INDIVIDUAL HEALTH INSURANCE POLICY

GENERAL CONDITIONS
CLAUSE 1. OBJECT OF THE INSURANCE
The Insurer agrees to assume the risks indicated in the insurance contract, up to the
insured sum indicated in the Policy Receipt Table.
CLAUSE 2. DEFINITIONS
For the purposes of this contract, it is expressly statedagreed upon by the parties that the following
Terms will have the meanings indicated, with the masculine gender also including
in the feminine, when appropriate, unless the text of this Policy indicates otherwise.
different interpretation
Insurer: Mercantil Seguros, C.A, who assumes the risks covered in this Policy.
Policyholder: Natural or legal person who, acting on their own or on behalf of others, contracts the insurance.
with the Insurer, transferring the risks and committing to the payment of the premium.
Insured: Natural person exposed to risks covered and protected by this Policy. The
Insured must to be identified in the Policy Receipt Table.
Insured Holder: The person indicated in this capacity on the Policy Receipt Table, who
exercise the rights of the Insured before the Insurer.
Person who has the right to receive the payment of the compensation to which
There will be a place. In case of reimbursement, the Insurer will pay the compensation to the Insured
Holder, regardless of the person who has incurred the expenses.
Age: It corresponds to the nearest birthday date, either before or after.
moment of issuance or renewal of the policy.
Documents that are part of the contract: The General Conditions, the Conditions
Particular, the Insurance Application, the Policy Receipt Table, the annexes issued for
complement the Policy and the other documents that by their nature are part of the contract.
Insurance Application: Questionnaire provided by the Insurer, which contains a set
of questions relating to the identification of the Policyholder, the Insured, and the Beneficiaries,
as well as the health status of each of the people who will be covered
due to the Policy and other data that may influence the risk assessment, which must be
fully and accurately answered by the Policyholder and/or Insured Holder, constituting
this declaration is the legal basis for the issuance of the insurance contract.
Policy Receipt Frame: Document that indicates, at a minimum, the following information:
policy number, complete identification of the Insurer and its main address,
full identification of the Policyholder, of the Insured and Beneficiaries, address of
Taker, billing address, address of the insured policyholder, name of the intermediary
seguros
contract, date of issuance of the contract, deductible, if any, and signatures of the Insurer and of
Taker.
Mercantil Seguros, C.A.–RIF: J-000901805–NIT: 00000-185-6-2. Registered in the First Commercial Registry of the Judicial Circumscription of the Federal District and Miranda State on 20-02-1974,
under No. 66, Volume 7-A, authorized by the Superintendency of the Insurance Activity of the Ministry of People's Power for Economy and Finance, under No. 74. Main Headquarters Address: Av.
Libertador C/A Isaías “Látigo” Chávez, Edif. Seguros Mercantil, floor 6, Urb. Chacao, P.O. Box 1060, Caracas - Bolivarian Republic of Venezuela. Phone (0212) 276.2000. P.O. Box 61.618 (of the East)
Z.P. 1060, Direc. Cable "Censeca". Telex 24119. Internet [Link]

SM. 477 (01-2018)

The Policy Receipt will be delivered to the Policyholder together with the Terms.
In general, the Particular Conditions, the annexes, if any, and the other documents
that are an integral part of the Policy. Upon renewal, the obligation will proceed for the
new documents or for those that have been modified.
Particular Conditions: Those that consider aspects specifically related to the risk.
that is ensured.
Premium: Consideration that, based on the risk, the Policyholder must pay the Insurer.
by virtue of the celebration of the contract.

Siniestro: Future and uncertain event upon which the obligation to indemnify depends.
from the Insurer.
Deductible: Amount indicated in the Policy Receipt Table that must be assumed by the Insured.
consequently, it will not be paid by the Insurer in the event of a claim
covered by the Policy. The deductible for each Insured will be applied per illness or accident and
validity of the contract.
Insured Sum: Maximum liability limit of the Insurer, indicated in the Table
Receipt Policy. The insured amount for each Insured will be applied per illness. o
accident and validity of the contract.
CLAUSE 3. DISCLAIMER OF LIABILITY The Insurer shall not be obliged to
payment of the compensation in the following cases:
If the Policyholder, the Insured, the Beneficiary, or any person acting on behalf of
of these presents a fraudulent or deceptive claim, or if at any time
uses misleading or fraudulent means or documents to support a claim or
to derive other benefits related to this Policy.
If the incident has been caused by willful misconduct Holder, of the Insured or of
Beneficiary.
3. If the loss has been caused by serious fault of the Policyholder, the Insured or the
Beneficiary. However, the Insurer will be obligated to pay the compensation
if the accident has occurred in the performance of legal duties of assistance or
in protection of common interests with the Insurer regarding the Policy.
4. If the incident begins before the validity of the contract and continues afterwards
that the risks they have begun to run on account of Insurer.
5. If the Policyholder, the Insured, or the Beneficiary does not use the means available to them
to mitigate the consequences of the disaster, provided that this non-compliance is
produced with the manifest intention of harming or deceiving the Insurer.
6. If the Policyholder or the Principal Insured acts with intent or gross negligence, according to
stated in Clause 8. Declarations in the Application of Sure, from these
General Conditions.
7. If the Insured or the Beneficiary fails to comply with what is established in Clause 12.
Subrogation of Rights, of these General Conditions, unless proven
that the non-compliance is due to a strange cause not attributable to him.
8. If the Policyholder, the Insured, the Beneficiary or any person acting on behalf
of these, acting with intent or gross negligence, obstructs the rights of the Insurer
stipulated in this Policy.
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9. Other liability exemptions established in the Conditions
Policy Details.
CLAUSE 4. DURATION OF THE CONTRACT
The duration of the contract will be annual and will be recorded in the Policy Receipt Table, with indication
from the date of issuance, the time and day of its initiation and expiration.
CLAUSE 5. PAYMENT OF THE PREMIUM
The Policyholder must pay the first annual premium within ten (10) consecutive days counted
from the start date of the contract's validity. If the premium is not paid or is made
impossible to collect due to reasons attributable to the Policyholder within the established deadline, the Insurer will have
right to demand the corresponding payment or resolve the Policy. In case of resolution, this
It will take effect from the start of the validity of the contract, without the need for prior notice to
Policyholder. If a loss occurs within the agreed timeframe for the payment of the premium, the
Insurer will pay the compensation, provided that the Policyholder pays before its due date.
the corresponding premium.
Upon payment of the premium, the Insurer will deliver the Policy Receipt to the Policyholder.
corresponding, signed and sealed by himself. The premiums paid in excess will not give
place any responsibility on the Insurer for the excess, but only and
exclusively to the interest-free reimbursement of the surplus, even if they have been
formally accepted by the Insurer.
The premiums corresponding to this contract will be paid directly at the offices of
Insurer. However, he may collect premiums at home and give notice of his
maturities and, if it does, it will not set a precedent of obligation and may suspend this process
at any time, without prior notice.
The premiums may be paid through any mechanism or means agreed upon by the parties.
CLAUSE 6. RENEWAL
The contract will be automatically renewed at the end of the last day of its duration.
previous validity period and for an equal term, provided that the Policyholder pays the premium
corresponding to the new period, in accordance with what is established in Clause 7. Deadline of
Grace, from these General Conditions, understanding that the renewal does not imply a new
contract, but the extension of the previous one. The parties can refuse to extend the contract
by means of a written notification to the other party, made with a notice period of at least one
1 month in advance of the conclusion of the current validity period.
Three (3) uninterrupted years having passed since the celebration of the contract, the Insurer does not
may cancel or refuse to renew under the same conditions, as long as the Policyholder pays the
corresponding premium.
CLAUSE 7. GRACE PERIOD
Thirty (30) continuous days of grace are granted for the payment of the renewal premium.
counted from the date of termination of the previous contract. If an event occurs, a
In the event of a loss during this period, the Insurer will pay the compensation, after deducting the premium.
corresponding. If the amount of the claim is less than the renewal premium, the Insurer
the compensation will be paid, provided that the Policyholder pays the premium within the granted grace period.
If the premium is not paid within the specified period, the contract will be rendered null and void starting from
the expiration date of the previous contract.

