health insurance rules no. 010
TRANSCRIPT
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HEALTH INSURANCE RULES No. 010
CONCEPTS
Effective from 1 August 2021
1.1. The concepts starting with a capital letter, used in the
insurance contract as well as in the notices of the parties, other
related documents shall have the meaning defined below and
shall be respectively interpreted, unless the context expressly
requires otherwise or unless clearly stated otherwise.
1.1.1. An ambulatory Surgery Service means a planned health
care service during which a treatment and/or diagnostic
intervention procedure is performed. The service must comply
with the list of ambulatory surgery services approved by the
Minister of Health of the Republic of Lithuania applicable at the
time of its provision. The duration of the service may not exceed
1 (one) bed day, which means that the Insured is admitted to the
Health Care Institution and discharged from it on the same day.
1.1.2. The Insured shall mean a natural person specified in the
Contract, whose Insurance Risk and property interests are
insured.
1.1.3. Day Surgery/Day Stationery Treatment Service shall
mean a planned treatment and/or diagnostic Health Care
Service during which the care of the Insured is guaranteed for
up to 24 hours (if necessary – up to 48 hours). The service must
comply with the list of day surgery/day treatment stationery
services approved by the Minister of Health of the Republic of
Lithuania applicable at the time of its provision.
1.1.4. The Policyholder shall mean a person who concludes
(concluded) or expresses the need to conclude a Contract with
the Insurer for his own or another person's benefit.
1.1.5. The Insurer shall mean Compensa Life Vienna Insurance
Group SE acting through the Lithuanian branch of Compensa
Life Vienna Insurance Group SE, or its successors and assigns or
successor in title (if applicable).
1.1.6. Insurance Coverage shall mean the obligation of the
Insurer to pay the Insurance Indemnity to the Beneficiary under
the terms and conditions and procedure set in the Contract
upon occurrence of the Insurable Event.
1.1.7. Insurance Indemnity shall mean the amount of money
payable by the Insurer to the Beneficiary under the Contract
upon occurrence of the Insurable Event.
1.1.8. The Beneficiary shall mean the Insured or the Partner, or
their successors and assigns, heirs who acquire the right to the
Insurance Indemnity or the portion thereof in accordance with
the procedure and terms established by the Contract and/or
applicable law.
1.1.9. The Insurance Premium shall mean the amount of money
payable by the Policyholder to the Insurer for the Insurance
Coverage and related services provided under the Contract, the
amount and terms of payment of which are determined in the
Insurance Certificate (Policy).
1.1.10. The Insurance Period shall mean a period of time defined
and stated in the Contract as specific time limits, during which
the Insurance Coverage is valid.
1.1.11. The Insurance Certificate (Policy) shall mean a document
confirming the Contract conclusion and its conditions and
issued under the procedure and terms set by the Insurer during
conclusion of the Contract and/or amendment s to its
conditions. Upon issuance of a new or subsequent Insurance
Certificate (Policy), all prior Insurance Certificates (Policies) to
the same Contract shall become invalid.
1.1.12. The Insured Risk shall mean a probability for occurrence of
the Insurable Event and/or the amount of possible damages or
injuries caused by this Insured Event.
1.1.13. The Sum Insured shall mean the maximum amount of
money indicated in the Insurance Certificate (Policy), within the
limits of which respective property interests are insured.
1.1.14. Insurance Rules shall mean these health insurance rules,
in accordance with which all Contracts on the health insurance
product distributed by the Insurer are concluded.
1.1.15. The Insurable Event shall mean the event provided for in
the Contract, upon the occurrence of which the Insurer
undertakes to pay the Insurance Indemnity in accordance with
the procedure and conditions provided for in the Contract..
1.1.16. The Date of the Insurable Event shall mean one of the
following dates, on the basis of which it is determined whether
the Insurable Event occurred during the validity of the
Insurance Coverage:
a) In the case of the purchase of medical aids, the date on which
the goods or aida are actually paid for. If goods or aids are
bought in instalments, the date of payment of the first
instalment shall be deemed to be such a date;
b) In case of provision of services, the date when the Insured
actually receives the service;
c) In the case of a critical disease, the date of diagnosis of the
critical illness.
1.1.17. The E-Help System shall mean an electronic system or
program, the procedure and conditions of use of which are
determined by the Insurer and which is intended for the
exchange of documents, information and/or notices (including
requests or other forms of expression of will) between the
Insurer and the Insured.
1.1.18. Long-Term Nursing/Care And Supportive Treatment
shall mean palliative care, supportive treatment, nursing/care at
home, in a health care institution or other social support
institution for people with severe chronic diseases when active
treatment is not required.
Adopted by Order No.V-4/21 of 15 July 2021 of the CEO of
Compensa Life Vienna Insurance Group SE, Lithuanian Branch
1. CONCEPTS
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1.1.19. The Franchise shall mean a part of the loss (expenses),
which is reimbursed by the Insured himself in case of each
Insurable Event.
1.1.20. The War and State of Emergency shall mean war or
actions similar to war in their nature, irrespective of their forms
or whether the war is officially declared or not, as well as military
incursion or similar military actions, military government
establishment, rebellion, mass riots, civil unrest, use of weapons,
occupation, revolution, civil wars, uprisings, government
upheaval, siege, declaration of martial law or the state of
emergency or any other events or circumstances that threaten
the constitutional order or public peace.
1.1.21. The Client shall mean a natural or legal person or their
representative, including the Policyholder or the Insured, who
uses the services of the Insurer or expresses a relevant interest
or intention.
1.1.22. The Card shall mean a card issued by the Insurer and
intended for the Insured, which confirms the provision of
Insurance Coverage in accordance with the terms and
conditions of the Contract.
1.1.23. The Critical Disease shall mean one or more diseases
and/or surgeries provided for as indicated in clause14 of
Addendum No.1 to the Insurance Rules, which meet the criteria
for diagnosing such diseases or surgeries as defined therein.
1.1.24. The Date of Diagnosing a Critical Disease shall be one of
the following dates:
a) In case of Critical Diseases referred to in sub-clauses
14.4.14–14.4.1.6 and sub-clause 14.4.1.13 (if a relevant surgery is
performed) of clause 14 of Addendum No.1 to the Insurance
Rules – the date of performance of surgery on the Insured;
b) In case of the Critical Diseases specified in sub-clause 14.4.1.7
of clause 14 of Addendum No. 1 to the Insurance Rules – the date
when the Insured is placed on the official waiting list for surgery
or the date when the Insured undergoes organ transplantation
if the Insured was not placed on the list of patents waiting for
organ transplantation;
c) In case of a critical disease referred to in sub-clause 14.4.1.1 of
clause 14 of Addendum No. 1 to the Insurance Rules –the date of
sampling of the histological examination on the basis of which a
medical specialist diagnosed a disease;
d) In other events of other Critical Disaees provided for in
Addendum No. 1 to the Insurance Rules – the date of diagnosing
a Critical Disease for the Insured.
1.1.25. Medical Aids shall mean bandages, patches, syringes,
insulin syringes, drip systems, stool collectors, bladder
catheters, ostomy bags or collectors.
1.1.26. Medically Reasonable Services shall mean the health
care services reasonably prescribed to the Insured by a
competent doctor as necessary ones according to the Insured's
complaints, established symptoms, and signs in the medical
documentation.
1.1.27. Medical Accessories shall mean medical devices and
medical aids; technical orthopedic aids; disposable instruments
and appliances used for day surgery or ambulatory surgery
services.
1.1.28. Medical devices shall mean glucometers and test strips
for them, hearing aids, parenteral nutrition systems, drip
infusion systems, pumps and inhalers.
1.1.29. The Uninsurable Event shall mean an event or
circumstances, upon which occurrence the Insurer shall not pay
the Insurance Indemnity.
1.1.30. Non-reimbursable expenses shall mean the expenses of
the Insured specified in the Health Insurance Program, which
are not reimbursed by the Insurer under the Contract, even if
they are caused by Health Disorders.
1.1.31. The Accident shall mean an accident which occurs
against the will of the Insured as a result of any abrupt,
inadvertent, unexpected external forces and causes the bodily
injury to the Insured including but not limited to sinking,
heatstroke, sunstroke, chilblain, exposure to gas or other toxic
substances which accidentally penetrate the body except for
food poisoning.
1.1.32. Alternative medicine shall mean the services of diagnosis
and treatment of diseases provided by a medical specialist in an
alternative way in a health care institution, including
acupuncture; electroacupuncture, bioresonance computer
diagnostics; food intolerance tests; hydrocollonotherapy;
phytotherapy; leech treatment; lithotherapy; apitherapy;
aerophytotherapy; music and art therapy; chromotherapy;
osteopathy; homeopathy; endobiogenic medicine; kinesiology;
reflexology; Chinese medicine; Ayurveda; yoga; Reiki;
autogenous training.
1.1.33. Remote Health Care Services shall mean health care
services that are provided by means of communication in
accordance with the procedure established by applicable law
without the physical presence of the Insured.
1.1.34. Technical Orthopedic Devices shall mean splint and
prosthetic systems, sticks, crutches, liners, compression
stockings and postoperative shoes.
1.1.35. The Partner shall mean an entity with whom the Insurer
has entered into a relevant agreement on the Insurer's Client
Service and other conditions of cooperation in providing health
insurance services. The Partner is not the representative of the
Insurer. The list of partners is published on the Insurer's website.
1.1.36. The Offer shall mean the conditions under which the
Insurer agrees to enter into the Contract.
1.1.37. The CHIF shall mean the Compulsory Health Insurance
Fund.
1.1.38. Radiation shall mean a radioactive radiation, pollution or
poisoning (intoxication), nuclear reaction or nuclear energy
impact, as well as unauthorised use of nuclear weapons.
1.1.39. Rehabilitation Treatment shall mean a complex remedial
measure applied due to the Insured's Health Disorder (acute
condition, exacerbation of the disease or Injury) together with
other treatment measures and/or as an adjunctive measure
after ineffective or insufficiently effective pharmacological,
surgical or immobilization treatment.
1.1.40. The Contract shall mean an insurance contract
concluded between the Insurer and the Policyholder, according
to which the Insurer undertakes to pay the Insurance Indemnity
upon occurrence of the Insurable Event for the fee and under
procedure set in the Contract, and o the Policyholder
undertakes to pay the Insurance Premiums properly and on
time and to perform other obligations assumed under the
Contract The Contract consists of the following integral parts:
Insurance Certificate (Policy), Insurance Rules, the Offer, terms
and conditions or requirements stated in other documents
related to the Insurance Contract or separately concluded by
the parties (e.g., individual terms and conditions) including all
addendums, amendments and supplements thereto and new
versions.
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1.1.41. The Health Insurance Program shall mean the insurance
program (s) specified in Addendum No. 1 to the Insurance Rules,
which determines the scope of the Insured Risk assumed by the
Insurer and the nature of the Insurance Coverage.
1.1.42. The Health Care Institution shall mean an (natural or
legal) entity that has a statutory licence and the right to provide
health care services and wellness services in accordance with
the procedure established by applicable law.
1.1.43. The Healthcare Service shall mean a service, aid and/or
product (e.g., Pharmaceuticals, Medical Aids) set forth in the
Contract and provided to the Insured in a Healthcare Institution,
the purpose of which is to diagnose, nurse and treat diseases
and Health Disorders, prevent them, help to recover and
strengthen health, as well as to provide services and supply
materials required for the restoration or improvement of health.
1.1.44. Wellness Services shall mean the services set forth in the
Contract and provided to the Insured, the purpose of which is to
prevent diseases, improve the immunity, resistance to diseases
and/or Injuries of the Insured.
1.1.45. Health Disorder shall mean health or physiological
condition of the Insured, which requires examination,
treatment and/or other services set forth in the Contract.
1.1.46. The Medical Speciaist shall mean a health care
professional who has a valid license for a specific activity that
has been issued in accordance with the procedure meeting
applicable requirements.
