimbursements Overview. You can check which
healthcare is reimbursed and the amount up to
which reimbursement is given there.
Please note!
• This healthcare may already be covered (in
part) in the health insurance. You can see if
you are entitled to this in Article B.
• We do not reimburse the additional costs,
costs for customs levies and return freight for
medicines and/or medical aids that have been
sent.
• When, for example, you have to be brought
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back to the Netherlands on the 'gipsvlucht' (ski
special), these costs are not covered by the
(additional) insurance (package). You can insure these costs under a travel insurance
however.
• The return of a deceased is not covered by the
health insurance and in very many cases it is
not covered by an additional insurance package either. Therefore, a reimbursement is only
included in a couple of very comprehensive
additional insurance package. A travel insurance does cover these costs.
• We only reimburse healthcare abroad if you
are staying there temporarily. If you are there
for longer than 365 days without a break, we
assume that you live there and are not staying
there temporarily.
General
• You are not reimbursed or will only be partly
reimbursed the costs under the health insurance, or a (travel) insurance taken out separately;
• The healthcare is urgent. This healthcare is a
medical necessity that cannot reasonably be
delayed.
• Your stay is temporary if you are abroad for
less than 365 consecutive days.
• The amount that you claim for healthcare
abroad must not be higher than is customary in
the country where you are staying temporarily;
• The healthcare was not foreseeable at the time
you left to go abroad;
• Once we have paid the costs, you must cooperate in the transfer of the rights to another
(travel) insurer;
• You must cooperate fully in the provision of
care and adhere to the instructions given by
the emergency services that have become involved.
Healthcare provider
The healthcare is provided by a healthcare provider who is established in the foreign country
where you are staying temporarily. this healthcare
provider complies with the requirements, legislation and regulations that are laid down for their
profession in that country.
You must request a care recommendation from us
or from the emergency service with whom we
have entered into an agreement for (mediation in)
healthcare abroad. We may stipulate additional
Rates
D.14.2. Lapsed
D.15. Foot care
D.15.1. General foot care
We reimburse foot care (podiatry and podotherapy).
The amount we reimburse is shown in the Reimbursements Overview.
Please note!
• We do not reimburse the following under this
Article:
o support soles;
o foot care medical aids;
o treatment of patients with diabetes mellitus,
rheumatoid arthritis or serious problems
with the blood vessels in the legs.
Healthcare provider
The foot care is carried out by a podotherapist or
podiatrist.
Referral
A doctor has determined that the foot care is a
medical necessity prior to the start of the treatment.
Rates
D.15.2. Foot care for certain disorders
For specific disorders we reimburse foot care
(podotherapy) by a podotherapist.
In other words, in case of foot problems with:
• rheumatoid arthritis, or;
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• serious problems with the blood vessels in the
legs, or;
• with diabetes mellitus.
Please note!
Article:
o support soles;
o foot care that is insured under the health insurance.
General
• You suffer from rheumatoid arthritis, serious
problems with the blood vessels in the legs or
diabetes mellitus.
• In the case of foot care for diabetes mellitus
the bill must state:
o what foot care you have been given.
Healthcare provider
The healthcare is provided by a podotherapist.
from us in advance and have received a statement of approval from us for rheumatoid arthritis
and/or serious problems with the blood vessels in
the legs. We may stipulate additional conditions in
the statement of approval.
Referral
A doctor has determined that the foot care or consultation is a medical necessity prior to the start of
the treatment.
Rates
D.15.3. Chiropody treatment for certain
disorders
We reimburse chiropody treatments for certain
disorders. In other words, in case of foot problems
with:
• rheumatoid arthritis; or
• diabetes mellitus.
Please note!
you are entitled to this in Article B. If you are,
that healthcare takes precedence over reimbursement under this additional insurance
package.
Article:
o support soles;
o foot care that is insured under the health insurance.
General
• You suffer from rheumatoid arthritis or diabetes
mellitus.
• In the case of foot care for diabetes mellitus
the bill must state:
o what foot care you have been given.
