International Private Medical Insurance for Foreign ... Imp… · Group insurance policy with...

Group insurance policy with optional membership A 4916.0001 à 0005 - ASPI

International Private Medical Insurance for Foreign Expatriates in France 2 0 1 9 C o n d i t i o n s

SwissLife Expatriates Insurance

Your membership document consists of this Information Notice and your Membership Certificate.

INFORMATION NOTICE

12/0

3/20

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Notice d’information / Impatriés SwissLife

SOMMAIREDEFINITIONS 3 I.THECONTRACT 44

ARTICLE 1 PURPOSE OF AGREEMENT 4ARTICLE 2 CHOICE OF COVERAGE LEVEL 4ARTICLE 3 MEMBERSHIP / JOIN THE CONTRACT - GUARANTEED PERSONS 4ARTICLE 4 ADMISSION TO INSURANCE 4ARTICLE 5 EFFECTIVE DATE, DURATION AND RENEWAL YOUR MEMBERSHIP - EFFECTIVE DATE OF YOUR COVERAGE 4ARTICLE 6 CHANGING YOUR COVERAGE FEATURES 5ARTICLE 7 TERMINATION OF YOUR MEMBERSHIP AND YOUR COVERAGE 5ARTICLE 8 CALCULATION OF YOUR CONTRIBUTION 5ARTICLE 9 PAYMENT OF YOUR CONTRIBUTION 6ARTICLE 10 REPRESENTATIONS AND COMMUNICATIONS 6ARTICLE 11 WAIVER OF MEMBERSHIP 6ARTICLE 12 LEGAL LIMITATION 7ARTICLE 13 EXAMINATION OF COMPLAINTS - MEDIATION 7ARTICLE 14 RIGHT OF COMMUNICATION AND CORRECTION 7

II.HEALTHCOVERAGE: HOSPITAL,MEDICALEXPENSES,MATERNITY 8

ARTICLE 1 COVERAGE BENEFIT 8ARTICLE 2 TABLE OF HEALTH COVERAGE 9 /10ARTICLE 3 LIMITATIONS OF REFUNDABLE FEES 11ARTICLE 4 MAXIMUM ENGAGEMENT 11ARTICLE 5 TERRITORIAL SCOPE 11ARTICLE 6 REQUEST FOR PRIOR AGREEMENT 11ARTICLE 7 DIRECT CARE 12 ARTICLE 8 WAITING TIMES 12ARTICLE 9 SETTLEMENT OF BENEFITS 12ARTICLE 10 EXCLUDED RISKS 13

This information includes the general conditions of the collective insurance policy with optional membership A 4916.0006 subscribed by the International Health Welfare Association («ASPI»).

It has been signed with:

SwissLife Prévoyance et SantéHead office: 7 rue Belgrand - 92300 Levallois-Perret - FRANCE with capital of € 150,000,000 - 322.215.021 RCS Nanterre

Company governed by the Insurance Code

The Insurer

Authority responsible for insurance control:

French Prudential Supervisory Authority (Autorité de Contrôle Prudentiel et de Résolution - A.C.P.R.)

61 rue Taitbout - 75 009 Paris - FRANCE

The Information Sheet is a document that defines the guarantees and modalities of entry into force and the formalities to be completed in case of a claim. It must be established by the Insurer and provided by the Underwriter Association to Members

(Article L.141-4 of the Insurance Code).

The “Assur Travel Health” Contract has been concluded by :

International Health Welfare Association49 bd de Strasbourg - 59 000 Lille - FRANCE

Association

Expatriates - Health

Cond i t i ons 2 0 1 9

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AccidentAny independent bodily injury of the Insured from sudden and unforeseen external causes.

You/Member:Natural Person who is a member of the Association which signed the Agreement, pays the fee and receives coverage.

Insured:Natural person mentioned on the Membership certificate for which a fee is paid by the Member and who takes on the risk. It is you and your beneficiaries (spouse and dependent children as defined in Article 3-I).

Association:“International Health Welfare Association” (ASPI) is the association (under the Act dated 1901) having subscribed to the Agreement which provides an opportunity for its Members to benefit from the guarantees described in the Schedule of Health Coverage (Article 2-II).

Membershipcertificate:This document specifies the guarantees granted by the Delegatee, deductibles if applicable, affiliation to the C.F.E. if applicable, the effective date and the data concerning you and your beneficiaries mentioned therein.

C.F.E.:Caisse des Français de l’Etranger.

Contract:It is the group insurance contract with optional A4916 membership, endorsed by the International Health Welfare Association («ASPI») and governed by French law and by the general and special conditions.

WaitingPeriod:Period during which a benefit is not paid. The waiting times for different guarantees are defined in Article 8-II.

Delegatee:Third party mandated by the Insurer and/or the Association to manage the various management tasks entrusted to them. Under the Agreement, Delegatee of the Insurer as well as the Subscriber is GAPI: Zone d’activité ACTIBURO - 99 Rue Parmentier - 59650 Villeneuve d’Ascq - France, SAS with a capital of 55,000 € - RCS PARIS 490 676 228, ORIAS No. 10056960.

EligibleHealthEstablishment:Establishment of public or private health (hospital or clinic) which, firstly, is authorized to practice procedures and to provide medical treatment to ill or injured persons and, on the other hand, holds all the administrative and health authorizations required for this purpose.

Expatriate:You, Member of the Association who lives outside your country of nationality, alone or with your entitled beneficiaries (excluding private or business trips of less than 90 consecutive days in a country other than that of expatriation). When your Host country is France, you are an Impatriate.

Dailyhospitalcharge:During treatment in France, it is the share of hosting and maintenance costs incurred by hospitalisation, not supported by the French Social Security or the C.F.E. if applicable pursuant to Article L. 174-4 of the Social Security Code.

Unusualorunreasonablecosts:Medical expenses that do not correspond to the rates normally applied for a service or a similar services and that exceeds the normal rates for such service or for such a benefit under the best possible conditions in the area where the service or the delivery is administered.

