INGOSSTRAKH Joint-Stock Insurance company

Transcription

1 Joint-Stock Insurance company REGULATIONS FOR MEDICAL EXPENSES INSURANCE AND TRANSPORT COSTS FOR TRIPS WITHIN RUSSIA 1. General conditions 2. Object of Insurance 3. Insured Events 4. Expenses covered by the Insurer 5. Expenses not covered by the Insurer 6. Sum Insured. Insurance premium 7. Validity of the Insurance Contract 8. Conclusion of the Insurance Contract 9. Claims Procedure 10. Refusals in payment of the Insurance Indemnity 11. Termination of the Insurance Contact 12. Dispute Resolution

2 2 1. GENERAL CONDITIONS 1.1 The present Regulations for the insurance of emergency medical and transport expenses during a trip within Russia (hereinafter referred to as the Regulations) have been developed accordance with legislative and other legal normative acts of the Russian Federation. The Regulations are an integral part of the Insurance Contract (hereinafter referred to as the Contract) for emergency medical and transport expenses during a trip within Russia. The Insurance Contract can comprise other terms and conditions agreed upon by the Parties thereto. 1.2 The Joint Stock Insurance Company is the Insurer and it concludes Contracts for the insurance of emergency medical and transport expenses during a trip within Russia. 1.3 The Insured under the Insurance Contract may act any legal entities and any capable physical persons. 1.4 Any Insured may conclude Insurance Contracts for benefit of third parties (Insured Persons). If the Insured concludes the Contract for his/her own benefit, rights and obligations of the Insured Person shall apply to him/her. Insured Persons under these Regulations shall be only physical persons. 2. OBJECT OF INSURANCE The object of insurance shall be recognised as insurance risk related to the expenses for medical emergency help, medical transportation, transport services including repatriation, provided the above expenses result from the Insured Event and are incurred during the trip within Russia. 3. INSURED EVENTS 3.1 The Insured Event shall be recognised as the Insured Person's or his \ her representative s request to the 24-hour Emergency Service Center in the event of sudden illness, accident or death of the Insured Person which cause expenses for medical help, medical transportation or other services stipulated in the present Regulations, provided the above events happened within the Contract term during the Insured Person s trip within Russia. The Emergency Service Center under the Regulations shall be recognised as a specialised facility specified by the Contract (Insurance policy), which on behalf of the Insurer provides the Insured Person with 24-hour services envisaged by the present Regulations. 3.2 A sudden illness shall be recognised as unexpected disease which requires urgent medical interference. 3.3 An accident shall be recognised as sudden short-term external event which causes injury or other health breakdown, or death of the Insured Person. 3.4 The request due to sudden illness, accident or death of the Insured Person shall not be recognised as the Insured Event if the above result from: alcohol, drug or toxic abuse of the Insured person; suicide (attempted suicide) of the Insured Person; nuclear explosion, radiation, radioactive contamination or other kinds thereof; any natural calamities and their consequences, epidemics, quarantine, weather conditions; any deliberate acts of the Insured Person and/or any concerned third parties aimed at the occurrence of the Insured Event; any Insured Person's unlawful act being in a direct causal relationship with occurrence of the Insurance Event; the Insured Person s piloting or flying by any aircraft except for flights as a passenger in a civil aviation plane run by a professional pilot; Insured Person's flying by any motorless aircraft, motor gliders, superlight aircraft; military operations and their consequences, civil commotion, strikes, revolts, riots, terrorist acts and their consequences; Insured Person's service in any military forces and formations; Insured Person's going in for any professional, leisure or organized sports including alpinism, rockclimbing, rafting, riding, diving, ski mountaineering, snowboarding as well as parachuting jumps and flights; any dangerous activities of the Insured Person (including as professional miners, builders, electricians etc.) 3.5 The occurrences stipulated in Para 3.2. shall not be recognized as the Insured Events if they are related to: chronic diseases known at the conclusion of the Contract regardless of whether they have been treated or not; oncologic diseases; psychic diseases, convulsive attacks, neuroses (panic attacks, depressions, hysteric syndromes etc.); HIV (Human Immuno Deficiency Virus), AIDS (Acquired Immune Deficiency Syndrome) and any types of hepatitis the Insured person has had. 3.6 The occurrences specified by Paras shall be recognised as the Insured Events if they are stipulated in the Insurance Contract under the agreement of the Parties applying the increasing coefficients determined by the Insurer. 