I.General Terms and Conditions
1. Under these General provisions United Health Insurance Fund "Doverie" SA hereinafter referred to as the INSURER subject to payment of insurance premiums to sign an agreement for health insurance “Illness” of individuals hereinafter referred to as INSURED which assures the financial support of the health care services used under this agreement.
2. (1) The INSURER assures the use of health care services of INSURED persons with a permanent or current address on the territory of the country in accordance with the Health Insurance Act and the Insurance Code.
(2) Health insurance “Illness” covers only the health care services, rendered on the territory of the Republic of Bulgaria.
3. The insurance is based on the following principles.
- 1. Voluntariness
- 2. Solidarity among the INSURED
- 3. Liability of the INSURED for their own health
- 4. Free choice of hospital
- 5. Accessibility of health services
4. The INSURANCE is based on contracts for medical insurance with individuals and legal entities (referred to as INSURED or POLICIHOLDER ); the INSURED and the POLICIHOLDER may be one and the same person or different persons.
5. The medical insurance offered by the INSURER is nominal and the rights under it may not be transferable. The insurance are individual, family and group
6. The INSURER ensures the provision of purchased health care plans by the INSURED through contracts with hospitals, called health care contractors or by free choice of hospital by the INSURED person.
7. (1) The INSURER performs two types of health insurance:
1. Cost reimbursement - the INSURER reimburses the costs of the INSURED according to their purchased health care plans performed by freely elected health care contractor.
2. Subscription service - the INSURER delivers the purchased health care plans by the INSURED only through health care providers it has signed agreements with.
(2) Health insurance under paragraph 1 may also be provided in combination of insurance under paragraph 1, item 1 and 2.
8. (1) The INSURER shall pay all or part of health care services, depending on the purchased health care plans by the INSURED.
(2) The INSURER shall pay all user fees for health care services regulated by the Law.
(1) Health insurance covers:
1. Persons aged from 16 to 65 years at the individual, family and group insurance of up to 50 persons.
2. Persons from 0 age with no limit for the age for group insurance of over 50 persons.
3. For the duration of the corporate agreement for group insurance within one month of signing the corporate agreement under the same conditions - coverage term, purchased health care plans and rates can be insured family members aged 0 to 65.
(2) Persons from 0 to 16 years of age, older than 65 years (except in the cases under item 2. of the preceding paragraph) and persons with chronic diseases may be insured under conditions of increased risk, according to the rates of the INSURER
10. (1) Apart from the exceptions referred to in Article 11, Insurance "Illness" covers health care services, grouped in the following plans:
1. Health Care and Illness Prevention,
2. Outpatient Medical Care,
3. Inpatient Medical Care,
4. Services related to living and other additional conditions for the provision of medical care,
6. Dental Care
(2). Depending on the volume of health care services the plan is basic and full.
(3) Preventive examinations and tests of "Health Care and Ilness Prevention" plan are used in hospitals organized and on schedule agreed in advance with the INSURER.
(4)Health services like pregnancy monitoring, choosing of physician/team, personal nurse duty, medical products not reimbursed by NHIF are used on the principal of cost reimburssment
(5) Health services covered by "Services related to living and other additional conditions for the provision of medical care", "Dental care","Cost reimbursement" are used on principal of cost reimbursement
(6)Concerning Inpatient care" plan, the INSURER does not cover health services included in Basic plan of NHIF
(7) “Inpatient medical care” plan is used only like an upgrading the basic plan of mandatory health insurance of persons subject to compulsory insurance in the country and after presenting "Direction for hospitalization/hospital treatment procedure/ambulatory treatment procedure" issued by the physician who prescribed the hospitalization or the patient's GP. In case the hospital doesn't require "Direction for hospitalization/hospital treatment procedure/ambulatory treatment procedure" the INSURED should coordinate the treatment with the INSURER in advance in written form including by email.
(8) Costs associated with ambulatory treatment procedure in hospital are reimbursed on the terms of "Inpatient care" plan.
(9) Costs associated with ambulatory treatment procedure in health care contractor for outpatient care are covered according to outpatient care plan and up to the annual limit, set in the rates. Medical products not covered by NHIF are reimbursed according to the limits provided in "Inpatient care" plan.
