Policy Conditions
UMC Ruime Keuze
These are the policy conditions that apply to your healthcare insurance. Here you can find important information about your heatlh insurance.
Do you want to know more about your health insurance? For more information, for example about claim forms or our healthcare insurance, please visit umczorgverzekering.nl.
You can find healthcare providers that have a contract with VGZ on umczorgverzekering.nl/zorgzoeker.
Do you want to contact us? Go to umczorgverzekering.nl/service-en-contact to see our contact details. We'll be pleased to help you.
Would you like to know which healthcare services and treatments are subject to our prior approval (authorisation)? You can find this in these policy terms and conditions. Go to umczorgverzekering.nl/machtiging for all the information.
UMC Ruime Keuze is an in-kind policy of the healthcare insurer, further referred to as ‘the healthcare policy’. Pursuant to this healthcare policy, you are entitled to healthcare in kind as set out in these policy conditions. You are also entitled to healthcare advice and healthcare mediation.
Our Healthcare Advice and Mediation department advises you about the healthcare provider you can consider for your healthcare issue. Please also contact our Healthcare Advice and Mediation department if you are confronted with a non-acceptable long waiting list for visiting a policlinic or for hospitalisation, for example. You can reach this department through our website.
You are entitled to (reimbursement of the cost of) healthcare as set out in these policy conditions if you are in reasonableness relying on the relevant form and content of healthcare, provided that the form of healthcare is effective and efficient. A key factor in the content and scope of the healthcare form is ‘what the relevant healthcare providers generally offer’. Other factors in the content and scope of the healthcare are the status of science and medical practice. This is determined using the Evidence-Based Medicine (EBM) method. If a standard of care (the status of science and medical practice) is not available, the content and form of care are determined by what is considered responsible and adequate care within the discipline concerned.
Your healthcare provider must meet certain conditions. The relevant healthcare provision sets out which healthcare providers may provide the healthcare services and the supplementary conditions the healthcare provider must fulfil. If the care provider does not meet the applicable conditions, you are not entitled to reimbursement.
Care in kind is provided by a care provider with whom we have concluded a contract for the relevant healthcare: a contracted care provider. An overview of our contracted care providers and the care they may or may not provide on the basis of the contract is available from our website.
The healthcare provider receives the fee for the healthcare provided from us directly. This is done on the basis of the rate agreed with the healthcare provider concerned.
We make agreements with healthcare providers on the quality, price and service of the healthcare to be delivered. Your interests are our number one priority. And if you select a contracted healthcare provider, this will make a difference in costs for you and us. If you selected a healthcare provider that we have not contracted for the relevant care, please take into account that you will have to pay some of the invoice yourself.
Sometimes we make agreements with healthcare providers about the volume of healthcare that any provider may fulfil for a patient: a volume limit or a financial ceiling. This applies only to certain forms of healthcare. More information is available from our website.
The Zorgzoeker reference shows the healthcare providers that we have made agreements with regarding the volume of healthcare. Does a volume contract or a financial ceiling prevent you from using a healthcare provider? Please contact our Healthcare Advice and Mediation department. We will make sure that you can find another care provider.
Exceptions:
Are you going to a healthcare provider with which we have not concluded a contract for the care in question? Then you may be required to pay all or part of the invoiced amount yourself. We reimburse the costs of insured care up to a maximum of 75% of the average rates agreed with the relevant healthcare providers for the relevant forms of care (‘average contracted rate’). If no rates have been agreed with healthcare providers for the care in question and Wmg rates apply, the costs will be reimbursed up to a maximum of 75% of the Wmg rates. If 75% of the amount claimed is less than the maximum reimbursement described in this article, we will reimburse a maximum of 75% of the amount claimed.
Please find the maximum reimbursements in the ‘List of maximum reimbursements non-contracted healthcare providers’. This list is available from our website. The maximum reimbursements were determined without factoring in your excess or personal contribution. These amounts will be set off against the maximum reimbursement.
If there is a case of acute care that is provided by a non-contracted healthcare provider, you are entitled to reimbursement of the costs up to the Wmg rates applicable in the Netherlands. If no Wmg rates apply, we will reimburse the costs up to the market price perceived as reasonable in the Netherlands. Please inform us about such healthcare as soon as possible.
Would you prefer to visit a GP or healthcare group with whom we have not concluded a contract for general practitioner care as set out in Article 11. General practitioner care items 11.1, 11.2 and 11.3.1? Then you are entitled to reimbursement of the cost of healthcare up to a maximum of the applicable Wmg rates. For testing requested by the general practitioner for you and carried out by a different, non-contracted care provider (for example an X-ray or a blood test) we reimburse the costs up to a maximum of 75% of the average contracted rate.
For more information on the reimbursement of medical aids on loan, please see Article 36. Medical aids and dressings.
The Health Insurance Act states that everyone is entitled to reimbursement for non-contracted care. Do you choose payment by a non-contracted healthcare provider? Then you will receive a maximum reimbursement of 75%of the average contracted rate. As a health insurer, we may determine the amount of this reimbursement at our discretion. However, the personal contribution may not prevent you from going to a non-contracted care provider (obstacle criterion). Do you think the amount of this contribution is an obstacle (i.e. prevents you from receiving care)? Then you may request application of the hardship clause. You can contact our Complaints Management Department for this. Indicate why you invoke the hardship clause in your situation. Whether or not your appeal is granted depends on factors such as the amount of the costs and the type of care.
You cannot transfer your claim on us for Nursing and Care (Article 14. Nursing and care (district nurses)), Mental Healthcare (Articles 25. Mental healthcare (GGZ) for insured age 18 and older and 37. Stay), Pharmaceutical care (Article 34. Medications) and Medical aids (Article 36. Medical aids and dressings) to care providers or others with whom we have not concluded a contract for this care (prohibition on assignment). This is a clause as referred to in Section 3:83 paragraph 2 of the Dutch Civil Code.
Most healthcare providers send their invoices directly to us. If you have received an invoice, you can submit your expense claims online using the mijnumczorgverzekering.nl or the UMZ Zorg app. You must keep the original invoice for up to one year after you submit the expense claim. We may request invoices for verification purposes. If you are unable to present the invoices, we may recover the amounts paid from you or set off the amounts paid against any amounts we owe to you. You can also submit expense claims by post. Send the original invoice to P.O. Box 25030, 5600 RS Eindhoven. In some cases, we ask you to complete an expense claim form and send it to us. More information can be found on our website. Please do not send us any photocopies or demands for payment. We only accept original invoices. We only reimburse invoices that we have receive within three years. This three-year period starts on the first day after the day that you become aware the claim is due.
The invoice should at least list the following details:
The invoices and any relevant documents must be itemised allowing for directly and unambiguously deducing which amount of reimbursement we are required to pay. We deduct any excess and statutory personal contribution from the reimbursement. For conversion of foreign invoices in currencies other than euros, we use the historical rates available from www.XE.com This is based on the rate on the day you were treated. Invoices and other relevant documents must be written in Dutch, German, English, French or Spanish. If we deem it necessary, we may ask you to have an invoice translated by a sworn translator. We will not refund the translation expenses.
If a contracted healthcare provider is expected not to be able to provide the care, or provide it on time, you are entitled to healthcare mediation if you have an in-kind insurance policy. We may give you permission to go to an non-contracted healthcare provider for this care. You will need prior written permission from us to receive that care. We will then reimburse the costs up to a maximum of the statutory Wmg rates. If no Wmg rates have been set, we reimburse the costs up to a maximum of the amount invoiced.
To determine whether care is provided on time, we use the following starting points:
We reserve the right to directly pay the healthcare costs to the healthcare provider. This payment voids your right to reimbursement.
If we pay directly to the healthcare provider and reimburse more than we are required to pay based on your healthcare insurance policy, or the costs are otherwise at your expense, the costs are payable to you, the policyholder. We will charge these amounts to you at a later stage. You have a legal obligation to pay such amounts. We reserve the right to settle such amounts with amounts due to you.
For some forms of healthcare, you require a referral, prescription and/or prior approval in writing demonstrating that you are dependent on this healthcare. Details are set out in the relevant healthcare article.
A prior referral, prescription and/or approval is not required for emergency healthcare, i.e. healthcare that cannot reasonably be postponed.
Does the healthcare article set out that you require a referral or a prescription? Then you can request one from the relevant healthcare provider referred to in the Article. This is generally the general practitioner.
In some cases you also require our permission prior to receiving the healthcare. This permission is referred to as prior approval. If you have not obtained prior approval where required, then you are not entitled to healthcare or to reimbursement of the cost of the relevant healthcare.
Do you visit a care provider with whom we have concluded a contract for the relevant care? Then you do not require prior approval. Your healthcare provider will in such cases assess if you fulfil the conditions and/or requests approval from us on your behalf. An overview of contracted healthcare providers is available from our website. You can also submit your request directly to us. Please find our address on our website.
Are you going to a care provider that does not have a contract with us for the care that concerns you? In that case, you need to request our approval in advance. For certain care, the healthcare provider may request permission on your behalf. More information can be found on our website. Before granting authorisation, we verify that your healthcare provider is of impeccable conduct. If this is not the case, this may affect the response to your application for authorisation.
If you have authorisation for insured care, it also applies if you switch to another healthcare insurer or if you received authorisation from your previous insurer.
You are entitled to (reimbursement of the cost of) care if the care has been provided during the term of your healthcare insurance. Should these Policy Conditions refer to a year or calendar year, the actual date of treatment or date on which services/goods were provided as stated by the healthcare provider will determine the year or calendar year to which the relevant costs should be allocated. If a treatment falls in two calendar years and the healthcare provider may charge the cost as a single amount (for example a Diagnosis Treatment Combination), we will reimburse these costs if the treatment was started within the term of the insurance policy and the cost will be allocated to the calendar year of the first treatment.
You are not entitled to:
Do you need care resulting from one or more terrorist acts? then the following rule applies. If the total amount of claims submitted within a year or calendar year for non-life, life or in-kind funeral insurers (including healthcare insurers) according to the Nederlandse Herverzekeringsmaatschappij voor Terrorismeschaden N.V. (NHT or Dutch Reinsurance Company for Terrorism-Related Claims) exceeds the maximum amount that this company reinsures annually, you are entitled to only a certain percentage of the cost or value of the healthcare. The NHT determines the exact percentage. This applies for non-life, life and funeral insurers (including healthcare insurers) that are subject to the Financial Supervision Act. The exact definitions and provisions for the above-mentioned entitlement are included in NHT’s Clauses Sheet Terrorism Cover.
If after a terrorist act an additional amount is provided under Section 33 of the Zvw (Healthcare Insurance Act) or Section 2.3 of the Besluit Zorgverzekering (Healthcare Insurance Decree), you are entitled to an additional scheme as set out in Section 33 of the Healthcare Insurance Act or Section 2.3 of the Healthcare Insurance Decree.