4. EXPENSES COVERED BY THE INSURER 4.1. In case of the Insured Event the Insurer or the Emergency Service Center arranges for medical emergency assistance, medical transportation, transport services including repatriation and covers the following expenses ensuing thereof: A. Emergency medical expenses: expenses for emergency and ambulance services; expenses for out-patient treatment including those for the doctor's services, diagnosis, medicines prescribed by the doctor, dressing materials and means of fixation (plaster cast, splint); expenses for hospital stay and in-patient treatment in a standard-type ward including those for surgery and diagnosis, medicines prescribed by the doctor, dressing materials and means of fixation (plaster cast, splint). B. Expenses for medical transportation: expenses for evacuation (transportation) by ambulance or other means of conveyance from the place of illness (accident) to the nearest hospital or doctor and expenses for medical transfer to another medical facility prescribed by the attending doctor and confirmed by the Insurer s or by the Emergency Service Center s consent;

3 expenses for emergency medical repatriation by an adequate means of conveyance including those for the accompanying person if prescribed by the doctor to the Insured Person's place of permanent residence if the medical treatment cannot be provided locally and this fact is confirmed by the Insurer or by the Emergency Service Center s consent relying on the appropriate documents from the local attending doctor. The expenses for emergency medical repatriation are covered within the Sum Insured stipulated in the Insurance Contract expenses for medical repatriation of the Insured Person to the place of his/her permanent residence or to the hospital nearest to the Insured Person's place of permanent residence when the expenses for hospital stay may exceed the liability limit stipulated in the Contract. Medical repatriation is carried out if there are no medical contra-indications. The expenses for medical repatriation are covered within the limits stipulated in the Insurance Contract. C. Transport expenses: the Insured Person s return to his/her permanent place of residence by economy class if the departure of the Insured Person is not effected in time (i.e. on the date specified in the Insured Person s return ticket) due to the Insured Event which caused the necessity for the Insured Person s in-patient treatment. The Insured Person shall undertake to return the unused travel tickets and to reimburse theirs cost to the Insurer. Should the Insured Person fail to observe this condition the Insurer reserves the right to deduct the cost of unused travel tickets from the amount to be reimbursed to the Insured Person; return of the Insured Person s accompanying children to theirs place of permanent residence by economy class if the children are left without care due to the Insured Event. The necessity to accompany the children shall be determined by the Insurer / by the Emergency Service Center. D. Expenses for Repatriation of Remains: repatriation of the remains authorised by the Emergency Service Center to the deceased s place of permanent residence if his/her death was caused by the Insured Event. However the Insurer does not cover morgue and funeral expenses. E. Expenses of Emergency Service Center for arranging the services specified by the present Regulations: 4.2 Emergency medical help (para ) is provided to the Insured Person by the medical facility recommended by the Insurer / by the Emergency Service Center. Means of transportation of the Insured Person (para ) are determined by the Insurer / by the Emergency Service Centre in view of medical indications. The Insurer bears no liability if the carrier fails the transportation timetable. 5. EXPENSES NOT COVERED BY THE INSURER 5.1 The Insurer does not cover the following expenses: for treatment of chronic diseases as well as diseases known at the conclusion of the Contract regardless of whether the disease was treated or not; caused by the Insured Person s health aggravation or death related to the treatment received by the Insured Person prior to the beginning of the Insurance or if the trip was contraindicated to the Insured Person due to his/her health condition; for prevention and treatment of convulsive attack, nervous and psychic diseases, neurosis; for diagnostic manipulations (including consultations and laboratory tests) without the following treatment; for heart and vessels operations including angiography, angioplasty and shunting; for treatment of oncologic diseases; for treatment of sunburns and any other acute changes