Conditions Commencement date 1 January 2013

Transcription

Conditions and reimbursements of the Keuze Zorg [Options Care] Plan
[Options Care Plan] and supplementary insurance policies of
Avéro Achmea 2013
Conditions
Commencement
date 1 January
2013
This booklet contains information on the terms and conditions and reimbursements of the Keuze Zorg [Options Care] Plan and the
supplementary insurance policies. It details the terms and conditions and reimbursements. Your policy and the related Keuze Zorg [Options
Care] Plan conditions and reimbursements ultimately serve as a basis for your basic insurance. In the overview of the document we explain
how this booklet should be used.
Introduction to the booklet
The booklet is laid out as follows:
• Overview of the conditions and reimbursements
• Alphabetical overview of the reimbursements
• Definition of terms used in the basic insurance
• General terms and conditions of the basic insurance
• Entitlements of Keuze Zorg [Options Care] Plan (basic insurance)
• Definition of terms used in the supplementary insurance policies
• General terms and conditions for the supplementary insurance policies
• Entitlements of the supplementary insurance policies (Start, Extra, Royaal, Excellent )
• Entitlements of the supplementary dental insurance (T Start, T Extra, T Royaal, T Excellent)
• Entitlements of the class insurance policy (Supplementary Ziekenhuis Extra [Hospital Extra] insurance policy)
• Services related to the Keuze Zorg [Options Care] Plan
Overview of the document
Conditions and reimbursements
The general terms and conditions contain general information relating to taking out the basic insurance, the premium, the deductible
excess, the commencement date and the term of the basic insurance. In the reimbursements section you can read about what
reimbursements you are entitled to and the applicable conditions.
How does the booklet work?
We show you how you can use this booklet based on the example of ‘Primary psychological care’:
1. You search for primary psychological care under the ‘P’ in the alphabetical overview of reimbursements in the first column.
2. In the second and third columns Keuze Zorg [Options Care] Plan you will find the article and page numbers where you can find the
cover via the basic insurance. In Article 10 of the Keuze Zorg [Options Care] Plan you can read that you are entitled to a reimbursement
of 5 sessions per calendar year with a statutory personal contribution of € 20.00 per session. In Article 10 you will also find which
conditions have to be fulfilled.
3. In the fourth and fifth columns you will find the article and page numbers where you can find the cover via the supplementary
insurance.
NB: The reimbursement via the supplementary insurance is in addition to the reimbursement via the basic insurance. In Article 7.1 of
the supplementary insurance you can read that you are entitled to a reimbursement of the statutory personal contribution of € 20.00
per session to a maximum of € 100.00 per calendar year via all supplementary insurance policies. In Article 7.2 you can read that you
are also entitled to extra sessions of primary psychological care.
Do you need permission?
In the case of a number of reimbursements we have to grant you permission beforehand. You can apply for this permission via telephone,
or by post or e-mail. Additional information on requesting permission can be found on our website. You can also download the application
forms from the website.
Avéro Achmea
Postbus 1717
3800 BS Amersfoort
The Netherlands
www.averoachmea.nl
2
BASIC INSURANCE
Keuze Zorg [Options Care] Plan
Reimbursement
Article
Page
SUPPLEMENTARY INSURANCE POLICIES
Start, Extra, Royaal, Excellent
Article
Page
Acne treatment
34
34
Maternity care for adopted children or medical screening in the event of adoption
24
31
Alternative forms of treatment, therapies and medicines
10
27
Contraceptives
11.3
28
17.12
30
19
30
Exercise programmes
14
28
Exercising in extra heated water
15
29
Glasses and contact lenses
17.9
30
(Dutch) Asthma Centre in Davos (Switzerland)
16
17
Audiological centre
19
18
32
21
Nanny Care baby sensor mat
Childbirth (personal contribution)
Abroad
26, 27
32
Abroad, vaccinations and medicines
19
13
28
33
Camouflage therapy
34
34
6
27
3.2
26
39.1
35
7
27
34
34
Circumcision
Combination test (neck fold measurement in combination with a blood test)
31.3
21
Cosmetic surgery
3
14
Counselling
31.1
21
Outpatient treatment
1
14
Dialysis
13
16
Dietary advice
28
20
Dyslexia care
9
15
Primary psychological care (personal contribution)
10
16
Egg cell vitrification
14.4
17
Hereditary research and consultancy
20
18
Occupational therapy
26
20
12
28
Pharmaceutical care (personal contribution)
24
18
11.1
28
Physiotherapy
25
19
13
28
Physiotherapy, exercise programmes
14
28
Guest house, accommodation near a hospital (in the case of outpatient treatment)
2
26
Guest house, accommodation and travel costs in the event of insured party being
admitted
1
26
GeboorteTENS
18
30
Flu vaccination
49
37
Herstel en Balans [Recovery and Balance], after-care training for ex-cancer patients
31
33
Convalescent homes
29
33
Health Check
50
37
Head covering in the case of oncology
17.3
29
Hearing aid with remote control (personal contribution)
17.1
29
Hospice
47
37
Skin care
34
34
17
29
Childcare during admission to hospital of parent(s)
46
37
Maternity pack
21
31
20
30
23
31
Depilation treatment
Medical mental health care, non-clinical
11
16
GP care
21
18
Nursing articles
30
21
IVF (In Vitro Fertilisation)
14.1
17
Dental surgery
37
22
Chain-based care
22
18
Maternity care (personal contribution)
Breastfeeding assistance
33
21
3
SUPPLEMENTARY INSURANCE
POLICIES
BASIC INSURANCE
Reimbursement
Article
Page
Article
Page
39
35
39.5
35
38
35
35
34
13
28
11.2
28
42
36
13
28
4
26
Orthodontics for children aged up to 18
43
36
Orthopaedic medicine
9
27
Menopause consultant
39.4
35
Patient associations
51
37
Parturition assistance (personal contribution)
20.1
30
Chiropodist care
33
34
Personal alarms on medical grounds
17.5
29
Personal alarms on social grounds
17.6
30
17.7
30
3.1
26
17.8
30
32
33
Preventive courses
39.3
35
Preventive examinations
37
34
Wigs (personal contribution)
17.2
29
8
27
7
27
17.12
30
Freezing sperm
41
36
Sports doctor
40
36
Sport-medical examination
5
27
Sterilisation
17.10
30
32
33
16
29
44
36
Lifestyle interventions
Lifestyle training sessions
Speech and language therapy
27
20
Mamma Print
Substitute volunteer care for handicapped people and the chronically ill
Manual lymph drainage
25
19
Mechanical respiration
17
17
Specialist medical care, extramural
5
14
Specialist medical care, clinical
1
14
Specialist medical care, on an outpatient basis
4
14
Melatonin
Kidney dialysis
13
16
25
19
Oncology examination for children
15
17
Obesity treatment
Eye laser treatment
Organ transplants
7
15
Orthodontics in exceptional cases
42
23
Breast prosthesis adhesive strips
Plastic surgery
3
14
Incontinence alarm
Podiatric treatment/podology/podopostural therapy/support soles
Prenatal screening
31
21
Psoriasis day treatment centre
Psychiatric hospital admissions
12
16
Psychological care (personal contribution)
10
16
Psychotherapy
11
16
Rehabilitation
8
15
Second opinion
6
15
Supplementary Dental Insurance Policies
Sensor mat
14.3
17
Support pessary
Support soles
23
18
Stopping smoking programme
27
20
Stutter therapy
31.2
21
Structural Echoscopic Examination
36
22
Dental care for insured parties aged up to 18
4
BASIC INSURANCE
Reimbursement
Article
Page
Dental care for insured parties aged up to 18 - crowns, bridges, inlays and implants
37
22
Dental care for insured parties aged 18 or over - general
38
22
SUPPLEMENTARY INSURANCE
POLICIES
Article
Page
41
41
45
37
18
30
30
33
28 TENS during childbirth
17.11
30
Therapeutic holiday camps
20.4
31
Dental care for insured parties aged 18 and over - removable complete prostheses
41
23
(false teeth) Supplementary Dental Insurance Policies
40
23
Dental care as a consequence of an accident for insured parties aged up to 18
39
23
Dental care, exceptional cases
Dental care, handicapped people
Dental care, implants
Thrombosis service
18
18
18
52
38
Transtherapy
17
28
33
Postponed maternity care
36
34
19
30
25
31
39.2
35
Payment in the event of an accident
32
21
Vaccinations and medicine in connection with travelling abroad
34
21
Holiday hotels and sailing holidays for handicapped people and the chronically ill
35
22
Obstetric care(personal contribution)
Nursing (extramural)
29
20
Patient transport(personal contribution)
14.2
17
Nutritional information
2
14
Foot care for insured parties with diabetes mellitus
1
14
40
Fertility-enhancing treatment
48
37
Independent treatment centre
22
31
Hospital nursing
Supplementary Ziekenhuis Extra [Hospital Extra] Insurance Policy
Care regulator
Pregnancy course
SUPPLEMENTARY DENTAL INSURANCE POLICIES
Page
T Start, T Extra, T Royaal en T Excellent
39
SUPPLEMENTARY ZIEKENHUIS EXTRA [HOSPITAL EXTRA] INSURANCE POLICY
40
Services related to the Keuze Zorg [Options Care] Plan
41
5
Centre for special dental treatment
A university or centre deemed by us to be equivalent for the
provision of dental care in special cases, requiring treatment
by a team and/or specialists is required.
Conditions and reimbursements
Commencement date 1 January 2013
Algemene voorwaarden Keuze Zorg [Options Care] Plan
Art. Subject
1 Definitions
2 Basis for the insurance
3 Application and registration
4Commencement date, duration and termination of the basic insurance
5Obligations of the insured party
6 Unlawful registration
7Obligatory deductible excess
8 Voluntary deductible excess
9Premium
10 Direct debit
11 Changes to the premium and/or conditions
12 Entitlements
13 Claiming care entitlements
14Liability of the health insurer
15Liability of third parties
16 Disputes
17Personal details 18 Fraud
19 International
Art. 1
Centre for hereditary advice
P.
6
8
8
8
9
9
10
10
10
11
11
12
12
12
12
12
13
13
13
Contract with preference policy
By this we mean a contract between us and the dispensing
specialist in which specific agreements are made regarding
the preference policy and/or the delivery and payment of
pharmaceutical care.
Outpatient treatment
Hospitalisation / admission for fewer than 24 hours.
Diagnose Behandelings Combinatie [Combined Diagnosis and
Treatment] (DBC)
As from 1 January 2012 new care performance for specialist
medical care are to be expressed in DBC healthcare products.
This process is referred to as DOT (DBCs on the road to
transparency). A DBC healthcare product is a claimable
performance based on the Wet Marktordening gezondheids
zorg [Market Organisation Health Care Act] within specialist
medical care which is the result of the total process from the
diagnosis made by the care provider up until (any) treatment.
The DBC process commences at the time when you submit a
request for care and is terminated at the end of the treatment
or after 365 days.
Dietician
Definitions
The following definitions apply for the purpose of this
insurance agreement:
Pharmacy
By pharmacy we mean: (internet) pharmacies, pharmacy
chains, hospital pharmacies, outpatient pharmacies or
dispensing GPs.
Dispensing specialist
The dispensing GP or an established pharmacist who is listed
in the register of established pharmacists, or a pharmacist
who is assisted in the pharmacy by pharmacists who are listed
in the same register, or the legal entity who has the care
provided by pharmacists who are listed in the abovementioned register.
Doctor
The party who, on the grounds of Dutch legislation, is
authorised to practice medicine and who is registered as such
with the authorised government body within the framework
of the Wet BIG [Individual Health Care Professions Act].
Youth health care doctor
A doctor who works in accordance with the Wet op de
Jeugdzorg [Youth Care Act].
Avéro Achmea
Avéro Achmea is a trade name of Avéro Achmea
Zorgverzekeringen N.V.
Avéro Achmea Zorgverzekeringen N.V.
The care insurer that is an authorised insurance company and
offers insurance policies within the meaning of the
Zorgverzekeringswet [Health Insurance Act].
The AWBZ
The Algemene Wet Bijzondere Ziektekosten [Exceptional
Medical Expenses Act].
Basic insurance
The health insurance as stipulated in the Zorgverzekeringswet
[Health Insurance Act] (Zvw).
Company doctor
A doctor who is registered as a company doctor in the register
set up by the Sociaal Geneeskundigen Registratie Commissie
[Board of Registration of Doctors of Social Medicine] (SGRC) of
the Koninklijke Nederlandsche Maatschappij tot Bevordering
der Geneeskunst [Royal Dutch Medical Association] and who
acts on behalf of the employer of the Arbodienst [Workplace
Health and Safety Agency] to which the employer is affiliated
as insured party.
Pelvic physiotherapist
A physiotherapist who is registered as such in accordance with
the terms and conditions referred to in Article 3 of the Wet
BIG [Individual Health Care Professions Act] and who is also
listed in the pelvic physiotherapy subregister of the Centraal
Kwaliteitsregister [Central Quality Register] of the Koninklijk
Nederlands Genootschap voor Fysiotherapie [Royal Dutch
Society for Physical Therapy] (KNGF).
Bureau Jeugdzorg [Youth Care Office]
An office as referred to in Article 4 of the Wet op the
Jeugdzorg.
6
An organisation which holds a licence under the terms of the
of the Wet op de bijzondere medische verrichtingen [Specialist
Medical Performances Act] for performing clinical genetic
research and providing hereditary advice.
A dietician who satisfies the requirements stipulated in the
so-called ‘Besluit diëtist, ergotherapeut, logopedist, mond
hygiënist, oefentherapeut, orthoptist en podotherapeut’
[Decree governing Dieticians, Occupational Therapists, Speech
Therapists, Dental Hygienists, Remedial Therapists,
Orthoptists and Podiatrists].
Dyslexia (serious)
A reading and spelling disorder as a result of a neurobiological
functional defect which is genetic and separate from other
reading and spelling problems.
Primary psychologist
A primary health care psychologist who is registered in
accordance with the conditions referred to in Article 3 of the
Wet BIG [Individual Health Care Professions Act] and who
fulfils the training and quality requirements as included in
the Kwalificatieregeling Eerstelijnspsychologen [Qualification
Regulations for Primary Psychologists] of the Nederlands
Instituut van Psychologen [Netherlands Institute of
Psychologists] (NIP).
Occupational therapist
An occupational therapist who satisfies the requirements
stipulated in the so-called ‘Besluit diëtist, ergotherapeut,
logopedist, mondhygiënist, oefentherapeut, orthoptist en
podotherapeut’.
EU and EEA state
This is deemed to refer to the following countries within the
European Union, besides the Netherlands: Belgium, Bulgaria,
Cyprus (the Greek part), Denmark, Germany, Estonia, Finland,
France, Greece, Hungary, Ireland, Italy, Latvia, Lithuania,
Luxembourg, Malta, Austria, Poland, Portugal, Romania,
Slovenia, Slovakia, Spain, the Czech Republic, the United
Kingdom and Sweden. Switzerland enjoys the same status
pursuant to the relevant treaty provisions. The EEA states
(those states which are party to the Agreement on the
European Economic Area) are Lichtenstein, Norway and
Iceland.
Pharmaceutical care
Pharmaceutical care is taken to mean:
• the provision of medication and dietary preparations
designated as such in this insurance agreement and/or
• advice and supervision as chemists are supposed to offer
on behalf of medication assessment and responsible use,
such while taking account of the Achmea Reglement
Farmaceutische Zorg Keuze Zorg Plan [Achmea
Pharmaceutical Care Regulations Options Care Plan] we
stipulate.
Physiotherapist
A physiotherapist who is registered as such in accordance with
the terms and conditions referred to in Article 3 of the Wet
BIG [Individual Health Care Professions Act]. A physiotherapy
masseur referred to in Article 108 of the Wet BIG [Individual
Health Care Professions Act] is also deemed to be a
physiotherapist.
Conditions and reimbursements of the Keuze Zorg Plan [Options Care Plan]
Birth centre
A birthing facility in, or on the site of, a hospital, possibly
combined with a maternity unit. A birth centre can be
regarded as equivalent to a birthing hotel and a delivery centre.
Family
One adult, or two people who are married or are cohabiting on
a permanent basis and the unmarried own, step, foster or
adopted children aged up to 30 who are entitled to family
allowance, to a grant on account of the Wet studiefinanciering
2000 [Student Finance Act]/Wet tegemoetkoming studie
kosten [Study Costs Allowances Act] or to a special benefit
pursuant to tax legislation.
Primary health care psychologist
A primary health care psychologist who is registered as such in
accordance with the terms and conditions referred to in Article
3 of the Wet BIG [Individual Health Care Professions Act].
GGZ institution
of Medical Specialists] maintained by the Koninklijke
Nederlandsche Maatschappij tot Bevordering der Geneeskunst.
Dental hygienist
A dental hygienist who has been trained in accordance with
the dental hygienist training requirements as referred to in
what is referred to as the Besluit diëtist, ergotherapeut,
podotherapeut and the Besluit functionele zelfstandigheid
[Decree on Functional Independence] (Bulletin of Acts, Orders
and Decrees 1997, 553).
Multidisciplinary cooperation
Integrated (chain of) care by a number of care providers with
various disciplinary backgrounds supplied in combination and
whereby control is essential to realise the care process relating
to the insured party.
Remedial therapist
An institution which provides medical care in connection with
a psychiatric disorder and which is registered as such.
A remedial therapist who satisfies the requirements stipulated
in the so-called ‘Besluit diëtist, ergotherapeut, logopedist,
mondhygiënist, oefentherapeut, orthoptist en podotherapeut’.
A dermatologist who has been trained in accordance with the
Besluit opleidingseisen en deskundigheidsgebied huid
therapeut [Decree Governing Dermatology Educational
Requirements and Expertise] (Bulletin of Acts, Orders and
Decrees 2002 no. 626). This decree is based on Article 34 of
the Wet BIG [Individual Health Care Professions Act].
Admission to a (psychiatric) hospital, psychiatric ward of a
hospital, rehabilitation centre, convalescence home, or an
independent treatment centre if and in so far as, on medical
grounds, nursing, examinations and treatment can only be
offered in a hospital, rehabilitation centre or convalescence
home.
Dermatologist
General Practitioner
A doctor who is registered as a GP in the register drawn up by
the Huisarts, Specialist Ouderengeneeskunde en Arts voor
Verstandelijk Gehandicapten Registratie Commissie [GPs,
geriatric specialist and doctors specialising in care for the
mentally handicapped Registration Committee] (HVRC) of
accredited general practitioners of the Koninklijke
Nederlandsche Maatschappij tot Bevordering der Geneeskunst
[Royal Dutch Medical Association] and who practices as a GP
in a usual manner.
Nursing articles
The fulfilment of the need for functioning nursing articles as
stipulated in the Regeling Zorgverzekering, as well as dressings
and bandages, with due regard for the regulations drawn up
by us regarding the requirements for consent, period of use
and volume.
IDEA contract
The Integraal Doelmatigheidscontract Excellente Apotheken
[Integral Efficiency Contract Excellent Pharmacies] contract
between us and a dispensing specialist in which specific
agreements about pharmaceutical care are made.
Dental surgeon
A dental specialist who is registered in the register of mouth
diseases and dental surgery specialists as maintained by the
Nederlandse Maatschappij tot bevordering der Tandheelkunde
[Dutch Dental Association].
Calendar year
The period that runs from 1 January to 31 December.
Chain-based care
A care programme organised in relation to a certain disorder.
Child and youth psychologist
A child and youth psychologist who is registered n accordance
with the terms and conditions referred to in Article 3 of the
Wet BIG [Individual Health Care Professions Act] and who is
listed in the Register Kinder- en Jeugdpsycholoog [Register of
Child and Youth Psychologists] of the Nederlands Instituut van
Psychologen [The Dutch Association of Psychologists] (NIP).
Clinical psychologist
A primary health care psychologist who is registered as such in
accordance with the terms and conditions referred to in Article
14 of the Wet BIG [Individual Health Care Professions Act].
Maternity centre
An institution which offers obstetrical care and/or maternity
care and which complies with the legal requirements.
Maternity care
The care provided by a qualified midwife or a nurse who
works in that capacity.
Laboratory research
Research carried out by a legally accredited laboratory.
Inspection
Orthodontist
A dental specialist who is listed in the register of mouth
diseases and dental surgery specialists as maintained by the
Nederlandse Maatschappij tot bevordering der Tandheelkunde
[Dutch Dental Association].
General remedial educationalist
A general remedial educationalist who is listed in the general
remedial educationalist register of the Nederlandse Vereniging
van pedagogen and onderwijskundigen [Association of
Educationalists in the Netherlands] (NVO).
Podiatrist
An occupational therapist who satisfies the requirements
stipulated in the so-called ‘Besluit diëtist, ergotherapeut,
podotherapeut’.
Policy document
The health insurance policy (deed) in which the details of the
basic insurance entered into by you (the policyholder) and the
health insurer are laid down.
Preferred medicines
The preferred medicines designated by us, within a group of
identical, mutually replaceable medicines.
Psychiatrist/neurologist
A doctor who is registered as a psychiatrist/neurologist in the
Specialistenregister maintained by the Koninklijke
Nederlandsche Maatschappij tot Bevordering der
Geneeskunst. Wherever psychiatrist is referred to this also
means neurologist.
Psychotherapist
A psychotherapist who is registered as such in accordance
with the terms and conditions referred to in Article 3 of the
Wet BIG [Individual Health Care Professions Act].
Rehabilitation
Research, advise and treatment of a medically specialist,
paramedic, behavioural science and technical rehabilitation
nature. This assistance is provided by a multi-disciplinary team
of experts, led by a medical specialist, affiliated to a
rehabilitation institution accredited in accordance with the
rules laid down by or pursuant to the law.
Sex therapist
A primary psychologist, doctor or nurse who has been
registered as a sex therapist with the Nederlandse Vereniging
voor Seksuologie [Dutch Sexology Association] (NVVS).
Specialist medical mental health care
Diagnostics and specialist treatment of complex psychological
disorders. A specialist (psychiatrist, clinical psychologist or
psychotherapist) must be involved.
Geriatric specialist
A doctor who advises us on medical matters.
A doctor who has completed geriatric specialist training and is
listed in the register of geriatric specialists of the Koninklijke
Nederlandsche Maatschappij tot bevordering der Geneeskunst
[Royal Dutch Medical Association]. This specialism has only
existed since 1 January 2009. It is an addition to the training in
nursing home medicine. Doctors who started the course
before 1 January 2009 are as nursing home doctors, but are
now also referred to as geriatric specialists.
A doctor who is registered in the Specialistenregister [Register
A dentist who is registered as such in accordance with the
Speech and language therapist
A speech and language therapist who satisfies the
requirements stipulated in the so-called ‘Besluit diëtist,
ergotherapeut, logopedist, mondhygiënist, oefentherapeut,
orthoptist en podotherapeut’.
Medical adviser
Medical specialist
Dentist
7
terms and conditions referred to in Article 3 of the Wet BIG
[Individual Health Care Professions Act].
Dental prosthetician
An independently established dental prosthetician who has
been trained in accordance with the Besluit opleidingseisen en
deskundigheidsgebied tandprotheticus [Decree governing
Educational Requirements and the Discipline of Dental
Prostheticians].
You/your
The insured party. The party referred to as such in the policy
document. ‘You (policyholder)’ means the person who has
taken out the basic insurance with us.
Places to stay
Admission for a period of 24 hours or longer.
Treaty country
Any state with which the Netherlands has entered into a
treaty relating to social security which includes regulations for
the provision of medical care. These states include Australia
(only a temporary stay), Bosnia and Herzegovina, Cape Verde,
Croatia, Macedonia, Morocco, Serbia and Montenegro, Tunisia
and Turkey.
Midwife
A midwife who is registered as such in accordance with the
terms and conditions referred to in Section 3 of the Wet BIG
[Individual Health Care Professions Act].
The insured
Each party referred to as such in the policy document.
expenses, for which a contracted health care provider has
submitted an expense claim, will be reimbursed by us directly
to said health care provider according to the fee that has been
agreed with this contracted health care provider. If the care is
provided by a non-contracted care provider, the costs are
reimbursed to a maximum equal to the (maximum) rate
applicable at the moment at which the care is provided on the
basis of the Wet Marktordening Gezondheidszorg [Market
Organisation Health Care Act] (WMG) [Health Care Market
(Regulation) Act]. If and in so far as no (maximum) rate has
been determined on the basis of the Wet Marktordening
gezondheidszorg [Market Organisation Health Care Act] the
costs will be reimbursed to a maximum of the amount which
applies on the market in the Netherlands.
2.4 The reimbursement of health care costs as described in the
basic insurance policy will also be determined by state of
science and practice, or in the absence of such criteria, by
what is considered to constitute prudent and appropriate care
and service in the relevant field of expertise.
2.5 You are only entitled to care in so far as, within the bounds of
reasonableness, you are reliant on care of that nature and to
that extent.
Art. 3
3.1
Policyholder
The person who has entered into the insurance agreement
with us.
3.2 Wet op the beroepen in the individuele gezondheidszorg
[Individual Health Care Professions Act]. This Act describes the
experts and authorities of the care providers. The related
registers include the names of the care providers that fulfil the
statutory requirements.
3.3 3.4 The Individual Health Care Professions Act
We/us
Avéro Achmea Zorgverzekeringen N.V
An institution for specialist medical care (IMSZ), for
examinations and treatment, which has been accredited as
such in accordance with regulations drawn up by, or pursuant
to, the law.
Hospital
An institution for specialist medical care (IMSZ), for
examinations and treatment, which has been accredited as
such in accordance with regulations drawn up by, or pursuant
to, the law.
