Zavarovalec – oseba, ki sklene zavarovalno pogodbo.
Splošni pogoji za zdravstveno zavarovanje oseb v tujini z asistenco 01-ZZTA-01/16
1. člen UVODNE DOLOČBE
(1) Splošni pogoji za zdravstveno zavarovanje oseb v tujini z asistenco (v nadaljevanju pogoji) so sestavni del zavarovalne pogodbe, ki jo zavarovalec sklene z Adriaticom Slovenico Zavarovalno družbo d. d. Koper (v nadaljevanju zavarovalnica).
(2) Izrazi v teh pogojih pomenijo:
Zavarovalec – oseba, ki sklene zavarovalno pogodbo.
Zavarovanec – oseba, katere premoženjski interes je zavarovan in je navedena na polici.
Upravičenec – oseba, ki je upravičena do zavarovalnine oz. povračila stroškov v primeru nastanka zavarovalnega primera.
Zavarovalna pogodba – pogodba o zagotavljanju asistence, ki jo skleneta zavarovalec in zavarovalnica.
Polica – listina o sklenjeni zavarovalni pogodbi za zdravstveno zavarovanje oseb v tujini z asistenco, ki jo je izdala zavarovalnica zavarovancu, ki potuje v tujino. Premija – znesek, ki ga zavarovalec plača zavarovalnici po zavarovalni pogodbi. Zavarovalnina – znesek, ki ga zavarovalnica plača v okviru določil zavarovalne pogodbe zavarovancu.
Zavarovalni primer – dogodek, ki ga krije to zavarovanje in nastopi v obdobju trajanja tega zavarovanja.
Asistenca – pomoč v primeru bolezni ali telesne poškodbe v času nahajanja v tujini. Asistenčna družba – Assistance CORIS, d.o.o., Ul. bratov Xxxxxx 00, 0000 Xxxxxxxxx, Xxxxxxxxx.
Tujina – področje, kjer zavarovalnica zavarovancu v skladu z zavarovalno pogodbo nudi zavarovalno kritje. Za tujino se ne šteje država, kjer ima zavarovanec stalno oziroma začasno bivališče (v nadaljevanju domovina).
Država stalnega bivališča – država, kjer ima zavarovanec stalno oziroma začasno uradno bivališče.
2. člen ZAVAROVANE OSEBE
(1) Pri posameznem zavarovanju je zavarovanec oseba, ki je navedena na polici.
(2) Pri družinskem zavarovanju so zavarovanci osebe, ki so navedene na polici in živijo v skupnem gospodinjstvu ter so med seboj v družinskem razmerju: zakonec ali partner iz druge pravno priznane skupnosti in njihovi otroci, pastorki ali posvojenci do 26. leta starosti.
(3) Pri skupinskem zavarovanju so zavarovanci vse osebe, ki so navedene na polici oziroma v prilogi k polici in predstavljajo skupino. Skupina pomeni 9 ali več oseb, ki skupaj istočasno odhajajo na isto destinacijo v tujino. Če je manj kot 9 oseb, se uporabljajo določila za posamezno zavarovanje, če ni drugače dogovorjeno.
(4) Zavarovanci po teh pogojih so lahko le osebe do dopolnjenega 75. leta starosti. Z ustreznim doplačilom na premijo se lahko zavarujejo tudi osebe, starejše od 75 let.
(5) Zavarovalec ne more biti oseba, ki ji je odvzeta popolna poslovna sposobnost, in duševno motena oseba.
3. člen ZAČETEK IN TRAJANJE ZAVAROVANJA
(1) Zavarovalno kritje se začne ob 00.00 uri tistega dne, ki je v polici naveden kot začetek zavarovanja, če je do takrat plačana premija. Če premija do tedaj ni plačana, se začne zavarovalno kritje ob 00.00 uri naslednjega dne, ko je plačana.
(2) Zavarovalno kritje preneha ob 24.00 uri tistega dne, ki je v polici naveden kot dan prenehanja zavarovanja.
(3) Pri celoletnem zavarovanju za večkratne odhode zavarovanca v tujino zavarovanje velja za neomejeno število odhodov v tujino v enem zavarovalnem letu, s tem da posamezno zadrževanje v tujini ne sme trajati več kot 90 dni.
4. člen KRAJ ZAVAROVANJA
Zavarovalno kritje je veljavno samo v tujini – to je izven območja države, kjer ima zavarovanec prijavljeno stalno bivališče oziroma začasno bivališče (v nadaljevanju domovina).
5. člen VELJAVNOST ZAVAROVANJA
(1) Zavarovalna pogodba je sklenjena, ko pogodbenika podpišeta zavarovalno polico ali potrdilo o kritju.
(2) Če ni drugače dogovorjeno, učinkuje zavarovalna pogodba od 00.00 ure dneva, ki je v polici označen kot dan začetka zavarovanja, pa vse do konca zadnjega dneva, za katerega je zavarovanje sklenjeno.
(3) Če je dogovorjeno, da je treba premijo plačati:
1. ob sklenitvi pogodbe in premija ni bila plačana, začne teči obveznost zavarovalnice, da izplača v pogodbi določeno zavarovalnino, ob 00.00 uri dne, ko je premija plačana;
2. po sklenitvi pogodbe, začne teči obveznost zavarovalnice, da izplača v pogodbi določeno zavarovalnino, na dan, ki je v pogodbi določen kot dan začetka zavarovanja.
(4) V primeru sklepanja na daljavo je zavarovalna pogodba sklenjena s plačilom premije, kar zavarovalec dokazuje s potrdilom o plačilu premije.
(5) Zavarovanje je potrebno skleniti pred odhodom zavarovanca v tujino. Če se ob sklenitvi zavarovanec nahaja v tujini, zavarovalno kritje po teh pogojih prične veljati šele po preteku 5 dni od dneva sklenitve zavarovanja.
(6) Zavarovanje je možno obnoviti najkasneje 5 dni pred iztekom tekočega zavarovalnega obdobja. Če se zavarovanje obnovi po izteku omenjenega roka, v prvih 5 dnevih obnovljenega zavarovanja ni zavarovalnega kritja za primer bolezni (karenca). Karenca se ne upošteva, če se zavarovanec ob obnovitvi nahaja v domovini.
6. člen OBSEG KRITJA
(1) Zavarovanje nudi naslednja kritja:
1. STORITVE ASISTENČNEGA KLICNEGA CENTRA:
- dostopnost asistenčnega klicnega centra 24 ur na dan 7 dni v tednu,
- organizacijo nujne zdravstvene pomoči,
- organizacijo nujnih zdravstvenih prevozov zavarovanca,
- obveščanje zavarovanca in njegovih najbližjih,
- telefonske stroške za nujne klice na asistenčno družbo.
2. NUJNE STROŠKE:
2.1 Medicinska oskrba in obisk zdravnika
Kriti so nujni stroški medicinske oskrbe in obisk zdravnika, ki so posledica nezgode ali bolezni zavarovanca v tujini.
2.2 Zdravljenje
Kriti so nujni stroški zdravljenja, ki so posledica nezgode ali bolezni zavarovanca v tujini. Obsegajo zdravljenje do dne, ko zdravstveno stanje zavarovanca le temu dovoljuje prevoz v državo stalnega prebivališča, kjer bo nadaljeval z zdravljenjem. Nujni stroški zdravljenja vključujejo tudi stroške zdravljenja za akutna poslabšanja, vendar le za naslednje kronične bolezni: bolezni srca, ledvičnih kamnov, astme in sladkorne bolezni.
2.3 Zdravila in zdravniški pripomočki
Vključeni so stroški zdravil in zdravniških pripomočkov, izdanih na zdravniški recept ali predpisanih na zdravniškem izvidu.
2.4 Nujne zobozdravstvene storitve
V kritje so vključeni nujni stroški za zobozdravstveno pomoč, ki je potrebna za odpravo akutne bolečine zaradi bolezni ali sveže poškodbe zobovja, vključno z ekstrakcijo zoba.
3. DODATNE STROŠKE:
3.1 Prevoz do najbližje bolnišnice in nazaj
Vključeni so stroški prevoza zavarovanca do najbližje bolnišnice ali klinike in nazaj do mesta nahajanja v tujini.
3.2 Prevoz v domovino
Kriti so stroški prevoza obolelega ali poškodovanega zavarovanca v domovino, če zdravstveno stanje zavarovanca dopušča prevoz, s tem da se predhodno pridobi soglasje asistenčne družbe in se zavarovanec iz zdravstvenih razlogov ne more vrniti v domovino na način, kot je to prvotno nameraval.
3.3 Prevoz in bivanje za osebo, ki ostane v spremstvu zavarovanca
Kriti so dodatni stroški prevoza in stroški bivanja za osebo, ki na zahtevo oziroma po priporočilu lečečega zdravnika ostane v spremstvu zavarovanca, oziroma stroški prevoza ožjega sorodnika iz domovine do kraja hospitalizacije, če zavarovancu ni mogoče zagotoviti drugačnega spremstva. Če je zavarovanec mladoletna oseba, se krijejo dodatni stroški prevoza in stroški bivanja za osebo, ki ostane v spremstvu zavarovanca, ne glede na to ali je spremstvo priporočil lečeči zdravnik.
