TERMS AND CONDITIONS OF STUDIUM ACCIDENT AND HEALTH INSURANCE WITH COST REIMBURSEMENT

Transcription

1 TERMS AND CONDITIONS OF STUDIUM ACCIDENT AND HEALTH INSURANCE WITH COST REIMBURSEMENT The present Terms and conditions, if there are no contrary agreements, govern the Generali- Providencia Biztosító Zrt. s health insurance with reimbursement of expenses, provided that the insurance contract (hereinafter referred to as the Contract) has been concluded with reference to the present Terms and conditions. Regarding the issues not provided for under the present insurance terms and conditions, the provisions of the Civil Code and the effective Hungarian rules of law shall apply. 1. Explanatory provisions 1.1. Sickness shall be any bodily or spiritual condition recognised as irregular pursuant to the general status of medical science Any sudden external impact independent of the insured s will that result in the insured s bodily injury shall be deemed an accident Medical treatment shall be a justified treatment that is, pursuant to the generally acknowledged opinion of medical science, suitable for restoring health, improving the condition, or preventing worsening of the condition, including outpatient treatment and hospital treatment Lying in hospital shall be hospital treatment during which the insured spend also the night at the hospital Outpatient treatment shall be medical treatment made necessary as a result of sickness or accident that is less than 24 hours; that is, it does not include lying in hospital In-patient treatment shall be medical treatment made necessary as a result of sickness or accident that includes lying in hospital Insurance period shall be the one year period starting from the day when the contract is concluded. 2. General provisions 2.1. The subjects of the insurance contract (the insurer, the contracting party, the insured) Generali-Providencia Biztosító Zrt. (hereinafter referred to as the insurer) shall take the risk against the premium determined under the contract and undertake to fulfil the obligations to provide the services defined under the present Terms and conditions The contracting party shall be the party who enters into the insurance contract, and undertakes to pay the premium The insured shall be the natural person regarding whose health-condition-related events the insurance contract is concluded When applying the present insurance contract the insured may be the person with foreign citizenship who at the time of concluding the insurance contract has become 18 years old, but has not yet become 65 years old, and shall not be covered by the protection of social insurance in Hungary. 1/6

2 The insured may be any person not yet having become 18 years old who is not covered by the protection of social insurance in Hungary, if any of the dependants of such person shall be deemed insured pursuant to the above clause When applying the present insurance contract any person with the professions or performing the activities described below shall not be deemed insured: stuntmen, circus acrobats, test pilots, parachutists, individuals belonging to the staff of jets in the army, bodyguards, commandos, legionnaires, peacekeeping soldiers, intelligence agents, armed guards, money transporters, persons fulfilling either professional or military service in the army who perform activity while being exposed to increased danger (e.g., bomb-disposal experts or divers) The conclusion of the contract The contract is concluded on the grounds of the agreement between the contracting party and the insurer, which is signed by the contracting party and the insurance company The insured s statement shall be the document which contain the insured s dispositions in particular the insured s approving statement regarding the conclusion of the contract, the waiver of the obligation of secrecy regarding authorities and institutions, and the assignment of his right to insurance service. The insured statement constitutes a part of the contract The insurer is entitled before concluding the contract to collect an advance fee equal to the first premium of the insurance or its non-recurrent premium, which it handles as an advance payment free of any interest. When the contract has been concluded, the insurer sets off the advance payment against the premium. Provided that the contract has not been concluded, the insurer shall reimburse the advance payment to the contracting party Prior to concluding the contract the insurer may perform risk assessment and may request the insured to provide a medical history or medical examination or other written statement. The insurer is entitled to review the data it thus becomes aware of Any and all circumstances described in the medical history or other written statement regarding which the insurer has asked any question shall be made known to the insurer, fully and truthfully The coming into effect of the contract, the commencement of risk taking The insurer may set forth a waiting period under the contract, the term of which shall be maximum 6 months from the date the contract comes into effect. The term of the waiting period, if the insurance enforces any, shall be determined in the additional clause under the contract and/or the policy. The insurer s risk taking during the waiting period is partial, covers exclusively accidents, or events causally related to such accidents The insurer s risk taking regarding the insured shall commence on the date the insurance contract regarding the insured comes into effect, taking into consideration the waiting period, if it is set forth by the insurer under the contract and/or the policy, provided that the premium has been transferred to the insurer s account, or from a date determined under the contract, if the parties have agreed in delaying the payment of the premium The termination of the contract The contract shall terminate with regard to the given insured: a) at the date determined under the contract, or b) in the event of failure to pay the premium, once 30 days have elapsed from the date the first failed premium payment is due, or c) in the event of the insured s death, or d) by notice The contract shall not be terminated unless in writing and as of the end of the year of insurance, provided that the term of the insurance is indefinite. If the term of the insurance is 2/6

