super health insurance cover
Group insurance terms and conditions
Contents
this is a translation of the original Finnish terms and conditions, which take precedence should there be any differences between the original and the translation.
super health insuranCe Cover ...3
1
the insureD ...3
2
Content oF insuranCe...3
3
valiDitY oF insuranCe ...3
4
MeDiCal treatMent eXpenses Cover ...3
4.1 coverable medical treatment expenses ...3
4.2 Maximum indemnity and maximum indemnity period ...3
4.3 Restrictions on indemnification ...3
4.4 reasonable costs ...3
5
Crisis Cover...3
5.1 coverable expenses ...3
5.2 Maximum indemnity and maximum indemnity period ...4
5.3 Restrictions on indemnification ...4
5.4 reasonable costs ...4
6
MeDiCal eXaMination Cover ...4
6.1 coverable medical examination expenses ...4
6.2 Restrictions on indemnification ...4
6.3 reasonable costs ...4
7
ClaiMinG CoMpensation unDer MeDiCal
treatMent eXpenses Cover anD MeDiCal
eXaMination Cover ...4
7.1 explanation of occurrence of insured event ...4
7.2 claims receipts ...4
7.3 period for claiming compensation ...4
8
ClaiMinG CoMpensation unDer
Crisis Cover...4
8.1 explanation of crisis therapy and compensation receipts ...4
8.2 period for claiming compensation ...4
General terMs oF ContraCt ...5
1
KeY ConCepts ...5
2
DisClosure oF inForMation prior to
ConCluDinG insuranCe ContraCt ...5
2.1 insurance company’s obligation to disclose information ...5
2.2 obligation of the policyholder and the insured to disclose information ...5
2.3 Failure to disclose information ...5
3
BeGinninG oF the insuranCe CoMpanY’s
liaBilitY anD valiDitY oF the insuranCe
ContraCt ...5
3.1 Beginning of the insurance company’s liability ...5
3.2 validity of insurance contract ...5
4
preMiuM ...5
4.1 premium payment ...5
4.2 Delayed premium ...6
4.3 payment of a delayed premium ...6
4.4 returning premiums ...6
4.5 setoff against premiums to be returned ...6
5
DisClosure oF inForMation DurinG
valiDitY oF ContraCt ...6
5.1 insurance company’s obligation to disclose information ...6
5.2 obligation to disclose information to the insured ...6
5.3 policyholder’s obligation to disclose information in the case of increased risk ...6
5.4 notice of termination of group insurance ...6
6
CausinG oCCurrenCe oF
an insureD event ...6
7
irresponsiBilitY anD neCessitY ...6
8
ClaiMs settleMent proCeDure ...6
8.1 obligations of claimant ...6
8.2 time limitation on claims ...7
8.3 insurance company’s obligations ...7
8.4 setoff against compensation ...7
9
loDGinG an appeal aGainst a DeCision
taKen BY the insuranCe CoMpanY ...7
9.1 right to correct ...7
9.2 Finnish insurance ombudsman Bureau and Finnish insurance complaints Board making recommendations for decision ...7
9.3 District court...7
10 insuranCe CoMpanY’s riGht oF reCoverY ...7
11 alterinG the insuranCe ContraCt ...7
11.1 altering the terms of contract during the insurance period ...7
11.2 altering the terms of contract of a continuous policy at the end of an insurance period ...7
11.3 effect of the index ...7
12 terMination oF insuranCe ContraCt ...7
12.1 policyholder’s right to terminate the insurance ...7
12.2 insurance company’s right to terminate the insurance during the insurance period ...7
12.3 insurance company’s right to terminate the insurance at the end of the insurance period ...8
12.4 termination of the insurance in terms of the insured ...8
13 Data proteCtion ...8
super health insuranCe Cover
Please pay special attention to the restrictions printed in italics.
the insurance terms and conditions comprise two parts: these special terms and conditions and the general terms of contract.
1 the insureD
those insured are the persons named in the insurance policy.
2 Content oF insuranCe
the insurance comprises three kinds of cover: - medical treatment expenses cover - crisis cover and
- medical examination cover.
the crisis cover is an additional cover and an integral part of the medical treatment expenses cover, and it is valid as long as the validity of the medical treatment expenses cover. the medical examination cover is optional in the super health insurance cover and is included in the insurance only if an entry has been made to that effect in the insurance policy.
3 valiDitY oF insuranCe
The insurance cover is valid as specified in the general terms of contract.
Compensation on the basis of an illness or injury caused by an accident is paid only for examination or treatment carried out in Finland.
