Condições gerais ocidental inglês ago08

GENERAL AND SPECIAL CONDITIONS
Médis Health Plan
Médis Health Plan
GENER AL CONDITIONS
D E F I N I T I O N S
AI M O F PO L I C Y
B AS I S O F I N SU R AN C E
I N SU R ED P ER SO N S
M O D AL I T I E S AN D C O V ER
E XC L U S I O N S
EL I M I N AT I O N P ER I O D
ST AR T D AT E AN D D U R AT I O N O F PO L I C Y
T ER M I N AT I O N O F PO L I C Y
PR EM I U M P AY M E N T
N O N - P AY M E N T O F P R EM I U M
AC C E S S , P R O C E D U R E S AN D C L AI M S ET T L EM EN T
R E S PO N S AB I L I T Y
SU B R O G AT I O N
C H AN G E S T O P O L I C Y T ER M S
C O O R D I N AT I O N O F P AY M E N T S
AR B I T R AT I O N
C O M M U N I C AT I O N AN D N O T I F I C AT I O N
P ER SO N AL D AT A
F O R U M AN D G O V ER N I N G L AW
SPECI AL CONDITIONS
IN-PATIENT MEDICAL CARE
O U T - P AT I E N T M ED I C AL C AR E
D E N T AL AN D D EN T AL M ED I C I N E
M ED I C I N E S
C H I L D B I R T H
PR O ST H ET I C D E V I C E S AN D O R T H O S E S
M ED I C AL C AR E AB R O AD
S ER I O U S I L L N E S S
H O M E AS S I ST AN C E
S EC O N D O P I N I O N N E T W O R K

G E N ER AL C O N D I T I O N S
insurance policy or individual membership. This document is an integral part of the policy and binds all parties – policy holder, C L AU S E 1 - D E F I N I T I O N S
1 . Concepts defined to ensure proper understanding of policy I n d i v i d u a l H e a l t h Q u e s t i o n n a i r e
A range of questions designed to form a clinical and health view by which the insurance company may make a proper risk 1 . 1 . The parties to the health insurance policy: assessment. In completing and signing this form members agree to provide a true and proper statement of their personal state of I n s u r a n c e c o m p a n y
Party legally authorised to conduct insurance business and which agrees an insurance policy with the policy holder. 1 . 4. Amounts referred in the health insurance policy: Exclusive trademarked brand of products developed by Médis - The amount paid by the policy holder to the insurance company in Companhia Portuguesa de Seguros de Saúde, SA, Companhia de exchange for covering the risk described under the insurance Seguros e Resseguros, which manages an in-network healthcare policy. In contributory group insurance policies the premium is insurance system covering health, assistance and accidents, met in full or in part by the insured persons. through policies it issues in its own name or by other authorised The amount the insured person must bear as the first part of each P o l i c y h o l d e r
agreed claim in terms of cover provided and capital sum insured. Person or corporation applying for insurance cover from an The excess is set out in the Specific Conditions/Individual insurance company and agreeing to pay the premiums. C o - p a ym e n t
Person who has completed a membership form and an individual An amount stipulated for each health claim, and always paid by the insured person in terms of the Specific Conditions/Individual Insurance Certificate. Co- payments may be stipulated for specific I n s u r e d p e r s o n
medical treatments where funding restrictions apply, independent Person identified in the Specific Conditions, who holds an of the capital sum insured and available. Individual Insurance Certificate, whose health or physical integrity is hereby insured, and who is entitled to benefits under the policy. I n d e x a t i o n
Amendments to the terms and conditions of the policy, at each H o u s e h o l d
annual renewal, related to capital sum insured and premium, Group of people economically dependent on the policy holder, for based on an index set out under Specific Conditions/Individual individual policies or, for group policies, the member named in the Specific Conditions/Individual Insurance Certificate. C o s t - s h a r i n g a m o u n t s
1 . 2 . Documents that set out terms and conditions and are part of Amounts met by the insurance company under in-network care provision and paid directly to the health care provider, without prejudice to rights to a co-payment contribution from insured G e n e r a l C o n d i t i o n s
Clauses that define and regulate the general terms and common responsibilities under the insurance policy. R e i m b u r s e m e n t a m o u n t s
Out-of-network contribution made directly to the insured person S p e c i a l C o n d i t i o n s
by the insurance company as reimbursement under terms and Clauses defining the benefits applicable under the General restrictions for each annual period, set out in the Specific Conditions/Individual Insurance Certificate and after deducting relevant excess and co-payments. The amount may be Specific Conditions
reimbursed directly to the health care provider when direct billing The specific aspects of each insurance policy as reflected in the Individual Certificate supplied to each household D i r e c t b i l l i n g
By which the insurance company includes authorisation for a The contract between the policy holder and the insurance medical consultation or procedure and agrees to pay related company which includes the agreed General, Special and charges, under terms and up to policy cover maximums Specific Terms and Conditions and all policy endorsements. P o l i c y E n d o r s e m e n t
1 . 5 . H e a l t h i n s u r a n c e p o l i c y b e n e f i t : Changes made to the terms and conditions of the policy. M e m b e r s h i p c o n d i t i o n s
1 . 3 . Subscription to the insurance policy: Established under the Individual Specific Conditions/Individual Insurance Certificate for each insured person, family unit or M é d i s H e a l t h I n s u r a n c e p l a n
Health policy agreed between the insurance company and the policy holder, set out in a policy document, whereby the insurance T h e c o v e r p r o v i d e d b y t h e p o l i c y
company provides the policy holder with access to the Médis Definition of benefits, cover, limitation or exclusion. healthcare provider network, on agreed terms and under certain restrictions, where specific financial criteria are expressly stated, A p p r o v e d P r o v i s i o n
or proven health costs from out-of-network providers are partially Approved provision implies automatic access for the insured person to a network of doctors and health care providers on a supplied list and/or through LinhaMédis, freedom of choice and M é d i s H e a l t h i n s u r a n c e p r o p o s a l
access subject to criteria set out in the Médis Guide, namely Insurer’s document, which is filled out and signed by the policy consultation with a medical practitioner or referral to a medical holder or member (membership form) and provides information specialist or authorisation for doctor visits and procedures. representing the basis on which we agree or decline the
O u t - o f - n e t w o r k
under medical supervision and guidance and which will Benefit involves partial reimbursement of costs incurred from an determine and limit the scope of responsibility of those involved. E x c l u d e d h e a l t h c o s t s
E v e n t / C l a i m
Expenses not recognised under the policy such as those related All and any event likely to activate the cover provided by this to treatments without a medical prescription, acquisition of goods even when medically prescribed, whose use is not entirely therapeutic such as cosmetics, mattresses, chairs, A c c i d e n t
cushions, dehumidifiers, respirators, air conditioning, bicycles, Fortuitous, abnormal and sudden event, attributed to external body-building equipment, hydro massage units, among others. causes, against the will of the insured and provoking bodily Also excluded are all consumer articles whose usefulness is exhausted during their own use, but have no therapeutic purpose or are not objectively justified by medical prescription. Except when expressly stated to the contrary, non-surgical All and any involuntary change in a person’s state of health not prosthetic devices and or thoses are excluded. Co-payment or caused by an accident and diagnosed by a doctor. excess related to any other Médis policy for the same insured person is excluded, up to the limit of the co-payment level of the P r e - e x i s t i n g c o n d i t i o n