In order to be able to guarantee that you will receive payment on terrorism-related claims, (almost all) insurers in the Netherlands are party to NHT (the Dutch Reinsurance Company for Terrorism-Related Claims). We are also a member. The NHT issued regulations that ensure pay-out of at least part of any terrorism-related claim.
The NHT has set a maximum to the total amount to be paid out relating to terrorist actions. The maximum amounts to 1 billion euros per year for all insured together. If the total claim amount is higher, each insured that submitted a claim will receive pay-out at an equal percentage of the maximum amount. NHT set out the rules for due processing of loss claims in the Protocol for Processing Claims.
In reality, this may mean you are not paid out the full amount claimed. But it also means that you are assured that you will at least be compensated some or all of the losses or cost.
The insurance contract has been concluded on the basis of the information that you have entered on the application form or that you have provided to us in writing. After taking out the healthcare insurance policy, you will receive a policy from us as soon as possible. Furthermore, you will receive a new policy prior to each new calendar year.
These policy conditions form an integral part of the policy. The policy schedule lists the insured and the healthcare insurance policy or policies taken out for them.
The healthcare insurance policy can be taken out by any person subject to mandatory healthcare insurance residing in the Netherlands or abroad.
The healthcare insurer operates throughout the Netherlands. If you are subject to mandatory insurance, you may continue this healthcare policy. Persons subject to mandatory insurance residing abroad are also entitled to concluding this insurance.
These insurance conditions refer to documents. These documents are part of the conditions. This concerns the following documents:
You can find these documents on our website. You can also request the documents via our customer service.
If we suspect fraud, we will conduct an investigation (or have one conducted). You are required to cooperate with this investigation and provide us with relevant and accurate information. During this investigation, we will not pay out any of your claims. Does the investigation reveal that you have, or someone else on your behalf has, committed fraud (for some or all of the relevant claims)? Then your right to (reimbursement of the cost of) care will lapse. In addition, we will recover from you any amounts paid out on the relevant claims. You are also required to pay the costs resulting from the fraud investigation.
In the event of fraud, we reserve the right to report the event to the police. We may also record, or have another party record, your information and that of co-perpetrators and accomplices:
If you commit fraud, we will terminate your healthcare insurance policy. In that event, you will not be accepted for a new healthcare insurance policy for 5 years. We will also terminate your supplementary insurance. In that case, you cannot take out supplementary insurance cover with the insurers of Coöperatie VGZ for 8 years.
We list any healthcare providers who commit fraud on the External Referral Registry (EVR). We do not reimburse care from healthcare providers listed in this registry and inform the relevant healthcare providers accordingly. Prior to providing care, the healthcare provider is required to inform you that we will not reimburse their care.
We process your private data when we carry out your insurance policies. This is completed in compliance with legislation and regulations, including the General Data Protection Regulation (GDPR). Please find more details about this in the privacy statement on our website. The privacy statement also states your rights. If you have any questions regarding processing private data, please contact our Data Protection Officer. For more information about privacy, please check the Privacy page on our website.
Communications sent to the last address known to us will be deemed to have reached you. If you mijnumczorgverzekering.nl want to receive all communications from us electronically, you can indicate this in the My environment or in the UMZ Zorg app.
Upon acceptance to this healthcare insurance policy, you, as the policyholder, also become a member of the cooperative society Coöperatie VGZ U.A., unless you notify us in writing that you do not wish to do so. This Coöperatie represents the interests of its members in the field of healthcare or other insurance. You may terminate your membership at any time, subject to a one-month notice period. Membership ends in any case on the date the insurance contract ends.
As a policyholder, you have a cooling-off period of 14 days when you take out the health insurance. You are entitled to cancel the insurance policy in writing within 14 days of signing the contract. In that event the insurance contract is deemed to have never been concluded.
Insofar as the provisions set out in Title 7.17 of the Dutch Civil Code or in the Healthcare Insurance Act have or ought to have an effect on the healthcare policy, these will be deemed to form an integral part of these policy conditions. Insofar as the provisions set out in Title 7.17 of the Dutch Civil Code or in the Healthcare Insurance Act are conflicting with the provisions of this contract, the provisions of the Healthcare Insurance Act will be leading, followed by the provisions of Title 7.17 of the Dutch Civil Code, followed by the provisions of this healthcare insurance.
Do the provisions of these English insurance conditions conflict with the provisions of the Dutch version of these insurance conditions? Then what is determined in the Dutch insurance conditions takes precedence.
The premium base is the premium without premium discount for any voluntary excess. The premium base and premium discounts applicable to you are set out in your policy schedule.
If you opt for a voluntary excess, you will receive a discount on the premium. This discount is listed on your policy schedule and on the premium annex on our website.
The policyholder is required to pay premiums. No premium is due for an insured person under age 18 until the first day of the calendar month following the person’s 18th birthday. Upon death of an insured, premium is due only up to the date of death. After a change of the insurance policy, we will recalculate the premium as per the effective date of the change.
Someone who turns 18 on 1 July pays the premiums as of 1 August.
The name of the account holder must be the same as the name of the policyholder. The account must be in a country that participates in the Single Euro Payments Area (SEPA).
You are required to pay the premium and (foreign) statutory contribution monthly in advance for all insured, unless otherwise agreed.
if you do not use digital mail, you will pay a fee for paper post. The cost amounts to €1.25 per month. You do not pay any fees for the policy and the European healthcare insurance Card (EHIC). More information on paper post costs is available from our website.
You will pay the premium, excess, personal contributions, fees for paper invoices and benefits paid to you in error using the payment method agreed with us.
Your authorisation for direct debit applies to the payment of premiums, excess, personal contributions, charges for paper post and any amounts paid to you in error. Such an authorisation applies during and if necessary also after expiration of the insurance contract. Please refer to your policy schedule to check the date of direct debit collection of the premium for the entire calendar year. For the other costs, we will notify you at least 3 days before the date on which the amount is collected, stating the amount to be taken out of your account and the direct debit transaction date. If you disagree with a processed payment, you can have the payment reversed later. Please contact your bank within 8 weeks of processing the payment.
You may not set off the amounts due against an amount that you still expect from us.
If you do not pay the premium, statutory contributions, personal contributions, excess, paper post charges and any amounts paid out to you in error before the due date, we will send you a reminder. If you do not pay within the term of at least 14 days as stated in the reminder letter, we may suspend cover of the healthcare insurance policy/policies. In that case you are not entitled to healthcare and reimbursement of healthcare costs from the last premium due date before the reminder. Your obligation to pay the premium will continue during any period of suspension. Entitlement to (reimbursement of costs of) healthcare is restored on the date following the date on which the amount due plus any fees were received.
We reserve the right to terminate the healthcare insurance policy if payments are in arrears. The insurance will not be terminated retroactively in that case.
If you have already been reminded for failure to pay premiums, statutory contributions, excess, personal contributions, paper post charges or any amounts paid out to you in error, we are not required to give you separate written notice if you fail to pay a subsequent charge on time.
We reserve the right to directly settle the premium due, fees and statutory interest with any amounts of claimed healthcare costs or other amounts payable to you.
If we terminate the insurance because you have not paid the premium on time, we reserve the right to refuse an insurance agreement with you for a period of 5 years.
Consequences of not paying 2 or more monthly premiums:
If you have other insured on your policy and payment arrears arose for them, they will receive copies of our messages to you about the premium arrears. You can read the consequences of non-payment of the premium and the administrative premium in Sections 18a to 18g of the Healthcare Insurance Act.
You are not liable for paying premiums to us on the period as referred to in Section 18e of the Healthcare Insurance Act.
You have the following obligations:
If you fail to fulfil your obligations and this harms our interests, we reserve the right to suspend your right to (reimbursement of the costs of) the covered healthcare.
We reserve the right to change the conditions and the premium or premium base of the insurance policy at any time. We will inform you, the policy holder, in writing accordingly. A change in the premium base will only become effective 7 weeks after the date on which you were notified of such change. A change in the conditions will only become effective one month after the date on which you were notified of such change.
If we change any conditions and/or the premium base of the healthcare insurance policy to your disadvantage, you, as the policyholder, have the right to cancel the insurance contract as per the effective date of the change. You may cancel the contract in any case during one month after being notified of the amendment. However, you do not have this right to give notice if a change in the insured healthcare cover results directly from an amendment of the provisions set out in Sections 11 through 14a of the Healthcare Insurance Act.
The insurance contract becomes effective on the date on which we receive your application or application form. You will receive a confirmation of receipt stating the date on which we received your application. If you are subject to mandatory insurance and you do not yet have a BSN (citizen service number), you can still be registered as an insured.
Sometimes we are unable to derive from the application whether or not concluding a healthcare policy with the person to be insured is mandatory for us. In such cases we will request information from you that would prove that concluding a healthcare policy with you is mandatory. The healthcare policy will only become effective on the day we receive such additional information. You will receive a confirmation of receipt stating the date on which we received your additional information.
If the previous insurance policy has been terminated effective 1 January of a calendar year or due to a change in the conditions, the insurance policy will commence at the new insurer as per the termination date of the old insurance policy. You must then sign up with the new healthcare insurer within 1 month after the termination date of your previous insurance.
If the insurance contract takes effect within 4 months after the insurance obligation has arisen, the healthcare insurance starts on the day the insurance obligation arose.
You are required to insure your child within 4 months of childbirth, ensuring that your child is insured from the date it was born.
The Healthcare Insurance Act includes provisions relating to mandatory insurance. It is not mandatory for us to conclude a healthcare policy with or for a person subject to mandatory insurance if that person is already insured pursuant to the Healthcare Insurance Act.
The insurance policy expires automatically on the day following the day:
You, as the policy holder, are required to inform us of the death of an insured or of the end of mandatory insurance of an insured as soon as possible. If you do not notify us of the end of mandatory insurance of an insured on time and we pay the cost of healthcare to a healthcare provider, we will claim these costs from you. If we determine that the insurance policy has terminated, we will send you a termination certificate as soon as possible.
Do you want to change your basic insurance policy to a different basic insurance policy? Then please send us the instructions latest by 31 January. Your new insurance policy will start on 1 January (with retroactive effect).
As the policy holder, you are entitled to terminate the healthcare insurance policy annually as per 1 January, subject to receiving your notice in writing latest by 31 December of the previous year. You then have until 1 February to find another insurer that will insure you retroactively from 1 January.
You, as the policy holder, are entitled to intermediate termination of the healthcare insurance policy in writing:
If your child turns 18, you may cancel your child's insurance before the end of the calendar year. This is only possible if your child has taken out their own healthcare insurance policy.
For cancellation of the insurance policy as set out in Articles 6.3.2 and 6.3.3, you may also make use of the cancellation service of the Dutch healthcare insurers. This means you authorise the insurer of your new healthcare policy to cancel the healthcare policy with the previous insurer.