Care group
This is a group of care providers from various disciplines who
together provide chain-based care.
Health care provider
The care provider or the institution that provides the care.
Health insurer
Art. 2
2.1
8
The insurance company which is accredited as such and which
offers insurance policies within the meaning of the
Zorgverzekeringswet [Health Insurance Act]. For the
implementation of this insurance agreement, this is Avéro
Achmea Zorgverzekeringen N.V. Avéro Achmea
Zorgverzekeringen N.V. is registered with the AFM
[Netherlands Authority for the Financial Markets] under
number 12001023.
3.4.2 Underlying premise of the basic insurance
Art. 4
This insurance agreement is based on the
Zorgverzekeringswet [Health Insurance Act], the Besluit
zorgverzekeringen [Health Insurance Decree] along with the
relevant health care insurance regulations, including the
explanatory notes thereto. This insurance agreement is also
based on the application form filled in by you (the
policyholder). The insurance agreement is laid down in the
policy document. This policy document is issued to you (the
policyholder) every year.
2.2 Besides the policy document, you will also be issued with a
care card. If you need health care assistance you have to
submit either the policy document or care card to the care
provider.
2.3 The insured can submit an expense claim to us for the costs of
care based on this basic insurance, with the exception of the
insured’s personal contributions unless the expense claim is
submitted directly to us. You can find the details of the care
providers we have contracted via the Care Finder on our
website, or we will send you them on request. The health care
3.4.3 Application and registration
You (the policyholder) can apply to us for basic insurance by
submitting a completely filled in and signed application form,
or by filling in the Internet application form on our website (as
described in Article 2.1).
During the application process we check whether the
conditions for registration in accordance with the
Zorgverzekeringswet [Health Insurance Act] have been
complied with. If this is the case, a policy document will be
issued and a reimbursement of the costs of care will then
apply in accordance with this Act.
We are legally obliged to include your burgerservicenummer
[Citizen’s Service Number] (BSN) in our records. Your care
provider or other care service providers within the framework
of the Zorgverzekeringswet [Health Insurance Act] are legally
obliged to use your BSN in all forms of communication. We too
will use your BSN in our communications with the parties
referred to above.
Registration on the grounds of Articles 9a to d of the
Zorgverzekeringswet [Health Insurance Act](Zvw)
If the College voor Zorgverzekeringen [Health insurance Board]
(CVZ) has insured you with us on the grounds of the Wet
Opsporing en verzekering onverzekerden zorgverzekering
[Detection and Insuring of Parties Uninsured for Health
Insurance Bill], you can, during a period of two weeks counting
from the date on which the CVZ has notified you, annul the
insurance policy in question if you can prove to the CVZ and
us that you were already insured by virtue of another health
insurance in the period referred to in Article 9d paragraph 1 of
the Zvw.
Contrary to Article 931 of Book 7 of the Dutch Civil Code, we
are authorised to annul an insurance agreement concluded
with you due to an error if it later transpires that you were not
obliged to have insurance at that point in time.
You may not, if need be in contradiction of Article 7 of the
Zvw, unless the fourth paragraph of that article applies, cancel
the health insurance as referred to in Article 9d paragraph 1 of
the Zvw during the first twelve months of the insurance.
ommencement date, duration and termination of the basic
C
insurance
4.1 Commencement date and duration of the basic insurance
4.1.1 The basic insurance commences on the date that is stated as
the date of commencement in the insurance policy document.
The date of commencement is the date on which we received
an application from you (the policyholder) to enter into a basic
insurance agreement. As of the following 1 January, the policy
will be tacitly renewed from year to year for the term of one
calendar year.
4.1.2 In the event that the person for the benefit of whom the basic
insurance has been concluded already has basic insurance on
the date on which we received the application referred to in
Article 4.1.1, and you (the policyholder) indicate that you wish
to have the basic insurance commence on a specific date,
which is later than the date referred to in Articles 4.1.1 and
4.1.2, the insurance will commence on said later date.
4.1.3 If the basic insurance commences within four months after
the insurance obligation has arisen, the commencement date
will be the day on which the insurance obligation arose.
4.1.4 If the basic insurance commences within a month after a
different basic insurance has ended as of 1 January or if it is
terminated by means of a cancellation due to a change in the
terms conditions subject to Article 940, paragraph 4 of Book 7
of the Dutch Civil Code, it will apply retroactively, if necessary
contrary to Article 925, paragraph 1 of Book 7 of the Dutch
Civil Code until the day after the one on which the previous
basic insurance ended.
4.1.5 You can change a basic insurance you have with us, barring
that stated in Article 4.1.1, as of 1 January of the coming
calendar year and only after we have provided a written
confirmation.
4.1.6 The group basic insurance also applies to your family. If
limiting agreements are made, within the framework of the
group contract, regarding the age at which your children are
eligible for your group discount, your children will be informed
accordingly in writing.
4.2 Termination of the basic insurance
4.2.1 You (the policyholder) can rescind a newly entered into basic
insurance. You can terminate the basic insurance within
14 days after receipt of your policy document in writing or by
email without having to state any reasons. The basic insurance
will then be regarded as not having been entered into. This
means that we will refund any premium already paid to you
(the policyholder) and that you will repay any compensation
costs you have received.
4.2.2 You (the policyholder) can terminate the basic insurance:
• by submitting a cancellation (in writing or by email) to us
by no later than 31 December. The basic insurance policy
ends on the following 1 January. Once a cancellation has
been made it will be irrevocable.
• by using the cancellation service provided by the care
insurers. This means that if you (the policyholder) take out
basic insurance for the subsequent calendar year on no
later than 31 December, the new health insurer will
contact us to cancel the basic insurance on your
(policyholder) behalf;
• if you (the policyholder) have insured someone other than
yourself and this insured party becomes insured via a
different basic insurance. If we receive the cancellation
before the commencement date of the new basic
insurance, the basic insurance can be terminated as of the
day on which the insured party receives the new basic
insurance. In other cases the end date will be the first day
of the second calendar month following the day on which
you cancelled.
• if the reason for cancellation concerns a switch from one
group basic insurance to another group basic insurance in
connection with the new employment. You (the
policyholder) may cancel the existing basic insurance up
to 30 days after the old employment relationship has
been terminated. The cancellation will not take place with
retrospective effect and will apply as of the first of the
next month.
• in the event of termination of participation in a group
basic insurance via a social security agency, if the reason
for termination concerns either participation in a group
basic insurance via a social security agency in a different
municipality, or participation in a group basic insurance
due to a new employment relationship. You (the
policyholder) may cancel the existing basic insurance up
to 30 days after participation in the group insurance has
been terminated. The cancellation will not take place with
retrospective effect and will apply as of the first of the
next month.
4.2.3 The basic insurance ends:
• as of the day following the day on which you no longer
fulfil the requirements for basic insurance registration;
• at the point in time at which you are no longer insured on
the basis of the AWBZ or become an active member of the
armed forces;
• in the event of established fraud as described in Article 18;
• in the event of death;
• if we are no longer allowed to provide or implement basic
insurance following an amendment to or the revocation
of our licence to pursue non-life insurance operations. We
will inform you of said revocation no later than two
months before it takes effect, stating the reason and the
date on which the basic insurance is to end.
4.2.4 If your basic insurance is to end, we will inform you to this
effect in writing.
Art. 5
5.1
5.2 5.3 5.4 5.5 Art. 6
6.1
Obligations of the insured party
You are obliged:
a. to identify yourself when seeking care in a hospital or
outpatients’ department with the aid of one of the
following valid documents: a driver’s licence, a passport,
Dutch identity card or alien’s identity card;
b. to ask the doctor or medical specialist who is treating you
to notify the medical advisor of the reason for your
hospitalisation, if the medical advisor requests this;
c. to assist us, our medical advisor, or any other person who
is responsible for monitoring the situation, in obtaining all
information that may be required, with due regard for the
applicable privacy regulations;
d. to assist us in seeking recourse against any third party
who is liable;
e. to inform us, within 30 days after you have been
remanded, of the commencement date and duration of
the period of custody;
f. to inform us of the date of release within two months
after you have been released; The obligations under e. and
f. are imposed on you in connection with the statutory
provision regarding the suspension of cover and the
premium obligation during the period of custody.
If you receive bills from a care provider, you are required to
send us the original and clearly specified bills to us.
Reimbursement will only take place if we have an original and
clearly specified bill. You can also scan in the original bills and
submit them to us digitally. If you choose this option you are
obliged to save the original bills for 1 year after we have
received them. We reserve the right to ask you to return these
original bills if we consider this to be necessary. We cannot
accept copies of bills, reminders, pro forma invoices, budgets
or estimates, etc. and these will not be reimbursed. The care
provider in question must have made out the bills in its own
name. If the care provider is a legal entity, the bill must state
which natural person has carried out the treatment. We will
always pay the reimbursement to which you are entitled to
you (the policyholder) and to the account number we have in
our records.
You are also obliged to submit the original bills, as necessary,
to us within twelve months of the end of the calendar year in
which treatment was provided. The date of the treatment
and/or the date on which the care was provided, as referred to
on the bill, are decisive in this respect, and therefore not the
date on which the bill is made out. In the event that the bill
relates to a DBC which commenced before the date on which
the basic insurance ends, the costs involved will be deemed to
have been incurred in the period during which the basic
insurance applied. In the event that you submit bills to us later
than 12 months after the end of the calendar year, we reserve
the right to allocate a lower reimbursement than that which
you were entitled to in accordance with the reimbursement.
On the basis of Article 942 of Book 7 of the Dutch Civil Code,
bills which are submitted to us later than 3 years after the
treatment date and/or the date on which the care was
provided, will not be processed.
You (the policyholder) are obliged to inform us within one
month of any events which may be relevant to the proper
implementation of the basic insurance, such as the
termination of the insurance obligation, moving house,
divorce, birth, death, a long-term stay abroad, etc. Any notice
sent to you (the policyholder) at your last known address will
be deemed to have reached you (the policyholder).
In the event that our interests are prejudiced by a failure to
comply with the aforementioned obligations, you will not be
entitled to a reimbursement of the costs of care.
Unlawful registration
In the event that an insurance agreement is concluded for
your benefit under the terms of the Zorgverzekeringswet
[Health Insurance Act] and it later emerges that you did not
have an insurance obligation, the insurance agreement will
lapse with retrospective effect until such time as the
insurance obligation ceases to exist (any longer).
6.2 We will set off the premium which you paid as of the day on
which your insurance obligation did not exist (any longer) with
the care you have received since then for your account and will
pay you or charge you the balance. The refund will be based
on a 30 day month.
9
Art. 7
7.1
7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 7.10 7.11 Art. 8
8.1
10
Obligatory deductible excess
The obligatory deductible excess applies to each insured party
required to pay premium for the basic insurance. The level of
the obligatory deductible excess is € 350.00 per insured party
per calendar year .
The obligatory deductible excess is deducted from the
reimbursement of the costs of care via the basic insurance.
The obligatory deductible excess of € 350.00 is deducted from
the reimbursement of care expenses incurred during the
course of the calendar year on the basis of the basic insurance.
The obligatory deductible excess is not deducted from:
• the costs of care or other services which relate to the
current calendar year and for which we received the bills
after 31 December 2014;
• the costs of receiving care normally provided by GPs, with
the exception of the costs of examinations related to this
care that are performed elsewhere and are charged
separately, on the condition that the person or institution
in question is entitled to charge the rate set by the NZa
(Dutch Health Care Authority);
• the direct costs for obstetrical care and maternity care;
• the costs of registering with a GP or an institution that
provides GP care. Registration costs mean:
a. an amount relating to registering as a patient not
exceeding the rate set as availability rate in the Wet
marktordening gezondheidszorg [Market
Organisation Health Care Act];
b. reimbursements that are related to the way in which
medical care is provided at the GP’s practice or at the
institution, based on the characteristics of the pool of
patients or the location of the practice or institution,
in so far as these reimbursements have been agreed
between the insured party’s insurer and his GP or the
institution and the GP or institution is allowed to
charge these reimbursements based on the abovementioned agreement when an insured party
registers.
follow-up checks of the donor after the period of caring
for the donor, for up to a maximum of thirteen weeks or
six months in the event of a liver transplant, has ended;
• care which is funded subject to application of the policy
rule laid down on the basis of the Wet marktordening
gezondheidszorg [Health Care Market (Regulation) Act] for
the funding of multidisciplinary care for the chronically ill.
Obligatory deductible excess exemption.
The obligatory deductible excess does not apply to the costs
of the online programme known as ‘Kleurjeleven.nl’, which are
covered by Article 10 of the Keuze Zorg Plan reimbursements.
Exemption is only possible if the entire programme treatment
is actually completed.
The costs of care reimbursed on the basis of the basic
insurance are first deducted from the obligatory deductible
excess and then from the voluntary deductible excess, as
referred to in Article 8.
If you reach the age of 18 during the calendar year, the
obligatory deductible excess will take effect as of the first day
of the month following the calendar month in which this age
was reached. The obligatory deductible excess is then
deducted proportionally for that calendar year.
If your basic insurance policy commences after 1 January of a
calendar year, the obligatory deductible excess for that
calendar year will be reduced proportionally.
If your basic insurance policy is terminated during the course
of the calendar year, the obligatory deductible excess for the
calendar year in question will be reduced proportionally.
In those cases in which an amount continues to be payable by
you on the grounds of the entitlements or reimbursements
based on the basic insurance, this amount will not count
towards topping up the obligatory deductible excess.
If treatment is claimed in the form of a DBC rate, the moment
at which the treatment starts will determine the applicability
of the obligatory deductible excess.
If we have reimbursed the costs of the care provided directly
to the care provider, the outstanding deductible excess
amount will, as necessary, be set off or reclaimed from you
(the policyholder). You are deemed to have authorised us to
collect the obligatory and obligatory deductible excess. In the
event of late payment we may charge you administration
costs.
Voluntary deductible excess
Each calendar year, an insured party aged 18 and over can opt
for a voluntary deductible excess. The basic insurance can be
8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 entered into without a voluntary deductible excess or, in the
case of insured parties aged 18 and over, with a voluntary
deductible excess of € 100.00, € 200.00, € 300.00, € 400.00 or
€ 500.00 per calendar year. A premium discount applies to the
choice for a voluntary deductible excess. The overview in
which these premium discounts are referred to is part of this
policy and can be found on our website.
The deductible excess chosen voluntarily per insured party is
deducted from the reimbursement of the costs of care via the
basic insurance.
The voluntary deductible excess is not subject to:
• the costs of receiving care normally provided by GPs, with
the exception of the costs of examinations related to this
care that are performed elsewhere and are charged
separately, on the condition that the person or institution
in question is entitled to charge the rate set by the NZa
(Dutch Health Care Authority);
• the direct costs for obstetrical care and maternity care;
• the costs of registering with a GP or an institution that
provides GP care. Registration costs mean:
a. an amount relating to registering as a patient not
exceeding the rate set as availability rate in the Wet
marktordening gezondheidszorg [Market
Organisation Health Care Act];
b. reimbursements that are related to the way in which
medical care is provided at the GP’s practice or at the
institution, based on the characteristics of the pool of
patients or the location of the practice or institution,
in so far as these reimbursements have been agreed
between the insured party’s insurer and his GP or the
institution and the GP or institution is allowed to
charge these reimbursements based on the abovementioned agreement when an insured party
registers.
follow-up checks of the donor after the period of caring for
the donor, for up to a maximum of thirteen weeks or six
months in the event of a liver transplant, has ended;
• care which is funded subject to application of the policy
rule laid down on the basis of the Wet marktordening
gezondheidszorg [Health Care Market (Regulation) Act] for
the funding of multidisciplinary care for the chronically ill.
The costs of care reimbursed on the basis of this basic
insurance are first deducted from the obligatory deductible
excess, as referred to in Article 7, and then from the voluntary
deductible excess.
The situation at the start of the basic insurance or the
situation on 1 January of any year will provide a basis for
determining the voluntary deductible excess. If the basic
insurance is arranged or terminated during the course of a
calendar year, the voluntary deductible excess will be reduced
proportionately.
In those cases in which an amount continues to be payable by
you on the grounds of the entitlements or reimbursements
based on the basic insurance, this amount will not count
towards topping up the voluntary deductible excess.
If treatment is claimed in the form of a DBC rate, the moment
at which the treatment starts will determine the applicability
of the voluntary deductible excess.
If we have reimbursed the costs of the care provided directly
to the care provider, the outstanding voluntary deductible
excess amount will, as necessary, be set off or reclaimed from
you (the policyholder). You are deemed to have authorised us
to collect the voluntary deductible excess. In the event of late
payment we may charge you administration costs.
You can change your voluntary deductible excess each year,
with due regard for Article 4.1.5, as of 1 January of the coming
calendar year.
Art. 9 Premium
9.1 Determination and levying of the premium
9.1.1 We determine the level of the basic insurance premium.
The payable premium is equal to the premium base less any
discount due to a voluntary deductible excess which is
deducted directly from the premium base or any group
discount which is also deducted directly from the premium
base. We levy premium for insured parties aged 18 and over.
9.1.2 Premium is payable as of the first of the month following the
calendar month in which insured parties reach the age of 18.
9.1.3 As soon as your participation in group insurance is ended, your
right to a group discount via this group insurance will lapse.
9.2 Payment of the premium
9.2.1 You (the policyholder) are obliged to pay the premium in
advance.
9.2.2 You are not permitted to set off the premium due against the
reimbursement of the costs that can be claimed from us.
9.2.3 If the basic insurance is terminated prematurely, premium
already paid will be proportionally refunded. The refund will
be based on a 30 day month. In the event of fraud or
deception we can deduct an amount for administration costs
from the premium to be paid back.
9.3 Late payment
9.3.1 The payment of premium is subject to the set rules. This
obligation also applies if the premium is paid by a third party.
We set off premium arrears which you still have to pay to us
against compensation costs for which you have submitted a
claim to us and which we are required to pay to you. In the
event of late payment we may charge you (the policyholder)
administration costs, collection costs and the statutory interest.
9.3.2 If you have opted to pay the premium per quarter or (half)
year and you do not pay the premium within the set payment
deadline, we reserve the revert the payment arrangement to
premium payment per month. The right to a discount will
then lapse.
9.3.3 Once we have sent you a reminder to pay one or more lapsed
premium instalments, you (the policyholder) may not cancel
the health insurance during the period that the due premium
and any collection costs have not been paid, unless we have
suspended the health insurance cover.
9.3.4 Article 9.3.3 does not apply if we have confirmed the
cancellation to you (the policyholder) within two weeks.
9.4 Procedure relating to the non-payment of the premium and
the administrative premium
9.4.1 In the event of premium arrears or two monthly premiums we
will offer you (the policyholder) a payment arrangement in
writing within 10 working days. The payment arrangement
consists, in any event, of the following elements:
• an authorisation from you (the policyholder) to us for a
monthly automatic direct debit of new instalments of the
premium or an instruction to a third party from which the
policyholder periodically receives payments to pay the
amount of the new premium instalments periodically and
directly to the health insurer, on its behalf and subject to
deduction of the respective amounts from these
amounts;
• agreements on the settlement of the debts resulting from
the health insurance by you (the policyholder) to us,
including interest and collection costs, and the periods of
time during which payment will take place;
• a commitment by us, to the effect that we will not
terminate, suspend, or defer the health insurance or its
cover during the term of the payment arrangement on the
grounds that debts exist, as referred to in the text following
the second dash of this article (9.4.1), as long as you (the
policyholder) do not retract the authorisation or instruction
referred to in the text following the first dash of this article
(9.4.1), and comply with the arrangements referred to in the
text following the second dash of this article (9.4.1).
9.4.2 If you (the policyholder) have insured someone else and
premium arrears have occurred with regard to this person’s
insurance as referred to in Article 18a, paragraph 1 of the Zvw,
the offer also implies a declaration of willingness to accept
cancellation of this insurance as of the day on which the
payment arrangement comes into effect, provided:
• the insured party has taken out other health insurance by
no later than the same day, and
• the insured party, if this health insurance has been taken
out with us, has issued to us an authorisation or instruction
with regard to the premium for this insurance as referred to
in the text following the first dash of Article 9.4.1.
9.4.3 The offer will also state that you (the policyholder) have four
weeks to accept it. If you (the policyholder) do not agree to the
proposed payment arrangement or do not make good the
payment arrears in some other way, you (the policyholder) will
receive, in the event of premium arrears (excluding interest
and collection costs) of four months, a warning (4-month
letter) that you (the policyholder) will be registered for the
administrative premium regime if the premium arrears
(excluding interest and collection costs) have increased to six
months. You (the policyholder) are entitled to lodge an
objection within four weeks after this intended registration
has been communicated to you (the policyholder).
9.4.4 If Article 9.4.2 applies we will send the insured party copies of
the documents which we send to you (the policyholder)
within the framework of Articles 9.4.1 to 9.4.3. This will take
place simultaneously.
9.4.5 If we uphold our position with regard to the dispute you (the
insured party or policyholder) can, within a period of four
weeks after receipt of this notification, submit a dispute to an
independent body on the grounds of Article 114 of the Zvw or
to a civil court (Article 18b, paragraph 2 of the Zvw).
9.4.6 As soon as six months of premium arrears arise (excluding
collection costs and interest) we will report this, with a
reference to the personal details required for the levying of
the administrative premium and for the execution of Article
34a of the Zvw relating to you (the policyholder and/or the
insured party), to the CVZ, and to you (the policyholder and/or
the insured party). From that moment you will no longer pay
us any nominal premium. Instead the CVZ will impose an
administrative premium on you (the policyholder). This
premium is higher than the standard premium and can be
deducted directly from your income. This notification will not
take place:
• if the premium arrears is disputed by you (the
policyholder) on time and we have not yet communicated
our point of view;
• during the period referred to in Article 9.4.5;
• in the event of a timely submission of the dispute to an
independent body or the civil court, as long as the dispute
has not been irrevocably decided on;
• if you (the policyholder) have registered with a debt
assistance organisation and can demonstrate that, within
that framework, you have entered into a written
agreement to stabilise your debts (Article 18c, paragraph
2 of the Zvw).
• if you enter into a payment arrangement as referred to in
Article 9.4.1 after premium payment arrears have arisen as
regards the health insurance, excluding interest and
collection costs, amounting to four monthly premiums and
as long the new due instalments of the premium are paid.
9.4.7 If, after the CVZ has become involved, you (the policyholder)
pay the due premium, the entitlement on account of the
medical expense bills, statutory interest and any collection
costs owed, we will deregister you with the CVZ. The
administrative premium collections will be stopped and you
(the policyholder) will again pay the nominal premium to us.
9.4.8 We will inform you (the policyholder and the insured party)
and the CVZ directly of the date on which:
• the debts resulting from the health insurance have or will
be paid off or cancelled;
• the natural persons debt rescheduling arrangement, as
referred to in the Faillissementswet [Bankruptcy Act],
becomes applicable to the policyholder;
• due to intervention by a debt assistance organisation as
referred to in Article 48 of the Wet op het
consumentenkrediet [Consumer Credit Act] an agreement
as referred to in Article 18c, paragraph two, section d has
been entered into or a debt repayment arrangement has
been created in which, in addition to the policyholder, at
least its health insurer participates.
9.5 In the event of (re-)registration after non-payment, you will
have to pay two months’ premium in advance.
rt. 10
A
10.1
Direct debit
rt. 11
A
11.1
Changes to the premium and/or conditions
Payments of the premium, the obligatory and voluntary
deductible excess, statutory personal contributions, personal
payments and any other amounts payable are to be made
preferably by direct debit. If you opt for a method of payment
other than direct debit we may charge administration costs.
10.2 We will try to send you the preliminary notification of the
direct debit fourteen days before the outstanding amount is
sent to you (the policyholder). This applies does not apply,
however, to the premium. The preliminary notification
regarding the premium is sent once a year along with the
policy document.
A change to the premium base will take effect no sooner than
six weeks after the day on which you (the policyholder) has
been notified to this effect. You (the policyholder) can cancel
the basic insurance as of the day on which the change takes
effect or, in any event, within one month after notification of
the change.
11.2 If the claims and/or entitlements or reimbursements are
changed to your detriment, you (the policyholder) can cancel
the basic insurance unless said change is a direct result of a
change to a statutory provision. You (the policyholder) can
cancel the basic insurance as of the day on which the change
takes effect and, in any event, you (the policyholder) have one
month’s time after the change has been communicated to you
(the policyholder) by us.
11
rt. 12
A
12.1
Entitlements
This basic insurance agreement contains entitlements to
reimbursement of the costs of care and can be entered into
with or for the benefit of any resident of the Netherlands who
has an insurance obligation, or with or for the benefit of any
person who has such an obligation and resides abroad.
12.2 You are entitled to reimbursement of the costs of care on the
basis of the Zorgverzekeringswet [Health Insurance Act], the
Besluit zorgverzekeringen [Health Insurance Decree] and the
health care insurance regulations. The content and extent of
the care in question are described in these acts and
regulations. The date of the treatment and/or the date on
which the care was provided, as referred to on the bill, are
decisive in this respect, and therefore not the date on which
the bill is made out. If treatment is claimed in the form of a
DBC rate, the moment at which the treatment starts is a
determining factor.
care. If you wish to receive pharmaceutical care from a
care provider with whom we have not entered into an
agreement, you will be entitled to a reimbursement as
described above in Article 13.1. As regards nursing articles
care, if you want nursing articles from a supplier with
whom we do not have an agreement, you will be entitled
to a reimbursement as described above in Article 13.1.