Pre-existing conditions excluded from cover are any illness or lesions of which the insured person was aware or should have I n d i v i d u a l p o l i c y
been aware, prior to the date on which the policy was signed, as Individual policy cover which may include cover for a household a result of having undergone a clinical assessment, doctor’s visit and/or prior treatment and where signs or symptoms were G r o u p p o l i c y
A policy covering a group of people associated with each other C o n g e n i t a l i l l n e s s
and the policy holder through some link or common interest. An illness existing at birth caused by hereditary factors or conditions arised during pregnancy and up to the moment of C o n t r i b u t o r y g r o u p p o l i c y
birth. Congenital illness may be evident or recognised Group policy where insured persons contribute in whole or in immediately after birth or discovered much later during the life of the person without prejudice to its nature. N o n - c o n t r i b u t o r y g r o u p p o l i c y
E l i m i n a t i o n p e r i o d
Group Insurance where the policy holder is entirely responsible The time that must elapse between the start date of the cover or membership when this is under a group policy, before benefit I n s u r a b l e g r o u p
A group of people associated with each other and the policy H e a l t h C a r e P r o v i d e r
holder through some link or common interest other than that of A legally registered body operating within the Médis network offering health care services, supplying health care resources or goods for contracted purposes namely doctors, health clinics 1.6. Médis network system of managed healthcare M é d i s n e t w o r k s ys t e m o f m a n a g e d h e a l t h c a r e
An organisation which channels direct funding via an approved A graduate of a Faculty of Medicine or a Faculty of Dental network to the insured person and healthcare providers, namely Medicine licensed to practise in Portugal and whose consultant doctors, hospitals, clinics, supplementary diagnostic and s p e c i a l i s t status and membership have been recognised by the Portuguese General Medical Council or General Dental L i n h a M é d i s
Permanent telephone support line enabling an insured person to H e a l t h C a r e U n i t
be directed to the most appropriate health care with a view to Establishment within or without of the National Health Service improving their health and where necessary to telephone advice and legally licensed to provide medical services and other health care. This covers establishments offering in-patients' treatment, recovery wards, general hospitalisation, in and out-patient M é d i s C a r d
services and specialist units for out-patient and supplementary Personal and non transferable card identifying the holder to the insurance company, enabling access to the Healthcare system designation and legal vehicle used, including hospitals, clinics and storing, if the card is so equipped, an electronic record of and supplementary diagnostic and therapeutic centres. medical treatment, consultations and other resources used. M e d i c a l t r e a t m e n t
R e f e r r a l s
Medical treatment provided by a doctor legally licensed by the Request for any referral to a specialist, performance of respective Medical Council and which includes health prevention diagnostic and therapeutic tests within some specialisation when and treatment of illness, rehabilitation of persons treated and expressly indicated by a Médis medical practitioner or other who may refer patients for additional treatment from other health Médis in-network doctor. The same doctor may make a self referral, which will consist of indicating a referral in this specialisation and arranging successive visits to the patient up C l i n i c a l l y r e q u i r e d s e r v i c e s
to agreed limits set out under Specific Conditions. Services consistent with the clinical condition of the patient in terms of protocols and standards recognised by the medical A u t h o r i s a t i o n
community justifying medical treatments performed under the Whereby the insurance company's clinical services authorises access to hospitalisation cover, some therapeutic treatments such as complementary diagnosis and assistance to the insured A c c e p t e d h e a l t h i n s u r a n c e e x p e n s e s
person. Without authorisation these would not be funded or Expenditure directly related to medical and/ or surgical treatment both diagnostic and/ or therapeutic, performed by duly licensed health care professionals after clinical diagnosis and always
M é d i s N e t w o r k
They complete the individual health questionnaire truthfully A range of agreed service providers within the Médis network system of managed healthcare covering health professionals in They are accepted by the insurance company; their own name and corporate managers of health units. They accept the rules for claiming benefit and use of the Médis network system of managed healthcare. M é d i s N e t w o r k a s s o c i a t e d d o c t o r
A specialist Doctor in other areas recognised by the competent 2. Acceptance of cover for each insured person will be General Medical Council and contracted by Médis to provide confirmed by the insurance company. It will issue a policy and health care treatments within such specialisation other than an individual certificate and deliver a Médis card. Some benefits those included in the in- network primary care. may be subject to an elimination period, excess or maximum funding or reimbursement level, co-payment, restrictions on I n - n e t w o r k P r i m a r y C a r e P r a c t i t i o n e r
frequency or other parameters for the management of the use of A doctor who has joined the primary care provider network , and health care services as set down under the General, Special and who is trained in General and Family Medicine, Internal Ophthalmology , Dental Work and Medical Dentistry. 3. On accepting the policy and depending on the information provided in the insurance proposal the insurance company may I n - n e t w o r k M e d i c a l S p e c i a l i s t
apply a loading for body mass index and other objectively A specialist doctor offering services in an area not covered by established factors set out in the underwriting rules. the primary health care network and who is a member of the Médis network system of managed healthcare. C L AU S E 5 - M O D AL I T I E S A N D C O V E R
M é d i s M e d i c a l p r a c t i t i o n e r
A specialist doctor in General and Family or Internal Medicine, For in-network care the insurance company secures direct access accessible and available as a result of proximity to the Médis for the insured persons to clinical services provided by the Médis customer, with a highly trained knowledge of Médis procedures in-network range of doctors, hospitals or health units, and who, along with Linha Médis, helps resolve rapidly and complementary diagnostic laboratories and other health services. adequately the benefit offered under the health plan, securing Terms and conditions of use are set out under the General the most appropriate management of a Médis client’s health Conditions and the respective Special and Specific Conditions of Qualifying conditions for benefit may include a maximum claim C L AU S E 2 - AI M O F P O L I C Y
level for the value of benefit available, as well as co-payments made by the insured person, for specific medical treatments 1. In terms of this contract the insurance company provides the independent of the capital sum insured or available at any insured person with a range of care which involves claims reimbursement, agreed payments and assistance services, in Application of cover as set down under Specific Conditions is isolation or jointly, in the terms defined under the policy and set subject to a review of clinical processes and may depend on down under the applicable General, Special and Specific express authorisation from the insurance company's clinical services. These will use exclusively medical criteria for assessment in accordance with good clinical practice. 2. Specific Conditions set out the terms and conditions of policy The insurance company will provide the insured person with a list benefits, indicate specific exclusions if these exist and mention for of in-network service providers in the Médis integrated system of information only, some of the applicable exclusions and managed healthcare, namely doctors, hospitals and health units, elimination periods which however do not release the insured complementary diagnostic services and other health services. person from the need to read the applicable General and Special The insured person is free to choose whom he will consult for his When an insured person uses an out-of-network service (not a C L AU S E 3 - B AS I S O F I N S U R AN C E