If we sent you a reminder for arrears in premium payments, you are not permitted to cancel your healthcare policy during that period until full payment of the premium, interest and collection fees has been received. You may cancel the health insurance policy if we have suspended cover or confirm your cancellation within 2 weeks.
We can cancel, rescind or suspend healthcare insurance in writing:
If the health insurance policy ends, you will receive a certification of cancellation with the following information:
If insurance is no longer mandatory, this will also be stated on the certification of cancellation.
If the CAK concluded this healthcare policy on your behalf pursuant to Section 9d, subsection 1 of the Healthcare Insurance Act, the following applies:
If you are age 18 or older, you have a statutory excess of € 385 per calendar year. The costs of healthcare are charged to you up to this amount. If you reach age 18 in the course of a calendar year, the statutory excess applies from the first day of the calendar month following the calendar month after your 18th birthday. The amount of the statutory excess will then be determined in accordance with the calculation method stated in Article 7.4. Calculation method of amount of statutory excess.
The statutory excess is applicable to all forms of care as included in these policy conditions, with the exception of:
We have the option of appointing healthcare providers or healthcare arrangements where you are charged no amount or a smaller amount of statutory excess. This also applies to health-promoting or preventive healthcare arrangements to be specified further. Please find this information on our website.
If your health insurance does not start or end on 1 January, we calculate the voluntary excess as follows:
The healthcare policy term is 1 January through 30 January. That is a total of 30 days. The calendar year has 365 days. The excess is: € 385 x 30 divided by 365 is €31.64 and is rounded off to €32.
When calculating the excess, the costs of care or another service will be allocated to the calendar year in which the care was received. If a treatment falls in 2 calendar years and the healthcare provider may charge the costs as a single amount (for example the Diagnosis Treatment Combination), these costs will be charged to the excess of the calendar year in which the treatment started.
If you are age 18 or older, you may select a healthcare policy with a voluntary excess amounting to: €0, €100, €200, €300, €400 or €500 per calendar year. The costs of healthcare are charged to you up to this amount. Depending on the selected amount of the voluntary excess, you will receive a discount on the premium basis. The selected voluntary excess and any discounts are stated on the policy schedule.
The voluntary excess is applicable to the same healthcare forms as set out in Article 7.2. Which types of care are subject to the statutory excess?.
If your health insurance does not start or end on 1 January, we calculate the voluntary excess as follows:
You selected a voluntary excess of € 100. The health insurance term is from 1 January to 30 January. That is a total of 30 days. The calendar year has 365 days. The voluntary excess is: €100 x 30 divided by 365 is €8.22 and is rounded off to €8. The statutory excess is € 385 x 30 divided by 365 is €31.64 and is rounded off to €32. The total excess amounts to €40 (€32 statutory excess and €8 voluntary excess).
If the healthcare insurance policy does not become effective on 1 January and you had taken out a healthcare policy with us previously with a different voluntary excess amount, then the total voluntary excess is calculated as follows:
You may change the voluntary excess annually as per 1 January. You are required to forward us such changes latest by 31 January. The change will then become effective as per 1 January (with retroactive effect).
If a voluntary excess applies, the healthcare costs will first be deducted from the statutory excess and subsequently from the voluntary excess. The provisions set out in Article 7.5. Calculation of statutory excess apply for the calculation of the voluntary excess amount relating to treatment spread over 2 calendar years.
If you live in or are temporarily residing in an EU/EEA or treaty country outside the Netherlands, you are entitled to the following healthcare:
In the event of emergency care provided by a non-contracted healthcare provider, you are entitled to reimbursement of the costs up to the Wmg rates applicable in the Netherlands or the reasonable market-level rates as applicable in the Netherlands. For foreseeable care that a contracted care provider is not expected to provide in time or at all, we may supplement the compensation for the costs of care provided by a non-contracted care provider up to a maximum of the Wmg rates applicable in the Netherlands or the reasonable market price applicable in the Netherlands.
On the reverse of your healthcare card, you can find the EHIC. If you travel to an EU/EEA country or Switzerland, this card entitles you to necessary medical care abroad. You can use the EHIC in Australia for emergency medical care. You may only use this EHIC if you are insured with us. If you use this EHIC abroad, while you know or could reasonably know that it is no longer valid, the cost of healthcare will be charged to you. Do you not have an EHIC healthcare card? You can request one free of charge.
If you are living in or residing in a non-EU/EEA country or non-treaty country, you may choose healthcare in your country of residence or temporary residence and select:
The costs of treatment abroad may be higher than the costs of the same treatment in the Netherlands. We will reimburse the costs up to the amount you would receive if you had the treatment in the Netherlands. Therefore please take into consideration that you will likely have to pay for a (large) part of the bill yourself if you are having treatments abroad.
You would like to be treated abroad? If you are admitted to a hospital or other institution for 1 or more nights for this treatment, you will need our prior consent. You also need permission for receiving care abroad if this is stated in the healthcare provisions (Articles 11 to 39). These Articles also set out when you need a referral or prescription.
Do you not need our permission, but would you like to know in advance whether your treatment abroad is eligible for reimbursement? Then contact us to ask us to review it for you. For more information, please check our website.
You do not require approval if you are unexpectedly hospitalised and the treatment cannot reasonably be postponed until you have returned to your country of residence. If you are admitted for 1 or more nights, you must call, or have someone else call, our emergency centre. The phone number is available in the UMZ Zorg app, on your healthcare card and on our website.
You may rest assured that we organise everything carefully relating to your healthcare insurance policy. However, one hundred percent satisfaction is not always achievable. We are open to hearing your complaints and suggestions. For more information regarding filing a complaint, please visit our website.
You will receive a response to your complaint from us within 30 days. If you are not satisfied with the decision or have not received a response within 30 days, you can submit your complaint or dispute to Stichting Klachten en Geschillen Zorgverzekeringen (SKGZ), PO Box 291, 3700 AG Zeist, www.skgz.nl. Alternatively, you may submit the dispute to the competent court in the Netherlands.
Do you find a form redundant or complicated? Then you may submit a complaint. For more information, see our website.
Alternatively, you can submit your complaint to the Dutch Healthcare Authority for the attention of the Information Line/the Notification Centre, PO Box 3017, 3502 GA Utrecht, the Netherlands, email: info@nza.nl. The website of the Dutch Healthcare Authority, www.nza.nl, sets out how to submit a complaint about forms.
Your insurance is an in-kind insurance policy. You are entitled to care on the basis of this insurance cover. Articles 11 through 39 list the details of the care to which you are entitled.
General practitioner care is medical care as general practitioners tend to provide and the accompanying examinations and diagnostics. GP care also includes health advice, assistance in giving up smoking and preconception care (childbirth consultation). Foot care as defined in the NZa policy rule Other medical care also falls under general practitioner care.
Counselling for quitting smoking is defined as:
Information about the Quit Smoking Programme is set out in Article 24. Quit Smoking programme.
Pre-conception healthcare (pregnancy wish visit) is defined as:
Specialist medical care bordering on the medical domain of the general practitioner. Examples of such healthcare include:
Multidisciplinary care (chain care) in connection with:
Contracted multidisciplinary care (chain care) in connection with:
Your healthcare group may charge you for this care only based on a contract concluded with us.
Multidisciplinary care specifically developed to organise healthcare for chronic patients in a region better in terms of quality and effectiveness. The healthcare providers work closely together within a healthcare group, ensuring that the healthcare you need is better aligned. The healthcare is based on a standard of care. This is a description agreed by the relevant healthcare providers that an insured person must receive in the event of a certain disorder. This standard forms the starting point for care the insured person receives and who provides this care. If no standard of care is described, care is provided on the basis of the professional standards of the professional groups involved.
The healthcare group is a partnership of healthcare providers with various disciplines, with a general practitioner in charge. Together, they provide chain healthcare. In addition to the general practitioner, healthcare is also delivered by a nurse, physician’s assistant, dietician, podotherapist or pedicurist, for example.
No excess applies for this healthcare. The excess is applicable to medications. The excess is also applied for laboratory tests and diagnostics conducted by a different healthcare provider at the request of the general practitioner and charged to you. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
You can ask your general practitioner's clinic about the possibilities for multidisciplinary care. For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions.
If you select a non-contracted healthcare group for contracted multidisciplinary care as described in item 11.3.2, you are not entitled to reimbursement.
Do you not use multidisciplinary care or are you unable to use it in your area? Then you are entitled to care provided by individual healthcare providers under the relevant healthcare Articles, such as general practitioner care (items 11.1 and 11.2) and dietetics (Article 29. Dietetics).
Would you prefer to visit a general practitioner or healthcare group with whom we have not concluded a contract for general practitioner care or multidisciplinary care as described in section 11.1, 11.2 or 11.3.1? Then you are entitled to reimbursement of the cost of healthcare up to a maximum of the applicable Wmg rates.
Would you prefer to visit a care provider other than a general practitioner or healthcare group with whom we have not concluded a contract for the relevant care? Then please take into consideration that you will likely have to pay part of the bill yourself. This also applies to testing requested by your general practitioner to be carried out by another non-contracted healthcare provider (for example X-rays or blood tests). For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
Medical care for specific patient groups is medical care such as general practitioners and clinical psychologists tend to offer. This is general medical care aimed at vulnerable elderly people, people with chronic progressive degenerative diseases, non-congenital brain injuries or a mental disability.
This care also comprises:
This healthcare is set off against the excess.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
General practitioner or medical specialist. Referral for care as listed in article 12.2 may also be issued by a specialist in geriatrics, physician for the mentally handicapped, GZ psychologist or general remedial educationalist.
You require our prior approval for:
More information about applying for approval is set out in Article 1.9. Referral, prescription or approval of these policy conditions.
The chain approach to care and support due to overweight and obesity is for insured up to age 18 with a moderately increased weight-related health risk (WRH). The WRH is determined based on the standard of care for obesity. The chain approach includes at least guidance and coordination by a central healthcare provider. A central healthcare provider:
A combined lifestyle intervention (CLI) for insured up to age 18 is part of the chain plan. A CLI is an accredited care programme on healthy eating, eating habits and increased exercise, and serves to develop and maintain a healthy lifestyle. Optionally, customised psychological interventions to support behavioural change may be part of the care programme.
The chain approach as a whole can be applied up to 3.5 years. This 3.5-year period includes a possible 6-month interim period during which activities in the social or public domain take place. The interim period may be extended in consultation with us if it can substantially contribute to achieving the goal of the care plan.
A CLI lasts for 24 consecutive months. You are not entitled to reimbursement of the costs of exercise and guidance.
Is a CLI not part of the care plan? Then the cost of coordination by a central care provider is not covered by healthcare insurance.
No excess applies for this healthcare.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
General practitioner, paediatrician, adolescents physician or level 5 adolescent nurse practitioner.