Healthcare provider
• Foot care for rheumatoid arthritis is carried out
by:
o a chiropodist who is registered as a chiropodist with the RV (rheumatic foot) specialism in the 'Kwaliteitsregister Pedicure' or
in the 'Register Paramedische Voetzorg'; or
o a medical chiropodist who is registered as a
medical chiropodist in the 'Kwaliteitsregister
Pedicure' or in the 'Register Paramedische
Voetzorg'; or
o a chiropodist who is registered as a paramedical chiropodist in the 'Register Paramedische Voetzorg '.
• Foot care for diabetes mellitus is carried out
by:
o a chiropodist who is registered as a chiropodist with the DV (diabetic foot) specialism in the 'Kwaliteitsregister Pedicure' or
in the 'Register Paramedische Voetzorg'; or
o a medical chiropodist who is registered as a
medical chiropodist in the 'Kwaliteitsregister
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Pedicure' or in the 'Register Paramedische
Voetzorg'; or
o a chiropodist who is registered as a paramedical chiropodist in the 'Register Paramedische Voetzorg '.
from us in advance and have received a statement of approval from us for rheumatoid arthritis.
Referral
A doctor has determined that the chiropody treatment or consultation is a medical necessity prior
to the start of the treatment.
Rates
Healthcare provider
See Article B.8. In addition, the healthcare can
also be provided by:
• a psychosomatic physiotherapist. This is a
physiotherapist who is registered as a psychosomatic physiotherapist in the 'Centraal
Kwaliteitsregister Fysiotherapie';
• a psychosomatic exercise therapist. This is an
exercise therapist who has the quality registered status of psychosomatic exercise therapist in the 'Kwaliteitsregister Paramedici'.
Rates
D.16. Physiotherapy and/or Cesar/Mensendieck exercise
therapy
We reimburse physiotherapy and/or exercise
therapy, see Articles B.8.1, B.8.2. and B.8.3.
Please note!
o a treatment with the aim improving your fitness by means of training;
o oedema physiotherapy/treatment of scars
as a result of cosmetic procedures;
o treatment of scars after what we judge to be
a normal wound recovery.
See the terms and conditions in Article B.8. The
following terms and conditions are supplementary
to them, or differ from them.
D.17. Occupational therapy
D.17.1. Occupational therapy up to 18
years
Over and above the reimbursement under the
health insurance, you are entitled to occupational
therapy, see Article B.9.1.
If you are entitled under the health insurance then
that healthcare takes precedence over reimbursement under this additional insurance package.
Please note!
See Article B.9.2. In addition, the insured person
is younger than 18 years.
D.17.2. Instructions for volunteer carers
We reimburse instruction from and supervision by
volunteer carers for insured persons undergoing
occupational therapy.
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Please note!
See Article B.9. The following terms and conditions are supplementary to them, or differ from
them.
General
• The insured person receiving the volunteer
care is, at that time, entitled to reimbursement
for occupational therapy under the health insurance or under the additional insurance
package.
• The volunteer carer him/herself does not have
to be insured by us or insured with us for this
cover.
D.18. Dietary advice
You are entitled to dietary advice. This comprises
information and advice about nutrition and eating
habits. Dietary advice such as is customarily provided by dieticians. See Article B.11.2.
Please note!
you are entitled to this in Article B.11.2. If you
are, that healthcare/reimbursement in the general insurance takes precedence over reimbursement under this additional insurance
package.
• This healthcare does not comprise the following (even if they are prescribed by the dietician):
o foodstuffs;
o dietary preparations (see Article B.16. for
these).
D.19.1. Prenatal screening
We reimburse a non medical necessity prenatal
screening (= combined test). This comprises the
NT measurement (also known as the 'nekplooimeting' (nuchal fold measurement)) and
serum test (blood test).
Please note!
General
You are a pregnant, insured person younger than
36 years. The combined test is not a medical necessity but takes place at your request;
Healthcare provider
The combined test is carried out by a medical
sonographer who has a permit based on the
Population Screening Act (WBO) or a cooperation
agreement with a Regional Centre for Prenatal
Screening which has a permit based on this Act.
Rates
Location
medical specialist or obstetrician, in an ultrasound
centre/prenatal screening centre or in a general
practitioners' laboratory.
D.19.2. Health courses for childbirth
See Article B.11.2. for the terms and conditions.