4 MeDiCal treatMent eXpenses Cover
4.1 Coverable medical treatment expenses
4.1.1 the medical treatment expenses cover covers examination and treatment expenses incurred through the insured’s illness or an injury caused by an accident. An illness of the insured
must begin and an accident must take place during the validity of the cover.
4.1.2 Compensation of expenses is conditional
on the examination and treatment of the illness or injury caused by an accident being carried out or prescribed by a physician. Furthermore,
the examination and treatment must be in keeping with generally approved medical principles and necessary for the treatment of the injury caused by an illness or accident. of these expenses, the following are coverable: a) charges for examination and treatment
carried out by health care professionals b) charges for medicinal products sold by
pharmacies under an authorisation issued by the Finnish Medicines agency
c) charges for basic creams and lotions coverable under the health insurance act d) daily hospital charges
e) charges for examination and treatment of dental injuries caused by an accident f) rental charges for temporary medical
aids required by post-operative treatment and recovery. The maximum period for
indemnity is three months. Rental charges for permanent or long-term use of aids are not coverable
g) supports required by post-operative treatment and other comparable temporary personal supports. the maximum period for indemnity is three months. expenses arising from
supports or other similar aids for permanent or long-term use are not coverable
h) charges for physiotherapy
i) charges for psychotherapy given by a psychotherapist approved by the national authority for Medicolegal affairs. Such
psychotherapy is coverable up to a maximum of 20 treatment sessions per insured during the validity of the medical treatment expenses cover
j) charges for neuropsychotherapy, occupational therapy or speech therapy. each type of
therapy is coverable up to a maximum of 20 treatment sessions per insured during the validity of the medical treatment expenses cover
k) reasonable travel expenses incurred in Finland caused by travel to a local physician, dentist or nursing institution due to an accident.
if surgical treatment of an injury caused by an insured’s coverable illness or accident requires an organ or tissue donation from another person, the insurance covers up to the remaining sum insured expenses for surgery incurred by this other person in Finland and related hospital care expenses as follows:
- charges for a surgical operation to an organ or tissue donor carried out by a physician - charges for hospital care in close connection
with a surgical operation.
4.2 Maximum indemnity and maximum indemnity period
expenses are coverable during the validity of the medical treatment expenses cover up to the sum insured recorded in the insurance policy per insured. compensation paid will reduce the remaining sum insured.
Compensation is paid only if the expenses are incurred during the validity of the cover. The insurance covers examination and treatment carried out in a public medical care unit up to the patient fees that the insured is charged.
4.3 Restrictions on indemnification
Expenses are coverable as far as they do not grant or would not have granted entitlement to compensation under the Sickness Insurance Act or some other act.
The insured’s illnesses or injuries caused by accicent that have a clear medical link will be regarded as a single illness or injury. The medical treatment expenses cover does not cover expenses
- for the examination or treatment of a person who is not in an employment or other contractual relationship with the policyholder
- for examination or treatment focusing on teeth or their support tissue or relating to bite correction or orthodontic treatment unless the purpose is to treat a dental injury caused by an accident. Injury caused by biting a tooth or dental prosthesis is not coverable even if external factors have contributed to the damage
- for examination or treatment relating pregnancy, prevention of pregnancy, giving birth, abortion of pregnancy or infertility or complications relating to them
- for examination and treatment relating to an illness or accident caused by the consumption of alcohol, other intoxicants, medicinal or narcotic substances - for examination and treatment relating to
addiction to narcotic substances, alcohol, medicinal substances, nicotine or other substances or some other addiction - for treatment of snoring unless the
treatment concerns sleep apnea confirmed
through sleep registration - for rehabilitation
- for physiotherapy, psychotherapy, neuropsychotherapy, occupational therapy or speech therapy or other comparable treatment unless it is a question of treatment referred to in sections 4.1.2 h), i) and j) above
- for trace element, mineral, nutritive, herbal medicinal, vitamin or anthroposophical or homeopathic products
- for the correction of refractive errors - for examination or treatment relating to
appearance, looks, obesity or primarily to enhancing the quality of life. These include examination and treatment relating to breast enlargement or reduction, eyelid enhancement or liposuction
- for the acquisition of artificial limbs, medical equipment or other aids excluding the cases referred to in sections 4.1.2 f) or g) - for the examination or treatment of an
illness or injury caused by an accident arising from a nuclear accident described in the Nuclear Liability Act (484/1972) regardless of where the nuclear accident has taken place
- for the examination or treatment of an illness or injury caused by an accident arising from war or armed conflict. This restriction does not apply during the 10 days from the beginning of the armed operations unless it is a major war or unless the insured has taken part in the said operations
The medical treatment expenses cover does not cover
- fees for medical certificates issued by physicians unless the company has requested a medical certificate
- other indirect expenses such as accommodation.
