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The terms and conditions of Voluntary insurance traveling abroad (Insuranse Contract series MVI)

 

Part B. Voluntary insurance traveling abroad

 

This Contract for voluntary insurance traveling abroad (hereinafter referred to as the "Contract") is concluded in accordance with the Additional Terms concerning voluntary insurance of medical and other expenses incurred when traveling abroad (Addendum 2 to Rules No. 1210 of voluntary medical expense insurance) of PROSTO-insurance, CJSC and Rules No. 1023 of voluntary accident insurance of PROSTO-insurance, CJSC (hereinafter referred to as the “Rules”).

 

7. General Provisions of Coverage

Insurer – shall mean Closed Joint-Stock Company “Joint-Stock Insurance Company providing emergency medical assistance to foreign citizens” (PROSTO-insurance, CJSC).

Policyholder (Insured) – shall mean a legal entity or a capable physical person that entered into an insurance Contract with the Insurer.

Insured Person – shall mean a physical entity to whose benefit the insurance Contract is concluded. An Insured who is a physical person that concluded an insurance Contract with respect to him-/herself shall be the Insured Person. The Insured Person may acquire rights and responsibilities of the Insured pursuant to the insurance Contract.

Sum Insured – shall mean monetary amount within the limits of which the Insurer shall be obligated, under provisions of this Contract, to pay insurance indemnity upon occurrence of an Insured Event. Limits of the insurance indemnity within the Sum Insured (liability limits) are stated in this Contract for payment of cost for certain services stipulated in the insurance Program.

Deductible – shall mean a portion of losses, specified by the provisions of this Contract, which shall NOT be indemnified by the Insurer. This Contract may stipulate a deductible - a percentage of the Sum Insured, or an absolute monetary value, which shall NOT be indemnified by the Insurer in case of occurrence of each Insured Event under voluntary insurance of medical and other expenses incurred when traveling abroad. Losses that exceed the amount of deductible shall be covered (indemnified) by the Insurer with the deduction of the deductible amount. Losses that do NOT exceed the amount of deductible shall NOT be covered (indemnified) by the Insurer, but shall be the responsibility of the Insured Person.

Insurance Program – shall mean a schedule of a certain scope of services, agreed between the Insurer and the Insured in the insurance Contract that shall be provided to the Insured Person upon occurrence of the Insured Event and covered by the Insurer.

Assistance company (service company) – shall mean a specialized establishment that shall act on behalf of the Insurer and shall coordinate activities among the Insured Person and entities, which provide services to the Insured Person upon occurrence of the Insured Event. Assistance company shall organize, control, pay for such services, and perform other activities on behalf of the Insurer.

Close Relatives of the Insured Person – shall mean his/her spouse, children (including adopted children); his/her mother, father (mother, father of his/her spouse); sister or brother.

Accident – shall mean a sudden and unforeseen impact on the Insured Person of a hazardous external factor or environment, occurred during validity term of this Contract that resulted in health disorder or death of the Insured Person.

Acute Pain – shall mean a reaction of the nervous system of a person to an exogenous irritant or internal stimulus which, in case of non-receipt of emergency medical assistance, may lead to the development of a shock, which can be life-threatening to the Insured Person.

Acute Disease – shall mean a sudden, unforeseen disruption of vital activity of a human body, which leads to deterioration of health of the Insured Person and which, in case of non-receipt of emergency medical assistance, may result in a prolonged health disorder, or become life threatening.

Insurance Risk – shall mean a certain event, against which the insurance is being put into effect, and which shall have characteristics of probability and accidental occurrence.

Insured Event – shall mean an event stipulated by the insurance Contract that took place; and which occurrence creates an obligation for the Insurer to make indemnity payment to the Insured, Insured Person or any other third party according to procedure and under terms and conditions as stated in the insurance Contract.

 

8. Subject of the Insurance Contract

Subject of this Contract shall be property interests that do NOT contravene the law and are related to the following:

Unforeseen expenses of the Insured Person incurred during his (her) travel abroad in connection with the necessity to provide such Insured Person with medical, medical transportation and other types of services stipulated by the insurance Program, as a result of occurrence of the Insured Event.

Life, health and ability to work of the Insured Person.

 

9. Validity Term of the Contract. Coverage Territory.

Validity Term of this Contract is stated in Clause 2 thereof.

Responsibility of the Insurer under this Contract (insurance protection) shall commence at 00 Hours 00 Minutes, Kyiv time, on the date set forth as the commencement date of the validity term of this Contract, but NOT before the moment of crossing by the Insured Person of the state border of Ukraine when traveling abroad.

Responsibility of the Insurer under this Contract (insurance protection) shall cease at the moment of crossing by the Insured Person of the state border of Ukraine when returning to the territory of Ukraine, or at 00 Hours 00 Minutes, Kyiv time, on the date set forth as the termination date of the validity term of this Contract, whichever occurs earlier.

The obligation of the Insurer under Contract shall cover the number of days as specified in Clause 2 thereof. If this Contract stipulates multiple trips in accordance with Clause 4.2.2 of this Contract, then each departure of the Insured Person abroad shall automatically decrease the validity term of this Contract by the number of days spent by the Insured Person on the Coverage Territory of this Contract.

