health insurance rules no. 010

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HEALTH INSURANCE RULES No. 010

CONCEPTS

Effective from 1 August 2021

1.1. The concepts starting with a capital letter, used in the

insurance contract as well as in the notices of the parties, other

related documents shall have the meaning defined below and

shall be respectively interpreted, unless the context expressly

requires otherwise or unless clearly stated otherwise.

1.1.1. An ambulatory Surgery Service means a planned health

care service during which a treatment and/or diagnostic

intervention procedure is performed. The service must comply

with the list of ambulatory surgery services approved by the

Minister of Health of the Republic of Lithuania applicable at the

time of its provision. The duration of the service may not exceed

1 (one) bed day, which means that the Insured is admitted to the

Health Care Institution and discharged from it on the same day.

1.1.2. The Insured shall mean a natural person specified in the

Contract, whose Insurance Risk and property interests are

insured.

1.1.3. Day Surgery/Day Stationery Treatment Service shall

mean a planned treatment and/or diagnostic Health Care

Service during which the care of the Insured is guaranteed for

up to 24 hours (if necessary – up to 48 hours). The service must

comply with the list of day surgery/day treatment stationery

services approved by the Minister of Health of the Republic of

Lithuania applicable at the time of its provision.

1.1.4. The Policyholder shall mean a person who concludes

(concluded) or expresses the need to conclude a Contract with

the Insurer for his own or another person's benefit.

1.1.5. The Insurer shall mean Compensa Life Vienna Insurance

Group SE acting through the Lithuanian branch of Compensa

Life Vienna Insurance Group SE, or its successors and assigns or

successor in title (if applicable).

1.1.6. Insurance Coverage shall mean the obligation of the

Insurer to pay the Insurance Indemnity to the Beneficiary under

the terms and conditions and procedure set in the Contract

upon occurrence of the Insurable Event.

1.1.7. Insurance Indemnity shall mean the amount of money

payable by the Insurer to the Beneficiary under the Contract

upon occurrence of the Insurable Event.

1.1.8. The Beneficiary shall mean the Insured or the Partner, or

their successors and assigns, heirs who acquire the right to the

Insurance Indemnity or the portion thereof in accordance with

the procedure and terms established by the Contract and/or

applicable law.

1.1.9. The Insurance Premium shall mean the amount of money

payable by the Policyholder to the Insurer for the Insurance

Coverage and related services provided under the Contract, the

amount and terms of payment of which are determined in the

Insurance Certificate (Policy).

1.1.10. The Insurance Period shall mean a period of time defined

and stated in the Contract as specific time limits, during which

the Insurance Coverage is valid.

1.1.11. The Insurance Certificate (Policy) shall mean a document

confirming the Contract conclusion and its conditions and

issued under the procedure and terms set by the Insurer during

conclusion of the Contract and/or amendment s to its

conditions. Upon issuance of a new or subsequent Insurance

Certificate (Policy), all prior Insurance Certificates (Policies) to

the same Contract shall become invalid.

1.1.12. The Insured Risk shall mean a probability for occurrence of

the Insurable Event and/or the amount of possible damages or

injuries caused by this Insured Event.

1.1.13. The Sum Insured shall mean the maximum amount of

money indicated in the Insurance Certificate (Policy), within the

limits of which respective property interests are insured.

1.1.14. Insurance Rules shall mean these health insurance rules,

in accordance with which all Contracts on the health insurance

product distributed by the Insurer are concluded.

1.1.15. The Insurable Event shall mean the event provided for in

the Contract, upon the occurrence of which the Insurer

undertakes to pay the Insurance Indemnity in accordance with

the procedure and conditions provided for in the Contract..

1.1.16. The Date of the Insurable Event shall mean one of the

following dates, on the basis of which it is determined whether

the Insurable Event occurred during the validity of the

Insurance Coverage:

a) In the case of the purchase of medical aids, the date on which

the goods or aida are actually paid for. If goods or aids are

bought in instalments, the date of payment of the first

instalment shall be deemed to be such a date;

b) In case of provision of services, the date when the Insured

actually receives the service;

c) In the case of a critical disease, the date of diagnosis of the

critical illness.

1.1.17. The E-Help System shall mean an electronic system or

program, the procedure and conditions of use of which are

determined by the Insurer and which is intended for the

exchange of documents, information and/or notices (including

requests or other forms of expression of will) between the

Insurer and the Insured.

1.1.18. Long-Term Nursing/Care And Supportive Treatment

shall mean palliative care, supportive treatment, nursing/care at

home, in a health care institution or other social support

institution for people with severe chronic diseases when active

treatment is not required.

Adopted by Order No.V-4/21 of 15 July 2021 of the CEO of

Compensa Life Vienna Insurance Group SE, Lithuanian Branch

1. CONCEPTS

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1.1.19. The Franchise shall mean a part of the loss (expenses),

which is reimbursed by the Insured himself in case of each

Insurable Event.

1.1.20. The War and State of Emergency shall mean war or

actions similar to war in their nature, irrespective of their forms

or whether the war is officially declared or not, as well as military

incursion or similar military actions, military government

establishment, rebellion, mass riots, civil unrest, use of weapons,

occupation, revolution, civil wars, uprisings, government

upheaval, siege, declaration of martial law or the state of

emergency or any other events or circumstances that threaten

the constitutional order or public peace.

1.1.21. The Client shall mean a natural or legal person or their

representative, including the Policyholder or the Insured, who

uses the services of the Insurer or expresses a relevant interest

or intention.

1.1.22. The Card shall mean a card issued by the Insurer and

intended for the Insured, which confirms the provision of

Insurance Coverage in accordance with the terms and

conditions of the Contract.

1.1.23. The Critical Disease shall mean one or more diseases

and/or surgeries provided for as indicated in clause14 of

Addendum No.1 to the Insurance Rules, which meet the criteria

for diagnosing such diseases or surgeries as defined therein.

1.1.24. The Date of Diagnosing a Critical Disease shall be one of

the following dates:

a) In case of Critical Diseases referred to in sub-clauses

14.4.14–14.4.1.6 and sub-clause 14.4.1.13 (if a relevant surgery is

performed) of clause 14 of Addendum No.1 to the Insurance

Rules – the date of performance of surgery on the Insured;

b) In case of the Critical Diseases specified in sub-clause 14.4.1.7

of clause 14 of Addendum No. 1 to the Insurance Rules – the date

when the Insured is placed on the official waiting list for surgery

or the date when the Insured undergoes organ transplantation

if the Insured was not placed on the list of patents waiting for

organ transplantation;

c) In case of a critical disease referred to in sub-clause 14.4.1.1 of

clause 14 of Addendum No. 1 to the Insurance Rules –the date of

sampling of the histological examination on the basis of which a

medical specialist diagnosed a disease;

d) In other events of other Critical Disaees provided for in

Addendum No. 1 to the Insurance Rules – the date of diagnosing

a Critical Disease for the Insured.

1.1.25. Medical Aids shall mean bandages, patches, syringes,

insulin syringes, drip systems, stool collectors, bladder

catheters, ostomy bags or collectors.

1.1.26. Medically Reasonable Services shall mean the health

care services reasonably prescribed to the Insured by a

competent doctor as necessary ones according to the Insured's

complaints, established symptoms, and signs in the medical

documentation.

1.1.27. Medical Accessories shall mean medical devices and

medical aids; technical orthopedic aids; disposable instruments

and appliances used for day surgery or ambulatory surgery

services.

1.1.28. Medical devices shall mean glucometers and test strips

for them, hearing aids, parenteral nutrition systems, drip

infusion systems, pumps and inhalers.

1.1.29. The Uninsurable Event shall mean an event or

circumstances, upon which occurrence the Insurer shall not pay

the Insurance Indemnity.

1.1.30. Non-reimbursable expenses shall mean the expenses of

the Insured specified in the Health Insurance Program, which

are not reimbursed by the Insurer under the Contract, even if

they are caused by Health Disorders.

1.1.31. The Accident shall mean an accident which occurs

against the will of the Insured as a result of any abrupt,

inadvertent, unexpected external forces and causes the bodily

injury to the Insured including but not limited to sinking,

heatstroke, sunstroke, chilblain, exposure to gas or other toxic

substances which accidentally penetrate the body except for

food poisoning.

1.1.32. Alternative medicine shall mean the services of diagnosis

and treatment of diseases provided by a medical specialist in an

alternative way in a health care institution, including

acupuncture; electroacupuncture, bioresonance computer

diagnostics; food intolerance tests; hydrocollonotherapy;

phytotherapy; leech treatment; lithotherapy; apitherapy;

aerophytotherapy; music and art therapy; chromotherapy;

osteopathy; homeopathy; endobiogenic medicine; kinesiology;

reflexology; Chinese medicine; Ayurveda; yoga; Reiki;

autogenous training.

1.1.33. Remote Health Care Services shall mean health care

services that are provided by means of communication in

accordance with the procedure established by applicable law

without the physical presence of the Insured.

1.1.34. Technical Orthopedic Devices shall mean splint and

prosthetic systems, sticks, crutches, liners, compression

stockings and postoperative shoes.

1.1.35. The Partner shall mean an entity with whom the Insurer

has entered into a relevant agreement on the Insurer's Client

Service and other conditions of cooperation in providing health

insurance services. The Partner is not the representative of the

Insurer. The list of partners is published on the Insurer's website.

1.1.36. The Offer shall mean the conditions under which the

Insurer agrees to enter into the Contract.

1.1.37. The CHIF shall mean the Compulsory Health Insurance

Fund.

1.1.38. Radiation shall mean a radioactive radiation, pollution or

poisoning (intoxication), nuclear reaction or nuclear energy

impact, as well as unauthorised use of nuclear weapons.

1.1.39. Rehabilitation Treatment shall mean a complex remedial

measure applied due to the Insured's Health Disorder (acute

condition, exacerbation of the disease or Injury) together with

other treatment measures and/or as an adjunctive measure

after ineffective or insufficiently effective pharmacological,

surgical or immobilization treatment.

1.1.40. The Contract shall mean an insurance contract

concluded between the Insurer and the Policyholder, according

to which the Insurer undertakes to pay the Insurance Indemnity

upon occurrence of the Insurable Event for the fee and under

procedure set in the Contract, and o the Policyholder

undertakes to pay the Insurance Premiums properly and on

time and to perform other obligations assumed under the

Contract The Contract consists of the following integral parts:

Insurance Certificate (Policy), Insurance Rules, the Offer, terms

and conditions or requirements stated in other documents

related to the Insurance Contract or separately concluded by

the parties (e.g., individual terms and conditions) including all

addendums, amendments and supplements thereto and new

versions.

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1.1.41. The Health Insurance Program shall mean the insurance

program (s) specified in Addendum No. 1 to the Insurance Rules,

which determines the scope of the Insured Risk assumed by the

Insurer and the nature of the Insurance Coverage.

