INTRODUCTORY PROVISIONS

Transcription

1 Generali Osiguranje Srbija a.d.o. Vladimira Popovića Beograd / Srbija T F kontakt@generali.rs generali.rs Special Terms and Conditions for Voluntary Health INTRODUCTORY PROVISIONS Article 1 (1) These Special Terms and Conditions for Voluntary Health (hereinafter: General Terms and Conditions) shall be integral part of the contract for Voluntary Health Insurance for Foreigners due to Occurrence of a Medical Emergency during Their Stay in the Republic of Serbia (hereinafter: insurance contract), concluded voluntarily by the Policyholder with joint stock insurance company (hereinafter: Insurer). (2) Certain terms in these Special Terms and Conditions have the following meanings: Policyholder a natural person, legal entity or other subject of rights or its associated legal entity concluding, in the name and on behalf of the Insured and/or in own name and on own behalf, the insurance contract with the Insurer and who has bound itself to pay premium; Insured a foreigner being entitled to indemnity for the expenses of a medical treatment in the Republic of Serbia pursuant to concluded insurance contract and in accordance with insurance contract and herewith; Foreigner a person not having citizenship of the Republic of Serbia; Country of residence a country of Insured s reported residence; Licensed physician any person who has obtained a medical school degree and possesses permit and/or license to work issued by competent medical chamber, employed at a medical institution within Plan of medical institutions network and/or private practice, and pursuant to valid law regulating healthcare except if licensed physician is the Insured, Policyholder and/or their spouse; Medically justified treatment healthcare service, medical-technical aids, implants, material or medicine justified if: 1. It is appropriate and necessary to diagnose or treat diseases or injuries covered under the policy and specified hereunder; 2. It is necessary for curing, improving health condition and/or preventing deterioration of the Insured s health; 3. It does not exceed, in scope, duration or intensity, the level of protection necessary to provide safe, adequate and appropriate treatment; 4. It has been prescribed by licensed physician; 5. It occurred during the policy period; 6. It complies with generally accepted medical practice professional standards in the Republic of Serbia; 7. Its primary purpose is not personal comfort or convenience of the patient, family, physician or other medical service provider; 8. It is neither a part of educational nor professional training of the patient nor has it been related to such; 9. It is not experimental or in research phase. Medical emergency sudden illness or injury which could, without urgent medical assistance, endanger life of the Insured, i.e. which could cause irrecoverable or severe deterioration or damage to his health or death. Urgent medical assistance direct, immediate medical assistance provided in order to avoid endangerment of the Insured s life, i.e. which could cause irrecoverable or severe deterioration or damage to his health or death. Urgent medical assistance implies the medical assistance provided within 12 hours from the moment of reception of the Insured in order to avoid the expected occurrence of urgent medical condition. Accident any sudden event, independent from the Insured s will, which, affecting mostly from the outside to the Insured s body, causes a health disturbance requiring urgent medical assistance. Sudden illness sudden and unexpected illness established by a licensed physician and/or infective disease or organic disorder which has occurred after the beginning of the insurance and of such nature requiring provision of urgent medical assistance; Preexisting condition any health condition resulting from any previously diagnosed disease or which would require hospital treatment, treatment or medicines before insurance contract came into force i.e. before inception of insurance coverage, and which the Insured was aware of at the time of conclusion of the insurance contract. Preexisting condition shall especially mean chronic disease and/or injury, illness or condition which could be expected to last a long period of time with no reasonably foreseeable date of termination and which could be characterized by remissions requiring permanent or occasional care, if needed. TL-U-02-OS-01-01

2 Medical expenses - amount borne by the Insurer in case of occurrence of the insured event covered under this insurance, which represents the cost for Insured for the provided, justified healthcare service due to occurrence of sudden illness or accident provided for under these Special Terms and Conditions and the insurance contract. Participation participation in the share of expenses for treatment of a particular, covered, medically justified treatment which must be paid if specified in the insurance policy and/or insurance contract. Doctor-censor a physician employed with the Insurer. General Provisions Article 2 (1) Under the insurance contract, the Policyholder shall be obliged to pay the Insurer the premium, and the Insurer shall be obliged, when the insured event has occurred, to indemnify for the expenses paid for treatment of medical emergencies pursuant to Article 7 hereof. (2) A person or group of persons not being citizens of the Republic of Serbia can be insured hereunder. (3) Insurer shall provide the insurance and shall undertake to pay the expenses resulting from an insured event which occurred within contracted insurance period for indemnification of expenses for provision of health care provided for under Article 7 hereof. (4) Insurance hereunder shall be valid on the territory of the Republic of Serbia. (5) Insurance beneficiary hereunder shall be exclusively the Insured who has experienced the insured event. Conclusion of the Insurance Contract Article 3 (1) Insurance contract shall be concluded based on a written application submitted in the Insurer s form by the Policyholder, containing data on each Insured to be included in the insurance contract. (2) In case of conclusion of a collective insurance contract for Policyholder s employees or members or Policyholder s service beneficiaries, the insurance contract shall be concluded based on a unified written application, submitted in the Insurer s form by Policyholder, containing data on each Insured to be included in the insurance contract. (3) Insurance contract shall be concluded when the contracting parties sign the policy or the