SM. 477 (01-2018) 3 out of 19

CLAUSE 8. STATEMENTS IN THE INSURANCE APPLICATION
The Insurer must inform the Policyholder, within a period of five (5) business days, that it has had
knowledge of an undisclosed fact in the Insurance Application, which may influence the
risk assessment, and may adjust or resolve the contract through communication addressed to
Taker, within a period of one (1) month from the knowledge of the facts that are
reserved or declared inaccurately by the Policyholder or the Main Insured. In case of resolution, this
will occur from the sixteenth (16th) day following its notification, provided that the party
proportional to the premium, deducted the commission paid to the insurance intermediary,
corresponding to the period that remains to elapse is available to the Policyholder in the
insurer's box. The premiums corresponding to the period elapsed will belong to the insurer.
until the moment this notification is made. The Insurer cannot terminate the contract
when the fact that has been the subject of reservation or inaccuracy has disappeared before the
sinister.
If the loss occurs before the Insurer makes the participation referred to in the
previous paragraph, the provision of this will be reduced proportionally to the difference between the
agreed price and the one that would have been established to have known the true nature of
risk. Likewise, if an incident occurs before the expiration of the terms of one (1) month or of
sixteen (16) days mentioned above, as the case may be, the payment of the benefit also
will be reduced in the terms mentioned in this paragraph. If the Policyholder or the Insured Holder
if acting with intent or gross negligence, the Insurer will be released from the payment of compensation and of
the refund of the premium.
When the reservation or inaccuracy was limited only to one or several of the persons covered by
the Policy will remain in effect with all its effects regarding the remaining ones, if that were the case
technically possible.
CLAUSE 9. FALSEHOODS AND BAD FAITH RETICENCE
The falsehoods and bad faith reticence by the Policyholder, the Insured, or the Beneficiary,
duly proven, they shall cause absolute nullity of the contract, if they are of such nature
that the Insurer, having known them, would not have contracted or would have done so in other ways
conditions.
CLAUSE 10. PAYMENT OF INDEMNITIES
The Insurer must pay the corresponding compensation within a period that does not exceed
thirty (30) continuous days following, counted from the date on which it has been received
last collection requested, unless due to an unusual cause not attributable to the Insurer.