If this Contract stipulates a “Multi-visa” variant of insurance coverage in accordance with Clause 4.2.3 of this Contract, then the Insurer shall have obligations with respect to Insured Events that occurred to the Insured Person only within the first 15 (fifteen) calendar days from the moment of crossing by the Insured Person of the state border of Ukraine. At the same time, the number of trips abroad by the Insured Person, performed during the validity term of this Contract set forth in Clause 2 thereof, shall be unrestricted. “Multi-visa” variant of the insurance coverage stipulates payment by the Insurer for those services that are specified in Program "A".

This Contract shall be in force on the territory specified in Clause 4.5 of this Contract, excluding the territory of Ukraine, country of permanent residence of the Insured Person, military conflict zones and territories under UN sanctions.

The territory of cover “All European countries” means the validity of this Contract on the territory of European countries, CIS, Baltic countries as well as in Turkey, Egypt, Cyprus, Israel, Tunisia, UAE according to the conditions indicated in p. 9.6.

The territory of cover “Worldwide” means the validity of this Contract on the territory of all other countries of the world according to the conditions indicated in p. 9.6.

 

10. List of Insured Events

The following events, occurring during validity term of the Contract, shall be considered insurance risks under insurance of medical and other expenses when traveling abroad:

Sudden acute disease of the Insured Person (Insurance Programs “A”,“С”, “D”, “Business Card”).

Health disorder, bodily injuries sustained by the Insured Person as a result of an Accident (Insurance Programs “A”,“С”, “D”, “Business Card”).

Sudden exacerbation of existing disease of the Insured Person (Insurance Programs “A”,“С”, “D”, “Business Card”).

Death of the Insured Person as a result of a disease or an Accident (Insurance Programs “A”, “С”, “D”, “Business Card”).

Death of a close relative of the Insured Person (Insurance Programs “С”, “D”, “Business Card”).

Delay or loss of luggage of the Insured Person (Insurance Programs “С”, “D”, “Business Card”).

Loss or theft of documents of the Insured Person (Insurance Programs “С”, “D”, “Business Card”).

Violation of rights of the Insured (Insured Person) (Insurance Programs “С”, “D”, “Business Card”).

Loss incurred by the Insured Person in connection with inconveniences of use of the air transportation (Insurance Programs “С”, “D”, “Business Card”).

Damage to the vehicle (owned or rented) of the Insured Person occurred during traffic accident and/or breakdown of the vehicle owned by the Insured (Insured Person) who travels by auto transport. (Insurance Programs “D”, “Business Card”).

Insured Events under voluntary insurance of medical and other expenses incurred when traveling abroad shall be documented events as specified in Clause 10.1. of this Contract, which occurred during the validity term of this Contract, while the Insured Person remained on the Coverage Territory of this Contract, and as a result of which the Insurer is obligated to cover medical and other expenses of the Insured Person for services, the scope and schedule of which is stipulated by the Insurance Program.

Insurance Programs for medical and other expenses insurance when traveling abroad

Program “A”.

Upon occurrence of the Insured Event the Insurer shall pay for the following expenses of the Insured Person for medical assistance:

a) Expenses for emergency out-patient treatment in a medical establishment or by a licensed doctor (necessary consultations, diagnostic analyses, carrying out therapeutic measures and medical manipulations, payment for medications prescribed by the doctor and for disposable medical materials, etc);

b) Expenses for emergency in-patient treatment in medical establishments (necessary consultations, diagnostic analyses, conservative treatment and surgery, payment for medications prescribed by the doctor and for disposable medical materials, hospital stay in a standard room, meals, according to standards followed by such medical establishment);

c) Expenses for emergency medical assistance provided by an ambulance (dispatch of the ambulance crew, on-the-spot diagnosis and treatment, supply of medications and disposable medical materials);

d) Expenses for emergency dental assistance within limits of liability:

• 150 Euro/ USD (Programs “A”, “С”) ;
• 200 Euro/ USD (Program “D”);

e) Expenses for communications services with the Assistance company in relation to the occurrence of the Insured Event, within limits of liability:

• 50 Euro/ USD (Programs “А”,“С”);
• 100 Euro/ USD (Program “D”);

f) Expenses for transportation of the Insured Person to the nearest medical establishment, if such dictated by the health condition of the Insured Person;

g) Expenses for medical evacuation of the Insured Person from abroad to the customs check point, specified by the Insurer, or a hospital nearest to the place of his/her permanent residence in Ukraine, including expenses for an accompanying person, provided that medical conclusion for the necessity of such accompaniment is available. Medical evacuation shall be carried out only upon consent of the Assistance company. The route, type and class of transportation means shall be determined by the Assistance company upon receipt of consent from the Insurer;

h) Expenses for repatriation of remains of the Insured Person to the place of his/her permanent residence (to the customs check point in Ukraine) in the country of permanent residence of the Insured Person in case of death of the Insured Person as a result of acute disease, exacerbation of chronic disease or an Accident. Necessary condition for carrying out the repatriation shall be a receipt of a confirmation from the relatives of the Insured Person regarding their readiness to collect the remains of the Insured Person after its crossing of the border.

 

Program «С».