D.19. Prenatal care
We reimburse health courses that are related to
pregnancy, the birth, support for the mother and
child(ren) following the birth and/or the recovery of
the female insured person after the birth.
You attend these courses during the pregnancy
and up to a maximum of 6 weeks after the birth.
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Please note!
• You are not entitled to reimbursement for exercise programmes. These are covered by Article D.22.
General
• On completion of the health course you provide us with proof of participation;
• During the entire period that you attend a
health course you have an additional insurance
package that entitles you to reimbursement of
this.
Healthcare provider
The health course is provided by:
• (an outpatients department of) an establishment for medical specialist care;
• a physiotherapist or Cesar/Mensendieck exercise therapist;
• a maternity centre;
• an obstetrician;
• a lactation consultant;
• a healthcare group or other body with whom
we have entered into agreements on the specified health course.
Rates
D.20. Care during childbirth
D.20.1. Personal contribution, outpatient
childbirth
We reimburse the personal contribution for outpatient childbirth without medical grounds in:
a. an establishment for medical specialist care or
b. a birthing centre with which we have an
agreement.
The amount we reimburse and the level of the
maximum amount is shown in your Reimbursements Overview.
Please note!
them.
General
You (the biological mother) are reimbursed the
healthcare in part from the health insurance.
Healthcare provider
An obstetrician or general practitioner supervises
the outpatient childbirth without medical grounds
or the birth in the birthing centre with which we
have an agreement.
D.20.2. TENS for birth
We provide TENS (Transcutaneous Electrical
Nerve Stimulation) on loan for the relief of pain
during the birth.
Please note!
• You are not entitled to reimbursement of the
costs of the normal use of the medical aid
(such as energy consumptions and accumulators/batteries) and for electrodes.
See Articles B.17.4 and B.17.5. The following
terms and conditions are supplementary to them,
or differ from them.
General
You (the biological mother) are insured by us.
Healthcare provider
The device is supplied by a supplier we have
granted recognition to, or with whom we have
entered into a healthcare agreement.
Proposed treatment
The obstetrician, general practitioner, attending
medical specialist or nursing specialist has determined that TENS is necessary.
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D.21. Healthcare following childbirth
D.21.1. Lactation consultant care
We reimburse care provided by a lactation consultant. This comprises advice, information and
practical support during the period in which breast
feeding is given. This care can also be provided
by phone and electronic consultation.
Please note!
• You are not entitled to reimbursement of travel
costs and medical aids.
General
You (the biological mother) are insured by us.
Healthcare provider
The lactation consultant:
• is affiliated with a professional group for lactation consultants, and;
• uses the 'Verwijzingsprotocol Lactatiekundige'
(Lactation Consultant Referral Protocol).
Rates
D.21.2. Personal contribution, postnatal
care
We reimburse the statutory personal contribution
for postnatal care. See Article B.7.a. for postnatal
care.
The amount we reimburse and the level of the
maximum amount is shown in your Reimbursements Overview.
Please note!
• We do not reimburse the statutory personal
contribution for:
o postnatal care for a longer period of hospitalisation days or a larger number of days
and/or hours of postnatal care than you are
entitled to in accordance with the health insurance;
o postnatal care for days for which a receive
a maternity allowance from the additional
insurance package.
them.
General
The postnatal care is reimbursed in part from your
health insurance.
D.21.3. Postnatal care allowance
You are entitled to a maternity allowance instead
of the reimbursement of (personal contribution for)
postnatal care. See Article B.7.a. for postnatal
care.
When calculating the amount of the maternity
allowance:
• we consider the day that you give birth in an
establishment for medical specialist care (not
outpatients) as a nursing day. You are not entitled to maternity allowance for that day.
if you have an outpatients childbirth and are
therefore only invoiced 1 nursing day for that,
we do not consider this to be a nursing day.
You are entitled to maternity allowance for that
day;
• the number of children born does not count;
• we do not consider the last day that the hospital (establishment for medical specialist care)
invoices you as a nursing day if you are discharged before 18:00 hours. You are entitled
to maternity allowance for that day.
The amount of the maternity allowance is shown
Please note!
• See articles A.21. and C.10. for general exclu-
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sions.