1.1.42. The Health Care Institution shall mean an (natural or

legal) entity that has a statutory licence and the right to provide

health care services and wellness services in accordance with

the procedure established by applicable law.

1.1.43. The Healthcare Service shall mean a service, aid and/or

product (e.g., Pharmaceuticals, Medical Aids) set forth in the

Contract and provided to the Insured in a Healthcare Institution,

the purpose of which is to diagnose, nurse and treat diseases

and Health Disorders, prevent them, help to recover and

strengthen health, as well as to provide services and supply

materials required for the restoration or improvement of health.

1.1.44. Wellness Services shall mean the services set forth in the

Contract and provided to the Insured, the purpose of which is to

prevent diseases, improve the immunity, resistance to diseases

and/or Injuries of the Insured.

1.1.45. Health Disorder shall mean health or physiological

condition of the Insured, which requires examination,

treatment and/or other services set forth in the Contract.

1.1.46. The Medical Speciaist shall mean a health care

professional who has a valid license for a specific activity that

has been issued in accordance with the procedure meeting

applicable requirements.

1.1.47. Wellness/Rehabilitation Aids shall mean the aids

intended for rehabilitation, kinesitherapy, physical exercises

and procedures, including massage tables and/or chairs,

exercise machines, massagers, exercise mats and balls, weights,

orthopedic/ergonomic pillows and mattresses and rubber

bands.

1.1.48. Pharmaceuticals shall mean the pharmaceuticals

registered by competent authorities in the Republic of

Lithuania or the European Community, which have an ATC

(anatomical-therapeutic-chemical) code and are purchased in

Pharmacies.

1.1.49. The Pharmacy shall mean a legal entity or the division

thereof which is licensed to engage in pharmaceutical

activities, including the remote sale of pharmaceuticals.

1.1.50. International Sanction shall mean an economic or

financial sanction, embargo or any other similar sanction,

prohibition or restrictive measure imposed by decisions of the

United Nations or by legal acts of the European Union or the

Republic of Lithuania or the United States (including sanctions

administered or applied by the Office of Foreign Assets Control

of the U.S. Treasury Department), the United Kingdom or any

other country.

1.1.51. The Injury shall mean an accident that occurs against the

will of the Insured as a result of any abrupt, inadvertent,

unexpected external forces and results in bodily injury and/or

impairment of organ functions of the Insured.

1.2. References in the Contract to any document shall be

construed as references to any amendments, supplements

thereto or new versions.

2. GENERAL

GENERAL

2.1. Contract Terms and Conditions

2.1.1. The Insurance Rules determine the general terms and

conditions of the Contract They shall be applicable to all

Contracts that enter into force from the date of entry into force

of the Insurance Rules, unless otherwise provided in the

Contract. The Insurance Certificate (Policy) specifies and

approves the specific terms and conditions of the Contract,

including, but not limited to the Insurance Coverage, additional

conditions or those agreed individually between the parties

2.1.2. These Insurance Rules are not subject to the Insurer's

General Insurance Terms and Conditions.

2.2. Contract validity, interpretation and application

2.2.1. The Contract shall enter into force on the date of its signing,

unless it provides for a different date or procedure for entry into

force.

2.2.2. The Contract shall expire:

2.2.2.1. Upon expiry of the Insurance Period set forth in the

Contract;

2.2.2.2. Upon payment of all Insurance Indemnities;

2.2.2.3. Upon the dissolution of the Policyholder as a legal entity

unless there is no successor of its rights and obligations;

2.2.2.4. Upon termination of the Contract under procedure and

in cases laid down in the Contract or applicable law;

2.2.2.5. If the Insured dies;

2.2.2.6. On other grounds for expiry of the obligations laid down

by the applicable law.

2.2.3. If the Contract is concluded for a group of Insured Persons,

then, on the grounds provided for in clause 2.2.2 of the

Insurance Rules, the Contract may expire only in respect of a

specific Insured (e.g., in respect of the deceased Insured or in

respect of the Insured to whom all Insurance Indemnities have

been paid). However, this does not change the validity of the

Contract for other Insured.

2.2.4. In cases of existence of inconsistencies and/or

contradictions among separate parts of the Contract, the

Contract terms and conditions shall be determined and

interpreted according to the rule, which grants the precedence

to the terms and conditions stated in the antecedent document

against the stated in the subsequent document in the following

order: the Insurance Certificate (Policy), including documents

establishing special or individually agreed conditions between

the parties, the Offer (if submitted in writing) and Insurance

Rules.

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3. CLIENT IDENTIFICATION

3.1. The Client or his representative shall submit to the Insurer

the following data and documents, required by the Insurer and

having the form and content acceptable by the latter and

conforming the identity, registration data, authorizations of the

Client, other documents or data, related to the Contract

conclusion, performance or termination and compliance with

the requirements of applicable law.

3.2. The Insurer shall be entitled to not accept a proxy document

that does not explicitly and unambiguously set forth the proxy

rights or authorizations regarding conclusion, performance of

respective transactions, or commission of actions and etc.

3.3. The Client shall inform the Insurer on changes, invalidity of

any identification and/or proxy documents submitted to the

Insurer or expiry thereof on other basis within a reasonable

term. Otherwise, the Insurer shall be entitled to refer to

documents and data submitted to it for such purpose at the

latest.

3.4. The Insurer shall have the right to establish the procedure

for identity verification for submission and receipt of notices

depending on their nature as well as requirements for signing

or approving specific documents. In case of any doubts, the

Client must confirm the Client's will, identity, the date of the

document and/or authenticity of the signature in the manner

requested by the Insurer and acceptable to it. The Insurer shall

have the right to refrain from performing any action or suspend

the performance of its obligations under the Contract until the

above doubts are resolved and the required confirmations are

obtained.

4. INSURANCE CONTRACT CONCLUSION

4.1. The Contract shall be concluded provided that the

Policyholder accepts the Insurer's Offer to conclude the

Contract under the conditions specified therein. In any case, the

Policyholder shall itself choose the desired nature and scope of

the Insurance Coverage and the Insured Risk from the possible

versions of the Health Insurance Program and/or other

conditions agreed between the parties.

4.2. When concluding the Contract, the Policyholder (the

Insured provided that the Policyholder gives its consent thereto

and provides such an opportunity) may choose the following

Health Insurance Programs:

4.2.1. Ambulatory treatment and diagnostics;

4.2.2. Stationary treatment;

4.2.3. Prenatanal care, childbirth and postnatanal

care;

4.2.4. Dental services;

4.2.5. Pharmaceuticals and medical aids;

4.2.6. Vitamins, over-the-counter pharmaceuticals;

4.2.7. Optics;

4.2.8. Preventive and periodical health examinations

and tests:

4.2.9. Vaccinations;

4.2.10. Rehabilitation treatment;

4.2.11. Medical services;

4.2.12. Wellness services;

4.2.13. All services;

4.2.14. Critical diseases.

4.3. The Insurer's Offer shall be valid for 30 (thirty) days from the

date of its issuance, unless otherwise specified in the Offer.

4.4. Before concluding the Contract and/or during the term of

validity of the Contract, the Insurer shall have the right to

request information and data relevant to the assessment of the

Insured Risk, the Client's needs and requirements, possibilities

to fulfil obligations under the Contract and/or to comply with

the requirements of applicable law. The Client shall provide

complete, true and full information requested by the Insurer.

4.5. When assessing the Insured Risk, the Insurer shall have the

right to take into consideration the age, health condition and

other circumstances relevant to the Insured Risk.

4.6. The Contract shall be deemed to be concluded, all its terms

and conditions shall be agreed and approved by the parties

from the date of signing the Insurance Certificate (Policy),

unless the Contract provides for otherwise.

4.7. Once the Contract is concluded, the Insurer shall issue the

Cards to the Policyholder, and the Policyholder shall transfer

them to each Insured personally and ensure the confidentiality

of personal data, unless the parties agree otherwise.

4.8. The Policyholder shall inform the Insured (s) about the

conclusion, amendment and/or termination of the Contract

and properly familiarize with the terms and conditions of the

Contract, as well as ensure that the Insured (s) duly and timely

fulfils all the terms and conditions of the Contract, including the

submission of consents, confirmations, data or other

information requested by the Insurer.

5. HEALTH EXAMINATION

5.1. When concluding or amending the Contract; investigating a

possible Insured Event; in case of reasonable doubts about the

accuracy, reasonability, authenticity or completeness of the

information provided by the Client; if new circumstances or

facts related to the health of the Insured are revealed; or in other

events when the Insurer needs additional information, the

Insurer shall have the right to request a medical examination of

the Insured in a medical institution acceptable to and indicated

by the Insurer and/or the conclusions of the relevant medical

expert. The Insurer shall pay the costs of the Insured's health

examination if such examination is requested by the Insurer

before concluding the Contract. If the Insured refuses to do so

while investigating a possible Insured Event, the Insurer shall

have the right to reduce the payable Insurance Benefit or refuse

to pay it.

CONTRACT CONCLUSION

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5.2. If necessary, the Insurer shall have the right to check the

health condition or medical history of the Insured by making

appropriate inquiries to the Partners, other medical institutions

before concluding the Contract and during the entire term of

the Contract, for example, when investigating the Insurable

Event and etc. If the Insurer does not receive the above

information, the Policyholder or the Insured shall provide the

Insurer with the relevant data and/or documents by themselves.

6. INSURANCE PREMIUMS

6.1. The insurance Premium shall be determined by the

agreement between the Policyholder and the Insurer for the

entire Insurance Period. The Insurance Premium depends on

the Insurance Programs chosen by the Policyholder, the Sum

Insured, Insured Risk Assessment and other terms and

conditions of the Contract.

6.2. Insurance Premiums shall be paid in accordance with the

procedure and terms specified in the Insurance Certificate

(Policy). In case of delay in payment of the Insurance Premium

or the portion thereof, the late payment penalty provided for in

the Contract may be charged, as well as the validity of the

Insurance Coverage may be suspended or the Contract may be

terminated at the choice of the Insurer.

6.3. The Insurance Premium shall be paid to the Insurer by a

payment order or in any other non-cash manner acceptable to

the Insurer in the currency of the Contract. If the Insurance

Premium is paid in a currency other than the Contract currency,

the Insurer shall have the right not to accept it or to deduct

currency conversion and related costs from it.

6.4. When paying the Insurance Premium, the payment

documents shall indicate the data required by the Insurer to

properly identify the Insurance Premium and assign it to the

Contract. The Policyholder shall be responsible for the payment

of Insurance Premiums in accordance with the terms of the

Contract.