In addition to expenses reimbursed under Program “A:”, upon occurrence of the Insured Event the Insurer shall also reimburse administrative expenses for the following:

a) Cost of a round-trip travel by a third party to the country of temporary stay of the Insured Person in case of in-patient treatment of the Insured Person for more than 10 (ten) calendar days. The Insurer shall reimburse the cost of the economy class tickets. The route, type and class of transportation means shall be determined by the Assistance company upon receipt of consent from the Insurer;

b) Cost of travel by the Insured Person to the place of his/her permanent residence in case of death or serious disease of his/her closest relatives. Cost of the economy class tickets shall be reimbursed. The route, type and class of transportation means shall be determined by the Assistance company upon receipt of consent from the Insurer;

c) Cost of travel of children under legal age of the Insured Person to the place of his/her permanent residence, and if necessary, their accompanying by a third person, if they cannot be looked after by the Insured Person due to his/her acute disease, an Accident or death of the Insured Person. The Insurer shall reimburse the cost of travel of children under legal age of the Insured Person to the place of their permanent residence only in case if health condition of any person of legal age traveling with the children precludes provision of necessary care for them. The route, type and class of transportation means shall be determined by the Assistance company upon receipt of consent from the Insurer;

d) Purchase by the Insured Person of the first-necessity items (personal hygiene items, acute pain medications etc.), food products (except for alcoholic beverages) in case of any delays of his/her luggage that was being transported by air, for more than 4 hours. The Insurer shall reimburse the Insured Person for such expenses within limits of liability 100 Euro / USD without taking deductible into account;

e) Purchase by the Insured Person of food products (except for alcoholic beverages), first-necessity items (personal hygiene items, acute pain medications etc.) and/or reimbursement of cost of staying of the Insured Person in a hotel in case of any delays of the aircraft departure for 4 hours or more. The Insurer shall reimburse the Insured Person such expenses within limits of liability 100 Euro / USD without taking deductible into account;

f) Renewal of lost or stolen documents (foreign passport) of the Insured Person during his/her stay abroad. The Insurer shall reimburse the Insured Person for such expenses within limits of liability 100 Euro / USD.

g) Under this Insurance Program, in addition to expenses covered under Program “B”, upon occurrence of the Insured Event, the Insurer shall reimburse the Insured Person for the expenses related to organization of legal protection services to the Insured Person in case of violation of his/her rights, or when legal advice is necessary in connection with his/her detention / arrest or threat of occurrence thereof, as well as any complications resulted from official claims from third parties within limits of liability 200 Euro /USD.

Program “D”.

Under this Insurance Program, in addition to expenses covered under Program “C”, upon occurrence of the Insured Event, the Insurer shall reimburse the Insured Person for the following expenses:

a) Organization and cost of transportation of the Insured (Insured Person) to a destination in European countries in case of a breakdown of the vehicle of the Insured (Insured Person) or an Accident. The route, type and class of transportation means shall be determined by the Assistance company upon receipt of consent from the Insurer. The Insurer shall reimburse the Insured Person for such expenses within limits of liability 200 Euro / USD;

b) Provision of a driver services, if the Insured (Insured Person), based on medical indications, is unable to operate transportation means as a result of a sudden disease or an Accident. The Insurer shall reimburse the Insured Person for such expenses within limits of liability 150 Euro / USD;

c) Towing of the vehicle of the Insured (Insured Person) to the nearest repair place. The Insurer shall reimburse the Insured Person for such expenses within limits of liability 100 Euro / USD.

 

Program “Business Card” (for Insureds that are legal entities or banking card holders). Insurance Contract shall be concluded for the term of 1 (one) year. Maximum duration of one trip of the Insured Person shall NOT exceed 90 (ninety) calendar days. Maximum stay abroad of the Insured Person within a year shall NOT exceed 200 (two hundred) calendar days.

a) Under the Program “Silver Card”, in addition to expenses under the Program “C”, the following expenses shall be covered:

– Posting a bail in court (up to 3 000 USD), if the Insured (Insured Person) had committed unintentional offense and a criminal case was initiated against him/her;

– Expenses for a trip to replace the Insured Person, if he/she is unable to fulfill his/her tasks due to a sudden disease or an Accident, within limits of liability of the Insurer stipulated in the insurance Contract.

b) Under the Program “Golden Card”, in addition to expenses covered under Programs “D” and “Silver Card”, expenses for spare parts delivery shall be reimbursed (within limits of liability up to 200 Euro /USD).

Assistance company shall also organize additional services for hotel reservation, car rental, booking, purchase and changing tickets and other services, cost of which shall be covered by the Insured Person at his (her) own expense.

 

Under voluntary Accident insurance, the following events shall be considered insurance risks:

Death of the Insured Person as a result of an Accident.

Establishment of primary disability of the Insured Person as a result of an Accident.

Traumatic injury and functional health disorders of the Insured Person as a result of an Accident.

Accident - shall mean a brief, sudden, accidental and unforeseen impact on the Insured Person of a hazardous external factor (physical, chemical, technical) or environment that occurs during validity term of this Contract while the Insured Person remains on the coverage territory of this Contract, and that is accompanied by damage to body tissues of the Insured Person, compromising their integrity and functions; by deformation and/or disorder of the musculoskeletal system; and that results in a temporary or permanent health disorder of the Insured Person or his/her death. Acute poisoning with noxious plants, medication (except for cases of self-treatment), chemical substances (industrial and domestic), poor quality food products (with exception of food toxic infection, dysentery, salmonellosis); drowning, asphyxiation resulting from the intake of foreign objects or liquids into respiratory tract; bites by animals, snakes, poisonous insects; tick-borne encephalitis (encephalomyelitis); burns, strike by a lightning or electrical current, frostbite, supercooling that occurs to the Insured Person during validity term of this Contract while he/she remains on the Coverage Territory of this Contract, shall also be considered Accidents.