cover note. (4) Written application for conclusion of the insurance contract shall be binding upon the Applicant (Policyholder), if shorter period has not been established, within eight days from the day when the application is received by the Insurer. (5) If the Insurer does not refuse the application not differing from its conditions within the period provided under previous paragraph of this Article, it shall be deemed to have accepted the application and that the insurance contract was concluded as of the date of insurance application delivery. (6) Insurer shall issue the policy to the Policyholder, based on the data from the application. (7) In case the insurance is concluded for a group of persons, a list of the Insured included in this insurance shall be integral part of insurance contract. Premium Payment Article 4 (1) Policyholder shall be obliged to pay the insurance premium in whole for the entire insurance period. (2) Notwithstanding the provisions of the previous paragraph of this Article, if stipulated, and if the contracted insurance period is longer than six months, insurance premium can also be paid in installments and the Insurer shall be entitled to insurance premium for the entire contracted insurance period. (3) Premium, expressed in EUR, shall be paid in RSD counter value at official mean exchange rate of the National Bank of Serbia on the date of insurance premium payment pursuant to insurance contract. Duration of the Insurance Contract Article 5 (1) Insurance contract can be concluded for a limited period not shorter than one month and not exceeding 12 months. Commencement and Termination of the Insurer s Liability Article 6 (1) Insurance shall begin at on the day specified on the policy as commencement of insurance but not before insurance premium has been paid. (2) Insurance shall terminate at on the day specified on the policy as insurance expiration date and/or at the end of stay in the Republic of Serbia. (3) Insurer s liability shall last only within the period of insurance coverage. (4) Insurer s liability can continue up to the date specified in the policy and/or insurance contract as insurance expiration date. Insured Event Article 7 (1) Insured event is a sudden illness or accident of the Insured resulting in provision of urgent medical assistance to the Insured and provision of health services necessary for treatment of medical emergencies occurred immediately after the provision of urgent medical assistance, which caused occurrence of expenses to be borne by Insured. (2) Indemnification for treatment of medical emergencies cannot exceed the contracted sum insured specified in the policy during the contracted insurance period.

3 (3) Indemnification for treatment of medical emergencies shall be limited to medically necessary procedures of in-patient and out-patient treatment. (4) In-patient treatment in Terms and Conditions hereof shall mean event when Insured has been provided with medically justified treatment for the purpose of treating medical emergencies up to the moment when, pursuant to medical standards, life of the Insured is no longer endangered, up to 30 days. (5) In-patient treatment in Terms and Conditions hereof, shall mean event when the Insured has been provided with a medically justified treatment of medical emergencies, at the institution which is considered to be general hospital in accordance with healthcare regulations, where the Insured is constantly monitored by medical personnel, and which has sufficient number of diagnostic, lab, surgical and therapeutic equipment and shall limit medical services to scientifically recognized methods, clinically tested in the Republic of Serbia, where Insured occupies a bed longer than 24 hours. (6) Out-patient treatment in Terms and Conditions hereof shall be event when the Insured is provided with medically justified treatment of medical emergencies, received by the Insured at a medical institution, as a provider of medical services, or at the place of medical urgency which is officially recognized as a place where such a treatment can be conducted and shall limit medical services to scientifically recognized methods clinically tested in the country where insurance coverage is valid pursuant to the policy, and thereat, the Insured has not spent consecutive 24 hours (stayed over night, and/or occupied a bed) at such institution. (7) In case of occurrence of the insured event, Insurer shall indemnify for: 1) Paid treatment expenses only for following medical services: 1. Infirmary treatment (out-patient treatment); 2. Medical supplies and drugs prescribed by a licensed physician; 3. Medical and technical aids which are necessary part of treatment for broken limbs and injuries, prescribed by a licensed physician; 4. X-ray diagnostics (roentgen) 5. In-patient treatment (hospitalization); 6. Surgeries and surgical expenses; 7. Surgical expenses shall also include implants prescribed by a licensed physician, but not exceeding the limit of EUR annually, per Insured. 2) Paid transportation expenses incurred due to provision of urgent medical assistance: 1. Transportation of the Insured to the nearest physician or hospital by ambulance, 2. Transportation of the Insured to the nearest physician or hospital by some other means of transportation, if medically justified and allowed but not exceeding the limit of EUR Transportation and accommodation of the Insured to the specialized hospital or hospital which is more appropriate for treatment of endangered health condition. (8) Medical emergency resulting from chronic diseases or injuries which existed before the commencement of insurance shall not be covered hereunder. (9) Necessity of urgent medical treatment shall be assessed by a doctor-censor based on medical records, in accordance with Article 10 hereof. Exclusion of the Insurer s Liability Article 8 (1) Insurer s liability shall be excluded in case of expenses resulting from: Illness or accident of any kind not requiring provision of urgent medical assistance; Treatment for cancer, HIV (AIDS) and venereal disease as well as expenses for treating terminal stadiums of chronic disease; Deliberate abortion with no medical reasons; Accident caused by illness, such as epilepsy or malaria; Explantation or transplantation of organs, tissues or cells; Treating symptoms and complications of illnesses or injuries for which, based on average person standard i.e. expected behavior of persons with average capacities and abilities in particular circumstances, such person would require