1.1.47. Wellness/Rehabilitation Aids shall mean the aids
intended for rehabilitation, kinesitherapy, physical exercises
and procedures, including massage tables and/or chairs,
exercise machines, massagers, exercise mats and balls, weights,
orthopedic/ergonomic pillows and mattresses and rubber
bands.
1.1.48. Pharmaceuticals shall mean the pharmaceuticals
registered by competent authorities in the Republic of
Lithuania or the European Community, which have an ATC
(anatomical-therapeutic-chemical) code and are purchased in
Pharmacies.
1.1.49. The Pharmacy shall mean a legal entity or the division
thereof which is licensed to engage in pharmaceutical
activities, including the remote sale of pharmaceuticals.
1.1.50. International Sanction shall mean an economic or
financial sanction, embargo or any other similar sanction,
prohibition or restrictive measure imposed by decisions of the
United Nations or by legal acts of the European Union or the
Republic of Lithuania or the United States (including sanctions
administered or applied by the Office of Foreign Assets Control
of the U.S. Treasury Department), the United Kingdom or any
other country.
1.1.51. The Injury shall mean an accident that occurs against the
will of the Insured as a result of any abrupt, inadvertent,
unexpected external forces and results in bodily injury and/or
impairment of organ functions of the Insured.
1.2. References in the Contract to any document shall be
construed as references to any amendments, supplements
thereto or new versions.
2. GENERAL
GENERAL
2.1. Contract Terms and Conditions
2.1.1. The Insurance Rules determine the general terms and
conditions of the Contract They shall be applicable to all
Contracts that enter into force from the date of entry into force
of the Insurance Rules, unless otherwise provided in the
Contract. The Insurance Certificate (Policy) specifies and
approves the specific terms and conditions of the Contract,
including, but not limited to the Insurance Coverage, additional
conditions or those agreed individually between the parties
2.1.2. These Insurance Rules are not subject to the Insurer's
General Insurance Terms and Conditions.
2.2. Contract validity, interpretation and application
2.2.1. The Contract shall enter into force on the date of its signing,
unless it provides for a different date or procedure for entry into
force.
2.2.2. The Contract shall expire:
2.2.2.1. Upon expiry of the Insurance Period set forth in the
Contract;
2.2.2.2. Upon payment of all Insurance Indemnities;
2.2.2.3. Upon the dissolution of the Policyholder as a legal entity
unless there is no successor of its rights and obligations;
2.2.2.4. Upon termination of the Contract under procedure and
in cases laid down in the Contract or applicable law;
2.2.2.5. If the Insured dies;
2.2.2.6. On other grounds for expiry of the obligations laid down
by the applicable law.
2.2.3. If the Contract is concluded for a group of Insured Persons,
then, on the grounds provided for in clause 2.2.2 of the
Insurance Rules, the Contract may expire only in respect of a
specific Insured (e.g., in respect of the deceased Insured or in
respect of the Insured to whom all Insurance Indemnities have
been paid). However, this does not change the validity of the
Contract for other Insured.
2.2.4. In cases of existence of inconsistencies and/or
contradictions among separate parts of the Contract, the
Contract terms and conditions shall be determined and
interpreted according to the rule, which grants the precedence
to the terms and conditions stated in the antecedent document
against the stated in the subsequent document in the following
order: the Insurance Certificate (Policy), including documents
establishing special or individually agreed conditions between
the parties, the Offer (if submitted in writing) and Insurance
Rules.
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3. CLIENT IDENTIFICATION
3.1. The Client or his representative shall submit to the Insurer
the following data and documents, required by the Insurer and
having the form and content acceptable by the latter and
conforming the identity, registration data, authorizations of the
Client, other documents or data, related to the Contract
conclusion, performance or termination and compliance with
the requirements of applicable law.
3.2. The Insurer shall be entitled to not accept a proxy document
that does not explicitly and unambiguously set forth the proxy
rights or authorizations regarding conclusion, performance of
respective transactions, or commission of actions and etc.
3.3. The Client shall inform the Insurer on changes, invalidity of
any identification and/or proxy documents submitted to the
Insurer or expiry thereof on other basis within a reasonable
term. Otherwise, the Insurer shall be entitled to refer to
documents and data submitted to it for such purpose at the
latest.
3.4. The Insurer shall have the right to establish the procedure
for identity verification for submission and receipt of notices
depending on their nature as well as requirements for signing
or approving specific documents. In case of any doubts, the
Client must confirm the Client's will, identity, the date of the
document and/or authenticity of the signature in the manner
requested by the Insurer and acceptable to it. The Insurer shall
have the right to refrain from performing any action or suspend
the performance of its obligations under the Contract until the
above doubts are resolved and the required confirmations are
obtained.
4. INSURANCE CONTRACT CONCLUSION
4.1. The Contract shall be concluded provided that the
Policyholder accepts the Insurer's Offer to conclude the
Contract under the conditions specified therein. In any case, the
Policyholder shall itself choose the desired nature and scope of
the Insurance Coverage and the Insured Risk from the possible
versions of the Health Insurance Program and/or other
conditions agreed between the parties.
4.2. When concluding the Contract, the Policyholder (the
Insured provided that the Policyholder gives its consent thereto
and provides such an opportunity) may choose the following
Health Insurance Programs:
4.2.1. Ambulatory treatment and diagnostics;
4.2.2. Stationary treatment;
4.2.3. Prenatanal care, childbirth and postnatanal
care;
4.2.4. Dental services;
4.2.5. Pharmaceuticals and medical aids;
4.2.6. Vitamins, over-the-counter pharmaceuticals;
4.2.7. Optics;
4.2.8. Preventive and periodical health examinations
and tests:
4.2.9. Vaccinations;
4.2.10. Rehabilitation treatment;
4.2.11. Medical services;
4.2.12. Wellness services;
4.2.13. All services;
4.2.14. Critical diseases.
4.3. The Insurer's Offer shall be valid for 30 (thirty) days from the
date of its issuance, unless otherwise specified in the Offer.
4.4. Before concluding the Contract and/or during the term of
validity of the Contract, the Insurer shall have the right to
request information and data relevant to the assessment of the
Insured Risk, the Client's needs and requirements, possibilities
to fulfil obligations under the Contract and/or to comply with
the requirements of applicable law. The Client shall provide
complete, true and full information requested by the Insurer.
4.5. When assessing the Insured Risk, the Insurer shall have the
right to take into consideration the age, health condition and
other circumstances relevant to the Insured Risk.
4.6. The Contract shall be deemed to be concluded, all its terms
and conditions shall be agreed and approved by the parties
from the date of signing the Insurance Certificate (Policy),
unless the Contract provides for otherwise.
4.7. Once the Contract is concluded, the Insurer shall issue the
Cards to the Policyholder, and the Policyholder shall transfer
them to each Insured personally and ensure the confidentiality
of personal data, unless the parties agree otherwise.
4.8. The Policyholder shall inform the Insured (s) about the
conclusion, amendment and/or termination of the Contract
and properly familiarize with the terms and conditions of the
Contract, as well as ensure that the Insured (s) duly and timely
fulfils all the terms and conditions of the Contract, including the
submission of consents, confirmations, data or other
information requested by the Insurer.
5. HEALTH EXAMINATION
5.1. When concluding or amending the Contract; investigating a
possible Insured Event; in case of reasonable doubts about the
accuracy, reasonability, authenticity or completeness of the
information provided by the Client; if new circumstances or
facts related to the health of the Insured are revealed; or in other
events when the Insurer needs additional information, the
Insurer shall have the right to request a medical examination of
the Insured in a medical institution acceptable to and indicated
by the Insurer and/or the conclusions of the relevant medical
expert. The Insurer shall pay the costs of the Insured's health
examination if such examination is requested by the Insurer
before concluding the Contract. If the Insured refuses to do so
while investigating a possible Insured Event, the Insurer shall
have the right to reduce the payable Insurance Benefit or refuse
to pay it.
CONTRACT CONCLUSION
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5.2. If necessary, the Insurer shall have the right to check the
health condition or medical history of the Insured by making
appropriate inquiries to the Partners, other medical institutions
before concluding the Contract and during the entire term of
the Contract, for example, when investigating the Insurable
Event and etc. If the Insurer does not receive the above
information, the Policyholder or the Insured shall provide the
Insurer with the relevant data and/or documents by themselves.
6. INSURANCE PREMIUMS
6.1. The insurance Premium shall be determined by the
agreement between the Policyholder and the Insurer for the
entire Insurance Period. The Insurance Premium depends on
the Insurance Programs chosen by the Policyholder, the Sum
Insured, Insured Risk Assessment and other terms and
conditions of the Contract.
6.2. Insurance Premiums shall be paid in accordance with the
procedure and terms specified in the Insurance Certificate
(Policy). In case of delay in payment of the Insurance Premium
or the portion thereof, the late payment penalty provided for in
the Contract may be charged, as well as the validity of the
Insurance Coverage may be suspended or the Contract may be
terminated at the choice of the Insurer.
6.3. The Insurance Premium shall be paid to the Insurer by a
payment order or in any other non-cash manner acceptable to
the Insurer in the currency of the Contract. If the Insurance
Premium is paid in a currency other than the Contract currency,
the Insurer shall have the right not to accept it or to deduct
currency conversion and related costs from it.
6.4. When paying the Insurance Premium, the payment
documents shall indicate the data required by the Insurer to
properly identify the Insurance Premium and assign it to the
Contract. The Policyholder shall be responsible for the payment
of Insurance Premiums in accordance with the terms of the
Contract.
6.5. The date of payment of the Insurance Premium shall be
considered the date when the Insurer assigns the Insurance
Premium credited to its bank account to the respective
Contract. If the Insurer is unable to determine for which
Contract the Insurance Premium has been paid, it shall be
deemed unpaid until the Insurer identifies under which
Contract the Insurance Premium has been paid and assigns it to
the respective Contract.
7. INSURANCE OBJECT
WHAT WE INSURE AGAINST
7.1. Insurance object is the property interest of the Insured related to the health of the Insured and health care.
8. INSURANCE COVERAGE
8.1. The Policyholder is free to choose all or some Insurance
Programs offered by the Insurer, their scope, other terms and
conditions of the Contract. The Insured Risk assumed by the
Insurer under the Contract will depend on this. By the
agreement of the Policyholder and the Insurer, the Insured shall
be provided with the Insurance Coverage the scope and limits
of which are specified in the Insurance Certificate (Policy),
annexes thereto, individual terms and conditions and the
Insurance Rules.
8.2. Unless otherwise provided in the Contract, the Insurance
Coverage under the Contract shall be valid only in the Republic
of Lithuania, which means that Insurance Indemnities may be
paid only for Health Care Services provided in the territory of
Lithuania or other Insurable Events that occur in the territory of
Lithuania.
8.3. The Insurance Coverage under the Contract shall take effect
at 0:00 hours on the first day of the Insurance Period (unless the
Contract stipulates that its entry into force depends on the date
of payment of the first Insurance Premium or part thereof) and
shall be valid until 24:00 hours on the last day of the Insurance
Period or the day of termination or expiry of the Contract on
other grounds.
8.4. The Insurer shall have the right to establish that the
Insurance Coverage for the Insured comes into force provided
only that the Card is activated and/or the consents,
confirmations or other information, data or documents
requested by the Insurer are submitted.
8.5. Insurance Coverage may be suspended in accordance with
the procedure and conditions provided for in the Contract. If the
Insurable Event occurs during the suspension of the Insurance
Coverage, the Insurer shall not pay Insurance Indemnity.
9. INSURABLE EVENTS
9.1. For an event to be recognized as Insurable on, it must meet
the following conditions:
9.1.1. The event must be provided for in the Contract and comply
with the requirements and conditions set out therein, including
the concepts and criteria provided for in each Health Insurance
Program, which are defined in Annex No. 1 to the Insurance
Rules, the parties may also agree on individual or special
conditions;
9.1.2. With due consideration of the date of the Insurable Event,
the event may occur after the entry into force of the Contract,
during the Insurance Period, during the validity of the Insurance
Coverage and within its limits;
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9.1.3. if the event relates to the health care services provided in a
health care institution, the medical specialist providing them
shall act within the limits of the rights and competence
established by applicable law and have a valid medical practice
license issued by a competent state authority;
9.1.4. The event must exclusively and directly concern the
Insured, and the costs (if applicable) related to the event must
be borne by the Insured himself.