3.4 Spremstvo in prevoz mladoletnega otroka
Kriti so stroški prevoza zavarovančevega otroka, mlajšega od 18 let, do stalnega bivališča, kot tudi stroški prevoza njegovega spremljevalca v primeru zavarovančeve hospitalizacije ali smrti, če otrok ostane brez spremstva odrasle osebe.
3.5 Prevoz družinskega člana
Kriti so stroški obiska zavarovanca. Vključeni so stroški povratne vozovnice za javni prevoz (ekonomski razred) za enega družinskega člana (otrok, partner, xxxxx, brat ali sestra, zakončev starš), če se zavarovanec iz zdravstvenih razlogov ne more vrniti v domovino in je hospitaliziran več kot 7 dni iz razlogov, kritih po teh pogojih.
3.6 Prevoz posmrtnih ostankov v domovino zavarovanca
Kriti so stroški prevoza posmrtnih ostankov zavarovanca iz tujine v domovino.
3.7 Povratek v domovino v primeru smrti družinskega člana
Kriti so stroški organizacije nujne vrnitve v domovino, če član družine (otrok, partner, xxxxx, brat ali sestra, zakončev starš) težje zboli ali umre. Kriti so stroški prestavitve letalske karte oz. povratnega rednega poleta (ekonomski razred), če prestavitev ni možna ali ni možna vožnja z vlakom (1. razred) zavarovanca v domovino.
Stroški, navedeni v točkah od 3.3 do 3.5 tega odstavka, se ne vrnejo brez predhodnega soglasja asistenčne družbe.
(2) Za nujne stroške štejejo stroški za storitve, ki so nujno potrebne za ohranjanje življenjskih funkcij ali preprečitev hudega poslabšanja zdravstvenega stanja nenadno obolelega ali poškodovanega zavarovanca.
(3) Skupni znesek stroškov na osebo, vključno s stroški, ki so z medicinskega stališča upravičeni, navedeni v 1. odstavku tega člena, za vse zavarovalne primere, ki nastanejo v času trajanja zdravstvenega zavarovanja, ne sme presegati zneska
zavarovalne vsote v preglednici kritij, navedeni na koncu teh pogojev. Ne glede na navedeno je zavarovalno kritje za stroške zdravljenja akutnega poslabšanja kroničnih bolezni in nujnih zobozdravstvenih storitev podano le do zneska, ki je v preglednici posebej naveden za ta zavarovalna kritja.
(4) Zavarovalnica in asistenčna družba na noben način ne odgovarjata za ravnanja izvajalcev storitev, ki se organizirajo in plačajo v okviru zavarovalnega kritja po teh pogojih. Odgovornost zavarovalnice ali asistenčne družbe za morebitno nekvalitetno izvedbo del ali storitev s strani posameznih izvajalcev je izključena.
7. člen IZKLJUČITEV OBVEZNOSTI ZAVAROVALNICE
(1) V celoti so izključene vse obveznosti zavarovalnice, če je primer nastal kot posledica:
1. potresa;
2. aktivnega služenja zavarovanca v oboroženih silah;
3. aktivnega sodelovanja zavarovanca v vojni (razglašeni ali nerazglašeni), invaziji, dejanju tujega sovražnika, sovražnosti, državljanski vojni, terorizmu, uporu, izgredu, revoluciji, javnem shodu, zborovanju ali vstaji;
4. samomora ali poskusa samomora zavarovanca;
5. dogodkov,ki so na kakršen koli način povezani z zavestnim samopoškodovanjem ali povzročitvijo bolezni, brezumnim ravnanjem, zlorabo alkohola, zlorabo drog ali drugih prepovedanih snovi oziroma z lastno izpostavitvijo nepotrebni nevarnosti (razen v primeru poskusa rešitve človeškega življenja);
6. vožnje motornih in drugih vozil brez ustreznih uradnih dovoljenj s strani zavarovanca;
7. namernega ali naklepnega kaznivega dejanja s strani zavarovanca;
8. dogodkov, ki so vezani na kakršen koli prispevek pri uporabi, sprostitvi ali grožnjah s kakršnim koli jedrskim orožjem ali napravami, kemičnimi ali biološkimi snovmi, kot tudi dogodkov, ki so na kakršen koli način povzročeni ali h katerim so prispevala dejanja vojne, uporov, vstaj ali nemirov;
9. radioaktivnih sevanj, epidemije, pandemije.
(2) Zdravstveno zavarovanje tudi ne nudi asistence in ne krije stroškov za dogodke, ki nastanejo kot posledica:
1. priprave ali udeležbe:
- na avto-moto tekmovanjih, pri vožnjah po dirkališčih in pripadajočih treningih ter rekreativni udeležbi;
- v športnem letalstvu, padalstvu, pri letenju z zmaji, z jadralnimi letali;
- pri alpinizmu;
- pri jamarstvu;
2. rekreativne udeležbe:
- pri planinarjenju in trekingu nad 3.000 metrov nadmorske višine, če to v polici ni posebej dogovorjeno;
- pri potapljanju in podvodnem ribolovu, če to v polici ni posebej dogovorjeno;
- pri kajtanju (kitesurfing, kiteboarding), če to v polici ni posebej dogovorjeno;
- pri smučanju in deskanju na snegu izven urejenih smučišč ali heliskiingu, če to v polici ni posebej dogovorjeno;
- pri prostem plezanju, če to v polici ni posebej dogovorjeno;
- pri spustu s kolesi (xxxxxxxx), če to v polici ni posebej dogovorjeno;
- na drugih športnih tekmovanjih in treningih, če to v polici ni posebej dogovorjeno;
3. izvajanja ekstremnega športa ali so v neposredni zvezi s še posebej nevarno dejavnostjo, če je le ta povezana z nevarnostjo, ki precej presega običajno tveganje pri nahajanju v tujini;
4. nastopa na ekspedicijah v neosvojena ali neraziskana področja;
5. poslabšanja že obstoječih ali ponavljajočih se bolezni, zaradi katerih je zavarovanec že bil zdravljen ali so se pojavile in niso bile v celoti odpravljene pred začetkom zavarovanja oziroma pred odhodom v tujino ter vseh kroničnih boleznih in stanj, razen tistih, ki so navedene v 2.2 točki 1. odstavka
6. člena teh pogojev.
6. ponavljajočih izvinov in izpahov ter zdravljenja poškodb, ki so nastale pred začetkom trajanja zdravstvenega zavarovanja oziroma pred odhodom v tujino;
7. prevoza za težave, ki se lahko zdravijo na kraju škodnega dogodka;
8. zdravljenja, ki ga nudi oseba, s katero zavarovanec potuje;
9. duševnih ali vedenjskih motenj;
10. nalezljivih spolnih bolezni;
11. nosečnosti, rednih pregledov v času nosečnosti, tipičnih težav v času nosečnosti, poroda po 37. tednu nosečnostne starosti, razen v primeru reševanja življenja matere oziroma otroka;
12. prekinitve nosečnosti;
13. zobozdravstvenih storitev, razen nujne zobozdravstvene storitve, ki je potrebna za odpravo akutne bolečine zaradi bolezni ali sveže poškodbe zobovja, vključno z ekstrakcijo zoba, do zneska v preglednici kritij, navedeni na koncu teh pogojev;
14. posebne storitve v bolnišnici – nadstandard, kot je enoposteljna soba, TV, posebne nastanitve itn.;
15. telefonskih stroškov, razen nujnih klicev na klicni center asistenčne družbe;
16. operacije ali zdravljenja, ki se lahko prestavi brez kakršnih koli posledic na čas povratka v državo stalnega bivališča zavarovanca;
17. nezgode pri delu ali kateri koli drugi dejavnosti, pri kateri so potrebni povečani fizični napori, če to v polici ni posebej dogovorjeno;
18. dogodkov, nastalih med odhodom v tujino, na katerega se zavarovanec odpravi v nasprotju z zdravniškim nasvetom;
19. dogodkov, nastalih med zadrževanjem v tujini, kamor se je zavarovanec odpravil z namenom zdravljenja;
20. izgube ali dogodka, za katerega v teh pogojih ni izrecno navedeno, da je zanj podano zavarovalno kritje;
21. dogodkov, ki so povezani s kozmetičnimi operacijami za popravo videza, razen če je kirurški poseg nujen zaradi akutne bolezni ali iznakaženosti, ki jo krije to zavarovanje;
22. telesne poškodbe, bolezni, smrti, izgube, stroškov ali kakršne koli druge obveznosti, povezane z virusom HIV (Human Immunodeficiency Virus) ali aidsom (Acquired Immune Deficiency Syndrome) oziroma kakršnim koli podobnim drugim sindromom, ne glede na to, kako se imenuje, razen če se zavarovanec okuži med medicinsko preiskavo, preizkusom ali zdravljenjem (vendar le, če to ni povezano z zlorabo drog ali spolno prenosljivimi boleznimi).