A combined lifestyle intervention (CLI) is an accredited programme on healthy eating, eating habits and increased exercise to develop and maintain a healthy lifestyle. Optionally, customised psychological interventions to support behavioural change may be part of the care programme. Are you age 18 or older? Then you may qualify for an accredited programme starting with a moderately elevated weight-related health risk (WRH or WRH). The WRH is determined on the basis of the Obesity Care Standard. Are you age 16 or 17? Then you are eligible for a CLI if you have a moderately elevated WRH and your GP estimates that you could benefit from a CLI for adults Please find the accredited programmes on our website. A programme is completed in 24 consecutive months. You are not entitled to reimbursement of the cost of exercise or assistance with exercise.
No excess applies for this healthcare.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
General practitioner.
Nursing and care is care such as nurses tend to provide without the need for a stay in an institution. The care is related to the need for or a high risk of medical care as set out in article 2.4 of the Healthcare Insurance Decree. In addition to nursing activities and care, this care also includes coordination, signaling, prevention, instruction, strengthening of the client's own control and autonomy, the client system and case management. This care also includes care such as a nurse would provide if you were to make use of an emergency call via a personal alarm (for example if you had fallen at home). Medical child care at home, in a nursery providing nursing care or in a child care home is also covered by nursing and care. Medical child care is also referred to as intensive child care.
You need an indication for nursing and/or care and a care plan must be prepared. The treatment plan describes the healthcare you need in terms of nature, scope and duration and the goals set.
An increasing number of specialist medical treatments are provided in a residential setting. We do not reimburse the associated nursing and care if we pay for it as part of specialist medical care.
You may be entitled to reimbursement of nursing and care in the form of a personal budget (pgb). This requires our prior approval. The Nursing and Care Personal Budget Regulations set out the terms and conditions that apply to having a pgb. The Nursing and Care Personal Budget Regulations are available from our website.
No excess applies for this healthcare. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
You cannot transfer your claim on us for nursing and care to care providers or others with whom we have not concluded a contract for this care (prohibition of assignment). This is a clause as referred to in Article 3:83 paragraph 2 of the Dutch Civil Code. A reimbursement for the costs of care provided by a care provider with whom we do not have a contract will be transferred to the policyholder's account number.
You require our prior approval for such healthcare. You do not need prior approval for the medical indication. More information about applying for approval is set out in Article 1.9. Referral, prescription or approval of these policy conditions.
Obstetric care, including pre and after care, is care as obstetricians tend to provide. Obstetric care also includes the use of the delivery room if delivery in a hospital or birth clinic is medically necessary.
No excess applies for obstetric care. Any fees associated with obstetric care, such as medication, blood tests and patient transport, are also subject to the excess. No excess applies for the placement and removal of an IUD (coil) by the obstetrician. The excess does apply to the IUD (coil). See Article 34. Medications and the Medical Devices Regulations for reimbursement of the IUD. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
Obstetricians, maternity care nurses and gynaecologists collaborating in an Integral Maternity Care Organisation are permitted to agree on an integral rate for maternity care with us. Integrated maternity care aims to facilitate cooperation between the various care providers and improve the quality of care for mother and child. The Integral Maternity Care Organisation (IMCO or IGO) may charge you for this care only based on a contract concluded with us. An overview of contracted Integral Maternity Care Organisations is available from our website. You may change healthcare providers during pregnancy, birth and aftercare.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
Maternity care includes care as maternity nurses tend to provide to mother and child in connection with childbirth, for up to 6 weeks counting from the day of delivery. The number of maternity care hours is indicated using the National Indication Protocol Maternity Care (LIP) and in consultation with the maternity care organisation. Please find this protocol on our website. After delivery and during your maternity period, the maternity care organisation will determine if the number of hours indicated needs to be adjusted. For each day of hospitalisation on which some maternity care has already been provided in the relevant hospital, we deduct the average number of hours of maternity care per day from the number of maternity care hours indicated. If several care facilities (for example, hospital and maternity care organisation) charge for the same day of maternity care, you are also entitled to maternity care on this double day.
Request maternity care at least 5 months prior to the expected due date via our website. Then you can be assured that your request will be processed in time.
You are charged a statutory personal contribution amounting to:
No excess applies for this healthcare.
A qualified maternity nurse who is registered with the Maternity Care Knowledge Centre or nurse. Maternity care as a part of integral birth care may be provided by an Integral Birth Care Organisation (IGO) that has a contract with us. Please find more information about integral maternity care in Article 15.1. Obstetric care.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
Are you using a non-contracted maternity nurse or nurse? Please enclose a copy of the indication in accordance with the LIP (Landelijk Indicatie Protocol Kraamzorg - National Referral Protocol Maternity Care). You can request a copy from your maternity care organisation and/or from the independent maternity nurse or nurse.
Delivery and maternity care at home | Personal contribution and maximum reimbursement | ||
|---|---|---|---|
Delivery and maternity care at home | Delivery at home | Personal contribution and maximum reimbursement | No personal contribution applies. |
Delivery and maternity care at home | Maternity care at home | Personal contribution and maximum reimbursement | Subject to a personal contribution for maternity care amounting to €5.40 per hour. |
Delivery and maternity care in a birth clinic or hospital with medical necessity | Personal contribution and maximum reimbursement | ||
|---|---|---|---|
Delivery and maternity care in a birth clinic or hospital with medical necessity | Delivery in a birth clinic or hospital with medical necessity | Personal contribution and maximum reimbursement | No personal contribution applies. |
Delivery and maternity care in a birth clinic or hospital with medical necessity | Maternity care in a birth clinic | Personal contribution and maximum reimbursement | Subject to a personal contribution for maternity care amounting to €5.40 per hour. |
Delivery and maternity care in a birth clinic or hospital with medical necessity | Maternity care in hospital after delivery with medical necessity | Personal contribution and maximum reimbursement | No personal contribution applies. |
Childbirth and maternity care in a birth clinic or hospital without medical necessity | Personal contribution and maximum reimbursement | ||
|---|---|---|---|
Childbirth and maternity care in a birth clinic or hospital without medical necessity | Childbirth without medical necessity in the delivery room of a birth clinic Childbirth and maternity care in a hospital without medical necessity | Personal contribution and maximum reimbursement | The maximum reimbursement for mother and child together is €261 per day. This fee is calculated as follows:
The difference between the rates charged by the birth clinic or the hospital and the maximum reimbursement of €261 per day is charged to you personally. |
Childbirth and maternity care in a birth clinic or hospital without medical necessity | Delivery without medical necessity in a birth clinic or hospital as part of integral maternity care by an Integral Maternity Care Organisation contracted by us | Personal contribution and maximum reimbursement | The personal contribution for mother and child combined amounts to €549.41. |
Childbirth and maternity care in a birth clinic or hospital without medical necessity | Maternity care in a birth clinic | Personal contribution and maximum reimbursement | Subject to a personal contribution for maternity care amounting to €5.40 per hour. |
Medical necessity | |
|---|---|
Medical necessity | Your midwife or the GP who provides the obstetric care determines whether it is medically necessary for the delivery to take place in a hospital or birth centre is medically necessary. |
Specialist medical care is medical care such as medical specialists tend to provide, including the relevant laboratory and other tests, medications, dressings and medical devices. Specialist medical care also includes:
To the extent you are participating in research testing as referred to in Article 2.2, healthcare insurance Regulations, medical specialist care also includes:
Once the research testing is completed, you are entitled to this care as described in Article 2.2, healthcare insurance Regulations. This does not apply in the event of intermediate suspension of the research testing.
The Minister of Health has the option of designating care as conditionally admitted care four times a year. The above list may not be up to date. It indicates the status insofar as known at the moment of preparing and printing these policy conditions. Please check Article 2.2 of the healthcare insurance Regulations on our website for the most current overview.
This healthcare is set off against the excess. Obstetric care by a gynaecologist is not subject to the excess. Any fees associated with obstetric care are subject to the excess. This means that medications, blood tests or patient transport invoiced separately are set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
A medical specialist. The care may also be provided by a clinical physician audiologist, clinical technologist, geriatric medical specialist, emergency aid physician, specialist nurse or physician assistant (PA), if the indicated care falls within the area of expertise of that healthcare provider.
The healthcare providers were contracted based on quality criteria for good healthcare. This means that certain specialist medical healthcare is purchased only from healthcare providers who fulfil these criteria. Would you like to know which care providers have a contract with us, and for which care? Please refer to our website to see a list of such information.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
Midwives, maternity nurses and obstetricians who work together in an Integral Maternity Care Organisation (IMCO or IGO) can agree an integral rate for maternity care with us. The IGO may charge you for this care only based on a contract concluded with us.
General practitioner, nursing specialist, physician assistant (PA), audiologist, company doctor, paediatrician/doctor in youth health care, geriatric specialist, doctor for the mentally disabled, dentist, obstetrician, optometrist, orthoptist, medical specialist, oral surgeon, Municipal Health Service doctor, clinical physicist audiologist, clinical technologist or physician assistant.
Some treatments are subject to prior approval. Please find such treatments in the Limitative List Authorisations Specialist Medical Care on our website. More information about applying for approval is set out in Article 1.9. Referral, prescription or approval of these policy conditions.
You need approval for all treatments stated in the Limitative List Authorisations Specialist Medical Care. This includes:
If in doubt, we recommend contacting us to check if prior approval is required for any treatment. Your medical specialist is required to notify you that you will be charged the cost of care if you have not received prior authorisation.
The Healthcare Insurance Scheme may exclude certain forms of medical care and medication for treatment of one or more new referrals. The Healthcare Insurance Regulations are available from our website.
Interdisciplinary specialist medical rehabilitation (Interdisciplinary SMR) is care as offered by rehabilitation physicians. This care is aimed at treating people who, due to certain diseases or conditions, experience serious problems in their daily activities and therefore getting by in society. In SMR interdisciplinary, a rehabilitation physician works with a rehabilitation team of specialised healthcare providers from various disciplines. The aim of interdisciplinary SMR is to enable the patient to become more self-reliant, take charge of matters for themselves and participate in society more effectively.
Where indicated by a rehabilitation physician, you may be entitled to Interdisciplinary SMR treatment if you have:
You are only entitled to this care if it is the most effective care for preventing, reducing or overcoming your problems and it enables you to achieve or maintain a degree of independence that is reasonably possible given your limitations.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
A multidisciplinary team of specialised healthcare providers under the supervision of a rehabilitation physician connected to a rehabilitation institution or hospital.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
General practitioner, company doctor or medical specialist.
You require our prior approval. Please find more information about applying for approval in Article 1.9. Referral, prescription or approval of these conditions.
Geriatric rehabilitation care (GRZ) comprises integrated and multidisciplinary rehabilitation care, as offered by geriatric care specialists in connection with vulnerability and complex multi-morbidity (the simultaneous occurrence of two or more diseases). The aim is to restore or improve your functioning and your participation in society.