CLAUSE 11. REJECTION OF THE CLAIM

The Insurer must notify the Policyholder, the Insured, or the Beneficiary in writing, within the period
indicated in the previous clause, the factual and legal reasons that in your opinion justify the
rejection, total or partial, of the requested compensation.
CLAUSE 12. SUBROGATION OF RIGHTS
The Insurer is fully subrogated, up to the amount paid, in
the rights and actions of the Policyholder, the Insured or the Beneficiary against third parties
responsible parties.
damage would have been caused by: the
Unless there is intent to deceive, subrogation shall not take place if the
descendants, the spouse or the person with whom they have a stable de facto union, others
relatives of the Insured or the people who permanently live with him or those by
those that I must respond to civilly.
SM. 477 (01-2018) 4 of 19
The Insured or the Beneficiary may not, at any time, waive their rights to demand from
other people compensation for the damages and losses they may have caused her.
In the event of a claim, the Insured or the Beneficiary is obliged to carry out at the expense of
Insurer, as many acts as necessary and everything that it may reasonably require,
in order to allow them to exercise the rights that correspond to them by subrogation, whether
before or after the payment.
If the Policyholder, the Insured, or the Beneficiary breaches the provisions established in this clause, they will lose
the right to payment granted by this Policy, unless it proves that the default is
due to a strange cause not attributable to him.
CLAUSE 13. OTHER HEALTH CONTRACTS
At the time of notifying the occurrence of the incident, the Policyholder, the Insured, or the Beneficiary
is obliged to inform the Insurer of the existence of any other health contract that
compare to the Insured who activated the coverage of the Policy.
When the Insured is covered by several health contracts that are obligated to
pay the compensation for the same incident, will choose the order in which to present the
claims and compensation must be provided, according to the benefits and limits of each of them, up to
the total amount of expenses, prior to the deduction of amounts paid for other contracts.
CLAUSE 14. ARBITRATION
The parties may submit the differences that arise to an arbitration procedure.
the interpretation, application, and execution of the contract. The processing of the arbitration will be adjusted to the
provided in the law that regulates the arbitration matters and supplementarily to the Code of
Civil Procedure.
The Superintendent of Insurance Activity will act as an arbitrator in those cases
as designated by mutual agreement between both parties, due to the disputes that
arise in the interpretation, application, and execution of the contract. In this case, the
The arbitration process will be in accordance with the provisions of the regulations to govern the mechanisms.
alternative conflict resolution in the insurance activity.
The arbitral award shall be binding.
CLAUSE 15. LAPSE
The Policyholder, the Insured or the Beneficiary will lose all right to take legal action against
the Insurer or agree with it to submit to the Arbitration provided for in the previous clause, if not
I would have done before passing the term of one (1) year counted from the date of the
notification, in writing:
1. The total or partial rejection of the claim.
2. From the Insurer's decision regarding the dissatisfaction of the Policyholder, the Insured or the
Beneficiary regarding the amount of compensation.
For the purposes of this provision, the judicial action will be understood to have begun once it is
the complaint has been filed before the judicial organs.
CLAUSE 16. PRESCRIPTION
Unless provided for in special laws, the actions arising from this contract are subject to statute of limitations to the
three (3) years counted from the incident that gave rise to the obligation.
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CLAUSE 17. MODIFICATION AND REHABILITATION
The Policy can be reinstated at the request of the Policyholder, provided that the Insured parties...
are in good health, according to health declaration or medical examination to
responsibility of the Insured. In this case, the acceptance of the Insurer and payment is required.
first pending, the contract entering back into force in the date indicated in the Table
Policy Receipt. The Insurer will recognize the seniority obtained by the Insured for purposes
from the application of waiting periods and temporary exclusions, but they will not be covered
expenses incurred from the date of contract termination until three (3) months thereafter
start date of your rehabilitation, except in cases of accidents and infectious diseases
agudas, mentioned in Clause 3. Immediate Coverage of the Specific Conditions of
this Policy, which occurs from the date of rehabilitation. No agreement will be made regarding the
rehabilitation, once ninety (90) continuous days have passed since the date of resolution of the
contract.
Written requests to modify the contract or to rehabilitate it are deemed accepted if the
The insurer does not reject the application within ten (10) business days of having received it.
the deadline will be twenty (20) business days when, in the opinion of the Insurer, the modification or
rehabilitation of this contract makes a medical examination necessary. The requirement of the
Ensuring that the Insured undergoes the medical examination does not imply acceptance.
The modification of the insured sum and/or the deductible will require the express acceptance of the other party.
part. Otherwise, it will be presumed accepted by the Insurer with the issuance of the Table
Receipt Policy, in which the insured amount and/or the deductible is modified, and on behalf of the
Policyholder by written communication or by paying the corresponding premium difference.
The proposal to modify the insured amount and/or the deductible must be made in a
a period no less than thirty (30) business days prior to the expiration of the contract's validity
in progress or on the date the modification becomes effective, as applicable.
CLAUSE 18. NOTICES
Any notice or communication that one party must give to the other regarding the Policy must be made
by written communication, telegram, or electronic means, with acknowledgment of receipt, addressed to
main address or branch of the Insurer or to the address of the Policyholder or the Insured that
as stated in the Policy, as applicable.
The communications delivered to the insurance intermediary have the same effect as if
would have been delivered to the other party.
Insurance intermediaries must deliver correspondence to its recipient within a timeframe.
of five (5) business days, counted from its receipt.
CLAUSE 19. SPECIAL ADDRESS
For all effects and consequences arising or that may arise from this Policy,
the parties choose as a special, unique, and exclusive domicile of any other, the place where
celebrated the insurance contract, to which Jurisdiction declares the parties to submit themselves.

PARTICULAR CONDITIONS
CLAUSE 1. INTERPRETATION OF TERMS
For the purposes of this Policy, the terms indicated below will have the following
meaning:
SM. 477 (01-2018) 6 out of 19
Accident: A violent, sudden, external occurrence that is beyond the intention of the policyholder or the
Ensured that it causes bodily injuries to the latter.
Medical Emergency: Condition that endangers the life or physical integrity of the Insured,
whose attention cannot be deferred and whose diagnosis has been made by a qualified doctor
of the healthcare service providing hospital institution.
Disease: Modification of health resulting from the action of pathogenic agents of origin
internal or external in relation to the organism, that causes a reduction in its functional capacity and that
requires medical treatment and/or surgical intervention.
Preexisting Condition: Disease or injury that can be verified as having been acquired with
prior to the start date of the validity of the contract or the inclusion of the Insured in the
Policy, and be known by the Policyholder or the Insured.
Disease, Defect or Congenital Malformation: Alteration or deviation of the physiological state
from one or more parts of the human body that exist from birth or before
of the same. It will be considered a pre-existing condition if it is known by the Policyholder or the
Insured as of the start date of the contract or the inclusion of the Insured in the
Policy.
Hospital Institution: A permanent establishment with a valid health permit to
provide medical assistance authorized by the competent public body. They will not be
considered hospital institutions for the purposes of this Policy, places of rest,
geriatric centers, spas, hydroclinics, and any institution that provides similar treatments,
exclusive centers for the treatment of drug addicts, of dipsomaniacs (alcoholics)
mental illnesses or behavioral disorders, nor places that provide treatments
naturists, alternative therapies, and acupuncture.
Doctor: A professional in medicine who is licensed and registered with the Ministry with competencies in
health matter or in the institution that legally corresponds, to practice the profession
doctor in the country where she provides her services.

Experimental or Investigative Procedure: Medical treatment, surgical intervention,

supply, medication, medical procedure or hospitalization that:
1. It has not been accepted as safe, effective, and appropriate for medical treatment of
diseases according to the consensus of the professional organizations that are recognized by
the international medical community; or
Its use is restricted to disciplined clinical objectives that have value or benefit for
clinical purposes of the discipline and scientific studies; or
3. It has not been objectively proven to have value. the therapeutic benefit; the
4. Be under study, research, in a probation period or in any phase of a
experiment or clinical trial.
Medical Treatment: A set of measures taken or ordered by a doctor that are implemented
in practice for the healing or relief of an illness or injury, including medications
prescriptions, supplies or prosthetics.