(3) Zavarovalnica ne krije stroškov v naslednjih primerih:
1. če zavarovanec telefonsko ali pisno ne obvesti zavarovalnice ali njenih predstavnikov o nastanku zavarovalnega primera v roku 3 dni od začetka bolezni ali poškodbe;
2. če zavarovanec ne spoštuje drugih navodil za uveljavljanje pravic iz zdravstvenega zavarovanja v primeru bolezni ali nezgode;
3. če se zavarovanec na zahtevo zavarovalnice ne pusti pregledati zdravniku, ki ga imenuje zavarovalnica ali njeni predstavniki.
(4) Izključene so vse obveznosti zavarovalnice v primeru dajanja neresničnih podatkov zavarovalca oziroma zavarovanca o trajanju zadrževanja v tujini, o okoliščinah poškodbe ali vrsti bolezni ter kakršnih koli prevar ali ponaredb.
(5) Ne glede na druge določbe te zavarovalne pogodbe s tem zavarovanjem ni krita škoda, ki je nastala v neposredni ali posredni povezavi s terorističnim dejanjem, niti kateri koli stroški, ki so nastali kot posledica škode, in sicer niti v primeru, če je skupaj s terorističnim dejanjem na nastanek škode vplival še kak drug vzrok ali dejanje. Šteje se, da je teroristično dejanje vsako nasilno dejanje ali dejanje, ki ogroža človeško življenje, premično oziroma nepremično premoženje ali infrastrukturo, in sicer s silo, nasiljem ali grožnjo in je izvedeno zaradi političnih, verskih, ideoloških ali podobnih namenov ter ima namen vplivati ali vpliva na vlado kakšne države ali ima namen ustrahovati ali ustrahuje javnost oziroma kateri koli njen del. Za teroristično dejanje se šteje tako dejanje, ki je izvedeno samostojno, kakor tudi tisto, ki je izvedeno v povezavi s katero koli organizacijo ali oblastjo. Iz kritja so izključeni tudi škoda in stroški, nastali zaradi preprečevanja oziroma zatiranja terorističnih dejanj.
(6) Od asistenčne družbe se ne more zahtevati, da zagotovi zavarovancu storitve, kadar se le-ta nahaja na območju, kjer obstaja tveganje vojne, političnih ali drugih okoliščin, ki bi takšne storitve onemogočile ali pa bi bile upravičeno neizvedljive.
8. člen NEVARNOSTNE OKOLIŠČINE
(1) Pred sklenitvijo kakor tudi med trajanjem zavarovalne pogodbe mora zavarovalec prijaviti zavarovalnici vse okoliščine, ki so pomembne za ocenitev nevarnosti in so mu bile znane ali mu niso mogle ostati neznane. Za okoliščine, ki so pomembne za ocenitev nevarnosti, štejejo zlasti okoliščine, ki so zavarovalcu znane in na podlagi katerih je določena in obračunana premija, kakor tudi one, ki so navedene v zavarovalni pogodbi. Te okoliščine lahko zavarovalec in zavarovalnica določita tudi skupaj.
(2) Zavarovalec mora omogočiti zavarovalnici pregled in oceno nevarnosti.
9. člen DOLŽNOSTI ZAVAROVANCA PO ZAVAROVALNEM PRIMERU
(1) Po nastanku zavarovalnega primera mora zavarovanec takoj storiti vse, kar je v njegovi moči, da bi preprečil nadaljnje nastajanje škode. Pri tem mora upoštevati navodila asistenčne družbe in poskušati omejiti stroške po svojih najboljših močeh.
(2) Zavarovanec mora obvestiti zavarovalnico o nastanku zavarovalnega primera najkasneje v treh dneh od dneva, ko zanj izve.
(3) Zavarovanec mora dati zavarovalnici vse podatke in druge dokaze, ki jih ima na voljo in so nujno potrebni za ugotavljanje vzroka, obsega in višine škode, organizacijo asistence ter drugo dodatno dokumentacijo na zahtevo zavarovalnice. V vsakem primeru mora zavarovanec ravnati po navodilih, ki jih dobi od zavarovalnice ali od njenih predstavnikov.
(4) Dokumentacija, ki jo zavarovanec dostavi, je naslednja:
a) v primeru bolezni:
- zdravstvena dokumentacija, ki opravičuje nujnost zdravljenja, ter dokumentacija, navedena pod točko c),
b) v primeru nezgode:
- zdravstvena dokumentacija,
- uradna poročila ali potrdila, napisana v tujini na podlagi okoliščin nesreče oziroma poškodbe, ter dokumentacija navedena pod točko c),
c) v obeh primerih:
- kopija zavarovalne police,
- originalni račun stroškov tuje zdravstvene pomoči,
- originalni račun za zdravila in prevoze,
- uradni prevod dokumentacije na zahtevo zavarovalnice,
- dokazilo, da nahajanje v tujini ni bilo daljše od 90 dni (velja samo v primeru veljavnosti določila 3. odstavka 3. člena teh pogojev),
- dodatne dokumentacije na zahtevo zavarovalnice.
(5) Če zavarovanec svojih obveznosti iz tega člena v dogovorjenem roku ne izpolni, zavarovalnica lahko odkloni plačilo zavarovalnine, če zaradi te opustitve ne more ugotoviti nastanka zavarovalnega primera.
(6) Če zavarovanec po svoji krivdi zavarovalnici ne prijavi nastanka zavarovalnega primera v času in na način, ki je določen s temi pogoji, mora zavarovalnici povrniti morebitno škodo, ki jo le-ta ima zaradi tega.
(7) Če zavarovanec ni uporabil zdravstvene asistence in je nujne zdravstvene storitve plačal sam, mu zavarovalnica povrne stroške skladno s 6. členom teh pogojev po predložitvi zahtevane dokumentacije.
10. člen DOLŽNOSTI ZAVAROVALNICE PO ZAVAROVALNEM PRIMERU
(1) Če nastane zavarovalni primer, mora zavarovalnica izplačati zavarovalnino v roku štirinajst dni, šteto od dneva, ko razpolaga z vso dokumentacijo, na podlagi katere lahko odloča o temelju in višini zahtevka. Če znesek njene obveznosti ni ugotovljen v tem roku, mora zavarovalnica zavarovancu oziroma upravičencu na njegovo zahtevo izplačati nesporni del svoje obveznosti kot predujem.
(2) Zavarovalnica plača ob vsakem zavarovalnem primeru obračunano škodo v celoti po referenčnem tečaju Evropske centralne banke (ECB) na dan plačila zavarovalnine, vendar največ do zneska v preglednici kritij, navedeni na koncu teh pogojev.
(3) Predhodno določilo tega člena ne velja, če zavarovanec dostavi dokazilo, iz katerega je razviden dejanski znesek stroškov v EUR na dan nastanka zavarovalnega primera.
11. člen PRAVICE ZAVAROVALNICE
(1) V primeru nezgode, ki jo povzroči tretja oseba, ima zavarovalnica od povzročitelja nezgode pravico terjati povračilo stroškov, ki jih je plačala zavarovancu.
(2) Zavarovalnica si pridržuje pravico do povračila vseh nastalih stroškov v primeru, ko se naknadno ugotovi, da je zavarovalni primer nastal zaradi dogodkov, navedenih v 7. členu teh pogojev.
12. člen PLAČILO PREMIJE IN POSLEDICE NEPLAČILA PREMIJE
(1) Premijo oziroma prvi obrok mora zavarovalec plačati ob sklenitvi pogodbe. Za plačilo ob sklenitvi pogodbe šteje tudi plačilo, ki je izvršeno najkasneje do dneva zapadlosti, ki je navedena na terjatvenem dokumentu. V tem primeru je zavarovalno kritje podano od dneva in ure, ki sta določena kot začetek zavarovanja. Če premija (oziroma prvi obrok) do dneva zapadlosti na terjatvenem dokumentu ni plačana v celoti, je zavarovalno kritje podano šele z naslednjim dnem po celotnem plačilu. Premije za naslednja zavarovalna leta (oz. prvi obrok v naslednjem zavarovalnem letu) pri večletnih zavarovanjih pa mora zavarovalec plačati prvi dan vsakega nadaljnjega zavarovalnega leta. Če ni drugače dogovorjeno, je dinamika plačil za naslednja zavarovalna leta enaka kot v prvem zavarovalnem letu.
(2) Če je dogovorjeno, da se premija plačuje v obrokih ali za nazaj, se lahko obračunajo redne obresti od zneska premije, za katero je dogovorjena odložitev plačila. Če obrok ni plačan do dneva zapadlosti, ima zavarovalnica pravico do zakonskih zamudnih obresti in pravico zahtevati takojšnje plačilo vseh še nezapadlih obrokov.