6.5. The date of payment of the Insurance Premium shall be

considered the date when the Insurer assigns the Insurance

Premium credited to its bank account to the respective

Contract. If the Insurer is unable to determine for which

Contract the Insurance Premium has been paid, it shall be

deemed unpaid until the Insurer identifies under which

Contract the Insurance Premium has been paid and assigns it to

the respective Contract.

7. INSURANCE OBJECT

WHAT WE INSURE AGAINST

7.1. Insurance object is the property interest of the Insured related to the health of the Insured and health care.

8. INSURANCE COVERAGE

8.1. The Policyholder is free to choose all or some Insurance

Programs offered by the Insurer, their scope, other terms and

conditions of the Contract. The Insured Risk assumed by the

Insurer under the Contract will depend on this. By the

agreement of the Policyholder and the Insurer, the Insured shall

be provided with the Insurance Coverage the scope and limits

of which are specified in the Insurance Certificate (Policy),

annexes thereto, individual terms and conditions and the

Insurance Rules.

8.2. Unless otherwise provided in the Contract, the Insurance

Coverage under the Contract shall be valid only in the Republic

of Lithuania, which means that Insurance Indemnities may be

paid only for Health Care Services provided in the territory of

Lithuania or other Insurable Events that occur in the territory of

Lithuania.

8.3. The Insurance Coverage under the Contract shall take effect

at 0:00 hours on the first day of the Insurance Period (unless the

Contract stipulates that its entry into force depends on the date

of payment of the first Insurance Premium or part thereof) and

shall be valid until 24:00 hours on the last day of the Insurance

Period or the day of termination or expiry of the Contract on

other grounds.

8.4. The Insurer shall have the right to establish that the

Insurance Coverage for the Insured comes into force provided

only that the Card is activated and/or the consents,

confirmations or other information, data or documents

requested by the Insurer are submitted.

8.5. Insurance Coverage may be suspended in accordance with

the procedure and conditions provided for in the Contract. If the

Insurable Event occurs during the suspension of the Insurance

Coverage, the Insurer shall not pay Insurance Indemnity.

9. INSURABLE EVENTS

9.1. For an event to be recognized as Insurable on, it must meet

the following conditions:

9.1.1. The event must be provided for in the Contract and comply

with the requirements and conditions set out therein, including

the concepts and criteria provided for in each Health Insurance

Program, which are defined in Annex No. 1 to the Insurance

Rules, the parties may also agree on individual or special

conditions;

9.1.2. With due consideration of the date of the Insurable Event,

the event may occur after the entry into force of the Contract,

during the Insurance Period, during the validity of the Insurance

Coverage and within its limits;

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9.1.3. if the event relates to the health care services provided in a

health care institution, the medical specialist providing them

shall act within the limits of the rights and competence

established by applicable law and have a valid medical practice

license issued by a competent state authority;

9.1.4. The event must exclusively and directly concern the

Insured, and the costs (if applicable) related to the event must

be borne by the Insured himself.

9.1.5. The event must be based on appropriate evidence and

documents the form and content of which is acceptable to the

Insurer.

9.2. Insurance indemnities shall be allocated for the payment or

reimbursement of expenses incurred due to the Insurable

Events provided for in the Contract and shall not exceed the

Sum Insured specified in the Contract.

9.3. If the Insurable Event incurs continuous or partial expenses

(for example, goods or aids are purchased by paying for them in

instalments), then, depending on the date of the Insurable

Event, in accordance with the procedure set in clause 1.1.16 of the

Insurance Rules, in any case, only the expenses actually incurred

during the Insurance Period may be reimbursed.

10. SUM INSURED

10.1. The Sum Insured shall be determined for each Health

Insurance Program, for each Insured individually, unless

otherwise provided in the Contract.

10.2. Upon payment of any Insurance Indemnity under the

Contract, the respective Sum Insured shall be reduced by the

amount of this Insurance Indemnity and the Sum Insured

cannot be recovered.

11. NON-PAYMENT OR REDUCTION OF INSURANCE INDEMNITIES

WHAT WE DO NOT INSURE AGAINST

11.1. The Insurance Indemnities shall not be paid:

11.1.1. For Uninsurable Events which may be the same for all

Health Insurance Programs or detailed separately for each of

them;

11.1.2. For non-reimbursable expenses;

11.1.3. When the Insurable Event occurs during the period when

the Insurance Coverage was suspended or was invalid on other

grounds;

11.1.4. When the Insurer is released from paying the Insurance

Indemnity in the cases specified in the Contract or applicable

law.

11.2. The Insurer shall have the right to reduce the Insurance

Indemnity or refuse to pay it in the following cases:

11.2.1. The obligations concerning the notification of the Insured

Event as provided for in the Contract or by applicable law are

breached or fulfilled improperly;

11.2.2. The date, circumstances and/or consequences of the

Insurable Event, expenses incurred, other relevant data cannot

be fully and accurately determined on the basis of the data or

documents submitted by the person claiming the Insurance

Indemnity or this person does not allow or hinders the

investigation of the Insurable Event and obtaining the

information required;

11.2.3. The Insurer was provided with fraudulent, erroneous,

deliberately false or incomplete information or documents, or

information that could affect the conclusion of the Contract, its

terms or the Insured Risk was not disclosed to the Insurer, or

other important information about the Health Care Services

provided, the Health Disorder or other circumstances relevant

to investigation or assessment of the Insurable Event was

hidden;

11.2.4. The Contract was used for illegal purposes, including – for

the purpose of obtaining profit or fraudulent receipt of

Insurance Indemnity;

11.2.5. If the Insured is insured for the same risk under several

insurance contracts concluded with different insurers (double

insurance), then in case of the Insurable Event the Insurance

Indemnity payable by the Insurer shall be reduced in proportion

to the Insurer's share of liability. In any case, the total amount

paid under all insurance contracts may not exceed the costs

incurred by the Insured;

11.2.6. If the Insured refuses to undergo a medical examination

when required by the Insurer in accordance with the procedure

and conditions provided for in the Insurance Rules;

11.2.7. If the Policyholder or the Insured fails to perform the

Contract or performs it improperly, which results in increase of

the probability of the occurrence of the Insurable Event or

increase of the loss/expenses to any extent;

11.2.8. In other cases and according to the procedure provided

for and prescribed by the Contract and/or applicable law.

12. UNINSURABLE EVENTS

12.1. According to the Contract, any Health Insurance Program

(unless otherwise stated in its description) shall treat the Health

Disorders, as well as Health Care Services provided with regard

to these disorders and other related diseases or conditions,

other services or goods provided for in the Contract and any

costs incurred, as Uninsurable Events if they are:

12.1.1. Related to a war and the state of emergency;

12.1.2. Related to Radiation, the use of chemical or biological

substances for unpeaceful purposes;

12.1.3. Related to pandemics, as well as natural disasters, mass

disasters caused by natural disasters;

7

12.1.4. Caused by the Insured's intentional injury or attempted

suicide;

12.1.5. Arising from the unauthorized termination or change of

the treatment prescribed by a doctor;

12.1.6. Incurred due to a planned or committed criminal act by

the Insured or due to another act or omission contrary to law,

morality and/or public order;

12.1.7. Caused by the intentional act or omission of the

Policyholder or the Insured;

12.1.8. Caused or aggravated by the use of alcohol, narcotic, toxic

or other dangerous substances, intoxication or other effects

thereof.

13. NOTICE ON THE INSURABLE EVENT

13.1. The duty to inform of the Insurable Event falls on:

13.1.1. The Insured, if the Health Care Services or other

services/goods provided for in the Contract are provided to the

Insured by the Partner or any entity other than the Partner

provided that the Insured does not use the Card for paying for

them. In this case, the notice shall be submitted to the Insurer in

writing or via the E-Help system.

13.1.2. The Partner if it provides the Insured with Health Care

Services or other services/goods provided for in the Contract

and the Insured uses the Card to pay for them in accordance

with the procedure set by the Partner; In this case, the notice

shall be submitted in accordance with the procedure provided

for in the cooperation agreement between the Insurer and the

Partner.

13.2. The notice on the Insurable Event must be submitted to the

Insurer immediately upon learning of it, but in any case not later

than within 30 (thirty) calendar days from the date of its

occurrence.

13.3. Delayed submission of the notice on the Insurable Event

shall be considered a material breach of the Contract, due to

which the Insurer shall have the right to refuse to pay the

Insurance Indemnity or reduce it.

14. INVESTIGATION OF THE INSURABLE EVENT

14.1. Upon receipt of the Notice on the possible Insurable Event,

the Insurer shall carry out an investigation to identify the fact,

causes, circumstances and consequences of the event and to

determine the amount of the Insurance Indemnity.

14.2. The Policyholder, the Insured and the Beneficiary shall

cooperate in investigation of circumstances of the event which

can be acknowledged as the Insurable Event and guarantee

that the Insurer could legally familiarize with the entire event-

related information.

14.3. A person claiming to the Insurance Indemnity shall submit

to the Insurer documents the form and wording of which is

acceptable for the Insurer, which would acknowledge the

possible Insurable Event and the circumstances and

consequences thereof, as indicated in clause 15.1 or individually

requested by the Insurer, and all other relative documents and

information that have an effect on the assessment of the event

or determination of the amount of the Insurance Indemnity.

14.4. The expenses related to the receipt and submission of

supporting documents shall be borne by the person claiming

for the Insurance Indemnity.

14.5. During investigation, the Insurer may request other natural

persons and legal entities, competent institutions or

organizations to submit information, explanations, documents

and etc.

14.6. Upon receiving all required information, data, documents

or other proofs, the Insurer shall valuate the circumstances of

the event, the compliance thereof with the requirements of the

Contract and shall make a decision on payment or non-

payment of the Insurance Indemnity, the calculation of the

Insurance Indemnity.

14.7. If during the investigation of the possible Insurable Event

or, to justify the decision of the Insurer, the Insurer requires

additional knowledge or an expert opinion with regard to any

circumstances, facts or the assessment thereof, it shall be

entitled to receive consultations, conclusions or opinions of

professionals and experts in the specific field of knowledge. The

expenses incidental to the provision of such services shall be

borne by the Insurer.