9.1.5. The event must be based on appropriate evidence and
documents the form and content of which is acceptable to the
Insurer.
9.2. Insurance indemnities shall be allocated for the payment or
reimbursement of expenses incurred due to the Insurable
Events provided for in the Contract and shall not exceed the
Sum Insured specified in the Contract.
9.3. If the Insurable Event incurs continuous or partial expenses
(for example, goods or aids are purchased by paying for them in
instalments), then, depending on the date of the Insurable
Event, in accordance with the procedure set in clause 1.1.16 of the
Insurance Rules, in any case, only the expenses actually incurred
during the Insurance Period may be reimbursed.
10. SUM INSURED
10.1. The Sum Insured shall be determined for each Health
Insurance Program, for each Insured individually, unless
otherwise provided in the Contract.
10.2. Upon payment of any Insurance Indemnity under the
Contract, the respective Sum Insured shall be reduced by the
amount of this Insurance Indemnity and the Sum Insured
cannot be recovered.
11. NON-PAYMENT OR REDUCTION OF INSURANCE INDEMNITIES
WHAT WE DO NOT INSURE AGAINST
11.1. The Insurance Indemnities shall not be paid:
11.1.1. For Uninsurable Events which may be the same for all
Health Insurance Programs or detailed separately for each of
them;
11.1.2. For non-reimbursable expenses;
11.1.3. When the Insurable Event occurs during the period when
the Insurance Coverage was suspended or was invalid on other
grounds;
11.1.4. When the Insurer is released from paying the Insurance
Indemnity in the cases specified in the Contract or applicable
law.
11.2. The Insurer shall have the right to reduce the Insurance
Indemnity or refuse to pay it in the following cases:
11.2.1. The obligations concerning the notification of the Insured
Event as provided for in the Contract or by applicable law are
breached or fulfilled improperly;
11.2.2. The date, circumstances and/or consequences of the
Insurable Event, expenses incurred, other relevant data cannot
be fully and accurately determined on the basis of the data or
documents submitted by the person claiming the Insurance
Indemnity or this person does not allow or hinders the
investigation of the Insurable Event and obtaining the
information required;
11.2.3. The Insurer was provided with fraudulent, erroneous,
deliberately false or incomplete information or documents, or
information that could affect the conclusion of the Contract, its
terms or the Insured Risk was not disclosed to the Insurer, or
other important information about the Health Care Services
provided, the Health Disorder or other circumstances relevant
to investigation or assessment of the Insurable Event was
hidden;
11.2.4. The Contract was used for illegal purposes, including – for
the purpose of obtaining profit or fraudulent receipt of
Insurance Indemnity;
11.2.5. If the Insured is insured for the same risk under several
insurance contracts concluded with different insurers (double
insurance), then in case of the Insurable Event the Insurance
Indemnity payable by the Insurer shall be reduced in proportion
to the Insurer's share of liability. In any case, the total amount
paid under all insurance contracts may not exceed the costs
incurred by the Insured;
11.2.6. If the Insured refuses to undergo a medical examination
when required by the Insurer in accordance with the procedure
and conditions provided for in the Insurance Rules;
11.2.7. If the Policyholder or the Insured fails to perform the
Contract or performs it improperly, which results in increase of
the probability of the occurrence of the Insurable Event or
increase of the loss/expenses to any extent;
11.2.8. In other cases and according to the procedure provided
for and prescribed by the Contract and/or applicable law.
12. UNINSURABLE EVENTS
12.1. According to the Contract, any Health Insurance Program
(unless otherwise stated in its description) shall treat the Health
Disorders, as well as Health Care Services provided with regard
to these disorders and other related diseases or conditions,
other services or goods provided for in the Contract and any
costs incurred, as Uninsurable Events if they are:
12.1.1. Related to a war and the state of emergency;
12.1.2. Related to Radiation, the use of chemical or biological
substances for unpeaceful purposes;
12.1.3. Related to pandemics, as well as natural disasters, mass
disasters caused by natural disasters;
7
12.1.4. Caused by the Insured's intentional injury or attempted
suicide;
12.1.5. Arising from the unauthorized termination or change of
the treatment prescribed by a doctor;
12.1.6. Incurred due to a planned or committed criminal act by
the Insured or due to another act or omission contrary to law,
morality and/or public order;
12.1.7. Caused by the intentional act or omission of the
Policyholder or the Insured;
12.1.8. Caused or aggravated by the use of alcohol, narcotic, toxic
or other dangerous substances, intoxication or other effects
thereof.
13. NOTICE ON THE INSURABLE EVENT
13.1. The duty to inform of the Insurable Event falls on:
13.1.1. The Insured, if the Health Care Services or other
services/goods provided for in the Contract are provided to the
Insured by the Partner or any entity other than the Partner
provided that the Insured does not use the Card for paying for
them. In this case, the notice shall be submitted to the Insurer in
writing or via the E-Help system.
13.1.2. The Partner if it provides the Insured with Health Care
Services or other services/goods provided for in the Contract
and the Insured uses the Card to pay for them in accordance
with the procedure set by the Partner; In this case, the notice
shall be submitted in accordance with the procedure provided
for in the cooperation agreement between the Insurer and the
Partner.
13.2. The notice on the Insurable Event must be submitted to the
Insurer immediately upon learning of it, but in any case not later
than within 30 (thirty) calendar days from the date of its
occurrence.
13.3. Delayed submission of the notice on the Insurable Event
shall be considered a material breach of the Contract, due to
which the Insurer shall have the right to refuse to pay the
Insurance Indemnity or reduce it.
14. INVESTIGATION OF THE INSURABLE EVENT
14.1. Upon receipt of the Notice on the possible Insurable Event,
the Insurer shall carry out an investigation to identify the fact,
causes, circumstances and consequences of the event and to
determine the amount of the Insurance Indemnity.
14.2. The Policyholder, the Insured and the Beneficiary shall
cooperate in investigation of circumstances of the event which
can be acknowledged as the Insurable Event and guarantee
that the Insurer could legally familiarize with the entire event-
related information.
14.3. A person claiming to the Insurance Indemnity shall submit
to the Insurer documents the form and wording of which is
acceptable for the Insurer, which would acknowledge the
possible Insurable Event and the circumstances and
consequences thereof, as indicated in clause 15.1 or individually
requested by the Insurer, and all other relative documents and
information that have an effect on the assessment of the event
or determination of the amount of the Insurance Indemnity.
14.4. The expenses related to the receipt and submission of
supporting documents shall be borne by the person claiming
for the Insurance Indemnity.
14.5. During investigation, the Insurer may request other natural
persons and legal entities, competent institutions or
organizations to submit information, explanations, documents
and etc.
14.6. Upon receiving all required information, data, documents
or other proofs, the Insurer shall valuate the circumstances of
the event, the compliance thereof with the requirements of the
Contract and shall make a decision on payment or non-
payment of the Insurance Indemnity, the calculation of the
Insurance Indemnity.
14.7. If during the investigation of the possible Insurable Event
or, to justify the decision of the Insurer, the Insurer requires
additional knowledge or an expert opinion with regard to any
circumstances, facts or the assessment thereof, it shall be
entitled to receive consultations, conclusions or opinions of
professionals and experts in the specific field of knowledge. The
expenses incidental to the provision of such services shall be
borne by the Insurer.
14.8. If any disputes regarding assessment or decision of the
Insurer arise between the parties to the Contract, the Insurer
and the Policyholder or the Insured may agree upon
investigation or assessment of the Insurable Event anew which
would be performed by an independent expert (experts). The
associated costs shall be borne by the initiator of the
investigation/assessment, unless the parties agree otherwise. In
this event, experts may not be the persons whose participation
could cause the conflict of interests. Each party shall in writing
provide an independent expert (experts) with all facts, data and
documents which may have any influence on fair and
reasonable assessment of the health condition of the Insured
and/or other circumstances of the event and/or the amount of
damage. Independent experts shall present their findings to all
parties at the same time. Either party shall be entitled to
disagree with the finding of the independent experts and apply
to competent institutions and/or court for a resolution of the
dispute in accordance with the procedure prescribed by
applicable law
UPON OCCURRENCE OF AN INSURABLE EVENT
8
15. CLAIM FOR THE INSURANCE INDEMNITY AND OTHER DOCUMENTS
15.1. The Insurable Event shall be investigated and the Insurance
indemnity shall be paid after submission to the Insurer of the
following documents the wording and form of which is
acceptable to the Insurer:
15.1.1. The claim for payment of the Insurance Indemnity in the
form set by the Insurer;
15.1.2. A document confirming the purchase of services and/or
goods (an invoice) and document confirming payment (a cash
receipt, a cash register receipt, a sales receipt, bank transfer
statement, etc.);
15.1.3. Excerpts from medical documents or copies thereof,
which reasonably indicate:
– The fact of the Insurable Event, the date and circumstances of
the Insurable Event (e.g. , a health disorder and the
circumstances of its occurrence, course of development;
objective condition of the Insured; prescribed examinations
confirming the Health Disorder; results of performed tests, etc.);
– The code of a disease;
– Other information relevant to the proper and complete
investigation of the Insurable Event or requested by the Insurer;
15.1.4. The prescription of a pharmaceutical or a medical aid, or
other medical document or the copy thereof . For
reimbursement from the Pharmaceuticals and Medical Aids
sub-type of the Health Insurance Program, a prescription or
other medical document is mandatory in all cases, regardless of
whether a Pharmaceutical or a Medical Aid can be prescribed
and purchased only with a prescription or over the counter. If a
Pharmaceutical is purchased with an electronic prescription,
the Insured shall:
– Make sure that the payment document contains information
on the purchase of the relevant Pharmaceutical by an electronic
prescription, or
– Provide the copy of such an electronic prescription or other
medical document;
15.1.5. Copies of the individual activity certificate or business
certificate of the person who provided the services (if services
were provided by a person who is engaged in this business);
15.1.6. Consents or other documents or data required under the
relevant Health Insurance Program;
15.1.7. Other documents, reasonably requested by the Insurer,
proving the Insurable Event and its circumstances.
16. INSURANCE INDEMNITY
16.1. Once the Event is recognized as insurable one, the Insurer
shall pay the Insurance Indemnity by reducing it by the
Franchise amount and applying other restrictions for the
calculation and/or payment of the Insurance Indemnity as
provided for in the Contract.
16.2. The Insurance Indemnity shall be paid:
16.2.1. To the Partner in accordance with the procedure provided
for in the Cooperation Agreement with the Partner, if the
Partner provides the Insured with Health Care Services or other
services/goods provided for in the Contract and the Insured
pays for them by the Card in accordance with the procedure set
by the Partner;
16.2.2. To the Insured, if the Health Care Services or other
services/goods provided for in the Contract are provided to the
Insured by the Partner or any entity other than the Partner, but
the Insured does not use the Card for paying for them and pays
by himself.
16.2.3. In the case provided for in clause 14.2.1.1 of Addendum No.
1 to the Insurance Rules – to the Insured.
16.3. The Insurance Indemnity shall be paid no later than within
30 (thirty) days from the date of receipt of all the information
and/or documents in a form and wording acceptable to and
requested by the Insurer, which are relevant to determination of
the fact and circumstances and consequences of the Insurable
Event and the amount of the Insurance Indemnity.
16.4. If the event is recognized as uninsurable one, the Insurer,
within 30 (thirty) days from the date of receipt of all information
relevant to determining the fact, circumstances and
consequences of the event, shall inform about such decision
and/or refusal to pay the Insurance Indemnity.
16.5. The Beneficiary shall immediately, but in any case not later
than within 10 (ten) business days from the date of receipt of the
respective Insurer's request, return to the Insurer the
unreasonably paid Insurance Indemnities requested by the
Insurer, including overpayments resulting from exceeding the
Sums Insured.