11. (1) The INSURER does not cover health services for the diagnosis and treatment of health damage due to:
1. suicide, attempted suicide or self-harming in a case of psychological disturbance;
2. fray, committing or attempting to commit an indictable offense, or when the insured person violate applicable laws or regulation through his actions;
3. detention by the authorities, stay in a place of detention;
4. fire, broken dam, gas and other industrial accidents and hazards;
5. emerging disease and / or devastating epidemic;
6. acute or chronic use of alcohol, drugs, narcotics, stimulants, anabolic hormones, other substances of doping character or other drug addiction;
7. participation in activities or events for experimental and research purpose;
8. war or hostilities, insurrection, coup, riot, act of terrorism, strike, lockout, civil commotion, confiscation or similar social phenomena;
9. nuclear energy operation, including nuclear explosions, radioactive radiation, earthquakes, floods, other natural disasters and other similar events with mass effect. Exception of nuclear energy does not apply in cases where nuclear energy is used for medical purposes;
10. self-treatment, non-adherence to medical prescriptions, willfully leaving the hospital for inpatient care;
11. engaging in high risk activities - for such are all kinds of motor, aviation, aircraft, waterborne and underwater sports and activities, high jumps, climbs, requiring special equipment;
12. preparation and / or participation in sport activities;
13. firearm handling;
14. domestic, industrial and car accidents;
(2) Not included in the scope of coverage are the following health care services:
1. examination, treatment and surgery not performed by a certified physician, by a medical-treatment facility created under the Medical-Treatment Facilities Act or committed by doctors-foreigners invited for scientific exchange between medical-treatment facilities.
2. outpatient and inpatient care for pre-existing disease or condition of the INSURED, unless the contract for group health insurance is for more than 10 persons;
3. emergency medical care and medical services within the scope of services provided by the state under Article 82 of the Health Act;
4. outpatient and inpatient care in the diagnosis and treatment of already established congenial illnesses: hemodialysis; chemotherapy and radiotherapy in case of oncological diseases
5.inpatient care of psychiatric diseases;
6.transplantation of cells, tissues and organs;
7.surgical treatment of the prostate gland by the "green laser";
8. parenteral immunotherapy, deep vein sclerotherapy, plasmapheresis;
9. diagnosis and treatment of obesity, gender reassignment, impotence, sterility and fertility in vitro and all diagnostic and therapeutic procedures related;
10. removal of skin anomalies without medical indications, plastic and cosmetic surgery, as well as all health services used for cosmetic effect;
11. application of treatments that are not approved by the medical standards for the respective specialty, non-traditional methods of medicine, psychotherapy, acupuncture, Iridology, spa treatments;
12. compulsory treatment and mandatory immunizations under the Health Act;
13. pregnancy prevention or optional abortion and all diagnostic and therapeutic procedures in connection therewith;
14. PET scanner, prenatal test, genetic tests, test for food intolerance;
15. health services provided for experimental or research purposes;
16. diagnosis and treatment of AIDS, body injuries and any diseases caused by / or associated with the AIDS virus (HIV), excluding a test for AIDS (HIV) in the case of preoperative preparation and pregnancy;
17. The following dental services: glass supports ZX-27; aesthetic inlays, veneers, removable dentures, implants and replanti and all proceedings relating thereto; orthodontic work, teeth whitening and other treatments with cosmetic purpose.
18. examinations and tests for: starting work, a reception at nurseries and kindergartens, driving lessons, insurance, forensic expertise and for Territorial Medical Expert Panels (TMEP);
19. administrative fees for the issuance of documents and copies of documents to obtain records of conducted studies (CD, DVD)/, issued by the hospitals;
20. nutritional supplements, homeopathic products, contraceptives, anabolic hormones, laxatives, medicines weight loss drugs;
21. medical devices for external use (bandages, gauze, disposable syringes, catheters, wheelchairs, battery cars, scooters, chairs, bathroom and toilet, mattresses and pillows, walkers, crutches, canes, etc.);
22. medical cosmetics, disinfectants, sanitary products (sanitary napkins, tampons, baby diapers and adult diapers, wet wipes etc.).
(3) The insurer may cover for an additional premium healthcare services and products not included in the coverage of individual health care plans
(4) Additional services covered under the preceding paragraph shall be determined explicitly in the Special conditions of the contract or amendment thereto
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RIGHTS AND OBLIGATIONS OF THE INSURED (POLICYHOLDER)
12. INSURED/ POLICYHOLDER is free to choose the health services plan and the type of health insurance (cost reimbursement, subscription service). A combination of both types of health insurance is possible only when a full health care plan is purchased and when this is mentioned in the special provisions of the medical insurance agreement.
13. The INSURED freely choose the coverage limit specified in the Rates of the INSURER.
14. The INSURED shall have the right to health care services to the limit set by in the selected health care plan. Health services costs not mentioned in the agreement for medical insurance are on behalf of the INSURED persons.