Annualdeductible:Annual sum which remains your responsibility.

Hospitalisation:Quality of patient stay prescribed by a doctor in an Eligible Health Establishment, since this trip is for the medical or surgical treatment of a disease or as a result of an Accident.

Unexpectedillness:Is recognized as a sudden illness to the Insured victim leading to a neurological mycotic impairment or contraction of one of the following infectious diseasesCholera, whooping cough, diphtheria, bacillary or amoebic dysentery, bird flu, meningococcal meningitis, mumps, malaria, polio, measles, scarlet fever, tetanus, typhoid, typhus, chicken pox, small pox, shingles or other health impairment which the medical board of the Delegatee recognizes as sudden and unpredictable.

PACS:Civil Solidarity Pact in the sense of articles 515-1 and as per the Civil Code.

CountriesofExpatriation:Countries listed as geographic zones of guarantee where you and your beneficiary reside in accordance with the definition of Expatriates. Your country of nationality may not coincide with your Host country.

CoveragePeriod:Period during which the insurer is contractually obliged to compensate the risks which may arise during the execution of the Contract. The coverage period of a risk begins at the earliest on the date shown in the certificate of membership and ceases not later than the end date of membership.

Medicalquestionnaire:Document showing your medical history to enable the Medical Board of the Delegatee to assess the health risk that you may represent. It must be less than 90 days from the date of membership or registration.

Rehabilitation:The Insured who underwent surgery may benefit from rehabilitation sessions in a rehabilitation centre only after hospitalisation.

GeographicZoneofcoverage:Geographical zone of coverage (Zone A, B, C or D) is determined by your Host country and is described in Article 5 II. The warranty applies to the reimbursement of health expenses that have been incurred in the geographical area of coverage applicable to you.

DEFINITIONS



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ARTICLE1-PURPOSEOFTHEAGREEMENT

The “Assur Travel Health” contract is intended for the payment of benefits as reimbursement of medical expenses incurred during the Coverage Period by You and your beneficiaries residing in the same country as you, when they are enrolled in the Agreement. These benefits are paid in addition to reimbursement of the C.F.E. or French Social Security, or the first EuroL.

ARTICLE2-CHOICEOFCOVERAGELEVEL

Health guarantee is exercised within the limits of the coverage level you choose from one of six formulas below. The level of provision of guarantee is increasing in the chosen Formula. This choice is applicable to you and your beneficiaries.

• Basic formula: it can only be selected if you are in expatriate zones A, B or C; • PREMIUM ACCESS formula: it can only be selected if you are in expatriate zones A, B or C;• PREMIUM formula: it can only be selected if you are an expatriate in the Zone A, B or C;• CONFORT ACCESS formula; • CONFORT formula;• SUMMUM formula.

Additionally, you can choose an Annual Deductible of € 150 or € 300applicable to the amount of your repayments. This deductible applies per calendar year.

Note: health guarantees are exercised within the limits of the Geographical area of coverage that applies to you (Zone A, B, C or D).

ARTICLE3-MEMBERSHIP/SUBSCRIPTIONOFTHECONTRACT-COVEREDPEOPLE

You, MemberTo join the Contract signed by the Association, you must meet the following conditions:

• you must be older than 18 years and less than 65 years of age on the day of becoming a member;• you must be of a nationality different from that of your country of expatriation;• you should have paid a membership fee to the Association for membership

Your beneficiariesAre considered the beneficiaries and can therefore benefit from the guarantees subscribed by you:

• Your spouse: your spouse, not legally separated (subject to providing a sworn statement of non-separation), your partner under a PACS (subject to providing a copy of the agreement registered with the Registry of the Tribunal d’Instance of common domicile), or registered partner (subject to providing a common proof of address and a sworn statement of common-law marriage), aged under 65 on the day of registration.Note: when you join the Contract in addition to the French Social Security or C.F.E., and your spouse is not recognized as your dependent by one of these organizations, they may benefit from the guarantees provided they are individually affiliated with one of these basic organizations;

• dependent children: vyour children and/or those of your spouse, your dependants for tax purposes and/or that of your spouse until their 16th birthday in all cases, and until their 26th birthday if they are in secondary education (under reserve to provide a school certificate or a photocopy of a valid student card at the time of enrolment

and at each annual renewal) and do not have a full-time profession. Also included are your children and/or your spouse and disabled holders of a disability card referred to in Article L. 241-1 of the Code of Social Action and Families.

Note: when you join the Contract in addition to the French Social Security or C.F.E., guarantees of dependent children may be maintained beyond their 20th birthday only if listed individually with the basic body.

Your beneficiaries must reside in the same Host country as you to benefit from the chosen coverage formula.

ARTICLE4-ADMISSIONTOINSURANCE

4.1 After acceptance of your membership, you must send the Delegatee: • the membership newsletter completed and signed by you;• The Medical Questionnaire dated less than 90 days before the desired effective date, completed and signed by you, for you and your beneficiaries. It must be transmitted confidentially to the medical board of the Delegatee;• certificate of affiliation to the C.F.E. where the guarantee is underwritten in addition to benefits paid by that body;• Documents to justify that your beneficiaries meet the definition of Article 3-I.

The Delegatee may demand any further information which it may consider useful for the study of the file and for risk assessment. Similarly, it reserves the possibility of asking your beneficiaries to provide any other document enabling them to prove their eligibility of being a beneficiary.

All documents provided to the Delegatee constitute your Membership File.

4.2 You are required to notify the Delegatee of any change of address, host country and/or status in writing, and to report changes about your family situation. The declarations and communications made during your membership have an effect if they are sent in writing to the Delegatee.

4.3 After studying the Membership File, the Delegatee shall notify its acceptance by issuing a Membership certificate stating the effective date of membership and guarantees, your full name (s) and those of your beneficiaries, the selected guarantee level, your Host country and geographical area corresponding to the guarantee and the amount of your contribution.