16.6. The Insurer shall have the right to demand that a person
claiming the Insurance Indemnity should open a bank account
in his name with a bank or other credit institution operating in
the Republic of Lithuania, to which the Insurance Indemnity
could be transferred.
16.7. The Insurer shall have the right to deduct from the payable
Insurance Indemnity the fees charged for a payment order (for
example, currency conversion costs, fees for submission or
execution of the payment order, etc.).
INSURANCE INDEMNITIES
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17. RIGHTS AND DUTIES OF THE PARTIES
17.1. Duties of the Policyholder:
17.1.1. To deliver to the Insurer or ensure that the Insured delivers
detailed, complete and true information required for the
conclusion and performance of the Contract;
17.1.2. Before entering into the Contract, to properly and
diligently review the terms and conditions of the Contract,
including the Insurance Rules;
17.1.3. To inform the Insured about the Contract concluded,
amendments thereto or termination thereof, to properly and in
detail familiarize the Insured with the terms and conditions of
the Contract, including the Insurance Rules;
17.1.4. To pay the Insurance Premiums in accordance with the
procedure and terms set in the Contract;
17.1.5. Being the main contact person of the Insurer, to
ensure communication and cooperation with the Insured
persons both during the conclusion and performance of the
Contract, as well as when transmitting to the Insured persons
the information related to the Contract, obtaining the
necessary data or consents from the Insured persons, etc .;
17.1.6. To inform about the existing insurance contracts
concluded with other insurers on the same Insured Risks that
are included in the Contract concluded with the Insurer or,
immediately within a reasonable time, to inform of new ones;
17.1.7. To take all possible actions to avoid or reduce the Insured
Risk and follow the Insurer's instructions, if such are given to the
Policyholder;
17.1.8. To immediately notify to Insurer increase of the Insured
Risk or other circumstances that have a material impact on the
terms and conditions of the Contract;
17.1.9. To provide the Insurer or its authorized representative with
conditions for checking whether the Policyholder and the
Insured follow the terms and conditions of the Contract;
17.1.10. Immediately, within a reasonable time f rom the
occurrence or identification of relevant circumstances or facts,
to inform the Insurer of any changes in the data, facts or
circumstances provided to the Insurer at the time of concluding
and/or amending the Contract, including but not limited to
identification data (personal identification data, taxpayer data,
data on the registration or legal status of a legal entity,
information about the representative and his authorizations,
etc.) and contact data (an address, a telephone number or an e-
mail address);
17.1.11. Immediately, but in any case not later than within 1 (one)
business day, to notify about termination of employment
relationship with the Insured, to terminate the validity of the
Insurance Coverage for such Insured and assume any losses
incurred due to improper performance of this obligation. In this
case, the Insurer shall terminate the validity of the Insurance
Coverage for the Insured no later than on the next business day
after receiving the relevant notice;
17.1.12. Properly and in a timely manner to perform all other
duties and to follow all other conditions and requirements
provided for in the Contract or by applicable law.
17.2. Duties of the Insured:
17.2.1. To diligently and thoroughly look through the terms and
conditions of the Contract, including the Insurance Rules, and
to follow them carefully and properly;
17.2.2. To provide the Insurer with the data, documents,
consents, confirmations or other information requested by the
Insurer and required for the conclusion and proper
performance of the Contract, assessment of the Insured Risk or
investigation of the Insurable Event;
17.2.3. On his own initiative and under his responsibility, in
advance to negotiate and obtain the Insurer's consents or
approvals for the provision of specific Health Care Services, if
and when such are mandatory in accordance with the terms
and conditions of the relevant Health Insurance Program;
17.2.4. To protect the Card from unauthorized use, damage or
loss and be liable for any damage resulting from improper
performance of this obligation;
17.2.5. Immediately, but in any case not later than within 1 (one)
business day from the occurrence of the respective event, to
inform the Insurer about the illegal use, loss, theft or any other
loss of the Card;
17.2.6. When and as required by the terms and conditions of the
Contract, to inform the Insurer of the Insurable Event and
provide detailed and true information about the causes and
circumstances of the Insurable Event and all related data,
information and documents specified in the Contract;
17.2.7. To keep documents confirming the Insurable Event for at
least 1 (one) year from the payment of the Insurance Indemnity,
if only copies thereof have been submitted to the Insurer, and to
deliver them upon the Insurer's request;
17.2.8. At the request of the Insurer, in the cases and according to
the procedure provided for in the Contract, to undergo a health
examination in the institution indicated by the Insurer;
17.2.9. At the request of the Insurer, in accordance with the
procedure and terms provided for in the Contract, to refund to
the Insurer the unreasonably paid Insurance Indemnities,
including overpayments resulting from exceeding the Sums
Insured;
17.2.10. Immediately, within a reasonable time f rom the
occurrence or identification of relevant circumstances or facts,
to inform the Insurer of any changes in data, facts or
circumstances provided to the Insurer, including but not
limited to identification data (personal identity data, etc.) and
contact details (an address, a telephone number or an e-mail
address);
17.2.11. Properly and in a timely manner to perform all other
duties and to follow all other conditions and requirements
provided for in the Contract or by applicable law.
OTHER TERMS AND REQUIREMENTS
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17.3. Duties of the Insurer
17.3.1. To provide information about the Insurer, insurance
services, dispute resolution procedures and essential
information in the cases and in accordance with the procedure
established by applicable law and the Contract;
17.3.2. Upon concluding the Contract, to issue the Insurance
Certificate (Policy) to the Policyholder and the Cards assigned to
each Insured or other document confirming the provision of
Insurance Coverage under the Contract;
17.3.3. To provide information and advice on Health Insurance
Programs;
17.3.4. Upon the occurrence of the Insurable Event, to pay the
Insurance Indemnities under the terms and conditions
provided for in the Contract;
17.3.5. Not to disclose confidential information about the
Policyholder and/or the Insured received during the
performance of the Contract unless otherwise provided for by
the Contract and applicable law;
17.3.6. To issue to the Policyholder the copies of the Contract, if
after concluding the Contract the Policyholder applies to the
Insurer with such a request;
17.3.7. Properly and in a timely manner to perform all other
duties and to follow all other conditions and requirements
provided for in the Contract or by applicable law.
17.4. The Insurer shall have the right to establish and change the
list of Partners, the conditions of cooperation with the Partner,
requirements or restrictions regarding the provision of all or
specific Health Care Services to Clients. In any case, the Partners
shall not be authorized to interpret the terms of the Contract or
to perform the obligations of the Insurer or the Client under the
Contract.
17.5. Other rights of the parties are provided for in the Contract
and by applicable law.
18. AMENDMENT OF THE INSURANCE CONTRACT
18.1. General provisions
18.1.1. The terms and conditions of the Contract may only be
amended or supplemented by a written agreement between
the Policyholder and the Insurer unless other clauses of the
Contract or applicable law provides otherwise.
18.1.2. Before amending the terms of the Contract, the Insurer
shall have the right to request additional information about the
Client, the Insured's medical examination and etc.
18.2. Amendments to the Contract upon the initiative of the
Policyholder
18.2.1. The Policyholder shall give to the Insurer a written notice
on the desired amendment to the terms and conditions of the
Contract not later than 30 (thirty) days prior to the effective date
of the desired amendment.
18.2.2. Amendments to the list of Insured persons (termination
of the Contract with respect to some Insured persons and/or
inclusion of new Insured persons) shall be made with the
consent of the Insurer and on terms and conditions agreed by
both parties.
18.3. Amendments to the Contract upon the initiative of the
Insurer
18.3.1. The right of the Insurer to amend the terms and
conditions of the Contract is provided for in the Contract and by
applicable law.
19. SUSPENSION AND RENEWAL OF INSURANCE COVERAGE
19.1. If the Policyholder fails to pay any Premium in full or in part
within the time specified in the Contract, the Insurer shall have
the right to notify this to the Policyholder in writing or in any
other notification manner and indicate that, if the Policyholder
fails to pay the Premium in full or in part within 30 (thirty) days
from the date of dispatch of the notice, the Insurance Coverage
under the Contract will be suspended and resumed only after
the Policyholder pays all the Insurance Premiums due under
the Contract.
19.2. If the suspension of the Insurance Coverage due to non-
payment of the Insurance Premium lasts for more than 1 (one)
month, the Insurer shall have the right to unilaterally terminate
the Contract by giving to the Policyholder a written notice on
termination of the Contract.
19.3. In case of circumstances when the Card is used by an
unauthorized person or the Card is lost, the Insurer shall have
the right to temporarily (until the violation is eliminated, the said
circumstances are investigated or the proper discharge of
obligations under the Contract is ensured otherwise, etc.)
suspend the validity of Insurance Coverage to the respective
Insured.
20. CONTRACT TERMINATION
20.1. Procedure for termination or expiration of the Contract
20.1.1. The Contract may be terminated upon a separate written
agreement of the parties, written request of the Policyholder,
court judgment or the Insurer's notice in cases and under
procedure laid down in the Contract and/or the applicable law.
20.1.2. Upon termination or premature expiry of the Contract
before the end of the Insurance Period on other grounds, the
Insurer shall always preserve the right to the Insurance
Premiums due but not paid before the respective termination
or expiration of the Contract, as well as to the amounts that are
formed as the difference between the Insurance Indemnities
actually paid and the Insurance Premiums actually received
(when the Contract provides for periodic payment of Insurance
Premiums). The Policyholder must cover them no later than
before the last day of the Contract validity.
20.1.3. Unless otherwise provided in the Contract, as well as in
the Insurance Rules or applicable law, upon termination or
expiry of the Contract before the end of the Insurance Period on
other grounds, the Insurance Premiums paid shall not be
refunded to the Policyholder.
11
20.2. Contract termination upon the initiative of the
Policyholder
20.2.1. The Policyholder shall be entitled to terminate the
Contract at any time during the Contract validity term, by giving
to the Insurer a written notice no later than 30 (thirty) days prior
to the planned date of the Contract termination.
20.2.2. If the Contract is terminated upon the initiative of the
Policyholder due to the fault of the Insurer, the Policyholder
shall be reimbursed the share of the Insurance Premiums paid
by the Policyholder, which exceeds the amount of the Insurance
Indemnities already paid and planned to be paid under the
Contract.
20.2.3. If the Contract is terminated upon the initiative of the
Policyholder through no fault of the Insurer, the Policyholder
shall be reimbursed the Insurance Premiums actually paid for
the remaining Insurance Period from the date of termination of
the Contract less the costs of concluding and performing the
Contract and the Insurance Indemnities paid and planned to be
paid under the Contract. The amount payable shall be
calculated 30 (thirty) days after the date of termination of the
respective Contract and shall be paid within following 30 (thirty)
days.
20.3. Contract termination upon the initiative of the Insurer
20.3.1. The Insurer shall have the right to terminate the Contract
unilaterally, without recourse to court, by giving prior 30 (thirty)
calendar days written notice before the expected date of
termination of the Contract in case of the following material
breaches of the Contract:
20.3.1.1. During the conclusion or validity of the Contract, the
Policyholder and/or the Insured violates or improperly performs
the established by applicable law duty to disclose full, complete,
true and detailed information on circumstances affecting the
Insured Risk assessment, the probability of the Insurable Event
or its possible consequences and the terms and conditions of
the Contract;
20.3.1.2. The Policyholder and/or the Insured fails to perform or
improperly performs other obligations provided for in the
Contract and, upon the Insurer's request, does not remedy the
situation within the reasonable term set by the Insurer, which in
any case may not be shorter than 14 (fourteen) calendar days;
20.3.1.3. There are other grounds for termination of the Contract
provided for in the Contract or applicable law.
