Generali Osiguranje Srbija a.d.o. Vladimira Popovića 8 11070 Beograd / Srbija T +381.11.222.0.555 F +381.11.711.43.81 [email protected] generali.rs TL-U-02-OS-01-01
Special Terms and Conditions for Voluntary Health
Insurance for Foreigners due to Occurrence of a Medical
Emergency during Their Stay in the Republic of Serbia
INTRODUCTORY PROVISIONS
Article 1(1) These Special Terms and Conditions for Voluntary Health Insurance for Foreigners due to Occurrence of a Medical Emergency during Their Stay in the Republic of Serbia (hereinafter: General Terms and Conditions) shall be in-tegral part of the contract for Voluntary Health Insurance for Foreigners due to Occurrence of a Medical Emergency during Their Stay in the Republic of Serbia (hereinaf-ter: insurance contract), concluded voluntarily by the Policyholder with joint stock insurance company (herei-nafter: Insurer).
(2) Certain terms in these Special Terms and Conditions ha-ve the following meanings:
− “Policyholder” – a natural person, legal entity or
other subject of rights or its associated legal entity concluding, in the name and on behalf of the Insured and/or in own name and on own behalf, the insuran-ce contract with the Insurer and who has bound itse-lf to pay premium;
− “Insured” – a foreigner being entitled to indemnity for
the expenses of a medical treatment in the Republic of Serbia pursuant to concluded insurance contract and in accordance with insurance contract and he-rewith;
− “Foreigner” – a person not having citizenship of the
Republic of Serbia;
− “Country of residence” – a country of Insured’s
re-ported residence;
− “Licensed physician” – any person who has
obtai-ned a medical school degree and possesses permit and/or license to work issued by competent medi-cal chamber, employed at a medimedi-cal institution wit-hin Plan of medical institutions network and/or priva-te practice, and pursuant to valid law regulating he-althcare except if licensed physician is the Insured, Policyholder and/or their spouse;
− “Medically justified treatment” – healthcare
servi-ce, medical-technical aids, implants, material or me-dicine justified if:
1. It is appropriate and necessary to diagnose or treat diseases or injuries covered under the policy and specified hereunder;
2. It is necessary for curing, improving health conditi-on and/or preventing deterioraticonditi-on of the Insured’s health;
3. It does not exceed, in scope, duration or intensity, the level of protection necessary to provide safe, adequate and appropriate treatment;
4. It has been prescribed by licensed physician; 5. It occurred during the policy period;
6. It complies with generally accepted medical pra-ctice professional standards in the Republic of Serbia;
7. Its primary purpose is not personal comfort or convenience of the patient, family, physician or other medical service provider;
8. It is neither a part of educational nor professional training of the patient nor has it been related to such;
9. It is not experimental or in research phase. − “Medical emergency” – sudden illness or injury which
could, without urgent medical assistance, endanger li-fe of the Insured, i.e. which could cause irrecoverable or severe deterioration or damage to his health or death. − “Urgent medical assistance” – direct, immediate
me-dical assistance provided in order to avoid endanger-ment of the Insured’s life, i.e. which could cause irreco-verable or severe deterioration or damage to his health or death. Urgent medical assistance implies the medical assistance provided within 12 hours from the moment of reception of the Insured in order to avoid the expected occurrence of urgent medical condition.
− “Accident” – any sudden event, independent from
the Insured’s will, which, affecting mostly from the outside to the Insured’s body, causes a health distur-bance requiring urgent medical assistance.
− “Sudden illness” – sudden and unexpected illness
established by a licensed physician and/or infective disease or organic disorder which has occurred af-ter the beginning of the insurance and of such natu-re natu-requiring provision of urgent medical assistance; − “Preexisting condition” – any health condition
− “Medical expenses” - amount borne by the Insurer
in case of occurrence of the insured event covered under this insurance, which represents the cost for Insured for the provided, justified healthcare service due to occurrence of sudden illness or accident pro-vided for under these Special Terms and Conditions and the insurance contract.
