Resolution Of 17 March 1993 Of The General Direction Of Insurance, By Which Publishes Health Care Framework Convention For Traffic Accidents For The Year 1993, With Public Health Institutions.

Original Language Title: Resolución de 17 de marzo de 1993, de la Dirección General de Seguros, por la que se publica el Convenio Marco de Asistencia Sanitaria para accidentes de tráfico para el año 1993, con instituciones sanitarias públicas.

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Article 13 of the regulation of insurance of Civil liability of the use and circulation of vehicles of Motor, compulsory subscription, approved by Royal Decree 2641 / 1986 of 30 December, establishes full coverage of medical and hospital expenses to victims whenever it is provided in centres recognized by the Consorcio de Compensación de Seguros.


With this purpose the Consorcio de Compensación de Seguros and the Spanish Union of insurance and reinsurance (UNESPA), has signed agreements with the Catalan health service, Andalusian health service, Servicio Valenciano de Salud, health service, health service Navarro, Galician service of health and the National Institute of health (INSALUD), in identical terms, establishing the tariffs during 1993 to assist provided in the centres of the same.


Being enforced in the first additional provision of the regulation of insurance of Civil liability of the use and circulation of Motor vehicles, it is necessary to make public the abovementioned framework agreement as well as the relationship of centres which, under cover of the same, are recognized by the Consorcio de Compensación de Seguros for the purposes of article 13 of the aforementioned regulation and insurance entities adhered to the one. By virtue of, this body has resolved as follows: first-published framework agreement on health care for traffic accidents 1993, within the framework of the public health system.


Second.-it publishes the relationship of public health care centres recognized by the Consorcio de Compensación de Seguros for the purposes of article 13 of the regulation of the liability insurance of use and circulation of vehicles of Motor, compulsory subscription, approved by Royal Decree 2641 / 1986 of 30 December.


Third.-published the relationship of insurance companies adhering to the Convention.


Fourth.-the insurance companies not being in the previous list wishing to benefit from the agreement or who still wish it, they shall communicate it to the Consorcio de Compensación de Seguros before the course of a month, it will be calculated from the day of its publication.


Madrid, 17 March 1993-the Director-general of insurance, Eduardo Aguilar Fernández-Hontoria.


Convention of assistance health derived from accidents of traffic for 1993, in the field of the health publishes the consortium of compensation of insurance, the Spanish Union of insurance companies and reinsurers, the national institutes of health, the Catalan health service, the Andalusian health service, the Valencia health service, the health service, service Navarro of health and the Galician health service agree the rules governing the health care allowance and the rates of compulsory observance for the entities involved and represented, in accordance with the following provisions first.-approve the rates for healthcare expenses that are incorporated as annex I to this agreement, that in accordance with its entry into force, shall apply to assistance provided from the 1 January 1993.


Second.-concerned rates shall apply to assistance costs provided to the injured by acts of the circulation caused by use, and vehicles forced to arrange insurance of Civil liability for use and circulation of vehicles of engine, subscription required, according to the regulation established in Royal Decree 1301 / 1986 of 28 June , by adjusting the consolidated text of the law of use and circulation of Motor vehicles to the community legal order and Royal Decree 2641 / 1986 of 30 December, which approves the regulation of insurance of Civil liability for the use and circulation of vehicles of engine, subscription required, and especially articles 12 and 13 (, and apply whereas the limits of coverage referred to in the above articles, ensuring total health care requiring victims of traffic accidents, taking into account the following specific cases: to) claims involved in that a single vehicle-in such claims, the insurance company is obligated to pay health care expenses that require the victims of the accident with the exception of the costs of health care provided to the policyholder, owner of the vehicle identified in the policy, or to the insured or the driver.


In the event of absence of subscription mandatory Civil liability insurance or other intervention on the claim of an unknown vehicle that is accredited, as well as when the vehicle has been stolen or hurtado, except that damage had been caused to people who occupy voluntarily referred vehicle and the Consortium proved that the same knew such circumstances health care expenditures of the victim of the accident, with the exception of the policyholder, owner of the vehicle identified in the policy, the insured or the driver of the insured vehicle, shall be borne by the Consorcio de Compensación de Seguros.


Also the Consorcio de Compensación de Seguros will satisfy such costs, when they are the result of an accident caused by a vehicle in the same.