20.3.2. The Insurer shall have the right to terminate the Contract
unilaterally, without recourse to court, by giving a written notice
with an immediate effect (unless such a notice specifies other
terms of entry into force) in case of the following material
breaches of the Contract:
20.3.2.1. if the Policyholder delays payment of the Insurance
Premium in full or in part within the time specified in the
Contract and upon the receipt of the Insurer's notice with a
request to cover the indebtedness within 30 (thirty) days from
the dispatch of the notice, the Policyholder fails to effect all
overdue payments within the specified term;
20.3.2.2. On the grounds and in accordance with the procedure
provided for in clause 19.2 of the Insurance Rules;
20.3.2.3. The Policyholder does not respond to the submitted
proposal to amend the terms and conditions of the Contract in
accordance with the procedure established by applicable law or
the Contract or refuses to do so;
20.3.2.4. There are other grounds for termination of the Contract
provided for in the Contract or applicable law.
20.3.3. When the Contract is terminated at the request of the
Insurer due to the fact that the Policyholder violates the terms
and conditions of the Contract, no Insurance Premiums shall be
refunded to the Policyholder.
20.4. Contract Termination upon Agreement of the Parties
20.4.1. The Insurer and the Policyholder may agree under a
separate written agreement on other conditions and procedure
of the Contract termination.
21. TRANSFER OF CONTRACTUAL RIGHTS AND OBLIGATIONS
21.1. Transfer of the Insurer's contractual rights and obligations
21.1.1. The Insurer shall be entitled to transfer the contractual
rights and obligations to other insurer or insurers upon
notifying such an intention and receiving a permit from a
competent supervisory institution in events and under the
procedure laid down by applicable law.
21.1.2. In the cases specified in the applicable law, the Insurer
shall publish the intention to transfer its contractual rights and
obligations at least in 2 (two) national newspapers and give the
Policyholder at least 2 (two) month period to object to the
Insurer with regard to respective intentions.
21.1.3. Within the terms specified in the relevant published
notice, the Policyholder shall have the right to give to the Insurer
a written notice of objection to the intended transfer of the
Insurer's contractual rights and obligations.
21.1.4. If the Policyholder does not agree with the transfer of
contractual rights and obligations and the change of the
Insurer, it shall have the right to terminate the Contract within 1
(one) month from the date of transfer of contractual rights and
obligations. In this case, the Policyholder shall be reimbursed
the Insurance Premiums actually paid for the remaining
Insurance Period from the date of termination of the Contract
less the costs of concluding and performing the Contract and
the Insurance Indemnities paid and planned to be paid under
the Contract.
21.2. Transfer of the Policyholder's contractual rights and
obligations
21.2.1. The Policyholder shall have no right to transfer its
contractual rights and/or obligations to other persons unless
the Insurer gives its prior written consent thereto.
22. NOTICES
22.1. All notices, applications or any other expression of will
between the Insurer and the Client shall be executed in writing
or in a manner equivalent to a written form and shall be
delivered personally under signature, by regular mail, via the E-
Help system or by e-mail according to the respective contact
details indicated in the Contract or the latest contact details
delivered to the other party for such a purpose.
22.2. The Client's notices to the Insurer shall be sent according to
the Insurer's contact details and shall be deemed to be received
upon their actual receipt. The Insurer's agents shall not be
entitled to accept any notices on behalf of the Insurer.
12
22.3. Any written notice of the Insurer to the Client shall be
deemed to be received, respective notification obligation of the
party shall be deemed to be fulfilled and counting of the related
terms shall start under the below indicated order and terms:
22.3.1. On the 5th (fifth) calendar day after its sending by
registered mail;
22.3.2. On the day of sending via the E-Help System. If the notice
is sent in this manner on a weekend or public holiday or after the
expiry of working hours, it shall be deemed to be received on the
next working day;
22.3.3. When delivering personally under signature – on the day
when the receiver receives the notice delivered to him and signs
that he received it.
22.4. A party shall not be entitled to make any claims regarding
not receiving any notices or that the actions of the other party
do not comply with the Contract terms and conditions, if the
notice was sent according to the latest contact details provided
by a party.
22.5. In cases and under the procedure laid down in the Contract
and/or applicable law or in other exceptional cases, the Insurer
shall be entitled to provide notices or essential information to
the Clients publicly: in the Insurer's Client Service Divisions, on
the Insurer's website and/or via mass media. In such cases the
notices shall be deemed to be received on the date of their
publishing.
23. CONFIDENTIALITY
23.1. The Contract terms and conditions and all the information
received by the parties during performance of the Contract shall
be deemed to be confidential and not publicly announced to
any third parties without prior written consent of the concerned
contractual party, except for disclosure of respective
information to the extent required provided that the further
protection of respective information is maintained:
23.1.1. To persons who lodged legitimate claims under the
Contract;
23.1.2. When such information is public (except for cases when it
becomes public due to the breach of the Contract);
23.1.3. To persons, providing audit services and performing the
audit of the party's activities or financial statements under the
Contract;
23.1.4. To attorneys at law who provide legal services related to
the Contract, to any Party;
23.1.5. To shareholders/stakeholders and/or parent and/or
subsidiary companies of the Party;
23.1.6. To expected legal successor or property acquirer of the
Parties;
23.1.7. To persons who provide to the Insurer services related to
the Contract conclusion, performance, accounting,
administration or storage;
23.1.8. To a re-insurer if the Insured Risk is subject to re-insurance
under the Contract;
23.1.9. To competent public authorities, including courts, law
enforcement authorities, the State Tax Inspectorate and etc.;
23.1.10. To the distributor of the insurance product who
mediated in concluding the Contract;
23.1.11. In other mandatory events provided for by the Contract
and/or applicable law.
24. RESPONSIBILITY
24.1. The parties undertake to perform all obligations set out in
the Contract in a due and timely manner, in good will and
cooperation, carefully and according to the established good
practice.
24.2. For delayed performance of the contractual monetary
liabilities, the Insurer shall pay to the Policyholder the late
payment interest amounting to 0.02% of the outstanding
amount for each delayed day until due performance of
monetary liabilities.
24.3. The Insurer shall not be liable for any losses incurred due to
the Contract termination on the grounds set out in the Contract
or applicable law.
24.4. The Insurer shall not be liable for the inability to use the
Card as intended if this is caused by technical malfunctions. The
Insurer shall eliminate such malfunctions within a reasonable
time if they occur due to the fault of the Insurer.
25. APPLICABLE LAW, PROCEDURE OF DISPUTE SETTLEMENT
25.1. The Contract, its conclusion and interpretation shall be
subject to the law of the Republic of Lithuania.
25.2. All and any disputes, disagreements or claims between the
Insurer the Client, arising out of or related to the Contract shall
be settled in a way of negotiations and in accordance with the
procedure for examination and management of complaints
established by the Insurer and published on its website
www.compensalife.lt.
25.3. On request of a concerned party, disputes may be resolved
in accordance with the procedure of amicable consideration
and settlement of disputes established by applicable law. The
Bank of Lithuania was provided with a competence to solve
disputes between consumers and financial market players
arising out of provision of financial services, in accordance with
the procedure prescribed by the Bank of Lithuania. For more
information see the address of the Supervision Service of the
Bank of Lithuania and other contact details on the website:
www.lb.lt.
25.4. In any case, if the parties fail to agree, such disputes shall be
settled in competent court under the procedure prescribed by
law of the Republic of Lithuania.
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26. MISCELLANEOUS
26.1. The Insurer shall not provide the Insurance Coverage under
the Contract and shall not be liable for paying the Insurance
Indemnity or any other amount under the Contract or
complying with any other contractual obligations if these acts
could result in violation by the Insurer of any International
Sanction. The Insurer shall not be liable for any claims or
damages arising from the foregoing.
26.2. If at any time it becomes apparent that any provisions of
the Contract are or become invalid, illegal or unenforceable, this
shall in no way affect or invalidate the remaining provisions of
the Contract, and such improper provisions shall be
immediately replaced by written agreement of the parties with
new ones that have the closest meaning, objectives, content
and the same economic effect.
1. AMBULATORY TREATMENT AND DIAGNOSTICS
1.1. The Insurable Event shall be deemed to be the following
Medically Reasonable Health Care Services provided to the
Insured due to a Health Disorder (an acute disease, a chronic
disease exacerbation or an injure) and its follow-up/monitoring
in the Health Care Institution and the associated costs.
1.2. Reimbursable health care services:
1.2.1. Consultation with a family doctor or medical specialist,
including remote healthcare services; home visits by family
doctors;
1.2.2. The examinations and tests performed by a doctor, which
are periodically required at a specified (prescribed by a doctor)
time interval in order to regularly monitor the health condition
of the Insured who suffers from a specific chronic disease or
takes specific pharmaceuticals;
1 . 2 . 3 . Consultat ions of a psychiatr ist , psychiatr ist-
psychotherapist, medical psychologist, medical psychologist-
psychotherapist and psychotherapeutic treatment performed
by the said medical specialists, but not more than 12 (twelve)
visits during 1 (one) year of the Insurance Period;
1.2.4. Diagnostic tests prescribed by a doctor:
(a) Laboratory tests: clinical, biochemical cytological-
h i s to l o g i c a l , i m m u n o e n z y m a t i c , m i c ro b i o l o g i c a l -
bacteriological;
b) Instrumental tests: clinical physiological, X-ray, ultrasound,
endoscopic, computed tomography, nuclear magnetic
resonance and other imaging tests;
1.2.5. Day surgery/day stationary services;
IMPORTANT CLAUSE: these costs in full or in part shall be
reimbursed only if:
a) They are not partially reimbursed from the CHIF budget; and
b) The Insurer is informed about the necessity to provide Day
Surgery/Day Stationary services by a written notice or via e-mail
[email protected] prior to starting treatment and gives its
prior written consent thereto. The Insured is responsible for
obtaining the consent of the Insurer..
1.2.6. Ambulatory surgery services;
1.2.7. Nursing services.
1.3. Non-reimbursable expenses for:
1.3.1. Termination of pregnancy; Health Disorders that occur or
exacerbate due to termination of pregnancy for medical
indications; pregnancy diagnostics, pregnancy care; childbirth
and postnatal care; Health Disorders caused by pregnancy or
childbirth (e.g., gynecological, endocrine, breast, neurological,
urological, etc. pathologies); pregnancy prevention services;
1.3.2. Reparative and aesthetic surgical treatment; procedures
and surgery performed for cosmetological, reparative and/or
aesthetic purposes; dermatological treatment, including but
not limited to phototherapy, photodynamic therapy, pulsed
light therapy, laser aesthetic procedures (pigmentation,
redness, dilated blood vessels, acne, stretch marks, scars, etc.);
hair removal procedures; hair loss treatment; treatment with
botulinum toxin injections; laser treatment of nail fungus;
I. This Addendum defines the scope and nature of the Insurance Coverage, Insurable Events, Uninsurable Events,
other terms and requirements under the Health Insurance Programs offered by the Insurer.
II. The Addendum is the integral part of the Insurance Rules.
III. In case of controversy or incompliance in provisions of the Addendum and the Insurance Rules, the provisions and
requirements provided for in the Addendum shall prevail.
HEALTH INSURANCE RULES No. 010
Effective from 1 July 2021
Addendum No. 1 to
HEALTH INSURANCE PROGRAMS
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1.3.3. Diagnosis and treatment of AIDS, HIV, syphilis, gonorrhea,
t r ichomonias is , ch lamydia , ureaplasmosis , human
papillomavirus, herpes genital and other sexually transmitted
diseases;
1.3.4. Diagnosis and treatment of infertility/inability to get
pregnant, potency disorders; artificial insemination procedures;
1.3.5. surgical treatment of overweight/obesity;
1.3.6. Vision correction; organ transplantation surgery,
acquisition of endoprosthesis and joint replacement surgery;
1.3.7. Bone marrow transplants; hemodialysis procedures;
1.3.8. Stem cell or autologous therapy;
1.3.9. Long-term nursing/care and supportive care services;
1.3.10. Treatment of benign tumours, warts, moles;
1.3.11. Diagnosis and treatment of varicose veins in the legs;
1.3.12. Consultations of a dentist or an oral cavity and orthognatic
surgeon and examinations or treatment prescribed by them;
1.3.13. Medical accessories used for day surgery/day stationery
services, which are not reimbursed by the CHIF;
1.3.14. Alternative medicine services;
1.3.15. Sports medicine doctor's services.
2. STATIONARY TREATMENT
2.1. The Insurable Event shall be deemed to be the following
Health Care Services provided to the Insured due to his Health
Disorder, the elimination of which required therapeutic and/or
surgical profile stationary treatment in the stationary Health
Care Institution, where the Insured is provided with care for
more than 48 hours.