− “Participation” – participation in the share of
expen-ses for treatment of a particular, covered, medically justified treatment which must be paid if specified in the insurance policy and/or insurance contract. − “Doctor-censor” – a physician employed with the
Insurer.
General Provisions Article 2
(1) Under the insurance contract, the Policyholder shall be obliged to pay the Insurer the premium, and the Insurer shall be obliged, when the insured event has occurred, to indemnify for the expenses paid for treatment of medical emergencies pursuant to Article 7 hereof.
(2) A person or group of persons not being citizens of the Republic of Serbia can be insured hereunder.
(3) Insurer shall provide the insurance and shall undertake to pay the expenses resulting from an insured event which occurred within contracted insurance period for indemni-fication of expenses for provision of health care provided for under Article 7 hereof.
(4) Insurance hereunder shall be valid on the territory of the Republic of Serbia.
(5) Insurance beneficiary hereunder shall be exclusively the Insured who has experienced the insured event.
Conclusion of the Insurance Contract Article 3
(1) Insurance contract shall be concluded based on a wri-tten application submitted in the Insurer’s form by the Policyholder, containing data on each Insured to be inclu-ded in the insurance contract.
(2) In case of conclusion of a collective insurance contract for Policyholder’s employees or members or Policyholder’s service beneficiaries, the insurance contract shall be concluded based on a unified written application, submi-tted in the Insurer’s form by Policyholder, containing data on each Insured to be included in the insurance contract. (3) Insurance contract shall be concluded when the
contra-cting parties sign the policy or the cover note.
(4) Written application for conclusion of the insurance contract shall be binding upon the Applicant (Policyholder), if shor-ter period has not been established, within eight days from the day when the application is received by the Insurer. (5) If the Insurer does not refuse the application not differing
from its conditions within the period provided under previo-us paragraph of this Article, it shall be deemed to have ac-cepted the application and that the insurance contract was concluded as of the date of insurance application delivery.
(6) Insurer shall issue the policy to the Policyholder, based on the data from the application.
(7) In case the insurance is concluded for a group of persons, a list of the Insured included in this insurance shall be in-tegral part of insurance contract.
Premium Payment Article 4
(1) Policyholder shall be obliged to pay the insurance premi-um in whole for the entire insurance period.
(2) Notwithstanding the provisions of the previous paragraph of this Article, if stipulated, and if the contracted insuran-ce period is longer than six months, insuraninsuran-ce premium can also be paid in installments and the Insurer shall be entitled to insurance premium for the entire contracted in-surance period.
(3) Premium, expressed in EUR, shall be paid in RSD counter value at official mean exchange rate of the National Bank of Serbia on the date of insurance premium payment pur-suant to insurance contract.
Duration of the Insurance Contract Article 5
(1) Insurance contract can be concluded for a limited period not shorter than one month and not exceeding 12 mont-hs.
Commencement and Termination of the Insurer’s Liability
Article 6
(1) Insurance shall begin at 24.00 on the day specified on the policy as commencement of insurance but not before in-surance premium has been paid.
(2) Insurance shall terminate at 24.00 on the day specified on the policy as insurance expiration date and/or at the end of stay in the Republic of Serbia.
(3) Insurer’s liability shall last only within the period of insu-rance coverage.
(4) Insurer’s liability can continue up to the date specified in the policy and/or insurance contract as insurance expira-tion date.
Insured Event Article 7
(1) Insured event is a sudden illness or accident of the Insured resulting in provision of urgent medical assistan-ce to the Insured and provision of health serviassistan-ces neassistan-ce- nece-ssary for treatment of medical emergencies occurred im-mediately after the provision of urgent medical assistan-ce, which caused occurrence of expenses to be borne by Insured.
(3) Indemnification for treatment of medical emergencies shall be limited to medically necessary procedures of in-patient and out-patient treatment.
(4) In-patient treatment in Terms and Conditions hereof shall mean event when Insured has been provided with cally justified treatment for the purpose of treating medi-cal emergencies up to the moment when, pursuant to me-dical standards, life of the Insured is no longer endange-red, up to 30 days.