RedeMédis member) the out-of-network terms of this policy will apply to expenses incurred. The insurance company will thus 1. The insurance proposal or the individual membership reimburse only the amount agreed under the Specific Conditions. application, the individual health questionnaire for each insured person as well as the clinical documentation required for acceptance of cover or individual membership application of the In terms of this policy the insurance company under the General, insurance company, is incorporated into and forms the basis of Special and Specific Conditions will reimburse expenditure incurred by the insured person in relation to out-of-network clinical services and healthcare providers subject to a benefit payable 2. The validity of the policy benefits are based and depend upon limit on the cost of the medical treatment (value of K). a truthful, accurate statement of all material matters by the When the insured person consults any integrated Médis network policyholder or the insured persons with regard to known entity but on an out-of-network basis they will benefit from in- circumstances and facts which could impact on the existence of network charges without prejudice to the fact that the insurance company will only reimburse amounts provided for under the 3. The policyholder and insured persons should inform the insurance company whenever their health status alters from that declared on the individual health questionnaire and accept any The insurance company in terms and within the limitations of the territorial scope of this contract and in compliance with the Special Conditions agrees to provide assistance services abroad for C L AU S E 4 - I N S U R E D P E R S O N S
illness or accident benefits covered by this policy. 1. The benefits under the present contract may apply to insured 4. Except where otherwise stated under Specific Conditions or persons who cumulatively meet the following conditions at the emerging from the extent of the Médis network, this policy is valid in Portugal, and only covers health expenses incurred or to be They comply with the acceptance criteria of the insurance incurred abroad in the case of accidents or sudden illness, company as a function of appraising existing risk including detailed in a medical report, and occurring during a temporary pre-existing conditions, observe age restrictions and 5. Benefits shown under the previous paragraph may be - Natural calamities, acts of war, declared or otherwise, acts suspended for a specific period whenever any insured person is of terrorism, sabotage, public order disturbances, use of absent abroad for more than 45 days or is called up on military chemical and/or bacteriological weapons; service. Such suspension will apply from the start of the absence - Consequences of exposure to radiation. or military service even when the insurance company is only Expenditure incurred with doctors by partners, parents, children or brothers and sisters of the insured person; C L AU S E 6 - E X C L U S I O N S AN D L I M I T AT I O N S
Experimental procedures, as well as any diagnostic and therapeutic procedures whose clinical safety and efficacy 1. Absolute Principal Exclusions
have not been scientifically proven, according to medical Benefit is always excluded in this policy whenever related to: Pre-existing illnesses or accidents occurring before the date Hospital treatment and social assistance; of acceptance for cover under the policy; Expenditure on services not clinically required; Workers’ compensation or professional illnesses; Accidents and illnesses covered by compulsory insurance; Infectious and contagious diseases where health authorities w) Expenditure involved in transporting the insured person to rehabilitation, physiotherapy and dialysis. Any pathology arising directly or indirectly, as a result of the action of the acquired human immunodeficiency virus; 2. Specific Absolute Exclusions under Hospital and Surgical
Any mental health symptoms except where otherwise Assistance
expressly agreed, regarding psychiatric treatment in terms For this policy benefit is always excluded when related to the set out under the Specific Conditions. Equally excluded from benefit is psychological counselling and or psychoanalysis, All and any surgery technique designed to correct eyesight Disturbances resulting from alcoholic intoxication, use of non medically prescribed substances or narcotics, abusive use of Self-inflicted illnesses or injuries resulting from any deliberate or seriously culpable act by the insured person, self harming or the result of any illegal act practiced by the Breast enhancement or reduction surgery whatever the Any methods of birth control and family planning and surgical indications, or removal of breast implant material. 3 Relative exclusions
Consultations, treatments and infertility tests, as well as Except where expressly stated to the contrary in the Specific artificial insemination and their consequences; Conditions/Individual Insurance Certificate or under the Special Conditions, benefit is also excluded for: And/or surgical intervention performed with a view to Dentistry and dental medicine, except for surgery as a result improving personal appearance and/or removing of an accident covered by benefit when the policy is in force; Experimental procedures, as well as any diagnostic and Obesity correction, slimming treatments and similar and therapeutic procedures whose clinical safety and efficacy have not been scientifically proven, according to medical And cosmetic and/or reconstructive surgery, except when resulting from accident or illness occurred during Nonsurgical Prosthetic Devices and Orthoses; Surgical and other treatments designed to correct pre- existing anomalies, illnesses or congenital malformations known at the start of the contract, except where otherwise Co-payment or elimination periods resulting from medical expressly agreed, in terms stipulated under the Specific procedures or interventions where benefit is available from Conditions with respect to a newly born included in the policy other Médis policies held by the same insured person, presented to the insurance company for out-of-network payment, up to the co-payment limit for the same medical m) Organ transplants and their implications, except where procedures or interventions covered by the same policy. otherwise expressly stated and subject to additional special C L AU S E 7 - E L I M I N AT I O N P E R I O D
Treatments in sanatoriums, health spas, health farms, old age homes and other similar establishments; consultations 1. Maternity cover, in terms of the respective Special Condition, is and hydrotherapy treatment, complementary medicine, subject to an elimination period of 18 months (540 days). homeopathy, osteopathy and chiropractors or similar, as well as any other medical treatments not recognized by the 2. In-patient cover, in terms of the respective Special Condition, is subject to an elimination period of 90 days. Medicines whose marketing has not yet been authorised by 3. Outpatient cover, in terms of the respective Special Condition, Accidents occurring and illnesses contacted as a result of: is subject to an elimination period of 60 days. - Hazardous pursuits such as participation in professional sports, as an amateur, in sporting events that are part of 4. Serious illness cover, in terms of the respective Special Condition, is subject to an elimination period of 180 days. - Participation in competitive sports and training with vehicles equipped or otherwise with an engine (skateboard, BTT, 5. Additional elimination periods of 12 months (365 days) apply to rafting, delta-wing, hand gliding and ultra light included); cover relating to the provision of, or medical treatment arising - Snow and water-ski, surfing, snowboarding, underwater diving, snorkelling, sub-aquatic diving, wrestling, martial arts, Sclerosis and/or surgical procedures for veins; parachuting, bullfighting, horse jumping , caving, canoeing, mountain climbing, abseiling, bungee-jumping and other Haemorrhoidectomy and other haemorrhoid treatment; - Use of motorized two-wheel or three-wheel vehicles or 6. Additional elimination periods of 18 months (540 days) apply to such occurrence. Failure to do so makes the cardholder cover relating to the provision of, or medical treatment arising Tonsillilectomy, adenoidectomy, myringotomy with or without C L AU S E 1 0 - P R E M I U M P A Y M E N T