Geriatric rehabilitation care is only covered if it is not preceded by a stay, as referred to in Section 3.1.1 of the Long-Term Care Act, that is accompanied by treatment at the same institution.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
A multidisciplinary team of experts in geriatric rehabilitation led by a specialist in geriatric medicine.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
Hereditary testing is medical care as referred to in Article 16. Specialist medical care and includes testing of hereditary defects by means of genealogical tests, chromosome tests, biochemical diagnostics, ultrasound tests and DNA tests, the provision of hereditary advice and the psychological-social assistance relating to this care. If this is necessary for the advice to be prepared for you, the examination will also include testing of persons other than the insured. In that case those persons may also receive advice.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
A centre for genetic counselling. This is an accredited and licensed institution for the application of clinical genetic research and genetic counseling.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
General practitioner or medical specialist.
In vitro fertilisation (IVF) is medical care as referred to in Article 16. Specialist medical care and includes a maximum of the first, second and third IVF attempts per pregnancy to be realised if you are age 42 or younger. If you have started with a first, second or third IVF attempt, you may complete this attempt after your 43rd birthday at the expense of your health insurance company. If you are under age 38, the first and second IVF attempts will only be reimbursed if one embryo is placed each time.
In this context, a realised pregnancy is defined as a continuous pregnancy of at least 10 weeks counted from the moment of follicle puncture. Fertilisation of the egg cell takes place immediately consecutive to the puncture. For cryos (cryo-preserved embryos), a term of at least 9 weeks and 3 days after the implantation date applies to define an ongoing pregnancy.
An IVF attempt, being healthcare in accordance with the in-vitro fertilisation method, comprises:
An IVF attempt does not count until successful follicular puncture has been performed in phase b. Only attempts subsequently aborted count toward the number of attempts. The transfer of embryos obtained in an earlier phase of treatment (whether or not cryopreserved in the meantime) is part of the IVF attempt that led to the creation of the embryos. If there are any embryos left over after an ongoing pregnancy has been established, you are entitled to have them re-placed on the grounds of Article 19.2. Other fertility‑related care.
After a continued (achieved) pregnancy or a (live) child born, whether or not as a result of IVF, a new entitlement to three attempts in the event of a new unsuccessful attempt at pregnancy arises due to unwanted infertility. Even after a change of partner, you are entitled to a new set of an IVF treatment course of 3 attempts if there is joint infertility.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
With a gynaecologist in a facility licensed for this purpose.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
Gynaecologist or urologist.
If egg cell donation is used in an IVF treatment, including an ICSI treatment (intracytoplasmic sperm injection), the above conditions for IVF also apply. You are not entitled to (reimbursement of the cost of) the egg cell donation.
Your eligibility for IVF treatment depends on your personal situation, for example your age and how long you have attempted to become pregnant. Would you like to go abroad for IVF treatment? Please contact us in advance. For more information, see our website.
Other fertility-related care is medical care as referred to in Article 16. Specialist medical care and includes gynaecological or urological treatments and operations to promote fertility. This care also includes artificial insemination and intra-uterine insemination. Fertility-related care is not reimbursed for women age 43 or older.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
A gynaecologist or urologist.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
General practitioner or medical specialist.
Audiological care is medical care as referred to in Article 16. Specialist medical care and includes care relating to:
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
In a multidisciplinary team of experts associated with an audiology centre, under the responsibility of a medical specialist.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
General practitioner, audiologist, company doctor, medical specialist, paediatrician, geriatric medical specialist or doctor for the mentally disabled.
Plastic and/or reconstructive surgery is medical care as referred to in Article 16. Specialist medical care and includes treatments of a plastic-surgical nature, if it concerns:
Treatments of a plastic surgical nature are understood to mean: interventions to change the shape or an aspect of the appearance. These procedures are not limited to the specialist field of plastic surgery. The ‘Reference Guide assessment plastic surgery treatments’ sets out a further explanation of when you are entitled to this care in accordance with the criteria listed. This guide was compiled by the Association of Public Health Physicians (Vereniging Artsen Volksgezondheid, VAV), the Dutch healthcare insurers (Zorgverzekeraars Nederland, ZN) and the Netherlands Healthcare Institute (Zorginstituut Nederland). You can find this reference guide on our website.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
A medical specialist. Epilation (hair removal) in transgender care may also be performed by a skin therapist.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
General practitioner, company doctor, medical specialist or dental surgeon.
You need prior permission for treatments included in the Exhaustive List of Specialist Medical Care Authorisations. This list can be found on our website. You do not need permission for a primary or secondary breast reconstruction (a first operation to repair the breast) following breast cancer or a risk of breast cancer. More information on requesting permission can be found in Article 1.9. Referral, prescription or approval of these conditions.
Tissue and organ transplants are classed as medical care as referred to in Article 16. Specialist medical care only if the transplant is performed in a country of the European Union or EEA member state. If the transplant is carried out in another country, the donor must be your spouse, registered partner or blood relative in the first, second or third degree and reside in that country.
Care also includes reimbursement for:
If the donor concluded a healthcare policy, the cost of transportation referred to under e and f will be charged to the donor’s healthcare insurer.
This healthcare is set off against the excess. The excess does not apply for:
For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
A medical specialist.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
Care for the sensory disabled is multi-disciplinary care in connection with a visual, auditory or communicative impairment resulting from a language development disorder or a combination of these impairments. This healthcare is aimed at learning how to manage, reverse or compensate for the disability, with the purpose of optimising independence in daily life.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
An institution specialised in treating people with a sensory disability, with a multidisciplinary treatment team.
Healthcare relating to a visual impairment: the ophthalmologist or healthcare psychologist has final responsibility for the healthcare delivered and the treatment plan. The clinical physician or other disciplines may also bear this responsibility. The activities of the clinical physician or other disciplines are limited in that case to the healthcare as set out in Section 2.5a of the Healthcare Insurance Decree, and the requirements and conditions imposed on sensory disability healthcare.
Healthcare relating to an auditive impairment or communicative impairment due to a language development disorder: the healthcare psychologist has final responsibility for the healthcare delivered. The orthopedagogist or other disciplines may also bear this responsibility. In that case, the activities of the remedial educationalist or other disciplines are limited to the care as described in Article 2.5a Health Insurance Decree and the requirements and conditions set out therein for sensory disability care.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
Medical specialist or general practitioner. Referral for care in connection with an auditory or communicative disability may also be made by a clinical physicist-audiologist at an audiology centre.
The quit smoking programme comprises medical care to support behavioural change with the aim of quitting smoking. Medications can also be part of this care if prescribed as part of the programme, to support behavioural change. You can attend the programme in a group or individually. The objective of the programme is for you to quit smoking. You may attend a Stop Smoking programme maximum once per calendar year.
No excess applies to this healthcare type. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
Healthcare providers who work in compliance with the Healthcare Module Tobacco Addiction. The medications may only be delivered by one of our contracted (online) pharmacies. These are listed on our website.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? Or do you use a pharmacist or dispensing general practitioner with whom we have not concluded a contract for these medications? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
Mental healthcare is medical care as psychiatrists and clinical psychologists tend to provide for insured age 18 and older. The treatment (intervention) must comply with the state of art and best practice. On our website, you can find information about treatments that meet this requirement in the List of Therapies GGZ. This overview states which therapies do or do not comply and in which situations they may be applied.
An exploratory consultation may form part of this care at the request of the general practitioner. In an exploratory consultation, the help you are requesting and the support or care you can be offered will be discussed with you. Relevant questions include whether you need support from the municipality or other civil society organisations, or mental healthcare, or support combined with mental healthcare. In the latter case, the most appropriate care - simultaneous or sequential - is also considered. If the exploratory consultation reveals that you are entitled to mental healthcare, you will require a referral letter for that care.
Care for which effectiveness is not, or not adequately, substantiated by evidence is not covered by basic insurance. To determine whether care is covered, we rely on DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), care standards, opinions of Zorginstituut Nederland, Zorgkompas Zorgverzekeringswet and the List of Therapies GGZ, among others.
Please find below a list of some conditions, treatments and interventions that are not covered by the GGZ mental health system. This list sums up examples and is not exhaustive:
The excess applies to this care. The excess does not apply to the exploratory consultation. For more information, see Section 7. Statutory excess and 8. Voluntary excess of these insurance conditions.
A care provider that has an approved GGZ quality statute, registered via the GGZ Quality statute website.
The National Quality Standard for Mental Healthcare contributes to the fact that the right care is provided at the right place by the right care professionals. All GGZ healthcare providers are required to prepare their own GGZ quality standard. In the section Public Data, the website www.zorginzicht.nl offers an overview showing which care providers have an approved GGZ quality standard and where you can view the standard. In the quality standard, the care provider must indicate how the quality standards are structured and specified. The care provider's quality statute also sets out who is responsible for the indication and/or coordination of care. This is the leading treatment professional. The quality certificate can help you select your healthcare provider.
In an independent practice, the primary practitioner usually performs the treatment personally. Several care providers may be involved in the treatment in an institution. Among other things, the coordinating primary care provider determines the cooperation with these care providers. The primary care provider also ensures that you participate in the decision-making process regarding your treatment options.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
You cannot transfer your claim for mental healthcare against us to healthcare providers or others that have no contract with us for this care. This is a clause as referred to in Section 3:83 paragraph 2 of the Dutch Civil Code. A reimbursement for the costs of care provided by a care provider with whom we do not have a contract will be transferred to the policyholder's account number.
General practitioner, occupational physician, medical specialist, psychiatrist, geriatrics specialist, doctor for the mentally handicapped, street doctor or your primary practitioner in case of a referral. A street doctor is a (family) doctor who provides care to homeless people.
Were you receiving mental healthcare based on the Youth Act and you do not have a referral letter for this from a referrer as listed above? Then you need a new letter of referral.
The referral must comply with the 'Mental Health Referral Agreements' as established by the Ministry of Health, Welfare and Sport.
More information about applying for approval is set out in Article 1.9. Referral, prescription or approval of these policy conditions.
Physiotherapy and remedial therapy is care such as physiotherapists and remedial therapists tend to provide. This care includes:
One-off 9 treatments in pelvic physiotherapy in connection with urine incontinence.
A maximum of 37 treatments of remedial therapy under the supervision of a physiotherapist or remedial therapist (walk training) for peripheral arterial vascular disease in stage 2 Fontaine (claudication) in a period of a maximum of 12 months.
A maximum of 12 treatment sessions for remedial therapy under the supervision of a physiotherapist or remedial therapist in the case of arthrosis of the hip or knee joint in a period not exceeding 12 months.
Remedial therapy under the supervision of a physiotherapist or remedial therapist in COPD (Chronic Obstructive Pulmonary Disease) GOLD class II and higher.
