Tariff ARS. vigo Krankenversicherung VVaG Konrad-Adenauer-Platz Düsseldorf

Transcription

1 General Conditions of Insurance (GCoI) for the travel health insurance for students, language students, au-pair, work & travel abroad of the vigo Krankenversicherung Tariff ARS vigo Krankenversicherung VVaG Konrad-Adenauer-Platz Düsseldorf

2 Content Page A: General part (valid for all tariffs listed in Part B) 4 1 Insurable persons and insurance protection and capability 4 2 Conclusion and termination of the insurance policy 4 3 Premium 5 4 Scope of application, commencement, duration and end of insurance protection 5 5 Subject of the insurance protection and extent of obligation to perform 6 I. General 6 II. Waiting periods 7 III. Medical treatment expenses 7 IV. Transportation- / funeral costs 7 6 Limitations of obligation to perform 7 7 Duties and consequences of breaches of obligations 8 8 Payment of insurance benefits 9 9 Compensation from other insurance policies and claims against third parties 9 10 Off-setting Declarations of intent and notifications Applicable law, contractual language Place of jurisdiction 10 B: Special Part of the Insurance Conditions 11 Temporary tariff ARS12K (Insured period up to 12 months) 11 I. Insurance year 11 II. Medical treatment expenses 11 III. Dental treatment costs, dental replacement 11 IV. Return transport, transportation and funeral costs 11 Long-term tariff ARS12L (Duration of insurance more than 12 months) 12 I. Insured year 12 II. Insurance protection in the homeland 12 III. Medical treatment expenses 12 2 AVB Tariff ARSv /001

3 IV. Dental treatment costs, dental replacement 13 V. Return transport, transportation and funeral costs 13 VI. Visiting the sick person 13 AVB Tariff ARSv /001 3

4 A: General part (valid for all tariffs listed in Part B) 1 Insurable persons and insurance protection and capability (1) All persons specified by name in the insurance policy, for which the agreed premium has been paid, are insured. (2) Insurance exists in the country of the temporary residence abroad (see Item 3) and, if applicable, in the Federal Republic of Germany, however not in case of residence in other states. (3) Insured are au-pairs, students, language students, scholars and doctoral candidates, participants in work & travel programs or other persons which verifiably reside abroad on a temporary basis for the execution of further education measures up to the conclusion of the age of 35 (35. birthday), if they fulfil the following requirements: Persons with German citizenship and permanent residence in the Federal Republic of Germany as well as citizens of EU states with permanent residence in the Federal Republic of Germany during a stay abroad. Abroad includes all countries outside of the Federal Republic of Germany. (4) Uninsurable and not insured despite payment of the premium are persons, who are permanently in need of care as well as mentally disabled persons. Persons requiring permanent care are those predominately requiring assistance in coping with daily life. 2 Conclusion and termination of the insurance policy (1) The application for the conclusion of an insurance policy has to be made prior to the commencement of the stay abroad. The date of crossing the border to the foreign country has to be verified upon demand. The conclusion of an insurance application is no longer possible after the commencement of the trip abroad. (2) The policy is formed if the application provided by the insurer is received by the insurer properly completed and the insurer sends out an insurance confirmation to the policy holder. An application is only properly completed if it clearly and completely contains all requested information. (3) The insurance policy is not formed for persons, which do not fulfil the requirements of insurability according to 1 (3) and (4) of this condition, also with the payment of the premium. If a premium is nonetheless paid for an uninsurable person, the amount is available to the sender. (4) The insurance policy has to be concluded for the entire period of the stay abroad. The anticipated duration of the stay may have to be verified with the provision of appropriate documents (e.g. confirmation of matriculation / verification of registered mail). (5) The maximum period of insurance is five years. (6) In the event of an extension of the stay abroad within the maximum insurance period, the originally agreed term of the policy can only be extended with a follow-up policy, if the application for the follow-up policy was presented to vigo Krankenversicherung prior to the expiration of the original insurance policy. In the event of extensions of the policy, insurance protection only exists for those insurance cases, illnesses, medical conditions as well as their consequences which newly occurred after the application of the extension (receipt of the application at vigo Krankenversicherung). (7) If the policy holder and the insured person are not identical, a termination by the policy holder is only effective if the insured persons affected by the termination are aware of the declaration of termination and if the policy holder verifies this accordingly. The affected insured persons are entitled to continue the insurance policy by nominating the future policy holder. This declaration has to be presented within two months following the receipt of the termination. (8) The statutory provisions regarding the right to extraordinary termination remain unaffected by the agreed stipulations. 4 AVB Tariff ARSv /001