15. The INSURED has the right to a free choice of:
1. Health Care CONTRACTOR, pharmacy, provider of medical devices, the terms and conditions for providing them in case the health insurance is reimbursement type;
2. Health Care CONTRACTORS with whom the INSURER has contracted with in the case of membership health insurance.
16. (1) Upon membership health insurance the INSURER shall inform the INSURED for any changes to the list of hospitals they have a signed contract with through its website.
(2) Upon membership health insurance the INSURED benefits a Coordinator for the respective Health Care CONTRACTOR, the name and mailing address of which are available on the website of the INSURER.
(3) The Coordinator of the relevant hospital upon membership health insurance agreement notifies the INSURED about the provisions and procedures to use health services and assists the INSURED. With the help of the Coordinator the INSURED passes the necessary medical examinations and tests.
17. Upon membership health insurance the INSURED shall has the right to:
1. an examination by a specialist on the very day the INSURED visits the appropriate hospital or the nearest possible day in case no other opportunity exists. On weekends and after working hours only in emergency cases;
2. an initial medical examination, examination for a second opinion from another doctor with the same specialization and up to two secondary examinations per month for a certain disease;
3. a mammography prescribed by a doctor
4.to be hospitalized and in case of emergency problem shall has the right to be hospitalized on the same day the problem arises. For elective hospitalization the accommodation term is within 48 hours after the coordinator of the chosen hospital is notified and in case that’s not possible due to an objective reason as soon as possible;
5. personal nursing care during hospitalization in case of medical necessity determined by the head of department;
6. an examination and manipulation at home by a specialist when the patient's condition does not allow a visit to the hospital. For these health services is necessary to phone the doctor, answering the 24-hour phone of the INSURER;
7. physiotherapy and rehabilitation, the necessity of which is established by the specialist conducting the treatment of the underlying disease, and the treatment is carried out in prescribed by a specialist in "Physical Medicine and Rehabilitation" treatment course;
8. highly specialized tests - CT and MRI are used only in cases when conventional research methods can not provide a definitive diagnosis. These test methods are used more than once a year for each insured person, only with the prior consent of the INSURER;
9. robotic surgery only in case of persistent abnormal histology of pre - cancer condition and in case of proven cancer diseases , after obtaining written approval from the INSURER
10. a sanatorium treatment in case of a full-hospital care plan as follow-up treatment. In this case, the INSURED shall provide the INSURER with the medical history of the conducted treatment during the insurance coverage term with the designated sanatorium treatment. The INSURER organized the accommodation in a suitable sanatorium and gives the records to the INSURED. When the INSURED benefits sanatoriums of the National Social Security Institute (NSSI), he presents the sanatorium documentation required by the NSSI. Otherwise the costs are on behalf of the INSURED, as in cases of using sanatorium treatment without notice / consent /of the INSURER;
11. use the 24-hour Call center for telephone consultations. Requests for elected health services have to be made within the working hours of the providers of medical assistance. On weekends and after working hours of medical institutions, requests can be made only for emergency cases. Telephone numbers are listed in the health insurance cards. After 17.30 and on public holidays only mobile phones are used, listed in the health insurance cards;
12. Sanitary transport from home to hospital and back within and outside the settlement for medical indications determined by the specialist, with the consent of the INSURER;
13. Upon a written request to obtain from the INSURER the available information about his personal health;
14. Right to confidentiality regarding his personal health status, except in cases provided for by law;
15. To make a written complaint to the INSURER in case when is not satisfied with the amount and timeliness of health services rendered according to membership health insurance and in any other occasion related to the agreement for medical insurance. The INSURER checked the information within 30 days and informed the INSURED about the results thereof; In case of complaint, concerning insurance claim, the term for resolving it is 7 days;
18. The INSURED shall be obliged to:
1. declare accurately and comprehensively the essential circumstances which are known and are relevant to the risk at assigning the insurance agreement. Essential are considered only circumstances for which the INSURER has written questions. During the coverage term of the agreement for medical insurance, the INSURED is obliged to disclose to the INSURER all new facts related to the INSURER's written questions at the assignment of the agreement. The announcement of the circumstances must be done immediately;
2. To pay a single insurance premium within the agreed period at the conclusion of an individual contract for health insurance.
3. To legitimize with a health insurance card and ID card to health care providers with whom the INSURER has a signed contract with
4. To comply with the terms and conditions of use of health services under the agreement for medical insurance and the General Provisions;
5. To refrain from allowing third parties use of their health insurance cards. When determined that health care services have been rendered to third parties through their health insurance cards, the INSURED shall reimburse the INSURER for the amounts paid for services rendered, in double. In this case, the INSURER may terminate the contract for medical insurance, if it’s an individual one and shall not return the paid insurance premium;
6. If the value of the used health care services in medical-treatment facility from the List of the Insurer exceeds the agreed limit on the respective purchased package of health care services, the INSURED PERSONS have to recover the sum over the limit, which sum the insurer has paid to medical-treatment facilities, within 15 days of receipt of written notice thereof.