Based on the results of the medical selection the Delegatee reserves the right:• to apply a surcharge, if applicable, to the amount of your contribution;• to accept an Insured sum while excluding health costs and all costs associated with a pathology specified on your Membership certificate;• To refuse your membership or registration of the entitled beneficiary. In this case, the Delegatee shall notify its refusal by registered letter with acknowledgement of receipt within one month of receipt of the Membership File.

ARTICLE5-TAKINGEFFECT,DURATIONANDRENEWALOFYOURMEMBERSHIP-EFFECTIVEDATEOFYOURGUARANTEES

5.1 Your membership and registration of your beneficiaries

You, MemberYour membership takes effect on the date specified on your Membership certificate. At the earliest, it begins on the first day following the receipt of the membership file by the Delegatee, subject in all cases, to:

• acceptance of your membership after medical screening;• full payment of your first premium;• acceptance of the appropriate premium proposed by the Delegatee;• entitlement to the C.F.E. if any.

I.I. THECONTRACT



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Your beneficiariesThe coverage of your beneficiaries takes effect on the same date and in the same conditions as that of your membership.

If your family situation changes (marriage, conclusion of a PACS, common-law marriage, birth or adoption of a child), registering your beneficiaries will take effect at the earliest on 1 day after express acceptance of their registration by the Delegatee under the same conditions as your membership.

Your children who may be born after you sign the Contract are to be accepted without medical formalities, provided that their birth was declared to the Delegatee no later than the month following their date of birth. In this case, registration takes effect from the day of their birth. If this one-month period is exceeded, registration will take effect no earlier than the day after the receipt of the declaration of birth by the Delegatee.

Your membership and registration of your beneficiaries will be in effect until 31 December of the current year. They are then renewed by tacit agreement on 1st January each year for successive periods of one year.However, you may terminate your membership in the Agreement during the annual renewal of your membership by registered letter sent to the Delegatee, at least two months before the due date. In addition, in case of an ongoing membership, if you must be affiliated to a compulsory scheme in your Host country, you have the right to terminate your membership in the Agreement by sending a registered letter to the Delegatee and any document justifying compulsory membership of the scheme.

5.2 Guarantees of your choice

LThe guarantees in the contract that you have chosen shall take effect on the date of your membership (and that of the registration of your entitled persons) subject to the waiting time. The Delegatee will assume the costs incurred from the date of the guarantees coming into effect and for the duration of the Coverage Period.

ARTICLE6-CHANGESINTHEFEATURESOFYOURGUARANTEE

6.1 In case of change of Host country, you should inform the Delegatee, in writing, at least 1 month before the effective date of the change. When this change results in a change of geographical area of guarantee, the coverage in the new area and its pricing will be applicable on the first day of the month following the effective date of the change.

6.2 You choose the guarantee level on the day of your membership, both for you and your entitled persons. However, it is possible to change the previously selected level of guarantee depending on the assumptions set out in paragraph 6.3 below. You must inform the Delegatee in writing.The new guarantee level and its pricing will apply from the first day of the calendar month following the date of receipt of the letter of the agreement expressly mentioning the new desired level of security

6.3 The hypotheses of change in the level of guarantee

You can change the previously selected level of guarantee:

• at each annual renewal of your membership (1st January). You must notify the Delegatee at least one month before the date of amendment;• in case of change in family situation (Marriage, conclusion of a PACS, common-law marriage, widowhood, birth or adoption of a child, divorce or legal separation, dissolution of the PACS, end of a well-known cohabitation). You must notify the Delegatee in the month following the change in your family situation;• in case of host country change resulting in a change of geographical area of guarantee. You must notify the Delegatee at least 1 month before the actual change of Host country

6.3.1 In case of increase in the guarantee level

You must complete a new application form and provide a new medical questionnaire for you and your beneficiaries. The Delegatee reserves the right to refuse the increased guarantee.The waiting periods (Article 8-II) are applied to the difference in benefits from the effective date of the new level of guarantee.

6.3.2 If level of guarantee is reduced

If you want to switch to a lower level of guarantee as compared to the previous level, you can, provided you have already joined the “Assur Travel Health” Contract for at least one year. To do this, you must complete and submit a new application form to the Delegatee.

6.4 Changing the type of guarantee (in addition to the C.F.E. or French Social Security, or 1st Euro)

When changing your situation vis-à-vis the C.F.E. or French Social Security with the beginning or end of the subscription to one of these plans you can, during the course of membership, change the guarantee type. You must inform the Delegatee by registered letter accompanied by documents justifying your change in circumstances, and certificate of affiliation to one of these plans as appropriate. The change in the type of guarantee and its pricing will take effect from the first day of the calendar month following the explicit acceptance of the Delegatee, subject to entitlement to the host regime if required.

ARTICLE7-TERMINATIONOFYOURMEMBERSHIPANDYOURGUARANTEES

For You, MemberYour membership and your benefits cease:

• at the next contribution deadline in case of termination of the Contract;• in case of termination of your membership at the time of the annual renewal (Article 5.1-I);• on the day of final return to your home country;• in case of non-payment of your dues (Article 9.1-I);• on the day of receipt of a letter stating that you wish to terminate your membership as part of your right of withdrawal (Article 11-I) by the Delegatee;• on the date of your death;• when you no longer meet one of conditions for accession to the Agreement (Article 3-I);• The guarantees of SUMMUM Formula ceases at the first renewal after your 70th birthday or that of one of your beneficiaries;• in the event of affiliation to a compulsory system of Host country (Article 5-I).

For your beneficiaries Registration and guarantees of your beneficiary cease:

• together with your membership if it ceases under the conditions defined above;• if they no longer meet the definition of spouse or dependent child (Article 3-I).

ARTICLE8-CALCULATIONOFYOURCONTRIBUTION

8.1 If you and/or your beneficiaries join/register temporarily, or in any case of departure during the year, the amount of your contribution will be adjusted on a pro rata basis and the assessment for the last months of membership/registration will be due for the entire month.