• We do not pay maternity allowance:
o for the days on which you receive postnatal
care or for which you receive a reimbursement for postnatal care and/or receive personal contributions for postnatal care;
o for the days that an establishment for medical specialist care invoices us for a hospitalisation;
o for more days of hospitalisation or for more
days of postnatal care than you are entitled
to under your health insurance or additional
insurance package.
See Article B.7.
D.21.4. Extra postnatal care
We reimburse extra postnatal care over and
above the number of hours postnatal care that
you are entitled to under you health insurance.
See Article B.7.a. for postnatal care.
Your Reimbursements Overview shows how
much extra postnatal care we reimburse.
Please note!
General
• You (the biological mother) are insured by us;
• You (the biological mother) or the child(ren)
you give birth to present with serious medical
problems that are connected to the birth;
• The extra postnatal care follows immediately
after the postnatal care under the health insurance.
Rates
D.21.5. Incubator care
We reimburse incubator care.
Please note!
• We do not reimburse the costs for the days
that we reimburse under the health insurance
for postnatal care as a substitute for them as
nursing days.
General
• You (the biological mother) are insured by us
for incubator care; and
• Your child(ren) has/have been in the incubator
for at least 5 days; and
• Your child(ren) has/have been in an establishment for medical specialist care for at least 8
days after the birth on medical grounds.
Rates
D.21.6. Postnatal care following hospital
admission
We reimburse postnatal care after the mother and
the child have been discharged from the hospital
(establishment for medical specialist care). See
Article B.7.a. for postnatal care.
Please note!
• We do not reimburse the costs for the days
that we reimburse under the health insurance
for postnatal care as a substitute for them as
nursing days.
General
• The hospitalisation of the (biological) mother and child(ren) - in an establishment for medical
specialist care is based on medical grounds for
the mother.
• The mother has been in the hospital (establishment for medical specialist care) for at least
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14 days consecutive to the birth.
Rates
D.22. Exercise programmes
D.22.1. Exercise programmes, general
D.21.7. Lapsed
D.21.8. Maternity care for adoption
You are entitled to reimbursement of the costs for
postnatal care, including instruction. See Article
B.7.a. for postnatal care.
We reimburse exercise programmes that are generally intended to prevent illnesses and/or to
maintain or improve your health.
Please note!
Please note!
o sports massage;
o occupational therapy and/or recreational
therapy;
o (exercise) programmes that are (also) intended to improve your fitness.
them.
General
• This involves adoption of a child by one or
more individuals who have taken out an additional insurance package with us;
• You register the child that is to be adopted with
us as an insured person;
• The adopted child is from abroad;
• The adopted child is at least 6 months old at
the time of the adoption.
Healthcare provider
The healthcare is provided by a fully certified maternity nurse. The maternity nurse is or is not affiliated with a maternity centre that we have
from us no later than 4 months prior to the probable adoption date and have received a statement
of approval from us. To do this please contact us
by phone or check out our website.
Rates
General
• On completion of the exercise programme you
furnish us with proof of participation;
which includes entitlement to the reimbursement of an exercise programme during the entire period that you attend the exercise programme.
Healthcare provider
The exercise programme is provided by:
• a national or regional patients' association. In
the case of diabetes patients, this patients' association must look after the health interests of
diabetes patients.
• (an outpatients department of) a hospital (establishment for medical specialist care);
• a physiotherapist with whom we have entered
into agreements on the specified exercise programme;
• a healthcare group with whom we have entered into agreements on the specified exercise programme. This involves an organisation
that is responsible for the (multidisciplinary)
care for chronic illnesses, such as, for example, COPD symptoms or Diabetes Mellitus.
Rates
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D.22.2. Exercise programmes for certain
disorders
Rates
We reimburse the exercise programme based on
the standard movement intervention of the
'Koninklijk Nederlands Genootschap Fysiotherapie' (KNGF), in case of one of these disorders:
• arthritis;
• COPD;
• diabetes mellitus type 2;
• coronary heart disease;
• osteoporosis;
• oncology;
• overweight and obesity in children.
Please note!
• We do not reimburse (exercise) programmes
that are (also) intended to improve your fitness.