((b) accidents involving two or more vehicles-in these claims, the insurance companies will contribute to the fulfilment of the obligations arising out of the facts as provided below: b) 1. In cases of involvement of two vehicles shall be paid by each insurer health care costs of victims occupants of the vehicle that is secure, except for the policyholder, owner of the vehicle identified in policy or the insured or driver thereof, remaining in charge of insurance of Civil liability of compulsory subscription of the opposite.


(b) 2. In cases of participation of three or more vehicles should they be paid by each insurance company, health care costs of victims occupants of each vehicle and own taker, owner of the vehicle identified in the policy, the insured and/or driver of the same.


In the two previous cases, the cost of health care from others whose injuries cause materially each vehicle, will be paid by the insurer of the material causing the injury vehicle. Accordingly, the parties in support of the victims of an accident that involved two or more vehicles should be sent for informational all insurance entities, notwithstanding that the amount of hospital care, is met by the insurance entities, in accordance with the preceding paragraphs.


In cases involving vehicles insured by the Consorcio de Compensación de Seguros, these same rules shall apply.


When any vehicle whose responsibility shall be assumed by the Consorcio de Compensación de Seguros subsidiary form (without insurance, unknown or stolen) intervene in the incident the Consorcio de Compensación de Seguros assumed expenses which legally corresponds you to liquidate under the vicarious liability and except for the driver, the owner of the vehicle identified in the policy taker or the insured's vehicle which assumes this responsibility, whose health care costs will pay own driver, holder, owner or insured.


((c) claims involving vehicles insured entities declared in bankruptcy, suspension of payments or who, being insolvent, its liquidation is operated or entrusted to the Commission of liquidator of insurance companies (CLEA).-in accordance with article 17.2 c) the regulation of insurance of Civil liability for use and traffic of Motor vehicles, the Consorcio de Compensación de Seguros (, it will assume in the same terms in which had made it the insurer, outstanding obligations of those who were in the previously defined so-called, in accordance with the following standards: c) 1. Copy of the parts of assistance corresponding to the unpaid bills of each insurer of the referred, on grounds that, within the period determined in this agreement, were sent to the insurers shall refer to the Consorcio de Compensación de Seguros.


(c) 2. The Consorcio de Compensación de Seguros will not assume the payment of invoices issued by assistance provided in a period exceeding one year, before declaring bankruptcy, suspension of payments or payment intervened or entrusted to the CLEA, in application of article 5. of the legislative Royal Decree 1301 / 1986 of 28 June, regulating the insurance of Civil liability of the use and circulation of Motor vehicles, except that the interruption of the limitation period is justified.


(c) 3. Declared bankruptcy, suspension of payments, or liquidation intervened or entrusted to the Commission of liquidator of insurance entities (CLEA) of an insurer, the Consorcio de Compensación de Seguros will attend court payments from that entity had claimed legal action provided that certifying the corresponding withdrawal of initiated processes.


(c) 4. The Consorcio de Compensación de Seguros undertakes to inform the national institutes of health and health services signatory of the Convention, all cases of insurance companies that are in the described situations.



Third.-all health centres of the National Institute of health, of the Catalan health service, service Andalusian health, Servicio Valenciano de Salud, health service, health and health service Gallego Navarro service shall be regarded as centers recognized by the Consorcio de Compensación de Seguros for the purposes of article 13 c) of Royal Decree 2641 / 1986 , 30 December. Without limiting the foregoing it becomes public, as annex IV to this agreement the relationship of hospital centres.


Unespa, be forwarded to the Consorcio de Compensación de Seguros, list of insurance companies that individually demonstrate their express wish not acceding to this Convention, as well as the ups and downs that occur. Those insurance companies that are not members of Unespa and wish to accede to the Convention, will apply it directly to the Consorcio de Compensación de Seguros, who shall notify the parties.


The relationship of member institutions served as annex V to this Convention.


Fourth.-each Health Centre represented in this Convention is fully responsible for the proper provision of service and application rates for them, according to the prices and types of service set forth in this Convention.


Fifth.-the rates referred to in annex I to this Convention refers to the totality of health care costs incurred by the injured party affected.


Sixth.-the parties subscribers of this Convention undertake to give publicity and dissemination required, for general compliance and knowledge.


Commission of monitoring and arbitration seventh.-it is a Commission of monitoring and arbitration, to ensure better compliance with the Convention. This Commission will be composed of two representatives from the national institutes of health, of the Catalan health service, of the Andalusian health service of the Valencia health service, of the Basque health service, of the Navarro health service, of the Galician health service, Unespa and the Consorcio de Compensación de Seguros. Territorial nature of tripartite subcommittees are formed.