of coverlet caused by ultraviolet radiation; for medical services rendered to the Insured Person, which are not related to a sudden illness or accident, for preventive measures and check-ups; for treatment of HIV-infection as well as the diseases resulting therefrom; for consultations and examinations related to pregnancy taking its normal course, for consultations, examinations and treatment of complications of pregnancy irrespective of the period thereof, as well as for assisting with childbirth and for the post-natal care of the child except for the cases when medical help is required by vital indications; for abortions unless a pregnancy-interruption operation is required due to saving of the Insured person s life; for treatment of diseases which are mostly sexually transmitted, as well as diseases resulting therefrom; for plastic and corrective surgery, as well as for any kind of prostheses including dentures and eye prostheses; for dental treatment except expenses for examination, urgent treatment and medicine in the event of acute inflammation of the tooth and adjacent tissues as well as tooth injuries resulting from an accident; for services not required upon proven medical necessity or connected with a treatment not prescribed by the doctor; resulting from the Insured Person's voluntary refusal to follow the doctor's advice given on the Insured Person s request due to the Insured Event; for treatment by methods of manual therapy, reflexotherapy (acupuncture), chiropractic, massage, homeopathic, phyto- nature-therapy; for treatment and/or health care services provided to the Insured Person by his/her relatives as well as expenses related to the Insured person relative s stay caused by the Insured person s treatment and following return to the country of permanent residence; for services rendered by medical facilities having no appropriate licence or by a person who is not entitled to provide medical practice; for rehabilitation, recovery treatment and physical therapy; for stay and treatment in balneal and health resorts, sanatoria, boarding houses, rest homes and other facilities of such profile; connected with the Insured Person s trip arranged for the purpose of getting treatment; for disinfecting, vaccination, injections, medical expertise and laboratory examinations not connected with either an accident or sudden illness; for extra conveniences such as a luxurious single ward, a TV-set, a telephone, an air-conditioner, an airmoistener, a hair dresser's, a masseur s or beauty parlour s, interpreter s services etc.; occurring after the Insured Person s return to the place of his/her permanent residence; exceeding the Sums Insured specified in the Contract;

4 for in-patient treatment, medical transportation, transport expenses, repatriation of remains not pre-approved by the Emergency Service Center. 5.2 If the Insurance Contact provides a deductible (the total amount of money which is paid to the doctor / medical facility by the Insured Person and is not reimbursed by the Insurer), it applies per each Insured Event. 6. SUM INSURED. INSURANCE PREMIUM 6.1 The Sum Insured which is stipulated in the Insurance Contract under agreement of the Parties separately per each type of the expenses paid or reimbursed by the Insurer (medical, transport, medical transportation, expenses for repatriation of the remains) is an amount of money within limits of which the Insurer reimburses or pays for the medical and medical transportation expenses, as well as transport expenses and expenses for repatriation of the remains. 6.2 The Insurance Premium is a fee for insurance that the Insured shall pay to the Insurer (its broker or agent) in accordance with the Insurance Contract. 6.3 The Insurance Premium is determined by the Insurer in accordance with its tariffs. The amount of the Insurance premium is specified in the Insurance Contract. If the Insurer decides to insure individuals practicing the activities related to the increased risks including those that specified in Paras , as well as persons over the aged 70, the Insurance Premium is adjusted in accordance with the increasing coefficients determined by the Insurer. 6.4 The Insurance Premium is paid by the Insured lump sum for the entire period of insurance. The Insurance Contract may provide for payment of the Insurance Premium by instalments. The Insurance Premium can be paid in cash or by bank transfers. 