The system of benefits of the General Judicial Mutual Law is regulated by the Royal Legislative Decree 3/2000, which approves the recast of the legal provisions in force on the Special Regime of Security Social of the staff at the service of the Administration of Justice (B.O.E. 28 of June 2000) and the Regulations of the Agency approved by Royal Decree 3283/1978 and the applicable legal provisions. In addition, the regulatory conditions for the benefits scheme are supplemented by means of circulars which come to the development of the previous legal standards and to reflect the agreements adopted by the General Assembly of the Agency in the exercise of the competence conferred on him by art. 6.e) of the Body Regulation (R.D. 3283/1978).

It is therefore essential to publish those circulars which concern the system of granting of benefits and which have not been published previously, for general knowledge of the beneficiaries of the scheme. Special Social Security managed by the Judicial General Mutuality.

For all the above, this Presidency resolves the publication in the Official Gazette of the State of Circular No. 77.

Madrid, November 29, 2005.-The President, Benigno Varela Autran.

ANNEX

1. Regulatory standards

Law 14/1986 of April 25, General Health Law.

RD 63/1995 of January 20, Health Care Management of the National Health System.

Royal Legislative Decree 3/2000 of 23 June approving the recast text of the legal provisions in force on the Special Social Security Regime of the staff at the service of the Administration of Justice.

Royal Decree 3283/1978 of 3 November approving the Regulation of the General Judicial Mutuality.

Law 16/2003 of May 28 on the cohesion and quality of the National Health System.

Current Health Care Legislation.

2. Extension of healthcare

Health care is intended to provide medical, surgical and pharmaceutical services aimed at preserving, preserving or restoring the health of the beneficiaries of this special social security scheme, as well as his aptitude for work. It will also provide the appropriate services to complete medical and pharmaceutical services and, in a special way, will address the physical rehabilitation for the professional recovery of the disabled entitled to it.

This circular only regulates the provision of medical care, on the understanding that the supplementary provision of orthopaedic services, the provision of pharmaceutical services and assistance abroad are the subject of throttling in specific circulars

Contingencies covered by the provision of health care are those of common or occupational disease and injuries caused by a common accident or act of service or as a result of accident or accident, or specific risk of the charge even if it is an act of terrorism, as well as pregnancy, childbirth and puerperium.

3. Content of healthcare

3.1 Health Care Content in the event of sickness and common accidents. -Health care shall be provided, at least, with the extent and scope to be determined in the general social security system, accessibility, mobility, quality, safety and information collected in the National Health System.

Health benefits are provided according to the following modalities: primary care, specialised care, pharmaceutical provision, supplementary benefits, information and health documentation services, and comprise:

(a) Primary care which, in general, includes healthcare in outpatient, home and emergency care and preventive primary care programmes.

b) Specialized care that includes:

1. Specialist care in outpatient and hospital settings, including day hospital and home hospitalization, as well as hospital and extra-hospital emergency care.

2. Psychiatric care in outpatient settings, including individual, group or family psychotherapy and hospitalization in acute and chronic processes.

(c) The pharmaceutical supply which includes the master formulae, the specialities and the pharmaceutical effects and accessories, with the extent determined for the beneficiaries of the general social security scheme and which is specific regulation object in the relevant circular on the subject.

(d) Additional benefits, for the definition, extension and content of which shall be taken into account in the general social security

:

Healthcare transport,

Home oxygen therapy,

Complex dietoterapic treatments,

Enteral diets,

Orthoprosthetic capabilities and

Other health benefits in charge of the General Judicial Mutuality that are subject to specific regulation.

e) Any other benefit to be determined in the scope of the general social security scheme.

3.2 Content of Maternity Health Care. -Maternity health care includes:

a) Preparation for delivery.

b) Care in the outpatient, hospital and emergency care of pregnancy, delivery and puerperium, as well as the obstetrics pathology that may occur in such situations.

c) The pharmaceutical and complementary benefits arising from such contingencies.

3.3 Content of health care by accident in the event of service and occupational disease. -Health care by accident in service and occupational disease, includes:

(a) All health treatments and actions deemed necessary and with the same content as specified in paragraph 3.1 of this circular.

b) The cosmetic surgery that is related to the accident of service or professional illness.