Prosthesis: Device or apparatus designed to replace a missing part of the body or to

make a part of the body work better.
Outpatient Care: Medical care provided to an Insured when their stay
in the Hospital Institution should be less than 24 hours.
SM. 477 (01-2018) 7 out of 19
Reasonable Cost: It is the average calculated by the Insurer of the expenses covered by
medical treatments and/or surgical interventions of Hospital Institutions located in
the same geographical area, that are of the same category or equivalent to the one where it was
attended the Insured, which correspond to a surgical intervention or treatment
doctor equal to or similar, free of complications and according to the conditions of this
Policy are covered. This average will be calculated based on the statistics.
that has the Insurer of the expenses billed in the immediately preceding calendar month
at the date on which the Insured incurred the expenses, increased according to the National Index of
Consumer Prices (I.N.P.C.) of the Central Bank of Venezuela recorded in the same month.
When this average cannot be obtained, the reasonable cost will be the amount billed.
However, if the Insurer has agreed with any provider on a scale, it must
make the indemnity for the services provided by this supplier in accordance with the
referred scale.
If applicable, the reasonable cost of covered expenses must adjust to the benchmarks or the
price structure that the State has established in the area of health service provision.
This concept applies to all acquisition of inputs, supplies, instruments.
specials or medical equipment.
Necessary Medication: Set of measures or procedures ordered and provided by
a doctor or hospital institution, that are implemented for treatment, healing or
relief from an illness or injury, under the following characteristics:
It should be appropriate for the diagnosis and treatment of the Insured's illness or injury.
2. Be consistent with the accepted professional standards in the practice of medicine in
the Bolivarian Republic of Venezuela and by the Venezuelan Medical Federation or by the
medical community of the country where the service or treatment is provided.
be provided without risk to it
3. That the level of service or supply is suitable and can
Insured.
4. That it is not primarily for the comfort or personal convenience of the Insured, of their
family or their doctor.
CLAUSE 2. COVERED EXPENSES
It is understood that the Insurer covers one hundred percent (100%) of the expenses.
damages caused during the term of the contract, subject to reasonable cost, in
excess of the deductible, if any, and up to the insured amount contracted. The amount
insured and the deductible of each Insured will be applied for illness or accident and
validity of the contract.
If the Insured is receiving medical assistance as a result of a
health impairment covered by the policy includes expenses that arise
after the contract has expired, that can be attributed to the same medical assistance,
as long as the insured amount has not been exhausted. The expenses incurred are covered.
for medical treatment, surgical intervention (including postoperative treatment),
hospital services, medical procedure, medications, supplies, equipment, and
special instruments, medically necessary for the treatment of alterations to
the health of the Insured covered by the Policy. It is also understood that:
1. The expenses for the payment of medical fees, together with the
Other benefits covered by this policy are subject to the insured sum.
contracted.
SM. 477 (01-2018) 8 out of 19
2. The medications must have been prescribed under specific medical prescription.
to be necessary for the medical treatment of the disease and/or injury that causes the
complaint of Insured and to be acquired in an establishment authorized for the
dispensing of pharmaceutical products.
3. The surgical medical material and supplies will be indemnified against the
presentation of the breakdown of your consumption and billed cost by the Institution
Hospitalization, as long as it has been necessary for the treatment of the
disease, injury or procedure performed on the Insured.
4. Covered hospital expenses refer exclusively to room service.
regular (different from special or luxury rooms, suites, and semi-suites), which
they include the patient's diet, as prescribed by the doctor, and until
for the maximum cost of the regular private room in the institution
hospitality. In addition, expenses for phone usage (local calls) are covered,
admission, use of the television in the room occupied by the hospitalized Insured and the
cost of overnight stays for the companion when occupying the same room as him
Patient Insured. Other hospital expenses are not considered covered expenses.
different from those mentioned earlier and those generated by the companion for the concept of
nutrition.
5. The private nursing service will be covered, as long as it is provided within
from the hospital institution and ordered by the treating physician, given the severity of the
patient and the need for specialized care. The private nursing service
for the care of the patient will be covered, as long as it has been previously
authorized by the Insurer. The nurse must be a professionally graduated, legally
authorization to practice the profession.
6. The costs for the acquisition and implementation of prosthetics are covered:
oculars, hip, upper and lower limbs, cardiovascular, joint
of digestive tracts, ventriculoperitoneal shunts, cardiac pacemakers, thus
such as dental, auditory, testicular, breast, and any others that could be
required due to the loss of organs or limbs as a result of
diseases and/or injuries suffered by the Insured, that have been diagnosed,
treated and covered during the validity of the contract and whose medical indication is of
permanent character.
Regarding hearing aids, one (1) is covered every three (3) years, except in
those cases where hearing loss progresses and requires, before that period,
of a prosthesis with higher gain or power in decibels.
The Insurer may supply the required prosthesis in accordance with the
availability and/or existence of it in your supply provider network
surgical-medical. In case the prosthesis is not available in the referred
red, the Insured may acquire it, prior agreement with the Insurer.
7. The expenses for the acquisition of crutches and manual wheelchairs are covered.
that are required for permanent use as a consequence of a health alteration
of the Insured covered by the Policy.
8. Rental expenses for orthopedic devices, wheelchairs are covered.
manual wheels and special beds, as well as equipment for administration of
oxygen, ventilators, other equipment for the medical treatment of paralysis
SM. 477 (01-2018) 9 out of 19
 respiratory and, in general, all those related to any kind of equipment and
special instruments, as long as they are not a consequence of alterations of the
health of the Insured occurring prior to the hiring of the Policy. When
the cost of rental for the estimated duration of use, according to the doctor's criteria
dealer, exceed the acquisition cost, the Insurer may make the purchase of
these and once the rehabilitation process of the Insured or its use is completed,
this must, at the request of the Insurer, be returned within thirty
(30) continuous days.
9. The costs for chemotherapy, radiotherapy, fluoroscopies are covered,
x-rays, radioactive isotopes, metabolism tests, electrocardiograms,
ultrasounds, magnetic resonances, tomography, laboratory tests and others
similar ones that are related to the cause or origin of medical treatment or of the
hospitalization, whenever required in the diagnosis or treatment of a
health alteration of the Insured covered by the Policy.
10. The coverage provided by this contract extends to treatments
dental issues that arise as a result of an accident that occurs
during its validity, as long as these treatments are carried out, at most, within
of the ninety (90) continuous days following the date of the accident.
11. The costs for outpatient care are covered.
12. The expenses for medical fees for surgical intervention are
limited to one (1) main surgeon, one (1) assistant, and one (1) anesthesiologist. The
Insurer will recognize the fees incurred for one (1) second and a third
assistant, as long as their participation in the surgical intervention is
medically justified. The expenses covered by medical fees
corresponding to the first assistant, the anesthesiologist, will be a maximum of forty
forty percent (40%) of the main surgeon's, for each one. In the case of being
the participation of a second assistant is necessary, the fees will be as
a maximum of thirty percent (30%) of the fees of the main surgeon and in the
In the case of a third assistant, the fees will be a maximum of twenty percent.
twenty percent (20%) of the main surgeon's fees.
If during the course of the same hospitalization or surgical procedure, the Insured is
attended by two or more surgeons, or if two or more interventions are performed
surgical procedures due to the same disease or accident, these will be considered as a
solely for the purpose of indemnification and if accidents and/or complications arise
and direct or indirect diseases arising from the primary disease, during the
course of hospitalization or that require new hospitalization, the compensation in