7. To inform the INSURER immediately upon any changes to their current address specified in the agreement within 7 days of occurrence. Until the notice about the change of the address is received by the INSURER the messages sent by him to the address of the INSURED, named in the insurance agreement shall be considered as delivered and received by the INSURED with all legal consequences
8. To return the health insurance card when are withdrawn from the list of insured persons under group health insurance agreement, or upon termination of the agreement.
19. The INSURED shall not have the right by himself to require diagnostic tests, treatment or prescribing of certain drugs from medical professionals. In these cases the INSURER does not pay the costs of health services.
20. (1) In case the POLICYHOLDER is a legal entity at the time of the agreement for medical insurance shall be obliged to:
1. inform comprehensively and fully in a written form the INSURED for the conditions of the signed agreement for medical insurance under which they can exercise their rights;
2. give every INSURED person upon signature the health insurance card issued by the INSURER in due time;
3. give back to the INSURER the written documents certifying the receipt of the health insurance cards but not later than 20 days after their receiving, and to return to the INSURER in this period any undelivered personal health insurance card, regardless of the reason for this
4. Immediately to inform the INSURED of any change in the applied initial list of CONTRACTORS of health services, about which has been informed by the INSURER or which is reflected in the website of the INSURER;
5. In case an INSURED is withdrawn from the list of insured persons before the expiry of the coverage term of the agreement to retrieve the health insurance card from the insured person and to give it back to the INSURER;
6. Upon early termination of the medical insurance promptly to inform the INSURED comprehensively and accurately in writing for the termination of the agreement and that they are not allowed to benefit from it, and no later than the date of termination of the agreement to collect from all insured persons their personal health insurance cards. No later than 7 days from the date of termination of the agreement the POLICYHOLDER returns to the INSURER with inventory lists the health insurance cards of the insured persons;
7. not require from the INSURER any information about the health status of the insured persons and to ensure the protection of confidentiality of such information when mediates its transmission from the INSURER to the INSURED;
8. pay the agreed full premium or the corresponding deferred installments thereof referred to in the agreement for medical insurance maturities.
(2) The INSURER cannot bear the blame or liability and no claims can be to be pretended from him for any payments in the event of default of the POLICYHOLDER under par. 1, items 1, 2, 4 and 7 of the General Provisions as a result of which the INSURED is unable to exercise his rights under the agreement for medical insurance and / or which is exercised in a way that the agreement for medical insurance or the General Provisions preclude the INSURER from financial provision for incurred expenses for medical services.
(3) In case the POLICYHOLDER fails to comply for any reason fully or partially or not implement in time, any of its obligations under par. 1, items 2, 3, 4, 5, 6, and therefore the INSURED has used health services from the CONTRACTORS and because of that an obligation occurred for the INSURER to pay the costs, the POLICYHOLDER is required to reimburse to the INSURER any amount paid by the last for the costs together with legal interest thereon from the date of the payment made by the INSURER;
(4) The POLICYHOLDER is bound for all the contractual obligations for medical insurance, including paying premium on it, and the INSURED have the right to use the health services. The INSURER may contend the insured person for any breach of obligation under the medical insurance of behalf of the POLICYHOLDER arising out of the law, the agreement for medical insurance, the General Provisions and any applications or annexes to them.
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III. COSTS REIMBURSEMENT FOR HEALTH SERVICES
21. (1) When submitting a claim for reimbursement for an insured event occurring during the coverage term of the agreement the INSURED shall within thirty (30) calendar days from the event to submit to the INSURER:
1. written notification of reimbursement in a form required by the INSURER; For INSURED PERSONS under 18 notification is submitted by the parent, concluded the contract of medical insurance "Disease" ;
2. medical document reflecting the examinations, prescribed tests and treatments, and a copy of the medical tests conducted under the agreed health services plan;
3. written prescription for medicines and / or medical devices, issued in accordance with applicable law;
4. original invoice for amounts paid on behalf of the INSURED certifying the health services, together with a cash register receipt or other document with details of primary accounting document in accordance with the Accounting Act. The invoice reflects the type and price of each health service and their total value ;
5. costs for package services are not reimbursed, if this is not agreed in the special conditions of the contract and in the relevant package are not specifically listed services provided and their unit prices.
(2) In case the deadline for notifying the INSURER under the preceding paragraph is not meet, the INSURED shall state in writing the reasons for the delay. Regardless of the merits of these reasons, the INSURER accepted and filed the notice.
