Health insurance COMFORT

Rf. SSC-HE-02-EN-2016
Date September 2016

Powered by Unirisc SA, member of Swiss Risk & Care group

 Summary
Article 1. Basis of the contract 3
Article 2. Persons covered by the insurance 3
Article 3. Scope of the insurance 3
Article 4. Geographical scope of cover 3
Article 5. Joining conditions 3
Article 6. Acceptance, refusal, inception and end of the contract 3
Article 7. Payment of premiums 4
Article 8. Changes to rates 5
Article 9. Definitions 5
Article 10. Participation in costs 5
Article 11. Benefits 6
Article 12. Reimbursements 7
Article 13. Duties and proving claims 8
Article 14. Declaration of loss 8
Article 15. Benefits from third parties, coordination 8
Article 16. Exclusions 9
Article 17. Confidentiality 10
Article 18. Information to be provided 10
Article 19. Applicable law 10
Article 20. Complaints 10

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 1 Basis of the contract
All the declarations which the Policyholder, Insured and their representative make on the proposal form and in any other
written document, as well as medical reports form the basis of the contract.
The rights and duties of the parties to the contract are set out in the policy of insurance, the endorsements and the
general conditions of insurance. Anything not expressly specified in these documents shall be subject to the provisions
of the federal law on insurance contracts.
Where the text is worded in the masculine form, it shall also apply accordingly to females.
The Insurers, together with the party to the contract which holds the policy, hereinafter referred to as: the Policyholder),
are the participating underwriters at Lloyds, jointly referred to as Lloyds of London (hereinafter: Insurers), whose
registered office and/or address are shown below and which have the following legal form:

Lloyds: Lloyds Insurers, London

Registered office: London / Great Britain
One Lime Street
London EC3M 7HA
Great Britain
Swiss office: Seefeldstrasse 7
8008 Zurich
Switzerland
Legal form: Association of individual insurers

2 Persons covered by the insurance

The purpose of the insurance is to allow foreign students staying in Switzerland as part of a course of training or
further training, as well as postgraduates and interns, to obtain reimbursement of medical, pharmaceutical and hospital
expenses recognised by the Swiss law on health insurance (LAMal). The insurance only covers the person insured as
stated on the policy.

3 Scope of the insurance

Services are reimbursed in the event of illness, accident and maternity in accordance with the Swiss law on health
insurance (LAMal).

4 Geographical scope of cover

The insurance is valid worldwide.
Outside Switzerland
In the event of a stay of less than 90 days, the insurance is only valid for costs consequent upon an accident or illness of
an urgent nature in accordance with the definitions of these terms in articles 9.1 and 9.2 provided that the treatment was
given by a GP or specialist doctor, or that the hospitalisation was required as a direct consequence of the emergency
and occurs within 24 hours. Other cases are subject to the Insurers express agreement. An emergency exists if the
Insured, who is staying temporarily abroad, needs medical treatment and returning to Switzerland is not appropriate. It
is not an emergency if the Insured goes abroad in order to obtain treatment.

5 Joining conditions
Information and medical examinations
By signing the proposal form, doctors, previous insurers and other insurance institutions are authorised to provide
information to the Insurer/the Insurers medical advisors. The Insurer is entitled to order, at its expense, a medical
examination. The doctor may be appointed by the Insurer.
5.1. Age at entry
The maximum age at entry is limited to 40 years of age.

6 Acceptance, refusal, inception and end of the contract

6.1. Acceptance of the policy
If the content of the policy or the endorsements relating thereto does not match previous agreements, the Policyholder
shall request that this is rectified within four weeks of receiving the policy, otherwise the content thereof shall be
deemed to have been accepted by the Policyholder.
6.2. Refusal
The Insurer may, on medical grounds, refuse a proposal without giving reasons up to the equivalent LAMal coverage.