The medical treatment expenses insurance does not cover expenses caused by examination or treatment, if the illness or injury was caused in professional sports as provided under the Act on athletes’ accident and pension cover (276/2009).
4.4 reasonable costs
if it is apparent that the claimed expenses substantially exceed the reasonable level which is generally accepted and applied, the insurance company has the right to lower the indemnity but not, however, below the reasonable level.
Costs incurred by the insured person using his/her own car are covered as reasonable or necessary expenses to the maximum amount of motor vehicle travel costs specified under the decree issued by the Ministry of Social Affairs and Health on the basis of the Health Insurance Act.
5 Crisis Cover 5.1 Coverable expenses
the death must have occurred or the codetermination negotiations must have begun during the validity of the cover.
5.1.2 the cover is valid in Finland. the crisis therapy must be started at the latest one week from the death or the beginning of the codetermination negotiations.
5.1.3 compensation for the expenses is conditional on the company officially deciding to provide therapy. a psychologist’s or health care professional’s fees for holding a crisis therapy session are covered under these expenses.
5.2 Maximum indemnity and maximum indemnity period
Crisis therapy expenses incurred by the policyholder are coverable up to three therapy sessions given to the same group over a maximum period of two months. the period is
calculated from the date when the first expense item is incurred.
The policyholder’s crisis therapy expenses are coverable up to the limit recorded in the insurance policy.
compensation paid will not reduce the sum insured for the medical treatment expenses cover recorded in the insurance policy.
5.3 Restrictions on indemnification
expenses are coverable as far as they do not grant or would not have granted entitlement to compensation under the sickness insurance act or some other act.
compensation is paid only if the expenses have arisen during the validity of the cover.
The crisis cover does not cover expenses for other therapy or individual therapy such as psychotherapy.
The crisis cover does not cover indirect expenses such as travel and accommodation.
5.4 reasonable costs
if it is apparent that the claimed expenses substantially exceed the reasonable level which is generally accepted and applied, the insurance company has the right to lower the indemnity but not, however, below the reasonable level.
6 MeDiCal eXaMination Cover 6.1 Coverable medical examination
expenses
the medical examination cover covers expenses for a medical examination of the insured carried out to prevent
- diabetes, hypertension, disorders in the lipid metabolism
- intestinal cancer, cervical cancer, breast cancer, prostate cancer and
- mental illness.
The medical examination must be carried out in a care institution named or separately approved by the insurance company.
regardless of the extent of the medical examination,
a maximum of one medical examination is covered per two years per insured.
the medical examination for diabetes, hypertension and disorders of lipid metabolism include BM, index, waist measurement, hypertension, blood sugar and lipid tests. the medical examination for intestinal cancer includes faecal blood testing, the medical examination for cervical cancer includes the pap test, the medical examination for breast cancer includes mammography, and the medical examination for prostate cancer includes the psa blood serum test.
the medical examination for mental illness includes the charting of symptoms during a single session using a standardized questionnaire or through a clinical interview.
the medical examination must be in accordance with the generally accepted medical principles and necessary in terms of screening for the illness in question.
6.2 Restrictions on indemnification
expenses are covered as far as they do not grant or would not have granted entitlement to compensation under the sickness insurance act or some other act.
Medical examinations carried out in a public medical care unit are coverable only up to the patient fees that the insured is charged. compensation is paid only if the expenses have arisen during the validity of the cover.
the medical examination cover does not indemnify expenses
- for the medical examination of a person who is not in an employment or other contractual relationship with the policyholder
- examinations or health checks that fall within the sphere of other occupational health care arranged by the policyholder The following are not coverable under the medical examination cover:
- fees for medical certificates issued by physicians unless the company has requested such a certificate
- other indirect expenses such as travel and accommodation.
6.3 reasonable costs
if it is apparent that the claimed expenses substantially exceed the reasonable level which is generally accepted and applied, the insurance company has the right to lower the indemnity but not, however, below the reasonable level.