5 3 Premium (1) The premium has to be paid by way of direct debit procedure at a German bank or Sparkasse. (2) Payment of initial premium: a) The initial premium is due and payable at the commencement of the policy. b) If the initial premium is not paid in the stipulated time, the insurer is entitled to withdraw from the policy until the payment has been effected, unless the policy holder is not responsible for the non-payment. c) If the initial premium is not paid at the time of the occurrence of the insured event, the insurer is not obligated to perform, unless the policy holder is not responsible for the non-payment. (3) Payment of subsequent premiums: a) If the subsequent premium is not paid in due time, the insurer shall submit a request for payment to the policy holder and grant a notice of payment of two months. b) If an insured event occurs after the expiration of the term and if the policy holder is in default of payment of the premium, the interest or costs at the moment of the occurrence, the insurer is not obligated to perform. c) The insurer connects the period of grace of two months with the termination of the policy at the expiration of the grace period. The termination becomes effective with the expiration of the grace period if the policy holder is still in default of payment at that time. d) The termination becomes invalid if the policy holder pays the premium within one month following the termination becoming effective. Item b) remains unaffected. The same applies in the event that the insured person nominates a new policy holder within two months of becoming aware of the termination and if the new policy holder pays the demanded amount. Item b) remains unaffected. 4 Scope of application, commencement, duration and end of insurance protection (1) Scope of application a) vigo Krankenversicherung provides insurance protection to insured persons in the context of a temporary stay abroad in the country of their temporary residence within the context of these conditions. b) Insurance protection is excluded in case of an insured event in the home country (country of permanent residence of the policy holder) of the insured person, unless otherwise specified in the tariff. (2) Start The insurance protection commences at the moment specified in the insurance policy (commencement of insurance), however a) not prior to the formation of the insurance policy, b) not prior to the moment of crossing the border abroad, c) not prior to the payment of the initial premium, d) not prior to the expiration of any waiting periods. AVB Tariff ARSv /001 5

6 (3) End The insurance protection ends also for suspended insurance cases a) at the agreed moment, b) upon death, c) upon the termination of the insured person's temporary stay abroad at the expiration of the respective end of the quarter, d) if the prerequisites for the insurability of the insured persons are void. (4) Extended liability period If an illness requires treatment in the country of temporary residence beyond the expiration of the insurance protection because the return trip to the homeland is not possible due to the verified inability to be transported, the obligation to perform continues in the context of this tariff up to the restoration of the transportability. 5 Subject of the insurance protection and extent of obligation to perform I. General (1) vigo Krankenversicherung provides compensation for acute insurance cases which occurred during the stay abroad. (2) An insurance case is the medically necessary treatment of an insured person due to illness or consequences of an accident. The insurance case commences with the treatment; it ends when the necessity for treatment ceases to exist according to medical findings. If the treatment has to be protracted for an illness or consequence of an accident which is not related to the cause of the previously treated illness or consequence of an accident, a new insurance case is created. Insurance cases also include examinations and medically necessary treatments due to pregnancy as well as the death of the insured person. (3) The extent of the insurance protection is based on the insurance policy, any separate written agreements, these General Insurance Conditions as well as the statutory regulations of the Federal Republic of Germany. (4) In the foreign country, the insured person is at liberty to select among the physicians and dentist legally approved and certified in the country of temporary residence, if these charge according to the respectively valid official scale of fees for physicians and dentists - if available - or the customary fees. If the tariff provides or performances, the insured person is at liberty to select among the certified physicians and dentists in the Federal Republic of Germany. (5) Pharmaceutical, surgical, medical and auxiliary products have to be prescribed by the treating physicians specified in (4); furthermore, pharmaceutical products have to be purchased at the chemist. Pharmaceutical products, even if they were prescribed as such, do not include nutriments and tonics, mineral water, disinfection and cosmetic products, diet and infant nutrition etc. (6) In case of medically required inpatient hospital treatment the insured person is at liberty to select among the public and private hospitals which are under constant medical direction, possess sufficient diagnostic and therapeutic facilities, maintaining medical records and which provide neither curative nor sanatorium treatment or accept convalescents. (7) The insurer provides for the examination or treatment methods or pharmaceutical products approved by conventional medicine at the contractual extent. The insurer furthermore provides for methods and pharmaceutical products which have been proven to be promising in practice or which have been applied because conventional methods or pharmaceutical products are not available; however, the insurer is entitled to reduce its performances to the amount which would have been incurred if existing methods or pharmaceutical products had been applied. 6 AVB Tariff ARSv /001