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6.3. Amendment of the contract by the Policyholder
A new proposal form shall be completed for any amendment. A further examination may be required.
6.4. Inception of the contract
The insurance cover commences as follows:
For requests made between the 1st and 15th of the month: affiliation is effective from the 1st of the month in which
the request is made
For requests made between the 16th and 31st of the month: affiliation effective from the 1st of the month following the
month in which the request is made
6.5. Period of the contract
The contract is entered into for an indefinite period. It shall be tacitly renewed each year from one year to the next,
unless it is cancelled by one of the parties in accordance with art. 6.9.
6.6. End of the contract
6.6.1. Termination by the Insurer
The Insurer expressly undertakes to waive the right granted to it by law to terminate the contract in the event of a loss,
except in the case of misrepresentations, abuse, deceit, non-disclosure, insurance fraud or attempts thereat by the
insured person or Policyholder.
6.6.2. Termination by the Policyholder
The contract may be terminated by the Policyholder with effect from the end of a policy year, subject to giving 3 months
notice.
In the event of the departure of the policyholder from Switzerland or the Policyholder ceasing his studies in a Swiss
establishment, the policyholder may request the cancellation of his policy for the end of the month in which he submits
that request to the insurer.
6.7. Cessation of Cover
The insurance cover shall cease on the day on which cancellation of the contract comes into effect; the insurance
benefits are payable up to and including that date.
6.8. Non-disclosure or misrepresentation
If when entering into the contract, the Policyholder or Insured failed to declare or inaccurately declared a circumstance
of which it was or should have been aware, in particular in the case of pre-existing illnesses, accidents or disabilities or
illnesses which, experience shows, are subject to relapses, the Insurer shall apply the following clauses:
6.8.1. Non-disclosure, omission or misrepresentation
The contract of insurance may be terminated by the Insurer in the event of non-disclosure, omission or misrepresentation
on the part of the Insured. This non-disclosure, omission or misrepresentation therefore allows the policy and insurance
cover to be cancelled, including in respect of losses which have already occurred, where the fact non-disclosed, omitted
or misrepresented influenced the occurrence or extent of the risk.
6.8.2. Cancellation of the Policy
The Insurer may terminate the contract in writing within four weeks from when it became aware of the non-disclosure,
omission or misrepresentation.
6.8.3. Paid premiums
The premiums paid shall then be retained by the Insurer, who is entitled to payment of all the premiums due by way of
damages and interest.
6.9. Notification of cancellation
Any notice of cancellation must be given by recorded delivery if it relates to a group policy or by simple email for individual
insureds.

7 Payment of premiums
7.1. Payment of premiums
Premiums are payable in advance. If the contract is terminated prior to expiry, the premiums shall be reimbursed for the
unexpired portion of the period of insurance. This clause is not valid in the event of abuse of the insurance, in particular
insurance fraud. Premiums payable do not have to be offset against current benefits.
7.2. Reminder and consequences of non-payment
If the premium has not been paid within the stated time, the Insurer shall send the Policyholder a warning notice, with a
reminder of the consequences of the delay, to pay within 14 days of when the notice is sent. A fee for this reminder letter
of CHF 40 will be invoiced in addition to the amount owing. If the warning notice has no effect, the duty to pay benefits
shall cease once the notice period has expired. In such a case the Insurer may terminate the contract and shall at the
same time inform the cantonal health insurance supervisory body.

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 8 Changes to rates
8.1. Changes to tariff
If the premiums and/or excesses for the tariff change, the Insurer may require the contract to be updated accordingly.
The same applies in the case of changes in benefits relating to:
changes in the circle of service providers and their services
types of therapy
new expensive medical treatments or if the statutory catalogue of health insurance services (LAMal) is changed.
In this case, the Insurer shall notify the new premiums/new policy terms to the Policyholder no later than 25 days prior
to when they come into effect. The Policyholder shall then be entitled to cancel the contract on the day on which the
new contract conditions come into force. In order to be valid, notice of cancellation given in accordance with art. 6.6
must reach the Insurer no later than on the working day prior to when the new contract comes into effect. If the contract
is not cancelled, the Policyholder shall be deemed to have accepted the changes to the contract.
8.2. Switch from group insurance to individual insurance
An Insured who leaves one of the Insurers group contracts or has to leave because of the cancellation of a group
contract, may switch to an individual insurance if he continues to have his legal place of residence within the area. If this
is the case, the Insured must exercise his right within 30 days. He is insured for benefits similar to those under the group
contract. Benefits received under the group insurance are imputed to those under the individual insurance. Any reserve
held under the group insurance is maintained.

9 Definitions
9.1. Illness
Any harm to physical or mental health which is not the result of an accident and requires a medical examination or
treatment.
9.2. Accident
Any indemnifiable, sudden and involuntary harm to the human body resulting from an external and extraordinary cause.
9.3. Maternity
Includes pregnancy and childbirth.
9.4. Hospitals
Hospital establishments and clinics which are directed and supervised by a doctor and which only take in people who
are ill or have suffered accidents. Spa centres, old peoples homes, medical-social establishments, homes for the
chronically sick and other institutions not mentioned for the treatment of persons suffering from acute illness, are not
deemed to be hospitals.
9.5. Spa centres
Thermal establishments recognised under art. 40 LAMal as well as convalescent homes directed or supervised by a
doctor.
9.6. Excess
The amount shown in the contract of insurance which the Insured agrees to retain for his own account in each calendar
year prior to being reimbursed by the Insurer.
9.7. Retention
The additional cost for which the Insured remains liable.