14.8. If any disputes regarding assessment or decision of the

Insurer arise between the parties to the Contract, the Insurer

and the Policyholder or the Insured may agree upon

investigation or assessment of the Insurable Event anew which

would be performed by an independent expert (experts). The

associated costs shall be borne by the initiator of the

investigation/assessment, unless the parties agree otherwise. In

this event, experts may not be the persons whose participation

could cause the conflict of interests. Each party shall in writing

provide an independent expert (experts) with all facts, data and

documents which may have any influence on fair and

reasonable assessment of the health condition of the Insured

and/or other circumstances of the event and/or the amount of

damage. Independent experts shall present their findings to all

parties at the same time. Either party shall be entitled to

disagree with the finding of the independent experts and apply

to competent institutions and/or court for a resolution of the

dispute in accordance with the procedure prescribed by

applicable law

UPON OCCURRENCE OF AN INSURABLE EVENT

8

15. CLAIM FOR THE INSURANCE INDEMNITY AND OTHER DOCUMENTS

15.1. The Insurable Event shall be investigated and the Insurance

indemnity shall be paid after submission to the Insurer of the

following documents the wording and form of which is

acceptable to the Insurer:

15.1.1. The claim for payment of the Insurance Indemnity in the

form set by the Insurer;

15.1.2. A document confirming the purchase of services and/or

goods (an invoice) and document confirming payment (a cash

receipt, a cash register receipt, a sales receipt, bank transfer

statement, etc.);

15.1.3. Excerpts from medical documents or copies thereof,

which reasonably indicate:

– The fact of the Insurable Event, the date and circumstances of

the Insurable Event (e.g. , a health disorder and the

circumstances of its occurrence, course of development;

objective condition of the Insured; prescribed examinations

confirming the Health Disorder; results of performed tests, etc.);

– The code of a disease;

– Other information relevant to the proper and complete

investigation of the Insurable Event or requested by the Insurer;

15.1.4. The prescription of a pharmaceutical or a medical aid, or

other medical document or the copy thereof . For

reimbursement from the Pharmaceuticals and Medical Aids

sub-type of the Health Insurance Program, a prescription or

other medical document is mandatory in all cases, regardless of

whether a Pharmaceutical or a Medical Aid can be prescribed

and purchased only with a prescription or over the counter. If a

Pharmaceutical is purchased with an electronic prescription,

the Insured shall:

– Make sure that the payment document contains information

on the purchase of the relevant Pharmaceutical by an electronic

prescription, or

– Provide the copy of such an electronic prescription or other

medical document;

15.1.5. Copies of the individual activity certificate or business

certificate of the person who provided the services (if services

were provided by a person who is engaged in this business);

15.1.6. Consents or other documents or data required under the

relevant Health Insurance Program;

15.1.7. Other documents, reasonably requested by the Insurer,

proving the Insurable Event and its circumstances.

16. INSURANCE INDEMNITY

16.1. Once the Event is recognized as insurable one, the Insurer

shall pay the Insurance Indemnity by reducing it by the

Franchise amount and applying other restrictions for the

calculation and/or payment of the Insurance Indemnity as

provided for in the Contract.

16.2. The Insurance Indemnity shall be paid:

16.2.1. To the Partner in accordance with the procedure provided

for in the Cooperation Agreement with the Partner, if the

Partner provides the Insured with Health Care Services or other

services/goods provided for in the Contract and the Insured

pays for them by the Card in accordance with the procedure set

by the Partner;

16.2.2. To the Insured, if the Health Care Services or other

services/goods provided for in the Contract are provided to the

Insured by the Partner or any entity other than the Partner, but

the Insured does not use the Card for paying for them and pays

by himself.

16.2.3. In the case provided for in clause 14.2.1.1 of Addendum No.

1 to the Insurance Rules – to the Insured.

16.3. The Insurance Indemnity shall be paid no later than within

30 (thirty) days from the date of receipt of all the information

and/or documents in a form and wording acceptable to and

requested by the Insurer, which are relevant to determination of

the fact and circumstances and consequences of the Insurable

Event and the amount of the Insurance Indemnity.

16.4. If the event is recognized as uninsurable one, the Insurer,

within 30 (thirty) days from the date of receipt of all information

relevant to determining the fact, circumstances and

consequences of the event, shall inform about such decision

and/or refusal to pay the Insurance Indemnity.

16.5. The Beneficiary shall immediately, but in any case not later

than within 10 (ten) business days from the date of receipt of the

respective Insurer's request, return to the Insurer the

unreasonably paid Insurance Indemnities requested by the

Insurer, including overpayments resulting from exceeding the

Sums Insured.

16.6. The Insurer shall have the right to demand that a person

claiming the Insurance Indemnity should open a bank account

in his name with a bank or other credit institution operating in

the Republic of Lithuania, to which the Insurance Indemnity

could be transferred.

16.7. The Insurer shall have the right to deduct from the payable

Insurance Indemnity the fees charged for a payment order (for

example, currency conversion costs, fees for submission or

execution of the payment order, etc.).

INSURANCE INDEMNITIES

9

17. RIGHTS AND DUTIES OF THE PARTIES

17.1. Duties of the Policyholder:

17.1.1. To deliver to the Insurer or ensure that the Insured delivers

detailed, complete and true information required for the

conclusion and performance of the Contract;

17.1.2. Before entering into the Contract, to properly and

diligently review the terms and conditions of the Contract,

including the Insurance Rules;

17.1.3. To inform the Insured about the Contract concluded,

amendments thereto or termination thereof, to properly and in

detail familiarize the Insured with the terms and conditions of

the Contract, including the Insurance Rules;

17.1.4. To pay the Insurance Premiums in accordance with the

procedure and terms set in the Contract;

17.1.5. Being the main contact person of the Insurer, to

ensure communication and cooperation with the Insured

persons both during the conclusion and performance of the

Contract, as well as when transmitting to the Insured persons

the information related to the Contract, obtaining the

necessary data or consents from the Insured persons, etc .;

17.1.6. To inform about the existing insurance contracts

concluded with other insurers on the same Insured Risks that

are included in the Contract concluded with the Insurer or,

immediately within a reasonable time, to inform of new ones;

17.1.7. To take all possible actions to avoid or reduce the Insured

Risk and follow the Insurer's instructions, if such are given to the

Policyholder;

17.1.8. To immediately notify to Insurer increase of the Insured

Risk or other circumstances that have a material impact on the

terms and conditions of the Contract;

17.1.9. To provide the Insurer or its authorized representative with

conditions for checking whether the Policyholder and the

Insured follow the terms and conditions of the Contract;

17.1.10. Immediately, within a reasonable time f rom the

occurrence or identification of relevant circumstances or facts,

to inform the Insurer of any changes in the data, facts or

circumstances provided to the Insurer at the time of concluding

and/or amending the Contract, including but not limited to

identification data (personal identification data, taxpayer data,

data on the registration or legal status of a legal entity,

information about the representative and his authorizations,

etc.) and contact data (an address, a telephone number or an e-

mail address);

17.1.11. Immediately, but in any case not later than within 1 (one)

business day, to notify about termination of employment

relationship with the Insured, to terminate the validity of the

Insurance Coverage for such Insured and assume any losses

incurred due to improper performance of this obligation. In this

case, the Insurer shall terminate the validity of the Insurance

Coverage for the Insured no later than on the next business day

after receiving the relevant notice;

17.1.12. Properly and in a timely manner to perform all other

duties and to follow all other conditions and requirements

provided for in the Contract or by applicable law.

17.2. Duties of the Insured:

17.2.1. To diligently and thoroughly look through the terms and

conditions of the Contract, including the Insurance Rules, and

to follow them carefully and properly;

17.2.2. To provide the Insurer with the data, documents,

consents, confirmations or other information requested by the

Insurer and required for the conclusion and proper

performance of the Contract, assessment of the Insured Risk or

investigation of the Insurable Event;

17.2.3. On his own initiative and under his responsibility, in

advance to negotiate and obtain the Insurer's consents or

approvals for the provision of specific Health Care Services, if

and when such are mandatory in accordance with the terms

and conditions of the relevant Health Insurance Program;

17.2.4. To protect the Card from unauthorized use, damage or

loss and be liable for any damage resulting from improper

performance of this obligation;

17.2.5. Immediately, but in any case not later than within 1 (one)

business day from the occurrence of the respective event, to

inform the Insurer about the illegal use, loss, theft or any other

loss of the Card;

17.2.6. When and as required by the terms and conditions of the

Contract, to inform the Insurer of the Insurable Event and

provide detailed and true information about the causes and

circumstances of the Insurable Event and all related data,

information and documents specified in the Contract;

17.2.7. To keep documents confirming the Insurable Event for at

least 1 (one) year from the payment of the Insurance Indemnity,

if only copies thereof have been submitted to the Insurer, and to

deliver them upon the Insurer's request;

17.2.8. At the request of the Insurer, in the cases and according to

the procedure provided for in the Contract, to undergo a health

examination in the institution indicated by the Insurer;

17.2.9. At the request of the Insurer, in accordance with the

procedure and terms provided for in the Contract, to refund to

the Insurer the unreasonably paid Insurance Indemnities,

including overpayments resulting from exceeding the Sums

Insured;

17.2.10. Immediately, within a reasonable time f rom the

occurrence or identification of relevant circumstances or facts,

to inform the Insurer of any changes in data, facts or

circumstances provided to the Insurer, including but not

limited to identification data (personal identity data, etc.) and

contact details (an address, a telephone number or an e-mail

address);




OTHER TERMS AND REQUIREMENTS

10

17.3. Duties of the Insurer

17.3.1. To provide information about the Insurer, insurance

services, dispute resolution procedures and essential

information in the cases and in accordance with the procedure

established by applicable law and the Contract;

17.3.2. Upon concluding the Contract, to issue the Insurance

Certificate (Policy) to the Policyholder and the Cards assigned to

each Insured or other document confirming the provision of

Insurance Coverage under the Contract;

17.3.3. To provide information and advice on Health Insurance

Programs;

17.3.4. Upon the occurrence of the Insurable Event, to pay the

Insurance Indemnities under the terms and conditions

provided for in the Contract;

17.3.5. Not to disclose confidential information about the

Policyholder and/or the Insured received during the

performance of the Contract unless otherwise provided for by

the Contract and applicable law;

17.3.6. To issue to the Policyholder the copies of the Contract, if

after concluding the Contract the Policyholder applies to the

Insurer with such a request;




17.4. The Insurer shall have the right to establish and change the

list of Partners, the conditions of cooperation with the Partner,

requirements or restrictions regarding the provision of all or

specific Health Care Services to Clients. In any case, the Partners

shall not be authorized to interpret the terms of the Contract or

to perform the obligations of the Insurer or the Client under the

Contract.

17.5. Other rights of the parties are provided for in the Contract

and by applicable law.

18. AMENDMENT OF THE INSURANCE CONTRACT

18.1. General provisions

18.1.1. The terms and conditions of the Contract may only be

amended or supplemented by a written agreement between

the Policyholder and the Insurer unless other clauses of the

Contract or applicable law provides otherwise.

18.1.2. Before amending the terms of the Contract, the Insurer

shall have the right to request additional information about the

Client, the Insured's medical examination and etc.

18.2. Amendments to the Contract upon the initiative of the

Policyholder

18.2.1. The Policyholder shall give to the Insurer a written notice

on the desired amendment to the terms and conditions of the

Contract not later than 30 (thirty) days prior to the effective date

of the desired amendment.