3 definite, then the contract may be terminated in writing and as of the end of the 4 th year of insurance, at the earliest The contract shall be terminated with 30 days notice The effect of the area of insurance The insurer s risk taking shall cover the territory of the Republic of Hungary The term of the insurance The term of the insurance shall be determined by the parties to the contract under the insurance contract and/or the policy The rights and obligations of the subjects under the contract The contracting party may make a proposal to modify the contract, to define a new insured, or to terminate the insurance cover with regard to the insured determined by it To conclude or modify the contract the written approval of the insured is necessary, which is granted by the insured by filling in and signing the insured s statement. In such event, the contracting party is obliged to obtain the insured s statement The contracting party is obliged to inform the insured persons regarding the content of the contract and any and all changes that might occur in it The contracting party s and the insured s obligation to communicate and report changes The contracting party and the insured are obliged to fulfil their obligation to communicate and report changes The obligation to communicate shall be that the contracting party and the insured are obliged when making the offer to communicate any and all circumstances to the insurer that are material in view of undertaking the contract, and that it knew or must have known. By giving answers, fully and truthfully, to the questions put by the insurer in writing the parties fulfil their obligation to communicate The obligation to report changes shall be that the contracting party and the insured are obliged during the term of the insurance to report in writing changes in any essential circumstances communicated under the contract or set forth within 30 days from such changes. Essential circumstances shall be those which the insurance contract provides for, or regarding which the insurer has put any question The insurer is entitled to review the data communicated In the event of infringement of the obligation to communicate and to report changes, the insurer shall be exempt of the obligation to provide services, except when it is proved that the circumstances not communicated or not reported had been known to or must have been known by the insurer prior to the occurrence of the event The fact that any of the events described above hold shall be proved by the party that refers to them If after the conclusion of the contract the insurer becomes aware of any material circumstances affecting the contract, then it may make a proposal, within 15 days from the date it becomes aware of such circumstances, to modify the contract, or, when it does not take the risk under the present conditions, it may terminate the contract in writing If the contracting party (the insured) does not accept the proposal to make modification, or does not reply to it within 15 days from receipt thereof, the contract shall become void regarding to given insured 30 days after communicating the proposal to modify the contract, provided that the insurer has called the insured s attention to this legal consequence when communicating the proposal to modify Premium With regard to the payment of the premium the insurance contract and/or policy shall apply The contracting party will fulfil its obligation to pay the premium at the time when it transfers the premium to the insurer s account. 3/6