(3) Costs reimbursement is applied only for medicines prescribed by a certified physician (including the personal GP of the INSURED) and included in the list of medicinal products of Bulgarian Drug Agency authorized for use in the country according to the Law on Medicinal Products in Human Medicine and Regulation (EC) № 726/2004 of the European Parliament and the Council., and are purchased no later than 7 days after the issuance of the recipe. For patients with chronic illnesses is not require compliance with the 7 day period for re-purchase of medicines if the medical document reflected the period of treatment longer than one month;
(4) The INSURER does not pay the cost of medicines and medical devices in the part that is reimbursed under compulsory health insurance or other regulatory basis, and those that are not authorized for use in the country. Costs for medical devices are reimbursed only if they are purchased by medical-treatment facilities or health facilities under the Medical Devices Act.
(5) The INSURER shall pay the INSURED the difference of the amount to be paid partly by the NHIF in accordance with the Health Insurance Act or other regulatory basis and the amount paid by him for medicinal products and medical devices to the insurance amount / compensation / fixed in the agreement for medical insurance.
(6) Do not pay any expenses for medicines purchased in volume greater than necessary for one course of treatment.
(7) Costs for medicinal products and medical devices purchased through online sale are not reimbursed.
(8) The INSURER shall pay costs of prescription glasses or contact lenses when prescribed by a doctor from a medical-treatment facility - health care provider and are purchased by optic in the country, registered under the Health Act. In cases when has been prescribed dioptric correction for one eye of the insured person, costs are covered for the both glasses or contact lenses. Expenses for anti-reflective glasses without spectacles are not paid.
(9) In cases where the INSURED has used health services in a hospital with which the INSURER has a contract without informing the coordinator of the relevant hospital and has paid for these health care services, the INSURER shall refund the costs agreed by the INSURER rates with the relevant hospital to the date of the provision of the health care services.
(10) The INSURER shall not reimburse costs related to the provision of health and other services at hospital treatment:
1. performed by medical-treatment facility for outpatient medical care, unless they are provided in the treatment of clinical pathway under contract with NHIF;
2. when the INSURED person has used health services for a condition for which the corresponding inpatient medical facility has not a contract with the NHIF and had not yet received a prior written consent of the INSURER for it.
(11) The INSURER does not reimburse costs related to the provision of additional requested services, which are outside the purchased packages health services, and services paid in violation of existing legislation in the field of health.
(12) Upon reimbursement of the costs for different health services plans is taken into account the percentage of self insurance.
22. (1) The INSURER shall pay to the bank account of the INSURED person the agreed amount of insurance amount/indemnity/ within 15 /fifteen/ days from the date of submission of all required documents.
(2) If after the initial presentation of the requested documents listed in the General Provisions or the insurance contract, the insurer considers that further evidence is required to establish a claim by the grounds and amount, he may in writing / paper or by e-mail / to request the submission of such within 15 days of receipt of the documents submitted originally. Up to submitting all required documents the term for payment of the insurance amount /compensation/ stop running.
(3) The INSURER makes motivated refusal when not all the documents referred to in paragraph 1 of the preceding article are presented or the presented ones do not meet the requirements of the law, of this General Provisions or the insurance contract.
(4) Upon payment of the amount of insurance amount the INSURER has the right to deduct any debts the INSURED has under the contract.
(5) Costs of insured person under the age of 18 shall be reimbursed to the bank account of the parent concluded the contract for medical insurance "disease".
23. (1) The INSURER is not obliged to pay the amount of insurance / indemnity / used for health services when the INSURED in submitting a claim under a medical insurance "Disease" has not submitted the required documents in accordance with the General Provisions and the agreement and if within 15 days after a receipt of a written notice under par. 2 of the preceding article has not submitted the required by the INSURER documents.
(2) If the POLICYHOLDER / INSURED under an agreement for medical insurance and / or submitting a claim for payment of the amount of insurance / indemnity / in case of an insurance event has used fraud or deception, the INSURER may deny full or partial payment subject to the provisions of the Insurance Code
(3) Deadlines for payment of indemnities and repayment are as required by the Insurance Code and the Law on Obligations and Contracts.
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IV. RIGHTS AND OBLIGATIONS OF THE INSURER
24. (1) The INSURER shall have the right to:
1. obtain complete information on the health status of the insured;
2. require the cooperation of the POLICYHOLDER / INSURED to carry out its obligations under the medical insurance agreement when such assistance is necessary to meet those obligations;
3. obtain insurance premium, as defined by its Rates;
4. check by his or independent experts the medical relevance of the health services provided to the INSURED.