18.2.2. Amendments to the list of Insured persons (termination

of the Contract with respect to some Insured persons and/or

inclusion of new Insured persons) shall be made with the

consent of the Insurer and on terms and conditions agreed by

both parties.

18.3. Amendments to the Contract upon the initiative of the

Insurer

18.3.1. The right of the Insurer to amend the terms and

conditions of the Contract is provided for in the Contract and by

applicable law.

19. SUSPENSION AND RENEWAL OF INSURANCE COVERAGE

19.1. If the Policyholder fails to pay any Premium in full or in part

within the time specified in the Contract, the Insurer shall have

the right to notify this to the Policyholder in writing or in any

other notification manner and indicate that, if the Policyholder

fails to pay the Premium in full or in part within 30 (thirty) days

from the date of dispatch of the notice, the Insurance Coverage

under the Contract will be suspended and resumed only after

the Policyholder pays all the Insurance Premiums due under

the Contract.

19.2. If the suspension of the Insurance Coverage due to non-

payment of the Insurance Premium lasts for more than 1 (one)

month, the Insurer shall have the right to unilaterally terminate

the Contract by giving to the Policyholder a written notice on

termination of the Contract.

19.3. In case of circumstances when the Card is used by an

unauthorized person or the Card is lost, the Insurer shall have

the right to temporarily (until the violation is eliminated, the said

circumstances are investigated or the proper discharge of

obligations under the Contract is ensured otherwise, etc.)

suspend the validity of Insurance Coverage to the respective

Insured.

20. CONTRACT TERMINATION

20.1. Procedure for termination or expiration of the Contract

20.1.1. The Contract may be terminated upon a separate written

agreement of the parties, written request of the Policyholder,

court judgment or the Insurer's notice in cases and under

procedure laid down in the Contract and/or the applicable law.

20.1.2. Upon termination or premature expiry of the Contract

before the end of the Insurance Period on other grounds, the

Insurer shall always preserve the right to the Insurance

Premiums due but not paid before the respective termination

or expiration of the Contract, as well as to the amounts that are

formed as the difference between the Insurance Indemnities

actually paid and the Insurance Premiums actually received

(when the Contract provides for periodic payment of Insurance

Premiums). The Policyholder must cover them no later than

before the last day of the Contract validity.

20.1.3. Unless otherwise provided in the Contract, as well as in

the Insurance Rules or applicable law, upon termination or

expiry of the Contract before the end of the Insurance Period on

other grounds, the Insurance Premiums paid shall not be

refunded to the Policyholder.

11

20.2. Contract termination upon the initiative of the

Policyholder

20.2.1. The Policyholder shall be entitled to terminate the

Contract at any time during the Contract validity term, by giving

to the Insurer a written notice no later than 30 (thirty) days prior

to the planned date of the Contract termination.

20.2.2. If the Contract is terminated upon the initiative of the

Policyholder due to the fault of the Insurer, the Policyholder

shall be reimbursed the share of the Insurance Premiums paid

by the Policyholder, which exceeds the amount of the Insurance

Indemnities already paid and planned to be paid under the

Contract.

20.2.3. If the Contract is terminated upon the initiative of the

Policyholder through no fault of the Insurer, the Policyholder

shall be reimbursed the Insurance Premiums actually paid for

the remaining Insurance Period from the date of termination of

the Contract less the costs of concluding and performing the

Contract and the Insurance Indemnities paid and planned to be

paid under the Contract. The amount payable shall be

calculated 30 (thirty) days after the date of termination of the

respective Contract and shall be paid within following 30 (thirty)

days.

20.3. Contract termination upon the initiative of the Insurer

20.3.1. The Insurer shall have the right to terminate the Contract

unilaterally, without recourse to court, by giving prior 30 (thirty)

calendar days written notice before the expected date of

termination of the Contract in case of the following material

breaches of the Contract:

20.3.1.1. During the conclusion or validity of the Contract, the

Policyholder and/or the Insured violates or improperly performs

the established by applicable law duty to disclose full, complete,

true and detailed information on circumstances affecting the

Insured Risk assessment, the probability of the Insurable Event

or its possible consequences and the terms and conditions of

the Contract;

20.3.1.2. The Policyholder and/or the Insured fails to perform or

improperly performs other obligations provided for in the

Contract and, upon the Insurer's request, does not remedy the

situation within the reasonable term set by the Insurer, which in

any case may not be shorter than 14 (fourteen) calendar days;

20.3.1.3. There are other grounds for termination of the Contract

provided for in the Contract or applicable law.

20.3.2. The Insurer shall have the right to terminate the Contract

unilaterally, without recourse to court, by giving a written notice

with an immediate effect (unless such a notice specifies other

terms of entry into force) in case of the following material

breaches of the Contract:

20.3.2.1. if the Policyholder delays payment of the Insurance

Premium in full or in part within the time specified in the

Contract and upon the receipt of the Insurer's notice with a

request to cover the indebtedness within 30 (thirty) days from

the dispatch of the notice, the Policyholder fails to effect all

overdue payments within the specified term;

20.3.2.2. On the grounds and in accordance with the procedure

provided for in clause 19.2 of the Insurance Rules;

20.3.2.3. The Policyholder does not respond to the submitted

proposal to amend the terms and conditions of the Contract in

accordance with the procedure established by applicable law or

the Contract or refuses to do so;

20.3.2.4. There are other grounds for termination of the Contract

provided for in the Contract or applicable law.

20.3.3. When the Contract is terminated at the request of the

Insurer due to the fact that the Policyholder violates the terms

and conditions of the Contract, no Insurance Premiums shall be

refunded to the Policyholder.

20.4. Contract Termination upon Agreement of the Parties

20.4.1. The Insurer and the Policyholder may agree under a

separate written agreement on other conditions and procedure

of the Contract termination.

21. TRANSFER OF CONTRACTUAL RIGHTS AND OBLIGATIONS

21.1. Transfer of the Insurer's contractual rights and obligations

21.1.1. The Insurer shall be entitled to transfer the contractual

rights and obligations to other insurer or insurers upon

notifying such an intention and receiving a permit from a

competent supervisory institution in events and under the

procedure laid down by applicable law.

21.1.2. In the cases specified in the applicable law, the Insurer

shall publish the intention to transfer its contractual rights and

obligations at least in 2 (two) national newspapers and give the

Policyholder at least 2 (two) month period to object to the

Insurer with regard to respective intentions.

21.1.3. Within the terms specified in the relevant published

notice, the Policyholder shall have the right to give to the Insurer

a written notice of objection to the intended transfer of the

Insurer's contractual rights and obligations.

21.1.4. If the Policyholder does not agree with the transfer of

contractual rights and obligations and the change of the

Insurer, it shall have the right to terminate the Contract within 1

(one) month from the date of transfer of contractual rights and

obligations. In this case, the Policyholder shall be reimbursed

the Insurance Premiums actually paid for the remaining

Insurance Period from the date of termination of the Contract

less the costs of concluding and performing the Contract and

the Insurance Indemnities paid and planned to be paid under

the Contract.

21.2. Transfer of the Policyholder's contractual rights and

obligations

21.2.1. The Policyholder shall have no right to transfer its

contractual rights and/or obligations to other persons unless

the Insurer gives its prior written consent thereto.

22. NOTICES

22.1. All notices, applications or any other expression of will

between the Insurer and the Client shall be executed in writing

or in a manner equivalent to a written form and shall be

delivered personally under signature, by regular mail, via the E-

Help system or by e-mail according to the respective contact

details indicated in the Contract or the latest contact details

delivered to the other party for such a purpose.

22.2. The Client's notices to the Insurer shall be sent according to

the Insurer's contact details and shall be deemed to be received

upon their actual receipt. The Insurer's agents shall not be

entitled to accept any notices on behalf of the Insurer.

12

22.3. Any written notice of the Insurer to the Client shall be

deemed to be received, respective notification obligation of the

party shall be deemed to be fulfilled and counting of the related

terms shall start under the below indicated order and terms:

22.3.1. On the 5th (fifth) calendar day after its sending by

registered mail;

22.3.2. On the day of sending via the E-Help System. If the notice

is sent in this manner on a weekend or public holiday or after the

expiry of working hours, it shall be deemed to be received on the

next working day;

22.3.3. When delivering personally under signature – on the day

when the receiver receives the notice delivered to him and signs

that he received it.

22.4. A party shall not be entitled to make any claims regarding

not receiving any notices or that the actions of the other party

do not comply with the Contract terms and conditions, if the

notice was sent according to the latest contact details provided

by a party.

22.5. In cases and under the procedure laid down in the Contract

and/or applicable law or in other exceptional cases, the Insurer

shall be entitled to provide notices or essential information to

the Clients publicly: in the Insurer's Client Service Divisions, on

the Insurer's website and/or via mass media. In such cases the

notices shall be deemed to be received on the date of their

publishing.

23. CONFIDENTIALITY

23.1. The Contract terms and conditions and all the information

received by the parties during performance of the Contract shall

be deemed to be confidential and not publicly announced to

any third parties without prior written consent of the concerned

contractual party, except for disclosure of respective

information to the extent required provided that the further

protection of respective information is maintained:

23.1.1. To persons who lodged legitimate claims under the

Contract;

23.1.2. When such information is public (except for cases when it

becomes public due to the breach of the Contract);

23.1.3. To persons, providing audit services and performing the

audit of the party's activities or financial statements under the

Contract;

23.1.4. To attorneys at law who provide legal services related to

the Contract, to any Party;

23.1.5. To shareholders/stakeholders and/or parent and/or

subsidiary companies of the Party;

23.1.6. To expected legal successor or property acquirer of the

Parties;

23.1.7. To persons who provide to the Insurer services related to

the Contract conclusion, performance, accounting,

administration or storage;

23.1.8. To a re-insurer if the Insured Risk is subject to re-insurance

under the Contract;

23.1.9. To competent public authorities, including courts, law

enforcement authorities, the State Tax Inspectorate and etc.;

23.1.10. To the distributor of the insurance product who

mediated in concluding the Contract;

23.1.11. In other mandatory events provided for by the Contract

and/or applicable law.

24. RESPONSIBILITY

24.1. The parties undertake to perform all obligations set out in

the Contract in a due and timely manner, in good will and

cooperation, carefully and according to the established good

practice.

24.2. For delayed performance of the contractual monetary

liabilities, the Insurer shall pay to the Policyholder the late

payment interest amounting to 0.02% of the outstanding

amount for each delayed day until due performance of

monetary liabilities.

24.3. The Insurer shall not be liable for any losses incurred due to

the Contract termination on the grounds set out in the Contract

or applicable law.

24.4. The Insurer shall not be liable for the inability to use the

Card as intended if this is caused by technical malfunctions. The

Insurer shall eliminate such malfunctions within a reasonable

time if they occur due to the fault of the Insurer.