care, treatment or consultation from the physician before insurance contract coming into force; Medical research, regular and/or control checkups, home visits from a physician, medical diagnostic methods, medical research or treatments unrelated to the occurrence of the insured event, as well as vaccination and use of contraceptives and drugs of any kind not prescribed by the physician treating the Insured; Experimental medical methods or methods used in case of research, and not recognized by social security, as well as esthetic-corrective treatments and operations; Thermal treatment, and/or expenses for preventive drugs, rehabilitation at the institutions specialized for rehabilitation, medical centers, recovery centers and other similar institutions, as well as expenses for psychiatric treatment, treatment of mental illnesses and their effects; Purchase, repair and use of glasses, contact lenses as well as prosthetic aids of any kind; Dental treatment not requiring urgent intervention, definitive dental treatment, jaws orthopedics (except in case of an accident), orthodontics, parodontopathy treatment, removing tooth scale, treating tooth root, tooth replacement, tooth crowns, making dental prosthesis and bridges, reparation or repair;

4 Insured being treated by his/her spouse, parent or child; Accommodation in single-bed or private room at the hospital, except if a licensed physician has found it necessary. (2) If established that Insured has known or has been warned by a licensed physician in the country of residence that his/her health condition is such that his/her life has been possibly endangered due to possible acute complications, and can be treated conservatively or surgically in the country of residence, Insurer s liability to indemnify treatment expenses for such condition in the Republic of Serbia shall be excluded, and shall be considered that Insured has arbitrarily taken the risk of occurrence of possible effects of such health condition when coming to the Republic of Serbia. (3) Insurer s liability shall be excluded in case of the insured event resulting from: 1. Preexisting conditions; 2. Pregnancy or delivery, as well as any other illness or complication related to pregnancy; 3. Following diseases: smallpox, plague, cholera, viral hemorrhagic fevers (except for hemorrhagic fever with renal syndrome), malaria or yellow fever and other infectious diseases for which the person is placed under medical supervision in accordance with the regulations governing the protection of the population from infectious diseases); 4. Venereal disease of foreigner who is a member of crew on foreign ships or vessels. (4) Insurer s liability shall be excluded for expenses arisen if established that foreigner has been a victim of trafficking (5) Insurer s liability shall be excluded if treatment expenses have resulted from provision of healthcare services not provided for under Article 7, paragraph (7) hereof. General Exclusions and Limitations of the Insurer s Liability Article 9 (1) All liabilities of the Insurer shall be excluded if an insured event occurred: In cases the Insured knew or could have known based on the circumstances that there have been possibility of occurrence of the insured event; Outside the territory of the Republic of Serbia where insurance is valid or the insured event has occurred before commencement of the insurance period and/or after the expiry of the insurance period, or has occurred after the return to the country of residence. As a consequence of an intentional act committed by the Insured, such as: suicide, suicide attempt or mental illness (mental disorder) of the Insured, intentional self-injury, self-treatment for alcoholism, addiction to psychoactive controlled substances as well as condition under the influence of alcohol or drugs. It shall be deemed that the Insured has been in intoxicated or under the influence of drugs if the presence of alcohol in the blood was higher than the allowed minimum pursuant to legal regulations of the Republic of Serbia and/or if traces of drugs have been detected after occurrence of the insured event Due to the fact that the Insured practices different hazardous and dangerous activities or sports, such as: hunt, acrobatics, diving, wind-surfing, paragliding, speleology, mountaineering, pyrotechnics and activities that include handling fireworks, ammunition and explosives, parachuting, ski jumping, acrobatic skiing, skating, carting, hockey, water skiing, bungee jumping, car races, motorcycle riding (without official document and protection equipment), street-boarding, rollerblade acrobatics, driving buggy, water scooters etc. As a consequence of war, invasion, actions committed by a foreign enemy, hostilities (whether the war was declared or not), terrorist activities, civil war, sabotage, terrorism or vandalism, rebellion, revolution, insurrection, military and other usurpation of power as well as active participation of the Insured in disorders or mutinies of any kind; As a consequence of a natural disaster (e.g. volcano eruptions, earthquake etc.), calamities, epidemics and pandemics; As a consequence of all other diseases not endangering life of the Insured pursuant to enclosed medical records related to the insured event and opinion of doctor-censor; As a consequence of ionizing radiation or contamination with radioactive materials from other radioactive waste generated by burning nuclear fuel, i.e. radioactive, poisonous, explosive or other dangerous characteristics of explosive nuclear assembly or some of its components. (2) Insurer s liability shall be excluded in case when the Insured is entitled to payment of indemnification pursuant to another policy except for indemnification not covered under another policy. (3) Insurer s liability shall be excluded when indemnification for the insured event is subject to payment in some other manner and/or when foreigner has exercised his/her right to treatment pursuant to compulsory health insurance, special regulations of the Republic of Serbia, bilateral treaties, motor third party liability insurance, etc. (4) If the claim is in any way fraudulent or grounded on false information and statements, it shall not be binding for Insurer. (5) Insurer shall be entitled to exclude from the insurance a person who was proven to have given false statements and/or to have covered important circumstances effecting the conclusion of the insurance contract as well as Insured not meeting obligations provided for under General Terms and Conditions and hereunder.