The Committee shall meet, at least once quarterly and, in any case, at the request of either party with fifteen days notice.


Shall be responsible for the monitoring and Arbitration Committee: 1. interpret the Convention on those issues which are submitted by the parties, including those relating to the inclusion of new or totally unknown techniques at the time of the conclusion of the Convention, if they are susceptible of assimilation to other existing.


2 resolving existing disagreements between the insurance companies and healthcare centres in order to content and amounts of invoices.


3 settle the differences that occur between different territorial subcommittees.


4. establish the tariff applicable to new techniques and treatments that appear during the term of the agreement and until its next revision or renewal.


5 report to the Consorcio de Compensación de Seguros, for their transfer to the General direction of the insurance activities of the insurance companies that unreasonably delayed the payment of invoices that are adjusted to the provisions of this Convention.


6 report also to the Consorcio de Compensación de Seguros, at health centers that fail to comply with this agreement or the agreements that for its implementation are taken by the Commission or territorial subcommittees for the purposes of refusal of the recognition referred to in subparagraph (c)) of article 13 of the regulation approved by Royal Decree 2641 / 1986 of 30 December.


7 issue certification proving any breach of the Convention in order to facilitate the exercise of the corresponding legal actions.


The second and seventh functions attributed to the monitoring and Arbitration Committee are delegated in the territorial subcommissions, shall immediately communicate to the Commission the agreements adopted. These subcommittees will meet monthly in the central services of each health service, or any part creates it when necessary.


If the Commission agreements take the form of general criteria to be applied in the future in the framework of the Convention, the monitoring and Arbitration Committee shall be obliged to broadcast them through circular, which shall be communicated to the national institutes of health, to the services Catalan, Andalusian Valenciano, Basque, Navarro, health Gallego, the Consorcio de Compensación de Seguros and Unespa leaving at the same time forced such Institute and services to make these circulars to all health centres, and Unespa insurance entities, respectively. For communications purposes, the domicile of the Commission will be the Consorcio de Compensación de Seguros, calle Serrano, 69, 28006 Madrid.


Eighth.-both the National Institute of health, Catalan health service, Andalusian health service, Servicio Valenciano de Salud, health service, health service Navarro, Galician health service, as the insurance companies that operate in the field of Civil liability, for the use and traffic of Motor vehicles, of compulsory subscription, are obligated to submit differences that in the field of the application of the same may arise, the Committee or subcommittees for monitoring and arbitration, prior to any judicial contest for its resolution.


When differences concerning refusal or delay exceeding one month in paying the Bills, the health centre shall report such fact to the Commission or Subcommittee on monitoring and arbitration. The Commission or Subcommittee on monitoring and arbitration will agree that communicated to the complainant and a copy of it will be transferred to the insurance company, and after thirty days from such notification without the insurance company to pay or justify the payment of the outstanding invoices, the Health Center may turn to the competent jurisdiction without further formalities, to claim the amount of the Bills extended to actual cost price.


When the insurance company, in accordance with the preceding paragraph, had been denounced previously, during the term of this agreement, the health centre can go to jurisdiction, in claim of bills at the cost, without exhausting the previous processing of the complaint to the Subcommittee on monitoring and corresponding territorial arbitration.


Rules of procedure ninth.-Parties subscribers of this Convention undergo the following procedural rules of action for the development of the same: 1. the health centers of the national institutes of health, Catalan service of health, Andalusian health service, Servicio Valenciano de Salud, health service, health and health service Gallego Navarro service are obligated to study within the period of thirty days from the receipt of an injured to the entity or entities insurance of vehicles involved in the accident, a part of assistance for each injured, according to model contained as annex II to the Convention, by filling in all the required data in this model, which will be forced use. The insurance entities and the Consorcio de Compensación de Seguros, in its case, must be within a maximum of thirty working days answer in writing to the health center a part of assistance sender expressing his acceptance of health care expenditures referred to in the part. In the case of Parties not completed correctly the deadline noted above until by the health centre has not proceeded to its total completion shall not apply.


2. in the event of accident caused by unknown vehicle, stolen or hurtado and uninsured, health centers will accompany the part or parts of assistance responsible for the circumstances of the accident Declaration subscribed and signed by the victim, witnesses of the accident or those who lent him assistance, accompanied by a photocopy of the national identity of the signer, depending on model being reproduced as annex III to the Convention. While such a statement has not been obtained, the Consorcio de Compensación de Seguros will be released from the acceptance of the costs of assistance to which it relates the part, except that by the health centre the impossibility of obtaining such a declaration occurs, through responsible statement.


