IAK Supplementary Health Care Insurances - IAK Verzekeringen

14
6.5
6.6
The policyholder may give notice of termination in writing or per email:
• no later than 31 December of any year, to take effect from 1 January of the subsequent calendar year;
• simultaneously with the termination of the statutory IAK Zorgverzekering;
• in the situations referred to in article 5.2.
Cancellation, dissolution or suspension by the health care insurer
The health care insurer may cancel, dissolve or suspend the insurance:
• because of failure to pay the premium on time as outlined in article 3.5;
• in cases of fraud as outlined in article 2.10;
• in the event of deliberately not supplying, not completely supplying or falsely supplying the health care insurer
with information or documents relevant to the performance of the insurance that may/will disadvantage the health
care insurer;
• if the policyholder and/or the insured person has deliberately acted with the intention of misleading the health
care insurer or if the health care insurer would not have entered into a health care insurance if it had been aware
of the true state of affairs. In such cases, the health care insurer can cancel the insurance within two months of
discovery and with immediate effect. The health care insurer will not, then be required to make any payments, or
may opt to reduce the payment amount. The health care insurer may set off the debt owed as a result of the
above deception against other benefits.
Health risk
The health care insurer cannot terminate or change the insurance in response to an increase in the health risk, insofar
as said risk relates to the insured person as an individual.
7 Exclusions
There is no entitlement to care or reimbursement of care costs:
• relating to illnesses or disorders that already existed before or at the time when the insurance was entered into and
of which the insured person was aware or could have been aware or in relation to which he was already experiencing
symptoms but of which the health care insurer was not informed in writing. This exclusion shall not apply in cases
where the insurance was effected without prior medical or dental selection;
• relating to written statements, mediation fees that are not accompanied by a written agreement from the health care
insurer, administration charges, costs of missed appointments or costs incurred as a result of failure to pay the
invoices submitted by health care providers on time;
• where these are incurred as a result of gross negligence or intention;
• arising from individual contributions or excess payable under a different insurance, unless otherwise specified in
these policy conditions;
• relating to which a claim could be submitted under the AWBZ (Exceptional Medical Expenses Act), where the insured
person was insured under this act;
• relating to which a claim could be submitted under a different insurance (possibly dated earlier) or under a different
act or provision if the insurance with the health care insurer had not existed. In such cases, all the alternative
options listed above will apply before this insurance applies, and even then payment under these policy conditions
will remain restricted to any amount exceeding the amount that the insured person would be able to claim
elsewhere;
• where a claim can or could be made under a health care policy based on the Zvw or an equivalent health care or
medical insurance; the health care insurer operates in accordance with the Convenant samenloop
zorgverzekering/reisverzekering (Agreement on the concurrence of health care/travel insurance policies). See also
www.iak.nl/zorg;
• caused by or resulting from armed conflict, civil war, uprising, civil disorder, riots or mutiny, as defined in article
3.38 of the Wft;
• resulting from damage that is indirectly caused by actions taken by or negligence on the part of the health care
insurer;
• in cases where the costs are charged by a partner, child, parent or other family member living in the same house,
unless the health care insurer has granted prior authorisation.
8 Complaints and disputes
8.1
8.1.1
8.1.2
8.1.3
Complaints and disputes relating to the performance of the insurance
Complaints and disputes relating to the performance of the insurance should be addressed to the management of the
health care insurer’s Zorgklachten department. They can also be addressed per email via zorgklachten@iak.nl.
Complaints can also be submitted via our website www.iak.nl/zorg. The Zorgklachten department acts on behalf of the
management.
A 'dispute' is a difference of opinion with regard to a decision relating to the performance of the insurance taken by the
health care insurer and upheld following reconsideration, as a result of which the interests of the policyholder or
insured person are affected. All other cases are referred to as 'complaints'.
The health care insurer will decide on its final position or reconsider its original decision within a period of 30 days. If
the policyholder or the insured person does not agree with the opinion of the health care insurer or if the health care
insurer has not responded within a period of 30 days, the policyholder or the insured person can submit his/her
complaint or dispute to the SKGZ (Health Insurance Complaints and Disputes Commission), Postbus 291, 3700 AG