13.2 You are entitled to care mediation.
13.3 If and in so far as we reimburse more than we are obliged to
on the basis of the agreement, you will be regarded as having
authorised us to deduct in our name the amount paid in
excess for the insured party to the care provider
Art. 14
Exceptions
12.3 We do not reimburse the costs caused by, or resulting from
armed conflict, civil war, insurrection, domestic disorder,
rioting and rebellion which occur in the Netherlands, as
referred to in Article 3:38 of the Wet op het financieel toezicht
[Act on Financial Supervision] (Wft).
12.4 We do not reimburse the costs of examinations, flu jabs,
treatment to solve snoring, treatment of plagiocephaly and
brachycephaly without craniostenosis with a moulding
helment, treatment relating to sterilisation or the reversal
thereof and the issuing of doctors’ certificates, unless one of
the insurance policies explicitly states that we do reimburse
these costs.
12.5 We do not reimburse the costs resulting from missed
appointments and nursing articles, medicines and dietary
preparations you fail to collect (irrespective of whether the
request to provide has been submitted to the care provider by
you or by the prescribing party).
12.6 We do not reimburse the costs of laboratory research and/or
X-rays requested by a GP or medical specialist in the capacity
of alternative/complementary doctor.
12.7 We do not reimburse the costs of treatment carried out by
yourself which are covered by your insurance policy. We have
to give you permission first for treatment by your partner,
member of your family and/or blood relative in the first and
second remove of you (the insured party) if you also want
claim the costs of this treatment from us.
12.8 Terrorism
12.8.1 If the need for care is the consequence of one or more terrorist
acts and the total damage in a calendar year as a result of
such acts to be claimed from non-life, life or prepaid funeral
services insurers to which the Wet op het financieel toezicht
(Wft) applies is expected by the Nederlandse
Herverzekeringsmaatschappij voor Terrorismeschade N.V.
(NHT) to be higher than the maximum amount that this
company has reinsured for a calendar year, then the insured is
only entitled to care or reimbursement of costs thereof up to a
percentage, to be determined by this company, of the costs or
the value of the care or other services. The exact definitions
and provisions relating to the reimbursement referred to
above are included in the NHT’s schedule governing terrorism
cover. This schedule and the related Protocol are part of this
policy and can be downloaded from our website, or we will
send you them on request.
12.8.2 In the event that, after a terrorist act, an extra contribution is
made available to us by virtue of Article 33 of the
Zorgverzekeringswet, you will have the right, in addition to the
entitlements referred to in paragraph 12.8.1, to an additional
reimbursement as referred to in Article 33 of the
Zorgverzekeringswet.
rt. 13
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13.1
12
rt. 15
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15.1
Liability of third parties
If a third party is liable for costs which are the result of an
illness, accident or injury suffered by you, you must provide us
free of charge with all the necessary information which is
required in order to recover the costs from the perpetrator.
The right of recourse is based on statutory regulations. This
does not apply to liability which results from a legal insurance,
a health insurance under public law or an agreement between
you and another (legal) entity.
15.2 If you suffer illness, an accident or injury by which a third
party is involved, as referred to in the first paragraph, you
must report this to us and the police at the earliest
opportunity.
15.3 You are not allowed to make any arrangement which
prejudices our rights. You may only make an arrangement with
a third party, or the party that acts on behalf of said third
party, if you have received written permission from us.
rt. 16
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16.1
16.3 16.4 16.5 16.6 Claiming care entitlements
We determine the level of the reimbursement you are entitled
to and/or the personal payment you are required to pay for
each care claim. We reimburse the costs of care provided by a
care provider to a maximum of:
• the (maximum) rate determined at that moment on the
basis of the Wet marktordening gezondheidszorg [Health
Care Market (Regulation) Act] (Wmg);
• if and in so far as no (maximum) rate applies on the basis
of the Wmg, the reimbursement of the costs will take
place to a maximum of the amount which applies on the
market in the Netherlands. A list of the reimbursement
amounts is available on our website or we will send it to
you on request. We have entered into agreements with
care providers for pharmaceutical and nursing articles
Liability of the health insurer
In the event of an act or omission on the part of a care
provider which causes you loss or damage, we are not liable,
not even if the care or assistance provided by that care
provider is part of the basic insurance.
16.7 Disputes
This agreement is governed by Dutch law. 16.2 If you do not
agree with a decision we have taken or if you are not satisfied
with our services, you can submit your complaint to the
Centrale Klachtencoördinatie [Central Complaints
Department] within six months after the decision has been
communicated to you or the service provided to you. You can
do so by letter, e-mail, telephone, Internet or fax.
After receipt your complaint will be recorded in our complaints
registration system and you will be sent a confirmation to this
effect. You will receive a detailed response within three weeks.
If more time is needed to process your complaint, the Centrale
Klachtencoördinatie will inform you accordingly.
If you are not happy with how your complaint was dealt with,
you have the option of requesting a reassessment. You can
submit your request for a reassessment to the Centrale
Klachtencoördinatie by letter, e-mail, telephone, internet or
fax. You will receive a confirmation of receipt and a detailed
response within three weeks. If more time is needed to
reassess your complaint, the Centrale Klachtencoördinatie will
inform you accordingly.
Contrary to the previous paragraph, or if you are unhappy
with the outcome of the reassessment, you can submit the
dispute to the Stichting Klachten en Geschillen
Zorgverzekeringen [Health Care Insurance Complaints and
Disputes Foundation] (SKGZ), Postbus 291, 3700 AG Zeist
(www.skgz.nl).
You should note that the SKGZ is no longer able to deal with
your complaint if it is already in the hands of a judicial body or
if such a body has already taken a decision on the matter. You
always have the option of submitting your complaint to a civil
court, even after the SKGZ has issued a binding
recommendation.
Irrespective of that stated in the other paragraphs of this
article, consumers, care providers and health insurers are
always entitled to submit a complaint to the Nederlandse
Zorgautoriteit regarding the forms we use. Such complaints
have to relate to forms which, in the opinion of the
complainant, are unnecessary or overly complicated. The
judgement of the Nederlandse Zorgautoriteit applies as a
binding recommendation to the care provider, health insurer
and consumer.
More information on how to submit a complaint to us, how
we process complaints and the procedure used by the SKGZ
can be found in the brochure entitled ‘Klachtenbehandeling bij
zorgverzekeringen’ [Dealing with Complaints relating to
Health Insurance]. You can download this brochure from our
website or we will send it to you on request.
rt. 17
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17.1
Personal details
We ask you to provide personal data to process applications
for an insurance policy or a financial service. We use this data
at Achmea to enter into and implement insurance
agreements, to inform you about relevant products and/or
services, to guarantee the security and integrity of the
financial sector, for statistical analyses, customer relationship
management and in order to comply with statutory
obligations. Health insurers who use your personal details
have to comply with the Gedragscode Verwerking
Persoonsgegevens Zorgverzekeraars [Code of Conduct for the
Processing of Personal Data by Health Insurers].
17.2 If you do not wish to receive information about our products
and/or services, or if you wish to withdraw your permission for
the use of your e-mail address, please write to us at Avero
Achmea, Postbus 1717, 3800 BS Amersfoort, via telephone
number 0900 - 9590, or send an e-mail to avero.
zorgverzekering@achmea.nl.
17.3 With a view to maintaining a sound acceptance policy, we are
allowed, as Achmea, to consult details kept at the Stichting
Centraal Informatie Systeem [Central Information System
Board] (CIS) in Zeist. Within that framework, those affiliated to
the Stichting CIS are also allowed to exchange data among
themselves. The aim is to manage the risks and combat fraud.
This is subject to the privacy regulations of the Stichting CIS.
More information can be found at www.stichtingcis.nl.
17.4 From the moment that the basic insurance commences, we
are allowed to request information from, and give information
to, third parties (care providers, suppliers, etc.) in so far as such
is necessary in order to fulfil the obligations on account of the
basic insurance. In this context information means your
address and policy details. If you have legitimate reasons for
not wanting care providers to have access to your address
details, please let us know in writing.
rt. 18
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18.1
19.2 19.3 19.4 19.5 gezondheidszorg [Health Care Market (Regulation)
Act];
-- if and in so far as no (maximum) rate applies on the
basis of the Wet marktverordening gezondheidszorg
[Health Care Market (Regulation) Act], the amount
which applies on the market in the Netherlands.
In the event of care being used in a country which is not an
EU/EEA country or a treaty country you can opt for a
reimbursement of costs of care provided by a care provider
not contracted by Avéro Achmea in accordance with the
entitlements referred to in the Keuze Zorg Plan to a maximum:
• if referred to in connection with an entitlement, the lower
reimbursement or the personal contribution you are
required to pay;
• the (maximum) rate determined at that moment on the
basis of the Wet marktordening gezondheidszorg [Health
Care Market (Regulation) Act];
• if and in so far as no (maximum) rate applies on the basis
of the Wet marktverordening gezondheidszorg [Health
Care Market (Regulation) Act], the amount which applies
on the market in the Netherlands.
In the cases referred to in the previous paragraphs, the costs
can be reimbursed for claiming care in a country other than
the country of residence. This reimbursement may amount to
more than the reimbursement referred to in paragraph 19.1.
This higher reimbursement is only possible if we have given
our permission beforehand.
Foreign currency exchange rate
We reimburse to you the costs of care provided by a care
provider not contracted by us in euros with due regard for the
exchange rate as published by the European Central Bank. We
apply the rate which applied on the invoice date. We will
always pay the reimbursement to which you are entitled to
you (the policyholder) and to the account number of a bank
established in the Netherlands which we have in our records.
Bills from abroad
These bills should preferably be drawn up in Dutch, French,
German, English or Spanish. If we consider it to be necessary,
we may ask you to have a bill translated by a sworn translator.
We do not reimburse the translation costs.
Fraud
Fraud is defined as obtaining an entitlement or a
reimbursement from an insurer or via an insurance agreement
under false pretences or on improper grounds and/or by
improper means.
18.2 Any right to an entitlement or reimbursement resulting from
this basic insurance lapses if you and/or one of the interested
parties involved in the entitlement or the reimbursement have
misrepresented matters, submitted false or misleading
documents or made a false statement relating to a claim that
has been submitted or have not disclosed facts which may be
important for us as regards assessing a claim that has been
submitted. In such cases, any right to an entitlement or
reimbursement relating to the entire claim will lapse, including
for that for which no false statement has been made and/or
no matters have been misrepresented.
18.3 Fraud can also result in us:
a. reporting the matter to the police;
b. terminating the insurance agreement(s) with you only
being able to enter into a new insurance agreement after
5 years;
c. recording the matter in the detection systems used
mutually by insurance companies;
d. demanding repayment of the paid out reimbursement(s)
and the (investigation) expenses incurred.
rt. 19
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19.1
International
In the event that you use care in an EU/EEA state or treaty
country you can choose for reimbursement of:
• care in accordance with the statutory regulations of the
country in question on the grounds of the provisions of
the EU social security regulations or the treaty in
question;
• care provided by a care provider contracted by us abroad;
• care provided by a care provider not contracted by us in
accordance with the agreements in the Zorg Plan to a
maximum:
-- if referred to in connection with an entitlement, the
lower reimbursement or the personal contribution
you are required to pay;
-- the (maximum) rate determined at that moment on
the basis of the Wet marktverordening
13
Reimbursements of the Keuze Zorg [Options Care] Plan
Art. 1
•
Hospital nursing and outpatient treatment in a hospital
•
In the case of outpatient treatment or hospital admissions for
an uninterrupted period of no longer than 365 days, we
reimburse the costs of the following types of care. Admission
for rehabilitation in a hospital or rehabilitation centre and
admission to a psychiatric hospital also count towards the
calculation of the 365 days.
An interruption of no more than 30 days is not considered to
be an interruption and is not included in the calculation of the
365 days. However, interruptions on account of a weekend or
holiday leave are taken into consideration for the calculation
of the 365 days.
We reimburse the costs of:
• accommodation, including class three based nursing and
care;
• specialist medical care;
• the paramedical care, medication, aids, dressings and
bandages that are part of the treatment, throughout the
period of hospitalisation. The extent of the care provided
is limited to the care that the relevant medical specialists
normally provide.
•
•
Conditions
•
•
We do not reimburse the costs of treatment for operations to
insert or replace breast prostheses other than after status
following a (partial) breast amputation, operations to remove
a breast prosthesis without any medical need, liposuction of
the abdomen, treatment of upper eyelids that are paralysed or
weak other than as a consequence of a congenital defect or
chronic disorder present at birth.
Art. 4
Exclusion
This article does not apply to mental health care (GGZ).
Mental health care is subject to Article 12.
Art. 2
In the event of treatment in an independent treatment centre
we reimburse the costs of:
• nursing and care;
bandages that are part of the treatment. The extent of
the care provided is limited to the care that the relevant
medical specialists normally provide.
•
•
•
Art. 3
14
You have to have been referred by a GP, a company doctor,
geriatric specialist, a doctor specialising in care for the
mentally handicapped, a youth health care doctor, an
obstetrician in the case of obstetric care, or another
medical specialist.
In the case of an ENT doctor you can also be referred via a
triage hearing.
In the case of plastic surgery or dental surgery, you must
ask us for permission at least three weeks before the
outpatient treatment. We will give the independent
treatment centre a guarantee declaration as proof of our
approval.
You have to authorise your GP, a company doctor, geriatric
specialist, a doctor specialising in care for the mentally
handicapped, a youth health care doctor, an obstetrician,
or another medical specialist to communicate the reason
for admission to our medical advisor.
Plastic surgery
We reimburse the costs of surgical operations of a plastic
surgery nature by a medical specialist if the treatment results
in the correction of:
• deviations in appearance which are linked to
demonstrably defective body functions;
• disfigurement resulting from an illness, an accident or
medical treatment;
Specialist medical care (on an outpatient basis)
bandages that are part of the treatment.
The extent of the care provided is limited to the care that the
relevant medical specialists normally provide. Until 1 January
2016 specialist medical care also includes: the treatment of
chronic aspecific lower back complaints using radiofrequency
denervation, if the grounds and the treatment of the insured
party is in accordance with the conditions as included in the
investigation proposal financed by ZonMw.
Until 1 January 2017 specialist medical care also includes:
• treatment of therapy-resistant hypertension with the use
of percutaneous renal denervation if the grounds and
your treatment are in accordance with the conditions
which have been included in the examination financed by
ZonMw;
• treatment of a cerebral infarction by means of intraarterial thrombolysis (IAT) if the grounds and your
treatment are in accordance with the conditions which
have been included in the randomised multicenter study
entitled ‘Multicenter Randomized Clinical trial of
Endovascular treatment for Acute ischemic stroke in the
Netherlands’ (MR CLEAN).
Conditions
•
Conditions
•
You must have been referred by a GP, or a medical
specialist.
We must have given you prior written permission.
Exclusion
Conditions
obstetrician in the case of obstetric care, or another medical
specialist.
• In the case of an ENT doctor you can also be referred via a
triage hearing.
• In the case of plastic surgery or dental surgery, you must
ask us for permission at least three weeks before being
admitted to hospital. We will give the hospital a
guarantee declaration as proof of our approval.
• You have to authorise your GP, a company doctor, geriatric
specialist, a doctor specialising in care for the mentally
handicapped, a youth health care doctor, an obstetrician,
or another medical specialist to communicate the reason
for admission to our medical advisor.
the following congenital disfigurements: cleft lip, jaw or
palate, disfigurements of the facial bone structure, benign
tumours in blood vessels, lymphatic vessels or connective
tissue, birthmarks or the disfigurement of the urinary
tract or sex organs;
upper eyelids which are paralysed or weak due to a
congenital defect or a chronic disorder present at birth;
the abdominal wall (abdominal plastic surgery), in the
event of a mutilation whose seriousness is comparable to
third degree burns, non-treatable stains in skin folds or
very seriously limited movement (meaning that the
omentum majus covers at least a quarter of the upper
leg);
primary sexual features in the case of established
transsexuality (including epilation of the pubic area and
beard).
•
medical specialist\.
triage hearing.
Exclusion
Art. 5
Specialist medical care (extramural)
We reimburse the costs of treatment provided by an
extramural medical specialist. An extramural medical
specialist is a medical specialist who does not work in a
hospital or independent treatment centre.
bandages that are part of the treatment. The extent of
the care provided is limited to the care that the relevant
medical specialists normally provide. Until 1 January 2016
specialist medical care also includes: the treatment of
chronic aspecific lower back complaints using
radiofrequency denervation, if the grounds and the
treatment of the insured party is in accordance with the
conditions as included in the investigation proposal
financed by ZonMw.
Until 1 January 2017 specialist medical care also includes:
• treatment of therapy-resistant hypertension with the use
of percutaneous renal denervation if the grounds and
your treatment are in accordance with the conditions
which have been included in the examination financed by
ZonMw;
• treatment of a cerebral infarction by means of intraarterial thrombolysis (IAT) if the grounds and your
treatment are in accordance with the conditions which
have been included in the randomised multicenter study
entitled ‘Multicenter Randomized Clinical trial of
Endovascular treatment for Acute ischemic stroke in the
Netherlands’ (MR CLEAN).
abroad. The latter costs do not, in any event, include the
costs of accommodation in the Netherlands and any lost
income.
Art. 8
8.1
Conditions
•
•
medical specialist\.
triage hearing.
Exclusion
Art. 6
Second opinion
We reimburse the costs of a second opinion. A second opinion
is the requesting of an assessment of a diagnosis or treatment
proposed by a doctor from a second, independent doctor who
works in the same specialism/field of expertise as the first
practitioner. The opinion or advice can be requested by both
you and the doctor providing the treatment.
Conditions
•
•
•
•
•
Art. 7
You must have been referred by your practitioner. This can
be a GP, medical specialist, clinical psychologist or
psychotherapist.
The second opinion must refer to your medical care, as
discussed with the initial practitioner.
Once you have the second opinion you must make an
appointment with the first practitioner. The latter is
responsible for the treatment.
You must submit a copy of the medical dossier from the
first practitioner during the second opinion by the second
practitioner.
We only reimburse the costs if the diagnostics or
treatment is covered by the conditions of this basic
insurance.
Organ transplants
• transplantation in a hospital of tissues and organs if the
transplantation is performed in a Member State of the
European Union, in a state which is party to the
Agreement on the European Economic Area or in another
state if the donor is resident in that state and is the
spouse, the registered partner or a blood relative in the
first, second or third remove of the insured party;
• the specialist medical care relating to the selection of the
donor and in connection with the surgical removal of the
transplant material from the selected donor; the
examination, the preservation, the removal and the
transportation of the post mortal transplant material in
connection with the planned transplant;
• transplantation in an independent treatment centre if this
is permitted on the basis of the law and regulations.
• The donor is entitled to a reimbursement of the costs of:
• care to which an entitlement exists according to the policy
document during a maximum period of 13 weeks, or six
months in the case of a liver transplant, after the date of
discharge from the hospital to which the donor is
admitted for selection or removal of transplant material
and only if the care provided is related to the admission in
question;
• transport based on the lowest class of public transport or if and in so far as such is medically essential - by car, in
connection with the selection, admission and discharge
from the hospital and with the care as referred to in the
previous sentence;
• transport from and to the Netherlands of a donor resident
abroad in connection with the transplantation of a kidney,
bone marrow or liver in the case of an insured party in the
Netherlands and the other transplantation costs, in so far
as these are related to the fact that the donor is resident
Rehabilitation
Specialist medical rehabilitation
We reimburse the costs of specialist medical rehabilitation but
only if:
• this care has been designated as most appropriate for you
to prevent, reduce or overcome a handicap which is the
consequence of disorders or limitations to mobility or a
handicap which is the consequence of an ailment
affecting the central nervous system resulting in a
communicative, cognitive or behavioural limitation;
• the care enables you to achieve or maintain a certain
degree of independence which is reasonably possible
given your limitations.
Rehabilitation can take place:
• in a clinical situation coupled with an admission over a
number of days, if this means that one can expect better
results in the short term than rehabilitation without
admission. In the event of rehabilitation in a clinical
situation, you are entitled to reimbursement of the costs
for an uninterrupted period not exceeding 365 days.
However, other admissions to (psychiatric) hospitals are
taken into consideration when calculating the 365 days.
An interruption of no more than 30 days is not considered
to be an interruption and is not included in the calculation
of the 365 days. However, interruptions on account of a
weekend or holiday leave are taken into consideration
when calculating the 365 days.
• in a non-clinical situation (part-time or outpatient
treatment).
Condition
You must have been referred by a GP, geriatric specialist, a
doctor for the mentally handicapped or a medical specialist.
8.2 Geriatric rehabilitation
We reimburse the costs of geriatric rehabilitation. This care
includes integral and multidisciplinary rehabilitation care like
that provided by geriatric specialists in connection with
vulnerability, complex multimorbidity and reduced capacity to
learn and train, with the aim being to reduce your functional
limitations and facilitate a return to the home situation.
The geriatric rehabilitation is only covered by the care if:
• the care is related to a stay in a hospital (as referred to in
Article 2.10 of the Besluit zorgverzekering [Health Care
Insurance Decree]) in connection with medical care like
that provided by medical specialists, with said stay not
being preceded by a stay in a nursing home (as referred to
in Article 9 of the Besluit zorgaanspraken AWBZ
[Exceptional Medical Insurance (Care Entitlements)
Decree]) accompanied by treatment as referred to in
Article 8 of said decree in the same institution, and
• the care is accompanied from the start by a stay as
referred to in Article 2.10 of the Besluit Zorgverzekering.
Conditions
•
•
Art. 9
You must have been referred by a GP, a doctor for the
mentally handicapped or a medical specialist.
The duration of the geriatric rehabilitation must not
exceed six months. In exceptional cases we may permit a
longer period.
Dyslexia-related care
We reimburse the costs of the diagnosis and treatment of
serious dyslexia affecting primary school children who start to
receive the care at the ages of seven, eight, nine, ten, eleven or
twelve. The care has to be provided by a specialised institution
for dyslexia assistance where the work is based on
multidisciplinary cooperation for which a primary health care
psychologist, child and youth psychologist or general remedial
educationalist who are qualified on the grounds of the
standards which are applicable and have been explained for
their profession for the care-based diagnosis and treatment of
serious dyslectici. This multidisciplinary cooperation must
comply with the Richtlijnen multidisciplinaire samenwerking
Diagnostiek en behandeling ernstige dyslexie [Guidelines for
multidisciplinary cooperation in connection with the diagnosis
and treatment of serious dyslexia], as drawn up by the
professional associations NIP, NVO, LBRT and NVLF.
Conditions
•
We only reimburse the costs of the diagnosis if you have
been referred by the school that has already completed
the Protocol Leesproblemen en Dyslexie [Reading
15
•
Art. 10
Difficulties and Dyslexia Protocol] with the insured party
and suspects on this basis that the case is one of serious
dyslexia without there being any other reading and
spelling problems for which a course of treatment is
available via a mental health care institution or local
authority.
Moreover, in order to become eligible for reimbursement
of the treatment costs, the diagnostic research has to
have identified serious dyslexia which is not part of a
complex series of problems, in accordance with the
criteria of the Protocol Dyslexie Diagnose en Behandeling
[Dyslexia Diagnosis and Treatment Protocol] and the
treatment also has to take place in accordance with this
protocol. We can send you the Protocol Dyslexie Diagnose
en Behandeling on request or you can download it from
our website.
Primary psychological care
We reimburse the costs of diagnostics and short-term,
generalistic treatment of non-complex psychological disorders
by a primary health care psychologist and/or a primary
psychologist and/or a clinical psychologist and/or a general
remedial educationalist and/or sex therapist and/or child and
youth psychologist. The extent of the care provided is limited
to the care that clinical psychologists normally provide. The
care comprises a maximum of five sessions (lasting a
maximum of one hour) of primary psychological care per
calendar year. A statutory personal contribution applies of
€ 20.00 per session. The care can also be provided in half or
quarter sessions, whereby the statutory personal contribution
is still proportional. A maximum of one treatment session per
insured party per day is reimbursed. Exceptions are
consultations by telephone, e-mail consultations and double
consultations. Consultations by telephone and e-mail can be
claimed in combination with another treatment session. In the
case of double consultations, up to two sessions per day can
be claimed. Primary psychological care can also be provided
via internet by means of programmes approved by us. An
overview of the internet programmes we have approved and
the conditions for being eligible for reimbursement can be
found on our website, or we will send you them on request. A
statutory personal contribution of € 50.00 applies to these
internet programmes.
Conditions
•
•
•
With the exception of the internet course entitled ‘Kleur
je Leven’ [Colour Your Life], you must have been referred
by a GP, company doctor, or a youth health care doctor.
In the case of young people as referred to in the Wet op
de Jeugdzorg, a decision by the Bureau Jeugdzorg is
necessary, or a referral by a doctor or another practitioner
referred to in Article 10 of the uitvoeringsbesluit Wet op
de Jeugdzorg in the case of care as described in the fifth
paragraph of Article 9b of the AWBZ.
The general remedial educationalist only treats children
and young people aged up to 18.
Exceptions
•
•
We do not reimburse the costs of (remedial) educational
assistance, examinations and courses of a social nature.
We do not reimburse the costs of treatment of
adjustment disorders and help with work and relationship
problems.
Art. 11Non-clinical medical mental health care (Second-line
mental health care GGZ)
We reimburse the costs of treatment by a GGZ institution,
psychiatrist/neurologist, or psychotherapist or clinical
psychologist.
• the specialist mental health care;
• the nursing relating to the treatment;
bandages that are part of the treatment.
The extent of the care provided is limited to the care that the
psychiatrists/neurologists and clinical psychologists normally
provide. If the treatment takes place in a GGZ [mental health
care] institution, this must be under the responsibility of a
psychiatrist/neurologist, or clinical psychologist (primary
practitioner).