25. APPLICABLE LAW, PROCEDURE OF DISPUTE SETTLEMENT

25.1. The Contract, its conclusion and interpretation shall be

subject to the law of the Republic of Lithuania.

25.2. All and any disputes, disagreements or claims between the

Insurer the Client, arising out of or related to the Contract shall

be settled in a way of negotiations and in accordance with the

procedure for examination and management of complaints

established by the Insurer and published on its website

www.compensalife.lt.

25.3. On request of a concerned party, disputes may be resolved

in accordance with the procedure of amicable consideration

and settlement of disputes established by applicable law. The

Bank of Lithuania was provided with a competence to solve

disputes between consumers and financial market players

arising out of provision of financial services, in accordance with

the procedure prescribed by the Bank of Lithuania. For more

information see the address of the Supervision Service of the

Bank of Lithuania and other contact details on the website:

www.lb.lt.

25.4. In any case, if the parties fail to agree, such disputes shall be

settled in competent court under the procedure prescribed by

law of the Republic of Lithuania.

13

26. MISCELLANEOUS

26.1. The Insurer shall not provide the Insurance Coverage under

the Contract and shall not be liable for paying the Insurance

Indemnity or any other amount under the Contract or

complying with any other contractual obligations if these acts

could result in violation by the Insurer of any International

Sanction. The Insurer shall not be liable for any claims or

damages arising from the foregoing.

26.2. If at any time it becomes apparent that any provisions of

the Contract are or become invalid, illegal or unenforceable, this

shall in no way affect or invalidate the remaining provisions of

the Contract, and such improper provisions shall be

immediately replaced by written agreement of the parties with

new ones that have the closest meaning, objectives, content

and the same economic effect.

1. AMBULATORY TREATMENT AND DIAGNOSTICS

1.1. The Insurable Event shall be deemed to be the following

Medically Reasonable Health Care Services provided to the

Insured due to a Health Disorder (an acute disease, a chronic

disease exacerbation or an injure) and its follow-up/monitoring

in the Health Care Institution and the associated costs.

1.2. Reimbursable health care services:

1.2.1. Consultation with a family doctor or medical specialist,

including remote healthcare services; home visits by family

doctors;

1.2.2. The examinations and tests performed by a doctor, which

are periodically required at a specified (prescribed by a doctor)

time interval in order to regularly monitor the health condition

of the Insured who suffers from a specific chronic disease or

takes specific pharmaceuticals;

1 . 2 . 3 . Consultat ions of a psychiatr ist , psychiatr ist-

psychotherapist, medical psychologist, medical psychologist-

psychotherapist and psychotherapeutic treatment performed

by the said medical specialists, but not more than 12 (twelve)

visits during 1 (one) year of the Insurance Period;

1.2.4. Diagnostic tests prescribed by a doctor:

(a) Laboratory tests: clinical, biochemical cytological-

h i s to l o g i c a l , i m m u n o e n z y m a t i c , m i c ro b i o l o g i c a l -

bacteriological;

b) Instrumental tests: clinical physiological, X-ray, ultrasound,

endoscopic, computed tomography, nuclear magnetic

resonance and other imaging tests;

1.2.5. Day surgery/day stationary services;

IMPORTANT CLAUSE: these costs in full or in part shall be

reimbursed only if:

a) They are not partially reimbursed from the CHIF budget; and

b) The Insurer is informed about the necessity to provide Day

Surgery/Day Stationary services by a written notice or via e-mail

[email protected] prior to starting treatment and gives its

prior written consent thereto. The Insured is responsible for

obtaining the consent of the Insurer..

1.2.6. Ambulatory surgery services;

1.2.7. Nursing services.

1.3. Non-reimbursable expenses for:

1.3.1. Termination of pregnancy; Health Disorders that occur or

exacerbate due to termination of pregnancy for medical

indications; pregnancy diagnostics, pregnancy care; childbirth

and postnatal care; Health Disorders caused by pregnancy or

childbirth (e.g., gynecological, endocrine, breast, neurological,

urological, etc. pathologies); pregnancy prevention services;

1.3.2. Reparative and aesthetic surgical treatment; procedures

and surgery performed for cosmetological, reparative and/or

aesthetic purposes; dermatological treatment, including but

not limited to phototherapy, photodynamic therapy, pulsed

light therapy, laser aesthetic procedures (pigmentation,

redness, dilated blood vessels, acne, stretch marks, scars, etc.);

hair removal procedures; hair loss treatment; treatment with

botulinum toxin injections; laser treatment of nail fungus;

I. This Addendum defines the scope and nature of the Insurance Coverage, Insurable Events, Uninsurable Events,

other terms and requirements under the Health Insurance Programs offered by the Insurer.

II. The Addendum is the integral part of the Insurance Rules.

III. In case of controversy or incompliance in provisions of the Addendum and the Insurance Rules, the provisions and

requirements provided for in the Addendum shall prevail.

HEALTH INSURANCE RULES No. 010

Effective from 1 July 2021

Addendum No. 1 to

HEALTH INSURANCE PROGRAMS

14

1.3.3. Diagnosis and treatment of AIDS, HIV, syphilis, gonorrhea,

t r ichomonias is , ch lamydia , ureaplasmosis , human

papillomavirus, herpes genital and other sexually transmitted

diseases;

1.3.4. Diagnosis and treatment of infertility/inability to get

pregnant, potency disorders; artificial insemination procedures;

1.3.5. surgical treatment of overweight/obesity;

1.3.6. Vision correction; organ transplantation surgery,

acquisition of endoprosthesis and joint replacement surgery;

1.3.7. Bone marrow transplants; hemodialysis procedures;

1.3.8. Stem cell or autologous therapy;

1.3.9. Long-term nursing/care and supportive care services;

1.3.10. Treatment of benign tumours, warts, moles;

1.3.11. Diagnosis and treatment of varicose veins in the legs;

1.3.12. Consultations of a dentist or an oral cavity and orthognatic

surgeon and examinations or treatment prescribed by them;

1.3.13. Medical accessories used for day surgery/day stationery

services, which are not reimbursed by the CHIF;

1.3.14. Alternative medicine services;

1.3.15. Sports medicine doctor's services.

2. STATIONARY TREATMENT


Health Care Services provided to the Insured due to his Health

Disorder, the elimination of which required therapeutic and/or

surgical profile stationary treatment in the stationary Health

Care Institution, where the Insured is provided with care for

more than 48 hours.


2.2.1. If the Additional Services in Public Hospitals sub-type of the

Health Insurance Program is chosen – a single or double paid

ward in public hospitals;

2.2.2. If the Stationary Treatment in State Hospitals sub-type of

the Health Insurance Program is chosen – diagnostic services

provided to the Insured during stationary treatment in public

hospitals; purchased medical aids, Pharmaceuticals, paid

wards;

2.2.3. If the Stationary Treatment in Private Hospitals sub-type of

the Health Insurance Program is chosen – diagnostic services

provided to the Insured during stationary treatment in private

hospitals; additional services including medical aids, purchase

of Pharmaceuticals and paid wards;


2.3.1. 1.3.1. Termination of pregnancy; Health Disorders that occur

or exacerbate due to termination of pregnancy for medical

indications; pregnancy diagnostics, pregnancy care; childbirth

and postnatal care; Health Disorders caused by pregnancy or

childbirth (e.g., gynecological, endocrine, breast, neurological,

urological, etc. pathologies);

2.3.2. Oral, maxillofacial surgery services in the stationary Health

Care Institution;

2.3.3. Endoprosthesis acquisition and joint endoprosthesis

surgery; organ transplant surgery; bone marrow transplants;

reparative and aesthetic surgical treatment; surgical treatment

of overweight/obesity;

2 . 3 . 4 . S t a t i o n a r y r e h a b i l i t a t i o n s e r v i c e s ; m e n t a l

illness/psychiatric treatment services; long-term nursing/care

and supportive care services.

3. PRENATANAL CARE, CHILDBIRTH AND POSTNATANAL CARE


Health Care Services provided to the Insured due to pregnancy,

childbirth and respective complications during the prenatanal,

child-birth and postnatanal period and associated costs.


3.2.1. Pregnancy diagnosis, pregnancy care services (i.e. periodic

visits; monitoring of normal or high-risk pregnancy) provided in

accordance with the requirements of applicable law on health

examinations of pregnant women;

3.2.2. Fetal diagnosis, prenatal examinations, consultation with

a geneticist doctor and prescribed treatment;

3.2.3. Diagnosis and treatment of health disorders identified

during visits of a pregnant woman; diagnosis and treatment of

health disorders that have worsened during pregnancy and

complications of pregnancy (e.g., gynecological, endocrine,

breast, neurological, urological, etc. pathologies);

3.2.4. Diagnosis and treatment of health disorders that

developed or worsened during childbirth, after giving birth

and/or breastfeeding;

3.2.5. Prenatanal, child-birth and postnatanal services provided

to the Insured, paid wards after childbirth in stationary Health

Care Institutions.

15

4. DENTAL SERVICES


Health Care Services provided to the Insured due to a Health

Disorder in connection with the treatment and prevention of

dental, oral and maxillofacial diseases and associated costs.


4.2.1. Oral care specialist consultations, oral hygiene

assessment, dental hard and soft plaque removal, fluorine

application services;

4.2.2. Consultation with a dentist or oral cavity and maxillofacial

surgeon; general dental endodontic, orthodontic, periodontal,

surgical dental diseases, orthognathic treatment services;

restoration services for dental hard tissue defects with fillings,

inlays, overlays and laminates; dental radiological examination,

analgesia, tooth extraction services, including dental day

surgery, bone replacement or artificial bone services; treatment

by teeth protectors (e.g., orthodontic, relaxation, bruxism);

4.2.3. Dental prosthetics with dentures, implants services.


4.3.1. Teeth whitening, including whitening by teeth protectors.

5. PHARMACEUTICALS AND MEDICAL AIDS

5.1. The Insurable Event shall be deemed to be the purchase of

Pharmaceuticals prescribed for the Insured due to the Health

Disorder according to a doctor's prescription or medical

document confirming the relevant prescription in Pharmacies,

Health Care Institutions and/or the purchase or rental of Medical

Aids in Pharmacies, Orthopedic Aids Stores and associated

costs.


5.2.1. Pharmaceuticals and Medical Aids reimbursable from the

CHIF budget. If the Pharmaceutical purchased are not fully

reimbursed from the CHIF budget, the balance of the full

amount shall be reimbursed, unless otherwise provided in the

Contract;

5.2.2. Pharmaceuticals and Medical Aids not reimbursed from

the CHIF budget shall be reimbursed as provided for in the

Contract;

5.2.3. Pharmaceuticals and Medical Aids used during Day

Surgery/Day Stationary and/or Ambulatory Surgery shall be

reimbursed as provided for in the Contract.