8.2 8.2 The pricing conditions are determined based on the selected guarantee level (BASIC, PREMIUM ACCESS, PREMIUM, COMFORT ACCESS, COMFORT, or SUMMUM Formula), the type of collateral (in addition to benefits paid by the C.F.E. or French Social Security, or 1 Euro), geographic guarantee Zone (Zone A, B, C or D) applies, your age, your family situation (individual or family) and application of a premium, if necessary, following the medical selection.



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8.3 Ages considered in the calculation of the contribution are yours and that of your beneficiaries as on the day of appeal of the assessment.

The Insurer reserves the right to adjust the amount of your contribution on April 1 each year according to the evolution of the medical costs of health spending in each country, the change of local legislation and technical results of the Contract signed with the Insurer.If modified, the new amount of your contribution will be applicable from the due date of contribution.

ARTICLE9-PAYMENTOFYOURCONTRIBUTION

9.1 You are responsible for paying your dues to the Association or its Delegatee. The fee is payable in advance only in Euro (€) by cheque, bank transfer, credit card on the secure website indicated by the Delegatee, or by direct debit from your bank or postal account, quarterly, semi-annually or annually depending on the fractionation and modes chosen on your enrolment form. Bank charges are your sole responsibility.

Pursuant to Article L. 141-3 of the Insurance Code, the Association or its Delegatee may exclude you from the benefit of the Contract if you stop paying your dues. The exclusion will take place after a period of 40 days from the sending of a letter of formal notice. This letter can be sent only ten days at the earliest after the date on which the amounts due must be paid.

In the notice, the Association informs you that after the expiry of 40 days, failure to pay the membership fee is likely to result in termination of your membership. This exclusion shall not preclude, where applicable, the payment of benefits acquired in return for the contributions you have paid previously.

9.2 You bear all taxes, charges and levies, charges and future, applicable to contributions or to the amounts due or which will become due in the future.

9.3 The contributions for the C.F.E. membership must be paid directly to the C.F.E.

9.4 The contribution is due up to the date of termination of your membership. After termination of your membership, payment of contributions, whether total or partial, will be only be for regularization of your account and will not, unless specifically requested by you and accepted by the Delegatee by mail, constitute a reinstatement of the coverage due under the Contract.

ARTICLE10-DECLARATIONSANDCOMMUNICATIONS

10.1 Pursuant to Article L. 113-8 of the Insurance Code, your membership or registration of your entitled beneficiaries for the Contract is void in case of deceitful concealment or intentional false declaration on your part and when such concealment or intentional false declaration may change the nature of the risk or diminish the assessment for the Insurer, even if the risk omitted or distorted by the insured is immaterial to the claim.

10.2 Pursuant to Article L. 113-9 of the Insurance Code:

• omission or unintentional misrepresentation to the Insurer on your part before the occurrence of the loss or incident results in either maintaining membership with an increase in the contribution, or termination of membership of the Agreement 10 days after the notification has been sent by registered letter;• omission or unintentional misrepresentation on your part after the occurrence of the incident will result in a reduction of the allowance in proportion to the amount of contributions paid in relation to the contributions that would have been payable if the risks had been correctly declared.

10.3 In case of concealment or intentional misrepresentation by you or your beneficiaries, the contributions you have paid will remain with the Insurer as compensation, as per article L. 113-8 paragraph 2 of the Insurance Code.

ARTICLE11-RENUNCIATIONOFMEMBERSHIP

You may terminate your membership to the Agreement by exercising your right to cancellation within the framework and under the conditions of the following articles:

11.1 Article L.112-9 first paragraph of the Insurance Code provides: “Every natural person who is the subject of a solicitation to his home, to his residence or to his workplace, even at his request, and who signs an insurance proposal or contract in this context for purposes which do not fall within the scope of their commercial or professional activity, has the right to withdraw by registered letter with acknowledgement of receipt within the period of 14 calendar days from the day of conclusion of the Agreement, without having to give reasons or to pay penalties. (….) Once it is aware of a claim involving Guarantee Agreement, the participant cannot exercise this right of cancellation.”

If you want to exercise your right to cancellation, it is advisable to write your letter as follows:

I (Full name (s) of the Member), residing in (Main residence) renounce my membership Contract with Assur Travel Health No. A 4916 (your complete membership number), I signed on (DD / MM / YYYY).(If contributions have been received) Please pay me the contributions paid, as provided by Article L. 112-9 of the Insurance Code, net of the contribution due in proportion to the coverage period.(In case of distance marketing) I agree, for my part, to repay the amount of benefits that have been paid to me.At …………………, on……………… Policyholder’s signature

Consequences in case of an applicant exercising the right to cancellation under Article L. 112-9 of the French Insurance Code:Exercising the right to cancellation leads to acceptance of the Contract, being revoked from the date of receipt of the registered letter. However, once you become aware of an incident involving guarantee of the Contract, you may no longer exercise this right to cancellation.In case of cancellation, the Delegatee will refund premiums within thirty days of the date of cancellation, after deducting the amount corresponding to the duration during which the policy was effective. The entire premium is still due to the Delegatee if you exercise your right to cancellation when a loss or incident involving the guarantee of policy and of which he is not aware occurs during the cancellation period.