7. VALIDITY OF THE INSURANCE CONTRACT 7.1 The Contract is concluded for a period of up to one year, if not otherwise specified in the Contract The insurance comes in force at the commencement of the trip but not earlier than 0.00 o'clock of the insurance starting date specified in the insurance policy (and in the identity card) provided the Insurance Premium paid for the entire period of insurance, if not otherwise specified in the Contract. The commencement of the trip shall be recognised as the following: for non-residents of Russia - the arrival at the territory of the Russian Federation (crosses the frontier which is confirmed by a passport control stamp in the passport); for Russian residents - the Insured Person s going over 100 km off the administrative borders of his/her permanent place of residence, if not otherwise specified in the Contract. The permanent place of residence shall be recognized as the place where the Insured Person permanently or mainly resides If the annual Contract provides for multiple trips of the Insured Person, the insurance shall cover the first 90 days of each trip If the Insured Person's return from a trip is impossible by the expiry date of the Contract due to the hospitalisation caused by the Insured Event supported by an appropriate medical report, the Insurer bears responsibilities specified in para 4 of the present Regulations and related to this Insured Event within the period of 4 (four) weeks from the expiry date specified in the Insurance Policy. 7.3 The Contract is not valid off the borders of the Russian Federation. 8. CONCLUSION OF THE INSURANCE CONTRACT 8.1 In order to conclude the Insurance Contract the Insured shall inquire the Insurer verbally or submit a written application of an approved form to the Insurer (agent or broker) confirming the intention to conclude the Insurance Contract or shall inform about it by letter, telefax or telex specifying the following data: the Insured Person s family name, first name, patronymic, sex, birthday, address and telephone number; the Insured s name, legal address, telephone number, banking details if the Insured is a legal entity. So the list of persons to be insured shall be attached to the application form; anticipated date of the trip commencement and expiry; purpose of the trip; profession and occupation, if the Insured Person is going to work; type of sport or sports competitions in which the Insured Person is going to participate; the Sum Insured. 8.2 When concluding the Insurance Contract the Insured shall inform the Insurer about all circumstances in his knowledge being important for assessment of insurance risk. 8.3 The Insured shall inform the Insurer about all in his knowledge insurance risk alterations occurring within the effective period of Insurance Contract. 8.4 The Insurance Contract is concluded without a medical examination of the Insured Person. The Insured Person shall fill in a questionnaire by the Insurer s request. 8.5 Conclusion of the Contract is confirmed by the Insurance Policy issued by the Insurer and given to the Insured together with the present Regulations. An identity card is also issued, if necessary. 8.6 When concluding the Insurance Contract the Insured Person releases the doctors from confidentiality as regards the Insurer as far as the Insured Event concerned. 9. CLAIMS PROCEDURE 9.1 When the Insured Event occurs the Insured Person shall immediately contact the Insurer s specialized Emergency Service Center by telephone number specified in the Insurance Policy or in the identity card (if it is issued) and inform the medical co-coordinator about the occurrence notifying the details of the insurance documents. Expenses for the first telephone call to the Emergency Service Center are reimbursed to the Insured Person if confirming documents are submitted. 9.2 Having received the information the Insurer or Emergency Service Center arranges rendering of required medical help, medical transportation and other services, specified by the Insurance Contract. 9.3 In the event of inability to call the Insure or the Emergency Service Center prior to any consultation with the doctor or transportation to the hospital, the Insured person shall do it afterwards as soon as possible if not otherwise specified by the Insurance Contract. Anyway in case of request to the doctor or hospitalization, the Insured Person

5 5 shall submit the Insurance Policy or identity card (if it is issued) to the medical staff In the event of inability to call the Insure or the Emergency Services Center the Insured Person is entitled to request to the nearest medical facility by himself/herself, submitting the Insurance Policy. If the Insured Person incurred the expenses related to the Insured Event, on return he/she shall notify the Insure in a written from about the event occurred and submit the following documents: If the Insured Person incurred the expenses related to the Insured Event, on return he/she shall notify the Insure in a written from about the event occurred and submit the following documents: a claim form for the reimbursement of expenses related to the Insured Event and explanation of his/her failure to contact the Emergency Service Center for the arrangement of the required medical help; the Insurance Policy or its copy; original invoice of the