(5) In-patient treatment in Terms and Conditions hereof, shall mean event when the Insured has been provided with a medically justified treatment of medical emergencies, at the institution which is considered to be general hospi-tal in accordance with healthcare regulations, where the Insured is constantly monitored by medical personnel, and which has sufficient number of diagnostic, lab, sur-gical and therapeutic equipment and shall limit medical services to scientifically recognized methods, clinically te-sted in the Republic of Serbia, where Insured occupies a bed longer than 24 hours.
(6) Out-patient treatment in Terms and Conditions hereof shall be event when the Insured is provided with medi-cally justified treatment of medical emergencies, received by the Insured at a medical institution, as a provider of medical services, or at the place of medical urgency whi-ch is officially recognized as a place where suwhi-ch a tre-atment can be conducted and shall limit medical services to scientifically recognized methods clinically tested in the country where insurance coverage is valid pursuant to the policy, and thereat, the Insured has not spent consecuti-ve 24 hours (stayed oconsecuti-ver night, and/or occupied a bed) at such institution.
(7) In case of occurrence of the insured event, Insurer shall indemnify for:
1) Paid treatment expenses only for following medical services:
1. Infirmary treatment (out-patient treatment); 2. Medical supplies and drugs prescribed by a
li-censed physician;
3. Medical and technical aids which are necessary part of treatment for broken limbs and injuries, prescribed by a licensed physician;
4. X-ray diagnostics (roentgen) 5. In-patient treatment (hospitalization); 6. Surgeries and surgical expenses;
7. Surgical expenses shall also include implants prescribed by a licensed physician, but not ex-ceeding the limit of EUR 1.000 annually, per Insured.
2) Paid transportation expenses incurred due to provisi-on of urgent medical assistance:
1. Transportation of the Insured to the nearest physician or hospital by ambulance,
2. Transportation of the Insured to the nearest physician or hospital by some other means of transportation, if medically justified and allowed but not exceeding the limit of EUR 50.
3. Transportation and accommodation of the Insured to the specialized hospital or hospital which is more appropriate for treatment of en-dangered health condition.
(8) Medical emergency resulting from chronic diseases or injuries which existed before the commencement of insu-rance shall not be covered hereunder.
(9) Necessity of urgent medical treatment shall be assessed by a doctor-censor based on medical records, in accor-dance with Article 10 hereof.
Exclusion of the Insurer’s Liability Article 8
(1) Insurer’s liability shall be excluded in case of expenses re-sulting from:
− Illness or accident of any kind not requiring provision of urgent medical assistance;
− Treatment for cancer, HIV (AIDS) and venereal disea-se as well as expendisea-ses for treating terminal stadiums of chronic disease;
− Deliberate abortion with no medical reasons; − Accident caused by illness, such as epilepsy or
ma-laria;
− Explantation or transplantation of organs, tissues or cells;
− Treating symptoms and complications of illnesses or injuries for which, based on average person standard i.e. expected behavior of persons with average ca-pacities and abilities in particular circumstances, su-ch person would require care, treatment or consulta-tion from the physician before insurance contract co-ming into force;
− Medical research, regular and/or control check-ups, home visits from a physician, medical diagno-stic methods, medical research or treatments unre-lated to the occurrence of the insured event, as well as vaccination and use of contraceptives and drugs of any kind not prescribed by the physician treating the Insured;
− Experimental medical methods or methods used in case of research, and not recognized by social se-curity, as well as esthetic-corrective treatments and operations;
− Thermal treatment, and/or expenses for preventive drugs, rehabilitation at the institutions specialized for rehabilitation, medical centers, recovery centers and other similar institutions, as well as expenses for psy-chiatric treatment, treatment of mental illnesses and their effects;
− Purchase, repair and use of glasses, contact lenses as well as prosthetic aids of any kind;
− Insured being treated by his/her spouse, parent or child;
− Accommodation in single-bed or private room at the hospital, except if a licensed physician has found it necessary.