11.2 In the event of exercise of the right to cancellation according to the terms of the articles L. 112-2-1 of the Insurance code and L. 121-20-8 of the Consumer code (remote sale or provision of services):

In return for the immediate and complete implementation of membership before the expiry of the cancellation period, the premium owed by you are equal in proportion to the annual premiums for the period between the effective date foreseen for the conclusion of membership period and the possible date of receipt of cancellation request.If benefits were paid, you agree to reimburse the amounts collected to the Delegatee within 30 days.If premiums have been received, the Delegatee shall reimburse, after deducting the premiums in proportion to the guarantee period within 30 days



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ARTICLE12-LEGALLIMITATION

Limitation is the extinction of a right after a time period specified by law. All action derived from the contract will be prescribed on time and under the following articles:

12.1 Article L. 114-1 of the Insurance Code

“All actions arising from an insurance contract are limited by two years from the event giving rise thereto.However, this period is not applicable: 1. In case of concealment, omission, false or inexact declaration on the risk involved on the day when the insurer becomes aware; 2. In case of loss or incident on the day when the parties concerned were aware, if they prove that they were unaware until then.In case of action of the insured against the insurer because of the use of a third party, the period of time begins to run from the day when the third party has exercised a lawsuit against the insured or was compensated.The requirement is extended to ten years in life insurance contracts when the beneficiary is a separate person from the subscriber, in insurance contracts against accidents where the beneficiaries are the people related to the deceased”.

12.2 Article L. 114-1 of the Insurance Code

Requirement is interrupted by one of the ordinary causes of interruption and the appointment of experts following a loss or incident. The interruption of the limitation of the action may also result from sending a registered letter with acknowledgement of receipt by the Insurer to the Member regarding the payment of fees and by the Member to the insurer regarding the payment of compensation.

12.3 Article L.114-3 of the Insurance Code

“Notwithstanding Article 2254 of the Civil Code, the parties to the insurance contract cannot, even by mutual agreement, modify the duration of the requirement, nor add to causes of suspension or interruption of the clauses mentioned above.”.

ARTICLE13-EXAMINATIONOFCOMPLAINTS-MEDIATION

Primary Contact: your local representativeIn case of complaint concerning the Contract, at first, you are invited to contact your usual contact (commercial intermediary or customer service).

Secondary contact: complaints departmentIf disagreement persists, you can intervene with service complaints: Claims Service of Group Insurance: SwissLife Prévoyance et Santé, Group Insurance Department, Complaints Department, 7 rue Belgrand 92682 LEVALLOIS CEDEX.

As a last resort: the Mediation Department The Mediation Department intervenes after all the tracks from the different services have been exhausted.Its details will be systematically indicated by the claims department, in case of partial or total refusal to accede to the claim.

After exhausting internal procedures: the Ombudsman of the FFSA The Ombudsman of the FFSA (French Federation of Insurance Companies) can be approached, after exhaustion of internal procedures. Only disputes relating to individuals are the responsibility of the Ombudsman of the FFSA. The Ombudsman of the FFSA may not be approached if legal action has been or is engaged. Its details are systematically indicated by the claims department, in case of partial or total refusal to accede to the claim.

ARTICLE14-RIGHTTOCOMMUNICATIONANDRECTIFICATION

In accordance with the «computer and liberties» dated 06.01.1978, the controller of the information collected is the entity of SwissLife Group mentioned in this document.The data is used for the management and monitoring of your application by this entity, and sending information documents related to products of SwissLife Group companies, recipients, agents, partners and reinsurers. They are also processed in the framework of the fight against money laundering and terrorist financing. Failure to reply to the mandatory information may result in the non-processing of your file. Optional data elements are marked.

You have a right to access and rectify data concerning you, and the right to object to their treatment for a legitimate reason. You must send inquiries to Swiss Life Marketing Department 1 rue du Mal de Lattre de Tassigny - 59671 Roubaix Cedex FRANCE 01. In case of requests related to medical data, please make them to the attention of Medical adviser 7 rue Belgrand - 92300 Levallois-Perret FRANCE.



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II.HEALTHCOVERAGE:HOSPITAL,MEDICALEXPENSES,MATERNITY

1.1 The aim of the Health guarantee is to reimburse all or part of your expenses and those of your beneficiaries for medical-surgical, optical or dental treatment, and expenses due to maternity. The expenses taken into account are exclusively those contained in the Table of Health Benefits (Article 2-II).

1.2 For You and your Beneficiaries, expenses are paid for treatments for which the starting date is between the effective date and termination date of membership (or registration), on condition that the medical treatment that gave rise to these expenses has been prescribed and carried out by doctors authorised and approved to do so, or by Eligible Health Establishments.

1.3 When the reimbursement shall complement C.F.E. or French Social Security payments:

• reimbursement of the Delegatee is subordinate to that of these organizations, it being understood that any reimbursement by one or other of these schemes will be deducted from the amount covered by the coverage provided for in the Contract in accordance with paragraph 1.5 below;• only those expenses are reimbursed for which the start date of care as it appears on the slip of the C.F.E. or the French Social Security is between the dates of entry into force and termination of membership (or registration).

1.4 1.4 For the care which is provided in France, the conditions for repayment are defined by the French Social Security or any other similar organization.

1.5 Cumulative insurance

The benefits under the Agreement are in addition to similar benefits which may be paid both by the C.F.E. or French Social Security, and any additional coverage you or your beneficiaries might have, where any of you can receive an amount greater than the expenses actually incurred.You must notify the Delegatee, if any, that you and/or your beneficiaries are insured from one or several other insurer(s) for the same, against the same risk as those covered by the “Assur Travel Health” Agreement.

ARTICLE1-COVERAGEBENEFITS



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(1) Request for preliminary agreement obligatory(2) Request for preliminary agreement obligatory for a series of procedures (>10 sessions)(3) Request for preliminary agreement obligatory for treatment or procedures costing over €300(4) Possible direct payment

€ 750 000

100%

100%

100%

100%

100%

€60 / day

€30 / day

100%

100%

100%

100%

100%

90%

not covered

not covered

not covered

not covered

€ 750 000

100%

100%

100%

100%

100%

€50 / day

€30 / day

100%

100%

100%

100%

100%

90%

not covered

not covered

not covered

not covered

€ 1 500 000

100%

100%

100%

100%

100%

€60 / day

€30 / day

100%

100%

100%

100%

100%

90%

100%

(max. €2500 /year)