No case will exceed the insured sum contracted.
In the case of two (2) or more surgical interventions performed in the same act
surgical, with the same surgical field, the Insurer will pay as follows: the
one hundred percent (100%) of the highest cost, fifty percent (50%) of the
next and twenty-five percent (25%) of the cost of each of the following, without
in no case exceed the insured sum contracted.
13. Medical expenses incurred for care received in hospital institutions are covered.
public and charitable institutions, which will be paid exclusively against the
presentation of invoices and original receipts that prove the cancellation of the
expenses incurred, provided that the illness and/or injury that caused them is covered
by this Policy.
SM. 477 (01-2018) 10 out of 19
14. The expenses for rehabilitation, prescribed by the doctor, are covered.
dealt with and practiced by authorized professionals in the field, intended for
recovery of lost physical capacity as a consequence of an accident
covered by this Policy.
15. Expenses for surgical intervention of type are covered.
reconstructive resulting from an incident covered by the Policy. The intervention
surgery must be performed within one hundred eighty (180) continuous days
following the occurrence of the incident. This period may be extended if, in the opinion of
the treating physician should perform the reconstruction on a later date, provided that
the policy remains in force at the time the intervention takes place
surgical.
16. The expenses for ground ambulance services within the Territory are covered.
National, whenever the treating physician considers it necessary.
17. The costs for Postoperative Analgesia Services are covered, provided that
required due to an illness or accident covered by the policy and the treating physician
theconsider it a necessary medication.
18. The children of the Insured Holder, born during the validity of the Policy, will be
covered during the first thirty (30) continuous days of life under the coverage
basic of the mother, as long as it is in effect at the time of the
birth. In order for the children to continue with the coverage, the Policyholder must
request your inclusion in the Policy during the mentioned period and pay the proportional part of the
first corresponding to the period that has yet to pass, in accordance with the established provisions
in the General Conditions of the Policy; in which case, the Insurer will not apply
the waiting periods and temporary exclusions provided in this Policy.
19. Surgical intervention expenses for morbid obesity are covered, based on
2 following
a body mass index over 40 Kg/m, prior to fulfilling the
protocol: two (2) evaluations by a Nutritionist, with a difference of at least
thirty (30) continuous days between each evaluation; one (1) evaluation of a
Endocrinologist; one (1) evaluation by a Pulmonologist; one (1) evaluation of a
Psychologist, one (1) evaluation from a Psychiatrist and one (1) evaluation from a Doctor
Internist, including a cardiovascular check-up report.
It is understood that the protocol must have a validity of no more than ninety (90) days.
days before the request for the surgical intervention. Likewise, it corresponds to
I assure compliance with the referred protocol and the expenses incurred will be
covered by this Policy, as long as there is a positive diagnosis of the
disease.
20. The costs for treatments of diseases originating from are covered.
direct consequence of Acquired Immunodeficiency Syndrome (AIDS).
CLAUSE 3. IMMEDIATE COVERAGE
Accidents covered by the policy will have immediate coverage and the following
acute infectious diseases: rheumatic fever, appendicitis, bronchitis, gastroenteritis
abscesses (intra-abdominal, intrathoracic, and intracranial) adenoiditis, vertigo or
labyrinthitis (alone or combined), otitis, laryngeal disorders,
SM. 477 (01-2018) 11 of 19
lower respiratory infection, hemorrhagic dengue, malaria, meningoencephalitis, pneumonia and
pyelonephritis, as well as the expenses incurred by the following viral diseases:
mumps, rubella, measles, and chickenpox.
CLAUSE 4. WAITING PERIODS
The insured participants in the insurance have the right to enjoy the coverages and
benefits established in this Policy, once the Waiting Periods have passed
specified below, which will be counted from the start date of
the Policy or the inclusion of the Insured, as applicable:
1. Once (11) months for the following diseases: non-infectious adenoiditis, headaches
vascular (migraine), vertigo or labyrinthitis, pharyngo - tonsillitis (alone or combined) no
infecciosa, hemorroides, hidrocele, incontinencia urinaria, otitis no infecciosa,
laryngeal disorders, skin and appendages disorders (non-infectious), skin tumors and
from subcutaneous cellular tissue and human papillomavirus, except as provided in
Clause 3. Immediate Coverage, of these Particular Conditions.
2. Ten (10) months for surgical intervention for morbid obesity and for the
diseases of the female reproductive system that require surgical intervention.
3. Three (3) months for any other alteration to the health of the Insured, provided that it does not
is excluded temporarily or permanently in this Policy.
If the Policyholder or the Insured requests an increase in the insured amount or a change
the plan, for the excess amounts will start to be considered again the
waiting periods, counted from the date on which the increase occurred or
change of plan, therefore in the event of a loss occurring before the expiration of the deadlines of
pending applicable to the new insured amount or plan, the Insurer will indemnify based on
the base of the insured sum or plan contracted before the modification, provided that
the previous waiting periods would have expired.
CLAUSE 5. TEMPORARY EXCLUSIONS
The insured individuals enrolled in the insurance are covered for the following cases or
health alterations, once eighteen (18) months have passed, counted from the
start date of the policy or the inclusion of the Insured in it, according to
allergy tests and desensitization treatments for allergies, tumors
benign breast conditions, juvenile gigantomastia that causes evident disorders at the level of the
columna cervical y dorsal, aneurisma, arritmia cardíaca, arterosclerosis, discopatías
degenerative diseases, arthropathies, bronchiectasis, chalazion, cancer, heart disease
ischemic, cataracts, cerebrovascular disease, disorders caused by cholesterol and
triglycerides, high blood pressure, diabetes and its complications, biliary disease and its
complications, chronic obstructive pulmonary disease, syndrome of
hiperreactividad bronquial, enfermedad de d'quervain, enfermedades desmielinizantes,
diffuse connective tissue diseases, diverticular disease and its complications
enfermedades endocrinas, enfisema pulmonar, estenosis de canal medular, estrabismo,
eventration, phimosis or paraphimosis, prostate diseases, testicular diseases,
fístulas, esofagogastroduodenopatías, glaucoma, hallux valgus, hepatopatías, hernias,
hypertrophy of turbinates, arteriovenous malformations, occupational lung diseases
osteoarthritis, osteoporosis, otosclerosis, tumors and eyelid ptosis, polyps,
pterigión, quiste de cápsula articular, valvulopatías, enfermedades renales, retinopatías,
rhinossinopathies, functional septoplasty, radicular compression syndrome, syndrome of
SM. 477 (01-2018) 12 of 19
the lateral recesses, urinary tract syndrome and its complications, syndrome of
carpal tunnel, neurological syndrome of alteration of the pyramidal or extrapyramidal pathway,
thyroid diseases, refractive defects (coverage is limited to treatment)
surgical treatment of myopia and hyperopia, greater than 3 diopters), hematological disorders
primaries, pulmonary thromboembolism, tumors different from those indicated in the
number 1 of Clause 4. Waiting Periods for these Particular Conditions, varices,
varicocele, diseases of the small intestine, large intestine, rectum, and anus, not mentioned in
the numeral 1 of Clause 4. Waiting Periods, of these Particular Conditions.
If the Policyholder or the Insured requests an increase in the insured sum or a change of
plan, for the excess amounts, the period will be reconsidered again
eighteen (18) months, counted from the date the increase occurred or
change of plan, therefore if an incident occurs before the expiration of this period, the
Insurer will compensate based on the insured sum or contracted plan before the
modification, provided that the previously applicable period of eighteen (18) months has elapsed
defeated.
CLAUSE 6. EXCLUSIONS
The Insurer does not cover expenses related to:
Injuries caused as a consequence of or occurring during: war, invasion,
act of foreign enemy, hostilities or military operations (there has been
declaration of war or not, military insubordination, military uprising, insurrection
rebellion, revolution, civil war, military power or usurpation of power, proclamation
from the state of emergency, act of terrorism or act by any person acting in
name of or in relation to any organization that carries out activities aimed at
replacement of the government by force or influencing it through terrorism or the
violence.
2. Injuries or diseases caused by nuclear radiation, fission, fusion, radiations
ionizing or radioactive contamination, unless they arise from an unusual cause
not attributable to the Insured.