3 health centers extend a part for each of the injured, even when several are the victims of an accident.


4. all communications and notifications referred to in this agreement will be in writing and, in any case, by certified mail.


5 sending the part of assistance within period exceeding the designated in the first rule of this stipulation, for cause, will not affect regarding acceptance of the insurance company to take care of the accident.


6 the term in the shipment of the part of assistance, in the case of injured coming from other health centers, expands to forty five days. In the case of income and successive outpatient attendances, carried out within the period of total healing of an injured you must also communicate to the insurance company, making express reference to the accident and causing the injury data. The insurance company, not to produce counter demonstration within a period of thirty days, shall agree costs of assistance.



7. in cases that involved two or more vehicles, not you can never claim as cause for not doing health care expenses the fact that guilt of said accident and, therefore, the obligation to compensate is attributable to the driver of the other vehicle.


8. in cases of intervention of insurance not attached, the attached may not, on the basis of that intervention, reject the payment.


9. the refusal by an insurance company to take care of health care expenditures will be for the health centre the right to remit the Bill in question and the appropriate effects to the Committee or subcommittees for monitoring and arbitration, observing the stipulation under eighth.


10. in the event of that to send the part of assistance, completed in its entirety, and, where appropriate, the responsible statement, by the health centre, there is reply in any sense, within the 30 working days by the insurance company, this silence be understood as acceptance of the accident and medical expenses arising from the same right to the health centre to send the invoice once the entity and, in the event of non-payment, put it to the attention of the Committee or subcommittees of surveillance and eighth arbitration for the purposes specified in the provision.


11 health care spending bill provided by the health centre should detail the concepts and items to different prescriptions, as well as the details of the incident, the victim, vehicle and insurance policy.


Presented bills to the insurance entities, these should be made effective amount, whenever it is of conformity, within forty-five days, irrespective of the legal proceedings. In case of unjustified non-compliance and in writing, the health centre can increase your bill by delay in a 20 per 100 of annual interest.


The payment will be independent of the Court ruling, and the health centre in any case will delay the submission of invoices for a period longer than one year. The insurance company may reject those invoices submitted outside of the aforementioned term.


Decima.-solamente will be coming the refusal by an insurance company to take care of medical expenses, in the following cases: to) when the entity has not secured any vehicle involved in the accident.


(b) that the accidents that involved a single vehicle, the injured is one of people excluded from the insurance coverage of Civil liability for use and traffic of motor vehicles, compulsory subscription, pursuant to article 3. of the legislative Royal Decree 1301 / 1986 of 28 June.


((c) course of the deadlines set in the provision 2, letter c).


The refusal by an insurance company to take charge of a claim, based on reasons other than those set forth in the preceding paragraphs, even when the negative is it for lack of statement of claim by the asegurdo, will result in the birth of the law so that the health centre can assert their rights as provided for in the provisions seventh and eighth which will accompany the necessary documentation to the Committee or subcommittees for monitoring and arbitration, should always include copy of the part of assistance relating to the injured party whose bills are called into question.


Eleventh.-any services that provide health centers and it is not specifically paid will be pricing, which will establish the monitoring and Arbitration Committee.


Twelfth.-extraordinary expenses not charged, such as Conference calls, cafeteria, etc., will always be borne by the injured party and the health centre, in his case, will invoice them this irrespective of the Bill for health care expenses charged to the insurance company.


Thirteenth.-health costs invoiced according to tariff shall include all the assists and periods of control and surveillance to corresponding discharge.


Fourteenth-the insurance companies may request care center appropriate clarifications to the contents of the Bills. Non-conformity with the amount thereof, shall forward it to the health center within a maximum of thirty working days from the date of receipt of the invoice and by certified mail.


The lack of agreement on the content or the amount of bills between a health centre and an insurance entity should be put to the attention of the Committee or subcommittees for monitoring and arbitration, who will then act pursuant to the provisions of this Convention.


In cases of partial disagreement with the content of a Bill, is liable for the insurance company payment of the agreeable and only Deferrable amount the amount of the concept or concepts on which there is no agreement with the previous rules.


You won't be any discharge value for an insurance company, for the payment of the invoice, any allegation, when it has not expressed their disagreement in reliably, in the procedures of notification that referred the first subparagraph of the present provision.