(3) Če je premija plačana po pošti ali banki, velja za čas plačila dan, ko je bil dan nalog za plačilo pošti ali banki. Če ob plačevanju premije ni naveden točen sklic, iz katerega bi bilo razvidno, katera premija oziroma kateri obrok premije in po kateri zavarovalni pogodbi se plačuje, se šteje, da se plačuje tista neplačana premija oziroma tisti obrok premije, ki je po dnevu zapadlosti najstarejši, in sicer ne glede na vrsto zavarovalne pogodbe, ki je sklenjena pri zavarovalnici.
(4) Če je bil glede na dogovorjeni čas zavarovanja priznan popust na premijo, zavarovanje pa je prenehalo pred potekom tega časa, lahko zavarovalnica terja razliko do tiste premije, ki bi jo moral zavarovalec plačati, če bi se bila pogodba sklenila le za toliko časa, kolikor je dejansko trajala.
(5) V primeru prenehanja zavarovalne pogodbe zaradi neplačane zapadle premije mora zavarovalec plačati premijo za čas do dneva prenehanja pogodbe ali celotno premijo za tekoče zavarovalno leto, če je do dneva prenehanja veljavnosti pogodbe nastal zavarovalni primer, za katerega mora zavarovalnica plačati zavarovalnino. Zavarovalec je dolžan povrniti tudi popust na premijo, ki mu je bil priznan za dogovorjeni čas zavarovanja, kot je opredeljeno v prejšnjem odstavku.
(6) Zavarovalnica ima pravico, da ob kakršnem koli izplačilu iz zavarovanja od zavarovalnine odtegne vse zapadle in neplačane premije tekočega zavarovalnega leta, kakor tudi druge zapadle obveznosti zavarovalca do zavarovalnice iz preteklih let.
(7) Obveznost zavarovalnice, da izplača zavarovalnino, preneha v primeru, če zavarovalec do zapadlosti ne plača premije, ki je zapadla po sklenitvi pogodbe, in tega tudi ne stori kdo drug, ki je za to zainteresiran, po tridesetih dneh od dneva, ko je bilo zavarovalcu vročeno priporočeno pismo zavarovalnice z obvestilom o zapadlosti premije, pri čemer pa se ta rok ne more izteči prej, preden ne preteče trideset dni od zapadlosti premije.
(8) Zavarovalnica lahko po izteku roka iz 7. odstavka tega člena, če je zavarovalec v zamudi s plačilom premije, ki jo je treba plačati po sklenitvi pogodbe oziroma druge in naslednjih premij, razdre zavarovalno pogodbo brez odpovednega roka, s tem da razdrtje zavarovalne pogodbe nastopi z iztekom roka iz 7. odstavka tega člena in s prenehanjem zavarovalnega kritja, če je bil zavarovalec na to opozorjen v priporočenem pismu z obvestilom o zapadlosti premije in o prenehanju zavarovalnega kritja.
(9) Če zavarovalec, v primerih ko zavarovalnica ni razdrla zavarovalne pogodbe, plača premijo po izteku roka iz 7. odstavka tega člena, vendar v enem letu od zapadlosti premije, je zavarovalnica dolžna, če nastane zavarovalni primer, plačati zavarovalnino od 24.00 ure po plačani premiji in zamudnih obresti. Če zavarovalec premije v tem roku ne plača, zavarovalna pogodba preneha veljati s potekom zavarovalnega leta.
(10) Na premijo se zaračunavajo zakonsko predpisane dajatve (davščine, takse ipd.). Če se med trajanjem zavarovanja spremenijo ali uvedejo nove dajatve, davčne stopnje ali takse, spremembe vplivajo na višino premije.
13. člen ODPOVED POGODBE IN VRAČILO PREMIJE
(1) Zavarovalec lahko odpove zavarovalno pogodbo v času, ko zavarovalno kritje še ni nastopilo - pred začetkom zavarovanja, kot navedeno v polici.
(2) Odpoved zavarovalne pogodbe je možna le v primeru, če odhod v tujino odpade zaradi smrti ali bolezni zavarovanca ali ožjega družinskega člana. Odpoved v nobenem primeru ni možna po začetku zavarovalnega kritja.
(3) V primeru odpovedi zavarovalne pogodbe zavarovalnica vrne 85 % plačane premije.
(4) Če trajanje zavarovanja ni določeno v pogodbi oziroma če je v zavarovalni pogodbi dogovorjen rok trajanja z možnostjo, da se pogodba podaljšuje za enako časovno obdobje, sme vsaka stranka od nje odstopiti z dnem zapadlosti premije, le da mora o tem pisno obvestiti drugo stranko najmanj 3 mesece pred zapadlostjo premije.
(5) Če je zavarovanje sklenjeno za več kot 3 leta, sme po preteku tega časa vsaka stranka z odpovednim rokom šestih mesecev odstopiti od pogodbe, s tem da to pisno sporoči drugi stranki.
(6) Če je bila zavarovalna pogodba sklenjena na daljavo (preko spleta, telefona ipd.) in za zavarovalno obdobje, daljše od 30 dni, lahko zavarovalec brez razloga
zavarovalno pogodbo odpove, vendar najkasneje 15 dni pred začetkom zavarovanja. V tem primeru zavarovalnica vrne celoten znesek vplačane premije. Odstop mora biti pisen in vložen na zavarovalnico do izteka roka, pri čemer se šteje, da je vložen v roku, če je do izteka roka priporočeno oddan na pošti. Zavarovalec nima pravice do odstopa od pogodbe po tem odstavku pri zavarovalnih pogodbah z veljavnostjo, krajšo od enega meseca.
14. člen IZVEDENSKI POSTOPEK
(1) Vsaka pogodbena stranka lahko zahteva, naj določena sporna dejstva ugotavljajo izvedenci.
(2) Vsaka stranka imenuje enega izvedenca izmed oseb, ki s strankami niso v delovnem ali sorodstvenem razmerju. Imenovana izvedenca pred začetkom dela imenujeta tretjega izvedenca, ki da svoje mnenje le, kadar so ugotovitve prvih dveh izvedencev različne in le v mejah njunih ugotovitev.
(3) Vsaka stranka nosi stroške za izvedenca, ki ga je imenovala, za tretjega izvedenca nosi vsaka stranka polovico stroškov.
(4) Končne ugotovitve so obvezne za obe stranki.
15. člen SPREMEMBE ZAVAROVALNE POGODBE
(1) Če zavarovalnica spremeni zavarovalne pogoje ali premijski cenik, mora o spremembi zavarovalca pisno ali na drug primeren način obvestiti vsaj 60 dni pred potekom tekočega zavarovalnega leta.
(2) Zavarovalec ima pravico, da v 60-ih dneh po prejemu obvestila odpove zavarovalno pogodbo. Pogodba preneha veljati s potekom tekočega zavarovalnega leta.
(3) Če zavarovalec ne odpove zavarovalne pogodbe, se ta z začetkom prihodnjega leta spremeni v skladu z novimi zavarovalnimi pogoji ali premijskim cenikom.
(4) Zavarovalnica si pridržuje pravico popraviti morebitne zastopnikove računske ali druge napake, o čemer mora zavarovalnica zavarovalca pisno obvestiti. Zavarovalec ima pravico, da v primeru nestrinjanja s popravki (spremembami zavarovalne pogodbe s strani zavarovalnice) v roku 15 dni od prejema obvestila odstopi od zavarovalne pogodbe, pri čemer odpoved učinkuje za naprej. Če zavarovalec od zavarovalne pogodbe v tem roku ne odstopi, se šteje, da se s temi popravki/ spremembami strinja, zato zavarovalna pogodba od izteka tega roka dalje velja z upoštevanimi popravki (spremembami zavarovalne pogodbe s strani zavarovalnice).
16. člen NAČIN OBVEŠČANJA
(1) Dogovori o vsebini zavarovalne pogodbe so veljavni le, če so sklenjeni v pisni obliki.
(2) Vsa obvestila in izjave, ki jih je treba dati po določbah zavarovalne pogodbe, morajo biti pisne.
(3) Obvestilo ali izjava je dana pravočasno, če se pošlje pred potekom roka s priporočenim pismom.
(4) Izjava, ki jo je treba dati drugemu, velja šele tedaj, ko jo ta prejme.
17. člen SPREMEMBA NASLOVA IN VROČANJE
(1) Zavarovalec mora obvestiti zavarovalnico o spremembi naslova svojega bivališča oziroma sedeža ali svojega imena oziroma firme v roku 15 dni od dneva spremembe.
(2) Če je zavarovalec spremenil naslov bivališča oziroma sedež ali svoje ime oziroma firmo, pa tega ni sporočil zavarovalnici, zadošča, da zavarovalnica obvestilo, ki ga mora sporočiti zavarovalcu, pošlje na naslov njegovega zadnjega znanega bivališča ali sedeža ali ga naslovi na zadnje znano ime oziroma firmo.
(3) Če poskus vročitve priporočenega obvestila zavarovalcu ni bil uspešen (zaradi preselitve, odklonitve sprejema ipd.), zavarovalnica vrnjeno pošto šteje za vročeno in jo deponira na sedežu zavarovalnice. Zavarovalec se strinja, da se vrnjena nevročena priporočena pošiljka šteje za prejeto na dan prvega poizkusa vročitve ter da velja, da je zavarovalec z njeno vsebino seznanjen.