(2) The INSURER shall be obliged to:
1. protect the interests of the INSURED from health care contractors
2. ensure the provision of health services according to purchased plans under the contract for medical insurance;
3. provide the INSURED health insurance card. The card is individual and the rights under it shall not be transferable.
4. in case of membership health insurance to inform in writing the INSURED of any changes in the list of hospitals with which it has a signed agreement within 5 days of their occurrence or through its website;
5. upon receipt of a written complaint from an INSURED person to check and take action to protect the rights of the INSURED and inform him in writing of the outcome within 30 days of receipt of the complaint;
6. keep a register of INSURED persons while ensuring their rights under Article 17, item 12 of the General Provisions;
7. pay the amount of insurance / indemnity / to the INSURED for the used health services under the agreement for medical insurance and the General Provisions.
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V. MEDICAL INSURANCE AGREEMENT.
INSURANCE PREMIUMS AND PAYMENTS
25. (1) Medical insurance contract is concluded on the basis of:
1. personal declaration of health status of applicants for individual or family insurance. Declaration on the health status of persons under age 18 with family insurance shall be signed by the POLICYHOLDER. Based on data from the declaration the INSURER has the right to require certain tests and examinations, the costs of which are on behalf of the applicant for insurance. Declaration of health status is checked by a doctor of the INSURER that concludes for: insurance at standard conditions; insurance for high risk and special clauses set out in the rates of the INSURER or refusal of insurance which is not necessarily motivated.
2. list of INSURED persons under an agreement of group health insurance that contains their full name, ID and location of employment.
(2) The agreement reflects the type of insurance / membership and / or reimbursement /, the purchased health services plans, the amount of the insurance premium, the insurance sum / limit / used for health services, special conditions, if any, method of payment and obligations of the parties under the agreement.
(3) For persons under 18 years of age health insurance agreement is signed by a legal representative, guardian or custodian of the INSURED, who is POLICYHOLDER.
(4) Inclusion of new employees in the list of the INSURED under an agreement of group medical insurance and a monthly payment of insurance premiums shall be done from the date in the month of notification coinciding with the date of the beginning of the insurance period, and their exclusion from the date specified as the deadline for insurance period in the month of notification or next month when the month of notification has already accrued premium.
(5) At once, twice or quarterly payment of insurance premiums in agreements for group medical insurance prior to any further payment or at the end of the coverage term a leveling of the number of INSURED persons and the premium payable is made, subject to the conditions of the previous paragraph.
26. (1) Premium under the agreement for medical insurance is determined by the applicable Rates of the INSURER.
(2) The insurance premiums are paid through a bank. The date of the premium paid shall be the date on which the account is credited by the INSURER.
(3) Annual insurance premium is paid only once for individual and family insurance. Upon an agreement for group medical insurance payment in installments is allowed. Terms of payment and the amount of due premiums are determined in the agreement.
(4) Upon inclusion of new employees in the list of INSURED, the POLICYHOLDER shall pay insurance premiums proportionally to the remaining coverage term. The annual limit is also used in proportion to the insurance period.
(5) Provided by the INSURER bonuses are defined in the agreement for medical insurance.
27. When the due payment of the premium is incorrect or not within the deadline, the INSURER shall send a written invitation and set the deadline for submission of the amounts due. Until the introduction of the premium payable the INSURER does not cover health services.
28. All taxes, fees and other payments that are legally established on the received insurance payment are on behalf of the POLICYHOLDER / INSURED.
29. Upon exhaustion of the insurance amount / limit / for the use of health services the INSURER notifies the POLICYHOLDER / INSURED and refuses further payment of costs for health services. In case of exceeding the agreed limit for the use of health care services in medical-treatment facility from the list of the INSURER, the INSURED shall reimburse the amount by which has exceeded the limit, which sum has been paid by the INSURER to the medical-treatment facility. The INSURED person is obliged to reimburse this sum within 7 days of receipt of written notice from the INSURER.
30. If during the coverage term of the agreement the insurance risk significantly increased, the INSURER may request an increase in the premium or termination.
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V. TERM OF THE AGREEMENT FOR MEDICAL INSURANCE
31 (1) An agreement for medical insurance will be valid for not less than one year.
(2) The agreement shall continue in effect from 00.00 hours on the day set as a beginning of the coverage term, provided that the whole amount or the first installment of the premium is paid to the INSURER, and expires at 24.00 hours on the day indicated as the end of the coverage term of the agreement.
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VI. TERMINATION OF THE AGREEMENT
32. The POLICYHOLDER / INSURED has the right to unilaterally terminate the agreement for medical insurance after one month's written notice, the return of health insurance cards along with an inventory list of the INSURER no later than 7 days from the date of termination of the agreement and subject to the obligations laid down in Art. 20, par. 1, items 5 and 6 of the General Provisins.