7 (8) The insurer performs to the contractual extent for transportation costs to the last permanent residence in the Federal Republic of Germany up to 10, in case of death abroad - or funeral costs abroad of up to 10, if the death of an insured person occurs due to an event included in the performance obligation of this policy. II. Waiting periods (1) The waiting periods are calculated from the commencement of the insurance and, in case of follow-up policies, from the commencement of the follow-up policy. (2) The waiting time for child birth is eight months. III. Medical treatment expenses The respective tariffs in Part B of these General Insurance Conditions specify which costs are reimbursed. IV. Transportation- / funeral costs The respective tariffs in Part B of these General Insurance Conditions specify which costs are reimbursed. 6 Limitations of obligation to perform (1) The obligation to perform is excluded: a) for treatments abroad which were the sole reason or one of the reasons for the trip abroad and for treatments which were destined to occur in the scheduled course of the stay abroad at the time of the departure, b) for existing illnesses and medical conditions known to the insured person at the time of the conclusion of the policy and/or the conclusion of the follow-up policy and the foreseeable consequences of those as well as the consequences of such illnesses or accidents foreseeable for the insured person, which have been treated within the last six months prior to the conclusion of the policy, (the worsening of an illness which existed at the conclusion of the policy / follow-up policy is included in the insurance. In this event, the additional costs caused by the worsening of the illness are reimbursed), c) for the treatment of tuberculosis, diabetes, tumours, abuse of alcohol and drugs as well as dialysis treatments, if the illness and/or requirement for treatment existed prior to the commencement of the insurance, d) for such illnesses including their consequences as well as consequences of accidents and deaths which are caused by nuclear energy, strike, war, war-like events or the active participation in unrests and which are not explicitly included in the insurance protection, e) for illnesses as well as illness and/or injury consequences due to extreme sports and accidents, including their consequences which are based on intent and/or gross negligence, f) for convalescence and sanatorium treatments, g) for rehabilitation measures including withdrawal treatments, h) for outpatient treatments in a health spa or health resort. The limitation does not apply if the health treatment becomes necessary due to an accident occurred there. In case of illnesses the obligation to perform is excluded if the insured person stayed at the health spa or health resort only temporary and not for healing purposes, i) for treatments by a spouse, parents or children. Verified material costs are reimbursed according to tariff, j) for treatments by persons with whom the insured person cohabits within the own or host family. Verified material costs are reimbursed according to tariff, k) for treatment or accommodation based on lingering illness, requirement for care or custody, AVB Tariff ARSv /001 7