Conditions
You must have been referred for the specialist mental health
care by a GP, company doctor, geriatric specialist, a doctor for
the mentally handicapped, or a youth health care doctor.
16
•
In the case of young people as referred to in the Wet op
Exclusion
•
We do not reimburse the costs of treatment of
adjustment disorders and help with work and relationship
problems.
Art. 12 Admission to a psychiatric hospital
We reimburse the costs of admission to a GGZ institution
(such as a psychiatric hospital, a psychiatric university clinic,
or a psychiatric department of a hospital) for a maximum of
365 days. Admission for rehabilitation in a hospital or
rehabilitation centre and not admission to a psychiatric
hospital also count towards the calculation of the 365 days.
An interruption of no more than 30 days is not considered to
be an interruption and is not included in the calculation of
the 365 days. However, interruptions on account of a
weekend or holiday leave are taken into consideration for the
calculation of the 365 days.
• the specialist mental health care in accordance with
Article 11;
• the stay, whether or not in combination with nursing and
care;
• the paramedical care and medication, aids, dressings and
bandages that are part of the treatment, throughout the
period of hospitalisation. The extent of the care provided
is limited to the care that the psychiatrists/neurologists
and clinical psychologists normally provide.
Conditions
• For admission to a GGZ institution (such as a psychiatric
hospital, a psychiatric university clinic, or a psychiatric
department of a hospital) you must have been referred by
a GP, company doctor, geriatric specialist, a doctor for the
mentally handicapped, or a youth health care doctor.
• In the case of young people as referred to in the Wet op
Exclusion
• We do not reimburse the costs of a stay related to the
treatment of adjustment disorders and help with work
and relationship problems.
Art. 13
Non-clinical dialysis
We reimburse the costs of dialysis in a hospital, dialysis centre
or at your home, possibly in conjunction with an examination,
treatment, nursing, pharmaceutical care required for your
treatment and psychosocial supervision and that of the
people involved in the execution of the dialysis at a location
other than in a dialysis centre.
In the case of dialysis at home we also reimburse:
• the costs relating to the training provided by the dialysis
centre to those who carry out, or are involved in, the
dialysis;
• the costs of loaning the dialysis equipment and
accessories, the reimbursement of the costs of the regular
checking and maintenance thereof (including
replacement) and of the chemicals and fluids required for
the actual dialysis;
• the costs of making the adaptations in and to the home
and of returning thereof to the original state, in so far as
we consider said costs to be reasonable and as long as no
other statutory regulations provide for such;
• the other costs which are related directly to the dialysis at
home in so far as we consider said costs to be reasonable
and as long as no other statutory regulations provide for
such;
• the costs of the necessary expert assistance provided
during dialysis at the dialysis centre.
Condition
In the case of dialysis at home, you must submit an estimate
of the costs.
Art. 14In Vitro Fertilisation (IVF), other fertility-enhancing
treatment and the freezing of sperm and egg cell
vitrification
14.1 IVF
We reimburse the costs of the first, second and third IVF
attempts for each lasting pregnancy including the medication
used, as long as you have not yet reached the age of 43. An
attempt covers a maximum of the sequential completion of
all four of the following phases.
a. ripening of the egg cells by means of hormonal treatment
in the woman’s body;
b. the follicular puncture (obtaining ripe egg cells);
c. fertilisation of the egg cells and the cultivation of
embryos in the laboratory;
d. the re-insertion of one or two embryos into the mouth of
the uterus in order to initiate a pregnancy. In addition, an
embryo may only be re-inserted during the first and
second attempts if you have not yet reached the age of
38. An attempt only counts as an attempt if successful
follicular puncture has taken place. Only attempts that
have been cut short before a lasting pregnancy count
towards the number of attempts. A new attempt after a
lasting pregnancy counts as a first attempt. The reinsertion of frozen embryos is covered by the IVF attempt
during which they were produced.
Conditions
• The IVF treatment must take place in a licensed hospital.
• Your application must be based on a medical certificate.
• We have to have given you our prior written permission
for treatment in a hospital abroad.
• ICSI treatment (intracytoplasmatic sperm injection) is
regarded as being equivalent to an IVF attempt.
• In the event of a physiological (spontaneous) pregnancy, a
lasting pregnancy is taken to mean a pregnancy of at least
12 weeks counting from the first day of the last
menstruation.
• In the event of a pregnancy after IVF treatment, a lasting
pregnancy is taken to mean a pregnancy of at least ten
weeks counting from the follicular puncture or, if IVF has
taken place by replacing frozen embryos, a pregnancy of
at least nine weeks and three days counting from the
implantation.
• Use of the required medicines is subject to the maximum
reimbursements set by us for the pharmacy and
medicines (partial) provisions. These can be found on our
website.
14.2 Other fertility-enhancing treatment
We reimburse the costs of other fertility-enhancing treatment
as long as you have not yet reached the age of 43.
Conditions
• We have to have given you our prior written permission
• Your application must be based on a medical certificate.
• We only reimburse the costs of the medication used if you
are prescribed the medication for fertility-enhancing
treatment other than the fourth and subsequent IVF
treatment.
• Use of the required medicines is subject
• to the maximum reimbursements set by us for the for the
pharmacy and medicines (partial) provisions. These can be
found on our website.
14.3 Freezing sperm
We reimburse the costs of collecting, freezing and storing
sperm as part of specialist medical treatment if this treatment
can lead to unintended infertility.
Conditions
The care is part of a specialist medical oncological care process
(or non-oncological comparable treatment) which includes the
following:
• a major operation on/around the genitals;
• chemotherapeutic treatment and/or a radiotherapeutic
treatment whereby the genitals are in the radiation area.
14.4 Vitrification of human egg cells and embryos
We reimburse the costs of vitrification (freezing) of human
egg cells and embryos in connection with the following
medical grounds:
• Treatment with chemotherapeutic agents which entail a
risk of permanent fertility disorder.
• Radiotherapeutic treatment whereby the ovaries are in
the radiation field and can suffer permanent damage.
• Operations whereby both ovaries or large sections thereof
have to be removed on medical grounds.
A number of additional grounds have also been referred to
which are either related to characteristics of female fertility
(medical grounds) or to efficiency considerations, namely:
• additional medical grounds:
-- in the case of women with Fragile X syndrome, Turner
syndrome (XO) or galactosemia because they have a
demonstrably increased risk of premature ovarian
insufficiency (POI) (before their 40th birthday).
• IVF-related grounds:
during the course of an IVF attempt (provided this attempt
in itself is covered by the basic insurance):
-- in the event of the unexpected lack of semen of a
sufficient quality;
-- the freezing of egg cells instead of the freezing of
embryos.
In the event of medical grounds the entitlement covers the
following elements of the treatment:
• follicle stimulation;
• egg cell puncture;
• vitrification of egg cells.
In the case of grounds which are related to the course of an
IVF attempt only covers the entitlement to egg cell
vitrification. For the realisation of a pregnancy after the
thawing of frozen egg cells you will require phases c and d of
IVF treatment, as described in Article 14.1. In addition, you
must not have reached the age of 43 at the moment of
re-insertion.
Conditions
•
•
•
•
Art. 15
Art. 16
The vitrification must take place in a licensed hospital.
We have to have given you our prior written permission
In the case of female insured parties, vitrification is
reimbursed on the basis of the grounds referred to until
the age of 42.
Use of the required medicines is subject to the maximum
reimbursements set by us for the for the pharmacy and
medicines (partial) provisions. These can be found on our
website.
Oncology examination for children
We reimburse the costs of the central (reference) diagnostics,
coordination and registration of submitted bodily material by
Skion (Stichting Kinderoncologie Nederland) [Dutch Childhood
Oncology Group].
Asthma Centre in Davos (Switzerland))
We reimburse the costs of treatment in the Dutch Asthma
Centre in Davos.
Conditions
•
•
•
Art. 17
Similar treatment must have taken place unsuccessfully in
the Netherlands and we must regard the treatment in
Davos as appropriate.
You have to have been referred by a GP, a lung specialist or
a paediatrician.
Mechanical respiration
We reimburse the costs of essential mechanical respiration
and the related specialist medical care at a respiration centre.
If the respiration takes place at your home on behalf of and
under the responsibility of a respiration centre, the care will
consist of:
• the provision and setting up by the respiration centre of
the equipment required for each course of treatment;
• the specialist medical care and the additional
pharmaceutical care provided in connection with the
mechanical respiration as provided by or on behalf of a
respiration centre.
Condition
You must be referred by a lung specialist.
Art. 18
Thrombosis service
We reimburse the costs of care provided by the thrombosis
service. The care covers:
• the regular taking of blood samples;
• the carrying out of the essential laboratory investigations or arranging for these to be carried out under the
responsibility of the thrombosis service - for the
determination of the blood’s coagulation time;
• the making available to you of equipment and accessories
with which you can measure your blood’s coagulation
time;
17
•
•
training for you in the use of the equipment referred to in
the previous sentence and your supervision during the
measurements;
the giving of advice to you regarding the application of
medicines in order to influence the blood’s coagulation.
provided provided by general practitioners, medical specialists,
or clinical psychologists.
Conditions
•
Condition
doctor for the mentally handicapped or another medical
specialist.
Art. 19
Audiological centre
We reimburse the costs of care provided at an audiological
centre. The care covers:
• research into your sense of hearing;
• advice on the hearing aid to be purchased;
• information on the use of the aid;
• psychosocial care if necessary in connection with
problems relating to a disrupted sense of hearing;
• assistance with diagnosing speech and language disorders
among children.
Condition
You have to have been referred by a GP, company doctor,
paediatrician, ENT doctor, via a triage hearing, by a geriatric
specialist or a youth health care doctor.
Art. 20
Hereditary research and consultancy
We reimburse the costs of hereditary research and advice in a
centre for hereditary research. The care covers:
• research relating to hereditary disorders by investigating
the genealogical tree;
• chromosome research;
• biochemical diagnostics;
• ultrasound and DNA research;
• hereditary advice and the psychosocial supervision
relating to this care. If necessary for the advice provided to
you, the research will also include research involving
people other than you, with advice also being provided to
them.
Condition
You have to have been referred by the doctor providing the
treatment or an obstetrician.
Art. 21
Art. 22
GP care
We reimburse the costs of medical care provided by a GP, or
similar doctor/care provider who works under the
responsibility of a GP. The reimbursement also includes X-rays
requested by the GP. The extent of the care provided is limited
to the care that GPs normally provide.
Chain-based care
We reimburse the costs of chain-based care for type 2
diabetes mellitus (for insured parties aged 18 and over) and
COPD if we have made relevant agreements with a care group.
Chain-based care is a care programme for a specific chronic
disorder like COPD or type 2 diabetes mellitus which is
participated in by a number of care providers from various
disciplines.
If you do not use chain-based care via a care group contracted
by us, you will only be entitled to reimbursement of care for
type 2 diabetes mellitus (for insured parties aged 18 and over)
and COPD as usually provided by GPs, medical specialists and
dieticians. The care is reimbursed in accordance with Articles
4, 5 21 and 28 of this policy. In the case of type 2 diabetes
mellitus you are also entitled to foot care in accordance with
Article 29 of this policy. You can find the details of the care
groups we have selected via the Care Finder on our website, or
we will send you them on request.
Condition
The care elements which are part of the chain-based care
must comply with the Diabetes mellitus care of COPD
standard.
Art. 23
18
Stop Smoking Programme
No more than once per calendar year we reimburse the costs
of a stopping smoking programme to help people to quit
smoking.
The Stop Smoking Programme consists of medical and
pharmacotherapy interventions to support behavioural
change, with the aim being to stop smoking, as typically
•
Art. 24
doctor for the mentally handicapped or a medical
specialist.
Pharmacotherapy with the nicotine-replacement
medicines nortriptyline and bupropion and varenicline is
only reimbursed in combination with behaviour-based
support.
Pharmaceutical care
We reimburse the costs of pharmaceutical care, subject to the
conditions described in the Achmea Reglement
Farmaceutische Zorg Keuze Zorg Plan [Achmea Pharmaceutical
Care Regulations Options Care Plan]. Pharmaceutical care is
taken to mean:
• the provision of medication and dietary preparations
designated as such in this insurance agreement and/or
• advice and supervision as chemists usually offer on behalf
of medication assessment and responsible use of the
medication and dietary preparations designated as such
in this insurance agreement.
Pharmaceutical Care includes a number of (partial) provisions.
A description of these (partial) provisions can be found in the
Achmea Reglement Farmaceutische Zorg Keuze Zorg Plan
[Achmea Pharmaceutical Care Regulations Options Care Plan].
We reimburse the costs for provision, advice and supervision of:
• all registered medicines as stipulated by ministerial
decree if provided by a dispensing specialist who has an
IDEA contract with us;
• the registered medicines as stipulated by ministerial
decree in so far as these have been designated as such by
us and have been included in the Achmea Reglement
Pharmaceutical Care Regulations Options Care Plan], if
provided by a dispensing specialist who has a contract
with preference policy with us or a dispensing specialist
without a contract;
• other than registered medicines which may be supplied in
the Netherlands on the basis of the Geneesmiddelenwet
[Medicines Act], in the case of rational pharmacotherapy.
These are medicines which:
-- are prepared on a small scale by order of a dispensing
specialist in his pharmacy;
-- in accordance with Article 40, paragraph 3, under c of
the Geneesmiddelenwet, at the request of a doctor as
referred to in said article, prepared by a manufacturer
as referred to in Article 1, paragraph 1, under mm of
said Act, or
-- in accordance with Article 40, paragraph 3, under c of
the Geneesmiddelenwet, which are on the market in
another Member State or in a third country and are
brought onto the territory of the Netherlands at the
request of a doctor as referred to in said article and
are intended for a patient of said doctor who is
suffering from an illness which occurs in a maximum
of 1 in 150,000 residents in the Netherlands;
• polymer, oligomer, monomer and modular dietary
preparations.
The maximum reimbursements set by Achmea for the
pharmacy, medicines and dietary preparations (partial)
provisions can be found on our website, as can the Achmea
Reglement Farmaceutische Zorg Keuze Zorg Plan [Achmea
Pharmaceutical Care Regulations Options Care Plan] [Achmea
Pharmaceutical Care Regulations] and the registered
medicines designated by Achmea. We can also send you
details of the maximum reimbursements, the Achmea
Reglement Farmaceutische Zorg Keuze Zorg Plan [Achmea
Pharmaceutical Care Regulations Options Care Plan] and the
list of registered medicines on request.
Conditions governing medicines and dietary preparations:
•
•
•
The medicines of dietary preparations must have been
prescribed by a GP, medical specialist, dentist, geriatric
specialist and doctors specialising in care for the mentally
handicapped, midwife or an authorised nurse (following a
ministerial decree to this effect).
The medicines must be provided by a dispensing
specialist. Dietary preparations may also be supplied by
other medically specialised suppliers.
In the case of identical, mutually replaceable medicines,
you are only entitled to reimbursement of a medicine not
designated by Achmea in the event of a medical necessity.
•
This means that the treatment using the medicine
designated by Achmea is medically not responsible. The
prescribing party must indicate this on the prescription.
We reimburse the costs of dietary preparations and the
medicines for which supplementary conditions apply only
if the conditions have been fulfilled which we refer to in
Appendix 1 ‘Additional reimbursement conditions’ of the
[Achmea Pharmaceutical Care Regulations Options Care
Plan].
Conditions governing (partial) provisions
In the case of a number of (partial) provisions we impose
supplementary requirements with regard to the quality of the
care and/or the preconditions which govern the claims for
pharmaceutical care. In that case we reimburse these (partial)
provisions only if these additional requirements are fulfilled.
The Achmea Reglement Farmaceutische Zorg Keuze Zorg Plan
[Achmea Pharmaceutical Care Regulations Options Care Plan]
details which (partial) provisions are subject to this regulation.
Exceptions
The following medicines and/or (partial) provcisions are not
eligible for reimbursement:
• contraceptives for insured parties aged 21 and over,
unless there is a medical necessity as described in the
[Achmea Pharmaceutical Care Regulations Options Care
Plan] in the annex entitled ‘Additional reimbursement
conditions’ under number 64 Contraceptives;
• medicines and/or advice to prevent an illness within the
framework of travel;
• pharmaceutical care in the cases referred to in the Health
Care Insurance Regulations;
• medicines for research as referred to in Article 40,
paragraph 3, under b of the Medicines Act;
• medicines for research as referred to in Article 40,
paragraph 3, under f of the Medicines Act;
• medicines which are therapeutically equivalent or more
or less equivalent to any non-stipulated, registered
medicine;
• self-care medicines other than those referred to in the
Regeling zorgverzekering (medicines which are available
without a prescription);
• all pharmacy (partial) provisions which are not covered by
the insured care (please refer to the Achmea Reglement
Pharmaceutical Care Regulations Options Care Plan]) for a
description per pharmacy (partial) provision;
• homeopathic, anthroposophic and/or other alternative
medicines/remedies.
The Achmea Reglement Farmaceutische Zorg Keuze Zorg Plan
[Achmea Pharmaceutical Care Regulations Options Care Plan]
is part of this policy and can be downloaded from our website
or we will send it to you on request.
Art. 25
Conditions
•
•
•
Chronic disorders
Per disorder we reimburse the costs of the 21st and
subsequent appointments for treatment by a physiotherapist
or by a remedial therapist in accordance with the Appendix 1
to the Besluit zorgverzekering [Health Insurance Decree]. The
overview from Appendix 1 of the Besluit zorgverzekering
[Health Insurance Decree] is included in the brochure entitled
‘Paramedische Zorg’ [Paramedic Care] which we can send you
on request or which you can download from our website.
For insured parties who are younger than 18 we also
reimburse the first 20 appointments. The extent of the care
provided is limited to the care that physiotherapists and
remedial therapists normally provide.
The reimbursement for physiotherapy and remedial therapy is
also subject to the contents of the brochure entitled
You need a referral from the referring party (GP, company
doctor or medical specialist. We need this referral in order
to establish whether you are entitled to a reimbursement
of the costs of physiotherapy and remedial therapy via the
basic insurance.
Manual lymph drainage in connection with serious
lymphoedema may also be performed by a dermatologist.
Treatment at school is only permitted if we have made
the necessary agreements with the care provider.
Exceptions
•
We do not reimburse the costs of individual or group
treatment of which the only aim is to improve fitness by
means of training.
• We do not reimburse the costs of gymnastics during and
following pregnancy, (medical) fitness, (sport) massage
and work and occupational therapy.
• We do not reimburse the costs of the following
allowances; allowance outside regular working hours;
missed appointments; simple, short reports or more
complicated, time-consuming reports.
• We do not reimburse the costs of the dressings and
resources provided by the physiotherapist or remedial
therapist.
25.2 Non-chronic disorders
We reimburse insured parties aged up to 18 the costs of 9
appointments per disorder per calendar year with a
physiotherapist or remedial therapist. If the result of these 9
appointments is still unsatisfactory, we reimburse a
maximum of 9 additional appointments, if this is medically
essential, with the total maximum of appointments then
being 18. The extent of the care provided is limited to the care
that physiotherapists and remedial therapists normally
provide.
The reimbursement for physiotherapy and remedial therapy is
also subject to the contents of the brochure entitled
‘Paramedische Zorg’ [Paramedic Care]. This brochure is part of
the policy and can be downloaded from our website or sent to
you on request.
Conditions
•
Physiotherapy and remedial therapy
NB! By chronic disorders we mean the disorders on what is
referred to as the ‘Chronic List’ (Annex 1 to the Besluit
zorgverzekering [Health Care Insurance Decree]) This
‘Chronic List’ is drawn up by the government. The name of
this list implies that it includes all disorders which are
chronic, but this is not the case! This list also includes nonchronic disorders. If you would like to know whether your
disorder is on this list, ask your physiotherapist. You can
also find the list in the brochure entitled ‘Paramedisch
Zorg’ [Paramedical Care], which you can download from our
website or which we will send to you on request. If you
have any questions, please feel free to contact us.
25.1
‘Paramedische Zorg’ [Paramedic Care]. This brochure is part of
the policy and can be downloaded from our website or sent to
you on request.
•
•
of the costs of physiotherapy and remedial therapy via the
basic insurance. An exception to this are the
physiotherapists and remedial therapists with whom we
have made agreements about direct access. We have
agreed with these physiotherapists and remedial
therapists that they may treat you without a referral. DTF
or DTO (Directe Toegang Fysiotherapie/Oefentherapie
[Direct Access Physiotherapy/Remedial Therapy]) are
subject to a screening as 1 appointment and the intake
and examination after this screening also as 1
appointment. In the case of DTF at a PlusPraktijk
physiotherapy practice, however, the screening and the
intake, and the examination after this screening, only
count as 1 treatment. If, in connection with your
problem(s), you cannot come to the practice for
treatment, the referring party must indicate this on the
referral. DTF or DTO can never take place at home. You can
find the details of the care providers and the PlusPraktijk
physiotherapy practices we have selected using the Care
Finder on our website, or we will send you them on
request.
Manual lymph drainage in connection with serious
lymphoedema may also be performed by a dermatologist.
Exceptions
•
•
•
•
means of training.
We do not reimburse the costs of gymnastics during and
We do not reimburse the costs of the following
We do not reimburse the costs of the dressings and
therapist.
19
25.3 Pelvic physiotherapy in connection with urine incontinence
For each needs assessment we reimburse the costs of the first
9 appointments by a pelvic physiotherapist for insured parties
aged 18 or older. The extent of the care provided is limited to
the care that physiotherapists normally provide. The
reimbursement for pelvic physiotherapy is also subject to the
contents of the brochure entitled ‘Paramedische Zorg’
[Paramedic Care]. This brochure is part of the policy and can
be downloaded from our website or sent to you on request.
•
Exceptions
•
Speech therapy is not taken to mean the treatment of
dyslexia and language development disorders in
connection with dialect or a foreign language.
• We do not reimburse the costs of the following codes:
allowance outside regular working hours; missed
appointments; simple, short reports or more complicated,
time-consuming reports.
Condition
doctor or medical specialist. We need this referral in order to
establish whether you are entitled to a reimbursement of the
costs of the pelvic physiotherapist via the basic insurance.
Exceptions
•
•
•
Art. 26
resources provided by the pelvic physiotherapist.
Art. 28
Dietary advice
We reimburse the costs of 3 hours of dietary advice per
calendar year provided by a dietician. Dietary advice covers
information and advising in the field of diet and eating habits
with a medical goal. The extent of the care provided is limited
to the care that dieticians normally provide.
The reimbursement for dietary advice is also subject to the
contents of the brochure entitled ‘Paramedische Zorg’
[Paramedic Care]. This brochure is part of the policy and can
be downloaded from our website or sent to you on request.
Conditions
We reimburse the costs of 10 hours of advising, instruction,
training or treatment per calendar year by an occupational
therapist with the aim being to improve or restore your selfreliance.
The extent of the care provided is limited to the care that
occupational therapists normally provide. The reimbursement
for occupational therapy is also subject to the contents of the
brochure entitled ‘Paramedische Zorg’ [Paramedic Care]. This
brochure is part of the policy and can be downloaded from
our website or sent to you on request.
•
Conditions
•
of the costs of occupational therapy via the basic
insurance. An exception to this are the occupational
therapists with whom we have made agreements about
direct access. We have agreed with these occupational
therapists that they may treat you without a referral. If, in
connection with your problem(s), you cannot come to the
practice for treatment, the referring party must indicate
this on the referral. DTE (Directe Toegang Ergotherapie
[Direct Access Occupational Therapy]) can never be
provided at home. Treatment at school is only permitted
if we have made the necessary agreements with the care
provider.
Exclusion
We do not reimburse the costs of the following allowances:
Art. 27
We reimburse the costs of treatment by a speech and
language therapist in so far as the care is used for a medical
goal and the treatment can be expected to result in
restoration or improvement of the person’s speech. The
extent of the care provided is limited to the care that speech
and language therapist therapists normally provide. This also
covers stutter therapy provided by a speech and language
therapist. The reimbursement for speech and language
therapy is also subject to the contents of the brochure
entitled ‘Paramedische Zorg’ [Paramedic Care]. This brochure
is part of the policy and can be downloaded from our website
or sent to you on request.
Conditions
•
20
•
You need a referral from the referring party (GP, medical
specialist, or dentist). We need this referral in order to
establish whether you are entitled to a reimbursement of
the costs of speech and language therapy physiotherapy
via the basic insurance. An exception to this are the
speech and language therapists with whom we have
made agreements about direct access. We have agreed
with these speech and language therapists that they may
treat you without a referral. If, in connection with your
problem(s), you cannot come to the practice for
doctor, dentist or medical specialist. We need this referral
in order to establish whether you are entitled to a
reimbursement of the costs of dietary advice via the basic
insurance. An exception to this are the dieticians with
whom we have made agreements about direct access. We
have agreed with these dieticians that they may treat you
without a referral. If, in connection with your problem(s),
you cannot come to the practice for treatment, the
referring party must indicate this on the referral. DTD
(Directe Toegang Dietist [Direct Access Dietician]) can
never be provided at home.
Exclusion
We do not reimburse the costs of the following allowances:
Art. 29
Foot care for insured parties with diabetes mellitus
We reimburse insured parties with diabetes the costs of foot
examinations and treatment by a podiatrist of chiropodist, in
conjunction with a moderately increased risk or a high risk of
ulcers, as laid down in the care profiles of the Nederlandse
Vereniging voor podiatristen [Dutch Association of Podiatrists]
(NVvP) and Provoet and in so far as this is covered by the basic
insurance.
Conditions
•
•
Speech and language therapy
treatment, the referring party must indicate this on the
referral. DTL (Directe Toegang Logopedie [Direct Access
Speech and Language Therapy) can never be provided at
home.