100%

(max. €5000 /year)

not covered

90%

€ 2 000 000

100%

100%

100%

100%

100%

€120 / day

€45 / day

100%

100%

100%

100%

100%

100%

100%

max. €5000/year

(€3000/year in

Zone A + France)

100%

max. €10000/year

(€6000/year in

Zone A + France)

100%

(max. €1000 year

and max. 3 IVF/

duration of policy)

100%

€ 1 500 000

100%

100%

100%

100%

100%

€120 / day

€45 / day

100%

100%

100%

100%

100%

100%

not covered

not covered

not covered

not covered

€ 2 500 000

100%

100%

100%

100%

100%

€180 / day

€60/ day

100%

100%

100%

100%

100%

100%

100%

max. €7500/year

(€4000/year in

Zone A + France)

100%

max. €15000/year

(€ 6000/year in

Zone A + France)

100%

(max. €1500/year

and max. 3 IVF/

duration of policy)

100%

Maximum limit by policyholder and calendar year

Medical or surgical hospitalisation (1) (4)

Outpatient Hospitalisation (1) (4)

Psychiatric hospitalisation (limited to 30 days/year) (1) (4)

Medical and surgical fees (1) (4)

Tests, analyses and pharmacy (1) (4)

Private room (1) (4)

Bed in room with child under 16

(limité à 30 jours/an) (1) (4)

Daily rate (1) (4)

Outpatient consultations related to Hospitalisation /

outpatients surgery (1)

Physiotherapy immediately after Hospitalisation

(up to 30 days/year) (1) (4)

Reconstructive dental surgery after an Accident (1) (4)

Organ transplant (1) (4)

Transport by land ambulance (1)

Maternity

- Childbirth costs and pre- and post-birth sessions (1) (4)

- AIDS screening test

- Diagnostic of chromosomal anomalies

Childbirth surgery (1) (4)

IVF - Sterility (pharmacy, in-vitro fertilisation, analyses,

follow-up tests(1) for women under 45

Transport by land ambulance in case of Hospitalisation (1)

FORMULASPREMIUM

ACCESSCONFORT

ACCESSBASIC PREMIUM CONFORT SUMMUM

The warranties made include refunds of C.F.E., the French Social Security or the 1st Euro of costs incurred, within the limits of actual costs

Hospitalisation (in% of real costs)

Maternity in% of real costs)

GUARANTEES1/2



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ARTICLE2-TABLEOFHEALTHCOVERAGE


(1) Request for preliminary agreement obligatory(2) Request for preliminary agreement obligatory for a series of procedures (>10 sessions)(3) Request for preliminary agreement obligatory for treatment or procedures costing over €300(4) Possible direct payment(5) Request for preliminary agreement obligatory for treatment or procedures costing over €500

€ 750 000

90% (max. €40/

consultation)

90% (max. €60/

consultation)

80% (max. €40/

procedure)

80%

80%

80%

90%

80% (max.

€30 per procedure

and €240/year)

not covered

not covered

not covered

not covered

not covered

-

not covered

not covered

not covered

€ 750 000

not covered

not covered

not covered

not covered

not covered

not covered

not covered

not covered

not covered

not covered

not covered

not covered

not covered

-

not covered

not covered

not covered

€ 1 500 000

90% (max. 40 €/

onsultation)

90% (max. €60/

consultation)

80% (max. €40/

procedure)

80%

80%

80%

90%

80% (max.

€30/ procedure

and €240/year)

not covered

90% within

limit of €300/year

90% within


90% within


90% within


€1000/year (€500

the first year)

90%

90% (max. €200

per tooth)

90%

(max. €600/ year)

€ 2 000 000

100% (max. €100/

consultation)

100% (max. €130/

consultation)

100% (max. €80/

procedure)

100%

90%

100%

100%

100% (max.

€70/ procedure

and €1000/year)

€100 (max. €300/year)

100% within


100% within


100% within


100% within


€2000/year (€1000

the first year)

100%

100% (max. €400

per tooth)

100%

(max. €1000/ year)

€ 1 500 000

100% (max. €100/

consultation)

100% (max. €130/

consultation)

100% (max. €80/

procedure)

100%

90%

100%

100%

100% (max.

€70/ procedure and

€1000/year

€100 (max. €300/year)

not covered

not covered

not covered

not covered

-

not covered

not covered

not covered

€ 2 500 000

100% (max. €150/

consultation)

100% (max. €170/

consultation)

100% (max. €120/

procedure)

100%

100%

100%

100%

100% (max.

€100/ procedure

and €1600/year)

€100 (max. €400/year)

100% within


100% within


100% within


100% within


€3000/year (€1500

the first year)

100%

90% (max. €600

per tooth)

100%

(max. €1200/ year)

Maximum limit by policyholder and calendar year

GP consultation

Specialist consultation

Treatment by medical auxiliary (2)

Technical medical treatment (outside hospital) (3)

Medical analyses (5)

Radiology (including IRM) (5)

Pharmaceutical expenses and vaccines

Alternative medicine: chiropractic, osteopathy, acupuncture,

homeopathy, and traditional Chinese medicine (limited to

China, Thailand, Hong Kong, Singapore and Vietnam)

Check-up (one check-up every two years)

Equipment for medical prostheses (1)

Lenses and frames

Contact-lenses

Refractive eye surgery (1)

Dentistry limit by policyholder and by year)

Dental treatment (5)

Dentures (including inlays and onlays) (1)

Orthodontia (children under 16, maximum of 3 years for entire

duration of the policy). (1)

The warranties made include refunds of C.F.E., the French Social Security or the 1st Euro of costs incurred, within the limits of actual costs

FORMULASPREMIUM

ACCESSCONFORT

ACCESSBASIC PREMIUM CONFORT SUMMUM

Out patient Services (in% of real costs)

Medical prostheses (in% of real costs)

Vision Care (in% of real costs)

Dental care (in% of real costs)

GUARANTEES2/2



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ARTICLE2(suite)-TABLEAUDESGARANTIESSANTE

ZONEA ZONEB ZONEC ZONED


ARTICLE3-LIMITATIONSOFREFUNDABLEFEE

3.1 Unusual or unreasonable expenses are subject to a refusal of treatment or a limitation of the amount of the guarantee by the Delegatee. To appreciate the «unusual or unreasonable» character of health care costs and to decide on the refusal or limitation of the cover amount, the Delegatee shall take into account the general applicable charge for a service or a similar service in the best possible conditions in the locality where the service or the delivery was administered.