Long-term active exercise therapy in the case of rheumatoid arthritis with severe functional limitations. This means you are not able to perform normal daily activities (such as self-care, walking, getting up and moving) or you need help with them. Information on healthcare providers that may give this exercise therapy can be found on our website.
Treatment of conditions requiring long-term or chronic treatment. This is set out in the List of Conditions for Physiotherapy and Remedial Therapy (Appendix 1 of the Healthcare Insurance Decree). Please take into consideration that the duration of the treatment of certain conditions is limited to a certain term. The first 20 treatment sessions will not be reimbursed.
The list of conditions for physiotherapy and remedial therapy is also referred to as the ‘Chronic List’. This name is not fully appropriate, as not all chronic conditions are listed. Listed conditions include certain conditions of the nervous system or the locomotor system, certain vascular and lung-related conditions, lymph oedema, soft tissue tumours and scar tissue on the skin. In some cases it also includes treatment of a condition after hospitalisation to accelerate recovery. Are you unsure if your condition is on this list? Then check with your healthcare provider beforehand. You can find the List of Physiotherapy and Remedial Therapy Disorders (Appendix 1 of the healthcare insurance Decree) on our website.
Up to 1 exercise programme every 12 months to improve muscle strength, balance and difficulty walking. You are entitled to an accredited programme if a fall risk assessment (also known as a fall analysis) has shown that you need guidance from a physiotherapist or remedial therapist due to physical or psychological problems. Check our website to see who may perform the fall risk assessment. Accredited fall prevention exercise programmes can also be found on our website.
Insofar as you are participating in research testing as referred to in Article 2.2 healthcare insurance Regulations, physical therapy also includes from 1 October 2019 to January 2026, long-term active physical therapy from the twenty-first session for patients with axial spondyloarthritis with severe functional limitations.
Once the research testing is completed, you are entitled to this care as described in Article 2.2 healthcare insurance Regulations. This does not apply in the event of intermediate suspension of the research testing.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
Do you have Parkinson’s syndrome and do you need physiotherapy or remedial therapy? For this type of care, we exclusively conclude contracts with physiotherapists and occupational therapists who are a ParkinsonNet member. If you go to a healthcare provider that is not on the ParkinsonNet list, you will receive a lower reimbursement. For more information, please refer to Articles 1.3. Care provided by a contracted healthcare provider and 1.4. Care provided by a non‑contracted care provider. For more information, see our website.
Do you need remedial therapy (walking training) for peripheral arterial vascular conditions in the legs (intermittent claudication)? For this type of care, we exclusively conclude contracts with physiotherapists and occupational therapists who are a Chronisch ZorgNet member. If you go to a healthcare provider that is not on the Chronisch ZorgNet (chronic care net) list, you will receive a lower reimbursement. For more information, please refer to Articles 1.3. Care provided by a contracted healthcare provider and 1.4. Care provided by a non‑contracted care provider. For more information, see our website.
Do you need a hand or finger splint for temporary use? Then you can only see a physical therapist with a Hand Therapist Certificate (CHT-NL). A hand or finger splint for preventive use, such as for playing sports, is not insured.
Do you need remedial therapy because of COPD? Then you can see a physiotherapist or remedial therapist who is a member of the national network Chronic CareNet. For more information, see our website.
General practitioner, company doctor, medical specialist, nursing specialist or physician assistant indicating that you have a condition stated in the List of Conditions for Physiotherapy and Remedial Therapy (Appendix 1 of the Healthcare Insurance Decree).
Speech therapy is care such as speech therapists tend to provide, if this care has a medical purpose and the treatment can be expected to result in restoration or improvement of the speech function or speech ability.
Speech therapy treatments related to:
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
A speech therapist.
Speech therapy treatments that deviate from regular treatments may only be provided by a speech therapist registered in one of the following sub-registers of the Dutch Association for Speech Therapy and Phoniatrics (NVLF):
Stutter therapy may also be given by a stutter therapist registered with the Nederlandse Vereniging voor Stottertherapie (NVST - Dutch Association for Stutter Therapy).
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
Do you suffer from Parkinson and you require speech therapy? We only contract with speech therapists affiliated with ParkinsonNet for this care. If you go to a healthcare provider that is not on the ParkinsonNet list, you will receive a lower reimbursement. For more information, please refer to Articles 1.3. Care provided by a contracted healthcare provider and 1.4. Care provided by a non‑contracted care provider. For more information, see our website.
Occupational therapy is care such as occupational therapists tend to provide, subject to the condition that the purpose of this care is to promote or restore your self-care, autonomy and independence, up to a maximum of 10 treatment hours per calendar year.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
An occupational therapist.
An occupational hand therapist with a Hand Therapist Certificate (CHT-NL) for a hand or finger splint for temporary use.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
Do you suffer from Parkinson and you require occupational therapy? We only contract with occupational therapists affiliated with ParkinsonNet for this care. If you go to a healthcare provider that is not on the ParkinsonNet list, you will receive a lower reimbursement. For more information, please refer to Articles 1.3. Care provided by a contracted healthcare provider and 1.4. Care provided by a non‑contracted care provider. For more information, see our website.
Do you need a hand or finger splint for temporary use? Then you can only see an occupational hand therapist with a Hand Therapist Certificate (CHT-NL). A hand or finger splint for preventive use, such as for playing sports, is not insured.
Dietetics is care such as dieticians tend to provide, if this care has a medical purpose, up to a maximum of 3 treatment hours per calendar year. Dietetics is defined as patient education with a medical purpose and the treatment of patients by means of diet therapy aimed at eliminating, reducing or compensating for food-related or nutritionally influenceable diseases or complaints.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
To a dietician.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
If you have diabetes mellitus type 2, COPD (chronic obstructive pulmonary disease), increased vascular risk or asthma, and you are receiving multi-disciplinary healthcare as set out in Article 11. General practitioner care, then dietetics for these or related conditions are provided via this multi-disciplinary healthcare.
Dental care is care as dentists tend to provide it. For insured persons under age 18, the care includes the following operations/treatments:
If you are under age 23, then you are entitled to reimbursement of the cost of crowns, bridges and implants if it concerns replacement of one or more permanent incisor or canine teeth that have not grown or are missing due to an accident. The necessity of this healthcare must be determined before reaching age 18.
If you are age 18 and up, then this healthcare service will be set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
A dentist, dental surgeon, prosthodontist or dental hygienist. The dentist or dental hygienist may work in a youth dental care facility. For an autotransplant with a multi-disciplinary treatment team where the surgical part is carried out by a periodontist, dental implantologist or oral surgeon and the dental treatment part by a dentist. The healthcare provider who performs the surgical part.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
More information about applying for approval is set out in Article 1.9. Referral, prescription or approval of these policy conditions.
Specialist dental care is for people with a specific condition. Such dental care takes more time and more expertise. You are only entitled to special dentistry if it enables you to maintain or acquire a dental function equivalent to that which you would have had if you had not had the disorder.
Dental care in special cases is care as dentists tend to provide, which is necessary:
The care referred to under 1. includes orthodontics if you have a very serious developmental or growth disorder of the mouth or teeth that requiring co-diagnosis or co-treatment of surgical dental care of a specialist nature or relating to other disciplines than dental care.
You are due a statutory personal contribution if you are age 18 or older concerning healthcare that is not directly related to the indication for special dentistry. The personal contribution is equivalent to the amount that may be charged if it is not a matter of special cases requiring dental care.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
Do you need a treatment under helium or other sedation or full anaesthesia? Then the healthcare may only be provided in a hospital or centre for specific dental care. A centre for specific dental care is:
Please refer to our website to see a list of such centres.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
Dentist, orthodontist or a dental surgeon.
You require our prior approval. Please find more information about applying for approval in Article 1.9. Referral, prescription or approval of these conditions.
The care includes the placement of a dental implant in the context of special dental care if you:
If you have had a full dental prosthesis (dentures) for a long time, your jaw may lapse so severely that your dental prosthesis hardly has any grip. In such a case, implants can be a solution. This generally concerns 2 implants in the lower jaw with 2 buttons or a rod screwed in that serve to click on the dentures. The dentures are still removable by hand. For prosthetic devices for insured age 18 and older, see Article 33. Prosthetic devices for insured age 18 and older.
You are due a statutory personal contribution if you are age 18 or older concerning healthcare that is not directly related to the indication for special dentistry. The personal contribution is equivalent to the amount that may be charged if it is not a matter of special cases requiring dental care.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
Dentists, certified oral hygienist working in a centre for specific dental care, dental surgeon or orthodontist in collaboration with a dental surgeon. In the event of implants in a very severely lapsed toothless jaw, this healthcare may also be provided by a dental implantologist.
Do you need a treatment under helium or other sedation or full anaesthetics? Then the healthcare may only be provided in a hospital or centre for specific dental care. A centre for specific dental care is:
Please refer to our website to see a list of such centres.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
Dentist, orthodontist or a dental surgeon.
You require our prior approval. More information about applying for approval is set out in Article 1.9. Referral, prescription or approval of these policy conditions.
Oral surgery is surgical dental care of a specialist nature and the accompanying X-ray examination as dentists tend to provide if you are age 18 or older.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
An oral surgeon.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
General practitioner, company doctor, dentist, orthodontist, obstetrician, medical specialist or dental surgeon.
Some treatments are subject to prior approval. Please find such treatments in the Limitative List Authorisations Dental Surgery on our website. More information about applying for approval is set out in Article 1.9. Referral, prescription or approval of these policy conditions.
The care includes a removable complete dental prosthesis for the upper and/or lower jaw, whether or not to be placed on implants if you are age 18 or older. The care also includes fitting the fixed part of the supra-structure (the meso-structure) for a removable complete dental prosthesis to be placed on dental implants. Repairing and filling (rebasing) these dentures is also part of this care.
You are charged a statutory personal contribution amounting to:
Your personal contribution is 17% of the cost of making a normal denture on one jaw and an implant-supported denture on the other jaw at the same time (code J50).
You are entitled to a dental prosthesis for the upper and/or lower jaw. This is subject to a personal contribution. The personal contribution also applies to the cost of placing the fixed part of the supra structure (meso structure). A meso structure is the non-removable construction between implants and the dentures (the click system). The costs of extracting teeth do not qualify for reimbursement, but may be reimbursed if you have supplementary (dental) insurance. In addition to a personal contribution, the excess also applies. For an implant for a full denture if you have a very severely shrunken toothless jaw, see Article 31.2. Dental implants.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
A dentist, dental implantologist or dental prosthodontist.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
More information about applying for approval is set out in Article 1.9. Referral, prescription or approval of these policy conditions.
Pharmaceutical care includes the supply of medications, or advice and guidance such as pharmacists tend to provide for medication assessment and responsible use of medication and drugs.
This care also comprises:
The care includes medications registered as preferred in the Healthcare Insurance Regulations. These are set out in Appendices 1 and 2 of the Healthcare Insurance Regulations.