Insured Events under voluntary Accident insurance shall be events listed in Clause 19.4 of this Contract that occurred during validity term of this Contract while the Insured Person remained on the Coverage Territory of this Contract and that are evidenced by documents from corresponding competent bodies (medical establishments, law-enforcement agencies etc) according to procedure established by current legislation.

 

11. Actions of the Insured (Insured Person) upon occurrence of the Insured Event

Upon occurrence of an event that has characteristics of the Insured Event, the Insured (Insured Person or his/her representative) shall, prior to contacting a corresponding establishment or a doctor for help, promptly at any time of a day contact the Assistance company that represents interests of the Insurer abroad by telephone, at the number stated in this Contract. The Insured Person shall provide the following information to the Assistance company employee:

– Name of the Insurer, Series and Number of this Contract;

– Validity term of this Contract;

– First and last name of the Insured Person;

– Insurance Program;

– His/her location and contact telephone number;

– Detailed description of the event and type of required help.

After contacting the Assistance company, the Insured Person shall carry out all further instructions of the Assistance company and agree with the company all of his/her actions in connection with receipt of assistance.

In exceptional situations, when for objective reasons the Insured Person is unable to contact the Assistance company in order to receive services stipulated by the insurance Program, the Insured Person shall independently pay the cost of services provided to him/her. The following reasons shall be considered objective: lack of communication means at location of the Insured Person, unconscious state of the Insured Person (in the absence of persons that could represent his/her interests). The Insurer shall indemnify the Insured Person for the cost of services stipulated by the insurance Program and paid for independently by the Insured Person on the basis of documentation evidencing the occurrence of the Insured Event and the amount of expenses incurred, upon return of the Insured Person to Ukraine.

In the event of independent payment for medical services, the Insured Person or his/her representative shall notify the Assistance company about the same as soon as possible, but not later than 24 hours from the moment of receipt of such services, unless another term is stipulated by the insurance Contract, and confirm with the Assistance company or the Insurer the possibility of independent payment for necessary services.

 

12. Terms of the Insurance Indemnity Payment under Insurance of Medical and Other Expenses when Traveling Abroad

The Insurer shall make insurance indemnity payments by means of compensation (reimbursement) of the cost of services provided to the Insured Person, which schedule and scope are stipulated by the insurance Program, upon occurrence of the Insured Event.

The Insurer shall make insurance indemnity payments only within the limits of the Sum Insured, set forth for insurance of medical and other expenses and limits of liability of the Insurer pursuant to the insurance Program. Currency, in which the limits of liability of the Insurer under insurance Programs are stated, shall correspond to the currency of the Sum Insured, defined by this Contract. In the event if the Contract stipulates a deductible, then the insurance indemnity shall be paid with the deduction of the deductible amount according to the conditions of the Insurance Program.

Insurance indemnity payment shall be made by the Insurer in one of the following ways:

Transfer of funds to the account of the Assistance company which, on behalf of the Insurer, organized and paid for the services provided to the Insured Person. The insurance indemnity payment shall be made on the basis of documentation that evidences and confirms occurrence of the Insured Event, and the cost of services actually provided to the Insured Person. Format of such documentation and terms of settlement shall be agreed between the Insurer and the Assistance company;

Reimbursement of the Insured Person for the cost of services received by him/her in the event, when the Insured Person paid the cost of expenses independently. Insurance indemnity payment shall be made on the basis of an application submitted by the Insured Person, documentation that evidences the fact of occurrence of the Insured Event and the fact and amount of payment for services received. Payment of the insurance indemnity shall be made in national currency of Ukraine at the exchange rate of the National Bank of Ukraine valid on the date of actual payment for services.

In the event if, in case of death of the Insured Person, the expenses for repatriation of his/her remains were paid for by a third party, then the Insurer shall reimburse the third party for such expenses on the basis of documents described in Clause 12.9 of this Contract.

The amount of insurance indemnity may NOT exceed the cost of services as stipulated by the insurance Program, and received by the Insured Person. Total amount of insurance indemnity payments for one or several Insured Events that occurred to the Insured Person during validity term of this Contract, may NOT exceed the Sum Insured or the limit of liability of the Insurer set forth in this Contract.

If medical and other expenses of the Insured Person are insured with several insurers, then upon occurrence of the Insured Event, the insurance indemnity payment made by all insurers may NOT exceed the amount of actual expenses incurred by the Insured Person. Each insurer shall make the insurance indemnity payment in proportion to a sum insured under a corresponding insurance Contract.

In the event if, upon occurrence of the Insured Event, the Insured Person receives services stipulated by the insurance Program, that were organized and paid for by the Assistance company, settlement of accounts for such services shall be made between the Insurer and the Assistance company, without involvement of the Insured Person.