(4) V prejšnjem odstavku navedena domneva uspele vročitve ima na podlagi pogodbenega dogovora z zavarovalcem pravno veljavne učinke.
18. člen VARSTVO OSEBNIH PODATKOV
(1) Zavarovalec oziroma zavarovanec do preklica dovoljuje zavarovalnici in njenim pooblaščenim podjetjem za zastopanje in posredovanje zavarovanj, da v svojih zbirkah shranjujejo, obdelujejo in uporabljajo njegove osebne podatke, ki so potrebni za izvajanje zavarovanja in za namene obveščanja zavarovalca in zavarovanca o novostih in ponudbah s področja finančnih produktov.
(2) Zavarovanec pooblašča zavarovalnico in asistenčno družbo, da v njegovem imenu pridobi in vpogleda v zdravstveno dokumentacijo ter drugo dokumentacijo, ki je potrebna za ugotavljanje okoliščin za sklenitev zavarovanja in pri ugotavljanju obveznosti zavarovalnice.
(3) Zavarovalec dovoljuje zavarovalnici, da posreduje osebne podatke (osebno ime, naslov stalnega ali začasnega prebivališča, telefonsko številko, naslov elektronske pošte ter številko telefaksa) tudi drugim družbam, ki so z zavarovalnico v kapitalskih povezavah, ter drugim, z zavarovalnico povezanim, odvisnim ali obvladujočim družbam. Le te lahko podatke uporabijo samo za namen neposrednega trženja, med drugim za namene obveščanja zavarovalca o novostih in ponudbah s področja finančnih produktov. Zavarovalec tudi dovoljuje, da zavarovalnica njune podatke pridobi od upravljavcev zbirk osebnih podatkov in jih posreduje biroju zelene karte ali drugemu organu, ki rešuje škodne primere.
(4) Zavarovalec oziroma zavarovanec lahko kadar koli zahteva, da se preneha z uporabo njegovih osebnih podatkov za namen neposrednega trženja po prejšnjem odstavku. Zavarovalnica se obvezuje, da bo najkasneje v 15 dneh preprečila uporabo osebnih podatkov, za katero je bilo dano dovoljenje po prejšnjem odstavku tega člena.
(5) Zavarovalnica se obvezuje, da bo vse osebne podatke skrbno varovala v skladu z veljavno zakonodajo s področja varovanja osebnih podatkov.
19. člen REŠEVANJE SPOROV
(1) Zavarovalec, zavarovanec ali upravičenec lahko v 15 dneh po prejemu pisne odločitve zavarovalnice vloži pisno pritožbo na zavarovalnico, ki mora pritožbo obravnavati skladno z internim pravilnikom. Odločitev pritožbene komisije je dokončna in nadaljnji postopki pri zavarovalnici niso možni.
(2) V primeru nestrinjanja z dokončno odločitvijo zavarovalnice se lahko po posebnem dogovoru nadaljuje postopek za izvensodno rešitev spora pri Mediacijskem centru, ki deluje v okviru Slovenskega zavarovalnega združenja iz določenih razlogov pa tudi pred Varuhom dobrih poslovnih običajev v zavarovalništvu.
(3) Za razmerja iz zavarovalne pogodbe, ki niso urejena s temi pogoji, se uporablja slovensko pravo.
(4) V primeru sodnega spora je za reševanje pristojno sodišče v Kopru.
(5) Za izvajanje nadzora nad zavarovalnico je pristojna Agencija za zavarovalni nadzor, Xxx xxxxxxxxx 0, Xxxxxxxxx.
PREGLEDNICA ZAVAROVALNIH KRITIJ ZA ZDRAVSTVENO ZAVAROVANJE OSEB V TUJINI Z ASISTENCO
ZAVAROVALNA KRITJA | ||||
Skupaj za vsa zavarovalna kritja, največ do zavarovalne vsote: | 25.000 EUR 20.000 EUR* | 50.000 EUR 40.000 EUR* | 100.000 EUR 60.000 EUR* | |
1. | Medicinska oskrba in obisk zdravnika | √ | √ | √ |
2. | Zdravljenje Omejitev - v okviru kritja Zdravljenje so stroški zdravljenja akutnega poslabšanja kroničnih bolezni kriti le do naslednjih zneskov: | √ 400 EUR | √ 800 EUR | √ 1.200 EUR |
3. | Prevoz do najbližje bolnišnice ali klinike in nazaj | √ | √ | √ |
4. | Prevoz v domovino | √ | √ | √ |
5. | Zdravila in zdravniški pripomočki | √ | √ | √ |
6. | Nujne zobozdravstvene storitve | 100 EUR | 200 EUR | 300 EUR |
7. | Prevoz in bivanje za osebo, ki ostane v spremstvu zavarovanca | √ | √ | √ |
8. | Spremstvo in prevoz mladoletnega otroka | √ | √ | √ |
9. | Prevoz družinskega člana | vozovnica | vozovnica | vozovnica |
10. | Prevoz posmrtnih ostankov v domovino zavarovanca | √ | √ | √ |
11. | Povratek v primeru smrti družinskega člana | √ | √ | √ |
Starostna omejitev | 75 let | 75 let | 75 let | |
Starostna omejitev (potrebna dodatna premija) | 85 let | 85 let | 85 let | |
Starostna omejitev (potrebna dodatna premija) | nad 85 let | nad 85 let | nad 85 let | |
Geografska veljavnost | cel svet | cel svet | cel svet | |
√ - vključeno | ||||
* Velja za zavarovanje oseb s stalnim bivališčem v tujini, ki začasno bivajo in delajo v RS.
General Terms and Conditions of Travel Health Insurance with Assistance Abroad 01-ZZTA-01/16
TRANSLATION: Only the Slovene version shall be legally binding
Article 1 INTRODUCTORY PROVISIONS
(1) The General Terms and Conditions of Travel Health Insurance with Assistance Abroad (hereinafter: the Terms and Conditions) are an integral part of the insurance contract concluded between the Policyholder and Adriatic Slovenica Zavarovalna družba d. d. Koper (hereinafter: the Insurance Company).
(2) The following terms contained in these General Terms and Conditions shall mean:
Policyholder – The person who has concluded the insurance contract.
The Insured – The person whose property interest is insured and who is stated in the policy.
Beneficiary – The person who is entitled to the benefit, i.e. the reimbursement of costs if an insured event occurs.
Insurance Contract – The contract on the provision of assistance, concluded by and between the Policyholder and the Insurance Company.
Policy – A document proving the conclusion of the insurance contract for health insurance of persons abroad with assistance, issued by the Insurance Company to the Insured who is travelling abroad.
Premium – A sum paid by the Policyholder to the Insurance Company under the Insurance Contract.
Benefit – A sum paid by the Insurance Company to the Insured under the provisions of the Insurance Contract.
Insured event – An event covered by this insurance and which occurs during the application period of this insurance.
Assistance – Aid in the event of illness or physical injury while being abroad. Assistance Company – Assistance CORIS, d.o.o., Xx. xxxxxx Xxxxxx 00, 0000 Xxxxxxxxx, Xxxxxxxx.
Abroad – The territory where the Insurance Company offers insurance cover to the Insured in accordance with the insurance contract. Abroad shall not include a country where the Insured has a permanent or temporary residence (hereinafter: homeland).
Country of permanent residence – The country of the Insured’s permanent or temporary official residence.
Article 2 INSURED PERSONS
(1) In individual insurance the Insured is the person stated in the Policy.
(2) In family insurance the Insured are the persons who are stated in the policy and who live in shared household and are connected by family relationship: a spouse or partner from another legally recognised type of relationship, their children, stepchildren or adoptees until the age of 26 years.
(3) In group insurance the Insured are the persons who are stated in the policy or in the attachment to the policy and who form a group. A group consists of nine
(9) or more persons, who are departing together to the same destination abroad at the same time. If there are less than nine (9) persons, the provisions for an individual insurance shall apply unless otherwise agreed.
(4) Under these Terms and Conditions the Insured can only be persons until their fulfilled 75th year of age. Persons older than 75 years may also be insured against additional premium payment.
(5) A person without any contractual capability or a mentally ill person cannot be the Policyholder.
Article 3 COMMENCEMENT AND EXPIRATION OF INSURANCE
(1) The insurance cover shall start at 00:00 hrs of the day stated in the policy as the insurance commencement date, if the insurance premium has been paid until then. If the insurance premium has not been paid, the insurance cover shall start at 00:00 hrs of the next day when the premium has been paid.
(2) The insurance cover shall cease at 24:00 hrs of the day stated in the policy as the insurance termination day.
(3) If the insurance contract is concluded for one full year, the insurance shall apply for an unlimited number of the Insured’s departures abroad in that year, provided that the Insured is not abroad more than 90 days each time.