•
•
•
If the treatment is carried out by a chiropodist, we impose
the following requirements:
The chiropodist must be registered, with the Diabetische
voet [Diabetic Foot] (DV) qualification or as a medical
chiropodist, in the ProCert KwaliteitsRegister voor
Pedicures [Chiropodist Quality Register] (KRP);
- Chiropodists (in the care sector) must be registered in
the Stipezo Register Paramedische Voetzorg [Paramedic
Footcare Register] (RPV) quality register.
In the event of treatment in connection with diabetic feet
(Simm’s 1 classification and higher) you must submit a
one-off doctor’s certificate from a GP, medical specialist
or diabetes nurse;
The care provider must state the diabetes type (1 or 2)
and the Simm’s classification on the bill. The bill must also
show that the chiropodist in question is registered in the
ProCert or RPV registers.
Exceptions
•
We do not reimburse the costs of foot examination and
treatment by a podiatrist or chiropodist for insured
parties with diabetes mellitus type 2 who are entitled to
chain-based care for diabetes mellitus type 2 which
includes the foot treatment (Article 22). We do not
reimburse the costs of nursing articles for foot treatment,
such as podotherapeutic soles and orthoses.
Reimbursement may be possible via the cover offered by
Article 30, Nursing Articles.
Art. 30
Nursing articles
• the provision of loaned functioning nursing articles and
dressings and bandages; in some cases a statutory
personal contribution or maximised reimbursement
applies;
• the changing, replacing or repairing of the nursing
articles;
• spare nursing articles;
in accordance with the Achmea Reglement Hulpmiddelen
Keuze Zorg Plan [Achmea Options Care Plan Nursing Articles
Regulations]. The Achmea Reglement Farmaceutische Zorg is
part of this policy and can be downloaded from our website,
or we will send you them on request.
In accordance with the Achmea Reglement Hulpmiddelen
Keuze Zorg Plan [Achmea Nursing Articles Regulations Options
Care Plan] and contrary to Article 12.1 of the general terms
and conditions of the basic insurance and the above, the
entitlement covers the loaning of nursing articles in some
cases.
Art. 33
Condition
As regards the supply, change, replacement or repair of a large
number of nursing articles, you do not need prior permission
and can contact a selected supplier directly. Article 3 of the
Achmea Reglement Hulpmiddelen Keuze Zorg Plan states for
which articles this applies. Prior permission from us is,
however, required for the supply, change, replacement or
repair of a number of nursing articles, based on our
assessment of whether the nursing article is essential,
appropriate and not unnecessarily expensive or complicated.
You always need our prior permission in the case of providers
not selected by us.
Art. 34
Exclusion
This article does not apply to nursing articles which are part of
specialist medical care. These nursing articles are covered by
Articles 1 to 5.
Art. 31
rt. 32
A
32.1
Childbirth and obstetrical care
Based on medical necessity
We reimburse to female insured parties the costs of:
• obstetric care provided by a midwife or, if the latter is not
available, by a GP. Obstetric care by a midwife in a hospital
will be provided under the responsibility of a medical
specialist;
• the use of the delivery room, if the delivery takes place in
a hospital (in an outpatient’s ward or otherwise). The
extent of the care provided by a midwife is limited to the
care that midwives normally provide.
32.2 Not based on medical necessity
We reimburse to female insured parties the costs of:
• the use of the delivery room if there are no medical
grounds for childbirth to take place in a hospital or birth
centre. A statutory personal contribution applies to the
use of the delivery room;
• obstetric care provided by a midwife or, if the latter is not
available, by a GP.
The extent of the care provided by a midwife is limited to the
care that midwives normally provide.
(Extramural) Nursing outside hospital
Instead of the nursing in an intramural institution referred to
in Articles 1, 2, 11, 12 and 13, you are also entitled, in the
home situation, to reimbursement of nursing care nurses
normally provide and which is necessary in connection with
specialist medical care. This concerns arranged treatment
which is carried out at the behest of a medical specialist, and
activities which the specialist has direct control over and/or
essential instructions and information related directly to the
specialist medical treatment.
Condition
You must still be receiving treatment from the medical
specialist.
Prenatal screening
For all the aspects of prenatal screening referred to below it
applies that the care provider in question must have a WBO
[Population Screening Act] licence or is engaged in a form of
cooperation with a regional centre that has a WBO licence,
except in the event of medical grounds.
31.1 Counselling
We reimburse female insured parties the costs of counselling
during which an explanation is given as to what prenatal
screening involves.
31.2 Structural Echoscopic Examination (SEO)
We reimburse female insured parties the costs of an
echoscopic examination, otherwise known as the 20 week
echo.
31.3 Combination test
We reimburse female insured parties the costs of the
combination test (neck fold measurement in combination
with a blood test) to establish congenital abnormalities during
the first three months of the pregnancy. The reimbursement
applies to female insured parties:
• aged 36 or older;
• younger than 36 who have been referred by a GP, midwife
or medical specialist.
Maternity care
We reimburse to female insured parties the costs of maternity
care:
• At home or in a birth or maternity centre. A statutory
personal contribution of € 4.00 applies per hour.
• The extent of the maternity care depends on your
personal situation after the birth and is determined by
the birth or maternity centre in proper consultation with
you and in accordance with the Landelijk Indicatieprotocol
Kraamzorg [National Maternity Care Guidelines]. We can
send you clarifying information on this protocol on
request or you can download it from our website.
• In hospital. If you give birth in hospital without there
being any medical grounds, a statutory personal
contribution applies for both mother and child of € 16.00
per day of admission, plus the amount with which the
hospital fee exceeds € 114.50 per day. You receive a
maximum of 10 days of maternity care, counting from the
day of the birth.
Information on our maternity care service can be found in the
brochure entitled ‘Bevalling en Kraamzorg’ [Childbirth and
Maternity Care] which we will send to you on request or
which you can download from our website.
Exclusion
We do not reimburse the costs of nursing which is necessary
in connection with artificial respiration at home or terminal
care.
Art. 35
Patient transport
We reimburse the costs of the following forms of transport:
• by ambulance;
• seated patient transport by public transport (lowest
class), transport by taxi or a kilometre reimbursement of
€ 0.31 per kilometre travelled using one’s own car in the
case of insured parties who:
-- undergo kidney dialysis;
-- receive oncological treatment by means of radio or
-- chemotherapy;
-- are visually impaired and cannot travel without being
accompanied;
-- are wheelchair-dependent.
• Transport of a companion if the insured party has to be
accompanied, or for the accompaniment of insured
parties aged up to 16. In the case of seated patient
transport (public transport, taxi or own car), a statutory
personal contribution of € 95.00 applies per person per
calendar year.
• A hardship clause applies in addition to the abovementioned criteria. This means that you are required, in
connection with treatment of a long-term illness or
disorder, to dependent in the long term on seated patient
transport, with the non-provision of that transport
leading to unreasonable hardship on your part. We
determine whether you are eligible for this.
We reimburse the costs of patient transport:
• from and to a care provider or an institution that provides
care which is completely or partially covered by this basic
insurance;
• to an institution at which you are going to stay on the
basis of cover provided by the AWBZ (not in the case of
care for just part of a day);
• from an AWBZ institution to a care provider or institution
at which you have to be examined or treated on the basis
of cover provided by the AWBZ;
• from an AWBZ institution to a care provider or institution
for the measuring and fitting of a prosthesis provided
completely or partially on the basis of the cover provided
by the AWBZ;
21
•
from the above-mentioned care providers or institutions
to your home address, or to another place of residence if
there are good reasons why you cannot receive the care at
your home address.
Conditions
•
•
•
•
•
•
We only reimburse the costs of ambulance transport if
seated patient transport is not sensible for medical
reasons.
In the case of seated patient transport, we must have
given you permission beforehand via the Vervoerslijn
[Travel Line]. The staff of the Vervoerslijn determine
whether you are entitled to reimbursement of the costs
of transport and which form of transport you can claim.
The telephone number of the Vervoerslijn is 071-365 41
54. Information on patient transport can be found in the
brochure entitled ‘Vevoer’ [Travel] which we will send to
you on request or which you can download from our
website.
The transport must be related to care which we reimburse
on the basis of your basic insurance or which is
reimbursed on the basis of the AWBZ.
If seated patient transport by public transport, taxi or
your own car is impossible, we must have given you
permission beforehand for a different means of transport.
In exceptional cases, you may be accompanied by two
companions. In that case we must have given you
permission beforehand.
In order to be eligible for reimbursement, the distance to
the care provider must not exceed 200 kilometres, unless
agreed otherwise with us.
Dental care articles 34 to 42
We reimburse the costs of essential dental care normally
provided by dentists, dental prostheticians, dental surgeons,
oral hygienists and orthodontists, as described in Articles 36
to 42. For more information please consult the brochure
entitled ‘Mondzorg’ [Dental care]. You can download this
brochure from our website or we will send it to you on
request.
Art. 36
Dental care for insured parties aged up to 18
We reimburse the costs of the following kinds of dental
treatment:
• periodical preventive dental examinations once a year,
unless you needed dental treatment more than once a
year;
• occasional dental consultations;
• the removal of tartar;
• fluoride applications twice a year from the moment that
permanent dental elements appear unless you need
dental treatment several times a year and we have given
you permission beforehand;
• sealing;
• periodontal treatment;
• anaesthesia;
• endodontic treatment;
• restoration of dental elements using synthetic materials;
• gnathologic treatment;
• removable prosthetic provisions;
• teeth replacement using non-synthetic materials and the
fitting of dental implants in the case of the replacement
of one or more missing, permanent incisors or canine
teeth which have not been constructed or because
extraction of the tooth or teeth is the immediate
consequence of an accident;
• dental surgery, with the exception of the fitting of dental
implants;
• X-rays, with the exception of X-rays in connection with
orthodontic treatment.
Conditions
•
•
•
•
•
22
The treatment must be carried out by a dentist, a dental
surgeon, an oral hygienist or a dental prosthetician. They
must be authorised to perform the treatment in question.
In the case of treatment by a dental surgeon, a referral is
required from a dentist, dental specialist or GP.
We must have given you permission beforehand for front
tooth replacement with an implant and the prosthetic
follow-up treatment.
The placing of bone anchors on behalf of orthodontic
treatment is only reimbursed if you have permission for
reimbursement of the orthodontics in exceptional cases
(see Article 42).
If care is required as described in Articles 40, 41 or 42, an
authorisation must be applied for.
Art. 37Dental care for insured parties aged 18 and over - dental
surgery
We reimburse the costs of surgical dental care of a specialist
nature and the related X-rays, whether in conjunction with a
stay in hospital or otherwise, with the exception of
periodontal surgery, the fitting of a dental implant and an
uncomplicated extraction.
Conditions
• The treatment has to be carried out by a dental surgeon.
• You must have been referred by a GP, dentist, company
doctor, geriatric specialist, a doctor for the mentally
handicapped, youth health care doctor, or another
medical specialist.
• If the treatment is carried out in a hospital we have to
have given you permission beforehand for:
-- osteotomy (jaw operations) except when this is part
of combined surgical/orthodontic treatment for
which you have permission for reimbursement of the
orthodontics in exceptional cases (see Article 42);
-- chin plastic surgery as a separate operation;
-- plastic surgery
• Extractions may only be carried out using a general
anaesthetic if there are substantial medical grounds.
• If the treatment is carried out in an independent
treatment centre for dental surgery you must have given
permission beforehand for treatment under general
anaesthetic, chin plastic surgery as a separate operation
and plastic surgery.
• You are only entitled to a maxillary sinus floor
augmentation procedure, jaw widening and/or raising if
the related implants are reimbursed via the basic
insurance.
• The placing of bone anchors on behalf of orthodontic
treatment is only reimbursed if you have permission for
reimbursement of the orthodontics in exceptional cases
(see Article 42).
• The application for permission is assessed for
appropriateness and legitimacy.
Art. 38Dental care for insured parties aged 18 and over - removable
complete prostheses (false teeth)
We reimburse the costs of constructing and fitting:
• a removable complete prosthesis for the upper and/or
lower jaw;
• a removable complete immediate prosthesis;
• a removable complete replacement prosthesis;
• a removable complete capping prosthesis on natural
elements.
A statutory personal contribution of 25% applies. This
statutory personal contribution does not apply to repairing
and rebasing a complete immediate prosthesis, an existing
removable complete prosthesis or an existing complete
capping posthesis.
We apply maximum technical and material costs. You can find
these amounts on our website, or we will send you them on
request.
Conditions
• The treatment has to be carried out by a dentist or dental
prosthetician.
• If the prosthesis is replaced within 5 years, or an
immediate prosthesis is replaced within six months, we
have to have given you permission beforehand. The
application for permission is assessed for appropriateness
and legitimacy.
• Combined upper and lower prosthesis.
• If the total costs relating to a combined upper and lower
prosthesis based on constructing and fitting by a dentist
are higher than € 1,200.00, we must have given you
permission beforehand. The amount referred to includes
the maximum technical costs.
• Full upper or full lower prosthesis
If the total costs relating to a full upper or full lower
prosthesis based on constructing and fitting are higher
than € 600.00, we must have given you permission
beforehand. The amount referred to includes the
maximum technical costs.
rt. 39
A
39.1
Implants
Implants
We reimburse the costs of dental implants in connection with
a removable complete prosthesis if you have such a serious
dental, jaw or mouth development disorder, growth disorder
or acquired disorder that, without this treatment, you would
be unable to maintain or acquire a dental function equal to
that which you would have had if the disorder had not
occurred. We apply maximum technical and material costs.
You can find these amounts on our website, or we will send
you them on request.
•
•
Conditions
Conditions
The treatment must be performed by a dentist, dental
surgeon or at a Centre for Special Dental Care.
• For treatment at a Centre for Special Dental Care a
referral is required from a dentist, dental specialist or GP.
• We must have given you permission beforehand. The
request for permission must be accompanied by a
treatment schedule and cost estimate. The application for
permission is assessed for appropriateness and legitimacy.
• You must be suffering from a seriously diminished
toothless jaw and the purpose of the implant must be fit
a removable prosthesis.
• An entitlement may also exist to implants based on
Article 41.
39.2 Removable complete prosthesis on implants
We reimburse the costs of dental implants in connection with
a removable complete prosthesis if you have such a serious
dental, jaw or mouth development disorder, growth disorder
or acquired disorder that, without this treatment, you would
be unable to maintain or acquire a dental function equal to
occurred. A statutory personal contribution of € 125.00
applies per upper or lower jaw. We also reimburse the costs of
repairing and rebasing removable complete prostheses on
implants. We apply maximum technical and material costs.
You can find these amounts on our website, or we will send
you them on request.
Conditions
•
•
•
•
•
For treatment at a Centre for Special Dental Care a
We must have given you permission beforehand. The
treatment schedule and cost estimate. The application for
permission is assessed for appropriateness and legitimacy.
You must be suffering from a seriously diminished
toothless jaw.
An entitlement may also exist to implants based on
Article 41.
•
•
•
•
Art. 42
you have an extreme fear of dental treatment, in
accordance with the validated fear rating scales described
in the guidelines of a Centre for Special Dental Care. In so
far as the care is not directly connected to the grounds for
special dental care, insured parties aged 18 and over pay a
contribution equal to the amount that the insured party
in question would be charged if this article did not apply.
hygienist, orthodontist, dental surgeon or at a Centre for
Special Dental Care.
For treatment at a Centre for Special Dental Care or by by
a dental surgeon a referral is required from a dentist,
dental specialist or GP.
treatment schedule and cost estimate drawn up by your
care provider. The application for permission is assessed
for appropriateness and legitimacy.
An entitlement may also exist to implants based on
Article 39.
Orthodontics (brace) in exceptional cases
We reimburse the costs of orthodontic treatment in the case
of very serious dental, jaw or mouth development or growth
disorders.
Conditions
•
•
•
•
•
We reimburse the costs only if you have such a serious
dental, jaw or mouth development disorder, growth
disorder or acquired disorder that, without the treatment,
you would be unable to maintain or acquire a dental
function equal to that which you would have had if the
disorder had not occurred.
The treatment must be performed by an orthodontist or
at a Centre for Special Dental Care.
For treatment at a Centre for Special Dental Care a
The treatment also requires diagnostics or treatment by
practitioners other than those involved in dental
disciplines.
Art. 40Dental care for insured parties with a physical or mental
handicap
We reimburse the costs of dental care if you have a nondental physical and/or mental handicap and cannot retain or
acquire any dental function without this care, which function
is equivalent to the dental function which you would have had
without the physical and/or mental handicap.
Conditions
• The treatment must be performed by a dentist, dental
• For treatment at a Centre for Special Dental Care or by a
dental surgeon a referral is required from a dentist, dental
specialist or GP.
• We only reimburse the costs if no dental reimbursement
can be claimed via the AWBZ.
• We must have given you permission beforehand. The
Art. 41
Dental care in exceptional cases
We reimburse the costs of dental treatment in cases in which:
• you have such a serious dental, jaw or mouth
development disorder, growth disorder or acquired
disorder that, without the treatment, you would be
unable to maintain or acquire a dental function equal to
occurred;
• medical treatment without that care will have a
demonstrably unsatisfactory result and that, without that
care, you would be unable to maintain or acquire a dental
function equal to that which you would have had if the
disorder had not occurred;
23
Conditions and reimbursements for the Avéro Achmea supplementary
insurance policies
3.1.1
General terms and conditions of the supplementary
insurance policies
The general terms and conditions Articles 1 to 18 that apply to
the Keuze Zorg Plan, with the exception of the first sentence
of Article 2.1, also apply to the supplementary (dental)
insurance policies. In addition to these articles, a number of
specific articles apply to the supplementary (dental) insurance
policies. These are described below.
Art. 1 Definitions
The following definitions apply for the purpose of the
supplementary (dental) insurance policies:
Supplementary insurance
The supplementary (dental) insurance policies to the Keuze
Zorg Plan.
Budget holder
Person to whom a personal budget (PGB) is allocated pursuant
to the AWBZ and/or the Wet maatschappelijke ondersteuning
[Social Support Act] (Wmo) and who has responsibility for the
PGB spending.
Voluntary carer
The person who provides long-term and/or intensive care free
of charge for a chronically ills, handicapped or infirm partner,
parent, child or other family member.
Accident
A sudden impact of violence to the insured’s body, coming
from an external source and not being of his own volition,
causing medically demonstrable physical injury.
We/us
Avéro Achmea Zorgverzekeringen N.V.
Care regulator
Those who fulfil complex care needs relating to the AWBZ and
the Wmo, who carry out searches and advise in the field of
care, work, welfare, living and finances and who (if necessary)
can take over the accompanying regulatory tasks from the
insured party and/or voluntary carer in so far as this care is not
covered by the legal care entitlements.
Health insurer
For the implementation of the supplementary insurance, this
is Avéro Achmea Zorgverzekeringen N.V.
Avéro Achmea Zorgverzekeringen N.V. is registered with the
AFM [Netherlands Authority for the Financial Markets] under
number 12000647.
Art. 2 Application and registration
2.1 Anyone who is entitled to insurance under the Keuze Zorg Plan
can apply for supplementary insurance. A supplementary
insurance policy can never be entered into retroactively, with
the exception of Article 3.1.1. You can register for
supplementary insurance by submitting a completely filled in
and signed application form or by completing the internet
application form on our website (only possible if the
application takes place at the same time as the application for
the (Keuze Zorg Plan).
2.2 We can refuse a request for registration for supplementary
insurance if:
• you (the policyholder) still have to pay premium for an
insurance policy you already have with us;
• you are guilty of fraud as described in Article 18 of the
Keuze Zorg Plan;
• your state of health gives cause to do so;
• you have reached the age of 65 when you take out the
Ziekenhuis Extra Verzekering [Hospital Extra Insurance];
• you already require care at the time of registration, or care
is expected, which as regards nature and extent is
included in the reimbursements for the supplementary
insurance.
2.3 Children under the age of 18 are not able to take out
supplementary insurance which is more extensive than the
supplementary insurance of (one of) the parents insured with
us.
Art. 3 Commencement date, duration and termination of your
supplementary insurance
3.1 Commencement date and duration of your supplementary
insurance
24
3.1.2 3.2 3.2.1 3.2.2 3.2.3 You (the policyholder) can extend a Keuze Zorg Plan already
taken out with us to include a supplementary insurance policy
until 31 January of the current calendar year. Such an
extension takes place retroactively as of 1 January and after
we have given written permission. A medical assessment may
be required.
You (the policyholder) can change a supplementary insurance policy already taken out with us until 31 January of the current
calendar year. The change takes place retroactively as of 1
January and after we have given written permission. A medical
assessment may be required. The change is accompanied by a
continuation of the supplementary insurance as regards the
periods of care entitlement as if the insurance package has not
been changed. However, the reimbursements provided during
the periods referred to do count when determining the
(maximum) reimbursement within the framework of the newly
concluded insurance package.
Termination of your supplementary insurance
You (the policyholder) can terminate the basic insurance:
• by submitting a cancellation (in writing or by email) to us
by no later than 31 December. The supplementary
insurance policy ends on the following 1 January. Once a
cancellation has been made it will be irrevocable.
• by using the cancellation service provided by the care
insurers. This means that if you take out supplementary
insurance for the subsequent calendar year on no later
than 31 December, the new health insurer will cancel the
basic insurance with us on your (the policyholder’s) behalf.
If you (the policyholder) do not want to use this service,
you (the policyholder) must give notice to this effect on
the application form to be completed for your new health
insurer.
We will terminate both your supplementary insurance and
that of the insured party/parties included in your
supplementary insurance:
• at a point in time to be determined by us if the amounts
owed have not been paid by the payment deadline set by
us in the second written reminder;
• with immediate effect:
-- if you do not respond on time to a request for
information (possibly in writing), if that information is
required for a proper execution of the supplementary
insurance;
-- if it transpires later that the policyholder has filled in
the application form incorrectly or incompletely, or
has not disclosed circumstances which could be
important for us;
• in the event of established fraud as described in Article 18
of the Keuze Zorg Plan;
As soon as your participation in group insurance is ended, your
right to a group discount via this group insurance and the
other benefits such as the extra reimbursements resulting
from the group insurance will lapse.
Art. 4 Obligatory and voluntary deductible excess
The obligatory and voluntary deductible excesses only apply
to the Zorg Plan and not to the supplementary insurance.
Art. 5 Premium
5.1 Level of the premium
5.1.1 The level of the premium depends on your age. If the premium
increases due to exceeding an age limit, the premium will
change on the first day of the month following the month in
which the age limit is exceeded.
5.1.2 If one of the parents has taken out Keuze Zorg Plan insurance
and a supplementary insurance with us, any insured party
below the age of 18 will not owe premium for the Keuze Zorg
Plan.
5.2 Late payment
Supplementary to Articles 9.3 and 9.4 of the Keuze Zorg Plan, it
applies that the supplementary insurance policies will be
terminated if the premium has not been paid by the set
payment deadline referred to in our second written reminder.
The reimbursements then lapse automatically as of the first day
of the month following the end of the payment period referred
to. The obligation to pay will continue to exist. Once the
premium arrears have been paid it will be possible to take out
the same supplementary insurance(s) again. A medical
assessment may be required beforehand. If the application is
approved, the supplementary insurance will be concluded as of
the first of the month following the month of the application.
Conditions and reimbursements for the Avéro Achmea supplementary insurance policies
Art. 6 Changes to the premium and/or conditions
6.1 We are entitled to change the conditions and/or the premium
of current supplementary insurance policies as a whole or in
batches. Such a change will be implemented on a date to be
determined by us.
6.2 If we increase the premium or limit the reimbursements based
on the insurance conditions, these changes will also apply if
you were already insured with us.
6.3 If you do not agree with the premium increase or the limiting
of the conditions, you can notify us (in writing or by e-mail)
within 30 days after we have given notice of the change. We
will terminate your insurance on the day on which the change
takes effect.
6.4 You may not refuse the change if:
• the premium increase and/or reimbursement limitations
are the consequence of statutory regulations;
• your premium increases due to you exceeding an age
limit.
Art. 7 Reimbursements
7.1 You are entitled to reimbursement of your costs based on the
supplementary insurance in so far as these are incurred during
the period in which this supplementary insurance is
applicable. The date of the treatment and/or the date on
which the care was provided, as referred to on the bill, are
decisive in this respect, and therefore not the date on which
the bill is made out. If treatment is claimed in the form of a
DBC care product, the moment at which the treatment starts
is a determining factor.
7.2 Entitlements in the event of a stay abroad
Reimbursement takes place with due regard for the conditions
and exclusions referred to in the relevant articles of the
supplementary insurance. In addition, the foreign care
provider or institution must be certified by the local authority
and it must comply with statutory requirements which are
equivalent to those with which Dutch care providers and
institutions have to comply in accordance with these
insurance conditions. Within the framework of this provision,
Article 19, which applies to Zorg Plan, applies mutatis
mutandis. Wherever a 100% reimbursement is referred to in
these conditions, this means, within the framework of this
article, a reimbursement to a maximum of 100% of the rate
that is usual in the Netherlands for a comparable treatment.
This article does not apply to the articles referred to in the
insurance conditions which relate specifically to the Dutch
situation. Neither does this article apply to Article 26 of the
conditions of the Start, Extra, Royaal and Excellent
supplementary insurance policies. In so far as the costs have
been incurred abroad, they will only be reimbursed if they
would have been reimbursed in the Netherlands on the basis
of the supplementary insurance policy.