10 Participation in costs
The Insured participates in the cost of the benefits granted to him. The participation in costs includes:
10.1. Excess
The amount shown in the contract of insurance which the Insured agrees to retain for his own account in each calendar
year prior to being reimbursed by the Insurer.
10.2. Retention
This is 10% of the costs generated in the following cases:
illness or accident self-inflicted by the Insured, self-mutilation or attempted suicide
treatment for drug addition or alcoholism
the effects of alcohol, obvious drunkenness or if it has been discovered that at the time of an accident, the Insured
had a blood alcohol level of 0.50 g or more per litre
psychotherapy.

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11 Benefits
11.1. Overall sum insured
The sum insured is limited to CHF 50,000,000 any one claim and to a maximum period of insurance coverage of
6 years. For insureds resident in the canton of Geneva the maximum period of insurance coverage is 7 years.
11.2. Doctors who come under the LAMal throughout Switzerland
The costs are covered in accordance with the tariff of the Swiss health insurance organisations.
11.3. Hospitalisations
Admission to a hospital or psychiatric clinic must be reported to the Insurer immediately, and in any event within no more
than 6 days. If confirmation of cover is required, the Insurer must be notified prior to admission.
In the event of hospitalisation, cover shall apply in respect of the costs on a general ward for:
medical hospitalisation in a public or private establishment
hospitalisation and surgery
the associated medical and paramedical costs incurred in the course of hospitalisation.
11.4. Medicines
100% of the medicines compulsorily payable according to the LAMal and prescribed by a doctor with the exception of
commonly used non-medicinal products such as:
medical alcohol
cotton wool
sun creams
dental hygiene products
shampoo
food products (including those for special diets)
mineral waters and tonic wines
fresh and dried glandular preparations
anti-conception products
contraceptives
cosmetics
sanitary articles
anti-baldness products
11.5. Assistance at home
Following hospitalisation or to replace hospitalisation, a maximum amount of CHF 20 per day is granted, up to a
maximum of CHF 2,000 per calendar year.
11.6. Psychiatric hospitalisation
Reimbursement in full for up to a maximum of 30 days per calendar year.
11.7. Organ transplant
Reimbursement in full. The costs of obtaining the organ are not covered.
11.8. Rehabilitation
Following hospitalisation, a maximum amount of CHF 500 per day is granted, for up to a maximum of 90 days per
calendar year.
11.9. Voluntary termination of pregnancy abortion
Where the termination of the pregnancy is not punishable under art. 119 of the Swiss penal code. the Insurer shall cover
the cost of the same services as for illness.
11.10. Maternity
The costs associated with pregnancy and childbirth are covered in accordance with the tariff of the Swiss health
insurance organisations.
11.11. Laboratory and imaging costs
Analyses, radiology, scanners and MRIs are covered in full if they are prescribed by a doctor.
11.12. Vaccinations
For medically prescribed vaccinations, the sum of CHF 150 is granted per calendar year.
11.13. HIV test
The sum of CHF 150 is granted per period of three calendar years.
11.14. Thermal spa treatments
For the award of a maximum of CHF 10 per day for a maximum of 21 days per calendar year, the following conditions
are applicable:
the spa treatments must be medically indicated
the spa treatments must take place in Switzerland
the spa treatments must have been prescribed as part of medical treatment and by a doctor authorised to practise
in Switzerland
the spa prescriptions must reach the Insurer before the spa treatment commences.

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11.15. Physiotherapy, speech therapy and orthoptics
A maximum amount of CHF 3,500 is granted per calendar year for physiotherapy, speech therapy and orthoptics if
prescribed by a doctor.
11.16. Chiropractor
Costs are only covered if the Insured has access to a chiropractor authorised by means of a certificate of competence
recognised under Swiss law.
11.17. Osteopathy
Costs are covered up to a maximum of 75%.
11.18. Alternative medicine
100% of the costs (examinations, therapies, medicines issued), up to a maximum of CHF 1,500 per calendar year,
provided that a medical prescription is submitted and that the service is provided by one of the following service
providers:
doctor
naturopathic doctor legally authorised by the Canton to practise
natural therapy practitioner APTN (NVS) (full member).
11.19. Psychotherapy
Cover applies, up to a maximum of 90%, to the costs of psychotherapy which has been medically prescribed and is
carried out by a qualified doctor.
11.20. Prevention and prophylaxis
100% of the costs, maximum CHF 300 per calendar year, for:
check ups
preventive gynaecological examinations (including 1 mammogram per calendar year)
course of back exercises (if medically prescribed) by qualified physiotherapists.
11.21. Spectacle lenses and contact lenses
Where these are medically prescribed, maximum CHF 200 per period of 3 calendar years.
11.22. Dental treatment
11.22.1. Urgent treatment following an accident
Reimbursement in full if the treatment must be administered within 15 days and consists of replacing healthy, natural
teeth which have been lost or damaged..
11.22.2 Treatment during a serious illness
Reimbursement in full during a serious illness of the masticatory system
11.23. Aids and devices
The costs are covered in accordance with the list of aids and devices (LiMA).