All health centers are committed to give all kinds of facilities for checks that can make the Consorcio de Compensación de Seguros, or any of the insurance entities adhered to the Convention in order to better comply with the same.


XV. any breach of these provisions and standards will report to the Committee and subcommittees of surveillance and arbitration, which exhausted its possibilities of action, as provided for in the provisions and standards of this Convention, except in the case provided for in last the stipulation of paragraph eighth.


Sixteenth.-health centers may charged expenses biweekly and partial manner, where the stay of the injured in the Center extends for more than the designated time, fifteen days.


High and low of seventeenth hospitals.-the National Institute of health, Catalan health service, Andalusian health service, Servicio Valenciano de Salud, health service, health and health service Gallego Navarro service must notify convincingly parts subscribers of this Convention further discharges of health centers under its jurisdiction and that adhere to the Convention. Such accession will start to be effective from the moment in which Unespa and the Consorcio de Compensación de Seguros accuse receipt of reliable form of communication made by those high.


Eighteenth-casualties of health centers under the jurisdiction of the National Institute of health, Catalan health service, Andalusian health service, Servicio Valenciano de Salud, health service, service Navarro's health and Galician health service, if it is to occur, they must be reported to Unespa and the Consorcio de Compensación de Seguros, and will be effective three months after the date on which both the Consorcio de Compensación de Seguros and Unespa accuse receipt, reliable form of communication before low hint.


Interpretation of the Convention 19th.-Parties subscribers of the Convention accepted in matters relating to the interpretation of this Convention, and in case of disagreement between them, the resolution provided to the issue with character casting the monitoring and Arbitration Committee without prejudice with a specific character in the previous provisions.


Validity and revisions 20th.-this agreement will be valid until December 31, 1993, with the possibility of extended tacitly on January 1 of each year with the increase of the rates according to timely agreement, if it is not denounced by either party subscribers within the period of three months prior to the expiration date.


The scales and rates approved by the present Convention shall apply to all the assistance provided from January 1, 1993.


Final declaration the signatories of this agreement, on behalf of the Consorcio de Compensación de Seguros, the national institutes of health, the Catalan health service, service Andalusian health, Servicio Valenciano de Salud, health service, health service Navarro, Galician service of health and the National Association of insurance of automobiles from Unespa, expect of all the strict compliance with the provisions and agreed standards for the benefit of mutual relationships and the handicapped covered by insurance of Civil liability of the use and circulation of motor vehicles of mandatory subscription.


And for the record, parties to this Convention, signed in triplicate and a single effect, in the place and date above.


Schedule I rates of health care to injured in traffic accidents with coverage of civil liability arising from the use and circulation of motor vehicles of compulsory subscription, applicable in the institutions or the non-concerted contract administration and direct funding 1. Hospitalization-for each day of hospital stay, and included all of health care costs but making express except for hemodialysis, transfusions and computed tomography (CT) and nuclear resonance magnetic which will be invoiced separately: price stay: 26.225 pesetas.


Stay UVI or UCI: 43.470 pesetas.


2. ambulatory assistance: first consultation: 11.744 pesetas.


Successive queries: 5,870 pesetas.



Initial emergency assistance, first consultation means being included all the diagnostic tests and fixing of treatment within fifteen days after this first check, except those specified in these rates.


Each and every one of the dispensed from the fifteen days of the initial visit, provided it is the same process shall be by successive queries.


3 physical therapy and rehabilitation.-for each day of outpatient treatment of physiotherapy and rehabilitation: 945 pesetas.


4. hemodialysis.-for each session: 15,000 pesetas.


5 orthesis and prosthesis-the amount of the orthosis and prosthesis that could be clarified for adaptation and individualized by the rugged use will be billed separately, according to the cost price. Won't this consideration devices which the various hospital services provided to the injured person and are reusable.


6. medical transportation-costs incurred by the transfer of the injured patient will be billed according to the rates set forth in each area for managing health care bodies.


In those cases use health transportation other than their own health or arranged by the Center, will be the insurance company which will be responsible for the direct payment of costs representing such transportation, prior agreement of the insurer.


7. computed axial tomography (CAT)-computed axial tomography (TAC) will be billed in the amount of 26,500 pesetas.


8 nuclear magnetic-resonance nuclear magnetic resonance: 50,000 pesetas.


9 blood transfusions and blood-transfusion of blood and blood products will be billed at the cost or fixed by each health service.


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