(c) All types of prostheses and orthotheses and other complementary services deemed necessary in relation to the pathological process arising from the accident in the event of service or occupational disease.

d) The pharmaceutical provision, in the terms that are regulated for this special social security regime.

4. Beneficiaries of healthcare

4.1 All mutualists and other beneficiaries falling within the scope of the special regime of the General Judicial Mutual Mutual Fund are beneficiaries of the health care by sickness and accident. Mutual pensioners, as well as their beneficiaries.

4.2 Health care and occupational disease health care recipients are beneficiaries of all active mutualists who suffer from any change in health as a result of one of these two contingencies. In such cases, the mutualists shall be considered as being fully entitled, even if their affiliation to the General Judicial Mutuality has not been dealt with.

4.3 The mutualists and other beneficiaries of health care included in the field of application of the special regime of the General Judicial Mutuality are beneficiaries of maternity health care. It is also the spouses of the mutualists and those persons who have been living with them in the same relationship of affectivity to that of the spouse, with the health insurance institution to which the mutualist belongs and even if they do not benefit under the rules of membership, provided that the conditions specifically laid down for such concerts are met.

5. Birth and effectiveness of health care right

5.1 The right to health care is born on the day of affiliation or discharge in the General Judicial Mutual Fund, both for the holder and for the beneficiaries. For family members or persons treated as beneficiaries whose inclusion as beneficiaries occurs at a later date, the effectiveness of the right to health care shall be at the date of application for recognition of their status as beneficiaries, except in the case of the newborn who, irrespective of that date, shall be entitled to the appropriate health care during the first month from the time of delivery.

5.2 For the purposes of the exception referred to in the previous paragraph, the adoption or acceptance assumptions, both pre-adopted and permanent, shall be equated to the newborn, with the first month being calculated, either on the basis of the decision (a) the administrative or judicial authority of the host Member State, or on the basis of the judgment in which the adoption is made.

6. Duration of healthcare

6.1 Healthcare will be provided from the day on which, by meeting the conditions required for its effectiveness, is requested from the relevant optional and the requirements established to preserve the right to be maintained. receive it.

6.2 Health care by accident at the event of service and occupational disease shall be provided to the person concerned from the time of the accident or the diagnosis of the occupational disease, and for the duration of the accident. pathological condition produced by such contingencies so requires.

7. Forms of healthcare delivery

Health care in charge of the General Judicial Mutuality is provided through concerts with insurance companies in the field of illness or with public or private establishments or by concert with institutions of Social Security.

8. Healthcare provided by outside media

8.1 The beneficiary who, by his or her family's own decision, uses health services other than those that correspond to him, shall pay, without entitlement to reimbursement, any costs that may be incurred.

8.2 In the case of receiving healthcare through private medical entities, the mutualist may ask for the reimbursement of expenses caused by the use of foreign media in two cases:

In case of unjustified denial of assistance, as stipulated in the concerts.

If the use of such healthcare services has been due to vital emergency assistance.

8.3 In the event of a discrepancy on the origin of the refund in the circumstances provided for in the two preceding cases, it shall be settled by the procedure provided for in paragraph 11 of this circular, in the case of of healthcare provided through insurance entities.

8.4 Where a beneficiary is assigned for health care purposes to a public body and makes use of health services other than those that correspond to it, it shall be subject to the legal and procedural rules of the the body has available for situations of use of other means of use, as well as its judicial system.

9. Concerted health care with the National Institute of Social Security (I.N.S.S.)

9.1 Content. -Social Security, through the Health Services of the corresponding Autonomous Communities or the Institute of Health Management, will provide medical assistance for any contingency to all the holders. and its beneficiaries who have chosen this form of coverage that at any time is established for the Public Health Network and without periods of absence in any case.

Health care through Social Security shall be provided from the date of discharge, taking into account that it is determined in accordance with the provisions of section 9.2.3. of this circular.