7 ClaiMinG CoMpensation unDer MeDiCal treatMent eXpenses Cover anD MeDiCal eXaMination Cover
7.1 explanation of occurrence of insured event
the claimant must at his/her own expense submit to the insurance company a written explanation of the occurrence of the insured event and other explanations necessary for settling a claim. This must be done by filling in a claims form that must be included in the documentation submitted to the insurance company.
if the insured has a customer card allowing direct debiting, the explanation of the occurrence may also be submitted by a provider of health services or some other party invoicing treatment expenses in accordance with guidelines agreed separately with the insurance company.
7.2 Claims receipts
the claimant must pay the expenses him/ herself and claim compensation under the sickness insurance act. compensation under the sickness insurance act must be claimed from the social insurance institution within one month of the payment of the expenses. the claimant must submit to the insurance company the original decision made by the social insurance institution on the compensation payable and copies of the receipts submitted to the social insurance institution. receipts for which compensation has not been paid under the sickness insurance act or any other act must be submitted to the insurance in original. if the insured has a customer card allowing direct debiting, it may be used on the condition that the provider of the health care service or some other party invoicing treatment expenses deducts from the invoice the part compensated under the sickness insurance act, after which the remaining part may be invoiced from the insurance company. users of customer cards must also present a valid sickness insurance card.
7.3 period for claiming compensation
claims for expenses must be submitted to the insurance company within one year of incurring the expenses concerned.
8 ClaiMinG CoMpensation unDer Crisis Cover
8.1 explanation of crisis therapy and compensation receipts
the policyholder must submit to the insurance company a written explanation of the crisis therapy given. This can be done by filling in the insurance company’s claims form which must be included in the documentation submitted to the insurance company.
the claimant must pay the expenses him/herself and submit the original receipts to the insurance company. A copy of the official decision on the provision of crisis therapy must also be submitted to the insurance company.
8.2 period for claiming compensation
General terMs oF ContraCt
the insurance terms and conditions comprise two parts: these special terms and conditions and the general terms of contract.
the insurer is pohjola insurance ltd (hereafter the insurance company).
1 KeY ConCepts accident and illness
an accident is a sudden, external occurrence causing bodily injury unintended by the insured.
the following are also considered to be accidents: unintentional drowning, heatstroke, sunstroke, frostbite, injury caused by considerable variation in atmospheric pressure, gas poisoning sustained by the insured, and poisoning caused by a substance taken inadvertently.
illness means a condition requiring medical care that on the basis of an explanation provided has been found to have been caused by means other than an accident and that is classified as an illness according to the official diagnosis. the concepts “accident” and “illness” do not include injury caused by suicide or attempted suicide.
examination
examination means a medical examination.
Daily hospital charge
a daily hospital charge means a charge by a medical care institution on the basis of the
insured having been recorded as a patient in the institution overnight. if the insurance covers
daily hospital charges, the daily maximum specified in the insurance policy is paid for the first day of care and for the following full days on a beginning day of care, which is charged separately.
2 DisClosure oF inForMation prior to ConCluDinG insuranCe ContraCt
2.1 insurance company’s obligation to disclose information
prior to concluding the insurance contract, the insurance company will provide the insurance applicant with the essential information on such matters as the insurance company’s own types of insurance, premiums and insurance terms and conditions, so that the applicant can evaluate his/ her insurance needs and choose the most suitable insurance cover.
When disclosing the information, attention will also be paid to essential restrictions in the insurance cover.
if the insurance company or its representative has failed to provide the policyholder with the necessary information when marketing the insurance or has provided him/her with erroneous or misleading information, the insurance contract is considered valid in the form that the policyholder has had reason to understand it in the light of the information he/ she received.
2.2 obligation of the policyholder and the insured to disclose information
Prior to the insurance being granted, the policyholder and the insured shall provide full and correct answers to all questions presented by the insurance company which may affect
the assessment of the insurance company’s liability. During the insurance period, the policyholder and the insured must also correct without undue delay any information provided to the insurance company by him/her which he/ she has found to be erroneous or deficient.
2.3 Failure to disclose information
If the policyholder or the insured has acted fraudulently with regard to the abovementioned obligation, the insurance contract is not binding on the insurance company. The insurance company has the right to withhold all premiums paid, even if the insurance is annulled.
If the policyholder or the insured has wilfully or through negligence which cannot be deemed minor failed in his/her obligation to disclose information in insurance, and the insurance company would have refused to grant the insurance altogether had the full and correct information been provided, the insurance company is free from liability. If the insurance company would have granted the insurance only against a higher premium or otherwise on terms other than those agreed, the insurance company’s liability is restricted to that which corresponds to the agreed premium or the terms on which the insurance would have been granted.
the consequences of the policyholder’s or the insured’s failure to disclose information as stated above will not apply if the result is clearly unreasonable from the point of view of the policyholder or other party entitled to the compensation.
the insurance company has the right to incorporate a restriction to the insurance cover of a single insured if the policyholder or the insured has given incorrect or deficient information on the state of health of the insured at the time of inclusion under the insurance.