General
• The healthcare provider uses an exercise programme that has been formulated based on
the standard movement interventions of the
'Koninklijk Nederlands Genootschap Fysiotherapie' (KNGF). In addition, the KNGF has
certified the exercise programme;and
• As a result the exercise programme is aimed at
motivation and coaching so you can continue
to exercise independently, in a responsible
manner, afterwards; and
• The reimbursement is made after completion
of the exercise programme; and
• you have an additional insurance package
which includes entitlement to the reimbursement of an exercise programme during the entire period that you attend the exercise programme.
Healthcare provider
The exercise programme is run by a physiotherapist who has been trained to run this programme
and with whom we have entered into agreements
on the exercise programme.
Referral
D.23. Home nursing/domestic
care
You are entitled to reimbursement of the statutory
personal contribution for:
a. home care (personal care or nursing) to which
you are entitled on the grounds of the AWBZ;
b. domestic care on the grounds of the WMO
(Social Support Act).
Please note!
General
• Grounds are set by:
o the CIZ ('Centrum Indicatiestelling Zorg') for
the personal care functions or nursing in
accordance with the AWBZ;
o the Municipality for the domestic care function pursuant to the WMO.
• Your Municipality or the CAK ('Centraal Administratie Kantoor') have imposed a statutory
personal contribution on you.
• If there is a gross PGB (Personal Budget) the
CAK will deduct the personal contribution. If
you receive a PGB for the healthcare from the
Care Administration Office, the statutory personal contribution is deducted from it. In any
case, you send us a copy of this notification
from the Care Administration Office.
• If there is a net PGB (Personal Budget) the
CAK will not deduct the personal contribution.
If you do not receive an invoice for the statutory personal contribution from the CAK then
send us a copy of your (net) PGB which shows
that the statutory personal contribution has
been deducted.
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Terms and Conditions of Insurance for Health Insurance and Additional Insurance Packages as per 1 January 2014
_________________________________________________________________________________
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CZ contact details
Locations
CZ Care Service
Would you like to speak to one of our advisers in
For issues such as waiting list mediation, advice
person? You can visit one of our service centres or
about a second opinion or advice about the best
our mobile office. You will find the addresses and
care.
opening times at www.cz.nl/location.
(013) 594 91 10
Postal addresses
Internet and email
General address
At www.cz.nl you can
CZ
• send us an email
Postbus 90152, 5000 LD Tilburg
• submit and change your insurance details
• find the best care providers for your situation
Address for sending bills
CZ
• ask the e-experts, such as a psychologist or
dietician
Postbus 4226, 5004 JE Tilburg
Address for sending complaints
CZ, Klachtencoördinator
Postbus 4349, 5004 JH Tilburg
Contact information for other
organisations
Stichting Klachten en Geschillen
Zorgverzekeringen
Telephone numbers
(council for disputes and the Healthcare Insurance
CZ Customer Service
Ombudsman)
For general questions about your insurance or bills
Postbus 291, 3700 AG Zeist
0900 0949 (on weekdays from 08.30 - 17.30, 7.5
www.skgz.nl
cents per call plus your usual call costs)
(030) 698 83 60
CZ Maternity Care Service
Nederlandse Zorgautoriteit (NZa)
To request maternity care
Postbus 3017, 3502 GA Utrecht
0900 202 03 40 (7.5 cents per call plus your usual
call costs)
College voor zorgverzekeringen (CVZ)
Postbus 320, 1110 AH Diemen
CZ Health Line
Personal advice about your health
0900 14 29 (7.5 cents per call plus your usual call
costs)
Legal entities and
Chamber of Commerce
registrations (KvK)
CZ Helpline
Onderlinge Waarborgmaatschappij Centrale
Help for urgent medical questions abroad
Zorgverzekeraarsgroep, Zorgverzekeraar U.A.
+ 31 13 468 04 02
KvK 41095222
CZ Medical Aids Helpline
Onderlinge Waarborgmaatschappij
0900 202 04 50 (7.5 cents per call plus your usual
Centrale Zorgverzekeraarsgroep
call costs)
Aanvullende Verzekering Zorgverzekeraar U.A.
KvK 18028752

Terms and conditions of insurance

Transcription

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