(2) If established that Insured has known or has been war-ned by a licensed physician in the country of residence that his/her health condition is such that his/her life has been possibly endangered due to possible acute compli-cations, and can be treated conservatively or surgically in the country of residence, Insurer’s liability to indemni-fy treatment expenses for such condition in the Republic of Serbia shall be excluded, and shall be considered that Insured has arbitrarily taken the risk of occurrence of po-ssible effects of such health condition when coming to the Republic of Serbia.
(3) Insurer’s liability shall be excluded in case of the insured event resulting from:
1. Preexisting conditions;
2. Pregnancy or delivery, as well as any other illness or complication related to pregnancy;
3. Following diseases: smallpox, plague, cholera, viral hemorrhagic fevers (except for hemorrhagic fever wi-th renal syndrome), malaria or yellow fever and owi-ther infectious diseases for which the person is placed un-der medical supervision in accordance with the re-gulations governing the protection of the population from infectious diseases);
4. Venereal disease of foreigner who is a member of crew on foreign ships or vessels.
(4) Insurer’s liability shall be excluded for expenses arisen if established that foreigner has been a victim of trafficking (5) Insurer’s liability shall be excluded if treatment expenses
have resulted from provision of healthcare services not provided for under Article 7, paragraph (7) hereof.
General Exclusions and Limitations of the Insurer’s Liability
Article 9
(1) All liabilities of the Insurer shall be excluded if an insured event occurred:
− In cases the Insured knew or could have known ba-sed on the circumstances that there have been possi-bility of occurrence of the insured event;
− Outside the territory of the Republic of Serbia whe-re insurance is valid or the insuwhe-red event has occu-rred before commencement of the insurance period and/or after the expiry of the insurance period, or has occurred after the return to the country of residence. − As a consequence of an intentional act committed by
the Insured, such as: suicide, suicide attempt or men-tal illness (menmen-tal disorder) of the Insured, intentional self-injury, self-treatment for alcoholism, addiction to psychoactive controlled substances as well as condi-tion under the influence of alcohol or drugs. It shall be
deemed that the Insured has been in intoxicated or under the influence of drugs if the presence of alco-hol in the blood was higher than the allowed minimum pursuant to legal regulations of the Republic of Serbia and/or if traces of drugs have been detected after oc-currence of the insured event
− Due to the fact that the Insured practices different hazardous and dangerous activities or sports, su-ch as: hunt, acrobatics, diving, wind-surfing, paragli-ding, speleology, mountaineering, pyrotechnics and activities that include handling fireworks, ammuniti-on and explosives, parachuting, ski jumping, acroba-tic skiing, skating, carting, hockey, water skiing, bun-gee jumping, car races, motorcycle riding (without of-ficial document and protection equipment), street-bo-arding, rollerblade acrobatics, driving buggy, water scooters etc.
− As a consequence of war, invasion, actions commi-tted by a foreign enemy, hostilities (whether the war was declared or not), terrorist activities, civil war, sa-botage, terrorism or vandalism, rebellion, revolution, insurrection, military and other usurpation of power as well as active participation of the Insured in disorders or mutinies of any kind;
− As a consequence of a natural disaster (e.g. volca-no eruptions, earthquake etc.), calamities, epidemics and pandemics;
− As a consequence of all other diseases not endan-gering life of the Insured pursuant to enclosed medi-cal records related to the insured event and opinion of doctor-censor;
− As a consequence of ionizing radiation or contamina-tion with radioactive materials from other radioactive waste generated by burning nuclear fuel, i.e. radioa-ctive, poisonous, explosive or other dangerous cha-racteristics of explosive nuclear assembly or some of its components.
(2) Insurer’s liability shall be excluded in case when the Insured is entitled to payment of indemnification pursuant to another policy except for indemnification not covered under another policy.