2.2. Reimbursable health care services:
2.2.1. If the Additional Services in Public Hospitals sub-type of the
Health Insurance Program is chosen – a single or double paid
ward in public hospitals;
2.2.2. If the Stationary Treatment in State Hospitals sub-type of
the Health Insurance Program is chosen – diagnostic services
provided to the Insured during stationary treatment in public
hospitals; purchased medical aids, Pharmaceuticals, paid
wards;
2.2.3. If the Stationary Treatment in Private Hospitals sub-type of
the Health Insurance Program is chosen – diagnostic services
provided to the Insured during stationary treatment in private
hospitals; additional services including medical aids, purchase
of Pharmaceuticals and paid wards;
2.3. Non-reimbursable expenses for:
2.3.1. 1.3.1. Termination of pregnancy; Health Disorders that occur
or exacerbate due to termination of pregnancy for medical
indications; pregnancy diagnostics, pregnancy care; childbirth
and postnatal care; Health Disorders caused by pregnancy or
childbirth (e.g., gynecological, endocrine, breast, neurological,
urological, etc. pathologies);
2.3.2. Oral, maxillofacial surgery services in the stationary Health
Care Institution;
2.3.3. Endoprosthesis acquisition and joint endoprosthesis
surgery; organ transplant surgery; bone marrow transplants;
reparative and aesthetic surgical treatment; surgical treatment
of overweight/obesity;
2 . 3 . 4 . S t a t i o n a r y r e h a b i l i t a t i o n s e r v i c e s ; m e n t a l
illness/psychiatric treatment services; long-term nursing/care
and supportive care services.
3. PRENATANAL CARE, CHILDBIRTH AND POSTNATANAL CARE
3.1. The Insurable Event shall be deemed to be the following
Health Care Services provided to the Insured due to pregnancy,
childbirth and respective complications during the prenatanal,
child-birth and postnatanal period and associated costs.
3.2. Reimbursable health care services:
3.2.1. Pregnancy diagnosis, pregnancy care services (i.e. periodic
visits; monitoring of normal or high-risk pregnancy) provided in
accordance with the requirements of applicable law on health
examinations of pregnant women;
3.2.2. Fetal diagnosis, prenatal examinations, consultation with
a geneticist doctor and prescribed treatment;
3.2.3. Diagnosis and treatment of health disorders identified
during visits of a pregnant woman; diagnosis and treatment of
health disorders that have worsened during pregnancy and
complications of pregnancy (e.g., gynecological, endocrine,
breast, neurological, urological, etc. pathologies);
3.2.4. Diagnosis and treatment of health disorders that
developed or worsened during childbirth, after giving birth
and/or breastfeeding;
3.2.5. Prenatanal, child-birth and postnatanal services provided
to the Insured, paid wards after childbirth in stationary Health
Care Institutions.
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4. DENTAL SERVICES
4.1. The Insurable Event shall be deemed to be the following
Health Care Services provided to the Insured due to a Health
Disorder in connection with the treatment and prevention of
dental, oral and maxillofacial diseases and associated costs.
4.2. Reimbursable health care services:
4.2.1. Oral care specialist consultations, oral hygiene
assessment, dental hard and soft plaque removal, fluorine
application services;
4.2.2. Consultation with a dentist or oral cavity and maxillofacial
surgeon; general dental endodontic, orthodontic, periodontal,
surgical dental diseases, orthognathic treatment services;
restoration services for dental hard tissue defects with fillings,
inlays, overlays and laminates; dental radiological examination,
analgesia, tooth extraction services, including dental day
surgery, bone replacement or artificial bone services; treatment
by teeth protectors (e.g., orthodontic, relaxation, bruxism);
4.2.3. Dental prosthetics with dentures, implants services.
4.3. Non-reimbursable expenses for:
4.3.1. Teeth whitening, including whitening by teeth protectors.
5. PHARMACEUTICALS AND MEDICAL AIDS
5.1. The Insurable Event shall be deemed to be the purchase of
Pharmaceuticals prescribed for the Insured due to the Health
Disorder according to a doctor's prescription or medical
document confirming the relevant prescription in Pharmacies,
Health Care Institutions and/or the purchase or rental of Medical
Aids in Pharmacies, Orthopedic Aids Stores and associated
costs.
5.2. Reimbursable health care services:
5.2.1. Pharmaceuticals and Medical Aids reimbursable from the
CHIF budget. If the Pharmaceutical purchased are not fully
reimbursed from the CHIF budget, the balance of the full
amount shall be reimbursed, unless otherwise provided in the
Contract;
5.2.2. Pharmaceuticals and Medical Aids not reimbursed from
the CHIF budget shall be reimbursed as provided for in the
Contract;
5.2.3. Pharmaceuticals and Medical Aids used during Day
Surgery/Day Stationary and/or Ambulatory Surgery shall be
reimbursed as provided for in the Contract.
5.3. Non-reimbursable expenses for:
5.3.1. Pharmaceuticals for addiction diseases, potency disorders,
weight loss; sex hormones and pharmaceuticals for the
reproductive system; contraceptives;
5.3.2. Vitamin and mineral supplements with ATC code A11 or A12
no matter how they are bought in Pharmacies: with or without
the doctor's prescription;
5.3.3. Thermometers, hygiene aids, appliances for hygiene,
testers, heaters, scales and blood pressure measuring
apparatus and other functional diagnostic appliances and/or
instruments;
5.3.4. Compensatory technical aids (wheelchairs, functional
beds);
5.3.5. Purchase or rental of wellness/rehabilitation aids;
5.3.6. Herbal, animal or homeopathic preparations; preparations
and articles having various functions without an ATC code.
6. VITAMINS, OVER-THE-COUNTER PHARMACEUTICALS
6.1. The Insurable Event shall be deemed to be the purchase of
vitamins, food supplements, prescription and over-the-counter
Pharmaceuticals for the treatment or prevention of the
Insured's Health Disorder in Pharmacies and associated costs.
6.2. Reimbursable health care services:
6.2.1. Vitamins, mineral supplements, food supplements,
homeopathic and medicinal preparations of herbal or animal
origin, multi-functional preparations and preparations that do
not have the assigned ATC code;
6.2.2. Over-the-counter Pharmaceuticals without the doctor's
prescription.
6.2.3. Vitamins and mineral supplements with ATC code A11 or
A12.
6.3. Non-reimbursable expenses for:
6.3.1. Pharmaceuticals for addiction diseases, potency disorders,
weight loss; sex hormones and pharmaceuticals for the
reproductive system; contraceptives;
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7. OPTICS
7.1. The Insurable Event shall be deemed to be the following
Health Care Services provided to the Insured due to the Health
Disorder related to his vision and associated costs.
7.2. Reimbursable health care services:
7.2.1. Consultancy on the choice of optical aids with an
ophthalmologist or optometrist;
7.2.2. Prescription glasses lenses, prescription glasses frames,
contact lenses and contact lens maintenance aids prescribed
by an ophthalmologist or optometrist, which are necessary for
the correction of the existing visual disorder provided that they
are purchased in specialized opticians;
7.2.3. Vision correction and/or vision preservation surgery,
disposable instruments and accessories used during this
surgery;
7.2.4. Prescription glasses and lens manufacturing service;
7.2.5. Purchase of VDU spectacles, dioptric sunglasses.
7.3. Non-reimbursable expenses for:
7.3.1. Glasses maintenance aids and accessories (e.g., spectacle
cases, cleaners, wipes, etc.);
7.3.2. sunglasses;
7.3.3. Purchase of artificial tears; supplements; medical
preparations.
8. PREVENTIVE AND PERIODICAL HEALTH EXAMINATIONS AND ANALYSES:
8.1. The Insurable Event shall be deemed to be the following
Health Care Services provided to the Insured in the Health Care
Institution with regard to Health Disorders seeking to avoid
them or pre-assess the Insured's health condition and
associated costs.
8.2. Reimbursable health care services:
8.2.1. The testa prescribed to the Insured by a doctor or chosen at
the request of the Insured and consultations of doctors;
8.2.2. Preventive health examination; medical examinations for
issuance of certificates; health examinations of employees to
determine fitness for work;
8.2.3. Diagnosis of genetically inherited, congenital diseases;
8.2.4. Sports medicine doctor's consultations.
8.2.5. Diagnosis of AIDS, HIV, syphilis, gonorrhea, trichomoniasis,
chlamydia, ureaplasmosis, human papillomavirus, herpes
genital and other sexually transmitted diseases;
8.2.6. Examinations and consultations not related to the Health
Disorder made at the request of the Insured provided that the
results of the performed examinations do not exceed the
normal limits;
8.2.7. Laboratory testing of vitamins;
8.2.8. Diagnostic tests for chronic diseases;
8.2.9. Diagnosis of infertility/inability to get pregnant, potency
disorders, contraception consultations;
8.2.10. Diagnostic tests for leg vein varicose.
8.3. Non-reimbursable expenses for:
8.3.1. Pregnancy diagnostics and care; diagnosis of health
disorders that occurred or worsened due to pregnancy and/or
pregnancy termination due to medical indications; diagnosis of
health disorders caused by childbirth and breastfeeding;
8.3.2. Alternative medicine services.
8.3.3. Consultations of a dentist or an oral cavity and orthognatic
surgeon and examinations prescribed by them.
9. VACCINES
9.1. The Insurable Event shall be deemed to be the following
Health Care Services related to vaccines, which are provided to
the Insured in the Health Care Institution, and associated costs.
9.2. Reimbursable health care services:
9.2.1. Vaccines chosen by the insured or prescribed by a doctor;
9.2.2. Vaccination services, vaccination consultations.
10. REHABILITATION TREATMENT
10.1. The Insurable Event shall be deemed to be the following
Health Care Services related to rehabilitation treatment due to
the Insured's Health Disorder, which are provided to the Insured
in the Health Care Institution, and associated costs.
10.2. Reimbursable health care services:
10.2.1. If the Medical Rehabilitation sub-type of this Health
Insurance Program is chosen, the following services shall be
reimbursed: physical medicine and rehabilitation doctor's
consultations; consultations of a kinesitherapist, ergotherapist
prescribed within the competence of the medical specialist;
physiotherapy (ultrasound, microwave, pulse therapy, magnet
therapy and other rehabilitation treatment procedures),
kinesitherapy, ergotherapy, mud and water procedures,
therapeutic massages, halotherapy, manual therapy;
10.2.2. if the Rehabilitation Treatment after 72 Hours of
Stationary Treatment sub-type of this Health Insurance
Program is chosen, the following services shall be reimbursed:
the consultations of a kinezitherapist and ergotherapist
prescribed within the competence of the medical specialist;
physiotherapy (ultrasound, microwave, pulse therapy, magnet
therapy and other rehabilitative treatment procedures),
kinezitherapy, ergotherapy, mud and water treatments,
therapeutic massages, halotherapy, manual therapy services
for the treatment of a health disorder in the stationary Health
Care Institution for at least 72 hours;
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10.2.3. If the Rehabilitation sub-type of this Health Insurance
Program is chosen, the following services shall be reimbursed:
physical medicine and rehabilitation doctor's consultations;
consultations of a kinesitherapist, ergotherapist prescribed
within the competence of the medical specialist; physiotherapy
(ultrasound, microwave, pulse therapy, magnet therapy and
other rehabilitation treatment procedures), kinesitherapy,
ergotherapy, mud and water procedures, therapeutic
massages, halotherapy, manual therapy;
10.2.4. If the Medical Wellness sub-type of this Health Insurance
Program is chosen, the following services shall be reimbursed:
sports medicine, physical medicine and rehabilitation doctor's
consultations; consultations of a kinesitherapist, ergotherapist;
physiotherapy (ultrasound, microwave, pulse therapy, magnet
therapy and other rehabilitation treatment procedures),
kinesitherapy, ergotherapy, mud and water procedures,
therapeutic massages, halotherapy, manual therapy;
alternative medicine services;
10.3. Non-reimbursable expenses for:
10.3.1. Overnight accommodation/accommodation, catering
services;
10.3.2. Purchase or rental of wellness/rehabilitation aids;
10.3.3. Facial massages and cosmetic procedures;
10.3.4. Rehabilitation treatment services provided to the Insured
due to his Health Disorder related to osteochondrosis and/or
degenerative changes (if the Medical Rehabilitation sub-type of
this Health Insurance Program is chosen).