1. Upon an agreement for individual medical insurance, if you have not used any health services, the INSURER shall refund 50% of the paid insurance premium.
2. Upon an agreement for group medical insurance the INSURER due the insurance premium till the termination date of the agreement. After this date the INSURER refused payment for health care services to INSURED persons.
33. (1) Upon termination of the medical insurance in accordance with Art. 32, item 2 the POLICYHOLDER due the INSURER the consumed by the insured persons amount for insurance payments, confirmed by the information system of the INSURER and approved by the Financial Supervision Commission amount of administrative costs specified in the program of the INSURER.
(2) When using the bonuses for pre-payment of the insurance premium, the INSURER charged them to the due amount by the POLICYHOLDER.
(3) When the amount paid by the POLICYHOLDER is insufficient to cover the above conditions, the POLICYHOLDER adds to the difference. When the deposited by the POLICYHOLDER amount exceeds the amounts in the above conditions the INSURER shall return the overpaid amount.
(4) When culpable breach of agreement by the INSURER proven in court the INSURER returns the excess amount paid by the POLICYHOLDER for the period after the date of such notice.
34. (1) Upon termination of the agreement for medical insurance the financial relationship between the parties shall be settled within one month after the termination.
2) The return of a premium or part of it, shall be returned and the corresponding amount of tax paid on insurance premiums in accordance with the provisions of the Law on tax on insurance premiums.
35. (1) The INSURER may terminate the agreement for medical insurance before the deadline in case of:
1. deliberately suppressed circumstance for which the INSURER has made a written question to the INSURED, within a month of its disclosure in accordance with the provisions of the Insurance Code;
2. for non-payment of premium after the expiration date of the written notice to settle the financial relations.
(2) The INSURER shall not refund any premium in the case of the preceding paragraph and the death of the INSURED.
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VIII. RELATIONSHIP BETWEEN THE PARTIES, JURISDICTION AND
STATUTE OF LIMITATIONS
36. The relationship between the INSURER and the POLICYHOLDER / INSURED are governed by these General Provisions, the medical insurance agreement and its annexes.
37. (1) The personal data obtained in connection with the agreement for medical insurance is used by the INSURER for the preparation and service of the agreement. The INSURER shall not, without the consent of the person to disclose personal information, except in cases provided by law or in the prevention of insurance fraud.
(2) The INSURED agrees the INSURER to obtain information from hospitals, medical and other units in relation to his health.
38. Pursuant to Art. 19, par. 1 of the Law on Personal Data Protection, the INSURER shall notify the POLICYHOLDER and the INSURED that:
1. The INSURER is registered as a data controller in the register kept by the Commission for Personal Data Protection.
2. Their personal data shall be used by the INSURER for the conclusion and performance of the medical insurance;
3. The provision of personal data is entirely voluntary. The refusal to provide them is the basis for the INSURER to refuse to sign an agreement or take other action in the case that the lack of such data does not give him the opportunity to make an objective assessment of the risk of signing the agreement for health insurance or otherwise jeopardize the realization of the legitimate interests.
4. Any person who provided the personal data shall have the right of access and the right to ask for rectification under the conditions of the law.
39. Disputes between the parties shall be settled amicably and in the absence of agreement - the competent Bulgarian court. Bulgarian law is applicable.
40. In case of a delay in payments under health insurance agreement a statutory interest is due for the time of the delay and forfeit, if agreed.
41. The rights under the insurance agreement shall be redeemed in accordance with the provisions of the Insurance Code.
42. The INSURED / the POLICYHOLDER shall not have the right to ransom under an agreement for insurance "Disease."
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IX. FINAL PROVISIONS
43. (1) All messages of the INSURER to the POLICYHOLDER / INSURED shall be addressed to the last address notified in writing and the INSURER is released from further responsible for non-receipt, as well as for the resulting consequences.
(2) Notices to the INSURER should be sent / submitted in writing to the mailing address specified in the agreement or his e-mail.
(3) The date of notification shall be the date of receipt of the notice. This rule does not apply when the POLICYHOLDER / INSURED has not notified the INSURER of the current address. In this case for the date of notification is accepted the output date of the communication.
44. Determination of the age according to these General Provisions shall be in whole years, up to six months is not considered, and six or more months are considered a year.
45. Changes in terms of the medical insurance agreement is carried by an additional settlement between the parties.
46 . (1) These General Provisions are an integral part of the agreement for medical insurance.
(2) In addition to the General Provisions under which the agreement is concluded special conditions may be negotiated. In this case, the General Provisions are applied, so far the special conditions provide no otherwise.