8 l) for psychoanalytic and psychotherapeutic treatment, m) for immunisation measures, n) for auxiliary equipment, unless otherwise stipulated in the tariff, o) treatments due to disorders of and damage to the reproductive organs including sterility, artificial insemination and associated preventive medical check-up and subsequent treatments, p) for the treatment of HIV infections and their consequences, q) for dental replacement, pivot teeth, fillings, crowns and orthodontic treatments, implants, occlusal appliances and gnathological measures unless otherwise stipulated in the tariff, r) for suicide, suicide attempts and their consequences, s) for organ donations and their consequences. (2) vigo Krankenversicherung is exempt from its obligation to perform if a) the policy holder and/or the insured person has intentionally or gross negligently provoked the insured event, b) the policy holder and/or the insured persons has maliciously attempted to deceive vigo Krankenversicherung regarding circumstances which are significant for the reason or the amount of the performance. (3) If a medical treatment exceeds the medically required measure, the insurer may reduce its performance to an appropriate amount. (4) In the event of the existence of a simultaneous claim for performance from the legal health, accident or pension insurance for statutory welfare, the insurer may deduct the statutory performances from its insurance benefits. 7 Duties and consequences of breaches of obligations (1) Following the occurrence of the insurance case, the policy holder and the insured person are obligated a) to keep the damage to a minimum and to avoid anything which may lead to an increase of the costs, b) to report the damage to vigo Krankenversicherung without undue delay, at the latest upon the conclusion of the stay abroad, c) to allow vigo Krankenversicherung to conduct any reasonable examination regarding the cause and the amount of its obligation to perform, to grant any necessary information, to submit original invoices as well as the death certificate in case of death, d) to contact vigo Krankenversicherung or the incident manager in case of inpatient treatment and prior to the commencement of extensive diagnostic and therapeutic measures. (2) Upon demand by the insurer, the insured person is obligated to undergo an examination by a physician commissioned by vigo Krankenversicherung. (3) Consequences of breaches of obligations If the policy holder or the insured person intentionally violates one of the contractually agreed duties, vigo Krankenversicherung is not obligated to perform. In the event of a gross negligent violation of the duty, vigo Krankenversicherung is entitled to reduce the performance at a ratio commensurate with the gravity of the policy holder's/insured person's violation. The onus of proof for the non-existence of gross negligence rests with the policy holder. 8 AVB Tariff ARSv /001

9 8 Payment of insurance benefits (1) The insurer is only obligated to perform if the following verifications (these become the property of the insurer) have been provided: a) Original invoices, which have to contain the name of the treated person, the specification of the illness as well as the specification of the performance provided by the treating physician according to type, place and treatment period. If insurance protection for medical treatment expenses exists otherwise and if it is utilised first, the copies of the invoices provided with reimbursement notes are sufficient for verification, b) prescriptions have to be submitted together with the invoice of the physician, the invoice for medical or auxiliary material together with the prescription, c) an official death certificate and a medical certificate regarding the cause of death, if transportation and/or funeral costs are to be paid, d) upon demand of the insurer, a verification regarding the commencement and end of each stay in the homeland, e) upon demand of the insurer, a verification regarding all health insurances with insurance protection for the Federal Republic of Germany concluded during the stay in the Federal Republic of Germany. (2) The least amount, which has to be paid according to the situation, can be claimed as partial payments one month following the notification of the damage. The progress of this term is interrupted as long as the verification of the claim by vigo Krankenversicherung is hindered as a result of a fault of the policy holder or the insured person. (3) In the context of the performance review it may be necessary for vigo Krankenversicherung to obtain personal health data at the legally admissible extent. If the policy holder or the insured person culpably refuses to grant their consent to such research and if vigo Krankenversicherung is not able to conclusively determine the amount and extent of the obligation to perform as a result, the settlement of the performance is interrupted. The same applies if the questioned institutions or persons are culpably not exempt from their obligation to confidentiality toward vigo Krankenversicherung. (4) The costs generated in foreign currency are converted into the currency applicable in the Federal Republic of Germany at the time according to the exchange rate of the day at which the documents are received by the insurer. The official currency exchange rate Frankfurt/Main applies as exchange rate of the day for traded currency, for non-traded currency the exchange rate according to "Currencies of the world", publications of the Deutsche Bundesbank, Frankfurt/Main, according to the respective current version, unless the foreign currency necessary for the payment of the invoice was verifiably purchased at an adverse exchange rate. (5) Additional costs, which were generated due to the insurer transferring funds abroad or selecting special methods of transfer at the request of the policy holder, may be deducted from the performances. (6) Claims to insurance benefits may be neither assigned nor pledged. (7) Claims from this insurance policy become statute barred in three years. The statute of limitation commences at the end of the year in which the performance was claimed. 9 Compensation from other insurance policies and claims against third parties (1) If compensation can be claimed from another insurance policy in case of an insurance case, the other policy precedes this policy. This also applies if a subordinate liability is agreed upon in one of these insurance policies, regardless of the fact when the other insurance policy was concluded. If the insurance case was reported to vigo Krankenversicherung first, vigo Krankenversicherung shall make an advance payment and shall contact the other insurer directly for the purpose of cost sharing. vigo Krankenversicherung shall waive its right to cost sharing with a MV company if the insured person incurs disadvantages, e.g. loss of refund of contributions. AVB Tariff ARSv /001 9