3 BeGinninG oF the insuranCe CoMpanY’s liaBilitY anD valiDitY oF the insuranCe ContraCt
3.1 Beginning of the insurance company’s liability
the insurance company’s liability commences at the point of time agreed jointly by the parties and entered in the insurance policy. if no point of time has been agreed, the insurance company’s liability starts when the insurance company or the policyholder has submitted or sent an affirmative reply to the offer of the other contracting party. if no record exists of the time of day when the reply or application was submitted or sent, it is considered to have taken place at 24.00. the insurance company’s liability does not begin, however, until the premium for the insurance has been paid if the policyholder has outstanding premiums overdue on other insurances taken from the insurance company
in the case of an individual insured, insurance cover begins from the day the insurance starts. if the policyholder later notifies the insurance company of the inclusion of a person in the insurance, the insurance cover for this particular insured begins when the written notification is submitted or sent to the insurance company. the commencement of insurance cover requires the insured to meet the criteria for inclusion in the insurance in accordance
with the risk selection principles applied by the insurance company. a separate agreement can also be made on the commencement of the cover at some other point of time.
the premium and other terms of contract are determined in accordance with the policy anniversary. if new cover or insurance is added to the contract, the premium and other terms of contract for this cover or insurance are determined in accordance with the time of commencement of the added cover or insurance.
The state of health of the insured is assessed on the basis of the date of submission of the medical report.
the age of the insured is calculated by subtracting the insured’s year of birth from the year of commencement of the insurance.
3.2 validity of insurance contract
After the first insurance period, the insurance contract is valid for one agreed insurance period at a time unless the policyholder or the insurance company terminates the contract or part of it. the insurance is terminated in the following cases:
- For the insured, the insurance is terminated at the end of the insurance period during which the insured becomes 68 years of age - For the insured, the insurance is terminated
on the date on which the insured moves outside Finland or on the last date of validity of his/her social security card
- For the insured, the insurance is terminated when compensation up to the sum insured in the insurance policy has been paid for the benefit of the insured
- For the insured, the insurance is terminated when the insured’s employment or other contractual relationship with the policyholder is terminated. The last date of validity for the insurance is the insured’s last day of employment or the last day of validity of some other contractual relationship
- The insurance is terminated on the death of the insured.
in cases other than those referred to above, the insurance is, for the insured, terminated one month from the date on which the policyholder or the insurance company sends notification of termination to the insured.
the insurance contract may also be terminated for other reasons referred to in sections 4.2 (Delayed premium) and 12 (termination of insurance contract).
4 preMiuM 4.1 premium payment
the insurance premium must be paid at the latest on the due date of the invoice sent by the insurance company. however, the initial premium need not be paid before the start of the insurance company’s liability.
If a payment by the policyholder is not sufficient to cover all of the insurance company’s insurance premium receivables, the policyholder has the right to decide for which outstanding premium he/she wishes to use the money.
the premium is determined on the basis of the size of the insured’s insurance cover in accordance with the technical principles.
4.2 Delayed premium
If the premium has not been paid in full by the due date the insurance company has the right to terminate the insurance contract 14 days after sending notice of termination.
the insurance continues if the premium is paid in full before the end of the notice period.
If the premium is not paid by the time limit set, penalty interest must be paid for the period of delay in accordance with the Interest Act.
4.3 payment of a delayed premium
if a policyholder pays a neglected premium in full after the insurance has expired, the insurance company’s liability commences on the day following payment. in this case, the insurance is valid until the end of the insurance period originally agreed, as of the time the insurance regained validity.
however, if the insurance company is against granting a renewal of validity, it notifies the policyholder within 14 days of receiving the premium that it will not accept the payment. the insurance company is entitled to compensation for expenses incurred through collection of a premium under the act on the collection of Debts. if a premium is collected through legal proceedings, the insurance company is entitled to statutory general fees for court proceedings and legal expenses. the insurance company may transfer its receivables to a third party for collection. the insurance company charges the minimum payment recorded in the insurance policy for the insurance.
4.4 returning premiums
if the insurance expires before the date agreed, the insurance company is entitled only to the premium for the period during which it was liable. the rest of the premium paid is returned to the policyholder.