If the Insured Person independently paid for services stipulated by the insurance Program, then the Insurer shall reimburse the Insured Person for such expenses upon his/her return to the territory of Ukraine, in accordance with the provisions of Clause 21.3.2 of this Contract. In such case, the insurance indemnity payment shall be made on the basis of written application submitted by the Insured Person in a format determined by the Insurer, documentation evidencing the fact of occurrence of an event that has characteristics of the Insured Event and the amount of expenses, in particular:

Original insurance Contract;

Original statement from medical establishment (on the letterhead of such establishment or with a corresponding seal) providing the last name of the patient (Insured Person), accurate diagnosis, date when medical assistance was sought, duration of treatment, detailed data regarding medical services provided, their schedule, cost and total amount of medical expenses.

Prescription written by attending physician to the Insured Person for purchase of medications, indicating names of the medications.

Originals of detailed billing statements regarding medical and other services, stipulated by the insurance Program, that were provided to and paid by the Insured Person, with their breakdown by date and cost, indicating the total amount paid.

Originals of detailed billing statements for telephone conversation (facsimile messages), indicating telephone number, date, time and cost of a call.

Original documents that confirm the fact of payment for services provided (medical, administrative, legal, technical) that are stipulated by the insurance program: payment receipts (cash register receipts), banking slips indicating the amount of wire transfer etc.

Original internal passport (certificate of birth) of the Insured Person.

Original foreign passport of the Insured Person with the border control stamps.

Original statement of issuance of identification number to the Insured Person.

Original travel documents (if required).

In the event when, in case of death of the Insured Person, the cost of repatriation of his/her remains was paid for by a third party without participation of the Assistance company, then in order to receive reimbursement, the third party must furnish the Insurer with a written application for receipt of insurance indemnity in a format determined by the Insurer, the original Contract and originals of the following documents:

Certificate of death of the Insured Person;

Documents regarding payment for transportation of the remains of the Insured Person;

Internal passport of the recipient of the insurance indemnity;

Statement of issuance of identification number to the recipient of the insurance indemnity.

Documents indicated in Clauses 21.8 and 21.9 of this Contract must be submitted to the Insurer by the Insured (Insured Person) within 15 (fifteen) business days after return to Ukraine.

 

13. Terms of the Insurance Indemnity Payment under Voluntary Accident Insurance

Insurance indemnity payments shall be made on the basis of a written application by the recipient of the insurance indemnity, and the insurance report.

The Beneficiary under this Contract is not appointed. In case of death of the Insured Person as a result of accident the amount of insurance indemnity shall be paid to legatee (legatees) of the Insured Person according to will or law.

Upon occurrence of the Insured Event as described in Clause 19.4.1 of this Contract, the amount of insurance indemnity shall be 100% of the Sum Insured, as set forth for Accident insurance.

If the Insured Event, described in Clause 19.4.2 of this Contract, occurs to a person over legal age, the amount of the insurance indemnity shall be as follows:

– Upon establishment of Category ІІІ (three) disability – 50% of the Sum Insured, as set forth for Accident insurance;

– Upon establishment of Category ІІ (two) disability – 75% of the Sum Insured, as set forth for Accident insurance;

– Upon establishment of Category І (one) disability – 100% of the Sum Insured, as set forth for Accident insurance;

– Upon establishment of primary disability of the Insured Person under legal age, the amount of insurance indemnity shall be 100% of the Sum Insured, as set forth for Accident insurance.

Upon occurrence of the Insured Event as described in Clause 19.4.3 of this Contract, the amount of insurance indemnity shall be determined in accordance with the Table 1 of insurance indemnity payments in the event of traumas and injuries, stated in Addendum 2 to the Rules No. 1023 of voluntary Accident insurance (hereinafter referred to as the “Table of insurance indemnity payments”).

If, upon occurrence of traumatic injury as a result of an Accident, the insurance indemnity payment under this Contract had been made to the Insured Person, and a disability of the Insured Person was established, and/or his/her death ensued at a later date as a consequence of the same Insured Event, then the insured indemnity payment shall be made in the amount as stipulated by Clauses 22.2 and 22.3 of this Contract, with the deduction of the amount of indemnity that had been made earlier by the Insurer.

In any case, the total amount of insurance indemnity payments made in regard to one Insured Person, may NOT exceed the amount of the Sum Insured under Accident insurance, stated in this Contract.

In order to receive insurance indemnity, subject to the type of Insured Event, the Insured (Insured Person) or the Beneficiary or heir of the Insured Person must submit the following documents to the Insurer:

This Contract;

Written application from the Insured Person (recipient of the insurance indemnity) in a format determined by the Insurer, indicating circumstances, causes and consequences of occurrence of the Insured Event;

Documents evidencing and confirming occurrence of a certain Insured Event (originals or copies, certified by corresponding medical establishments or authorized representative of the Insurer):

- Original statement from a medical establishment (on the letterhead of such establishment or with a corresponding seal) providing the last name of the patient (Insured Person), accurate diagnosis, date when medical assistance was sought, duration of treatment;

 Documents issued by a Treatment Consulting Commission (“ЛКК”) or Medical and Social Expert Commission (“МСЕК”), confirming establishment of a disability category;

 In case of death of the Insured Person as a result of an Accident - certificate of death of the Insured Person (or notary certified copy);

Documents regarding legal succession or a document confirming the right of inheritance (for heirs);

Statement of issuance of identification number to the recipient of the insurance indemnity;

Original internal passport (certificate of birth) of the Insured Person;

Original foreign passport of the Insured Person with the border control stamps.