(3) Subsequent amendments to these General Provisions shall become effective only for medical insurance agreements concluded after the date of the change and does not affect the existing ones, unless a change in legislation requires it or the parties agree otherwise.
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X. DEFINITIONS, CONCEPTS AND TERMS
For the purposes of these General Provisions:
1. "MEMBERSHIP SERVICE" is a form of insurance "Illness" in which the insured use only hospitals on the list of the INSURER;
2. COST REIMBURSEMENT is a form of health insurance where the insured persons pay for using health services, then the INSURER reimbursed the costs under the terms of the contract;
3. AGREEMENT FOR MEDICAL INSURANCE is a contract under which an INSURER assumes a certain risk insurance against insurance premium paid and to repay the amount of insurance / indemnity / in case of occurrence of an insured event. The contract for medical insurance includes general and special conditions, health care plans, declaration of condition, statement of use of personal data rate, and all annexes with changes both sides agreed to.
4. HEALTH CARE CONTRACTOR is hospital, established in the Republic of Bulgaria under the Medical-Treatment Facilities Act.
5. SPECIALIST is a person of higher medical education and qualified medical specialist.
6. INSURED is al person for whom a contract for medical insurance is concluded.
7. INSURER is United Health Insurance Fund "DOVERIE" SA.
8. POLICYHOLDER is a legal entity, sole proprietorship or individual who concludes a contract for medical insurance and pay insurance premiums. The INSURED and the POLICYHOLDER may be the same or different persons.
9. INSURANCE RISK is an objective likelihood of occurrence of the disease, the realization of which is uncertain, unknown, and regardless of the wishes of the INSURED.
10. INSURANCE EVENT is the occurrence of a covered health risk during the term of the contract for medical insurance;
11. COVERAGE TERM means the period from the date and time set for the start in the agreement for medical insurance until the day and time of the expiry of the contract period;
12. INSURANCE PREMIUMS is the amount the INSURED/ POLICYHOLDER pays to the INSURER against obligations under the contract for medical insurance.
13. INSURANCE AMOUNT (limit of liability) is agreed or fixed by law and specified in the contract for medical insurance sum of money representing the upper limit of liability of the INSURER to the INSURED.
14. HEALTH SERVICES PLAN is a group of regulated type and range of health services that are covered by the INSURER under the terms and conditions stipulated in the contract for medical insurance for which the INSURER is licensed under the Insurance Code.
15. “MEDICAL DEVICE” for hospital treatment is a medical device, which NHIF does not pay for or partially paid upon hospital treatment by clinical pathway.
16. SELF INSURANCE means that a part of the expenditure covered by insurance for healthcare services, pharmaceuticals and medical devices in the event of illness during the coverage term are paid by the INSURED. For juvenile INSURED deductibles are due from their legal representatives / parents / guardians or trustees.
17. FAMILY MEMBERS are spouses, conjugal partners and children up to age 25 who are still studying and who have uninterrupted rights under the compulsory health insurance
18. RATES means the amount of the insurance premium for one or more health care plans, differentiated according to the number of plans, the number of insured persons and other factors.
19. PHYSIO THERAPEUTIC COURSE OF TREATMENT is a complex treatment, which includes an initial examination of a specialist in "Physical Medicine and Rehabilitation" with an assigned total number of procedures from all groups up to 20 for a one-year insurance period and final secondary examination with the assessment of the results of the treatment.
20. MEDICAL EXPERTISE OF CAPACITY FOR WORK is an expertise for temporary incapacity for work carried out pursuant to Article 101 and the following of the Health Act.
21. PREGNANCY MONITORING includes all costs for tests and examinations of the pregnant woman and the fetus during the period of pregnancy, who have been agreed in the special conditions of the contract for medical insurance up the amount of the agreed insurance sum / limit /;
22. CONFINEMENT EXPENSES are all expenses for medical care during childbirth, which are not covered by compulsory health insurance and who have been agreed in the special conditions of the contract for medical insurance, the amount of the agreed insurance sum / limit /;
23. SANATORIUM is a rehabilitation hospital registered under the Health Establishments Act or a hotel for prevention and rehabilitation program of the National Social Security Institute.
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XI. FINAL PROVISIONS
These General Provisions for insurance "Disease" were adopted at a meeting of the Board of Directors on 16/08/2013, amended and supplemented at a meeting of the Board of Directors with Protocol on 12.02.2015, amended and supplemented at a meeting of the Board of Directors with Protocol on 19.04.2018, amended and supplemented at a meeting of the Board of Directors with Protocol on 04.06.2016, amended and supplemented at a meeting of the Board of Directors with Protocol on 1.12.2018.