However, the premium is not returnable if fraudulent action has been taken in a matter pertaining to the obligation of the policyholder and the insured to disclose information (section 2.2).
When determining the amount of returnable premium, the validity is calculated in days, according to the insurance period to which the premium pertains. the premium is not returned separately, however, if the returnable sum is smaller than the sum recorded in the insurance contracts act or laid down by decree.
4.5 setoff against premiums to be returned
The insurance company may deduct any outstanding premiums overdue and other overdue receivables from the premium to be returned.
5 DisClosure oF inForMation DurinG valiDitY oF ContraCt 5.1 insurance company’s obligation to
disclose information
after making an insurance contract, the insurance company issues the policyholder with
an insurance policy and the insurance terms and conditions.
During the validity of the insurance, the insurance company notifies the policyholder annually about the sum insured and any other insurance-related matters which are of obvious relevance to the policyholder.
if, during the validity period of the insurance, the insurance company or its representative has provided deficient, incorrect or misleading information on the insurance, the insurance contract will be considered valid in the form that the policyholder has had reason to understand it, if such deficient, incorrect or misleading information can be regarded as having influenced the policyholder’s conduct. however, this does not apply to information provided by the insurance company or its representative on future compensation payable after an insured event has occurred.
5.2 obligation to disclose information to the insured
if it has been agreed in the group insurance that the insurance company will keep a list of those insured under the group insurance, the insurance company will, on the entry into force of the insurance cover and at reasonable intervals thereafter, provide the insured with information on the extent of the cover, essential restrictions in the cover, obligations of the insured on the basis of the insurance contract and how the validity of the insurance depends on the inclusion of the insured in the group specified in the group insurance contract.
if the insurance company does not keep a list of the insured, the abovementioned information will be given to the insured in a suitable manner agreed in the group insurance contract, taking circumstances into account.
5.3 policyholder’s obligation to disclose information in the case of increased risk
The policyholder and the insured must notify the insurance company of any changes in factors increasing risk that were reported when the insurance contract was concluded and that are relevant in terms of assessment of the insurance company’s liability, such as changes in profession, hobbies or domicile, or the termination of any other insurance cover. The insurance company must be notified of any such changes without delay and at the latest when the next premium following the change is paid.
If a policyholder has wilfully or through negligence which cannot be deemed minor failed to notify increased risk as mentioned above, and the insurance company would not, as a result of the changed circumstances, have kept the insurance in force, the insurance company is released from liability. If, however, the insurance company, would have extended the validity of the insurance for a higher premium or on some other terms, the insurance company’s liability is limited to what corresponds to the premium paid or the terms on which the insurance would have been extended.
5.4 notice of termination of group insurance
if a group insurance is terminated as a result of action by the insurance company or the group insurance policyholder, the insurance company will inform the insured of the termination. if it is agreed in the group insurance that the insurance company will keep a list of those insured under the group insurance, notification will be sent to the insured on the termination. if the insurance company does
not keep a list of the insured, the notification of termination will be given in the way agreed in the group insurance contract concerning disclosure of information referred to in section 5.2.
in terms of the insured, the insurance will be terminated one month from the date on which the insurance company sent to the insured notification of the termination or gave notification of the termination in the way agreed in the group insurance contract.
6 CausinG oCCurrenCe oF an insureD event
The insurance company is released from liability to any insured who has wilfully caused the occurrence of the insured event.
If the insured has caused the occurrence of the insured event through gross negligence, the insurance company’s liability may be reduced, depending on what is reasonable in the circumstances.
if a person other than the insured who is entitled to compensation has wilfully caused the occurrence of the insured event, the insurance company is released from liability to such party.
if such a person has caused the occurrence of the insured event through gross negligence or if he/she was at an age or in a state of mind which means that he/she could not be sentenced for a crime, the indemnity or part of the indemnity may be paid to him/her, but only when this is deemed reasonable considering the circumstances in which the occurrence was caused.
7 irresponsiBilitY anD neCessitY
the insurance company will not appeal to section 6 above to release itself from or restrict its liability if the insured was under 12 years of age at the time he/she caused the occurence of the insured event or was in such a state of mind that he/she could not have been sentenced for a crime.
the insurance company will not appeal to sections 5 and 6 to release itself from or restrict its liability if the insured was seeking to prevent injury to a person or damage to property in circumstances where his/her negligence or action was justifiable at the time he/she increased the risk or caused the occurence of the insured event.