10 (2) The claims of the policy holder and/or the insured person against third parties are transferred to vigo Krankenversicherung within the limits of the law, if vigo Krankenversicherung has compensated the damage. If required, the policy holder and/or the insured person are obligated to issue a declaration of assignation to vigo Krankenversicherung. The policy holder's obligation to perform is suspended until the issuance of a declaration of assignation. (3) The claims of the policy holder and/or the insured person against physicians based on excessive remuneration are transferred to vigo Krankenversicherung within the limits of the law, if vigo Krankenversicherung has compensated the respective invoices. If required, the policy holder and/or the insured person are obligated to assist in the assertion of the claims. If required, the policy holder and/or the insured person are furthermore obligated to issue a declaration of assignation to vigo Krankenversicherung. 10 Off-setting The policy holder may only offset against claims of the insurer if the counterclaim is uncontested or conclusively determined. 11 Declarations of intent and notifications Declarations of intent and notifications toward the insurer require the written form. 12 Applicable law, contractual language The laws of the Federal Republic of Germany apply unless opposed by international law. The contractual language is German. Original invoices have to be translated into German at the request of the insurer. 13 Place of jurisdiction Place of jurisdiction for complaints based on the insurance relationship is Düsseldorf. 10 AVB Tariff ARSv /001

11 B: Special Part of the Insurance Conditions Temporary tariff ARS12vK (Insured period up to 12 months) I. Insurance year An insurance year is a period of twelve months, calculated from the commencement of the insurance, including all extensions of the policy. II. Medical treatment expenses (1) The insurer reimburses the costs of medically necessary treatments abroad (place of stay abroad) if these are calculated according to the respectively applicable official scale of fees for physicians and dentists - if available - or according to the customary budget. (2) Medical treatments in terms of these conditions are: a) medical treatments due to acute medical conditions, medically necessary pregnancy treatments and necessary preventive medical check-ups as well as treatments due to miscarriage, b) medically prescribed pharmaceutical and surgical products from chemists, c) medically prescribed radiation and light treatments, medically prescribed massages, physiotherapeutic treatments, medical poultices and inhalations at a maximum amount of per insurance year, d) medically prescribed auxiliary equipment as well as the repair of existing auxiliary equipment which are purchased and/or performed by a chemist or similar facility at a maximum of per insurance year. Visual aids are not reimbursed, e) X-ray diagnostics, f) medically required inpatient treatment in the general care class (shared room) without elective performances (private medical treatment), g) patient transports to inpatient treatment to the nearest suitable hospital and to the nearest suitable physician in case of first aid following an accident and return in case of medical necessity, h) operations which cannot be delayed. III. Dental treatment costs, dental replacement The insurer furthermore reimburses the following costs under the consideration of Item 1 (scale of fees or within the customary budget), which were incurred during the stay abroad: a) pain-killing conserving dental treatments including fillings of a simple type, b) measures to restore the function of existing dentures (repairs) up to maximally per insurance year. In the event of a dental replacement also for the new production due to an accident up to a maximum of per insurance year. IV. Return transport, transportation and funeral costs The insurer reimburses (1) the additional costs for a medically required or sensible and medically prescribed return transport from the place abroad. The return transport has to be medically justifiable. The transport shall be assumed to the next suitable hospital at the residence in the homeland. The costs for one coinsured escort are assumed if the accompaniment is medically necessary, officially ordered or prescribed by the executing transport company, (2) in the event of the death of an insured person abroad, the necessary additional costs generated by the transportation of the deceased to the homeland up to 10,000.00, (3) the costs for a funeral abroad up to the amount of the expenditures which would have been incurred in case of transportation up to a maximum of 10, AVB Tariff ARSv /001 11