11. MEDICAL SERVICES
11.1. The Insurable Event shall be deemed to be the following
Health Care Services provided to the Insured to treat or prevent
his Health Disorder in the Health Care Institution, Specialized
Optician, Pharmacy or the Store of Orthopedic Aids and
associated costs.
11.2. Reimbursable health care services:
11.2.1. Reimbursable and non-reimbursable Healthcare Services
in accordance with the descriptions of the following Health
Insurance Programs and subject to the following exceptions:
a) Ambulatory treatment and diagnostics;
b) Stationary treatment;
c) Prenatanal care, childbirth and postnatanal care
d) Dental services;
e) Pharmaceuticals and medical aids;
f) Vitamins, over-the-counter pharmaceuticals;
g) Optics;
h) Preventive and periodical health examinations and analyses:
I) Vaccines;
j) Rehabilitation treatment.
11.2.2. Alternative medicine services;
11.2.3. Psychologist services (including those provided by entities
operating on the basis of a certificate for individual activity).
11.3. Non-reimbursable expenses for:
11.3.1. Reparative surgeries and procedures if they are performed
in the absence of a Health Disorder; hair removal, botulinum
toxin treatment procedures; facial massages and cosmetic
procedures;
11.3.2. Purchase of hygiene aids, goods and appliances; skin and
hair care, decorative cosmetics;
11.3.3. Overnight accommodation/accommodation, catering
services;
11.3.4. Purchase or rental of wellness/rehabilitation aids;
11.3.5. Teeth whitening procedures;
11.3.6. Purchase of eyeglass care aids and accessories,
sunglasses.
12. WELLNESS SERVICES
12.1. The Insurable Event shall be deemed to be the following
Health Care and/or Wellness Services provided to the Insured in
the Health Care Institution, SPA centres and sanatoriums,
sports clubs, swimming pools, entertainment parks or by any
other person entitled to engage in the respective activity and
associated costs.
12.2. Reimbursable health care services and wellness
services:
12.2.1. Consultations and services provided by a sports medicine
doctor, a physical medicine and rehabilitation doctor, a
kinezitherapists, a reflexologist; water, physiotherapy, manual
therapy, massage, mud procedures; body composition analysis,
ergonomic body position tests and other services provided for
in the Contract;
12.2.2. Consultations of a psychiatrist, a medical psychologist, a
psychologist, a psychologist-psychotherapist and their
psychotherapeutic treatment;
12.2.3. Alternative medicine services;
12.2.4. Physical activity: individual and group health, wellness,
physical education services for all sports;
12.2.5. Consultations of a dietarian, nutritionist and drawing up a
nutrition plan.
12.3. If the services specified in clause 12.2.4 of Addendum No.1 to
the Insurance Rules are purchased under the Wellness Services
Subscription, only a part of the expenses for the period of the
subscription coinciding with the validity period of the Insurance
Coverage may be reimbursed.
12.4. Non-reimbursable expenses for:
12.4.1. Overnight accommodation/accommodation, catering
services;
12.4.2. Purchase or rental of wellness/rehabilitation aids;
12.4.3. Facial massages and cosmetic procedures;
12.4.4. Competition / participant / camp fee; entertainment
services (e.g., bowling, carting, billiards, saunas, hot tub, etc.);
meditation classes / practices;
12.4.5. occupations without physical activity (e.g., brain/desk
games).
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13. ALL SERVICES
13.1. The Insurable Event shall be deemed to be the following
Health Care and/or Wellness Services and other goods and
services provided to the Insured in the Health Care Institution,
Pharmacies, the store of orthopaedic aids, SPA centres and
sanatoriums, sports clubs, swimming pools, entertainment
parks or by any other person entitled to engage in the
respective activity and associated costs.
13.2. Reimbursable services:
13.2.1. reimbursable and non-reimbursable Healthcare Services
and Wellness Services in accordance with the descriptions of
these Health Insurance Programs and subject to the following
exceptions:
a) Ambulatory treatment and diagnostics;
b) Stationary treatment;
c) Prenatanal care, childbirth and postnatanal care
d) Dental services;
e) Pharmaceuticals and medical aids;
f) Vitamins, over-the-counter pharmaceuticals;
g) Optics;
h) Preventive and periodical health examinations and analyses:
I) Vaccines;
j) Rehabilitation treatment;
k) Wellness services.
13.2.2. Alternative medicine services;
13.2.3. personal hygiene aids; dental care aids, including
toothbrushes, toothpaste, mouthwash, irrigators, etc .; skin and
hair care medical aids.
13.3. Non-reimbursable expenses for:
13.3.1. Overnight accommodation/accommodation, catering
services;
13.3.2. Purchase or rental of wellness/rehabilitation aids;
13.3.3. Facial massages and cosmetic procedures; reparative
surgeries and procedures if they are performed in the absence
of a health disorder; hair removal, botulinum toxin treatment
procedures;
13.3.4. Purchase of decorative cosmetics aids; hair styling aids,
cosmetics appliances;
13.3.5. Competition / participant / camp fee; entertainment
services (e.g., bowling, carting, billiards, saunas, hot tub, etc.);
meditation classes / practices;
13.3.6. Occupations without physical activity (e.g., brain / desk
games).
14. CRITICAL DISEASES
14.1. The Insurable Event shall be deemed to be the Critical
disease diagnosed for the first time during the validity period of
the Insurance Coverage provided for in the List of Critical
Illnesses/Contract, due to which the Insured incurs expenses for
Medically Reasonable Services that are not reimbursed by the
CHIF.
14.2. Insurance Indemnity
14.2.1. The Insurance Indemnity for the Insurable Event under
this Health Insurance Program (regardless of the number of
Critical diseases diagnosed at one time) shall be paid to the
Insured as indemnity for the expenses incurred for Health Care
Services in one of the following ways chosen by the Policyholder
when concluding the Contract:
14.2.1.1. As the Sum Insured for Critical Diseases provided for in
the Contract; or
14 .2 .1 .2 . As Insurance Indemnities according to the
requirements applicable to the Health Insurance Programs:
Ambulatory Treatment and Diagnostics, Stationary Treatment,
Rehabilitation Treatment, Pharmaceuticals and Medical Aids,
within the limits of the Sum Insured of the relevant Health
Insurance Program.
14.2.2. In case Insurance Indemnity is paid in the manner
provided for in sub-clause 14.2.1.2 of Addendum No. 1 to the
Insurance Rules, the expenses of the Insured sustained due to
the Insurable Event that occurs during the Insurance Period
shall be subject to indemnification. However, a claim for the
Insurance Indemnity and reimbursement of such expenses
may be submitted no later than within 6 (six) months from the
last day of the Insurance Period.
14.3. Non-insurable events under this Insurance Program:
14.3.1. An event recognized as a Non-insurable one in
accordance with the provisions of clause 12 of the Insurance
Rules;
14.3.2. The Critical Disease or a disease that caused the Critical
disease is diagnosed before the conclusion of the Contract or
less than 60 (sixty) days after the entry into force of the
Insurance Coverage. This period shall also be applicable if the
Insurance Coverage is suspended or terminated during the
validity of the Contract. However, this period shall not be
applicable when the Insurance Coverage provided under the
Contract under the Critical Diseases Health Insurance Program
is renewed for a new Insurance Period, as well as when the
Critical Disease is caused by the Accident during that period;
14.3.3. The Critical Disease does not meet the criteria for
recognition as a Critical Disease and an Insurable Event as
indicated in this Health Insurance Program and the List of
Critical Diseases;
14.3.4. Recurrence of the same Critical Disease;
14.3.5. The Insured dies within 30 (thirty) days after he was
diagnosed with one of the Critical Diseases.
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14.4. The List of Critical Diseases:
14.4.1. The list of critical diseases, concepts, criteria and
requirements for recognizing an event as the Insurable Event or
the Non-Insurable Event:
14.4.1.1. Malignant tumor (cancer) means the uncontrolled
growth, spread and invasion (penetration) of malignant cells
into tissues.
The Insurance Indemnity shall be paid only in case of
incontrovertible evidence of invasion into tissues and when the
malignancy of the cells is supported by histological findings.
The diagnosis must be confirmed by an oncologist.
The concept of cancer shall also include leukaemia and
malignant lymphoma as well as myelo-dysplastic syndrome. In
these cases, the diagnosis must be confirmed by an oncologist
or haematologist.
The Insurance Indemnity shall not be paid for:
– Localised non-invasive tumours classified as pre-malignant
changes (carcinoma in situ), including ductal and lobular
carcinoma in situ of the breast, cervical dysplasia, cervical
intraepithelial neoplasia (CIN-1, CIN-2 and CIN-3);
– Chronic lymphocytic leukaemia unless having progressed to
at least Binet Stage B;
– Any prostate cancer unless histologically classified as having a
Gleason score greater than 6 or having progressed to at least
clinical TNM classification T2N0M0;
– Basal (stab) cell carcinoma and squamous cell carcinoma of
the skin and malignant melanoma stage IA (T1aN0M0) unless
there is evidence for metastases of this tumour;
– Papillary thyroid cancer less than 1 cm in diameter and
histologically described as T1N0M0;
– Papillary micro-carcinoma of the bladder histologically
described as Ta;
– Polycythemia rubra vera and essential thrombocythemia;
– Monoclonal gammopathy of undetermined significance;
– Gastric MALT Lymphoma (gastric extranodal lymphoma of the
basal border) if the condition can be treated with Helicobacter-
eradication (elimination);
– Gastrointestinal stromal tumour (GIST) stage I and II according
to the AJCC (The American Joint Committee on Cancer) Cancer
Staging Manual;
– Cutaneous lymphoma unless the condition requires
treatment with chemotherapy or radiation;
– Microinvasive carcinoma of the breast (histologically classified
as T1mic) unless the condition requires treatment with
mastectomy, chemotherapy or radiation;
– Microinvasive carcinoma of the cervix uteri (histologically
classified as stage IA1) unless the condition requires treatment
with hysterectomy, chemotherapy or radiation;
– The Insured's malignancy (cancer) due to HIV or AIDS, if HIV or
AIDS was diagnosed to the Insured before the conclusion of the
Contract or during its validity.
14.4.1.2. Myocardial infarction shall mean the acute irreversible
injure of heart muscle (necrosis) due to occlusion of an
adequate artery, which prevents the blood flow to an area of
myocardium.
Myocardial infarction must be supported by change in the
number of cardiac biomarkers (troponin or CK-MB enzymes) to
levels considered diagnostic for myocardial infarction provided
that at least 2 (two) following criteria are found:
– Ongoing angina pectoris (protracted cardiac angina);
– New electrocardiographic (ECG) changes indicative of
myocardial infarction showing myocardial ischemia (new ST-T
wave changes or new block of the left bundle branch)
– Development of pathological Q waves in the ECG.
The diagnosis must be confirmed by a cardiologist.
The Insurance Indemnity shall not be paid for:
– Elevations of troponin in absence of overt ischemic heart
disease (e.g., myocarditis, stress-induced cardiomyopathy,
palpitations, pulmonary embolism, drug intoxication);
– Myocardial infarction that occurs in the presence of intact
coronary arteries due to coronary artery spasm, myocardial
“bridges” (compression of the coronary arteries of the heart) or
drug use;
– Myocardial infarction that occurs within 14 (fourteen) days
after coronary angioplasty or graft-bypass surgery.