1. The premium owed for the period of the insurance policy is Surgical removal of benign skin lesions; payable in full, without prejudice to arrangements agreed for the 2. The premium or initial instalment falls due on the date when the C L AU S E 8 - S T AR T D A T E AN D P E R I O D O F
policy is signed. In the case of a group policy, the premium or I N S U R AN C E
initial instalment with respect to each membership is due on the 1. The policy or membership, once accepted, will be valid from 0h on day 1 or day 15 of the month following receipt of the proposal 3. Benefit only applies under this policy once the premium or by the insurance company, provided this occurs respectively up to the 15th day after day 15 of any given month, with benefit for the insured person in force from the start date under the Specific 4. Premiums or subsequent instalments are due on dates shown Conditions, without prejudice to elimination or other suspensive 5. The insurance company will notify the policyholder in writing up 2. The time for which this policy is in force is set out under the to 60 days before the date on which premiums or subsequent Specific Conditions. This may be for a fixed term or for one year instalments fall due, of the payment date, amount owed and how 3. When fixed term the contract will void at midnight of the day 6. In the event of any early cancellation of the policy for any reason the premium or instalment owed by the policyholder will be calculated as a percentage of the period expired to the moment of 4. When agreed for one year renewable annually, renewal is cancellation. If the policyholder has paid in full or by instalment, automatic and for successive 12 month periods, except if either they will be reimbursed for the unexpired period. party should cancel. Cancellation must be by registered mail or other written means, delivered 30 days before the end of the 7. Except where otherwise expressly stated in the Specific Conditions, the whole annual premium is due for contributory group insurance plans calculated on the entire insured group. No 5. Benefits provided by the insurance company are valid reduction will be offered on the premium as a result of exclusion exclusively for the period of the insurance. There is no provision for prolonging or extending benefit beyond such date, without prejudice to procedures for non- renewal of policy or membership. 8. The Policyholder or the Insured Person, whichever is the case, should provide for a bank account and interbank codes on the C L AU S E 9 - T E R M I N AT I O N O F B E N E F I T U N D E R
application form. This is so the insurance company may debit T H E P O L I C Y
premiums owed, credit reimbursements or other payments settling claims against the policy, or renewals. The policyholder or 1. Policy benefits cease automatically with respect to each the insured person whichever is the case, may choose to pay the insured person, except when otherwise expressly stated, in the premium by any other legally permitted means. End of the year in which the insured person reaches the C L AU S E 1 1 - N O N - P AY M E N T O F P R E M I U M
maximum upper age limit shown in Specific Conditions ; For members of a household, when they cease to be 1. Non-payment of a premium or initial instalment will mean the insurance policy pays no benefits. Benefits are only available At the end of the year in which the member or group member no longer belongs to the group by which they were 2. Non-payment of any subsequent premium, or of its first failure to pay the premium as legally required; instalment, will prevent policy renewal and void cover. Non- non-renewal of policy or non-renewal of membership. payment of any premium instalment during a renewal year will mean automatic immediate cancellation of the policy from the 2. This policy or, where a group policy, membership of that group, date on which such instalment was due, in terms of the relevant may be cancelled by any of the parties, on the date of annual ruling legislation. There is no option for reinstatement. renewal, by registered letter or other written means, delivered to the other party at least 30 days in advance of the renewal date. P R O C E D U R E S
B E N E F I T P AY M E N T S
3. If the policy or membership is not renewed, insurance company obligations cease at the end of the policy period, without prejudice 1. In the event of illness or accident benefits covered by this policy, an insured person may access the Médis network system of managed healthcare or consult a doctor of choice, any hospital 4. In both cases set out above, the insurance company will clinic in the case of in-patient treatment, and should follow the honour the benefits guaranteed for a twelve month period and prescriptions supplied by the medical practitioner. until the annual capital sum insured is exhausted, with respect to illnesses manifesting while the policy is in force or, in the event of 2. In the case of in-network care provision the insured person accidents and other factors generating claims during the same period, provided these are covered by the policy and are declared up to 8 days after expiry, except for force majeure. Consult an in-network medical practitioner or contact the Linha Medis and take their advise with regard to a medical 5. The Médis card may no longer be used and should be returned practitioner or health service that can treat their case. In the to Médis as soon as any insurance policy under which it was event of need, any of these contacts will also make a referral to a specialist or an in-network health unit; communicate any loss, deterioration or theft within 72 hours of Contact Linha Medis where a nurse will take notes and assess what further medical help is required and how urgently. She will also suggest appropriate courses of action insuring the policyholder or the policy conditions applied; any and warn of other signs and symptoms which may require mistakes by the policyholder or insured person leading to any further action. Under no circumstances is such advice to be incorrect payout by the insurance company. regarded as a clinical diagnosis or medical consultation. 3. If any of the above was deliberate or negligent, the insurance 3. In any of the above, the following procedures should be company has the right to retain the premium and reserve the right observed by the insured person to make maximum use of benefit: to cancel the policy, in terms of the previous paragraph. Identify themselves as a Médis policy holder or show their Médis card to the Médis network health care providers; 4. It is the policyholder’s duty to notify all insured persons of their Give full information for an appropriate assessment of their contractual benefits and exclusions, claims obligations and rights and any changes to these that may be introduced, using the Obtain a referral where required under the health plan, to specimen provided by the insurance company, except where consult a Médis in-network specialist or for any otherwise expressly stated under Specific Conditions. supplementary diagnostic and therapeutic treatment in a 5. In contributory insurance plans, failure to comply with Ensure the medical practitioner obtains clearance from the conditions in the previous paragraph makes the policyholder liable insurance company where funding is required, to ensure for that part of the premium owed by the insured person, without benefit is available for procedures and medical consultations. loss of benefits to that person, until all obligations have been met. 4. In the case of out-of-network payment the insured person 6. When monetary transactions have been made – returning amounts owed by the insured person to Médis for payments in Verify, when necessary, whether prior authorization is excess of existing benefit or other adjustments to accounts, Médis required to ensure the medical practitioner obtains payment reserves the right to prevailing legal compensation. for procedures and medical consultation; Notify the insurance company of the accident or diagnosis of C L AU S E 1 4 - S U B R O G AT I O N