3.2 Health expenses incurred in a private health institution are eligible for reimbursement only if the property was regularly and previously authorized by the competent authorities of the country.

3.3 The Delegatee reserves the right to refuse reimbursement for any medical or administrative reasons if unusual or unreasonable costs are presented. It may call you or call your beneficiaries for examination except in cases of incompatibility with your / their health. Transport costs remain your sole responsibility.

3.4 The costs that were the subject to a refusal of treatment by the Delegatee are your sole responsibility.

ARTICLE4-MAXIMUMENGAGEMENT

Contract coverage is carried up to the following sums per Insured and per calendar year of insurance, including benefits paid by the C.F.E. or French Social Security:

• € 750,000 for the BASIC formula;• € 750,000 for the PREMIUM ACCESS formula;• € 1.5 million for the PREMIUM formula;• € 1.5 million for the COMFORT ACCESS formula;• € 2,000,000 for COMFORT formula;• € 2.5 million for SUMMUM.

ARTICLE5-TERRITORIALSCOPE

The geographical area of coverage is determined by your Host country.

Your coverage applies to reimbursement of expenses that have been incurred in the geographical area applicable to you. However, your benefits will also be held to apply as follows:

• in Zones A, B and C if your geographical area of coverage is Zone D;• in Zones A and B if your geographical area of coverage is Area C;• in Zone A if your geographical area of coverage is Zone B.

5.2 In case of emergency hospitalisation (accident or sudden illness), health costs incurred in countries located outside the geographical area, coverage will be applicable if they are reported by you or your beneficiaries as a private trip or professional up to a maximum of 60 days, and if they were not predictable before travelling. Travel costs are your sole responsibility.

ARTICLE6-REQUESTFORPRIORAGREEMENT

6.1 For all of the procedures listed in paragraph 6.2 below, you must request the prior approval of the Delegatee for realization of treatment methods. The prior approval application must be accompanied by a doctor’s prescription and the prescriber should mention the pathology and the anticipated duration of the treatment.

You must send to the medical board of the Delegatee, in confidence, at least two weeks before the start of the execution of medical procedures, the prior approval application completed and signed by the practitioner. The Medial board reserves the right to request additional documents necessary for the processing of the application.

6.2 The prior approval of the Delegatee must be sought for all the fees listed below.

Hospitalisation• all costs covered by this coverage.

n case of emergency (accident or sudden illness), the request for prior agreement should be addressed to Delegatee within 48 hours after admission to the Eligible Health Institution (hospital or clinic), indicating the urgency of hospitalisation.In exceptional cases, this period of 48 hours may be extended if the Delegatee clearly attests that the urgent situation made it impossible for you to make a request for prior agreement on time.

For any extension of the hospitalisation beyond 10 consecutive days, the application for prior approval must be renewed every 10 days. It must reach the Delegatee within 48 hours after the end of that period.

Maternity• the costs of delivery;• costs related to the surgical delivery;• the costs of in vitro fertilization.

In case of emergency (complication related to pregnancy or childbirth at an unexpected date), prior approval must be sought in the same way as for an emergency hospitalisation.

Common medical expenses• the paramedical procedures performed in series, when their number is greater than 10 per prescription per Insured (prior approval must also be requested in case of renewal of a prescription for less than 10 procedures bringing the number of procedures to more than 10);• the costs of technical medical procedures when they exceed € 300;• legal costs of radiology, medical imaging and medical analysis when the amount exceeds € 500.

Dental• all costs relating to this warranty except for dental care for which prior agreement is required when the amount exceeds € 500.

Optical• cost of refractive surgery treatment of the eyel.

Other prostheses• the cost of equipment and medical prostheses.

6.3 In case of non-compliance with the procedure for prior approval, reimbursement of benefits will be denied. The reimbursable services that were the subject of a refusal by the Delegatee are your sole responsibility.

Africa (excluding South

Africa) Belgium and

France.

Brazil, China, Spain, Hong

Kong, Israel, Italy, Lebanon, United Kingdom, Russia, Singapore, UAE and Australia.

Canada, United States, Japan and the

Bahamas.

Countries not listed in

Zones A, C and D.



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ARTICLE7-DIRECTPAYMENT

7.1 Direct payment means that your health costs are directly paid by the Delegatee to the Eligible Health Establishment.

7.2 Subject to compliance with the procedure of the preliminary approval (Article 6-II), the Delegatee assures direct payment for the following costs:

Hospitalisation• all costs related to Hospitalisation except outpatient procedures directly related to hospitalisation (post and pre-hospitalisation), emergency re-constructive surgery following an Accident, transport by ground ambulance and hospitalisations for less than 24 hours.

Maternity • the delivery costs;• the surgical delivery costs.

ARTICLE8-WAITINGTIMES

8.1 The guarantees in the Contract are valid after a waiting period of:

• 3 months for hospital costs except in cases of accident or sudden illness;• 3 months for the costs of dental and periodontal treatment;• 6 months for physiotherapy costs, if they are not due to surgery;• 9 months for the cost of dentures, orthodontics, vision treatment and other prostheses;• 10 months for the cost of maternity.

8.2 The Waiting periods apply:

• for membership or registration with the Contract;• in case of increase of coverage: in this case, during the waiting period, you and your eligible persons are covered by your former level of coverage.

The waiting time specified in paragraph 8.1 above, except for Maternity coverage can be removed if you justify an equivalent coverage in the month before taking your membership by sending a certificate of radiation to the Delegatee.