5 Reporting the Insured Event Article 10 (1) In case of occurrence of the insured event, insurance beneficiary shall report the insured event to Insurer by submitting claim and enclosing: Original policy and/or insurance certificate; Certificate of residence reported in the Republic of Serbia; Document proving identity of foreigner (foreign travel document, ID card of foreigner, special ID card or other official document containing a photo based on which identity and citizenship of the Insured can be established); Complete medical records relating to occurred insured event (including, inter alia, all fiscal receipts, certificates and RTGs) pursuant to which relevant facts, important for Insurer when liquidating damage, can be indisputably established; Fiscal receipt which must contain, in order to be accepted, as follows: 1. Institution name; 2. Institution address; 3. Institution TIN; 4. Description of provided services and amount; 5. Date of service provided. Official police report on occurrence and type of accident (casualty) in case that Insured s injury resulted from accident (casualty); All other documents in relation to occurred insured event requested by Insurer, which are necessary for establishing necessity of claim. (2) At the request of the Insurer, the Insured shall be obliged to provide all necessary medical records in relation to occurred insured event from the country of residence which Insurer found necessary in the process of claim handling. (3) Insurer shall be entitled to request from the Insured the notification on all the facts and to deliver all the documents relating to occurred insured event recognized as important by Insurer, for authenticity of insured event reporting and for the purpose of complying with their obligations to the Insured. At the request, Insured must collect and deliver to the Insurer all important facts from third parties (physicians, pharmacists, druggists or other medical personnel or medical institution of any type, transporter of Insured, medical or pension institutions). By signing the claim, Insured agrees that hospital or medical institution providing him the treatment can communicate all necessary information in relation to his/her health conditions and treatment related to the insured event. Rejecting to provide such approval shall result in the loss of Insured s right pursuant hereto. (4) Existence of another insurance policy covering the same risk must be reported to Insurer by the Insured. (5) Insurer shall be entitled to reject to pay indemnification if: 1. Insured s statement, representing grounds for conclusion of policy or statement of beneficiary made in the process of claim reporting, has been false, untrue or covering facts aiming at deliberate fraud, etc. 2. Insured has failed to pay or to deliver evidence of payment of treatment expenses. (6) If expenses resulting from insured event have exceeded contracted sum insured and/or maximum limits provided under insurance contract and hereunder, insurance beneficiary shall not be entitled to the difference. Fulfillment of Insurer s Obligations Article 11 (1) Insurer shall indemnify the Insured for treatment expenses pursuant hereto, according to insurance contract within 14 working days from the date when Insurer received evidence and established existence of liability and with participation if such was contracted. (2) Insurer shall indemnify the Insured by making payment to the account of the Insured in the Republic of Serbia. (3) Insurer s liability shall be met in whole as of the date of confirmed payment through post office or bank, if payment was made to the Insured s account in the Republic of Serbia. Obsolescence Article 12 (1) Pursuant hereto, claims shall become obsolete in accordance with the Law on Obligations and Contracts. Closing Provisions Article 13 (1) Provisions of General conditions, if not contrary hereto, shall apply to everything not regulated hereunder. (2) Insurer shall be obliged to publish updated version hereof on its web page. (3) Special Terms and Conditions for Voluntary Health shall come into force and shall become effective as of the date of obtaining positive opinion from the Republic of Serbia Ministry of Health. (4) Commencement of the application of Terms and Conditions regarding paragraph (3) of this Article shall terminate application of Special Terms and Conditions for Voluntary Health Insurance for Foreigners due to Occurrence of a Medical Emergency during Their Stay in the Republic of Serbia, dated on 16th of June 2010.