(3) Insurer’s liability shall be excluded when indemnification for the insured event is subject to payment in some other manner and/or when foreigner has exercised his/her ri-ght to treatment pursuant to compulsory health insuran-ce, special regulations of the Republic of Serbia, bilateral treaties, motor third party liability insurance, etc.
(4) If the claim is in any way fraudulent or grounded on fal-se information and statements, it shall not be binding for Insurer.
Reporting the Insured Event Article 10
(1) In case of occurrence of the insured event, insurance be-neficiary shall report the insured event to Insurer by sub-mitting claim and enclosing:
− Original policy and/or insurance certificate;
− Certificate of residence reported in the Republic of Serbia;
− Document proving identity of foreigner (foreign tra-vel document, ID card of foreigner, special ID card or other official document containing a photo based on which identity and citizenship of the Insured can be established);
− Complete medical records relating to occurred in-sured event (including, inter alia, all fiscal receipts, certificates and RTGs) pursuant to which relevant fa-cts, important for Insurer when liquidating damage, can be indisputably established;
− Fiscal receipt which must contain, in order to be ac-cepted, as follows:
1. Institution name; 2. Institution address; 3. Institution TIN;
4. Description of provided services and amount; 5. Date of service provided.
− Official police report on occurrence and type of acci-dent (casualty) in case that Insured’s injury resulted from accident (casualty);
− All other documents in relation to occurred insured event requested by Insurer, which are necessary for establishing necessity of claim.
(2) At the request of the Insurer, the Insured shall be obliged to provide all necessary medical records in relation to oc-curred insured event from the country of residence which Insurer found necessary in the process of claim handling. (3) Insurer shall be entitled to request from the Insured the
notification on all the facts and to deliver all the docu-ments relating to occurred insured event recognized as important by Insurer, for authenticity of insured event re-porting and for the purpose of complying with their obli-gations to the Insured. At the request, Insured must colle-ct and deliver to the Insurer all important facolle-cts from third parties (physicians, pharmacists, druggists or other medi-cal personnel or medimedi-cal institution of any type, transpor-ter of Insured, medical or pension institutions). By signing the claim, Insured agrees that hospital or medical institu-tion providing him the treatment can communicate all ne-cessary information in relation to his/her health conditions and treatment related to the insured event. Rejecting to provide such approval shall result in the loss of Insured’s right pursuant hereto.
(4) Existence of another insurance policy covering the same risk must be reported to Insurer by the Insured.
(5) Insurer shall be entitled to reject to pay indemnification if: 1. Insured’s statement, representing grounds for conc-lusion of policy or statement of beneficiary made in the process of claim reporting, has been false, untrue or covering facts aiming at deliberate fraud, etc. 2. Insured has failed to pay or to deliver evidence of
pay-ment of treatpay-ment expenses.
(6) If expenses resulting from insured event have exceeded contracted sum insured and/or maximum limits provided under insurance contract and hereunder, insurance bene-ficiary shall not be entitled to the difference.
Fulfillment of Insurer’s Obligations Article 11
(1) Insurer shall indemnify the Insured for treatment expenses pursuant hereto, according to insurance contract within 14 working days from the date when Insurer received evi-dence and established existence of liability and with par-ticipation if such was contracted.
(2) Insurer shall indemnify the Insured by making payment to the account of the Insured in the Republic of Serbia. (3) Insurer’s liability shall be met in whole as of the date of
con-firmed payment through post office or bank, if payment was made to the Insured’s account in the Republic of Serbia.
Obsolescence Article 12
(1) Pursuant hereto, claims shall become obsolete in accor-dance with the Law on Obligations and Contracts.
Closing Provisions Article 13
(1) Provisions of General conditions, if not contrary hereto, shall apply to everything not regulated hereunder. (2) Insurer shall be obliged to publish updated version hereof
on its web page.
(3) Special Terms and Conditions for Voluntary Health Insurance for Foreigners due to Occurrence of a Medical Emergency during Their Stay in the Republic of Serbia shall come into force and shall become effective as of the date of obtaining positive opinion from the Republic of Serbia Ministry of Health.