illness and the medical treatments provided, and mail a Up to the amount of claims paid by reimbursement, or the value of undergo a medical examination by the insurance company if benefit used for in-network care provision, the insured person’s rights regarding third parties responsible for accidents or illness present all documents justifying expenditure made, in terms occurring under this policy, are subrogated to the insurance company. The policyholder and/or insured person must supply the insurance company with all information to enable it to exercise 5. Reimbursement of expenditure incurred under the policy will be these rights. If not damages and losses incurred will be for their made after all respective related tax valid documents are received When claiming for an accident state the date, hour, place, C L AU S E 1 5 - H AN G E S T O T E R M S O F C O N T R AC T
causes and outcome of the event, any witnesses, the authority recorded the event and identification of any one 1. The insurance company may endorse the cover, the sums insured, excess, co-payments and premiums, and other aspects Within a maximum of 120 days from the date of the related to use of funds or reimbursement of healthcare expenses. expenditure, subject to loss of right to be reimbursed, Such endorsements may be applied for subsequent periods of provide all originals of documents for the expense incurred. insurance, provided the insurance company notifies the These must set out services provided and include a medical policyholder or the member, 45 days before the current period of photocopies if the insured person requires the originals for reimbursement from other authorities where the insured 2. Endorsements are regarded as accepted if the policyholder or person must show proof of amounts spent and member does not respond within 30 days after receipt of the 6. In any of the cases set out above, each insured person 3. Should the proposed endorsements be rejected, the policy will authorises the insurance company’s clinical services, under the terminate at the end of the existing period of insurance. proposal and this policy, to obtain information from medical practitioners attending the insured persons and to copies of 4. The sum insured, premiums and excess may be subject to clinical reports and other documents associated with the claim or annual endorsements taking into account economic factors illness. These will be used for insurance administration in strict affecting the policy, namely medical inflation and the claims index. compliance with Data Protection legislation and safeguards for It may also be subject to annual indexation considered automatically on the date of the anniversary of the policy under 7. The policy does not cover the outcome of any delay or negligence by the insured person in obtaining medical assistance, 5. Whenever insurance premiums are based on age brackets, the or any refusal to comply with treatments prescribed. premium related to any age bracket movement by insured persons becomes automatically payable upon policy renewal. C L AU S E 1 3 - R E S P O N S I B I L I T Y
This applies also to any increased risk. 1. The policy holder and/or the insured person may be held 6. The insurance company will notify the policyholder or member responsible for losses and damages, if they do not submit of new policy conditions through an endorsement. requests for medical expenditure reimbursement up to 120 days after the date when health care was provided. Equally they may C L AU S E 1 6 - C O - O R D I N A T I O N O F P AY M E N T S
be held responsible for any failure to observe the rules in force with regard to referrals and insurance company authorisation. 1. The insured person shall notify the insurance company of any existing or future policies that are identical to the current one, so 2. Without prejudice to outright policy cancellation under approved provision or agreed claims may be coordinated across legislation in force, the policy holder or insured person is responsible for any damages to the insurance company in the following circumstances: incorrect, inaccurate or omitted information regarding facts or circumstances known to the The clinical services of the insurance company or Linha Medis policyholder or the insured persons, likely to affect the risk of may, in exceptional cases, authorise use of out-of-network doctors who may be funded up to the limit of the capital sum insured where the services or doctors required are not available 3. Telephone calls made to Linha Médis may be recorded and through the agreed Médis in-network services. monitored for service improvement and training purposes. Such recordings are authorised by Comissão Nacional de Protecção de Dados, the national data protection agency, and are handled in 3.1. Without prejudice to that set out under the Special and strictly in compliance with the laws and regulations governing reimbursement will be the amount directly incurred by the insured person and not payable by any other body, provided the following C L AU S E 2 0 - J U R I S D I C T I O N AN D G O V E R N I N G
original documents proving expenditure are presented and All matters related to this policy are governed by Portuguese law. reflect a total against which the percentage reimbursement The courts of the district of Lisbon will be the competent jurisdiction for any litigation that may arise. with documents from other bodies used to prove expenditure and respective authorized share of the insured person, the percentage to be reimbursed is calculated only on the outstanding unpaid amount.
3.2. Reimbursement of medical expenses may be subject to a
maximum cover limit independent of capital sum insured and
available under Specific Conditions.
C L AU S E 1 7 - AR B I T R AT I O N

1. In exclusively clinical matters if there is any disagreement
about the rights of insured persons to health care through the
insurance company, the parties may go to arbitration.
2. In case set out in previous number, each party will appoint a
doctor to represent them. These two doctors will appoint a third to
chair the arbitration board. He will hold a qualifying vote.
3. Arbitration costs will be met by each party in relation to their
own representative and shared equally for the presiding arbiter.
C L AU S E
C O M M U N I C AT I O N S
N O T I F I C A T I O N S

1. Communications or notifications from the policyholder or the
insurance company under this policy are considered to be valid
and legally enforceable if made by registered letter or other
means of written record to the head office of the insurance
company or the last known address of the policyholder or insured
person mentioned in the contract, respectively.
2. If the policyholder or the insured person changes head-office or
home addresses they should notify the insurance company within
30 days of such change, by registered recorded letter. If this is not
done insurance company communications and notification will
continue to be delivered to the last known address and remain
legally enforceable.
3. In the event of individual policies, correspondence is sent to the
address of the policyholder in the name of the insured person
except were otherwise agreed to the contrary, and in the case of
group policies correspondence is sent to the insured person or
holder of the Individual Certificate.
4. All documentation containing clinical information may only be
made available by doctors or parties holding specific power of
attorney for that purpose. This is to safeguard the confidentiality
of personal health data.