4 The contracting party agrees to pay the premium in one amount pursuant to the terms the premium is due regarding all the insured persons. 3. Cover 3.1. Events An event shall be the insured s medical treatment, determined under the present terms and conditions, made necessary during the term of insurance as a result of sickness or accident and medically justified at the designated institution specified in the policy (Health insurance card). Medical treatment at other institutes or service providers shall be reimbursed by the insurer only in case the insured s health condition did not allow medical treatment provided or organized by the designated institution The insurer s service The insurer s obligation to provide service shall cover only the outpatient service and hospital treatment (in-patient treatment) provided in Hungary The insurer shall reimburse the expenses related to the medical treatment medically necessary given to the insured, determined under the present terms and conditions, in the event that the designated institution proves that such medical treatments have been reasonably used Within the framework of the benefit limits determined under the contract and/or the policy and applying deductibles, if any, the insurer shall reimburse the expenses related to the medical treatment determined under the present Terms and conditions As part of the outpatient treatment the following items shall be reimbursed: a) basic medical treatment expenses b) the costs of special medical treatment, c) the physician travel expenses; that is, when a physician goes to see someone at home, its costs shall be reimbursed if the patient s condition did not allow for the patient to visit the surgery (e.g. in case of urgency) d) the costs of separate examinations, (e.g., laboratory examination, x-ray diagnostics, ultrasound scan); which shall not be reimbursed by the insurer unless they are necessary for exploring, curing the illness As part of the in-patient treatment the insurer shall reimburse the costs of the insured s stay and treatment at hospital. In particular, the following items shall be reimbursed: a) the cost of medical treatment pursuant to the physician s instructions, including the necessary operations, b) nursing cost, c) the costs of medically justified abortion The insurer will reimburse the expenses of the medicines, bandages, temporary therapeutic aids into consideration taking the deductible determined under the contract and/or the policy The expenses of travelling to the physician or transport shall be reimbursed by the insurer in the event that transport to hospital (by either ambulance or taxi) takes place within the country and are medically justified The expenses of transporting the patient home when the patient s health condition either requires or allows it, and the designated institution also recommends that the patient is transported home. Transporting home means transporting the patient to the country defined by his citizenship The insurer s completion The demand for service regarding the reimbursement of expenses of the health care service shall be reported to the insurer within 15 days after the date of the invoice To obtain reimbursement of expenses of the health care service, it is necessary to submit: a) the original invoices proving the payments, b) all medical documents related to the event. 4/6

5 The insurer will fulfil the demand for service, in the event the legal base holds, within 15 days from submission of all the required documents Exclusions The following items shall not constitute the subject of an event: a) medical treatment because of pregnancy, b) medical treatment because of abortion (except for medically justified cases), c) cosmetic treatments and operations not arising from accidents, d) acquisition of spectacles, contact lenses, or hearing aids, e) dental treatments (except for acute and emergency cases and the consequences of accidents), f) rehabilitation treatments, cures, g) all forms of artificial insemination, h) treatment of illness due to the HIV virus, i) of superior level accommodation (e.g., room with one bed), j) the consequences of illnesses existing, known prior to the commencement of the insurance or earlier accidents, k) treatments arising from consumption of alcohol or drugs, l) acupuncture treatments and psychotherapy, m) vaccinations Furthermore, the insurer s risk taking shall not cover the events that are caused either fully or partially by: a) pathological mental state, b) ionizing radiation, c) nuclear energy, d) war event, or anti-state crime. For the purpose of the present Terms and conditions, a war event shall be war (with or without declaration of war), frontier incidents, uprising, revolution, rebellion, anti-government coup, or attempt at coup, civil war The insurer s risk taking shall not cover the events that are causally related to the insured s sport activities defined below: a) motoring: car racing, motor sports, rally, motocross, competitions of driving skill, go-cart sports, auto-crash sports, motorboat sports; b) aerial sports: skydiving, gliding and soaring with motorised glider, hang-gliding and ultralight gliding, strip parachuting, hot-air ballooning; c) other: skin diving with aqualung below 40 meters, single-handed and ocean-going sailing, mountain climbing and rock climbing at degree 5 and above, mountaineering expeditions, caving, caving expeditions Exemption The insurer shall be exempt from fulfilling the service provided that it proves that the event has been caused by the contracting party or the insured illegally, knowingly or with gross negligence The insured acts with gross negligence in particular when a) being in an intoxicated state at the time of the accident, and this fact being concurrent due to the accident. If a blood test has been made, an alcoholic state shall be blood alcohol concentration above 1.5 and 0.8 while driving, b) driving a car without a valid vehicle licence, or without a valid driver s licence necessary for driving such vehicle and this fact being concurrent due to the accident. 4. Miscellaneous provisions 5/6

6 4.1. Legal statements, notices Any and all notices to the insurer shall be submitted addressed to the insurer in writing Lodging a complaint Complaints arising with regard to the contract shall be reported to the insurer in writing at the following address: Generali-Providencia Biztosító Zrt., Customer Services Group, 1066 Budapest, Teréz krt The insurer will inquire into the complaints reported in writing, and will inform the party lodging the complaint in writing within 30 days from receipt of the notice. 6/6