12 Long-term tariff ARS12vL (Duration of insurance more than 12 months) I. Insured year An insurance year is a period of twelve months, calculated from the commencement of the insurance, including all extensions of the policy. II. Insurance protection in the homeland For insurance policies of more than three years the insurance protection also exists in case of a temporary return to the homeland (Federal Republic of Germany) of the insured person after 12 months. The insurance protection in the homeland is limited to maximally six weeks for all stays in the homeland per insurance year. Commencement and end of each trip to the homeland during the term of the policy have to be verified by the policy holder upon demand of the insurer in case of performance. 8 Item 1 d applies in this case. III. Medical treatment expenses (1) The insurer reimburses the costs of medically necessary treatments a) at the place of residence abroad if these are calculated according to the respectively applicable official scale of fees for physicians and dentists - if available - or according to the customary budget; b) during a stay in Germany (expenditures are reimbursed after 12 months of residence abroad at the earliest) up to the so-called threshold values of the scale of fees applicable in Germany for physicians GOÄ (scale of fees physicians) and dentists GOZ (scale of fees dentists). The following so-called threshold values apply for performances - according to GOZ the 2.3 fold rate, - according to GOÄ according to No. 437 and paragraph M, (laboratory performances) of GOÄ the 1.15 fold rate, - according to sections A, E and O (technical services) the 1.8 fold rate, - for all other performances of GOÄ the 2.3 fold rate. (2) Medical treatments in terms of these conditions are: a) medical treatments due to acute medical conditions, medically necessary pregnancy treatments and necessary preventive medical check-up as well as treatments due to miscarriage, b) medically prescribed pharmaceutical and surgical products from chemists, c) medically prescribed radiation and light treatments, medically prescribed massages, physiotherapeutic treatments, medical poultices and inhalations at a maximum amount of per insurance year; expenditures exceeding this amount are reimbursed at 50%, d) medically prescribed auxiliary equipment as well as the repair of existing auxiliary equipment which are purchased and/or performed by a chemist or similar facility at a maximum of per insurance year, expenditures exceeding this amount are reimbursed at 70%. Visual aids are not reimbursed, e) X-ray diagnostics, f) medically required stationary treatment in the general care class (shared room) without elective performances (private medical treatment), g) patient transports to inpatient treatment to the nearest suitable hospital and to the nearest suitable physician in case of first aid following an accident and return, h) childbirth following the expiration of the waiting period. 12 AVB Tariff ARSv /001

13 IV. Dental treatment costs, dental replacement The insurer furthermore reimburses the following costs under the consideration of III No. 1 (scale of fees or within the customary budget), which were incurred during the stay abroad: a) pain-killing conserving dental treatments including fillings of a simple type, b) costs of the dental prophylaxis of maximally per insurance year, c) measures to restore the function of existing dentures (repairs), d) dentures required for the first time due to an accident, e) dentures which are medically required up to 50% of the invoiced amount. The performances from lit. c), d) and e) are jointly limited to a maximum of 1,000 per insurance year. V. Return transport, transportation and funeral costs The insurer reimburses (1) the additional costs for a medically required or sensible and medically prescribed return transport from the place abroad. The return transport has to be medically justifiable. The transport shall be assumed to the next suitable hospital at the residence in the homeland. The costs for one coinsured escort are assumed if the accompaniment is medically necessary, officially ordered or prescribed by the executing transport company, (2) In the event of the death of an insured person abroad, the necessary additional costs generated by the transportation of the deceased to the homeland up to 10,000, (3) the costs for a funeral abroad up to the amount of the expenditures which would have been incurred in case of transportation up to a maximum of 10,000. VI. Visiting the sick person If a hospitalisation abroad is expected to last longer than four weeks, the insurer may also assume the costs of a visitation trip of a relative in a reasonable amount upon application. This is based on the premise that the inpatient treatment of the insured person continues for at least another 10 days at the commencement of the trip. The necessity of the duration of the inpatient treatment has to be proven to the insurer. The application has to be made prior to the commencement of the trip. AVB Tariff ARSv /001 13

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16 vigo Krankenversicherung VVaG Konrad-Adenauer-Platz 12, Düsseldorf Phone , Fax Internet: Registry court: District court Düsseldorf, HRB Version: ARSv /001