C L AU S E 1 9 - P E R S O N AL D AT A

1. The terms of execution and contracting of services for this
insurance policy may be transmitted to Médis - Companhia
Portuguesa de Seguros de Saúde, SA. This includes personal
data and electronic processing of all medical consultations and is
exclusively for the purpose of improving service levels and
insurance management, financing and reimbursement of
expenditure with health care benefits held by the insured person.
2. Personal healthcare data processing at Médis - Companhia
Portuguesa de Seguros de Saúde, SA is performed by health
professionals only and conforms to legal requirements, and all
current Data Protection provisions.

S P EC I AL C O N D I T I O N S
Nursing fees related to out-patient treatment; S P E C I AL C O N D I T I O N - I N - P A T I E N T M E D I C AL C AR E
Ambulance or other means of transportation from and to health care centres, providing the insured person’s health Under this Special Condition the insurance company undertakes to fund or authorise access by the insured person to in-network 4. Benefit provided for under this condition includes a provision for Healthcare service providers where specific in-patient resources establishing elimination periods and excesses, as well as and services are required, in terms of and to the limits established minimum and maximum reimbursable amounts, as indicated in S P E C I AL C O N D I T I O N - D E N T AL AN D D E N T AL
Under this Special Condition the insurance company undertakes M E D I C I N E
to reimburse the insured person, in terms and up to the limits fixed under the Specific Conditions, for health care expenditure related to in-patient resources and services. Under this Special Condition the insurance company undertakes to reimburse the insured person, in terms of and to the limits 3. The benefit is for provision of in-patient health care including established under Specific Conditions, for expenditure with dental out-patient care, subject to clinically proven need for such in- and dental medical care provided by in-network healthcare 4. Eligible expenditure under in-patient cover is that related to payment for medical treatment, surgery or laboratory analyses Under this Special Condition the insurance company undertakes that require resources and specific services that can only be to reimburse the insured person, in terms of and to the limits provided and performed as an in-patient in a hospital established under Specific Conditions, for expenditure with dental Fees related to treatment carried out in the hospital namely 3. Reimbursable expenditure under policy cover for healthcare providers within the approved network relate to: Supplementary Diagnostic and Therapeutic resources associated with the treatment carried out in the hospital Dentistry (restoration and filling of cavities); Medicines administered during in-patient treatment; Materials, equipment and products associated with treatment Nursing fees related to in-patient treatment; Resources used in in-patient treatment (operating theatres, recovery ward, private room or nursing ward); 4. For the purpose of the above, the following are taken into Ambulance or other means of transportation from and to hospital, providing the insured person’s health requires it; Surgically implanted Prosthetic Devices; All clinically conceived and/or recommended instruments Medical treatment or procedures in the closed price regime, designed to replace, totally or partially, a member of or organ in 5. Benefits provided for under the Special Condition include All clinically conceived and/or recommended instruments elimination periods and excesses, as well as minimum and designed to help, totally or partially, the functioning of a member maximum reimbursable amounts shown in the Specific 5. Benefit provided for under this condition includes a provision for S P E C I AL C O N D I T I O N - O U T - P A T I E N T M E D I C AL
establishing elimination periods and excesses, as well as minimum and maximum reimbursable amounts, as indicated in Under this Special Condition the insurance company undertakes S P E C I AL C O N D I T I O N - M E D I C I N E S
to reimburse the insured person, in terms of and to the limits established under Specific Conditions, for in-network healthcare 1. Under this Special Condition the insurance company service provider expenditure which requires specific out-patient undertakes to reimburse the insured person, in terms of and to the limits established under Specific Conditions, for expenditure on medicines as officially defined, and as may be subsidised, on Under this Special Condition the insurance company undertakes to reimburse the insured person, in terms of and to the limits 2. Reimbursable expenditure under policy cover is the amount not established under Specific Conditions, for health care expenditure subsidised by the National Health Service in respect of the over requiring specific outpatient resources and services. 3. Eligible expenditure under in-network healthcare service 3. Non-reimbursable expenses include those incurred acquiring: provider cover is that related to payment for medical treatment, surgery or laboratory analysis, that does not require to be Vaccines except where prescribed by a doctor and where provided and performed as an in-patient, namely: such vaccines are compulsory for foreign travel; Dietary products, natural products and health supplements; Supplementary Diagnostic and Therapeutic resources Aesthetic and cosmetic products, general hygiene including associated with out-patient treatment provision; Medicines administered during such treatment period; Materials, equipment and products associated with out- 4. Reimbursable expenses are only paid after the assumptions All clinically conceived and/or recommended instruments medicine should be prescribed by a registered practitioner designed to help, totally or partially, the functioning of a member and be for treatment of lesions arising from illness or accident covered by the contracted benefit; depending on the case, the original or copy of the medical prescription, countersigned by the supplying pharmacy and Within the terms of this special condition, the insurance company to include package price tag and/or barcode, or prescribed undertakes to reimburse the Insured Person, within the terms and medicine registration number and corresponding receipt according to the limits defined in specific conditions, for expenses should be sent to the insurance company. The claim should with acquisition or hire of medically prescribed prosthetic devices clearly and legibly set out the medicines supplied and the amounts, following deduction of reimbursable amount where these apply, paid by the insured person. The Insurance Company will not reimburse expenditure for which Expenses with acquisition of ocular prostheses and orthoses are necessary documentary proof has not been provided. eligible for partial reimbursement, provided they are prescribed by an ophthalmologist, within the terms and limits included in the 5. Benefit provided for under this condition includes a provision for specific conditions of the insurance policy. establishing elimination periods and excesses, as well as minimum and maximum reimbursable amounts, as indicated in Under the present special condition, expenses with acquisition of ocular prostheses, namely to replace enucleated eyes, will be S P E C I AL C O N D I T I O N - C H I L D B I R T H