8 ClaiMs settleMent proCeDure
8.1 obligations of claimant
the claimant must provide the insurance company with documents and information necessary for the assessment of the insurance company’s liability. these include documents and information which confirm the occurrence of an insured event, the extent of the claims incurred and to what action the compensation is allocated. the claimant is required to acquire the explanations which he/she is best equipped to obtain.
the claimant must obtain the documentation and explanations and submit them to the insurance company at his/her own expense unless otherwise agreed in the terms and conditions or otherwise.
If the claimant has, after the occurence of the insured event, fraudulently provided the insurance company with incorrect or deficient information which is of importance in investigating the occurrence of the insured event and assessing the insurance company’s liability, the indemnity can be reduced or disallowed, depending on what is reasonable in the circumstances.
8.2 time limitation on claims
A claim must be presented to the insurance company within one year of the date on which the claimant was informed of his/her right to obtain compensation, at the latest within 10 years of the occurrence of the insured event. Making notification of the occurrence of the insured event is comparable to presentation of the claim. If the claim is not presented within the said period, the claimant loses his/her right to obtain compensation.
8.3 insurance company’s obligations
after the occurrence of an insured event, the insurance company will provide the claimant with information on the contents of the insurance and the claim procedure. no advance information given to the claimant on the future compensation, its amount or the method of payment will affect the payment obligation as stated in the insurance contract.
the insurance company will pay the indemnity resulting from the occurrence of the insured event in accordance with the insurance contract or notify the claimant of non-payment of indemnity without delay or, at the latest, one month from the date when it received the documentation and information necessary for the assessment of its liability. if the amount of the indemnity is disputed, the insurance company will nonetheless pay any undisputed part of the compensation in the said period.
the insurance company will pay penalty interest on delayed compensation in accordance with the interest act.
8.4 setoff against compensation
The insurance company may deduct any outstanding premiums overdue and other overdue receivables from the indemnity, should the beneficiary be the policyholder.
9 loDGinG an appeal aGainst a DeCision taKen BY the insuranCe CoMpanY 9.1 right to correct
if a policyholder or a claimant suspects that the insurance company has made a mistake in its indemnity decision or some other decision, he/ she has the right to obtain more information about matters which have led to the decision. the insurance company will revise the decision if the new investigations give cause to do so.
9.2 Finnish insurance ombudsman Bureau and Finnish insurance Complaints Board making recommendations for decision
If the policyholder or claimant is dissatisfied with the company’s decision, he/she may ask the Finnish insurance ombudsman Bureau for advice and counselling. the Bureau is an impartial body whose function is to advise consumers in insurance and claim matters. the insurance company’s decision can be submitted to the Finnish insurance complaints Board, which operates in conjunction with the Finnish insurance ombudsman Bureau.
its function is to make recommendations for decisions in disputes which concern interpretation and application of the law and insurance terms and conditions in an insurance relationship.
the Board will not handle a case while it is pending or when a ruling has been given in court.
9.3 District court
if the policyholder, the insured or some other claimant is dissatisfied with the insurance company’s decision, he/she may bring action against the insurance company in the helsinki district court, in the district court of his/her domicile in Finland, or in the district court in the place of loss in Finland.
action against the insurance company’s compensation decision must be brought within three years of the relevant person being informed in writing about the insurance company’s decision and the time limit or the right to bring action is forfeited.
10 insuranCe CoMpanY’s riGht oF reCoverY
the insured’s right to claim compensation from a third party for expenses incurred through illness or accident for which the insurance company has paid compensation to the insured is transferred to the insurance company if the third party had caused the occurrence of the insured event wilfully or through gross negligence or is liable under law to pay compensation regardless of negligence.
11 alterinG the insuranCe ContraCt
11.1 altering the terms of contract during the insurance period
the insurance company has the right to alter the insurance premiums or other terms of contract during the insurance period to correspond to the current or changed circumstances if
- the policyholder or the insured has wilfully or through negligence which cannot be deemed minor neglected his/her obligation to disclose information as referred to in section 2, and the insurance company, had it been given the correct information, would have granted the insurance only against a higher premium or on terms other than those agreed on; or
- during the insurance period, a change as referred to in section 5.3 has occurred in the circumstances disclosed by the policyholder or the insured to the insurance company at the time the contract was concluded, and the insurance company would grant the insurance only against a higher premium or on other terms in these changed circumstances.
after being informed of the abovementioned change, the insurance company will notify the policyholder without undue delay of any change in the premium or terms and conditions.