Article 4 PLACE OF INSURANCE APPLICATION
The insurance cover shall only apply abroad, i.e. outside of the territory of the country where the Insured has a registered permanent or temporary residence (hereinafter: homeland).
Article 5 VALIDITY OF INSURANCE
(1) The insurance contract shall be concluded when both contracting parties have signed the insurance policy or the cover note.
(2) Unless otherwise agreed, the insurance contract shall take effect from 00:00 hrs of the day stated in the policy as the insurance commencement date, and it shall cease at the end of the last day stated as the termination date of insurance.
(3) If it has been agreed that the premium must be paid:
1. upon the conclusion of the contract and the premium has not been paid, the liability of the Insurance Company to pay the benefit stated in the contract shall start at 00:00 hrs of the day when the premium is paid;
2. after the contract is concluded, the liability of the Insurance Company to pay the benefit stated in the contract shall start on the day stated in the contract as the insurance commencement date.
(4) In the case of remote conclusion of the insurance contract, the contract shall be concluded when the premium has been paid, which the Policyholder proves with the premium payment receipt.
(5) The insurance must be taken out before the Insured departs abroad. If the Insured is abroad when the Insurance Contract is being concluded, the insurance cover under these Terms and Conditions shall only take effect after the end of five (5) days from the insurance commencement date.
(6) The insurance policy may be renewed five (5) days before the end of the current policy period at the latest. If the insurance is renewed after the end of the above-mentioned period, there will be no insurance cover for illness in the first five (5) days (deferment period). Deferment period shall not apply if the Insured is in the homeland when the insurance is being renewed.
Article 6 SCOPE OF COVER
(1) The insurance covers the following:
1. ASSISTANCE CALL CENTRE SERVICES:
- the availability of the assistance call centre 24/7, year-round,
- the arrangement of urgent medical aid,
- the arrangement of urgent medical transportation for the Insured,
- informing the Insured and his/her closest family members,
- telephone charges for calling the Assistance Company’s call centre.
2. URGENT COSTS:
2.1 Medical treatment and doctor’s visit
Costs of urgent medical care and doctor’s visit due to an injury or disease of the Insured abroad are covered.
2.2 Treatment
Costs of urgent treatment due to an injury or disease of the Insured abroad are covered. Such costs include treatment until the day when the Insured’s state of health permits him/her being transported to the country of permanent residence, where he/she shall continue the treatment. Urgent treatment costs include the cost of treatment in the event of acute deteriorations, however only for the following chronic diseases: heart diseases, kidney stones, asthma and diabetes.
2.3 Medications and medical supplies
The cost of medications and medical supplies prescribed by a doctor or prescribed in the medical record.
2.4 Urgent dental services
Costs of urgent dental treatment which is necessary for suppressing acute pain due to illness or fresh injury of teeth, including tooth extraction are covered.
3. ADDITIONAL COSTS:
3.1 Transportation to the nearest hospital and back
Costs of transporting the Insured to the nearest hospital or clinic and back to the previous location abroad are covered.
3.2 Transportation to homeland
Costs of transporting the sick or injured Insured to his/her homeland, if permitted by the Insured’s health condition, are covered according to prior consent of the Assistance Company, if the Insured should for health reasons be unable to return to his/her homeland in the way as originally planned.
3.3 Transportation and accommodation for the person who remains in attendance of the Insured
Additional transportation and accommodation costs are covered for the person, who under request or according to recommendation of attending physician, remains in attendance of the Insured, or costs of transporting a close relative from the home country to the place of hospitalization, if no other type of escort can be provided to the Insured. If the Insured is a minor, additional costs of transportation and accommodation shall be covered for the person who remains in attendance of the Insured, may it be recommended by the attending physician or not.
3.4 Accompanying and transportation of a minor
The cost of transportation for an Insured’s child aged under 18 years to the place of permanent residence is covered, as well as the cost of transportation for the person accompanying the child in the event the Insured is hospitalized or dies.
3.5 Transportation of a family member
Costs of visiting the Insured are covered and they include the cost of the return ticket for public transport (economy class) for one family member (child, partner, parent, brother or sister, spouse’s parent) if the Insured cannot return to his/her homeland for medical reasons and is hospitalized more than seven (7) days for reasons covered under these Terms and Conditions.
3.6 Transportation of mortal remains to the Insured’s homeland
Costs of transporting the Insured’s mortal remains to his/her homeland are covered.
3.7 Return to homeland in case of death of a family member
The cost of arranging the urgent return to the home country is covered in case of a family member’s (child, partner, parent, brother or sister, spouse’s parent) severe illness or death. The cost of changing the
scheduled flight or a return regular flight (economy class) is covered, provided that the rescheduling is not possible, or the cost of train ticket (1st class) for the Insured to the homeland.
No cost indicated in points 3.3 to 3.5 of this paragraph shall be refunded without the prior consent of the Assistance Company.
(2) Urgent costs shall be costs for the services which are urgently necessary for the preservation of vital functions or for the prevention of severe deterioration of the suddenly diseased or injured Insured’s medical condition.
(3) The total amount of the costs per person including the medically justified costs that are stated in the first paragraph of this Article for all insured events that occur in the period of the health insurance duration, may not exceed the amount of sum insured specified in the insurance cover chart at the end of these General Terms and Conditions. Irrespective of this, the insurance cover for the cost of treating acute deterioration of chronic diseases and urgent dental services is only provided up to the amount that is specifically stated for such types of insurance cover in the insurance cover chart.
(4) The Insurance Company and the Assistance Company are not responsible for any activities of the service performers that are organised and paid as part of the insurance cover in accordance with these Terms and Conditions. The Insurance Company’s or the Assistance Company’s liability for any low-quality performance of works by individual performers is excluded.
Article 7 EXCLUSION OF INSURANCE COMPANY’S OBLIGATIONS
(1) The obligations attaching to the Insurance Company shall be fully excluded if an event has occurred as a result of:
1. an earthquake;
2. the Insured’s active serving in the armed forces;
3. the Insured’s active engagement in war (whether declared or undeclared), invasion, act of a foreign enemy, hostility, civil war, rebellion, riot, revolution, public assembly, rally or insurrection;
4. the Insured’s suicide or attempted suicide;
5. events which are in any way connected with conscious self-inflicted injuries or disease, reckless behaviour, abuse of alcohol or drugs or other prohibited substances, or with self-exposure to unnecessary risk (except in case of trying to save a human life);
6. the Insured’s driving of motor vehicles without holding appropriate official permits;
7. an intentionally committed criminal offence;
8. events related to any participation in the use, release or threats of using any kind of nuclear weapon, devices, chemical or biological substances, as well as claims for costs, which have in any way been incurred by or contributed by acts of terrorism, war, rebellions or riots;
9. radioactive radiation, epidemic, pandemic.
(2) The health insurance shall also not offer assistance or cover the costs for events occurred as a result of:
1. training or participation:
- in any motor competitions as well as when driving on racecourses and the relevant trainings and recreational activities;
- in sport aviation, parachuting, hang-gliding and gliding;
- in mountain climbing;
- in speleology;
2. recreational activities:
- at mountaineering and trekking above 3,000 meters above sea level, unless specially agreed in the insurance policy;
- at diving and underwater fishing, unless specially agreed in the insurance policy;
- at kiting (kitesurfing, kiteboarding), unless specially agreed in the insurance policy;
- in skiing and snowboarding outside of ski centres or heliskiing, unless specially agreed in the insurance policy;
- at free climbing, unless specially agreed in the insurance policy;
- at downhill cycling, unless specially agreed in the insurance policy;
- at other sport competitions, unless specially agreed in the insurance policy;
3. doing an extreme sport or an activity in direct connection with a particularly dangerous activity, if it poses a risk that strongly exceeds an ordinary risk when being abroad;
4. attending expeditions to the yet unreached or unexplored areas;
5. the deterioration of existing or recurring diseases for which the Insured has already received treatment or which have occurred and were not entirely treated before the commencement of insurance or before the departure abroad, and any chronic disease and other diseases, except those included in point 2.2 of the first paragraph of Article 6 herein;
6. repeated dislocations and sprains and the treatment of injuries which have occurred before the commencement of the health insurance or before the departure abroad;
7. transportation for problems that can be treated at the scene of the loss event;
8. treatment offered by a person travelling with the Insured;
9. mental or behavioural disorders;
10. sexually transmitted diseases;
11. pregnancy, regular check-ups during pregnancy, typical nuisances in the time of pregnancy while giving birth after the 37th week of pregnancy except in cases of saving mother’s or child’s life;
12. the termination of pregnancy;
13. dental treatment, except urgent dental treatment, necessary for suppressing acute pain due to illness or fresh injury of teeth, including tooth extraction, up to the amount stated in the insurance cover chart at the end of these Terms and Conditions;
14. special hospital services – higher standard, such as a single room, TV, special accommodation, etc.;
15. telephone charges except emergency calls to the Assistance Company’s call centre;
16. a surgery or medical treatment, which can be postponed without any consequences to the time when the Insured returns to the country of his/her permanent residence;
17. accidents at work or during any other activity that requires increased physical efforts, provided that this is not separately agreed in the policy;
18. events that took place while departing abroad despite being advised not to travel abroad by the doctor;
19. events that occurred while staying abroad where the Insured went in order to get treatment;
20. loss or an event, for which these Terms and Conditions do not explicitly state that is covered by insurance;
21. events connected with any cosmetic surgery intended for corrections of the appearance, except if a surgery is urgent due to an acute illness or deformation, which is covered under this insurance;
22. a bodily injury, disease, death, loss, costs or any other necessity related with the HIV virus (Human Immunodeficiency Virus) or AIDS (Acquired Immune Deficiency Syndrome) or any other similar syndrome, regardless of its name, unless the Insured gets infected during a medical examination, test or treatment (however only if this is not connected with drug abuse or sexually transmitted diseases).