7.3 Concurrence
7.3.1 You can only claim reimbursements via the supplementary
insurance which are not or only partially issued via a statutory
regulation and which are covered by the supplementary
insurance. The supplementary insurance does not provide a
reimbursement as compensation for:
• higher reimbursements provided via the Keuze Zorg Plan
in connection with the use of non-contracted care;
• costs which have been set off against the deductible
excess of the Keuze Zorg Plan, unless the obligatory or
voluntary deductible excess is reimbursed via the group
supplementary insurance policy;
• statutory personal contributions and amounts in excess
of the statutory maximum reimbursement, unless the
supplementary insurance policy explicitly includes cover
for these.
7.3.2 There is no cover on account of this supplementary insurance
if and in so far as the medical costs which are covered by any
law or other provision or by another insurance policy
(including travel insurance), whether with an older date or
otherwise, or which would be covered if this supplementary
insurance had not existed.
7.4 We only reimburse the costs as a consequence of terrorism via
the supplementary insurance up to the payment amount
described in the schedule governing terrorism cover of the
Nederlandse Herverzekeringsmaatschappij voor
Terrorismeschaden N.V. This schedule and the related Protocol
are part of this policy and can be downloaded from our
website or sent to you on request.
7.5 If you have taken out a number of insurance policies with us,
the bills you submit will be paid for via the health insurance
policies in the following order:
• the Keuze Zorg Plan;
• Services related to the Keuze Zorg Plan
• the supplementary dental insurance (T Start, T Extra, T
Royal or T Excellent);
• the supplementary insurance policies (Start, Extra, Royaal
and Excellent);
• the supplementary Ziekenhuis Extra [Hospital Extra]
insurance policy
Art. 8 Claiming care entitlements
Article 13.2 of the Keuze Zorg Plan does not apply to the
supplementary insurance policies.
Art. 9 Substantive checks and fraud
We carry out research into the legitimacy (whether the care
provider has indeed provided the service) and the
appropriateness (is the service provided the most appropriate
service for the insured party’s state of health) of the bills
submitted in accordance with that specified in relation to this
matter in the context of the Keuze Zorg Plan by or pursuant to
the Zorgverzekeringswet.
Conditions and reimbursements for the Avéro Achmea supplementary insurance policies
25
Entitlements via the supplementary insurance policies
Conditions and reimbursements for the supplementary
insurance policies. The insurance policies you have taken out
with us are referred to on your policy document. We
reimburse the costs of:
Art. 1 Accommodation in a guest house and transport of family
members in the event of a hospital admission
If you are admitted to a hospital in the Netherlands, we
reimburse
• the accommodation costs incurred by your family
members in a Ronald McDonald house or other guest
house located in the vicinity of the hospital;
• the costs of transport of your family members by their
own vehicle or taxi from their home address to the
hospital or guest house and between the guest house and
the hospital. We reimburse € 0.31 per kilometre;
• the costs of public transport (second class) from the home
address to and from the hospital or guest house and
between the guest house and the hospital. We also
reimburse the above-mentioned costs if the treatment
takes place at no more than 55 kilometres from the
border with Belgium or Germany and no care mediation
has taken place as referred to in Article 26.3.
Conditions
• You have to submit to us a specification of the costs
incurred so that we can check whether the visit has
actually taken place. If we request such, you must provide
proof of this visit. This can take the form of parking tickets
or an attendance list drawn up by the insured party and
authenticated by the hospital or rehabilitation institution
in question.
• In the case of the Start en Extra packages it applies that
the one-way distance travelled between the hospital and
your home must be more than 50 kilometres.
Exclusion
We do not reimburse these costs in the event of admission to
a psychiatric hospital.
Starta maximum of € 35.00 per day to a maximum
€ 500.00 per calendar year for all family members
together
Extraa maximum of € 35.00 per day to a maximum
together
Royaala maximum of € 35.00 per day to a maximum
together
Excellenta maximum of € 1,000.00 per calendar year for all
family members together
Art. 2 Accommodation in a guest house in the event of a cycle of
outpatient treatment
We reimburse the costs of accommodation in a Ronald
McDonald house located in the vicinity of the hospital or
another guest house in the Netherlands if you have to
undergo a cycle of outpatient treatment. A cycle of outpatient
treatment concerns treatment on 2 or more consecutive days.
Start
Extra
Royaal
Excellent
a maximum of € 35.00 per day
26
Conditions
•
•
The treatment must be medically necessary.
We must have given you permission beforehand.
Exclusion
We do not reimburse the costs of treatment with Botox,
fillers, (autologous) lip augmentation, peeling, laser or
refraction surgery.
Start
no cover
Extra
no cover
Royaal no cover
Excellent 100% for all care providers
3.2 Cosmetic surgery (without medical grounds) We reimburse
the costs of surgical operations of a cosmetic nature whereby
personal needs, necessity or circumstances provide the
motive.
Condition
The treatment must be provided by a medical specialist.
Exclusion
We do not reimburse the costs of treatment with Botox,
fillers, (autologous) lip augmentation, peeling, laser or
refraction surgery.
Start100% correction of the ear position for children
aged up to 18 by care providers we have selected,
no cover applies to other treatment
Extra100% correction of the ear position for children
aged up to 18 by care providers we have selected,
no cover applies to other treatment
Royaal100% correction of the ear position for all care
providers we have selected, no cover applies to
other treatment
Excellent100% for the correction of the ear position for all
care providers, other forms of treatment to a
maximum of € 500.00 per insured party per
calendar year
Art. 4 Eye laser treatment/intraocular lenses
We reimburse the costs of eye laser treatment and/or the
additional costs of a lens other than a monofocal (standard)
plastic intraocular lens.
Conditions
• The ophthalmologist who carries out the treatment must
be registered as refraction surgeon with the Nederlands
Oogheelkundig Genootschap [Netherlands Opthalmic
Association] (NOG) or fulfil the appropriate quality
requirements of the NOG.
• Although ophthalmologists are registered In the register
of the NOG, you are only entitled to reimbursement if the
ophthalmologist is also registered as a refraction surgeon.
• For reimbursement of the additional costs of a lens you
must be entitled to reimbursement of intraocular lenses
via the Zorg Plan.
Startno cover
Extraa maximum of € 500.00 per insured party for the
entire duration of the supplementary insurance
Royaala maximum of € 500.00 per insured party for the
Excellenta maximum of € 750.00 per insured party for the
Eye laser treatment discount scheme
Art. 3 Plastic surgery/Cosmetic surgery
3.1 Plastic surgery (on medical grounds) correction of upper eyelids
We reimburse the costs of plastic surgery to correct the upper
eyelids in the event of demonstrably defective body functions.
In the case of the Start and Extra packages you can find the
care providers we have selected whose costs we reimburse
using the Care Finder on our website, or we will send you
them on request. Start 100% for care providers selected by us
Extra 100% for care providers selected by us Royaal 100% for
all care providers Excellent 100% for all care providers
Start
Extra
Royaal
Excellent
3.1.1 Plastic surgery (on medical grounds) other forms of treatment
Supplementary to Article 3.1 we reimburse treatment by a
medical specialist.
In addition to the above reimbursement, all insured parties
with a supplementary insurance policy are eligible for a
discount scheme, upon production of their care pass, at
VisionClinics, Eyescan en Oogkliniek Heuvelrug.
You can find information about the discount schemes on our
website or we will send it to you on request.
no cover
no cover
no cover
100% for all care providers
Art. 5 Sterilisation
We reimburse the costs of sterilisation if the treatment takes
place in:
• the practice of an authorised GP, in the case of male
insured parties;
• a hospital or independent treatment centre (on an
outpatient basis).
Exclusion
We do not reimburse the costs of a reversal operation.
Start
Extra
Royaal
Excellent
no cover
100%
100%
100%
Art. 6 Circumcision
We reimburse the costs of circumcision by a man on religious
grounds
Condition
The treatment has to take place at the premises of a GP, care
provider, in an independent treatment centre or a circumcision
clinic. You can find the details of the care providers we have
selected which we reimburse via the Care Finder on our
website, or we will send you them on request.
Start
Extra
Royaal
Excellent
no cover
a maximum of € 250.00
Art. 7 Primary psychological care
7.1 Personal contribution for primary psychological care
We reimburse the statutory personal contribution you are
required to pay in conjunction with a reimbursement of
primary psychological care via the Zorg Plan.
Starta maximum of € 100.00 per insured party per
calendar year
Extraa maximum of € 100.00 per insured party per
calendar year
Royaala maximum of € 100.00 per insured party per
calendar year
Excellenta maximum of € 100.00 per insured party per
calendar year
7.2 Supplementary primary psychological care
As a supplement to the reimbursement on the grounds of the
Zorg Plan, we reimburse the costs of extra sessions of primary
psychological care.
Condition
The conditions and exclusions as apply to the reimbursement
of primary psychological care via the Zorg Plan (see Article 10)
apply in full to the right to the reimbursement of these extra
sessions.
Start
Extra
Royaal
Excellent
2 sessions per insured party per calendar year
Art. 8 Treatment of psoriasis
We reimburse the costs of treatment of psoriasis in a psoriasis
day treatment centre.
Conditions
• You have to submit a doctor’s certificate from the
dermatologist to the psoriasis day treatment centre.
• The psoriasis day treatment centre must have given you
prior written permission.
calendar year
Extraa maximum of € 1,000.00 per insured party per
calendar year
Royaala maximum of € 1,000.00 per insured party per
calendar year
Excellenta maximum of € 1,000.00 per insured party per
calendar year
Art. 9 Orthopaedic medicine
We reimburse the costs of consultations with an orthopaedic
doctor. The consultations consist of the diagnosis and the
treatment of disorders affecting the locomotor apparatus
without any operations taking place.
Conditions
•
•
You must be referred by a GP.
The orthopaedic doctor must be affiliated to the
Vereniging van Artsen voor Orthopedische Geneeskunde
[Association of Orthopaedic Doctors] (VAOG) or fulfil the
quality requirements of this association.
If you are treated by an orthopaedist, the treatment will fall
under specialist medical care, to which a reimbursement via
the Zorg Plan applies.
calendar year
calendar year
calendar year
calendar year
Art. 10 Alternative forms of treatment, therapies and medicines
We reimburse the costs of consultations or treatment by
alternative healers or therapists (doctors and non-doctors)
who are affiliated to professional associations which fulfil our
criteria. The summary of professional associations that fulfil
our criteria are part of this policy and can be downloaded from
our website or we will send it to you on request. We only
reimburse consultations or treatment in the specific area for
which the professional association has been included in the
list.
We also reimburse the costs of homeopathic and
anthroposophic medicines prescribed by a doctor. These
medicines are subject to the maximum reimbursements set
by us.
Conditions
• The consultation must take place within the framework
of medical treatment.
• The consultation is to be provided on an individual basis.
• The homeopathic and anthroposophic medicines must be
registered in the G-standard of the Z-index (database in
which all medicines are included which are available from
pharmacies) as homeopathic or anthroposophic
medicines.
• The homeopathic and anthroposophic medicines must
have been prescribed by a dispensing specialist.
Exceptions
We do not reimburse the costs:
• if the alternative healer or therapist is also the GP;
• of (laboratory) examinations;
• of manual therapy provided by a physiotherapist;
• of treatment, examinations and courses with a social
nature or with a focus on well-being and/or prevention;
• of work and school-related coaching;
Starthomeopathic and anthroposophic medicines 100%,
consultations with alternative healers or therapists
to a maximum of € 40.00 per day A maximum of
€ 440.00 per insured party per calendar year for
alternative forms of treatment and antroposophic
and/or homeopathic medicines together.
Extrahomeopathic and anthroposophic medicines 100%,
consultations with alternative healers or therapists
to a maximum of € 40.00 per day A maximum of
€ 640.00 per insured party per calendar year for
alternative forms of treatment and antroposophic
and/or homeopathic medicines together.
Royaalhomeopathic and anthroposophic medicines 100%,
consultations by doctors who practise alternative
medicine to a maximum of € 60.00 per day, and
consultations by alternative non-doctors to a
maximum of € 40.00 per day. A maximum of 16
consultations per insured party per calendar year
for alternative forms of treatment by doctors and
non-doctors together
Excellenthomeopathic and anthroposophic medicines 100%,
consultations by doctors who practise alternative
medicine to a maximum of € 60.00 per day, and
consultations by alternative non-doctors to a
maximum of € 40.00 per day. a maximum of 20
consultations per insured party per calendar year
for alternative forms of treatment by doctors and
non-doctors together
27
rt. 11 Pharmaceutical care
A
11.1 Statutory personal contribution (GVS upper limit price)
We reimburse the personal contribution (GVS upper limit
price) which you have to pay for pharmaceutical care on the
grounds of the Zorg Plan.
Exclusion
We do not reimburse the personal contributions as a
consequence of the maximum reimbursements set by us for
the pharmacy, medicines and dietary preparations (partial)
provisions.
applies as a supplement to the reimbursement available via
this policy. The reimbursement for physiotherapy and
remedial therapy is also subject to the contents of the
brochure entitled ‘Paramedische Zorg’ [Paramedic Care]. This
brochure is part of the policy and can be downloaded from
our website or sent to you on request. In the case of other
treatment we reimburse in accordance with the Overzicht
Vergoedingen Basisprestatie Paramedische Zorg [Summary of
Basic Paramedic Care Reimbursements] as included in the
brochure entitled ‘Paramedische Zorg’.
Start
no cover
Extra
no cover
Royaal 100%
Excellent 100%
11.2 Melatonin
In the event of sleeping problems as a result of DSPS, ADHD
and PDD-NOS we reimburse the costs of the medicine
melatonin. This medicine is subject to the maximum
reimbursements set by us.
You must have been referred by a GP, company doctor or
medical specialist. An exception to this are the
physiotherapists or remedial therapists selected by us with
whom we have made agreements about direct access. We
have agreed with these physiotherapists and remedial
therapists that they may treat you without a doctor’s referral
being necessary. We refer to this as direct access
physiotherapy/remedial therapy (DTF/DTO). DTF or DTO
(Directe Toegang Fysiotherapie/Oefentherapie [Direct Access
Physiotherapy/Remedial Therapy]) are subject to a screening
as 1 appointment and the intake and examination after this
screening also as 1 appointment. In the case of DTF provide by
a PlusPraktijk physiotherapy practice, however, the screening
and the intake, and the examination after this screening, only
count as 1 treatment. You can find the details of the care
providers and PlusPraktijk physiotherapy practice we have
made agreements with via the Care Finder on our website or
we will send you them on request.
Conditions
•
•
•
•
In the case of complaints as a consequence of DSPS, the
melatonin must have been prescribed by a doctor
affiliated to a sleep therapy institute in the Netherlands.
In the case of complaints as a consequence of ADHD and
PDD-NOS, the melatonin must have been prescribed by a
(child) psychiatrist, paediatrician or (child) neurologist.
The melatonin must be provided by a dispensing
specialist.
Startno cover
Extra100% if supplied via Internet pharmacy eFarma or
max. € 100 per insured party per calendar year if
supplied via another dispensing specialist
Royaal100% if supplied via Internet pharmacy eFarma or
max. € 150 per insured party per calendar year if
supplied via another dispensing specialist
Excellent100%
11.3 Contraceptives for insured parties aged 21 and over
We reimburse female insured parties the costs of hormonal
contraceptives and coils (IUDs). These medicines are subject to
the maximum reimbursements set by us.
Exceptions
•
•
•
•
means of training.
therapist.
We do not reimburse the costs of individual treatment if
you are eligible for exercise programmes as described in
Article 14.
Conditions
•
•
Startup to the age of 18: an unlimited number of
appointments if treated by a care provider selected
by us. A maximum of 12 appointments per insured
party per calendar year in the event of treatment by
a care provider not selected by us
from the age of 18: a maximum of 12
appointments per insured party per calendar year
Extraup to the age of 18: an unlimited number of
Royaalup to the age of 18: an unlimited number of
Excellentunlimited number of appointments per insured
party per calendar year
•
•
•
The contraception must be included in the GVS.
The contraception must have been prescribed by a GP or
medical specialist.
A general practitioner’s or medical specialist’s prescription
is only required for the first delivery of birth control pills.
The contraception must be supplied by a dispensing
specialist.
Start100%, no reimbursement of statutory personal
contribution (GVS upper limit price)
Extra100%, no reimbursement of statutory personal
contribution (GVS upper limit price)
Royaal 100%
Excellent 100%
Art. 12 Additional occupational therapy for insured parties aged up
to 18
As a supplement to the reimbursement on the grounds of the
Zorg Plan, we reimburse the costs of extra sessions of
occupational therapy to insured parties aged up to 18.
Condition
The conditions and exclusions as apply to the reimbursement
of occupational therapy via the Zorg Plan (see Article 26) apply
in full to the right to the reimbursement of these extra
sessions.
Start
Extra
Royaal
Excellent
no cover
3 hours per insured party per calendar year
Art. 13 Physiotherapy and remedial therapy
We reimburse the costs of treatment by a physiotherapist
and/or a remedial therapist. Manual lymph drainage in
connection with serious lymphoedema may also be
performed by a dermatologist. For insured parties who are
entitled, on the grounds of the Zorg Plan, to a reimbursement
of physiotherapy or remedial therapy, the reimbursement
28
Condition
Art. 14 Exercise programmes
We reimburse the costs of treatment by a physiotherapist
and/or a remedial therapist. An exercise programme is
intended for people whose illness or complaint means they
should exercise more, but who are unable to do so. During the
exercise programme a physiotherapist and/or remedial
therapist teaches you how to move independently so that
you can continue the exercise after the programme has
finished. The reimbursement applies to insured parties with
obesity (BMI >30), rehabilitating insured parties who have
suffered heart failure, insured parties with rheumatism (as
defined by the Reumafonds), patients with type 2 diabetes
and patients with COPD with a light to medium burden of
disease with a lung function value of FEV1/VC < 0.7, a
dyspnoea score of >2 on the MRC scale and a health score of
>1 to >1,7 on the CCQ scale.
Conditions
•
•
•
medical specialist.
The exercise programme must take place in the exercise
room of the physiotherapist and/or remedial therapist
providing the treatment.
The exercise programme must last at least 3 months.
calendar year
calendar year
calendar year
calendar year
Art. 15 Exercising in extra heated water
We reimburse insured parties with rheumatism the costs of
remedial therapy in extra heated water in a swimming pool.
Conditions
• You must submit a one-off doctor’s certificate from a GP
or medical specialist which shows that remedial therapy
in extra heated water is necessary in connection with
rheumatism.
• The remedial therapy must take place in a group and
under the responsibility of a physiotherapist or remedial
therapist.
Start
no cover
calendar year
calendar year
Excellent 100%
Art. 16 Stutter therapy
We reimburse the costs of stutter therapy:
• according to the method of the Del Ferro institute in
Amsterdam;
• according to the Hausdörfer method used by the
Natuurlijk Spreken institute in Deurningen;
• according to the BOMA method used by the De Pauw
institute in Harlingen;
Condition
You must have been referred by a GP, medical specialist or
dentist.
Starta maximum of € 225.00 per insured party for the
Royaala maximum of € 1,000.00 per insured party for the
Excellenta maximum of € 1,250.00 per insured party for the
rt. 17 Nursing articles
A
17.1 Hearing aids
17.1.1 Statutory personal contribution for hearing aids
We reimburse the statutory personal contribution for a
hearing aid.
Condition
You must be entitled to reimbursement via the Zorg Plan
(Article 30, Nursing Articles).
Start
no cover
Extra
no cover
calendar year
device
17.1.2 Hearing aid with remote control
We reimburse the personal contribution of a hearing aid with
remote control.
Conditions
•
•
•
The remote control must be issued on medical grounds.
Start
no cover
Extra
a maximum of € 185.00 per device
Royaal a maximum of € 185.00 per device
Excellent a maximum of € 230.00 per device
17.2 Wigs
17.2.1 Personal contribution for wigs (Start, Extra and Royaal)
Supplementary to the statutory maximum reimbursement of
a wig via the Zorg Plan you are entitled to an extra
reimbursement.
Condition
Start
no cover
calendar year
calendar year
17.2.2 Personal contribution for wigs (Excellent)
A reimbursement will be paid for the costs of a wig to a
maximum of € 493.00, including the reimbursement on the
basis of the Zorg Plan. Further reimbursement is only possible
if the insured party is unable to wear the wig in connection
with a demonstrable allergic disorder of the scalp.
In that case, the insured party will submit to Avéro Achmea a
written explanation with arguments from the prescribing
doctor prior to the purchase of the wig. Avéro Achmea
determines whether, and if so to what extent, any additional
reimbursement applies.
Avéro Achmea will pay an additional reimbursement if it
ascertains that a wig costing a maximum of € 493.00 does not
suffice.
Conditions
•
•
Excellent€ 100.00 per insured party per calendar year, extra
reimbursement is possible in the event of a
demonstrable allergic disorder
17.3 Head covering in the case of oncology
We reimburse the costs of a head covering pair in the event of
(temporary) hair loss due to chemotherapy
Condition
You must be able to submit details of the medical grounds
from a GP or medical specialist which show that you have
suffered hair loss in connection with chemotherapy.
Exclusion
We do not reimburse the costs of purchasing a wig on the
grounds of this article.
Start
no cover
calendar year
calendar year
calendar year
17.4 Personal contribution for other nursing articles
Supplementary to the statutory maximum reimbursements,
or as a reimbursement of the statutory personal contributions
of nursing articles via the (Avéro) Achmea Reglement
Hulpmiddelen [Achmea Nursing Articles Regulations] you are
entitled to an extra reimbursement.
Condition
Exclusion
We do not reimburse the costs of the statutory savings
contribution for orthopaedic shoes and allergy-free shoes.
Start
no cover
Extra
no cover
calendar year
Excellent 100%
17.5 Personal alarms on medical grounds
17.5.1 Alarm system via Eurocross Assistance
We reimburse the subscription costs relating to the use of an
alarm system via Eurocross Assistance.
Condition
You must be entitled, on medical grounds, to reimbursement
29
of the personal alarm unit via the Zorg Plan (Article 30,
Nursing articles).
Start
100%
Extra
100%
Royaal 100%
Excellent 100%
17.5.2 Alarm system via an emergency centre other than Eurocross
Assistance
alarm system via an emergency centre other than Eurocross
Assistance.
Conditions
•
•
You must be entitled, on medical grounds, to
reimbursement of the alarm equipment via the Zorg Plan
(Article 30, Nursing articles).
We must have given you permission beforehand. You can
arrange this by contacting the Nursing Articles Line on
071 - 751 00 77.
Start
a maximum of € 35.00 per calendar year
Extra
a maximum of € 35.00 per calendar year
Royaal a maximum of € 35.00 per calendar year
Excellent a maximum of € 35.00 per calendar year
17.6 Personal alarms on social grounds
17.6.1 Alarm system via Eurocross Assistance
We reimburse the costs relating to the use of an alarm system
via Eurocross Assistance.
Condition
We reimburse the costs on social grounds in accordance with
the Eurocross Assistance protocol.
Start
no cover
Extra
no cover
Royaal no cover
Excellent 100%
17.6.2 Alarm system via an emergency centre other than Eurocross
Assistance
alarm system via an emergency centre other than Eurocross
Assistance.
Conditions
•
•
We reimburse the costs on social grounds in accordance
with the Eurocross Assistance protocol.
We must have given you permission beforehand. You can
arrange this by contacting the Nursing Articles Line on
071 - 751 00 77.
Start
no cover
Extra
no cover
Royaal no cover
Excellent a maximum of € 35.00 per calendar year
17.7 Breast prosthesis adhesive strips
We reimburse the costs of adhesive strips used to attach of
external breast prostheses following a mastectomy.
Start
100%
Extra
100%
Royaal 100%
Excellent 100%
17.8 Incontinence alarm
We reimburse the costs of purchasing or hiring an
incontinence alarm. We also reimburse the costs of the
accompanying briefs.
Royaala maximum of € 100.00 per insured party for the
Excellent 100%
17.9 Glasses and contact lenses
We reimburse the costs of prescription glasses or contact
lenses (prescription lenses or extended wear contact lenses)
per period of 3 calendar years. A period covers entire calendar
years of 1 January to 31 December and starts in the year in
which they are first purchased.
Condition
The glasses and contact lenses must have been supplied by an
optician or optics business.
period of 3 calendar years for glasses and contact
lenses together
30
lenses together
lenses together
lenses together
Discount scheme at Eye Wish, Specsavers and the Collectief
van Zelfstandige Opticiens (CvZO)
In addition to the above reimbursement, all insured parties
with a supplementary insurance policy are eligible for a
discount scheme, upon production of their care pass, at Eye
Wish, Specsavers and the Collectief van Zelfstandige Opticiens
(CvZO). You can find information about the discount schemes
on our website or obtain the information from the opticians.
17.10 Support pessary
We reimburse the costs of a support pessary supplied by a GP
to prevent or assist in the event of a prolapse of the womb.
Start
no cover
Extra
100%
Royaal 100%
Excellent 100%
17.11 Transtherapy
We reimburse the costs of hiring the transtherapy equipment
for the treatment of incontinence.
Conditions
•
•
You have to have been referred by a doctor, a pelvic floor
physiotherapist or an incontinence nurse.
The equipment must be supplied by a nursing articles
supplier.
Start
100%
Extra
100%
Royaal 100%
Excellent 100%
17.12 Nanny Care baby sensor mat
We reimburse the NannyCare baby sensor mat. You should
contact NannyCare directly.
Start
Extra
Royaal
Excellent
100%
100%
100%
100%
Art. 18 TENS during childbirth
We reimburse female insured parties the costs of a TENS for
pain control during childbirth administered by a midwife or GP
acting as a midwife.
Condition
The equipment must be supplied by a supplier selected by us.
You can find the details of the suppliers we have selected via
the Care Finder on our website or we will send you them on
request.