14. Reasons for Denial the Insurance Indemnity Payment.

The grounds for denial of payment of insurance indemnity shall be as follows:

Deliberate actions of the Insured (Insured Person) aimed at occurrence of the Insured Event. Such provision shall NOT apply to actions connected with fulfillment by them of their civil or official duties, in a state of necessary self-defense (without exceeding its limits) or protection of property, life, health, honor, dignity and business reputation. Classification of this actions of the Insured shall be determined in accordance with the current legislation of Ukraine.

Commitment by the Insured – a physical entity, or the Insured Person of a deliberate crime that resulted in the Insured Event.

Submission by the Insured (the Insured Person) of intentionally false information with respect to the Subject of the Contract or the fact of occurrence of the Insured Event.

. Untimely notification by the Insured (Insured Person) regarding occurrence of the Insured Event without any valid reason, or creation of obstacles to the Insurer clarification process of circumstances of occurrence of the Insured Event, determination of character and amount of losses.

Receipt by the Insured Person of services, the type and/or scope of which are not stipulated by the insurance Program.

Failure of the Insured (Insured Person) to submit to the Insurer all necessary documents confirming the fact of occurrence of the Insured Event and the amount of losses, or documents required by current legislation of the Ukraine.

Refusal of the Insured Person to be transferred to a treatment facility of the country of his /her permanent residence from such moment when doctor determines that, by medical indications, the state of health of the Insured Person does not preclude his/her return to the country of permanent residence, independently or accompanied by another person.

Other cases stipulated by law.

In any case, the insurer shall NOT pay and shall NOT reimburse for the following expenses of the Insured (Insured Person):

Expenses for transportation, medical evacuation or repatriation that were NOT organized by the Assistance company and/or were made without prior consent of the Insurer.

Expenses for evacuation of the Insured Person in case of insignificant illnesses or injuries that can be treated locally and do not prevent the Insured Person from continuation of his/her travel.

Expenses for transportation of the Insured Person from one medical establishment to another that was not organized by the Assistance company and/or was done without prior consent of the company or the Insurer.

Expenses related to a course of treatment that commenced prior to, and is continuing during validity term of the Contract, or if the travel started in spite of existing medical counter-indications stated by a qualified doctor.

Expenses for services that exceed reasonable or justifiable amounts paid for them in specified region (determined by the Assistance company), or expenses that exceed the necessary ones.

Expenses for medical services with respect to a course of any planned treatment, including planned surgical operations.

Expenses for medical services with respect to vessels angiography, coronarography.

Expenses related to pregnancy, abortions or childbirth (with exception in such cases that are life-threatening to the Insured Person and in cases of therapeutic abortion that is a consequence of an Accident).

Expenses related to treatment of mental disorders and diseases, except for such cases that are life-threatening to the Insured Person.

Expenses for any treatment and rehabilitation on the territory of Ukraine and/or the country of permanent residence of the Insured Person, including expenses related to medical error, incorrect or insufficient medical manipulations and their consequences at the time of travel.

Expenses and losses due to inability to work, participate in traveling, excursions, spend vacations abroad, for booking and reservation of tickets and hotel accommodation

Expenses for prosthetics of all kinds, including dental and ophthalmologic prosthetics.

Expenses for medical examinations and medical monitoring that are NOT connected to a sudden disease, exacerbation of a chronic disease or injury.

Expenses for correctional and rehabilitation treatment, physiotherapy and resort & sanatorium treatment.

Expenses for cosmetic and plastic surgery, unless they are prompted by an injury caused by an Accident during insurance coverage period.

Expenses for medical services which, from the medical viewpoint (based on conclusions of the Assistance company, conclusions of expert commission), can be postponed until return to Ukraine.

Expenses for preventive vaccinations, disinfection, medical expertise.

Expenses for providing additional comfort, such as: separate hospital room, telephone, TV set, services of a hairdresser, masseur, cosmetologist etc.

Expenses for diagnosis and treatment of congenial, chronic, oncological illnesses and diseases that existed prior to the validity term of the Contract, except for cases that require immediate medical assistance in order to save life of the Insured Person.

Expenses related to venereal diseases, AIDS and all diseases caused by HIV-infection.

Expenses for purchase and repair of medical aids devices (lenses, eyeglasses, hearing aids, cardio stimulators, prosthetics, thermometers, crutches, wheelchairs etc)

Expenses related to the Insured Person being in the state of alcoholic, narcotic or toxic intoxication.

Expenses related to injuries received by the Insured Person while operating transportation means, if he/she had no right to operate such transportation means, or operated them under the influence of alcoholic, narcotic and toxic substances.

Expenses due to unforeseen events, caused by military actions of any kind and their consequences, mass disorders, uprisings or other acts of civil disobedience, terrorist acts.

Expenses related to commitment by the Insured Person of a deliberate offence abroad that is recognized as such under the laws of a country of temporary stay or the laws of the country of permanent residence of the Insured Person.

Expenses that exceed the necessary ones beyond such moment when the state of health of the Insured Person has so improved (by medical indications) that he/she may return to the country of his/her permanent residence independently, or accompanied by another person.

Expenses for any kind of services stipulated by the Contract, if the trip had been conducted with the aim to receive such services.

Expenses for treatment in a medical establishment, as well as expenses for administrative, legal, technical assistance in such case when the Insured Person has the right to receive such services free of charge.