ARTICLE9-PAYMENTOFBENEFITS

9.1 For the payment of benefits, you must send in a refund request to the Delegatee accompanied by original pieces as supporting evidence:

• The medical prescription;• The detailed and receipted invoice, as well as fee notes from any practitioner and any Eligible Health Establishment;• The statements of benefits of C.F.E. or French Social Security when the guarantee is underwritten in addition to benefits paid by one of these organizations;• For the treatment provided in France: the CERFA sheet completed by the physician, the pharmacy or the Eligible Health Establishment;• The receipts issued by pharmacies with relative prescription;• The agreement with Delegatee for health care is subject to an application for prior agreement (Article 6-II);• If the costs were incurred outside the geographical area of coverage applicable to you: proof of the expenses incurred is covered under benefits.

9.2 Requests for refunds must be submitted to the Delegatee, under penalty of forfeiture, within two years from the start date of treatment.

9.3 The payment is made to your account or that of an agent you have specifically designated.

9.4 If your Host country is outside the Euro zone you can be paid benefits by bank transfer to a foreign account and in the currency of your choice according to the exchange rate in effect on the date of treatment on receipt of the request for reimbursement, on the basis of financial newspapers used by the insurer or his Delegatee.



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The following risks are excluded from coverage:

• Addictive pathologies and disorders: treatments, or series of, addictive diseases and disorders, or consumption or abuse of any substances, drugs or alcohol. The treatments include detoxification cures, psychoanalysis, psychotherapy;• Conflict and disaster: the treatment of any disease, illness or injury resulting from a nuclear or chemical contamination, war, riot, revolution, terrorism, riot or similar events in which the Insured has taken an active part. It is stated that the case of legitimate defence, fulfilment of professional duty and assisting a person in danger are covered;• Care related to treatment or cosmetic surgery: Treatment undertaken for aesthetic or psychological reasons to enhance appearance, unless the treatment is subsequent restorative surgery to the insured via an accident which occurred during the Coverage Period or subsequent reconstructive surgery operation for breast cancer;• The treatments for teeth whitening even on prescription and executed by a qualified practitioner;• Organ donation: expenses incurred for the acquisition of an organ, including the removal of an organ from a donor, the removal of an organ of the Insured for the purpose of transplantation into another person, the compatibility tests, the transport of the donor organ and the cost of administrative procedures;• Experimental treatments: treatment, including medications, which in the reasonable opinion of the Insurer or his Delegatee, is experimental or whose effectiveness has not been proven on the basis of established medical practices, and has not been approved by the official authorities of the country where the insured has received treatment;• Thalassotherapy: living expenses, treatment or services received in thalassotherapy centres, spa, or similar establishments, even on prescription,• Treatments for the relief of symptoms due to aging, or another natural physiological cause;• Intentional injury: the treatment resulting from injuries and strokes made voluntarily by the Insured himself, during a suicide attempt;• Sport & Hobbies : the costs resulting from diseases linked to the professional practice of sports or leisure activities, and the consequences of participation in dangerous sports, leisure or dangerous competitions including air sports, combat sports, high mountain climbing, off road mountain sports, scuba diving (except that which is practised as a leisure activity in a depth of less than 50 meters), sports requiring the use of air vehicles;• Expenses related to Hospitalisation comforts are not covered, such as newspapers, meals for visitors, and consumer telephone subscriptions, subscriptions to television and cosmetics;• All expenses of personal use, including alcohol, toothpaste, shampoo, and clothing,• Health Establishment or an unrecognized practitioner: treatment administered by a practitioner who is not recognized by the official authorities of the country where the treatment was given;

• Treatment in Health Establishment, or performed by a practitioner or other service provider, which was informed by the Insurer or his Delegatee, by written notice, that it is no longer recognized for insurance purposes;• Treatment relating to any type of non-refundable contraception by the C.F.E. or French Social Security, sterilization, abortion or family planning unless proven danger to the health of the pregnant woman;• Diagnosis and treatment of obesity such as tests and slimming cures;• Treatment of growth diseases such as growth hormones;• The treatment of personality disorders, including affective disorders, histrionic personality disorder, conduct disorder, schizoid personality, autism spectrum disorders, obsessive compulsive disorder, hyperactivity, adjustment disorder , eating disorders and treatments designed to encourage socio-emotional relationships, such as communication therapies except for psychiatric treatment by a psychiatrist as opposed to psychoanalysis, psychotherapy or coaching;• Genetic testing to determine the risk of developing a disease where the disease has not been reported, unless they are reimbursed by the French Social Security or the C.F.E. ;• The diagnosis and treatment of hair loss unless it is due to the treatment of cancer;• The treatment of sexual problems, including impotence, gender reassignment and sexual reduction;• Transportation costs incurred during treatment, unless they are covered in post hospitalisation;• Costs relating to the treatment of complications due to excluded illness or injury;• The treatments related to surrogacy of the Insured or the surrogate mother or foster parent;• Not classified as medical equipment or prosthetics;• Foot care treatments, such as corns, callouses and fingernails, not performed by a podiatrist;• Stay in an Eligible Health Establishment (hospital or clinic) for purposes other than to receive treatment such as convalescence, general nursing care or supervision, or where the treatment given does not require a stay in an Eligible Health Establishment, such as assistance with activities of daily living or services of a therapist or a physician assistant. the coverage of providing a bed Is not excluded when the child accompanying the hospitalized patient is under the age of 16;• Products classified as vitamins or minerals as well as dietary supplements except during a pregnancy if they are subject to a prescription;• Costs incurred prior to the date of taking effect or after the date of termination of membership;• Costs which are not or were not supported by theC.F.E. or French Social Security, except lentils, private room, daily rate, alternative medicine, laser treatment of myopia and the health check-ups;• Unsupported expenses by the C.F.E. due to non-payment of C.F.E. contributions ;• Preventive medical costs not reimbursed by the Agreement.

ARTICLE10-EXCLUDEDRISKS



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