Start1 device for the entire duration of the
supplementary insurance policy
Extra1 device for the entire duration of the
Royaal1 device for the entire duration of the
Excellent1 device for the entire duration of the
Art. 19 Personal contribution for childbirth and obstetrical care
We reimburse to female insured parties the costs of the
(statutory) personal contribution charged on the basis of the
Zorg Plan in the event of outpatient childbirth without
medical grounds by a midwife or GP.
Start
Extra
Royaal
Excellent
100% of the (statutory) personal contribution
rt. 20 Maternity care
A
20.1 Personal contribution for parturition assistance
statutory personal contribution charged on the basis of the
Zorg Plan for parturition assistance (hours that the midwife is
present during the childbirth).
Start
Extra
Royaal
Excellent
100% of the statutory personal contribution
20.2 Personal contribution for maternity care at home or in a birth
centre
Zorg Plan for maternity care (at home or in a birth centre).
Starta maximum of 24 hours of the statutory personal
contribution per pregnancy
Extraa maximum of 24 hours of the statutory personal
contribution per pregnancy
Royaal100% of the statutory personal contribution
Excellent100% of the statutory personal contribution
20.3 Personal contribution for maternity care in a hospital without
medical grounds
Zorg Plan for maternity care in a hospital without medical
grounds.
Start
no cover
Extra
no cover
Royaal 100% of the statutory personal contribution
Excellent 100% of the statutory personal contribution
20.4 Postponed maternity care
We reimburse to female insured parties the costs of
postponed maternity care provided by a maternity centre:
Condition
The maternity centre must regard the postponed maternity
care as medically essential.
Start
no cover
Extraa maximum of 15 hours per pregnancy, personal
payment € 4.00 per hour
Royaala maximum of 15 hours per pregnancy (no personal
payment)
Excellenta maximum of 15 hours per pregnancy (no personal
payment)
Art. 21 Maternity pack
We will send female policyholders a maternity pack to their
home address well before the due date.
Condition
You must apply for the maternity pack at least 2 months
before the expected due date.
Start
Extra Royaal
Excellent
100%
100%
100%
100%
Art. 22 Pregnancy course
We reimburse to female insured parties the costs of attending
courses:
• during the pregnancy in preparation of the birth and
supervision during the birth;
• to encourage the physical recovery, up to a maximum of
six months after the birth.
Conditions
• You must submit to us an original proof of registration
and payment.
• The courses must be given by:
-- a home care institution;
-- a qualified care provider that is affiliated to, and fulfils
the quality requirements of, the Samen Bevallen
association;
-- a physiotherapist, Cesar/Mensendieck remedial
therapist;
-- a care provider qualified in hypnobirthing;
-- a qualified care provider that is affiliated to Zwanger
en Fit;
-- a care provider that is qualified in psychoprophylaxis
(to combat fear of childbirth);
-- Mom in Balance.
Start
Extra
Royaal
Excellent
€ 50.00 per person per pregnancy
Art. 23 Breastfeeding assistance
We reimburse to female insured parties with breastfeeding
problems the costs of help and advice provided by a
breastfeeding expert.
Condition
The breastfeeding expert must be affiliated to the Nederlandse
Vereniging van Lactatiekundigen [Netherlands Association of
Lactation Consultants] (NVL) or fulfil the relevant quality
requirements of the NVL or be employed by a maternity centre.
Start
no cover
calendar year
calendar year
calendar year
Art. 24 Maternity care for adopted children or medical screening in
the event of adoption
After one or more children, who have been legally adopted
during the term of the supplementary insurance, have been
registered with us in the Zorg Plan, we reimburse the costs of:
• maternity care provided by a maternity centre or
• medical screening (preventive examination) in the case of
a child adopted from abroad.
Conditions
• In the case of maternity care, the adopted child must be
younger than 12 months at the time of adoption and not
already be a member of the family in question.
• The medical screening has to be carried out by a
paediatrician.
• The medical screening must be an obligatory part of the
adoption process.
Exclusion
We do not reimburse the costs of medical screening of the
adopted child after the adoption has taken place.
Startmaternity care for adopted babies: a maximum of 3
days for 3 hours a day or a medical screening upon
adoption: to a maximum of € 300.00 per adopted
child
Extramaternity care for adopted babies: a maximum of 3
child
Royaalmaternity care for adopted babies: a maximum of 3
child
Excellentmaternity care for adopted babies: a maximum of 3
child
rt. 25 Patient transport
A
25.1 Travel costs
We reimburse the costs of seated patient transport if and in
so far as the use of public transport is impossible on medical
grounds. The reimbursement applies to insured parties that
are not entitled to a travel reimbursement on the basis of
Article 35 of the Zorg Plan. We reimburse the costs of
transport by taxi or by your own car both to and from.
• a hospital or obstetric clinic for admission;
• a hospital for outpatient treatment or examination at the
request of a medical specialist;
• the location at which the medical specialist providing the
treatment has his practice;
• an orthopaedic instrument maker for the adaptation of a
prosthesis;
• an institution to which you are admitted and/or treated
on the basis of the AWBZ.
If you cross a border from the Netherlands to Belgium or
Germany we reimburse the above-mentioned costs of seated
patient transport if the treatment takes place at a maximum
of 55 kilometres from the border. In the event of a hospital
31
admission via our care mediation department, reimbursement
is possible in accordance with Article 26.2.
Conditions
•
•
•
25.2
We must have given you permission beforehand via the
Vervoerslijn [Travel Line]. The staff of the Vervoerslijn
determine whether you are entitled to reimbursement of
the costs of transport and which form of transport you
can claim. The telephone number of the Vervoerslijn is
071 - 365 41 54. Information on patient transport can be
found in the brochure entitled ‘Vevoer’ [Travel] which we
will send to you on request or which you can download
from our website.
The transport must be linked to care reimbursed via the
Zorg Plan, the AWBZ or your supplementary insurance.
For the Extra package you must be treated at the closest
location at which the required care can be supplied unless
agreed otherwise with us. The distance to the care
provider must not exceed 200 kilometres, unless agreed
otherwise with us.
Start
no cover
Extraown vehicle € 0.31 per km; transport by taxi: 100%.
After payment of a personal contribution of € 95.00
per insured party per calendar year, a
reimbursement will be available of the costs of
travel by your own vehicle and by taxi to a
maximum of € 1,000.00 per insured party per
calendar year. This personal contribution is not
payable if the maximum has been reached of the
statutory personal contribution for seated patient
transport on the basis of the Zorg Plan.
Royaal own vehicle € 0.31 per km; transport by taxi: 100%
Excellent own vehicle € 0.31 per km; transport by taxi: 100%
Personal contribution for travel costs
We reimburse the statutory personal contribution you are
required to pay in conjunction with a reimbursement of
transport via the Zorg Plan.
Start
Extra
Royaal
Excellent
no cover
no cover
100%
100%
Travel costs in the context of care mediation abroad
We reimburse the costs of transport from the Netherlands in
the event of hospital admission arranged via our care
mediation department in a care institution in Belgium or
Germany and the costs of the return journey to the
Netherlands. We reimburse the costs of transport by taxi, by
your own car and public transport.
Conditions
•
•
•
You have to submit to us a specification of the costs
incurred.
A waiting time reduction has to apply.
We must have given you permission beforehand via the
Vervoerslijn [Travel Line]. The staff of the Vervoerslijn
determine whether you are entitled to reimbursement of
the costs of transport and which form of transport you
can claim. The telephone number of the Vervoerslijn is
071 - 365 41 54. Information on patient transport can be
found in the brochure entitled ‘Vevoer’ [Travel] which we
will send to you on request or which you can download
from our website.
Starttransport by taxi 100%; public transport (lowest
class) 100%; own vehicle € 0.31 per km
Extratransport by taxi 100%; public transport (lowest
Royaaltransport by taxi 100%; public transport (lowest
Excellenttransport by taxi 100%; public transport (lowest
26.3 Accommodation and travel costs incurred by family members
in the event of care mediation abroad
If you are admitted for care to a foreign care institution on the
grounds of Article 7.2 of the general terms and conditions of
the supplementary insurance policies, we reimburse the
following for your family members, in the event of admission
for more than 14 days per calendar year, as from the 15th day
of admission:
• the accommodation costs in a guest house located in the
vicinity of the hospital;
• a kilometre reimbursement in the event of transport by
one’s own car from and to the hospital.
Condition
You have to submit to us a specification of the costs incurred.
rt. 26 International
A
26.1 Emergency care
We reimburse the costs of emergency medical care during a
stay abroad for holiday, study or business purposes in a
country other than the country of residence. We only
reimburse the costs in the event of care that was not to be
foreseen at the time of the departure for abroad and that
could not be postponed until after the return to the country
of residence. The situation has to be acute and the result of an
accident or illness whereby medical care is immediately
necessary. For insured parties who are entitled, on the
grounds of the Zorg Plan, to a reimbursement of emergency
care abroad, the reimbursement applies as a supplement to
the reimbursement available via this policy.
The following costs qualify for reimbursement:
• treatment by a GP, company doctor or medical specialist.
• hospital admission and operation;
• treatment examinations and medicines and dressings
prescribed by a GP;
• medically essential patient transport by ambulance to and
from the closest doctor and/or the closest hospital;
• dental treatment for insured parties aged up to 18.
Conditions
• The costs are only reimbursed if they would also have
been reimbursed in the Netherlands via the Zorg Plan.
• You must notify us immediately of any hospital admission
via Eurocross Assistance.
• We only reimburse dental care for insured parties aged 18
and over if you have supplementary dental insurance. The
costs are covered by this dental insurance.
Startsupplement to the cost price, in the event of a
maximum continuous stay of 12 months
Extrasupplement to the cost price, in the event of a
Royaalsupplement to the cost price, in the event of a
Excellentsupplement to the cost price, in the event of a
32
26.2
Startaccommodation costs: a maximum of € 35.00 per
day for all family members together; own vehicle,
public transport or transport by taxi: € 0.31 per
kilometre, a maximum reimbursement for 700
kilometres per admission
Extraaccommodation costs: a maximum of € 35.00 per
Royaalaccommodation costs: a maximum of € 35.00 per
Excellentaccommodation costs: a maximum of € 35.00 per
Art. 27 Repatriation of insured party and transport of human
remains to the Netherlands
• medically essential patient transport by ambulance or
aeroplane from a location abroad to the Netherlands;
• transport of the human remains from the place of death
to the place of residence in the Netherlands.
Conditions
• The patient transport is the result of emergency care
abroad.
• Eurocross Assistance must have granted permission
beforehand.
Start
Extra Royaal
Excellent
100%
100%
100%
100%
Art. 28 Vaccinations and medicine in connection with travelling
abroad
We reimburse the costs of consultations, medicine and
vaccinations for the prevention of the following diseases when
making a trip abroad:
• malaria;
• diphtheria, tetanus and poliomyelitis (DTP);
• yellow fever;
• typhoid;
• cholera (or a declaration/cholera stamp that reads
‘cholera not indicated’);
• rabies;
• Früh Sommer Meningo Encephalitis (Lyme disease);
• hepatitis A/B.
These medicines and vaccinations are subject to the
maximum reimbursements set by us.
Conditions
Consultations, medicines and vaccinations to prevent rabies
are only eligible for reimbursement if you have stayed for a
long period of time in a country where rabies is endemic and
where there is also poor access to adequate medical
assistance. In addition, at least one of the following conditions
has to be fulfilled:
• you go on a walking or cycling tour lasting several days
outside tourist areas;
• you spend more than 3 months with or stay overnight
with the local population;
• you stay outside a resort or protected environment;
• you are younger than 12 years old.
Startconsultations and vaccinations at branches of
Meditel and the Travel Clinics of Achmea Vitale in
Eindhoven and Voorburg: 100%
medicines to prevent malaria if supplied via eFarma:
100%, or consultations, vaccinations
and medicines from other care providers:
a maximum of € 75.00 per insured party per
calendar year
Extraconsultations and vaccinations at branches of
100%, or consultations, vaccinations and medicines
from other care providers:
calendar year
Royaalconsultations and vaccinations at branches of
100%, or consultations, vaccinations and medicines
from other care providers:
calendar year
Excellent 100%
Art. 29 Convalescent homes
We reimburse the costs of a stay at a convalescence home for
somatic health care selected by us. You can find the details of the
convalescence home we have selected via the Care Finder on our
website or we will send you them on request.
Condition
Exclusion
We do not reimburse the costs of treatment within the
framework of psychosomatic health care.
Start
no cover
Extra
no cover
Royaala maximum of € 50.00 per day to a maximum of 28
days per calendar year
Excellent a maximum of 48 days per calendar year
rt. 30 Therapeutic camps
A
30.1 Therapeutic holiday camp for children
For children aged up to 18 we reimburse the costs of staying
in a therapeutic holiday camp organised by:
• Stichting Lekker Vel;
• Stichting de Luchtballon for asthmatic children;
• Diabetes Jeugdvereniging Nederland;
• Stichting Kinderoncologische Vakantiekampen;
• Stichting de Ster (Sterkamp and Maankamp);
•
•
Nederlandse Hartstichting [Netherlands Heart
Foundation] (Jump);
Bas van Goor Foundation (sport camps for diabetics).
Start
no cover
calendar year
calendar year
calendar year
30.2 Therapeutic holiday camp for handicapped people
We reimburse insured parties who are handicapped the costs
of staying in a therapeutic holiday camp.
Start
no cover
calendar year Royaal a maximum of € 250.00 per
insured party per calendar year Excellent a
calendar year
Art. 31 Herstel en Balans [Recovery and Balance]
We reimburse the costs of participation in the Herstel en
Balans rehabilitation programme for ex-cancer patients
provided by institutions licensed by the Stichting Herstel en
Balans [Recovery and Balance Foundation]. The Herstel en
Balans rehabilitation programme is a group programme
consisting of physical training and psycho-education.
Condition
medical specialist.
Extraa maximum of € 1,000.00 per insured party for the
Art. 32 Podotherapie/podologie/podoposturale therapie/
steunzolen
32.1 Podiatric therapy/podology/podopostural therapy/support soles
We reimburse the costs of treatment by a podiatrist,
podologist or podopostural therapist and a pair of support
soles. In addition to the consultations, the costs of measuring,
manufacturing, delivering and repair of podotherapeutic or
podological soles and orthoses are also included in the
treatment.
Conditions
• We only reimburse the costs of a podiatrist if you have
been referred by a doctor.
• The podiatrist providing the treatment must be registered
as a B Podiatrist with the Stichting Landelijk
Overkoepelend Orgaan voor de Podologie (LOOP) or fulfil
the relevant quality requirements of the Stichting LOOP.
• The podopostural therapist providing the treatment must
be affiliated to the Omni Podo Genootschap professional
association.
• The support soles must have been supplied or repaired by
a support sole supplier that is affiliated to a Dutch
association of professional support sole suppliers or that
fulfils the quality requirements of the relevant
professional association.
Exceptions
• We do not reimburse the costs of shoes and shoe
adaptations.
• We do not reimburse the costs of foot examinations and
treatment in connection with diabetic feet (Simm’s 1
classification and higher). This treatment is covered by the
entitlement of the Zorg Plan (see Article 29).
Start
no cover
calendar year
calendar year
Excellent 100%
33
rt. 33 Chiropodist care
A
33.1 We reimburse the costs of foot care provided by a chiropodist for
insured parties with rheumatism or diabetes.
Conditions
• You must submit to us a one-off doctor’s certificate from
a GP, medical specialist or diabetes nurse which shows
that foot care in extra heated water is necessary in
connection with diabetes or rheumatism.
• The chiropodist must be registered with the Diabetische
voet [Diabetic Foot] and/or Reumatische voet [Rheumatic
Foot] (RV) qualification, or as a medical chiropodist in the
ProCert KwaliteitsRegister voor Pedicures [Chiropodist
Quality Register] (KRP);.
• Chiropodists (in the care sector) must be registered in the
Stipezo Register Paramedische Voetzorg [Paramedic
Footcare Register] (RPV) quality register.
• The care provider must state the diabetes type (1 or 2)
and the Simm’s classification on the bill. The bill must also
show that the chiropodist in question is registered in the
ProCert or RPV registers.
Exclusion
We do not reimburse the costs of foot examinations and
treatment in connection with diabetic feet (Simm’s 1
classification and higher). This treatment is covered by the
entitlement of the Zorg Plan (see Articles 22 and 29).
Start
no cover
Extraa maximum of € 23.00 per appointment to a
calendar year
Royaala maximum of € 25.00 per appointment to a
calendar year
Excellent 100%
33.2 We reimburse the costs of foot care provided by a chiropodist for
insured parties with a cerebral infarction (CVA).
Conditions
•
•
The chiropodist must be registered as a medical
chiropodist in the ProCert KwaliteitsRegister voor
Pedicures [Chiropodist Quality Register] (KRP);
You must submit to us a one-off doctor’s certificate from
a GP or medical specialist which shows that foot care in
connection with a cerebral infarction (CVA).
Start
Extra
Royaal
Excellent
no cover
no cover
no cover
100%
Art. 34 Skin care
• acne treatment (in the face) by a beautician or skin
therapist;
• camouflage therapy by a beautician or skin therapist;
• electrical depilation and Intense Pulsed Light (IPL)
treatment by a beautician or dermatologist or laser
depilation treatment by a dermatologist in the case of
women with seriously disfiguring facial hair.
Conditions
• You must have been referred by a GP, or a medical
specialist.
• The beautician must be registered with the Algemene
Nederlandse Branche Organisatie Schoonheidsverzorging
(ANBOS) or fulfil the relevant ANBOS quality
requirements.
• Laser depilation must be carried out by a dermatologist.
Exclusion
We do not reimburse the costs of cosmetic resources.
Start
no cover
calendar year
calendar year
Excellent € 1,000.00
Art. 35 Substitute volunteer aid for handicapped people and the
chronically ill
We reimburse to insured parties who are handicapped or
chronically ill and who receive volunteer care at home, the
costs of replacement care if the volunteer care is not available.
34
Conditions
•
•
The care has to be provided by Handen-in-Huis (the Dutch
substitute volunteer care organisation in Bunnik).
Handen-in-huis also processes the application. The direct
contact telephone number is 030 - 659 09 70
The care must be applied for 8 weeks in advance.
Start
no cover
Extraa maximum of 21 days per insured party per
calendar year
Royaala maximum of 21 days per insured party per
calendar year
Excellent 100%
Art. 36 Hotels, bungalow or sailing holidays for handicapped people
and the chronically ill
We provide insured parties who are handicapped or
chronically ill with a contribution towards the costs of a hotel,
bungalow or sailing holiday organised by the Nederlandse
Rode Kruis [Dutch Red Cross] or the Zonnebloem organisation.
Conditions
• The holiday coordinator of the Dutch Red Cross or the
Zonnebloem organisation conducts an intake with the
chronically ill or handicapped person and determines
eligibility on the basis of the illness or the handicap and
previous participation.
• The ship J. Henry Dunant, which is owned by the
Nederlandse Rode Kruis [Dutch Red Cross], and the
Zonnebloem organisation’s vessel are used for the sailing
holidays.
• The hotel holidays of the Dutch Red Cross (IJsselvliedt in
Wezep and De Valkenberg and De Paardestal in Rheden)
are used for the hotel holidays.
• The Rode Kruis Bungalow in Someren is used for the
bungalow holidays.
Start
no cover
Extrasailing holiday: a contribution of 25% towards the
costs on the basis of the rates applied by the
Nederlandse Rode Kruis [Dutch Red Cross] or the
Zonnebloem organisation: hotel or bungalow
holiday: a contribution of 25% towards the costs on
the basis of the rates applied by the Nederlandse
Rode Kruis
Royaalsailing holiday: a contribution of 25% towards the
Rode Kruis
Excellentsailing holiday: a contribution of 25% towards the
Rode Kruis
rt. 37 Preventive examinations
A
37.1 Preventive examinations
We reimburse the costs of an examination by a GP or medical
specialist with a view to the early detection of:
• cervical cancer (pap smear);
• breast cancer;
• heart and vascular diseases
• prostate cancer
Conditions
• The examination must be performed by a GP or medical
specialist who works in a hospital or independent
treatment centre.
• The examination has to be permissible in accordance with
the applicable legislation.
Exclusion
We do not reimburse the costs of population screening for
which the necessary licence has not been issued. Such a
licence is necessary in conjunction with population screening
for breast cancer, cervical cancer and prostate cancer.
Start
Extra
100%
100%
Royaal 100%
Excellent 100%
37.2 Periodic general examination (preventive examinations)
Royaal and Excellent
We reimburse a periodic general examination (check-up) by a
GP or medical specialist limited to the maximum rate for a
major general check-up by a GP (no more than once every two
years).
•
Conditions
•
•
The examination must be performed by a GP or medical
specialist who works in a hospital or independent
treatment centre.
The examination has to be permissible in accordance with
the applicable legislation.
Start
Extra
Royaal
Excellent
•
•
no cover
no cover
once per two years
once per two years
•
Art. 38 Mamma Print
We reimburse the costs of a Mamma Print. In some cases a
Mamma Print can help the doctor providing the treatment to
make a better diagnosis and thereby determine whether
chemotherapy is, or is not, necessary.
Condition
The examination has to be carried out by the Agendia
laboratory.
Start
Extra Royaal
Excellent
•
•
100%
100%
100%
100%
•
rt. 39 Lifestyle interventions
A
39.1 Dietary advice by a dietician
We reimburse the costs of dietary advice by a dietician.
Dietary advice covers information and advising in the field of
diet and eating habits with a medical goal. For insured parties
who are entitled to dietary advice on the grounds of the Zorg
Plan, the reimbursement applies as a supplement to the
entitlement available via this policy.
Exclusion
For the same diagnosis we do not reimburse both the costs of
dietary advice and nutritional information (Article 39.2).
Start
no cover
Extra
no cover
Royaal no cover
calendar year
39.2 Nutritional information by a weight consultant or a dietician
We reimburse the costs of nutritional information by a weight
consultant or a dietician. Nutritional information covers
information and advising in the field of diet and eating habits
without a medical goal.
•
Condition
You must submit to us an original proof of registration and
payment.
Start75% to a maximum of € 115.00 per course per
insured party per calendar year
Extra75% to a maximum of € 115.00 per course per
Royaal75% to a maximum of € 115.00 per course per
Excellent 100%
39.3.1 (Preventive) courses
Supplementary to Article 36.3 we reimburse the costs of the
following (preventive) courses:
• a course and/or training in preventing falls organised by a
home care institution.
• exercise programmes for elderly people organised by a
home care institution or Pim Mulier;
• memory training organised by a home care institution.
Condition
Condition
The weight consultation must be affiliated to the
Beroepsvereniging Gewichtsconsulenten Nederland
[Netherlands Association of Professional Weight Consultants]
or fulfil the quality requirements of this association.
Exceptions
•
•
We do not reimburse the costs of nutritional information
group treatment by a weight consultant.
We do not reimburse the costs of nutritional information
and dietary advice for the same diagnosis (Article 39.1).
Start
no cover
Extra
no cover
Royaal no cover
calendar year
39.3 (Preventive) courses
We reimburse the costs of the following (preventive) courses:
• heart problems, course designed to help patients learn to
cope with heart problems, organised by a home care
institution;
• lymphoedema, awareness and/or self-management
course designed to make an active contribution to
preventing, identifying and/or treating lymphoedema.
The course has to be organised by an authorised teacher
who has completed a course for self-management
teachers in conjunction with lymphoedema at the
Stichting Lymfologie Centrum Nederland [Netherlands
Lymphology Centre Foundation] (SLCN). You can find a list
of authorised teachers on our website, or we can send it
to you on request.
rheumatoid arthritis, arthrosis or Bechterew’s disease: a
course intended to teach patients how to cope with their
illness, organised by the Reuma Patiëntenbond
[Association of Rheumatoid Arthritis Sufferers] or a home
care institution;
type 2 diabetes patients: a basic or follow-up course
organised by Diabetes Vereniging Nederland (DVN) or a
home care institution;
losing weight, organised by a home care institution, one
of the written and online programmes organised by
Happy Weight or the 10-week nutritional and exercise
programme entitled ‘Afvallen & Afblijven’ as organised by
an Achmea health Center with 1 on 1 nutritional
supervision, personal coaching and group lessons;
stopping smoking, organised by Allen Carr, I Quit Smoking
or a home care institution and laser therapists at Prostop
Lasertherapie, Lasercentrum SMOKE FREE and Lasercentra
Noord – Oost Nederland;
basic first aid resuscitation course via the Nederlandse
Hartstichting [Netherlands Heart Foundation];
first aid, which leads to the ‘Eerste Hulp’ (First Aid)
diploma issued by Oranje Kruis or the ‘Eerste Hulp’ (First
Aid) certificate issued by the Red Cross, organised by:
-- the local first aid association;
-- Iedereen EHBO (Internet course);
-- the Red Cross;
first aid for children’s accidents, organised by a home care
institution or the local first aid association or the Internet
course entitled EHBO bij kinderen [First Aid and Children]
organised by Iedereen EHBO;
online sleep course, organised by Somnio. This online
sleeping course offers online professional advice and
practical solutions for a better night’s rest.
You must submit to us an original proof of registration and
payment.
Start
no cover
Extra
no cover
Royaal no cover
Excellent 100%
39.4 Menopause consultant
We reimburse the costs of the consultation rate charged by a
menopause consultant.
Condition
The menopause consultant must be affiliated to Care for
Women or theVereniging Verpleegkundig
Overgangsconsulenten [Association of Menopause
Consultants] (VVOC) or fulfil the quality requirements of one
of these organisations.