14.4.1.3. Insult (cerebral infarction) shall mean the death of
brain tissue due to acute cerebrovascular event caused by intra-
cranial vessels thrombosis, blood haemorrhage (including
subarachnoid haemorrhage or embolism from extra-cranial
sources) which causes acute onset of new neurological
symptoms and a new neurological deficit.
The Insurance Indemnity shall be paid only if the fixed
neurological deficit persists for more than 3 (three) months
after cerebral infarction (paralytic stroke). The fixed
neurological deficit must be confirmed by a neurologist and
supported by imaging findings (MRT; CT, and others).
The Insurance Indemnity shall not be paid for:
– Reversible cerebral ischemic attack (RCIA) and reversible
ischemic neurologic deficit (RIND);
– Direct and/or postoperative indirect injury to brain tissue or
blood vessels that occurs due to injury and/or during surgery;
– Neurologic deficit due to general hypoxia, infection,
inflammatory disease, migraine, or medical intervention;
– Incidental imaging findings (computer tomography or
magnetic resonance tomography) without clearly related
clinical cerebral infarction symptoms (“silent stroke”).
14.4.1.4. Coronary artery bypass graft surgery shall mean
open-heart coronary artery surgery to correct narrowing or
blockage of two or more coronary arteries with bypass grafts
using an autologous transplant (any superficial vein of a leg,
internal thoracic artery or other suitable artery, etc.) as a bypass
graft.
The Insurance Indemnity shall be paid provided only that
surgery is confirmed to be necessary by a cardiologist or a
cardiac surgeon and supported by angiographic findings.
The Insurance Indemnity shall not be paid for:
– Bypass surgery that is performed to treat one narrowed or
blocked (occluded) coronary artery;
– Coronary artery angioplasty or stent-placement.
20
14.4.1.5. Prosthesis of heart valves shall mean a cardiac surgery
to replace one or more heart valves in one of the following ways:
– Heart valve replacement or correction surgery performed in
an open manner (opening the chest);
– Ross-procedure;
– Transcatheter correction of coronary arteries (catheter-based
valvuloplasty);
– Transcatheter aortic valve implantation (TAVI).
The surgery must be confirmed to be medically necessary by a
cardiologist or a cardiac surgeon and supported by
echocardiogram or cardiac catheterization findings.
The Insurance Indemnity shall not be paid for transcatheter
bicuspid (mitral) valve clipping.
14.4.1.6. Surgery of the aorta shall mean aortic surgery to
correct (treat) aortic narrowing, occlusion, aneurysm or
exfoliation
The concept includes open surgery and minimally invasive
procedures such as endovascular correction. The surgery must
be confirmed to be medically reasonable by a cardiac surgeon
and supported by imaging findings.
The Insurance Indemnity shall not be paid for:
– Thoracic and abdominal aortic branch surgeries (including
aortic and femoral artery or aortic and iliac artery bypass grafts);
– Surgery of the aorta related to hereditary connective tissue
disorders (e.g. Marfan syndrome, Ehlers–Danlos syndrome);
– Surgery following traumatic injury to the aorta.
14.4.1.7. Visceral organ/bone marrow transplantation shall
mean the situation when the Insured as a recipient actually
undergoes the following organ transplantation surgery
(regardless of the number of surgeries or transplants) or when
the Insured's condition requiring such organ transplantation is
considered incurable by other means and a medical specialist
provides a proof that the Insured is on the official waiting list for
an organ transplant.
Insurance Indemnities shall be payable for the following organ
transplantation surgeries : heart, kidney (-s), liver (including split
liver and living donor liver transplantation), lung (including
living donor lobe or single-lung transplantation), bone marrow
(allogenic hematopoietic stem cell transplantation proceeded
by total bone marrow ablation), the transplantation of small
bowel, pancreas, partial or full face, hand, arm and leg
transplantation (composite tissue allograft transplantation).
The Insurance Indemnity shall not be paid for:
– Transplantation of other organs, body parts, or tissues
(including cornea and skin);
– Transplantation of other cells (including pancreatic islet cells
and stem cells other than hematopoietic).
14.4.1.8. Kidney failure shall mean the end-stage kidney failure
due to irreversible failure of both kidneys to function leading to
the necessity of regular haemodialysis or peritoneal dialysis.
The dialysis must be confirmed by a nephrologist and
supported by the findings of kidney function analyses.
The Insurance Indemnity shall not be paid for an acute
reversible kidney failure, which means when temporary renal
dialysis is required.
14.4.1.9. Multiple sclerosis shall mean the multiple sclerosis
diagnosed by a neurologist after a comprehensive stationary
neurological examination based on clinical neurological
symptoms meeting the following criteria
– Multiple neurological deficit is present for more than 6 (six)
months; and
– The disease is confirmed by magnetic resonance imaging
findings showing at least 2 (two) lesions of demyelination in the
brain or spinal cord indicative of multiple sclerosis.
The Insurance Indemnity shall not be paid for:
– Possible multiple sclerosis and neurologically or radiologically
isolated syndromes suggestive but not diagnostic of multiple
sclerosis;
– Isolated optic neuritis and/or neuromyelitis optica.
14.4.1.10. Parkinson's disease (under 65 years old) shall mean
the definite initial Parkinson's disease diagnosed to the Insured
by a neurologist before the Insured reaches the age of 65 (sixty
five).
The Insurance Indemnity shall be paid provided that all the
following conditions are met:
a) At least 2 (two) following clinical manifestations are
diagnosed:
– Muscle stiffness (rigidity);
- Trembling (tremor);
– Bradykinesia (abnormal slowness of movement, sluggishness
of the physical and mental response).
b) Total inability to perform, by oneself, at least three out of six
activities of daily living for a continuous period of at least 3
(three) months:
– Washing: the ability to take a bath or shower (including
getting into/out of a bath or shower) or satisfactory washing by
other aids;
– Getting dressed and undressed: the ability to put on, take off,
secure or fasten all garments, if necessary – braces, artificial
limbs or other orthopedic aids;
– Feeding oneself : the ability to feed oneself when food has
been prepared and made available;
– Maintaining personal hygiene: the ability to maintain a
satisfactory level of personal hygiene by using the toilet or
otherwise managing bowel and bladder function;
– Getting between rooms: the ability to get from room to room
on a level floor;
– Getting in/out of bed: the ability to get up/get out of bed into a
chair or wheelchair and back.
The implantation of a neurostimulator to control symptoms by
deep brain stimulation is, independent of the Activities of Daily
Living, covered under this definition of Critical Illnesses. The
implantation must be determined to be medically necessary by
a neurologist or neurosurgeon.
The Insurance Indemnity shall not be paid for:
– Secondary parkinsonism (including drug- or toxin-induced
parkinsonism);
– Essential tremor;
– Parkinsonism related to other neurodegenerative disorders.
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14.4.1.11. Alzheimer's disease(under 65 years old) shall mean
the Alzheimer's disease diagnosed by a neurologist to the
Insured before the Insured reaches the age of 65 (sixty five)
provided that the following needs for care of the Insured are
identified and approved.
The Insurance Indemnity shall be paid provided that all the
following conditions are met:
– The disease is supported by typical neuropsychological and
nervous system imaging findings (e.g., computed tomography,
magnetic resonance imaging);
– Loss of intellectual capacity involving impairment of memory
and cognitive functions (sequencing, organizing, abstracting,
and planning), which results in a significant deterioration of
mental and social function;
– Diagnosed personality disorder;
– Gradual onset and continuing decline of cognitive functions;
– No disturbance of consciousness;
– Need for constant supervision 24 hours daily confirmed by a
neurologist.
The Insurance Indemnity shall not be paid for other forms of
mental handicap (dementia) due to brain, systemic or mental
diseases.
14.4.1.12. Third-degree burns shall mean the burns of the
Insured's body, which destroy all layers of the skin, cover at least
20% of the body surface area and are approved by a medical
surgeon.
The body surface area can be determined either by the “Rule of
Nines” or the “Lund and Browder Chart”, or the “Rule of Palms”
(1% of the body surface area is equal to the palm surface of the
Insured's hand, i.e. both the palm and fingers).
14.4.1.13. Benign brain tumour shall mean non-malignant
growth of tissue located in the cranial vault (brain, meninges, or
cranial nerves) diagnosed by a neurologist and neurosurgeon
and supported by imaging examination findings.
The Insurance Indemnity shall be paid provided that:
a) The tumour is treated in at least one of the following ways:
– Complete or incomplete surgical removal;
– Stereotactic radiosurgery;
– External beam radiation; or
b) None treatment options indicated in item a) are possible due
to medical reasons, but the tumour causes a persistent
neurological deficit, which has to be documented for at least 3
months following the date of diagnosis.
The Insurance Indemnity shall not be paid for:
– Diagnosis or treatment of any cyst, granuloma, hamartoma or
malformation of the arteries or veins of the brain;
– Diagnosis of tumors of the pineal gland (pituitary gland).
14.4.1.14. Blindness shall mean total and irreversible loss of
vision in both eyes as a result of injury or illness which cannot be
treated by refractive correction, pharmaceuticals or surgery The
diagnosis must be supported by the findings of objective tests
and the conclusion of the commission of medical experts on
vision loss after the expiry of 6 (six) months after diagnosis.
Profound vision loss is evidenced by either a visual acuity of 3/60
or less (0.05 or less in the decimal notation) in the better eye
after correction or a visual field is less than 10° diameter in the
better eye after correction. The Insurance Indemnity shall not be
paid for:
– Loss of vision in one eye only;
– Different reversible vision disorders.
14.4.1.15. Deafness shall mean a permanent and irreversible loss
of hearing of the Insured in both ears as a result of sickness or
physical injury. The diagnosis must be confirmed by an
otolaryngologist and supported by an auditory threshold (at
least 90 db at 500, 1000 and 2000 hertz in the better ear using a
pure tone audiogram).
14.4.1.16. Loss of speech shall mean a definite diagnosis of the
total and irreversible loss of the ability of the Insured to speak
confirmed by an otolaryngologist and resulting from physical
injury or disease not subject to correction by any medical
treatment means provided that this condition persists for a
continuous period of at least 6 months. The Insurance
Indemnity shall not be paid for the loss of speech due to
psychiatric disorders or diseases.
14.4.1.17. Loss of limb function shall mean Total and irreversible
loss of two or more limbs or their function due to injury or illness
of spinal marrow and brain. Loss of limb function shall mean
loss of limbs above the elbow or knee joints
The Insurance Indemnity shall be paid provided that the loss of
the limb function persists for more than 3 (three) months and is
confirmed by a neurologist and supported by clinical
symptoms and diagnostic findings.
The Insurance Indemnity shall not be paid for:
– Paralysis due to self-harm or psychological disorders;
– Guillain-Barre syndrome;
– Periodic (reversible) or hereditary paralysis..
14.4.1.18. Coma shall mean a state of unconsciousness
diagnosed by a neurologist provided that all the following
conditions are satisfied:
– No response from the Insured to exogenous irritants (results in
a score of 8 or less on the Glasgow coma scale) or no response to
needs of nature for at least 96 (ninety six) hours;
– Need for the use of life support systems;
– Results in a persistent neurological deficit which must be
assessed at least 30 (thirty) days after the onset of the coma. The
Insurance Indemnity shall not be paid for:
– Medically induced coma;
– Any coma due to self-inflicted injury, alcohol or drug use.
14.4.1.19. Viral encephalitis shall mean a diagnosis of brain
(cerebral hemispheres, cerebral trunk, cerebellum) fever
induced by viral infection. The diagnosis must be confirmed by
a neurologist after stationary examination indicating typical
cl in ical symptoms, changes in cerebrospinal fluid ,
immunological/serological indicators.
The Insurance Indemnity shall be paid provided that all the
following conditions are met:
– Neurological deficit; and
– Neurological deficit is documented for at least 3 months
following the date of diagnosis. . The Insurance Indemnity shall
not be paid for:
– Encephalitis induced by HIV;
– Encephalitis caused by bacterial or protozoal infections;
– Paraneoplastic encephalomyelitis.