5.3.1. Pharmaceuticals for addiction diseases, potency disorders,

weight loss; sex hormones and pharmaceuticals for the

reproductive system; contraceptives;

5.3.2. Vitamin and mineral supplements with ATC code A11 or A12

no matter how they are bought in Pharmacies: with or without

the doctor's prescription;

5.3.3. Thermometers, hygiene aids, appliances for hygiene,

testers, heaters, scales and blood pressure measuring

apparatus and other functional diagnostic appliances and/or

instruments;

5.3.4. Compensatory technical aids (wheelchairs, functional

beds);

5.3.5. Purchase or rental of wellness/rehabilitation aids;

5.3.6. Herbal, animal or homeopathic preparations; preparations

and articles having various functions without an ATC code.

6. VITAMINS, OVER-THE-COUNTER PHARMACEUTICALS

6.1. The Insurable Event shall be deemed to be the purchase of

vitamins, food supplements, prescription and over-the-counter

Pharmaceuticals for the treatment or prevention of the

Insured's Health Disorder in Pharmacies and associated costs.


6.2.1. Vitamins, mineral supplements, food supplements,

homeopathic and medicinal preparations of herbal or animal

origin, multi-functional preparations and preparations that do

not have the assigned ATC code;

6.2.2. Over-the-counter Pharmaceuticals without the doctor's

prescription.

6.2.3. Vitamins and mineral supplements with ATC code A11 or

A12.


6.3.1. Pharmaceuticals for addiction diseases, potency disorders,

weight loss; sex hormones and pharmaceuticals for the

reproductive system; contraceptives;

16

7. OPTICS


Health Care Services provided to the Insured due to the Health

Disorder related to his vision and associated costs.


7.2.1. Consultancy on the choice of optical aids with an

ophthalmologist or optometrist;

7.2.2. Prescription glasses lenses, prescription glasses frames,

contact lenses and contact lens maintenance aids prescribed

by an ophthalmologist or optometrist, which are necessary for

the correction of the existing visual disorder provided that they

are purchased in specialized opticians;

7.2.3. Vision correction and/or vision preservation surgery,

disposable instruments and accessories used during this

surgery;

7.2.4. Prescription glasses and lens manufacturing service;

7.2.5. Purchase of VDU spectacles, dioptric sunglasses.


7.3.1. Glasses maintenance aids and accessories (e.g., spectacle

cases, cleaners, wipes, etc.);

7.3.2. sunglasses;

7.3.3. Purchase of artificial tears; supplements; medical

preparations.

8. PREVENTIVE AND PERIODICAL HEALTH EXAMINATIONS AND ANALYSES:


Health Care Services provided to the Insured in the Health Care

Institution with regard to Health Disorders seeking to avoid

them or pre-assess the Insured's health condition and

associated costs.


8.2.1. The testa prescribed to the Insured by a doctor or chosen at

the request of the Insured and consultations of doctors;

8.2.2. Preventive health examination; medical examinations for

issuance of certificates; health examinations of employees to

determine fitness for work;

8.2.3. Diagnosis of genetically inherited, congenital diseases;

8.2.4. Sports medicine doctor's consultations.

8.2.5. Diagnosis of AIDS, HIV, syphilis, gonorrhea, trichomoniasis,

chlamydia, ureaplasmosis, human papillomavirus, herpes

genital and other sexually transmitted diseases;

8.2.6. Examinations and consultations not related to the Health

Disorder made at the request of the Insured provided that the

results of the performed examinations do not exceed the

normal limits;

8.2.7. Laboratory testing of vitamins;

8.2.8. Diagnostic tests for chronic diseases;

8.2.9. Diagnosis of infertility/inability to get pregnant, potency

disorders, contraception consultations;

8.2.10. Diagnostic tests for leg vein varicose.


8.3.1. Pregnancy diagnostics and care; diagnosis of health

disorders that occurred or worsened due to pregnancy and/or

pregnancy termination due to medical indications; diagnosis of

health disorders caused by childbirth and breastfeeding;

8.3.2. Alternative medicine services.

8.3.3. Consultations of a dentist or an oral cavity and orthognatic

surgeon and examinations prescribed by them.

9. VACCINES


Health Care Services related to vaccines, which are provided to

the Insured in the Health Care Institution, and associated costs.


9.2.1. Vaccines chosen by the insured or prescribed by a doctor;

9.2.2. Vaccination services, vaccination consultations.

10. REHABILITATION TREATMENT


Health Care Services related to rehabilitation treatment due to

the Insured's Health Disorder, which are provided to the Insured

in the Health Care Institution, and associated costs.


10.2.1. If the Medical Rehabilitation sub-type of this Health

Insurance Program is chosen, the following services shall be

reimbursed: physical medicine and rehabilitation doctor's

consultations; consultations of a kinesitherapist, ergotherapist

prescribed within the competence of the medical specialist;

physiotherapy (ultrasound, microwave, pulse therapy, magnet

therapy and other rehabilitation treatment procedures),

kinesitherapy, ergotherapy, mud and water procedures,

therapeutic massages, halotherapy, manual therapy;

10.2.2. if the Rehabilitation Treatment after 72 Hours of

Stationary Treatment sub-type of this Health Insurance

Program is chosen, the following services shall be reimbursed:

the consultations of a kinezitherapist and ergotherapist

prescribed within the competence of the medical specialist;


therapy and other rehabilitative treatment procedures),

kinezitherapy, ergotherapy, mud and water treatments,

therapeutic massages, halotherapy, manual therapy services

for the treatment of a health disorder in the stationary Health

Care Institution for at least 72 hours;

17

10.2.3. If the Rehabilitation sub-type of this Health Insurance


physical medicine and rehabilitation doctor's consultations;

consultations of a kinesitherapist, ergotherapist prescribed

within the competence of the medical specialist; physiotherapy

(ultrasound, microwave, pulse therapy, magnet therapy and

other rehabilitation treatment procedures), kinesitherapy,

ergotherapy, mud and water procedures, therapeutic

massages, halotherapy, manual therapy;

10.2.4. If the Medical Wellness sub-type of this Health Insurance


sports medicine, physical medicine and rehabilitation doctor's

consultations; consultations of a kinesitherapist, ergotherapist;


therapy and other rehabilitation treatment procedures),

kinesitherapy, ergotherapy, mud and water procedures,

therapeutic massages, halotherapy, manual therapy;

alternative medicine services;


10.3.1. Overnight accommodation/accommodation, catering

services;


10.3.3. Facial massages and cosmetic procedures;

10.3.4. Rehabilitation treatment services provided to the Insured

due to his Health Disorder related to osteochondrosis and/or

degenerative changes (if the Medical Rehabilitation sub-type of

this Health Insurance Program is chosen).

11. MEDICAL SERVICES


Health Care Services provided to the Insured to treat or prevent

his Health Disorder in the Health Care Institution, Specialized

Optician, Pharmacy or the Store of Orthopedic Aids and

associated costs.


11.2.1. Reimbursable and non-reimbursable Healthcare Services

in accordance with the descriptions of the following Health

Insurance Programs and subject to the following exceptions:

a) Ambulatory treatment and diagnostics;

b) Stationary treatment;

c) Prenatanal care, childbirth and postnatanal care

d) Dental services;

e) Pharmaceuticals and medical aids;

f) Vitamins, over-the-counter pharmaceuticals;

g) Optics;

h) Preventive and periodical health examinations and analyses:

I) Vaccines;

j) Rehabilitation treatment.


11.2.3. Psychologist services (including those provided by entities

operating on the basis of a certificate for individual activity).


11.3.1. Reparative surgeries and procedures if they are performed

in the absence of a Health Disorder; hair removal, botulinum

toxin treatment procedures; facial massages and cosmetic

procedures;

11.3.2. Purchase of hygiene aids, goods and appliances; skin and

hair care, decorative cosmetics;


services;


11.3.5. Teeth whitening procedures;

11.3.6. Purchase of eyeglass care aids and accessories,

sunglasses.

12. WELLNESS SERVICES


Health Care and/or Wellness Services provided to the Insured in

the Health Care Institution, SPA centres and sanatoriums,

sports clubs, swimming pools, entertainment parks or by any

other person entitled to engage in the respective activity and

associated costs.

12.2. Reimbursable health care services and wellness

services:

12.2.1. Consultations and services provided by a sports medicine

doctor, a physical medicine and rehabilitation doctor, a

kinezitherapists, a reflexologist; water, physiotherapy, manual

therapy, massage, mud procedures; body composition analysis,

ergonomic body position tests and other services provided for

in the Contract;

12.2.2. Consultations of a psychiatrist, a medical psychologist, a

psychologist, a psychologist-psychotherapist and their

psychotherapeutic treatment;


12.2.4. Physical activity: individual and group health, wellness,

physical education services for all sports;

12.2.5. Consultations of a dietarian, nutritionist and drawing up a

nutrition plan.

12.3. If the services specified in clause 12.2.4 of Addendum No.1 to

the Insurance Rules are purchased under the Wellness Services

Subscription, only a part of the expenses for the period of the

subscription coinciding with the validity period of the Insurance

Coverage may be reimbursed.



services;


12.4.3. Facial massages and cosmetic procedures;

12.4.4. Competition / participant / camp fee; entertainment

services (e.g., bowling, carting, billiards, saunas, hot tub, etc.);

meditation classes / practices;

12.4.5. occupations without physical activity (e.g., brain/desk

games).

18

13. ALL SERVICES


Health Care and/or Wellness Services and other goods and

services provided to the Insured in the Health Care Institution,

Pharmacies, the store of orthopaedic aids, SPA centres and

sanatoriums, sports clubs, swimming pools, entertainment

parks or by any other person entitled to engage in the

respective activity and associated costs.

13.2. Reimbursable services:

13.2.1. reimbursable and non-reimbursable Healthcare Services

and Wellness Services in accordance with the descriptions of

these Health Insurance Programs and subject to the following

exceptions:

a) Ambulatory treatment and diagnostics;

b) Stationary treatment;

c) Prenatanal care, childbirth and postnatanal care

d) Dental services;

e) Pharmaceuticals and medical aids;

f) Vitamins, over-the-counter pharmaceuticals;

g) Optics;

h) Preventive and periodical health examinations and analyses:

I) Vaccines;

j) Rehabilitation treatment;

k) Wellness services.


13.2.3. personal hygiene aids; dental care aids, including

toothbrushes, toothpaste, mouthwash, irrigators, etc .; skin and

hair care medical aids.



services;


13.3.3. Facial massages and cosmetic procedures; reparative

surgeries and procedures if they are performed in the absence

of a health disorder; hair removal, botulinum toxin treatment

procedures;

13.3.4. Purchase of decorative cosmetics aids; hair styling aids,

cosmetics appliances;

13.3.5. Competition / participant / camp fee; entertainment

services (e.g., bowling, carting, billiards, saunas, hot tub, etc.);

meditation classes / practices;

13.3.6. Occupations without physical activity (e.g., brain / desk

games).