Under the present special condition, expenses with acquisition of ocular orthoses will be partially reimbursed, provided they are Under this Special Condition the insurance company undertakes prescribed by an ophthalmologist, according to the following to ensure access for the insured person, in terms of and to the limits established under the Specific Conditions, to in-network healthcare service providers in terms of childbirth and voluntary One pair of lenses (normal or contact) per calendar year, or interruption of pregnancy except for illegal abortion, (if in the case 2 pairs if the Insured Person is under 16 years of age on the of normal pregnancy birth occurs after the elimination period). date of the expense. For disposable contact lenses, the annual limit is not established in units, corresponding to the capital indicated in the specific conditions of the insurance Under this Special Condition the insurance company undertakes to reimburse the insured person, in terms of and to the limits established under the Specific Conditions, for expenditure One set of frames every two calendar years, or one set of incurred with in-network healthcare service providers in terms of frames per calendar year if the Insured Person is under 16 childbirth and voluntary interruption of pregnancy except for illegal years of age on the date of the expense. abortion (if in the case of normal pregnancy birth occurs after the Expenses with sunglasses, including frames and lenses (corrective or not), individually or as a set, are not eligible for 3. Reimbursable or fundable expenditure under policy cover for the purposes of the present special condition, even if in-network healthcare service providers, relates to: accompanied by specialist’s prescription. Fees related to anaesthetist, assistant and instrument The following documents must be presented for partial Medical fees for Paediatrics during hospitalization of the reimbursement of expenses with acquisition of ocular prostheses Supplementary Diagnostic Methods during hospitalization Photocopy of the ophthalmologist’s prescription, which must have been issued within 90 days of the date of acquisition of Medicines administered during in-patient treatment; Materials, equipment and products associated with the in- Receipt from the supplier of the prosthesis/orthosis, expressly indicating the quality, quantity and price of (operating theatres, recovery ward, private room or nursing 5. Benefit provided for under the present special condition includes a provision for establishing elimination periods and Daily charges related to the newly born child while the excesses, as well as minimum and maximum reimbursable mother remains hospitalised and in terms of the Special Condition; amounts, as indicated in the Specific Conditions. Ambulance or other means of transportation from and to hospital, providing the insured person’s health condition so S P E C I AL C O N D I T I O N - M E D I C AL C AR E W H I L E
4. Benefit provided for under this condition includes a provision for 1. Under this Special Condition the insurance company establishing elimination periods and excesses, as well as undertakes to provide assistance to insured persons in need of minimum and maximum reimbursable amounts, as indicated in health care abroad, in the event of an accident or illness covered by the policy up to the limit established under Specific Conditions. S P E C I AL C O N D I T I O N - P R O S T H E T I C D E V I C E S
2. Application of cover and benefit under this Special Condition A N D O R T H O S E S
requires authorisation from the insurance company’s clinical services. This is requested directly or through Linha Médis, which should be notified within 48 hours in an emergency. For the purpose of the present special condition, the following are All clinically conceived and/or recommended instruments In the event of illness or accident affecting the insured person and designed to replace, totally or partially, a member or organ in the requiring proven hospitalization or treatment in a medical facility, the insurance company will handle required procedures for the Services provided under number 3 of Special Condition is outside insured person’s admission to the selected hospital. the national territory, valid only through the Best Doctors 1 Should the insured person require transport to the hospital for in-patient treatment, or after treatment, be physically In accordance with the Special Condition, the insurance policy, up unable to use ordinary transportation, the insurance to the limits established under Specific Conditions, will cover reimbursement of expenditure incurred by the insured person on ambulance, light sanitary vehicle or other such means, depending on the seriousness of the illness, to the in-patient prescriptions considered clinically necessary, whenever these unit or treatment indicated by the insured person. at the arise or as a consequence of any of the serious illnesses or request of the insured person the insurance company will clinical situations shown below and where the early symptoms arrange for identical services for a companion – doctor, and first diagnosis occurred during the period of insurance. For the purposes of the above any serious illness or clinical Following recovery the insurance company will arrange for situation for which benefit is available under the present Special adequate means of transportation for the insured person and a companion, as set out in conditions defined in the policy. 4.1. Cancer treatment which implies treatment of a malign tumour 3.2.1. The insurance company undertakes to provide transport for characterized as not encapsulated and by growth and the insured person requiring in-patient treatment in a hospital unit uncontrolled dispersion of malignant cells and by invasion of outside national territory, when such person is already abroad at the time of the emergency or when there is no such treatment unit The following treatments are not covered by this policy: available domestically. Service benefit is provided when in-patient Any tumour histologically described as pre-malignant which treatment in a health unit in national territory cannot be provided shows only the first signs of any malign change; in appropriate time and the insured person’s life is at risk. 3.2.2. If the insured person has a contagious infection, use of air Tumours related to acquired human immunodeficiency transport is conditional upon authorisation by the airline. Should this not be forthcoming the insured person may if they so wish, Skin cancer except for malignant melanoma; opt for any other means of transport if agreed in advance between doctor and the insurance company’s clinical services. “IN SITU” cancer: This is a malignant tumour restricted to the epithelium from where it originates and which has not invaded the 3.3.1. If during in-patient treatment the insured person should die, the insurance company will meet the costs of legal formalities at the place of death and those involved in repatriating the body and Any surgical intervention to the brain or other intracranial structure coffin from the place of death to the funeral in Portugal, up to the Brain surgery is excluded when the pathology results from limit set down under the Specific Conditions. 3.4.1. If for the purposes of the consultation or after medical Benefit is provided only for surgical treatment involving open heart recovery after in-patient treatment, the insured person requires for surgery and use of bypass to correct stenosis of at least two medical supervision purposes, to be accommodated away from their habitual place of residence, the insurance company Prior authorisation is dependent on angiographic evidence of undertakes to reserve lodgings chosen by them Also excluded is surgery due to traumatic lesions or congenital After medical recovery following in-patient treatment, the insurance company will handle the paperwork required for 4.4. Surgical procedures for the replacement of heart valves, departure from hospital of the insured person, and ensure similar namely total substitution of one or more heart valves. service in the event of the death of the insured person in hospital. Prior authorisation is dependent on angiographic evidence of Should a doctor prescribe medicines to an insured person, the Corrective surgical procedures for congenital changes to cardiac insurance company will ensure they are obtained and delivered if they are not available where the insured person is presently 4.5. Organ transplants, namely surgical transplant of the heart, lung, liver, kidney, pancreas or bone marrow as a result of total and irreversible loss of respective organ function Organ or bone 4. Benefit provided for under this condition includes a provision for marrow should be replaced by another of the same type coming establishing elimination periods and excesses, as well as from a human being identified as a donor. minimum and maximum reimbursable amounts, as indicated in All organ or tissue transplants are excluded in the following cases: The insured person is a donor to a third party; The need for transplant arises from congenital pathologies; S P E C I AL C O N D I T I O N - S E R I O U S I L L N E S S