Expenses related to a sudden disease, an Accident or another unforeseen event that resulted from paid physical labor, practicing amateur or professional sports, except for cases if the Contract stipulates insurance against such risks in accordance with Clause 12 of this Contract, and the Insured had paid а proper insurance premium.

Expenses for services that can be postponed until return to Ukraine (by medical indications), including expenses for surgeries that can be substituted on this stage with a course of conservative treatment.

Expenses for treatment for diseases or injuries caused by ionizing radiation, radioactive contamination.

Expenses for dental assistance, except for emergency assistance.

Expenses that are not stipulated by the insurance Program.

Expenses for treatment of sunburn, allergic reactions to sun radiation.

Expenses for services connected with the delay of an aircraft departure, if:

– The Insured Person did not complete flight registration, except for such cases when he/she was unable to complete flight registration due to strikes or technical reasons of which the Insured Person was NOT informed prior to registration.

– Aircraft delay was caused by a strike, or occurred due to technical reasons of which the Insured Person was informed prior to registration.

Expenses related to delay or loss of luggage of the Insured Person, if:

– The luggage was transported by a flight, which final destination is Ukraine and/or the country of permanent residence of the Insured Person.

– Delay of luggage is caused by customs clearance and/or violation of customs regulations.

– The Insured Person did not notify an authorized airline representative about a delay of luggage delivery, or loss thereof.

– Expenses were made by the Insured Person after delivery of his/her luggage by a carrier.

The Insurer shall NOT be responsible for, and shall NOT make indemnity payments in case of death, establishment of disability, traumatic injury of the Insured Person, if they are directly or indirectly connected with the following:

Deliberate actions of the Insurer / Insured Person or the Beneficiary.

Suicide or attempted suicide, with exception of such cases when the Insured Person was led to such condition by unlawful actions of third parties.

Diseases of various kinds.

Deliberate self-infliction of bodily injuries by the Insured Person.

Events that occurred as a result of the following shall NOT be considered the Insured Events:

Consumption by the Insured Person of alcohol, narcotics or other substances that may cause intoxication.

Self-treatment.

Violation by the Insured Person of safety rules, fire safety rules and traffic rules.

Conscious presence of the Insured Person in places known to be life- and health-threatening to a human being (such as places that carry out explosions, construction sites, military training grounds, shooting ranges etc), unless such presence is connected with work necessity or an attempt to save a human life.

Force majeure (war, revolution, conspiracy, uprising, civil disorders, strikes, terrorist acts, emergency, special or military regimes declared by government bodies according to procedure established by law, radioactive, chemical or bacteriological contamination, effect of ionizing radiation).

Pregnancy or childbirth (under accident insurance).

Military service in the Armed Forces and military formations.

Operating of transportation means by the Insured Person who does not have a driver’s license, as well as passing over by the Insured Person the operating of transportation means to a person who is under the influence of alcoholic, narcotic or toxic substance, or does not have a driver’s license.

Flying in any kind of flying devices, with exception of cases when the Insured Person is flying as a passenger in a civil aircraft, the owner of which has the license for passenger transportation.

The insurer shall NOT compensate for moral damage and lost profit.

 

15. Rights and Obligations of the Parties for Non-Fulfillment or Improper Fulfillment of the Terms and Conditions of the Contract

The Insured (Insured Person) shall have the following rights:

To conclude insurance Contracts for its (his / her) own benefit and for the benefit of third parties.

To initiate making amendments to the terms and conditions of the Contract.

To terminate the Contract early, according to procedure stipulated by this Contract.

To receive insurance indemnity according to terms and procedure of this Contract.

To appeal the decision of the Insurer to deny payment of the insurance indemnity according to procedure stipulated by current legislation of Ukraine.

To obtain a duplicate copy of the Contract in the case of loss thereof (one copy during the validity terms of the insurance Contract), on the basis of written application of the Insured to receive of a duplicate.

The Insured (Insured Person) shall have the following obligations:

To make timely payment of the insurance premium.

When concluding this Contract, to furnish the Insurer with information about all circumstances known to him/her that are significant for assessment of insurance risk, and to further inform the Insurer about any changes of the insurance risk.

To notify the Insurer about other valid insurance Contracts of medical and other expenses of the Insured Person.

To apply measures in order to prevent and minimize losses incurred due to occurrence of the Insured Event.

In case if it necessary to receive services stipulated by the insurance Program, to promptly contact the Assistance company and to coordinate with the Assistance company all its actions related to receipt of medical and other services upon occurrence of the Insured Event.

In case of return to the territory of Ukraine ahead of schedule, to surrender to a representative or the Insurer all unused airline or railroad tickets that are still valid, and in case of inability to do so due to a health condition – as soon as it becomes possible.

To agree to the transfer to a medical establishment of the country of permanent residence for further treatment after such moment when a doctor determines that the state of health of the Insured Person allows him/her to return to the country of permanent residence independently, or accompanied by a third person.

At his/her expense, to pay for services, cost of which does NOT exceed the amount of deductible.

To furnish the Insurer with all necessary documentation stipulated by this Contract that evidences the occurrence of the Insured Event and the amount of losses and identify the Insured (Insured person), within the term stated in this Contract.

To return to the Insurer the full amount of the insurance indemnity already received, if within limitation period stipulated by current legislation of Ukraine, such circumstances were revealed that deprive the Insured (Insured Peron) of the right to receive insurance indemnity in accordance with current legislation or these Additional provisions.