3. Injuries or diseases caused by earthquake, tremor, tsunami,

tsunami
typhoon, cyclone, climate events, hail, volcanic eruption or any other
convulsion of nature or atmospheric disturbance.
4. Injuries caused as a result of the active participation of the Insured
in criminal acts, riot, civil commotion, popular unrest, looting, disturbances
labor or work conflicts.
5. Suicide or attempts thereof, as well as injuries caused by the Insured.
intentionally.
6. Injuries caused as a result of the active participation of the Insured
in duels or fights, unless it is proven that they have not been provoked by the
It is assured that he acted in legitimate defense.
7. Injuries caused as a result of the Insured's practice of the
following high-risk sports or activities: hunting, motorsport, motorcycling
motocross, karting, scooters cycling competition, benji, diving, underwater diving
esquí acuático, esquí en nieve, rafting, descensos de rápidos, surf, windsurf, remo,
SM. 477 (01-2018) 13 out of 19
 deep-sea fishing, spearfishing, boating, navigation in waters
international in vessels not intended for public passenger transport,
American football, rugby, diving, skydiving, Icarus flight, flight to
vela, vuelo en globo, vuelo en parapente, vuelo en planeador, vuelo en ultraligero,
velerismo, vuelo delta, coleo, competencia de equitación, polo, hipismo, rodeo, boxeo,
lucha, artes marciales, jiu jitsu, viet vo dao, full contact, competencia de levantamiento
of weights, shooting, spelunking, mountaineering, and climbing, unless the Insurer agrees
with the Insurer the coverage of these expenses.
8. Diseases declared as epidemics by the competent public authority, in
which refers to the expenses that have been incurred after being declared
as such.
9. Treatments for alcohol dependence, narcotic drugs and
psychotropic substances and their complications, acute or chronic, alcoholism; as well as the
accidents occurring under the influence of alcohol or non-prescribed drugs
medication and the consequences and/or diseases caused by consumption of
alcohol or the use of non-prescribed drugs.
10. Organ or tissue transplants.
11. Diseases caused by an organ or tissue transplant.
12. Medical treatments and/or surgical interventions on healthy organs for purposes
condoms.
13. Rest cures, treatments for psychiatric and mental illnesses, examinations and
therapies performed by psychiatrists, functional behavioral disorders,
neurosis, depression, psychosis, schizophrenia, mental deficiencies, epilepsy, disorders
repetitive convulsions without structural cause, senile dementia, presenile dementia
bipolar disorders, Alzheimer’s and sleep disorders.
14. General medical check-ups or examinations for diagnostic or monitoring purposes, with or without
hospitalization, when there is no illness or not related to the illness
what originated medical attention. Cold states, except as noted in Clause 3
Immediate coverage of these Particular Conditions, and application of vaccines.
Acupuncture, naturopathy, homeopathy, or any other unapproved treatment
by the Venezuelan Medical Federation.
15. Experimental or investigative treatment.
16. Sexually transmitted diseases, their consequences and complications, except for what
established in numeral 1 of Clause 4. Waiting Periods, of these Conditions
Individuals.
17. The transfer of the Insured to and from the hospital institution. Nevertheless,
the provisions established in numeral 16 of Clause 2. Covered Expenses,
these Particular Conditions.
18. Eye exams or consultations, correction of visual refractive errors or defects
(myopia, hyperopia, astigmatism, presbyopia) through surgical or non-surgical treatments
surgical (glasses and/or contact lenses), intraocular or subocular lenses that
do not correspond to verified cataract pathologies. Nevertheless, it remains safe the
established in Clause 5. Temporary Exclusions from these Conditions
Particulars.
SM. 477 (01-2018) 14 of 19
19. Surgical treatment of non-tumoral pathology of the mammary glands.
Mastoplasty for aesthetic, functional, or anatomical purposes and gigantomastia, except for the...
established in Clause 5. Temporary Exclusions, of these Conditions
Particulars. Accumulation of breast fat or lipomastia in men.
20. Treatments and controls for menopause and andropause.
21. Gynecological check-ups and controls.
22. Medical treatments or cosmetic, plastic, or aesthetic surgery. No
However, the provisions established in numeral 15 of Clause 2 remain intact. Expenses
Covered by these Particular Conditions.
23. Dental and periodontal diseases and treatments, intervention
surgical treatment of myofascial dystonias due to dental misalignment and/or anomalies of
growth of jaws, treatments of any kind of the joint
temporomaxillary. However, what is provided in numeral 10 remains safe.
Clause 2.- Covered Expenses, of these Particular Conditions.
24. Pregnancy, childbirth, cesarean section, abortion, and uterine curettage due to abortion, their consequences and
complications. Prenatal and postnatal consultations and examinations.