medical facility (on its letterhead or bearing an appropriate stamp) specifying the patient s name, diagnosis, date of the patient s request for medical help, duration of treatment, list of rendered services detailed by date and cost and the total amount to be paid; original prescriptions issued by the doctor related to this illness; the detailed laboratory invoice specifying by dates, names and costs of the services rendered; original checks printed by cash register which confirmed the payment for treatment, medicines and other services (or in case of checks absence other documents confirming payment of the invoices which are submitted for reimbursement) 9.5 In order to reimburse for the expenses for outpatient treatment the Insurer accepts only the paid invoices. If the unpaid invoices are submitted the Insured Person shall provide the written explanations. 9.6 The claim from and documents specified by Para 9.4 shall be submitted to the Insurer within 30 (thirty) calendar days after the date of the Insured Person s return from the trip during which the Insured Event occurred 9.7 Payment of the insurance indemnity to reimburse for the expenses, which the Insured Person incurred, is effected by the Insurer within 15 (fifteen) working days after all the documents specified by Para.9.4 have been received. The Insurer is entitled to review the submitted documents, to inquire the facilities possessing the information about the circumstances of the Insured Event and to carry out the medical examination of the Insured Person by the Insurer s doctor. If any additional information on the Insured Event is required the indemnity shall be paid within 15 (fifteen) days after the Insurer receives all the requested documents. 10. REFUSELS IN INSURANCE INDEMNITY 10.1 The Insurer is entitled to refuse totally or partially to pay the insurance indemnity under the Insurance Contract if the following events happened during the effective period of insurance: breaking the Paras 8.2, 8.3, 9.1, 9.3, 9.4.3, 9.5, 9.6 of the present Regulations; submitting to the Insurer the documents with deliberately false information on the Insured Person s health condition or about the medical and other related to them services rendered to the Insured person; willful act or because of carelessness augmentation of the loss amount to be reimbursed by the Insurer due to the Insured Event, or failure to undertake reasonable measures to reduce them An insurance indemnity refusal is submitted to the Insured or Insured Person in written form with explanation of refusal reasons. 11. TERMINATION OF THE INSURANCE CONTRACT 11.1 The Insurance Contract shall terminate in following cases: on contract expiration (at o clock of the insurance expiry date specified by the Insurance Policy (or identity card); departure from the territory of the Russian Federation; after the Insured Person's return from the trip but not later than o'clock of the insurance expiry date specified in the Insurance Policy (and in the identity card); complete fulfillment of the contractual obligations by the Insurer; in other cases envisaged by the legislation of the Russian Federation The Insurance Contract can be cancelled any time by a written notice of either party (also due to failure to fulfill the Insurance Contract s obligations by the other party) in accordance with in-force legislation of the Russian Federation. The Insurance Premium refund is effected as following: If the Contract is cancelled before the expiry date by the Insurer's request the latter refunds to the Insured the paid Insurance Premium for the non-expired period of the Contract less the Insurer s expenses. If the Insurer s request is caused due to the Insured s non-fulfilment of the Insurance Contract, the Insurance Premium refund shall not be effected If the Contract is cancelled before the expiry date by the Insured's request, submitting to the Insure in a written form before the contract expiry date, the Insurer refunds the paid insurance premium for the non-expired period of the Contract less the Insurer s expenses. If the Insured's request is caused due to the Insurer s violating of the Insurance Contract the latter refunds the Insurance Premium to the Insured in total amount No refund of the insurance premium shall be effected if the Insured Person notifies the Insurer about the trip cancellation after the expiry date of the insurance specified in the insurance Contract If the Insurance Contract is cancelled before the expiry date the Insurance Premium refund is effected within 5 (five) banking days after the written notice of termination is received by the Insurer. 12. DISPUTE RESOLUSION The disputes related to the Insurance Contact shall be settled by negotiations. Should the negotiations fail the dispute shall be submitted to court in accordance with the in-force legislation of the Russian Federation.