(3) The Insurance Company shall not cover costs in the following cases:
1. if the Insured does not inform the Insurance Company or its representatives, either by phone or letter, about the insured event within three (3) days after the occurrence of sickness or injury;
2. if the Insured does not follow other instructions for asserting his/her rights from health insurance in case of illness or accident;
3. if on the Insurance Company’s request the Insured does not allow medical examination by a doctor nominated by the Insurance Company or its representatives.
(4) All obligations of the Insurance Company will be excluded if the Policyholder or the Insured provides false data about the duration of a journey abroad, about the circumstances of an injury or the type of disease, as well as in the event of fraud or forgery.
(5) Notwithstanding the other provisions contained herein, this insurance shall not cover any loss which has occurred in connection, either direct or indirect, with an act of terrorism, or any costs which have occurred as a result of loss, even if an act of terrorism, which resulted in the occurrence of loss, was accompanied by another cause or act. An act of terrorism shall be any act of violence or an act endangering human life, movable or immovable property or infrastructure, with force, violence, or threat, and which is performed for political, religious, ideological or similar intentions and which is intended to affect or which affects the government of any country, and which is intended to raise fear or which raises fear among the public or any of its parts. An act of terrorism shall be an act performed independently or in connection with any organisation or authority. Moreover, the insurance excludes the loss and costs, which have occurred for the purpose of preventing or suppressing acts of terrorism.
(2) The Assistance Company cannot be demanded to ensure services to the Insured who it believes is in an area where there is risk of war, political or other circumstances, which might prevent such services or make it justifiably impossible to implement such services.
Article 8 RISK CIRCUMSTANCES
(1) Prior to concluding as well as throughout the duration of the insurance contract, the Policyholder shall be obliged to report to the Insurance Company any circumstances which are important to assess the risk and which he/she was aware of or could not prevent being unaware of. The circumstances important to assess the risk are in particular the circumstances known to the Policyholder and based on which the premium has been determined and accounted for, as well as those, which are stated in the insurance contract. The Policyholder and the Insurance Company may determine such circumstances together.
(2) The Policyholder shall enable the Insurance Company an overview and assessment of risk.
Article 9 OBLIGATIONS ATTACHING TO THE INSURED AFTER THE INSURED EVENT
(1) After the occurrence of an insured event, the Insured shall immediately do everything in his/her power to prevent any further loss by following the instructions of the Assistance Company, and trying to limit the costs to the best of his/her knowledge.
(2) The Insured shall inform the Insurance Company about the occurrence of an insured event at the latest within three days after the day when he/she has become aware of it.
(3) The Insured shall give to the Insurance Company all the data and other evidence, which are available to him/her and which are vital to establish the cause, volume and amount of loss as well as for the arrangement of assistance, and other additional documentation on the Insurance Company’s request. In any case, the Insured shall observe the instructions provided by the Insurance Company or any of its representatives.
(4) The documentation, which the Insured must present, is:
a) in case of illness:
- medical records justifying the urgent nature of treatment and the documents stated under point c),
b) in case of accident:
- medical records,
- official reports or certificates written abroad based on the circumstances of the accident or injury, and the documents stated under point c),
c) in both cases:
- a copy of insurance policy,
- the original receipt of the costs of medical assistance abroad,
- the original receipt for medications and transportation,
- the official translation of documents on request of the Insurance Company,
- a proof that the stay abroad was not longer than 90 days (applies only in the case the provision stated in the third paragraph of Article 3 herein is in effect),
- additional documents on request of the Insurance Company.
(5) The Insured’s failure to fulfil his/her liabilities referred to in this Article within the agreed period of time may result in the Insurance Company’s refusal to pay the benefit, if such failure makes the Insurance Company unable to establish the occurrence of the insured event.
(6) If the Insured fails to report the occurrence of the insured event at his/her fault in the time and the way as determined herein, he/she shall reimburse the Insurance Company for any loss it might have suffered in respect thereof.
(7) If the Insured did not use the medical assistance and paid the urgent medical services himself/herself, the Insurance Company shall reimburse him/her for the costs in accordance with Article 6 herein, upon presenting the required documentation.
Article 10 OBLIGATIONS ATTACHING TO THE INSURANCE COMPANY AFTER THE INSURED EVENT
(1) In case the insured event occurs, the Insurance Company shall pay the benefit within fourteen days starting from the date when it has received the entire documentation based on which it is able to establish the basis and the amount of the claim. If the sum of its liability is not established within this period, the Insurance Company shall pay, on the Insured’s or Beneficiary’s request, the incontestable part of its liability in form of advance payment.
(2) Upon each insured event, the Insurance Company shall pay the established loss in full at the official rates of exchange of the European Central Bank (ECB) on the benefit payment date, however not exceeding the amount stated in the insurance cover chart at the end of these Terms and Conditions.
(3) The previous provision of this Article shall not apply if the Insured presents a document proving the actual amount of costs in € on the insurance event occurrence date.
Article 11 RIGHTS ATTACHING TO THE INSURANCE COMPANY
(1) In the event of an accident caused by a third party, the Insurance Company shall have the right to the collect from such third party the costs that the Insurance Company paid to the Insured.
(2) The Insurance Company reserves the right to the refund of all the costs incurred in the event it is subsequently established that the insured event has resulted from events stated in Article 7 herein.
Article 12 PREMIUM PAYMENT AND CONSEQUENCES OF DEFAULT
(1) The Policyholder shall pay the premium or the first instalment for the first policy year upon the conclusion of the insurance contract. Payment upon the conclusion of the contract shall also include payment executed by the maturity date such as specified in the claim document. In such case, the insurance cover shall take effect on the date and hour determined as insurance inception. If the premium (or the first instalment) are not fully paid by the maturity date specified in the claim document, the insurance cover shall take effect the day following the date when full payment is made. In case of long-term insurance contracts, the Policyholder shall pay the premiums for the subsequent policy years (or the first instalment in the next policy year) on the first day of every subsequent policy year. If not agreed otherwise, the dynamics of payment for the subsequent policy years shall be the same as in the first policy year.
(2) If it is agreed for the premium to be paid in instalments or retroactively, regular interest may be charged on the amount of premium for which the deferment of payment has been agreed. If an instalment is not paid by the maturity date, the Insurance Company shall have the right to charge legal default interest and to demand immediate payment of all non-past due instalments.
(3) If the premium is paid at a post office or bank, the date of payment shall be the day when the payment order was submitted at a post office or bank. If the reference is not clearly stated on the payment order, thus making it impossible to see which premium or which instalment of premium and which type of insurance contract is being paid for, it shall be considered that the default premium or the instalment of premium, which is the oldest by the maturity date, is being paid for, regardless of the type of insurance contract, which has been concluded with the Insurance Company.
(4) If a premium discount was agreed according to the agreed time of insurance, and the insurance terminated before the end of this time, the Insurance Company may collect the difference up to the premium which should be paid by the Policyholder were the contract concluded only for the period of time, which it actually lasted for.
(5) In case the insurance contract ends because of a default premium, the Policyholder shall pay the premium for the time until the contract termination date of the contract or the total premium for the current policy year, if the insured event for which the Insurance Company must pay the benefit has occurred by the termi- nation date of the contract validity. The Policyholder shall also return the discount on the premium, which was awarded to him/her for the agreed duration of insurance, as determined in the previous paragraph.
(6) The Insurance Company has the right to deduct from the benefit all past due and
default premiums of the current policy year as well as other default liabilities the Policyholder has to the Insurance Company from previous years.
(7) The liability of the Insurance Company to pay the benefit shall terminate if the Policyholder has not paid, by the maturity date, the premium which fell due after the conclusion of the contract, and if no interested party has done this after thirty days from the date when the Policyholder was served the registered letter of the Insurance Company with the notice on the premium maturity, whereby this period cannot end before the end of thirty days from the maturity of the premium.
(8) After the end of the deadline referred to in the seventh paragraph of this Article, the Insurance Company may rescind the insurance company without notice period, if the Policyholder is in default with the payment of the premium which must be paid after the conclusion of the contract or the second and subsequent premiums; the rescission of the contract shall take effect at the end of the deadline referred to in the seventh paragraph of this Article and with the end of the insurance cover, provided that the Policyholder was informed about this in the registered letter with the notice on the maturity of the premium and on the end of the insurance cover.