25. Medical treatments or surgical intervention for dysfunctions or insufficiencies

sexual, infertility, artificial insemination, in vitro fertilization, impotence, Peyronie's disease,
frigidity, sterilization, reversal of sterilization, sex change and the
complications that arise from them, as well as contraceptive treatments and their
consequences.
26. Treatments for obesity or weight reduction. However, it remains safe.
established in numeral 19 of Clause 2. Covered Expenses, of these Conditions
Individuals.
27. Studies, treatments, and hospitalizations for hormonal disorders with
impact on growth and/or development.
28. Treatments for Human Immunodeficiency Virus (HIV) and/or the Syndrome
Acquired Immunodeficiency (AIDS). However, what is established in the
number 20 of Clause 2. Covered Expenses, of these Particular Conditions.
Fees as a consequence of any treatment provided by a doctor
the nurse who is related to the Policyholder or the Insured, within the second
degree of consanguinity or affinity, or living with them.
30. Treatments for occupational, educational, or speech therapy. Treatments.
physiotherapy. Nevertheless, what is established in numeral 14 of the
Clause 2.- Covered Expenses, of these Particular Conditions.
31. Taxes, collection expenses, cleaning, microfilming, medical records, parking,
miscellaneous and other costs not defined or related to the treatment of the
declared affection.
32. Medical treatment, surgical intervention, hospital services, procedure
doctor, medications, supplies, equipment and special instruments, whose invoices
do not meet the requirements of the National Integrated Administration Service
Customs and Tax (SENIAT).
SM. 477 (01-2018) 15 out of 19
33. Over-the-counter medications, nor prescription medications
optional not related to the disease or injury treated.
The acquisition of the following medical equipment used for health checks
Prevention: sphygmomanometer, glucometer, toothbrushes, humidifier, irrigator
dental, anti-decubitus air mattress and resuscitation equipment.
CLAUSE 7. OTHER EXEMPTIONS FROM LIABILITY
The Insurer shall not be obliged to pay the compensation if the Policyholder, the Insured
or the Beneficiary does not notify the claim or does not deliver the requested documents by
the Insurer within of the deadlines established in Clause 8. Procedure in case
of Activation of the Coverage, of these Particular Conditions, except for unforeseen circumstances
not attributable to the Policyholder, the Insured, or the Beneficiary.

CLAUSE 8. PROCEDURE IN CASE OF ACTIVATION OF COVERAGE

If any Insured requires the provision of services guaranteed by this Policy, it will be taken into account.
bear in mind next:
1. The Policyholder, the Insured, or the Beneficiary may request reimbursement of expenses.
incurred. The Insurer will pay the compensation to the Policyholder based on the
original documents of: medical certifications, information from the provider of
service, invoices, recipes with medical indication concerning the products and/or services
expressly covered by this Policy and granted to the Insured, who meet the
legal requirements. If another company in the insurance activity has paid part of the
Expenses incurred by the Insured must be submitted to the Insurer along with the settlement and the invoices.
originals compensated, with the corresponding stamp.
The Policyholder, the Insured, or the Beneficiary must notify the claim within the period
a maximum of ten (10) business days after receiving the products and/or services or to
upon leaving the hospital institution, as applicable, using the usual forms
from the Insurer, and submit the aforementioned documentation within twenty (20) days
skilled following the notification has been made. Likewise, the Policyholder, the Insured or the
Beneficiaries commit to supplying the Insurer, especially in cases of
continued or prolonged treatment, monthly, the invoices and
payment receipts for the products and/or services received and covered by this Policy.
When the Insured receives services outside the Bolivarian Republic of Venezuela, the
invoices must be translated into Spanish, if applicable, and be stamped by the
respective Consulate or Embassy of the Bolivarian Republic of Venezuela. The
Compensation will be made at the reasonable cost that services have in the Republic.
Bolivariana of Venezuela, in national currency at the current official selling exchange rate,
established by the Central Bank of Venezuela, on the date the Insurer carries out the
payment, as long as the claim is valid according to the conditions of this Policy.
The Insurer may request additional documents beyond those described above, in a
single opportunity, the application must be made at most within ten (10) days
skilled following the date on which the last of the required documents was delivered in
the two previous paragraphs. However, if from the analysis of the submitted documents
derive, reasonably, the necessity of requiring supplementary documentation, the
The insurer may request it within ten (10) business days following the date on which
the last of the additional documents was submitted. In these cases, a deadline is set
SM. 477 (01-2018) 16 of 19
 thirty (30) continuous days for the submission of the requested documents by the
Insurer, counted from the date of application for the same, except for external causes.
not attributable to the Policyholder, the Insured, or the Beneficiary.