The Insurer shall have the following rights:

To verify information provided by the Insured regarding the Subject of the Contract.

To submit requests to medical establishments and other competent bodies in order to clarify circumstances of occurrence of the Insured Event, to independently ascertain causes and circumstance of occurrence of the Insured Event.

To conduct an independent analysis of the state of health of the Insured Person.

To postpone payment of the insurance indemnity until clarification of circumstances and consequences of the event that has characteristics of the Insured Event. The duration of such delay shall NOT exceed 90 (ninety) calendar days.

To deny payment of insurance indemnity or to decrease the amount of the insurance indemnity pursuant to provision of the Contract and current legislation of Ukraine.

To make Insurance indemnity payments in cases foreseeing by the legislation of Ukraine to demand from Insured (Insured person) the documents for its identification.

To make changes to the terms and conditions of the Contract, according to procedure stipulated by this Contract.

To terminate this Contract early, according procedure stipulated by this Contract.

To use the return ticket of the Insured Person in case of his/her return to the Ukraine ahead of schedule.

The Insurer shall have the following obligations:

To familiarize the Insured with the terms of coverage and the Rules.

Within 2 (two) business days, as soon as the fact of occurrence of the Insured Event becomes known to the Insurer, to apply measures with respect to execution of all necessary documents for the timely payment of the insurance indemnity.

To make decisions regarding payment or denial of payment of the insurance indemnity within in 10 (ten) business days from the day of receipt of the last of all documents that confirm the occurrence of the event that has characteristics of the Insured Event from the recipient of the insurance indemnity.

To make insurance indemnity payment within 5 (five) business days from the date of adoption by the Insurer of a decision to make insurance indemnity payment and the compilation of the insurance report.

To inform the Insured in writing about denial of payment of the insurance indemnity, with substantiation of reasons for such denial within 5 (five) working days from the date of adoption of such decision to deny payment.

Not to divulge information about the Insured and its property position, except for such cases when it is required by law.

If the Insured Person is a child under legal age, then his or her rights and obligations stipulated by this Contract shall be exercised by his/her lawful representatives.

For non-fulfillment or improper fulfillment of the provisions of this Contract the parties shall bear responsibility in accordance with current legislation of Ukraine.

If the insurance indemnity payment has been delayed through the fault of the Insurer, then when making insurance indemnity payment directly to the Insured (Insured Person), the latter shall receive a penalty in the amount of 0.01% of the indemnity amount overdue per each day of delay, but not less than the double rate of the National Bank of Ukraine, valid for the period for which penalty is applied.

 

16. Procedure for Amendment and Termination of the Contract

Changes of the terms and conditions of the Contract shall be made upon consent of the Insured and the Insurer on the basis of a request from any of the parties, within 5 (five) business days from the day of receipt of such request by another party, and shall be executed in an form of an Addendum to the Contract, that shall become an integral part of the Contract. The initiating party shall inform the other party in writing no later than 5 (five) business days prior to making amendments. If any of the parties disagree with amendments to the insurance Contract, then the decision shall be made within 5 (five) business days concerning validity of the insurance Contract on prior terms and conditions, or termination thereof. From the moment of receipt of the request by one party and until the decision is made regarding changes to terms and conditions of the Contract, the insurance Contract shall continue to be in force on prior terms and conditions.

The validity term of the Contract shall be terminated upon mutual consent of the parties, as well as in the following cases: expiration of the validity term of the Contract, fulfillment by the Insurer of its obligations in full, non-payment by the Insured of the insurance premiums within the terms stipulated by the Contract, liquidation of the Insured - legal entity or death of the Insured – physical entity or loss of his/her ability to work, with exception of cases stipulated by Articles 22, 23 and 24 of the Law of Ukraine “On Insurance”, liquidation of the Insurer according to procedure established by the legislation of Ukraine, adoption of court decision finding the insurance Contract annulled; in other cases stipulated by legislation of Ukraine.

Any party shall inform another party on its intention to terminate the Contract early, not later than 10 (ten) calendar days prior to the date of Contract termination.

In case of early termination of the validity term of the Contract at the request of Insured, the Insurer shall return to the former the insurance premium for the period remaining until the end of the validity term of the Contract, with the deduction of administrative expenses for case processing (40%), and actual payments of the insurance indemnity that were made under this Contract. If the request of the Insured is caused by violation by the Insurer of the terms of the insurance Contract, then the latter shall return to the Insured already paid insurance premium in full.

If the early termination of the Contract is requested by the Insurer, then insurance premium paid by the Insured shall be returned to him in full. If the request of the Insurer is caused by non-fulfillment by the Insured of terms and conditions of the Contract, then the Insurer shall return to the Insured the insurance premium for the period remaining until the end of the validity term of the Contract, with the deduction of administrative expenses for case processing (40%) and actual payments of the Insurance Indemnity that were made under this insurance Contract.

Cash refund shall NOT be allowed if the insurance premium was made in a non-cash form, provided the Contract is terminated early.

 

 

INSURER: CJSC “PROSTO-Insurance”

Address: 10, Hertsena Str., 04050, Kiev, Ukraine

tel: (044) 206 28 85, fax: (044) 206 28 84, e-mail: Этот e-mail адрес защищен от спам-ботов, для его просмотра у Вас должен быть включен Javascript

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