12 Reimbursements
12.1. Recognition of service providers
In the event of treatment in Switzerland, only invoices issued by persons holding a Federal or Cantonal diploma or
authorisation to practise their profession shall be considered.
12.2. Outpatient treatment: third party guarantor
In order to obtain reimbursement for outpatient treatment, in particular the invoice from a specialist or general
practitioner, you need only send us the original invoice, giving details, paid and duly receipted.
12.3. In-patient treatment: third party payer
In order to obtain reimbursement for in-patient treatment, the hospital establishments send the original invoice, with
details, directly to us.
12.4. Invoices issued abroad
In the case of treatment abroad, only invoices issued by persons holding a diploma issued in the country where they
practise their profession and who are authorised to practise shall be considered.
12.5. Settlement
Claims for reimbursement will only be honoured if the Insurer deems the amount of the invoices and receipts supplied
to be reasonable and usual. If not, the Insurer reserves the right to reduce the amount of its benefits.
12.6. Apportionment
If the costs are not set out in detail or not set out in enough detail, the Insurer shall apportion them itself.

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13 Duties and proving claims
13.1. General duties
The Insureds must obey the doctors instructions.
13.2. Prior approval
The reimbursement of costs is subject to prior approval by the Insurer, unless there is a specific emergency, in the
following cases:
any hospitalisation outside Switzerland
treatment at home outside Switzerland
childbirth costs outside Switzerland
psychotherapy outside Switzerland
MRI scans outside Switzerland
organ transplants
the costs of physiotherapy, speech therapy and orthoptics outside Switzerland
homeopathy and acupuncture charges
spa treatments
rehabilitation outside Switzerland.
In specific emergencies, the declaration to the Insurer must be made within 7 days following admission to a hospital
establishment. Approval by the Insurer is deemed to have been given if the Insurer has not responded within 20 days
following receipt of the claim. However, this tacit approval is only valid for treatment given within 30 days following the
said period of 20 days. Should this claim not be obtained at the time of hospitalisation or of any other treatment for
which this service is possible, the Insurer reserves the right to refuse the claim for reimbursement.
13.3. Proving claims
If insurance payments are required, all the detailed invoices, supporting documentation from service providers and
proofs of payment must be sent to the Insurer. Only original documents will be considered. Invoices and documents
from abroad may be written in French, German, Italian or English. In the case of invoices and documents drawn up in
other languages, a translation must be attached. If insurance for the treatment exists with another insurer, detailed
breakdowns from this Insurer must also be submitted.
13.4. Breach of duty
If the Insured breaches its duties with regard to the Insurer when claiming benefits, the latter may be reduced or refused.

14 Declaration of loss
14.1. Illness occurring abroad
If benefits are claimed in the case of illness occurring abroad, the declaration of illness occurring abroad form must be
submitted to the Insurer.
14.2. Accident
If benefits are claimed in the case of an accident, the accident declaration form must be submitted to the Insurer.

15 Benefits from third parties, coordination

15.1. Multiple insurances
If, in the case of insured costs, insurance cover exists with several insurers, the costs shall only be paid a total of once.
In such cases, the Insurer shall only cover the costs on a pro rata basis.
15.2. Benefits from third parties
The Insureds must inform the Insurer immediately about any benefits from third parties and any indemnity agreements,
provided that the Insurer has to provide benefits in the same insurance case.
15.3. Assignment
If the Insurer provides benefits in place of a third party who is responsible, the Insured shall assign his rights up to the
extent of the benefits to be provided by the Insurer.
15.4. Medical files
In the case of a contract in common with another Insurer, both parties shall have the reciprocal right to consult the
medical file before and after the insurance begins. Agreements with third parties shall not be binding on the Insurer.