In case the Main Insured becomes incapacitated or has passed away before receiving the
payment of the compensation, the reimbursement will correspond to your Beneficiaries, and failing that, to
his heirs.
2. The Policyholder, the Insured, or the Beneficiary may request a Guarantee Letter from the Insurer. In this
supposedly, you must provide the detailed budget of medical expenses for the
products and the services to be provided by the supplier, as well as the results of the
preoperative exams and the medical report indicating the diagnosis, the treatment
doctor and/or the surgical intervention to be carried out. The Policyholder, the Insured or the
The beneficiary must submit these documents at least seven (7) business days before
anticipation of the date on which the medical treatment and/or intervention should take place
surgical.
The Insurer may request, at its own expense, a second medical evaluation and/or documents.
additional to those described above, in a single instance. The request must
to be carried out no later than within two (2) business days following the date on which it is
delivered the last of the documents required in the previous paragraph. In this case, it
set a deadline of five (5) business days for the Insured to undergo the second
medical evaluation and/or for the new requested requirements to be submitted by the
Insurer, as applicable, counted from the date of application, except for cause
strange not attributable to the Policyholder, the Insured or the Beneficiary. The Insurer is
required to provide a list of at least three (3) specialist doctors, with the
the purpose of the Insured choosing who will carry out the medical evaluation. The Insurer will
commits to delivering the Letter of Guarantee to the Insured within three (3) business days
following the date on which the aforementioned documents were submitted and
I would have completed the medical evaluation, if it were the case.

3. In cases of medical emergency, at the request of the Hospital Institution, the

Insurer must report immediately, through any provided mechanism
for this, the Insured is covered by this Policy.
4. The Insurer will use all necessary mechanisms to seek that the Insured
receive immediate attention.
5. The Insured has the right to freely choose the provider that will provide them with the
services or supplies guaranteed by this Policy. The Insurer may enter into contracts
with providers that ensure the provision of these services or supplies. In this
It will indicate quarterly, through notices placed in each of its offices.
of public attention and in electronic information media, the referred providers.
6. In any case, the compensation will be subject to a prior analysis conducted by the
Insurer, so that it can determine that the injury or illness that originated the
the request is covered by the Policy.
7. The Insured authorizes the treating doctor and the Hospital Institution to provide information.
about your physical condition, medical history, and other circumstances that originated the
claim, relieving them of keeping the medical secret.

SM. 477 (01-2018) 17 of 19

8. If after the payment has been made, it turns out that the expenses incurred by the
Insured and paid by the Insurer, they were originated or related to any of the
exclusions or limitations of this Policy, the Insurer will proceed to recover from the Insured
Title or of the person who has received the compensation, the amount that has been paid
unduly.
CLAUSE 9. INSURABLE PERSONS.
The insured under this Policy are the Main Insured and the following persons:
that the masculine gender will also include the feminine, which must be identified in the
Policy Receipt Frame:
The spouse of the Insured Holder or the person with whom they have a stable de facto union.
2. The children under the age of twenty-five (25) years old Insured
of the Holder or their spouse or
of the person with whom I have a stable de facto union.
3. The parents of the Main Insured or of their spouse or of the person with whom they have a union.
de facto.
4. Relatives of the Insured Holder, economically dependent on them.
5. The workers who provide services in the home of Principal Insured or those who are under their
personal service or that of your family.
The Insured who are eighty (80) years of age or older that have remained covered by
uninterruptedly for at least twenty-five (25) years, will remain covered under the insurance.
from the present Policy, under the same conditions and without premium payment.

CLAUSE 10. TERMINATION OF THE INSURANCE FOR EACH INSURED.

The insurance under this Policy will end when any of the following situations occur:
1. When the spouse or the person with whom they have a stable de facto union with the
The insured holder terminates his relationship with him.

2. If the child of the Main Insured or of their spouse or a person

of thewith whom I maintain a union
actually establishes, reaches the age of twenty-five (25) years, marries or maintains
stable common-law union.
3. When any of the persons mentioned in numeral 4 of the previous clause ceases to
economically dependent on the Principal Insured.
4. When the worker ceases to provide services for the Insured Holder.
5. By written notice from the Policyholder or the Insured Holder, communicating to the Insurer the
decision not to renew the Policy or the insurance of any Insured.
In the aforementioned cases, termination will occur at the end of the contract's validity.
In the event of the death of the Insured Holder, for the renewal to be applicable
contract, any Insured, relative of the deceased Insured Holder and of legal age, will be able to
to appear as the Main Insured, with the condition that the designation shall be notified to the Insurer
no later than within thirty (30) continuous days following the termination date of the
current validity. The Insurer is obliged to accept the designation of the new Insured
Title.
SM. 477 (01-2018) 18 out of 19
The termination will be carried out without prejudice to the right of the Insured or the Beneficiary to
compensation for incidents that occurred prior to the termination date.
If an Insured, in accordance with the indications in the previous numbers, is excluded from the
Policy may be requested from the Insurer no later than within thirty (30) continuous days.
following the date on which the termination of the contract becomes effective, the issuance of a policy of
health insurance, subject to the payment of the corresponding premium, and the Insured will not lose the
acquired seniority rights with the previous policy, regarding the same amount
insured or active plan at the time of the termination of the insurance. If the Insured was
continuously covered for three (3) years until the date of termination of the insurance,
The insurer is obligated to issue the requested insurance policy.
CLAUSE 11. SCOPE OF COVERAGE
The coverage of this Policy extends to any part of the world.

_______________________________________________
By the INSURER By THE TAKING PARTY

Approved by the Superintendence of the Insurance Activity through Resolution FSAA-003856 of 11/18/2013.
Published in the Official Gazette of the Bolivarian Republic of Venezuela No. 40,316 of 16/12/2013

SM. 477 (01-2018) 19 out of 19