Appendix 1 of the Healthcare Insurance Scheme sets out groups of medications with the same active ingredient. We select certain active ingredients and a preferred medication. You are only entitled to such preferred medications. Please find a list of such preferred medications in the Pharmaceutical Care Regulations on our website. We do not reimburse other medications with the same active ingredient. If treatment with a preferred medication is not medically warranted, your doctor will list 'medical necessity' on the prescription. In that case, you have the right to choose a different medication.
Doctors may only list ‘medical necessity’ on the prescription if they can substantiate it. Does the pharmacist have any questions about the medical necessity? For example because you have not used the medication before? Then the pharmacist will contact your doctor. The pharmacist will choose which medication to give you based on the active ingredient prescribed by your doctor and your doctor's explanation. If there is no medical necessity, the pharmacist will give you the preferred medication.
The excess does not apply for preferred medication. Please find a list of such preferred medications in the Pharmaceutical Care Regulations on our website. The excess does apply to pharmacy services. This may include the fees for supplying a medication and assistance regarding the use of new medications. If you use a medication other than the preferred medication due to medical necessity, the excess applies.
Care includes self-care medications if you need to use these medications for more than 6 months. You are only entitled to laxatives, remedies for allergies, remedies for diarrhoea, remedies to empty the stomach and remedies for dry eyes, which are listed in Appendix 1 of the healthcare insurance Regulations. For the first 15 days, you are not entitled to reimbursement of the cost of such medication.
Care includes non-registered drugs if rational pharmacotherapy is involved. Rational pharmacotherapy is the treatment, prevention or diagnosis of a condition with a medicine in a form suitable for you, the efficacy and effectiveness of which has been demonstrated in scientific literature and which is also the most economical for health insurance purposes.
You are entitled to the following non-registered medications:
If a registered medicine cannot be supplied in the Netherlands or cannot be supplied in sufficient quantities, the care will include a replacement medicine from abroad. This drug must have been brought from abroad with permission from the Health and Youth Inspectorate or with a temporary license from the Medicines Evaluation Board.
The Healthcare Insurance Scheme is available from our website.
Pharmaceutical counselling during hospitalisation, day treatment or polyclinic visits and pharmaceutical counselling in the context of discharge from hospital are reimbursed exclusively as part of specialist medical care.
Some medications are subject to a statutory personal contribution.
Your statutory personal contribution amounts to a maximum of € 250 per calendar year.
If your health insurance does not start or end on 1 January, we will calculate the personal contribution as follows:
The Minister of Health, Welfare and Sport determines which medications are covered by the Healthcare Insurance Act and which medications are subject to a personal contribution. Your maximum personal contribution amounts to € 250 per calendar year. In addition to a personal contribution, an excess may apply. For more information, please check our website.
This healthcare is set off against the excess. Do you use preferred medications as set out in the Pharmaceutical Care Regulations? Then the excess does not apply. The excess also does not apply to the healthcare providers we selected for the Blauwe Zorg experiment in the Maastricht and Heuvelland area, insofar as they supply the preferred lung medication we selected. Please find a list of such healthcare providers and preferred lung medication in the Pharmaceutical Care Regulations, Appendices D and E. You may also choose other lung medication that is not preferred by us. But this is subject to your statutory and voluntary excess.
Please take into consideration that the services of the pharmacy, for example the issue fee, the instructions for a new drug or inhaling instructions, are not exempt from your excess.
For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
Pharmacist or dispensing general practitioner.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
You cannot transfer your claim on us for pharmaceutical care as referred to in this article to care providers or others with whom we have not concluded a contract for this care (prohibition of assignment). This is a clause as referred to in Article 3:83 paragraph 2 of the Dutch Civil Code. A reimbursement for the costs of care provided by a care provider with whom we do not have a contract will be transferred to the policyholder's account number.
General practitioner, obstetrician, dentist, orthodontist, medical specialist, oral surgeon, physician assistant or nurse (with appropriate prescribing rights).
Your pharmacist may give you drugs for a certain period. The period depends on your prescription, the specific medication and the period during which you are required to use the medication.
For the contraceptive pill and for insulin, you only need a prescription the first time.
More information about applying for approval is set out in Article 1.9. Referral, prescription or approval of these policy conditions.
If you are under age 21, you are entitled to reimbursement of contraceptives, including the contraceptive pill, a contraceptive rod, diaphragm, ring or cervical cap. Some items are subject to a personal contribution.
If you are age 21 and up, You are only entitled to contraceptives if these items are used to treat endometriosis or menorrhagia (if suffering from anaemia). Please note: This requires our prior approval. For information on requesting approval, see Item 1 under the Approval heading of this article.
If you are not entitled to such reimbursement, you may be reimbursed for the cost of the contraceptive if you have supplementary insurance. For more details, please refer to the conditions of your supplementary insurance policy.
Irrespective of your age, you are entitled to having a contraceptive such as a diaphragm or implanon rod placed or removed by a general practitioner or by a medical specialist. For placing or removing a diaphragm, you may also choose an obstetrician certified for this service.
Dietary preparations are polymeric, oligomeric, monomeric and modular dietary preparations. Dietary preparations are only part of the care if you cannot manage with adapted normal food and other products of special nutrition and you are:
Dietary preparations are medical food with a different form and formula than standard food. There are various types, including liquid nutrition and tube feeding. Liquid nutrition may include extra energy, protein, fat or vitamins and minerals. Catheter-administered nutrition (tube feeding) is special nutrition directly taken into your stomach or digestive system via a thin tube (catheter).
A dietary product is a nutrition product with an adjusted formula. Examples are gluten-free or low-sodium products. We do not reimburse such products.
This healthcare is set off against the excess. The Pharmaceutical Care Regulations set out a list of preferred products for liquid nutrition, puddings and custards with various flavours. The excess does not apply to such preferred products. You may also choose alternative products. Then the excess does apply. Please find the Pharmaceutical Care Regulations on our website. We reserve the right to amend the list of preferred products at any time. For more information about excess, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
A pharmacist, dispensing general practitioner or a preferred healthcare provider. For tube feeding, you can only go to a medical specialty store, also called a facility.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
If you are buying a dietary preparation in a general store such as a supermarket or chemist, Then you don't get any compensation.
General practitioner, medical specialist, dental surgeon, physician assistant, nurse or dietician.
You will need our permission in advance. To apply for approval, you can use the prescription issued by your general practitioner or the Declaration of Dietary Preparations filled in by your medical specialist, dental surgeon, physician assistant, nurse or dietician (ZN Declaration of Polymeric, Oligomeric or Modular Dietary Preparations). More information about applying for approval is set out in Article 1.9. Referral, prescription or approval of these policy conditions.
Medical aids and dressings are functional support aids and dressings materials as referred to in the Healthcare Insurance Decree and the Healthcare Insurance Regulations. In the Medical Devices Regulations we have set out further conditions for obtaining such medical devices/aids. The Healthcare Insurance Decree, the Healthcare Insurance Scheme and the Medical Aids Regulations are available from our website. Certain groups of medical aids are included in the Healthcare Insurance Scheme with a functional description. This means that the healthcare insurer can determine which medical aids are covered in the Medical Aids Regulations. If you want a medical aid that is part of the group of functional descriptions of medical aids, but the specific medical aid is not included in the Medical Aids Regulations, you may submit an application form to us.
Most medical aids and bandaging are given to you under direct ownership. If you receive a medical aid as such, you simply own the medical aid permanently. Other medical aids are generally leased out to you. Lease means that you may use the medical aid as long as you need and as long as you remain insured with us. You conclude a loan agreement with us or the care provider that sets out your rights and obligations. Medical aids and devices on loan can be obtained only from a care provider with whom we have concluded a contract.
The following information is available from the Medical Devices Regulations:
You will receive the medical aids ready for use. If applicable, you receive the medical aid including the first batteries, chargers and/or user instructions.
We make agreements with healthcare providers on quality, price and service. If you go to a care provider with whom we have a contract for the relevant care, you can expect a good product and excellent service. Also, you do not need to apply for permission or pay any costs. We will pay the healthcare provider directly.
The Medical Aids Regulations set out the statutory personal contribution or maximum reimbursements for the relevant medical aids.
This healthcare is set off against the excess. The excess does not apply to medical aids on a lease basis. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
A healthcare provider for medical aids. Please refer to the Medical Aids Regulations to see if the healthcare provider is required to meet certain quality requirements.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
You cannot transfer your claim on us for Medical aids to care providers or others with whom we have not concluded a contract for this care (prohibition of assignment). This is a clause as referred to in Article 3:83 paragraph 2 of the Civil Code. A reimbursement for the costs of care provided by a care provider with whom we do not have a contract will be transferred to the policyholder's account number.
If a healthcare provider (medical aid supplier) with a contract provides a medical aid on loan, but you go to a non-contracted healthcare provider for that medical aid, we will reimburse no more than 75% of the average costs per user per year that we would have paid if you had gone to a healthcare provider (medical aid supplier) that had a contract for the care in question. The amount of the average costs is equal to the costs we would have paid for providing a medical aid on loan. The Medical Aids Regulations specify which medical aids are provided on loan by a healthcare provider (medical aid supplier) with a contract.
The Medical Aids Regulations set out which medical aids require a referral. This referral letter must include the indication.
The Medical Aids Regulations set out which medical aids require prior approval.
Please find more information about applying for approval in Article 1.9. Referral, prescription or approval of these conditions.
Stay is a medically necessary stay of 24 hours or longer in the context of general practitioner care (Article 11. General practitioner care), obstetric care (Article 15.1. Obstetric care), medical specialist care (Articles 16 to 23), mental healthcare (Article 25. Mental healthcare (GGZ) for insured age 18 and older) and surgical dental care of a specialist nature (Article 30. Dental care for insured under age 18, 31. Specific dental care and Article 32. Oral surgery for insured age 18 and older) as set out in these insurance terms and conditions, during an uninterrupted period of up to 3 years (1095 days), as defined in Article 2.12 of the healthcare insurance Decree. An interruption of up to 30 days is not considered an interruption, but these days do not count towards the calculation of the 3 years (1095 days). Interruptions due to weekend and holiday leave do count towards the calculation of the 3 years.
A stay is also possible for insured persons under the age of 18 who require medical child care (intensive child care) as described in Article 14. Nursing and care (district nurses).
Reimbursement for a stay in the vicinity of a hospital is possible if this is necessary in connection with specialist medical care. The maximum reimbursement is €91 per day.
Are you receiving CAR T-cell therapy and do you live more than 60 minutes away from the expert hospital where you are receiving the treatment? If so, we can provide a reimbursement for accommodation near the hospital at your request. Reimbursement begins on the day you leave the hospital and stops after 14 days, unless you need to stay longer due to medical complications. The maximum reimbursement is €91 per day.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
The stay may take place in a hospital, in a psychiatric ward of a hospital, in a GGZ mental healthcare institution, or in a recovery/rehabilitation institution.