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16 Exclusions
16.1. Excluded risks
The costs incurred are not covered by the Insurer if they are the result of the following circumstances:
the consequences of war, whether civil or otherwise, insurrection, riot, attack or civil commotion, unless the Insured
does not actively take part in the event
a loss resulting directly or indirectly from the disintegration of the atomic nucleus.
The Insurer reserves the right to amend the cover in one or more specified territories, subject to giving fifteen days
notice to the member.
16.2. Excluded benefits
It is noted that this contract does not cover:
16.2.1. Experimental or non-controlled treatment
Any form of experimental or non-controlled treatment which does not follow the commonly accepted, customary or
traditional practices of medicine, unless the Insurer specifically gives its consent.
16.2.2. Single room
The supplement for a single room in the event of hospitalisation.
16.2.3. Dental care
Restorative dental treatment, orthodontics, dental prosthetics.
16.2.4. Ancillary hospital costs
Ancillary or comfort costs in the event of hospitalisation (telephone, television etc.)
16.2.5. Organ transplant
Costs incurred in acquiring an organ.
16.2.6. Sex change
Any operation or treatment associated with a sex change.
16.2.7. Cosmetic treatments
Cosmetic treatments, rejuvenation, weight loss.
16.2.8. Non-care treatments
Treatments for self-fulfilment, self-development or personality development or for other reasons not associated with
treating an illness.
16.2.9. Thinness
Weight loss treatments, cell therapy, strengthening therapy.
16.2.10. Measures ordered by a judicial authority
Measures ordered by a judicial or administrative authority, e.g. therapy in place of enforcement of a sentence, alcohol
or drug test.
16.2.11. Military service
Treatments in the case of military service abroad and/or subsequent treatments.
16.2.12. Fertility
Verifications, investigations, treatments and complications associated with sterility, sterilisation, sexual dysfunction,
contraception including the insertion and removal of contraceptive devices, termination of pregnancy unless it is not
punishable within the meaning of art. 119 of the Swiss penal code.
16.2.13. Elective surgery
Any elective/voluntary surgery and/or plastic/aesthetic surgery.
16.2.14. Spa treatments
Spa treatments outside Switzerland.
16.2.15. Transport costs
The cost of transport and accommodation in connection with spa treatments.
16.2.16. Fitness
Medical expenses associated with a stay at a thalassotherapy centre and wellness centre and rest home, even if such
stay has been medically prescribed.
16.2.17. Convalescent homes
Medical expenses associated with a stay at a convalescent home, even if such stay has been medically prescribed.
16.2.18. Hair treatments
Consultations, treatments and complications associated with hair loss or hair implants unless such treatment is
associated with hair loss caused by a serious illness.
16.2.19. Eye treatments
Treatments aimed at altering the refraction of one or both eyes (ocular or laser correction), including refractive
keratotomy (KR) and photo refractive keratotomy (KPR).
16.2.20. Medicine
Medicines without a prescription, and non-medical products in common use such as medical alcohol, cotton wool, sun
creams, dental hygiene products, dressings, shampoos.

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17 Confidentiality
17.1. Data entry, request for information
The Insureds authorise the Insurer to enter all data on its computer system and to obtain the information required for
settlement of the right to benefits.
17.2. Data protection
The confidentiality of the information relating to the Insureds is of paramount importance to the Insurer. To this end,
the Insurer complies strictly with the data protection legislation and the directives of confidentiality in the medical field
applicable in the countries where it operates.

18 Information to be provided
Change of name and address
Changes of name and address must be notified in writing to the Insurer within a period of 30 days. The last known
address of the Insurer is legally valid.

19 Applicable law
Your policy is subject to Swiss law. Any dispute which cannot be resolved in any other way shall be submitted to the
Swiss courts. In the event of a dispute as to the interpretation of this document, the version in French shall be deemed
to apply and to take precedence over any version of the document in another language.
You may obtain a copy hereof at any time on the site www.swissriskcare.ch.

20 Complaints
20.1. Complaints
We are happy to hear your comments regarding aspects of your insurance cover which you have particularly appreciated
or which have caused you problems. If you have any concerns, we have put in place a simple procedure to ensure that
your complaint is handled as quickly and efficiently as possible. For any comments or complaints, you can call Unirisc
SA customer services on +41 58 178 85 85.
You can also write to us at the address below:

Unirisc SA
Route de Thonon 63
1222 Vsenaz

20.2. Next level

If you are still unsatisfied you can submit the case to Lloyds General Representative for Switzerland whose contact
details are:

Graham West,
Lloyds General Representative for Switzerland
Seefeldstrasse 7,
8008 Zurich,
Switzerland
+41 44 266 60 70
[email protected]

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