9.2 Assistance Documents:

9.2.1 The General Judicial Mutuality shall deal with the affiliation and casualty of the holders and the high, low and variances of beneficiaries in the form established in general, and the documents of membership and, where appropriate, those of the beneficiaries of the Agency without any other speciality than that provided for below.

9.2.2 Such documents, under the conditions set out in the collective management procedures, shall be presented in the relevant Social Security Territorial Treasury, either by the provincial delegation or by the services central, or by the holder, for the purposes of which the attachment produces effects.

9.2.3 If the presentation in the Territorial Treasury is carried out within the five calendar days following the one issued by the General Judicial Mutuality, the date of discharge to be entered by the Treasury shall be that of the issue. In another case, it shall be entered on the fifth day following the day of presentation at the Territorial Treasury.

10. Concerted health care with insurance entities

10.1 Content.-The modalities, form and conditions under which health insurance entities agreed with the General Judicial Mutual Assistance provide medical assistance to the holders and beneficiaries They are contained in the text of the concert currently in force and published in the Official Gazette of the State. This concert shall be understood to be complemented by the agreements signed by the General Judicial Mutuality with the Autonomous Communities, on behalf of such entities, for the provision of health care in the rural area.

10.2 Identification:

10.2.1 In order to receive healthcare, the mutualist or beneficiary must first prove his or her condition, by displaying the corresponding affiliation document of the General Judicial Mutuality or the document of health care, issued by it in accordance with its own rules. In the case of maternity assistance to beneficiaries not included in the beneficiary's document of beneficiaries, the link or situation shall be credited by displaying the family book or any other means of proof admitted in law. In the event of failure to provide accreditation in an emergency, the mutualist shall have a maximum of 48 hours to present the relevant documentation.

10.2.2 The entity shall issue the corresponding health magnetic card, which shall be sent to the beneficiary's address and which it must present to make use of the means of the entity. In the event that the entity has not issued the card, it will be sufficient to present the document of affiliation to the Judicial General Mutuality in which the Entity of affiliation is established, as stated in the previous point.

10.3 Beneficiaries not attached to Medical Entity:

10.3.1 The mutualist that he has not formalized his membership of one of the Concerted Entities and that, specifying health care for himself or his beneficiaries, requires it in the offices of the Entity, will be entitled to to receive it once it accredits its status as an affiliate of the General Judicial Mutuality. The entity shall provide the assistance and, within the period provided for in the present agreement, shall notify the facts to the General Judicial Mutuality to proceed to the discharge of the mutualist in the Entity, with the effect of the fifth of these days and the payment of the expenses of the assistance provided up to the date of discharge.

10.3.2 The holder shall submit to the General Judicial Mutual the appropriate application, in which it shall contain a brief description of the causes for which the affiliation was not formalized at the appropriate time, accompanying the next documentation:

(a) A certificate from the competent administrative body certifying the date of effect of the takeover and the administrative situations in which the mutualist has been found from that date to the present day.

b) Medical report of the assistance received.

c) Invoices of the expenses incurred.

The President of the Judicial General Mutuality will dictate Resolution, in accordance with the appropriate membership procedure.

11. Beneficiary claims

11.1 Claims with Insurance Entities. -Payees will be able to claim before the General Judicial Mutuality:

(a) When the Entity refuses any of the authorisations specifically referred to in the Concert or when it does not answer the request for the same and, in addition, there is no positive effect on that absence of response.

b) When the Entity is required to directly assume some expense or to reintegrate its amount and, upon request of the beneficiary, do not do so.

c) When the Entity fails to comply with any other obligations under the terms of the Concert.

The complaints will be made in writing to the corresponding Provincial Delegation or the Central Offices of the General Judicial Mutuality, accompanying all documents that can justify it. Received any complaint, the Provincial Delegation, if you initially consider that there are reasons for its estimation, will immediately take the necessary steps before the Entity to obtain the satisfaction of the same, in which case file without further processing. In the event that the aforementioned steps do not prosper and regardless of their amount, the Provincial Delegation will formulate the appropriate case, convening an immediate meeting of the Provincial Joint Commission.