39.5
Start
no cover
Extra75% of the consultation rate to a maximum of
€ 115.00 per insured party per calendar year
Royaal75% of the consultation rate to a maximum of
Excellent75% of the consultation rate to a maximum of
Lifestyle training sessions
We reimburse the costs of a maximum of one lifestyle training
35
course organised by the Leefstijl Training & Coaching in
Dalfsen for:
• heart patients;
• whiplash patients;
• people with stress and burn-out related problems.
Condition
medical specialist.
Start
no cover
Extraa maximum of € 1,000.00 per insured party per
calendar year
Royaala maximum of € 1,000.00 per insured party per
calendar year
Excellenta maximum of € 1,500.00 per insured party per
calendar year
Art. 40 Sport-medical examination
We reimburse the costs of a sport-medical examination in a
Sport Medical Institution.
Condition
The Sport Medical Institution must be affiliated by the
Federatie van Sportmedische Instellingen [Federation of
Sports Medical Institutions] (FSMI).
Exclusion
We do not reimburse the costs of a(n) (obligatory) sports
examination or sport-medical examination which is
performed by a sports doctor in order to assess the individual
state of health and suitability of the insured party for a
specific sport or for admission to a sport training institute.
Starta maximum of € 100.00 per insured party per 2
calendar years
Extraa maximum of € 100.00 per insured party per 2
calendar years
Royaala maximum of € 150.00 per insured party per 2
calendar years
Excellenta maximum of € 300.00 per insured party per 2
calendar years
Art. 41 Sports doctor
We reimburse the costs of an injury or repeat consultation
with a sports doctor at a Sport Medical institution.
Condition
The Sport Medical Institution must be affiliated by the
Federatie van Sportmedische Instellingen [Federation of
Sports Medical Institutions] (FSMI).
calendar year
calendar year
calendar year
calendar year
Art. 42 Obesity treatment
We reimburse the costs of participation in the part-time
outpatients’ programme for obese patients at the
Nederlandse Obesitas Kliniek [Netherlands Obesity Clinic]
(NOK) or a programme provided by Santrion. The programmes
are intended to change behaviour by means of non-surgical,
multidisciplinary treatment.
Conditions
• The patient must be suffering from grade 3 obesity. This
is the case if the Body Mass Index (BMI) is equal to or
greater than 40.
• We must have given you permission beforehand.
• You must have completed the entire programme.
Start
no cover
36
rt. 43 Orthodontics
A
43.1 Orthodontics up to the age of 18 (Start and Extra)
We reimburse insured parties aged up to 18 the costs of
orthodontics (straightening of the teeth) and a second
opinion. For more information please consult the brochure
request.
Condition
The treatment or second opinion has to be carried out by an
orthodontist or dentist.
Exclusion:
We do not reimburse the costs of repairs or replacements in
the event of loss or damage to existing orthodontic provisions
due to your own fault or negligence.
Start90% to a maximum of € 1,500.00 per insured party
aged up to 18 for the entire duration of the
supplementary insurance.
Extra90% to a maximum of € 2,000.00 per insured party
43.2 Orthodontics up to the age of 22 (Royaal and Excellent)
request.
Condition
The treatment or second opinion has to be carried out by an
orthodontist or dentist.
Exclusion:
Royaal90% to a maximum of € 2,500.00 per insured party
Excellent100% per insured party aged up to 22 for the entire
duration of the supplementary insurance
43.3 Orthodontics for insured parties aged 22 and over
We reimburse insured parties aged 22 or older the costs of
request.
Conditions
•
•
The treatment or second opinion has to be carried out by
an orthodontist or dentist.
Prior to the treatment, you are required to submit the
treatment schedule drawn up by the orthodontist
providing the treatment together with a dental
radiograph, orthopantomogram, digital mouth X-rays
and/or X-rays of tooth models and the ‘Index for
Orthodontic Treatment Need’ (IOTN) for assessment by us
for the attention of the dental advisor. Treatment for
which, in accordance with the score guidelines of the
‘Index for Orthodontic Treatment Need’ (IOTN), no or a
minor need for treatment exists (score 1 or 2) are not
eligible for reimbursement. The orthodontist can provide
you with the relevant information.
Exclusion
Start
no cover
Extra
no cover
Royaal70% to a maximum of € 1,000.00 per insured party
for the entire duration of the supplementary
insurance
Excellent70% to a maximum of € 1,500.00 per insured party
for the entire duration of the supplementary
insurance
Art. 44 Dental care for insured parties aged up to 18
dental treatment. For more information please consult the
brochure entitled ‘Mondzorg’ [Dental care]. You can download
this brochure from our website or we will send it to you on
request.
Condition
The treatment has to be carried out by a dentist or dental
surgeon.
Starta maximum of € 225.00 per person per calendar
year for crowns, bridges, inlays and implants,
including technical costs
Extraa maximum of € 225.00 per person per calendar
year for crowns, bridges, inlays and implants,
including technical costs
Royaal 100%
Excellent 100%
Art. 45 Dental care as a consequence of an accident for insured
parties aged up to 18
We reimburse dental care provided by a dentist or dental
surgeon for insured parties aged 18 and over, provided the
treatment is the consequence of an accident during the
duration of this insurance policy. The treatment must take
place within one year after the accident, unless postponement
of (definitive) treatment is essential as a consequence of the
set of teeth not being fully grown. Our advising dentist will
determine whether the set of teeth is mature and whether
temporary treatment is possible.
Condition
We must have given you permission beforehand. The request
for permission must be accompanied by a treatment schedule
and cost estimate drawn up by your care provider. The
application for permission is assessed for appropriateness and
legitimacy.
Start
no cover
Extra
no cover
Royaal75% to a maximum of € 200.00 per element, and to
a maximum of € 2,500.00 per accident
Excellent75% to a maximum of € 200.00 per element, and to
a maximum of € 2,500.00 per accident
Art. 46 Childcare while the parent(s) is/are in hospital
If a parent, who has insurance with us, is admitted to hospital,
we arrange childcare at home for children aged up to 12 who
live at home from the third day of the admission. The amount
of childcare depends on the age of the youngest child.
Conditions
• We must have given you permission beforehand.
• The childcare must be arranged and provided by a
childcare institution selected by us. If you want to use
childcare, you should contact our Customer Services.
Exclusions:
• We do not reimburse these costs in the event of
admission to a psychiatric hospital.
• We do not reimburse the costs if the number of hours at a
day care centre is increased.
Start
Extra
Royaal
Excellent
a maximum of 50 hours per week
Art. 47 Hospice
We reimburse the personal contributions in connection with a
stay in a hospice on behalf of an insured party if the hospice
participates in the Palliatieve Zorg [Palliative Care] network in
the region and is not part of a health care institution such as a
nursing home, an old people’s home or a home for the elderly.
Exclusion
We do not reimburse the personal contribution which is
charged on the grounds of the AWBZ in connection with a
stay in a hospice.
Start
no cover
Extraa maximum of € 40.00 per day up to a maximum of
€ 3,600.00
Royaala maximum of € 40.00 per day up to a maximum of
€ 3,600.00
Excellenta maximum of € 50.00 per day up to a maximum of
€ 4,500.00
Art. 48 Care Regulator
We reimburse the costs of the support of the Care Regulator
for insured parties with complex care issues relating to the
Zorgverzekeringswet [Health Insurance Act], the Algemene
Wet Bijzondere Ziektekosten [Exceptional Medical Expenses
Act] (AWBZ), the Wet maatschappelijke ondersteuning [Social
Support Act] (Wmo) and accompanying regulatory tasks in the
field of care, work, welfare, living and finances. The right to
reimbursement applies both to insured parties that use the
Care Regulator for their own purposes and insured parties
who are voluntary carers and who use the Care Regulator on
behalf of the person they are caring for.
Conditions
•
The Care Regulator services are covered in so far as these
are not already covered on the grounds of the
Zorgverzekeringswet, the Wmo or de AWBZ.
• The Care Regulator services must be separated from the
services which are part of the existing duty to care of the
health insurer and/or the care office for the insured party
on account of the Zorgverzekeringswet and/or the AWBZ.
In order to be eligible for this reimbursement you must
contact us beforehand on telephone number 0900 - 9500. In
the first instance we will carry out a telephone assessment of
your care issues and, if possible, address them directly.
If we establish that, in connection with the complexity of your
care needs, there is a need for far-reaching support, we will
engage the Care Regulator on your behalf. The entitlement to
the Care Regulator reimbursement starts from the moment of
engagement.
The moment of engagement differs depending on the insured
party and the voluntary carer. For the voluntary carer the
reimbursement starts immediately upon engagement. For the
insured party the reimbursement starts when the support goes
beyond the duty to care referred to in the Zorgverzekeringswet
and the AWBZ. The Care Regulator sets the number of hours
required for the support in consultation with you.
In the case of support within the framework of a personal
budget (PGB) AWBZ and/or Wmo the Care Regulator hours are
only reimbursed on the grounds of this article if and in so far
as these exceed the maximum costs which the budget holder
may use for mediation via the PGB. In this instance the insured
party must contact the relevant care office. The amount that
can be spent on costs of mediation in the context of drawing
up a care agreement and the organisation of the provision of
care can differ per care office.
Start
no cover
Extra
no cover
Royaal no cover
Excellenta maximum of 6 hours support per insured party
per calendar year
Art. 49 Flu vaccination
We reimburse the costs of a flu vaccination up to the age of
60. This vaccination is subject to the maximum
reimbursement set by us.
Exclusion
Vaccination within the framework of the national flu
prevention programme (risk groups) is covered by the AWBZ.
Start
Extra
Royaal
Excellent
no cover
no cover
100%
100%
Art. 50 Health Check
We reimburse the costs of the Health Check (preventive
health assessment) by a care provider we have selected. You
can find the details of the nurses we have selected on our
website or we will send you them on request.
Start
Extra
Royaal
Excellent
no cover
no cover
no cover
100% once per insured party per calendar year
Art. 51 Patient associations
We do not reimburse the membership costs.
Start
no cover
Extra
no cover
Royaala maximum of € 25.00 per membership per insured
party per calendar year Excellent 100%
Excellent 100%
37
Art. 52 Payment in the event of an accident
We provide a reimbursement if, as shown by a statement by a
doctor, as a consequence of an accident which occurs during
the term of this insurance, complete or partial loss or
functional loss is caused of any part, capacity or organ of the
body.
Exclusion
We do not pay in the event of complete loss or functional loss
of dental elements.
Start
Extra
Royaal
Excellent
38
no cover
no cover
€ 250.00 per accident
€ 250.00 per accident
(T Start, T Extra, T Royaal of T Excellent)
We reimburse insured parties aged 18 and over the costs of
dental treatment by a dentist, dental hygienist or a dental
prosthetician.
In the case of a dentist, we reimburse 100% of the costs of
consultations (C codes) and a second opinion, oral hygiene (M
codes), fillings (V codes) and extractions (H codes). Oral
hygiene and small fillings may also be performed by a dental
hygienist if you have been referred by a dentist.
Depending on which treatment you receive, a dental
hygienist can declare both M codes and T codes (periodontic
treatment). If a dental hygienist declares T codes, you will
receive a reimbursement of 75% in the case of a T Start, T
Extra or T Royal policy, with due regard for the total
maximum reimbursement.
We reimburse 75% of the costs of the other treatment to a
maximum of 75% if you have a T Start, T Extra or T Royaal
policy and 100% of the costs if you have a T Excellent policy.
Gum disorders may also be treated by a dental hygienist.
For more information please consult the brochure entitled
‘Mondzorg’ [Dental care]. You can download this brochure
from our website or we will send it to you on request.
The total maximum reimbursement depends on which
package you have.
Exceptions
We do not reimburse the costs of the following forms of
treatment:
• examination reports and dental declarations (C70, C75
and C76)
• missed appointments (C90);
• external bleaching of teeth and molars (E97, E98 and E00);
• Mandibular Advancement Device (MRA) and diagnostics
and related aftercare (G71, G72 en G73);
• orthodontics;
• subscriptions.
T START
• C codes, M codes, V codes and H codes: 100%
• other codes: 75%
• the total reimbursement is a maximum of € 225.00 per
T EXTRA
T Royaal
T EXCELLENT
• all codes: 100%
• the total reimbursement is a maximum of € 1,150.00 per
39
The right to the reimbursement of the insured entitlements
pursuant to the aforementioned supplementary insurance
exists only in the event that this supplementary insurance is
cited on the insurance policy document.
1.1 Comfort facilities in the event of hospital admission
We reimburse the costs of comfort facilities in the event that
an insured party aged 18 or older is admitted to a hospital
nursing ward for longer than 24 hours. The comfort facilities
consist of:
• admission to a 1 or 2 person room which is not necessary
from a medical point of view and
• additional comfort services via contracted hospitals
(depending on the hospital, for example TV connection,
internet, telephone, newspaper or fridge filled with drinks
in the room).
We do not reimburse the costs of comfort facilities in the
event of admission to the rehabilitation ward or psychiatric
ward of a (psychiatric) hospital.
The cover consists of three possible reimbursements:
Hospitals in the Netherlands with which we have made
agreements.
Agreements on extra comfort facilities have been made with
various hospitals in the Netherlands. We reimburse the
relevant costs charged by the hospital. If the comfort facilities
are unavailable, we reimburse € 70.00 per day that you stay in
the hospital (daily fee reimbursement), to a maximum of
€ 4,900.00 per calendar year. We can send you an overview of
the hospitals we have selected for comfort facilities on
request, or you can find it on our website.
Hospitals in the Netherlands with which we have not made
agreements.
If you are admitted to a hospital in the Netherlands with
which we have not made any agreements about extra
comfort facilities, you are entitled to a maximum of € 150.00
per day to compensate the extra costs for a 1 or 2 person
room which the hospital has charged. If the 1 or 2 person
room is unavailable, we reimburse € 70.00 per day that you
stay in the hospital, to a maximum of € 4,900.00 per calendar
year. In both cases there is no entitlement to reimbursement
of additional comfort services.
Comfort facilities in a foreign hospital
If you are admitted to a foreign care institution and undergo
medical treatment there which has been contracted by us, we
will reimburse the extra costs in connection with admission to
a 1 or 2 person room. We will also reimburse the costs of any
fee surcharge. If the 1 or 2 person room is unavailable, we
reimburse € 70.00 per day that you stay in the hospital, to a
maximum of € 4,900.00 per calendar year.
If you are admitted to a foreign care institution and undergo
medical treatment there which has not been contracted by us,
we will reimburse a maximum of € 70.00 per day of the extra
costs which the hospital charged for a 1 or 2 person room to a
maximum of € 4,900.00 per calendar year. Any fee surcharge
does not qualify for reimbursement. There is no entitlement
to reimbursement of additional comfort services. If a daily fee
reimbursement applies in both the Netherlands and abroad, a
maximum reimbursement of € 4,900.00 applies per calendar
year for admission in the Netherlands and abroad jointly.
1.2 Convalescence home
We reimburse the costs of a stay at a convalescence home for
somatic health care selected by us. You can find the details of
the convalescence home we have selected via the Care Finder
on our website or we will send you them on request.
The reimbursement amounts to a maximum of € 100.00 per
day to a maximum of 28 days per insured party per calendar
year.
Condition
40
1.3
Transport by taxi from and to the hospital
We reimburse the costs of transport by taxi on the first and
last day of a stay in hospital in the Netherlands. If you are
accompanied by someone during the journey, his or her
outward and return journey is also reimbursed. We reimburse
a maximum of 4 journeys by taxi per hospital admission.
Services related to the Keuze Zorg Plan
connected with a Dutch-speaking medical expert. The Holiday
Doctor can be contracted from Monday to Friday from 8:00
a.m. to 5:00 p.m.
The following descriptions are of the other entitlements and
services based on the insurance agreement
Art. 1 General contact information
To arrange the services you can call our Customer Services on
telephone number 0900 - 9590 (local rate) or contact us via
our website www.averoachmea.nl/zorgverzekeringen.
Art. 2 Information/questions about your policy details and the
submission of bills
Submit your bills quickly and easily You can get most of your
medical expenses reimbursed via your health insurance. We
usually pay your care provider directly without you being
involved at all.
If you do receive a bill, you can submit your bill to us yourself.
For more information you can call our Customer Services on
telephone number 0900 - 9590 (local rate) or contact us via
our website www.averoachmea.nl/declarerenzorg.
Art. 3 Information/questions about reimbursements
Visit our website www.averoachmea.nl/vergoedingen to find
out exactly:
• how much reimbursement you can receive;
• when you get a reimbursement and when not;
• whether you have to pay any costs;
• what arrangements you have to make;
• who you need to contact.
Here you will also find information about the amount of the
reimbursement in the case of non-contracted care providers.
Of course you can also contact our Customer Services on
telephone number 0900 - 9590 (local rate).
Art. 4 Achmea health Centers
Your tailor-made programme. With the right advice on healthy
exercise, mental relaxation and healthy nutrition we can help
you live healthily according to your own style and tempo. You
receive 20% discount on the regular exercise packages. Surf to
www.achmeahealthcenters.nl for information on the exercise
packages to which the discount applies and for a location
close to your home.
Art. 5 Eurocross Assistance (emergency centre)
If you unexpectedly fall ill during a temporary stay abroad and
require emergency assistance, you should contact the
Eurocross Assistance emergency centre. This is obligatory in
the event that you are admitted to hospital. The staff at the
Eurocross Assistance emergency centre can be contacted day
and night to help if you want to visit a doctor, have to be
admitted to hospital or need advice on a medical problem.
You can contact the help desk 24 hours a day via +31 (0)71 364
18 50. You can count on the following service:
• available 24 hours per day, 365 days per year for advice
and assistance;
• worldwide knowledge of the local health care and quality
of hospitals;
• regular contact with the doctor providing the care abroad
by the medical team at the Eurocross Assistance
emergency centre during the admission;
• supervision until your recovery abroad;
• the organising of medical repatriation if required (if you
have basic insurance with supplementary cover).
Art. 7 Care Regulator
We reimburse the costs of the support of the Care Regulator
for insured parties with complex care issues relating to the
Zorgverzekeringswet [Health Insurance Act], the Algemene
Wet Bijzondere Ziektekosten [Exceptional Medical Expenses
Act] (AWBZ), the Wet maatschappelijke ondersteuning [Social
Support Act] (Wmo) and accompanying regulatory tasks in the
field of care, work, welfare, living and finances. The right to
reimbursement applies both to insured parties that use the
Care Regulator for their own purposes and insured parties
who are voluntary carers and who use the Care Regulator on
behalf of the person they are caring for.
Conditions
The Care Regulator services are covered in so far as these are
not already covered on the grounds of the
Zorgverzekeringswet, the Wmo or de AWBZ.
• The Care Regulator services must be separated from the
services which are part of the existing duty to care of the
health insurer and/or the care office for the insured party
on account of the Zorgverzekeringswet and/or the AWBZ.
In order to be eligible for this reimbursement you must
contact us beforehand on telephone number 0900 - 9500. In
the first instance we will carry out a telephone assessment of
your care issues and, if possible, address them directly. If we
establish that, in connection with the complexity of your care
needs, there is a need for far-reaching support, we will engage
the Care Regulator on your behalf.
The entitlement to the Care Regulator reimbursement starts
from the moment of engagement. The moment of
engagement differs depending on the insured party and the
voluntary carer.
For the voluntary carer the reimbursement starts immediately
upon engagement. For the insured party the reimbursement
starts when the support goes beyond the duty to care referred
to in the Zorgverzekeringswet and the AWBZ. The Care
Regulator sets the number of hours required for the support in
consultation with you.
In the case of support within the framework of a personal
budget (PGB) AWBZ and/or Wmo the Care Regulator hours are
only reimbursed on the grounds of this article if and in so far
as these exceed the maximum costs which the budget holder
may use for mediation via the PGB. In this instance the insured
party must contact the relevant care office. The amount that
can be spent on costs of mediation in the context of drawing
up a care agreement and the organisation of the provision of
care can differ per care office.
You are entitled to a maximum of 6 hours of support per
person per calendar year.
Art. 8
Recourse assistance and/or legal advice
Recourse assistance and/or legal advice can be granted in the
event of:
1. a compensation claim for bodily injury as a consequence
of an accident, from a legally liable third party or the party
that is liable according to civil law.
2. claims for compensation vis-à-vis liable third parties both
on the grounds of an attributable failure and on the
grounds of an unlawful act as a consequence of a medical
activity.
The recourse assistance is provided by an Avéro Achmea
partner organisation and only for occurrences in the
Netherlands. The organisation in question will assess and
determine whether, and if so to what extent, recourse
assistance is to be granted to the insured party. The applicable
scheme (from which no rights can be derived) is not part of
this insurance agreement and will be sent on request by Avéro
Achmea.
Art. 6 Holiday Doctor
Suppose you are on holiday with your family and one of your
children has had stomach ache for the past two days. Should
you contact the local doctor? Or should you wait and see what
happens? If you are in any doubt, you can always contact the
Holiday Doctor.
You can call the Holiday Doctor on telephone number
+31 (0)71 364 18 02 for free advice in the event of nonemergency medical assistance while on holiday. You will be
41
Care mediation
In connection with waiting times for some forms of treatment
in Dutch hospitals, you can make use of our care mediation
service. A team of specialised and qualified staff will then, at
your request, actively search for another health care
institution offering a shorter waiting time. Of course, whether
they are successful and how much time this saves depends on
the situation. However, in by far the majority of cases to date,
Avéro Achmea has managed to find a faster alternative.
Care guarantee
Avéro Achmea issues a care guarantee for a large number of
different types of treatment. This guarantees an initial
consultation for such treatment within five working days. In
addition, Avéro Achmea guarantees that treatment will
actually start within 10 working days, provided the diagnosis
by the medical specialist permits such without any further
diagnosis being required. Insured parties can submit requests
to Avéro Achmea’s Afdeling Zorgbemiddeling [Care Mediation
Department].
42
Disclaimer
This brochure provides general information on reimbursements. The
exact extent of the cover is detailed in the policy terms and conditions.
These can be found at www.averoachmea.nl/zorgverzekeringen.
Privacy
We need personal data to process applications for an insurance policy
or a financial service. This data is used within the Achmea Group to
enter into and implement insurance agreements, to inform you about
relevant products and/or services, to guarantee the security and
integrity of the financial sector, for statistical analyses, customer
relationship management and in order to comply with statutory
obligations. The use of your personal details is subject to the
Gedragscode Verwerking Persoonsgegevens Financiële Instellingen
[Code of Conduct for the Processing of Personal Data by Financial
Institutions]. Health care insurers also have to comply with the
Gedragscode Verwerking Persoonsgegevens Zorgverzekeraars [Code of
Conduct for the Processing of Personal Data by Health Care Insurers]. If
you do not wish to receive information about our products and/or
services, or if you wish to withdraw your permission for the use of your
e-mail address, please write to us at Avéro Achmea, Postbus 1717, 3800
BS Amersfoort. With a view to maintaining a sound acceptance policy,
we are allowed, as the Achmea Group, to consultation details kept at
the Stichting Centraal Informatie Systeem [Central Information System
Board] (CIS) in Zeist. Within that framework, those affiliated to the
Stichting CIS are also allowed to exchange data among themselves. The
aim is to manage the risks and combat fraud. This is subject to the
privacy regulations of the Stichting CIS. More information can be found
at www.stichtingcis.nl.
Applicable law and complaints procedure
The insurance policies are exclusively subject to Dutch law. It goes
without saying that we do our very best to provide you with an optimal
service at all times. Nevertheless, you may still be unhappy about some
aspect of the services we provide. In such instances, you should first
contact your adviser or contact person. If you still feel it is necessary to
submit a complaint, you can do so by e-mail via our websitewww.
averoachmea.nl (under the section klacht doorgeven [‘submit
complaint’]) or in writing to Avéro Achmea, t.a.v. Klachtenbureau Avéro
Achmea, Postbus 2241, 8000 VB Zwolle. If, in your opinion, we do not
manage to solve the problem satisfactorily and if you are a natural
person that is not involved in running a business or engaged in a
profession, you can submit your complaint to the authorised complaints
board to which we are affiliated: Stichting Klachten en Geschillen
Zorgverzekeringen (SKGZ), Postbus 291, 3700 AG Zeist, tel. +31 (0)30 698 83 60, www.skgz.nl.
Information about Avéro Achmea
Avéro Achmea is a provider of insurance products and uses independent
brokers and advisers. Avéro Achmea is a trade name of Achmea
Zorgverzekeringen N.V., which is located in Noordwijk and registered
with the AFM under number 12000647, and of Avéro Achmea
Zorgverzekeringen N.V., which is located in Utrecht and registered with
the AFM under number 12001023. The office of Avéro Achmea is
located on the Van Asch van Wijckstraat 55, 3811 LP Amersfoort, the
Netherlands.
Avéro Achmea has acquired the Klantgericht Verzekeren [Customeroriented Insurance] quality mark. Confidence and certainty are essential
for the quality of services provided in the insurance sector. The
Klantgericht Verzekeren quality mark is issued by the independent
Stichting toetsing verzekeraars [Insurers Assessment Foundation] (Stv).
The quality mark is only awarded to insurers that provide honest
information and dynamic services, are easy to contact, assess customer
satisfaction and use the ensuing results to improve services, and pursue
a consistent quality policy.
43
More Care for private individuals
Basic insurance policies
(Keuze) Zorg Plan (Options) Care Plan
Supplementary insurance policies
Dental insurance policies
T Start, T Extra, T Royaal, T Excellent
3588E-12-11
Specially for young people and students
Juist voor Jou [Just for You]
Specially for 50+
Beter voor Nu [Better for Now]
Comfort nursing
Ziekenhuis Extra [Hospital Extra]

Conditions Commencement date 1 January 2013

Transcription

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