First-line stay is permitted in an institution performing medical care under the responsibility of the general practitioner, geriatric medical specialist or doctor for mentally disabled.
The stay related to medical child care may take place in a children’s care home.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Are you going to a care provider that does not have a contract with us for the care that concerns you? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
You cannot transfer your claim on us for a stay in a GGZ institution to care providers or others with whom we have not concluded a contract for this care (prohibition of assignment). This is a clause as referred to in Article 3:83 paragraph 2 of the Dutch Civil Code. A reimbursement for the costs of care provided by a care provider with whom we do not have a contract will be transferred to the policyholder's account number.
General practitioner, obstetrician, medical specialist, psychiatrist or dental surgeon. For medical child care stays, a paediatrician or level 5 paediatric nurse practitioner may issue a prescription.
They determine whether a stay is medically necessary in connection with medical care or medically necessary in connection with surgical care of a specialist nature as referred to in Article 32. Oral surgery for insured age 18 and older Oral Surgery for insured age 18 and older.
You need our prior approval for stays in connection with medical child care (Article 14. Nursing and care (district nurses)), specialist medical care (Article 16. Specialist medical care), rehabilitation (Article 17.1. Interdisciplinary specialist medical rehabilitation), plastic and/or reconstructive surgery (Article 21. Plastic and/or reconstructive surgery), mental healthcare (Article 25. Mental healthcare (GGZ) for insured age 18 and older) and oral care (Articles 30. Dental care for insured under age 18, 31. Specific dental care and 32. Oral surgery for insured age 18 and older) if this is indicated in the relevant care Article. Look for more information in the relevant healthcare Article.
You also need our permission for a stay in the vicinity of a hospital if this is necessary in connection with specialist medical care.
Ambulance and patient transport includes:
Your visual disability must be such that you are unable to travel by public transport. This is determined, among other things, by your vision (visual acuity) and your field of vision. You are entitled to patient transport if your vision in both eyes is less than 0.1 or if you have a field of vision less than 20 degrees. You may also have a combination of poor vision and a very severely impaired field of vision. In this case, an individual assessment will be required to determine your right to transport.
If the outcome of the sum ‘number of consecutive months that transport is necessary X number of times per week X number of km, single journey’ exceeds or is equal to 250. For instance: you had to go to hospital twice per week for 5 months. The one-way distance was 25 kilometres (km). In this case you may apply for the hardship clause, as 5 months x 2 times per week x 25 km single journey makes 250.
The patient transport set out in this article also includes the transport of an accompanying person, if support is necessary, or if it concerns support for children younger than 16 years of age. In special cases, we can allow the transportation of 2 escorts.
Are you dependent on transportation as referred to in 2a through 2g for at least three consecutive days? Then at your request, we may grant reimbursement for lodging costs up to a maximum of €89 per day. In that case, you are entitled to transport or a mileage allowance for the return journey to the treatment location and to reimbursement of two or more overnight stays in the vicinity of the treatment location. The lodging allowance therefore partly replaces the transport allowance.
You are charged a statutory personal contribution of up to €126 per calendar year for patient transport. This is not subject to a personal contribution for ambulance transportation and accommodation costs.
This healthcare is set off against the excess. For more information, please refer to Articles 7. Statutory excess and 8. Voluntary excess of these policy conditions.
For more information about healthcare provided by a contracted healthcare provider, please refer to Article 1.3. Care provided by a contracted healthcare provider of these policy conditions. Do you use a taxi operator that does not have a contract with us? For more information, please refer to Articles 1.4. Care provided by a non‑contracted care provider and 1.6. Punctual healthcare of these policy conditions.
General practitioner or medical specialist. For patient transport as set out in item 2e (medical child care), you need a prescription from the paediatrician or level 5 child nurse. For patient transport as set out in item 2g (medical care specific patient groups), you need a prescription from a general practitioner, medical specialist, geriatric specialist, doctor for the mentally handicapped, healthcare psychologist or general remedial educationalist. You do not need a prescription for emergency ambulance transport.
You need our prior consent for patient transport and reimbursement of lodging expenses. For more information, see our website.
You can request permission from the transportation desk via our website for:
You are entitled to mediation for care if there is an unacceptably long waiting list for treatment by a care provider that may provide this care in accordance with the health insurance policy. You may use the services of our Healthcare Advice and Mediation department for such mediation services. You can reach this department through our website.
You may also approach this department for general questions on care, such as relating to looking for a healthcare provider with a certain area of expertise or help in navigating through the care sector. Together with you, our healthcare advisors will look into the possibilities.
If no solution can be offered or the solution does not result in the care being provided on time, we may give you permission to use a healthcare provider with whom we have not concluded a contract for the care in question. You will need prior written permission from us to receive that care. We reimburse the costs of the care from this non-contracted healthcare provider up to a maximum of the Wmg rates applicable in the Netherlands. If no Wmg rates apply, we reimburse the costs up to a maximum of the amount invoiced.
Acute care: Healthcare that cannot reasonably be postponed. Acute healthcare is also referred to as emergency care. If it concerns care provided abroad, acute care also concerns care that cannot reasonably be postponed until you have returned to your country of residence.
Certified translator: this is a translator authorised to provide certified translations. This is necessary when translating official documents such as medical certificates and civil status documents. Certified translators are listed in the Register of Certified Translators and Interpreters (Rbtv), www.bureauwbtv.nl
Group health insurance contract: a group health insurance contract (group contract) concluded between the healthcare insurer and an employer or legal entity with the object of offering associated participants the option of obtaining a healthcare insurance policy and any supplementary covers under the conditions as set out in this contract.
Diagnosis treatment combination (DTC or dbc): A DTC (Diagnosis-Treatment Combination (dbc)) describes the completed and validated process of specialist medical care by means of a dbc code that is determined by the Dutch Healthcare Authority (NZa). This includes part of the care process or the full care process from the diagnosis as made by the healthcare provider up to the ensuing treatment (if any). The dbc regimen begins the moment that you register with a care need, and ends at the end of the treatment or after 120 days.
Personal contribution: A fixed amount/share of (reimbursement of the costs of) care referred to in these policy conditions that you yourself must pay before becoming entitled to (reimbursement of the cost of) the remaining part of the healthcare.
Excess:
European Union and EEA Member State: This includes the following countries within the European Union in addition to the Netherlands: Austria, Belgium, Bulgaria, Croatia, Cyprus (the Greek area), the Czech Republic, Denmark, Estonia, Finland, France (including Guadeloupe, French Guyana, Germany, Martinique, St. Barthélemy, St. Martin and La Réunion), Greece, Hungary, Ireland, Italy, Croatia, Latvia, Lithuania, Luxembourg, Malta, Austria, Poland, Portugal (including Madeira and the Azores), Romania, Slovenia, Slovakia, Spain (including Ceuta, Melilla and the Canary Islands), Czech Republic and Sweden. On the basis of treaty provisions, Switzerland is classed as equivalent to the above countries in this context. EEA countries (Member States who are a party to the Agreement on the European Economic Area) are also included: Liechtenstein, Norway and Iceland.
Fraud: intentionally committing or attempting to commit forgery, deception, injuring the rights of debt collectors or beneficiaries and/or misappropriation or embezzlement in the process of entering into and/or performing an insurance contract or healthcare insurance contract, with the objective of obtaining a benefit, reimbursement or performance to which the party is not entitled, or obtaining insurance cover under false pretences.
Birth clinic: institution where you can give birth under the responsibility of a midwife. You can often also receive maternity care in a birth clinic. A birth clinic is located in a hospital or close to a hospital. The hospital will be accessible via a covered walkway (a ‘dry’ corridor).
GGR (Weight-Related Health Risk): The WRH indicates the extent to which the health risk is increased. This factor is based on the BMI (Body Mass Index) in combination with the presence of risk factors for a certain condition or existing conditions.
Institution:
KNMG: The Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst (KNMG) is a federation of professional associations of doctors and the association De Geneeskundestudent and represents the interests of doctors in the Netherlands.
Policy: The healthcare policy as set out in Article 1, paragraph 1 under i of the healthcare insurance Act, i.e., the deed recording the healthcare insurance policy concluded between the policyholder and a healthcare insurer. The (healthcare) policy consists of a policy schedule and these insurance terms and conditions.
In writing: wherever reference is made in these insurance terms and conditions to ‘in writing’ it shall also mean ‘by email’.
Approval (consent, authorisation): Approval in writing for receiving certain care provided to you by or on behalf of the healthcare insurer, prior to receiving the relevant healthcare service.
UMC Ruime Keuze: A healthcare insurance policy concluded between the healthcare insurer and the policyholder for an insured person. These policy conditions refer to the UMC Ruime Keuze as ‘the healthcare policy’.
Treaty country: A country that is not a member state of the European Union or EEA, with which the Netherlands has concluded a treaty on social security and which includes a regulation on the provision of medical care. This includes the following countries: Australia (for holiday/temporary stay), Bosnia-Herzegovina, Cape Verde, North Macedonia, Morocco, Serbia-Montenegro, Tunisia, Turkey and the countries of the United Kingdom (England, Northern Ireland, Scotland and Wales).
Insured: The person for whom the risk of needing medical care, as referred to in the healthcare insurance Act, is covered by healthcare insurance and who is listed as such on the healthcare insurer's policy schedule.
Policyholder: The person who has contracted health insurance with the health insurance company. These policy conditions refer to the policy holder and the insured as ‘you’. Provisions referring only to the policy holder specifically specify this accordingly in the relevant Article.
Person subject to statutory insurance: A person who is subject to statutory insurance pursuant to the Healthcare Insurance Act; the person must take out a healthcare insurance or have this taken out.
Policy Conditions UMC Ruime Keuze /policy conditions: The healthcare insurer's model contract referred to in Article 1j of the healthcare insurance Act.
Care Provider: A person or legal entity who provides care professionally or commercially as defined in Article 1, opening words and sub c, part 1 of the Wmg. The term 'Care provider' also includes all practitioners engaged for the delivery of care at the risk and expense of the healthcare provider.
Healthcare insurer/UMC: N.V. Zorgverzekeraar UMC, with its registered office in Arnhem, Chamber of Commerce registration number: 09154428. The healthcare insurer is registered in the Insurers Register of AFM (Financial Markets Authorities Netherlands) and DNB (the Dutch Central Bank), licence number: 12001037. The healthcare insurer is part of Coöperatie VGZ U.A. The healthcare insurer is referred to as ‘we’ and ‘our’ in these policy conditions.
Healthcare Insurance: A non-life insurance agreement relating to healthcare entered into between a healthcare insurer and a policyholder for a person with an obligation to take out insurance as referred to in Article 1 under d of the Healthcare Insurance Act (Zvw), and these policy conditions form an integral, inseparable part of this insurance agreement.