The need for transplant arises from hepatic cirrhosis with 1. Under this Special Condition the insurance company The transplant is a result of a surgical act of self undertakes to provide assistance to insured persons without transplantation except for bone marrow transplant. health care abroad in the event of an accident or illness set out under number 4 of the Special Condition and up to the limit established under the Specific Conditions. When a serious illness or clinical situation identified in the previous paragraph occurs the insurance company ensures 2. Provision of benefits under the Special Condition requires prior funding for expenditure referred to below in accordance with limits authorization from the insurance company’s clinical services, requested directly or through LinhaMedis at least 14 working days General nursing care during in-patient stay in a room, The insured person should in any event, authorise doctors and nursing ward, intensive care or observation unit; hospitals consulted, to supply the insurance company’s clinical Other hospital services including those provided by the out- services with clinical reports and any other data and information Daily expenditure of the insured person; (1) Best Doctors is the registered trademark of Best Doctors, Inc, with head office at One Boston Place, 32nd Floor, and Boston, USA. Expenses relating to the cost of an additional bed for a 7. Benefit provided for under this condition includes a provision for companion if the hospital offers this service. establishing elimination periods and excesses, as well as 5.2. Expenditure incurred in out-patient surgical centres or minimum and maximum reimbursable amounts, as indicated in independent surgical centres provided that the treatment, surgery or prescription is covered under the Special Conditions. 5.3. Medical fees relating to consultations, treatments, medical or S P E C I AL C O N D I T I O N - H O M E AS S I S T AN C E
5.4. Medical consultants fees charged to the insured person 1. Under this Special Condition the insurance company during a hospitalization stay and during the hospital in-patient undertakes to reimburse the insured person, in terms of and to the amounts fixed by Specific Conditions, for health care 5.5. Expenses incurred with the following services, treatments or expenditure which requires specific out-patient resources and Anaesthetic and its application, whenever this is provided by 2. For the purposes of that set out under this condition assistance Laboratory and pathological examinations, radiography for services are those provided by a Healthcare service provider diagnostic purposes, radiotherapy, radioactive isotopes, contracted by Médis to provide the services described under the electroencephalograms, angiograms, computed tomography and other similar treatments required for diagnosis and 3. Request for use of benefit under this Special Condition should treatment of an illness covered by benefit, whenever such is be notified to the assistance services or through LinhaMédis provided by doctor or under the supervision of a doctor; Blood transfusions, application of plasma and drips ; 4. A reimbursement under Home Assistance includes: Oxygen consumption and use of intravenous solutions and In an emergency the insurance company provides for medical 5.6. Cost of pharmaceuticals or medicines on medical prescription consultation at home for the insured person between 2000 and when the insured person is in hospital or after recovery up to a 0800 and on holidays or weekends at any time, with the insurance maximum of 30 days, provided such products are prescribed as company meeting the cost of the doctors’ fees and travel in accordance with limits established under Specific Conditions. 5.7. Expenditure with travelling and transport by land or air ambulance when use is recommended and prescribed by a The insurance company ensures delivery of medicines to the home whenever the insured person has a medical prescription 5.8. Cost of an economy class return journey for the insured and is unable to obtain these on their own. The cost of the 5.9. Accommodation expenses for the insured person and In the event of the insured person becoming seriously ill or 5.10. In the event of the death of the insured person during hospitalised and as a result confined to bed or incapacitated, as treatment, the insurance company will meet expenses with legal confirmed by medical report, the insurance company will make formalities at the place of death and the cost of shipping body and available to the insured person nursing professionals for the time coffin to the place of the funeral in Portugal. needed for recovery in accordance with Specific Conditions. When the annual sum insured is exhausted, the fees will be met directly by the insured person who will be notified in advance of Without prejudice to that contained in Clause 6 of the General Conditions applicable to this policy, the following items are not an 5. Home Assistance provided for under the Special Condition will covered under Special Conditions - expenses incurred or be provided exclusively by health professionals belonging to the motivated by any diagnosis, treatment, service, provision, medical approved Healthcare network and is available exclusively in prescription of any form related with or the result of: 6.1. Any serious illness or clinical situation not set out under 6. Benefit provided for under this condition includes a provision for 6.2. Acquired immunodeficiency syndrome (AIDS) or any illness establishing elimination periods and excesses, as well as secondary to or provoked by AIDS, as well as all those that are a minimum and maximum reimbursable amounts, as per Specific consequence of the treatment including Kaposi syndrome. 6.3. Expenditure involving custody, health care at home or services provided at a convalescence centre or institution, asylum C O N D I T I O N
or old age home, even when such services are required or needed as a result of an illness under benefit. 6.4. Any expenses incurred outside the framework of the 1. Under this Special Condition the insurance company international medical providers recommended by the insurance undertakes to reimburse the insured person, in terms of the amounts fixed under Specific Conditions, for health care 6.5. Any type of processes, orthopaedic apparatus, belts, expenditure requiring specific out-patient resources and services. bandages, crutches, artificial organs or members, wigs, ( even when their use is required during chemotherapy treatment), 2 . For the purpose of that set out in this Special Condition the orthopaedic shoes, hernia supports and other equipment or Best Doctors network is that group of doctors belonging to Best similar articles with the exception of artificial breasts. 6.6. All pharmaceutical products and medicines not supplied by a licensed pharmacist or for which no medical prescription is 3. Application of benefits under this Special Condition must be directly requested from the health care provider or through 6.7. Expenses incurred with alternative medicine even when 6.8. Expenditure involved in acquiring or hiring wheelchairs, special beds, air conditioning apparatus, air purifiers and any Service under this Special Condition outside national territory shall be provided exclusively by health professionals of the Best 6.9. Expenses which are not of a medical nature incurred by the insured person or their companions except for those expressly covered under the present Special Condition. 5. What benefits are provided 5.1. In terms of this Special Condition the insurance policy ensures, in accordance with the limits set down under Specific Conditions and for the illnesses shown below, that the insured person has access to a second opinion service provided by health professionals of the Best Doctors network. This comprises a review of the clinical situation, respective diagnosis and an indication of the most appropriate health care. 5.2 For the purposes stated above any serious illness or clinical situation covered by the present Special Condition includes: 6. What benefits are not provided Any additional medical acts are excluded, even when they result from a recommendation obtained within the scope of the Special Condition. Ocidental – Companhia Portuguesa de Seguros, S.A . Sociedade anónima com sede na Avenida José Malhoa, nº 27, em Lisboa, pessoa colectiva nº 501 836 918 e matriculada sob esse número na Conservatória do Registo Comercial de Lisboa, com o capital social de € 12.500.000,00. Morada para correspondência: Tagus Park, Edifício 10 - Piso 1, 2744-005 Porto Salvo

Source: http://www.sottomayor.pt/multimedia/archive/00413/CG_M_dis_Ingl_s_413236a.pdf