11.2 Mixed Commissions. -Joint Committees, with joint membership, are responsible for the monitoring, analysis and evaluation of compliance with the Health Care Concert with medical entities.

a) Provincial Mixed Commissions: the complaints will be presented in the Provincial Delegation, which will be analyzed by the Provincial Joint Committee when they refer to the provincial level. If there are discrepancies within the Provincial Joint Commission, the case will be raised for study by the National Joint Commission. In the case of an agreement in the Provincial Joint Commission, the appropriate resolution will be issued by the Delegate. In the absence of agreement in the Provincial Joint Committee, the Provincial Delegation shall inform the person concerned and forward the file to the Central Services. The decisions of the Provincial Delegates shall be issued within the maximum period of three months.

(b) National Joint Commission: to understand the complaints that affect the entire national territory as well as the files that have been submitted by the provincial joint committees for lack of agreement. The files of the National Joint Commission will be studied, and the Presidency of the General Judicial Mutuality will be resolved within a maximum of six months.

11.3 INSS Claims. -They may be presented, by the mutualist, in all healthcare facilities (Hospitals, Ambulatories, Health Centers, etc.) or administrative departments of the Health Service of the corresponding Autonomous Community. and shall follow the applicable procedure in the field of this, through the Patient Care services or health administration units empowered to facilitate their processing.

12. Entity changes

12.1 Ordinary Changes. -As a general rule and as a common standard, holders attached to the I.N.S.S., as well as healthcare insurance entities, may change their Entity during the month of January of each year. Within that period, the holders who so wish shall submit their application for change in the Provincial Delegation or the Central Services of the General Judicial Mutuality, together with the affiliation document, which they must submit for their substitution.

In any case, the beneficiaries will be assigned to the same option as the holder of which their right depends.

12.2 Extraordinary Changes. -Mutualists attached to the INSS may change their Entity outside the ordinary period when a change of destination occurs for the holder with a transfer of the province.

Mutualists attached to private entities may also change entities in two other cases:

When the data subject obtains the compliance, in writing, from the two affected insurance entities.

When, for the sake of objective circumstances justifying the change of a plurality of holders affected by the same medical assistance problem, the Presidency of the General Judicial Mutuality agrees to open the deadline. The choice of entities.

13. Special medical treatments

13.1 Under this heading is regulated health partner assistance of exceptional nature for cases of technical incapacity of the Spanish public or private medicine in order to be able to attend to the pathology of mutualists or their beneficiaries.

13.2 In the cases of special medical intervention or treatment that, being financed by the National Health System, cannot be administered through the public or private medical means, due to the technical impossibility, the General Judicial Mutuality may authorize, in so far as it considers more appropriate in each case, the reimbursement of expenses arising from the assistance provided in foreign countries. To the above effects, it is assimilated to foreign medicine that could be provided in Spain, through foreign centers based in the national territory

13.3 For the initiation of the procedure that is regulated under the following heading, it is essential that the General Judicial Mutuality has had prior knowledge of the facts and has authorized special treatment, without the applications for treatments already practised for which no such prior authorisation of the Agency has been granted shall be considered.

13.4 The person concerned shall initiate the procedure prior to the treatment or intervention in question, by completing the relevant application form, in which he must explain the facts and to which he must accompany, in any case, the following documents:

1. Detailed medical report issued by the Hospital Service of Social Security or concerted medical entity, in which the applicant is being treated, indicating:

a) Impossibility of imparting treatment or reference intervention through ordinary means of the National Health System.

b) Reason and need for treatment or intervention.

c) Center where treatment or intervention can be provided.

2. Budget of the health centre where intervention or treatment is to be carried out.

13.5 In the light of the reports provided, the Judicial Mutual General will carry out as many checks as required and will request as many reports as it deems necessary. The file will be raised to the Governing Board of the Judicial Mutual General, which will resolve in accordance with the current regulations.

13.6 The drawback, in case it is relevant, will be limited to the health costs and the patient's displacement, the latter calculated in the form foreseen in RD 462/2002, of 24 May, on compensation for the service referred to the group listed in Annex I. Accompanying costs shall be reimbursed where the patient is a minor or has a disability degree of more than 65%.