11.2 altering the terms of contract of a continuous policy at the end of an insurance period
11.2.1 Notification procedure
the insurance company has the right to alter the insurance terms and premiums and other terms of contract at the end of the insurance period on the basis of
- new or amended legislation or a regulation by the authorities
- changes in judicial practice
- an unforeseen change in circumstances (e.g. an international crisis, exceptional natural event, catastrophe)
- a change in the index affecting the insurance and recorded in the policy - a change in the claims expenditure of the
insurance.
the insurance company also has the right to make minor changes to the insurance terms and conditions provided that the changes do not affect the primary content of the insurance contract.
if the insurance company alters the insurance contract as outlined above, it will send to the policyholder with the insurance policy notification concerning how and from what date the premium or other terms will change. The notification will include the mention that the policyholder has the right to terminate the insurance. the change will take effect from the beginning of the next insurance period or immediately after one month has passed from the date the notification was sent.
11.2.2 changes requiring termination of insurance
if the insurance company alters the insurance terms and conditions, premiums or other terms of contract in cases other than those listed above in 11.2.1 or discontinues a forcefully marketed benefit, the insurance company must give notice of the termination of insurance as of the end of the insurance period. the notice must be given in writing one month before the end of the insurance period at the latest.
11.3 effect of the index
premiums and the remaining sum insured under the special conditions will be increased on each main due date in accordance with the price trend in the health and medical care category of the consumer price index.
the increase is determined on the basis of the september index.
12 terMination oF insuranCe ContraCt
12.1 policyholder’s right to terminate the insurance
the policyholder has the right to give notice of termination of the insurance contract during the insurance period. the notice must be given in writing. any other notice is invalid. if the policyholder has not specified a later termination date for the insurance, the insurance will terminate when the notice has been submitted or sent to the insurance company.
12.2 insurance company’s right to terminate the insurance during the insurance period
the insurance company has the right to give notice of termination of the insurance during the insurance period if:
1) the policyholder or the insured has wilfully or through negligence which cannot be deemed minor neglected his/her obligation to disclose information as referred to in section 2, and the insurance company, had it been given the correct information, would have refused to grant the insurance altogether;
pohjola insurance ltd, lapinmäentie 1, Fi-00013 pohjola Domicile: helsinki, main field of operations: insurance business
the company has been entered in the Finnish trade register, business iD 1458359-3
3) the policyholder has wilfully or through negligence which cannot be deemed minor neglected his/her obligation to disclose information about an increase in risk as referred to in section 5.3 and the insurance company, due to the changed circumstance, would no longer have continued the validity of the insurance, unless the notice of termination of the insurance would lead to a clearly unreasonable situation for the policyholder or some other party entitled to indemnity;
4) during the insurance period, a change as referred to in section 5.3 has occurred in the circumstances disclosed to the insurance company by the policyholder or the insured at the time the contract was concluded and the insurance company would no longer grant the insurance in the changed circumstances.
the insurance company may terminate the insurance cover of a single insured during the insurance period if the policyholder or the insured has, when the insured was included in the insurance, given the insurance company incorrect or deficient information and the insured would not have been included in the insurance if correct or complete information had been given.
having been informed of the grounds for termination, the insurance company will give written notice of termination without undue delay. the insurance will terminate one month from the time the notice was sent.
the insurance company’s right to give notice of termination of insurance as a result of failure to pay the premium is defined under section 4.2.
12.3 insurance company’s right to terminate the insurance at the end of the insurance period
the insurance company has the right to terminate an insurance as of the end of the insurance period. if no agreement has been made on the insurance period, the insurance company correspondingly has the right to terminate the insurance as of the end of the calendar year. however, insurance cannot be terminated because the state of health of the insured has deteriorated since the time the policy was taken out or because the insured event has occurred.
the notice of termination is sent one month before the end of the insurance period at the latest or, if no agreement has been made on the insurance period, one month before the end of the calendar year at the latest.
12.4 termination of the insurance in terms of the insured
in cases referred to in section 3.2 and in section 12 above, the insurance company will notify the insured of the termination of the insurance through the procedure specified in section 5.4. in terms of the insured, the insurance will be terminated one month from the date on which
the insurance company sent to the insured notification of the termination or gave notification of the termination in the way agreed in the group insurance contract.
13 Data proteCtion
the policyholder is a company and those insured are all the employees of the policyholder or part of the employees as specified in the insurance policy.
the policyholder is not entitled to obtain information about the state of health of those insured. For the same reason, the insurance company may refuse to justify or explain possible restrictions or increases in the premium to the policyholder.
14 insuranCe ContraCt anD appliCaBle laW