(9) If, in cases when the Insurance Company has not rescinded the insurance contract, the Policyholder pays the premium after the end of the deadline referred to in the seventh paragraph of this Article within one year after the maturity of the premium, the Insurance Company shall be obliged, in case the insured event occurs, to pay the benefit from 24:00 hrs after the premium and default interest have been paid. If the Policyholder does not pay the premium within this period of time, the insurance contract will end with the end of the policy year.
(10) Legally determined duties (charges, taxes, etc.) are charged on the premium. If charges change during the term of the insurance or if new charges, tax rates or taxes are imposed during the term of the insurance, such changes will affect the amount of the premium.
Article 13 CONTRACT CANCELLATION AND PREMIUM RETURN
(1) The Policyholder may cancel the insurance contract when the insurance cover has not yet begun, i.e. before the insurance commencement, as stated in the policy.
(2) The insurance contract may be cancelled only if the journey abroad does not take place as a result of death or illness of the Insured or his/her close family member. The insurance contract cannot be cancelled after the start of the insurance cover.
(3) In the event of the insurance contract cancellation, the Insurance Company shall return 85% of the paid premium.
(4) If the insurance duration is not specified in the contract or if it is specified with the possibility of extending the contract for the same period of time, each party may rescind the contract on the premium maturity date, provided that he/she has informed the other party about this a minimum of three (3) months before the maturity of the premium.
(5) If the insurance is taken out for more than three (3) years, each party may after the end of such period rescind the contract with a six-month notice period, provided that he/she has informed the other party about this in writing.
(6) In the event of a distance insurance contract (concluded online, via telephone, etc.), which has been concluded for a period longer than 30 days, the Policyholder may cancel the contract, however not later than 15 days before the insurance commencement. In this case, the Insurance Company will return the total amount of the paid premium. The cancellation must be made in writing and submitted to the Insurance Company by the end of the deadline, whereby it shall be considered that the cancellation has been filed in time if it was sent by registered mail by the end of the deadline. Under this paragraph, the Policyholder shall not have the right to cancel the contract in case of insurance contracts valid less than one month.
Article 14 EXPERT OPINION PROCEDURE
(1) Each contracting party may demand expert opinion on certain disputable matters.
(2) Each party shall appoint one expert from among the persons who are not in an employment or family relationship with the parties. Before the beginning of work, the appointed experts shall appoint a third expert to give opinion when the findings of the first two experts are different, and only within the limits of their findings.
(3) Each party shall bear the costs for the expert it has nominated. For the third expert, each party shall bear one half of the costs.
(4) Final conclusions are compulsory for both parties.
Article 15 CHANGES TO INSURANCE CONTRACT
(1) Should the Insurance Company change the insurance Terms and Conditions or the premium rating system, it must inform the Policyholder about the change in writing or in another appropriate way at least 60 days prior to the end of the current policy year.
(2) The Policyholder has the right to cancel the insurance contract within 60 days after having received the notice. The contract shall be terminated when the current policy year ends.
(3) Should the Policyholder not cancel the insurance contract, the contract will be changed in compliance with the new terms and conditions of insurance or the premium rating system as of the beginning of the following year.
(4) The Insurance Company reserves the right to correct any calculation or other mistakes made by the agent; the Policyholder must be informed in writing about any such correction. The Policyholder shall have the right to rescind the insurance contract within 15 days from the receipt of notice, provided that he/she does not agree with the corrections (changes to the insurance contract by the Insurance Company), whereby the rescission has a prospective effect. If the Policyholder does not rescind the insurance contract within this period of time, it shall be considered that he agrees with these corrections/changes, therefore the insurance contract shall apply from the end of this period onwards with the corrections (changes to the insurance contract by the Insurance Company).
Article 16 METHOD OF NOTIFICATION
(1) Agreements as regards the content of the Insurance contract shall be valid only if concluded in writing.
(2) Any notices and statements that must be provided under the provisions of the insurance contract must be made in writing.
(3) A notice or statement shall be deemed to be timely if it is sent by registered mail prior to the end of the deadline.
(4) A statement which must be made to the other party shall become effective only when the other party has received it.
Article 17 CHANGE OF ADDRESS AND SERVICE
(1) The Policyholder must inform the Insurance Company about a change of his/her address of residence or the seat or his/her name or company name within 15 days from the day of change.
(2) Should the Policyholder change his/her address of residence or his/her name or company name and should he/she fail to communicate it in writing to the Insurance Company, it shall be enough that the Insurance Company sends the notice, which it must communicate to the Policyholder, to the address of the Policyholder’s last known address or seat, or to address it to the name or company name last known to it.
(3) If the attempt of servicing a registered notice to the Policyholder was unsuccessful (due to having moved, refusing to accept the notice, etc.), the Insurance Company shall consider the returned mail as being served and it will keep it at the seat of the Insurance Company. The Policyholder agrees that such notice is considered as having been received on the date of the first attempt of serving it and that it is considered that the Policyholder is familiar with the content of the notice.
(4) The assumption of successful servicing from the previous paragraph hereof has legally valid effects on the basis of the contractual agreement with the Policyholder.
Article 18 PROTECTION OF PERSONAL DATA
(1) Until recall, the Policyholder hereby allows the Insurance Company and the brokerage companies authorized by it to keep, process and use in their databases his/her personal data, which are needed for the implementation of insurance and for the purposes of informing the Policyholder and the Insured about news and offers related to financial products.
(2) The Insured hereby authorizes the Insurance Company and the Assistance Company to obtain and check on his/her behalf the medical documentation which is necessary to establish the circumstances for taking out the insurance and to establishing the Insurance Company’s liability.
(3) The Policyholder hereby allows the Insurance Company to also provide personal data (name, permanent or temporary address, telephone number, e-mail address and telefax number) to other companies connected with the Insurance Company in terms of capital, and other affiliated or managing companies connected with the Insurance Company. These companies can use data only for direct marketing purposes including purposes of informing the Policyholder about news and offers related to financial products. The Policyholder also allows the Insurance Company to obtain necessary data from personal database administrators and provide them to the green card bureau or another body engaged in the settlement of the loss event.
(4) The Policyholder or the Insured may at any time demand the Insurance Company to stop using their personal data for direct marketing purposes from the previous paragraph. The Insurance Company hereby undertakes to prevent the use of personal data, for which permission was given according to the previous paragraph of this Article, not later than within 15 days.
(5) The Insurance Company hereby undertakes to keep all personal data with due diligence and care, pursuant to the applicable personal data protection law.
Article 19 SETTLEMENT OF DISPUTES
(1) The Policyholder, the Insured or the Beneficiary may within 15 days after having received a written decision from the Insurance Company file a written complaint to the Insurance Company, which must treat the complaint in accordance with its internal rules. The decision of the complaint committee shall be final and no further proceedings at the Insurance Company shall be possible.
(2) In case of disagreement with the decision made by the Insurance Company, proceedings for out-of-court settlement of dispute at a mediation centre operating within the Slovenian Insurance Association may be continued if a special agreement is made. In certain cases this may be even brought before the Insurance Ombudsman.
(3) Slovenian law shall apply for relations concerning the insurance contract, which are not regulated herein.
(4) The Court in Koper shall be competent for deciding on any judicial disputes.
(5) The Insurance Supervision Agency, Xxx xxxxxxxxx 0, Xxxxxxxxx, is competent for the supervision over the Insurance Company.
INSURANCE COVER CHART FOR TRAVEL HEALTH INSURANCE WITH ASSISTANCE ABROAD
TYPES OF INSURANCE COVER | ||||
Total for all insurance covers, a maxi- mum up to the sum insured: | €25,000 €20,000* | €50,000 €40,000* | €100,000 €60,000* | |
1. | Medical care and doctor’s visit | √ | √ | √ |
2. | Treatment Limitation – under the Treatment cover, the cost of treating acute deterioration of chronic diseases is covered up to the following amounts: | √ €400 | √ €800 | √ €1,200 |
3. | Transportation to the nearest hospital or clinic and back | √ | √ | √ |
4. | Transportation to homeland | √ | √ | √ |
5. | Medications and medical supplies | √ | √ | √ |
6. | Urgent dental services | €100 | €200 | €300 |
7. | Transportation and accommodation for the person accompanying the Insured | √ | √ | √ |
8. | Accompanying a minor and transportation of a minor | √ | √ | √ |
9. | Transportation for a family member | Ticket | Ticket | Ticket |
10. | Transportation the Insured’s mortal remains to his/her homeland | √ | √ | √ |
11. | Return in case of death of a family member | √ | √ | √ |
Age limit | 75 years | 75 years | 75 years | |
Age limit (additional premium required) | 85 years | 85 years | 85 years | |
Age limit (additional premium required) | above 85 years | above 85 years | above 85 years | |
Geographic coverage | worldwide | worldwide | worldwide | |
√ - included | ||||
* Applicable for the insurance of persons who have permanent residence abroad but temporarily live and work in the Republic of Slovenia.