14. CRITICAL DISEASES

14.1. The Insurable Event shall be deemed to be the Critical

disease diagnosed for the first time during the validity period of

the Insurance Coverage provided for in the List of Critical

Illnesses/Contract, due to which the Insured incurs expenses for

Medically Reasonable Services that are not reimbursed by the

CHIF.

14.2. Insurance Indemnity

14.2.1. The Insurance Indemnity for the Insurable Event under

this Health Insurance Program (regardless of the number of

Critical diseases diagnosed at one time) shall be paid to the

Insured as indemnity for the expenses incurred for Health Care

Services in one of the following ways chosen by the Policyholder

when concluding the Contract:

14.2.1.1. As the Sum Insured for Critical Diseases provided for in

the Contract; or

14 .2 .1 .2 . As Insurance Indemnities according to the

requirements applicable to the Health Insurance Programs:

Ambulatory Treatment and Diagnostics, Stationary Treatment,

Rehabilitation Treatment, Pharmaceuticals and Medical Aids,

within the limits of the Sum Insured of the relevant Health

Insurance Program.

14.2.2. In case Insurance Indemnity is paid in the manner

provided for in sub-clause 14.2.1.2 of Addendum No. 1 to the

Insurance Rules, the expenses of the Insured sustained due to

the Insurable Event that occurs during the Insurance Period

shall be subject to indemnification. However, a claim for the

Insurance Indemnity and reimbursement of such expenses

may be submitted no later than within 6 (six) months from the

last day of the Insurance Period.

14.3. Non-insurable events under this Insurance Program:

14.3.1. An event recognized as a Non-insurable one in

accordance with the provisions of clause 12 of the Insurance

Rules;

14.3.2. The Critical Disease or a disease that caused the Critical

disease is diagnosed before the conclusion of the Contract or

less than 60 (sixty) days after the entry into force of the

Insurance Coverage. This period shall also be applicable if the

Insurance Coverage is suspended or terminated during the

validity of the Contract. However, this period shall not be

applicable when the Insurance Coverage provided under the

Contract under the Critical Diseases Health Insurance Program

is renewed for a new Insurance Period, as well as when the

Critical Disease is caused by the Accident during that period;

14.3.3. The Critical Disease does not meet the criteria for

recognition as a Critical Disease and an Insurable Event as

indicated in this Health Insurance Program and the List of

Critical Diseases;

14.3.4. Recurrence of the same Critical Disease;

14.3.5. The Insured dies within 30 (thirty) days after he was

diagnosed with one of the Critical Diseases.

19

14.4. The List of Critical Diseases:

14.4.1. The list of critical diseases, concepts, criteria and

requirements for recognizing an event as the Insurable Event or

the Non-Insurable Event:

14.4.1.1. Malignant tumor (cancer) means the uncontrolled

growth, spread and invasion (penetration) of malignant cells

into tissues.

The Insurance Indemnity shall be paid only in case of

incontrovertible evidence of invasion into tissues and when the

malignancy of the cells is supported by histological findings.

The diagnosis must be confirmed by an oncologist.

The concept of cancer shall also include leukaemia and

malignant lymphoma as well as myelo-dysplastic syndrome. In

these cases, the diagnosis must be confirmed by an oncologist

or haematologist.

The Insurance Indemnity shall not be paid for:

– Localised non-invasive tumours classified as pre-malignant

changes (carcinoma in situ), including ductal and lobular

carcinoma in situ of the breast, cervical dysplasia, cervical

intraepithelial neoplasia (CIN-1, CIN-2 and CIN-3);

– Chronic lymphocytic leukaemia unless having progressed to

at least Binet Stage B;

– Any prostate cancer unless histologically classified as having a

Gleason score greater than 6 or having progressed to at least

clinical TNM classification T2N0M0;

– Basal (stab) cell carcinoma and squamous cell carcinoma of

the skin and malignant melanoma stage IA (T1aN0M0) unless

there is evidence for metastases of this tumour;

– Papillary thyroid cancer less than 1 cm in diameter and

histologically described as T1N0M0;

– Papillary micro-carcinoma of the bladder histologically

described as Ta;

– Polycythemia rubra vera and essential thrombocythemia;

– Monoclonal gammopathy of undetermined significance;

– Gastric MALT Lymphoma (gastric extranodal lymphoma of the

basal border) if the condition can be treated with Helicobacter-

eradication (elimination);

– Gastrointestinal stromal tumour (GIST) stage I and II according

to the AJCC (The American Joint Committee on Cancer) Cancer

Staging Manual;

– Cutaneous lymphoma unless the condition requires

treatment with chemotherapy or radiation;

– Microinvasive carcinoma of the breast (histologically classified

as T1mic) unless the condition requires treatment with

mastectomy, chemotherapy or radiation;

– Microinvasive carcinoma of the cervix uteri (histologically

classified as stage IA1) unless the condition requires treatment

with hysterectomy, chemotherapy or radiation;

– The Insured's malignancy (cancer) due to HIV or AIDS, if HIV or

AIDS was diagnosed to the Insured before the conclusion of the

Contract or during its validity.

14.4.1.2. Myocardial infarction shall mean the acute irreversible

injure of heart muscle (necrosis) due to occlusion of an

adequate artery, which prevents the blood flow to an area of

myocardium.

Myocardial infarction must be supported by change in the

number of cardiac biomarkers (troponin or CK-MB enzymes) to

levels considered diagnostic for myocardial infarction provided

that at least 2 (two) following criteria are found:

– Ongoing angina pectoris (protracted cardiac angina);

– New electrocardiographic (ECG) changes indicative of

myocardial infarction showing myocardial ischemia (new ST-T

wave changes or new block of the left bundle branch)

– Development of pathological Q waves in the ECG.

The diagnosis must be confirmed by a cardiologist.


– Elevations of troponin in absence of overt ischemic heart

disease (e.g., myocarditis, stress-induced cardiomyopathy,

palpitations, pulmonary embolism, drug intoxication);

– Myocardial infarction that occurs in the presence of intact

coronary arteries due to coronary artery spasm, myocardial

“bridges” (compression of the coronary arteries of the heart) or

drug use;

– Myocardial infarction that occurs within 14 (fourteen) days

after coronary angioplasty or graft-bypass surgery.

14.4.1.3. Insult (cerebral infarction) shall mean the death of

brain tissue due to acute cerebrovascular event caused by intra-

cranial vessels thrombosis, blood haemorrhage (including

subarachnoid haemorrhage or embolism from extra-cranial

sources) which causes acute onset of new neurological

symptoms and a new neurological deficit.

The Insurance Indemnity shall be paid only if the fixed

neurological deficit persists for more than 3 (three) months

after cerebral infarction (paralytic stroke). The fixed

neurological deficit must be confirmed by a neurologist and

supported by imaging findings (MRT; CT, and others).


– Reversible cerebral ischemic attack (RCIA) and reversible

ischemic neurologic deficit (RIND);

– Direct and/or postoperative indirect injury to brain tissue or

blood vessels that occurs due to injury and/or during surgery;

– Neurologic deficit due to general hypoxia, infection,

inflammatory disease, migraine, or medical intervention;

– Incidental imaging findings (computer tomography or

magnetic resonance tomography) without clearly related

clinical cerebral infarction symptoms (“silent stroke”).

14.4.1.4. Coronary artery bypass graft surgery shall mean

open-heart coronary artery surgery to correct narrowing or

blockage of two or more coronary arteries with bypass grafts

using an autologous transplant (any superficial vein of a leg,

internal thoracic artery or other suitable artery, etc.) as a bypass

graft.

The Insurance Indemnity shall be paid provided only that

surgery is confirmed to be necessary by a cardiologist or a

cardiac surgeon and supported by angiographic findings.


– Bypass surgery that is performed to treat one narrowed or

blocked (occluded) coronary artery;

– Coronary artery angioplasty or stent-placement.

20

14.4.1.5. Prosthesis of heart valves shall mean a cardiac surgery

to replace one or more heart valves in one of the following ways:

– Heart valve replacement or correction surgery performed in

an open manner (opening the chest);

– Ross-procedure;

– Transcatheter correction of coronary arteries (catheter-based

valvuloplasty);

– Transcatheter aortic valve implantation (TAVI).

The surgery must be confirmed to be medically necessary by a

cardiologist or a cardiac surgeon and supported by

echocardiogram or cardiac catheterization findings.

The Insurance Indemnity shall not be paid for transcatheter

bicuspid (mitral) valve clipping.

14.4.1.6. Surgery of the aorta shall mean aortic surgery to

correct (treat) aortic narrowing, occlusion, aneurysm or

exfoliation

The concept includes open surgery and minimally invasive

procedures such as endovascular correction. The surgery must

be confirmed to be medically reasonable by a cardiac surgeon

and supported by imaging findings.


– Thoracic and abdominal aortic branch surgeries (including

aortic and femoral artery or aortic and iliac artery bypass grafts);

– Surgery of the aorta related to hereditary connective tissue

disorders (e.g. Marfan syndrome, Ehlers–Danlos syndrome);

– Surgery following traumatic injury to the aorta.

14.4.1.7. Visceral organ/bone marrow transplantation shall

mean the situation when the Insured as a recipient actually

undergoes the following organ transplantation surgery

(regardless of the number of surgeries or transplants) or when

the Insured's condition requiring such organ transplantation is

considered incurable by other means and a medical specialist

provides a proof that the Insured is on the official waiting list for

an organ transplant.

Insurance Indemnities shall be payable for the following organ

transplantation surgeries : heart, kidney (-s), liver (including split

liver and living donor liver transplantation), lung (including

living donor lobe or single-lung transplantation), bone marrow

(allogenic hematopoietic stem cell transplantation proceeded

by total bone marrow ablation), the transplantation of small

bowel, pancreas, partial or full face, hand, arm and leg

transplantation (composite tissue allograft transplantation).


– Transplantation of other organs, body parts, or tissues

(including cornea and skin);

– Transplantation of other cells (including pancreatic islet cells

and stem cells other than hematopoietic).

14.4.1.8. Kidney failure shall mean the end-stage kidney failure

due to irreversible failure of both kidneys to function leading to

the necessity of regular haemodialysis or peritoneal dialysis.

The dialysis must be confirmed by a nephrologist and

supported by the findings of kidney function analyses.

The Insurance Indemnity shall not be paid for an acute

reversible kidney failure, which means when temporary renal

dialysis is required.

14.4.1.9. Multiple sclerosis shall mean the multiple sclerosis

diagnosed by a neurologist after a comprehensive stationary

neurological examination based on clinical neurological

symptoms meeting the following criteria

– Multiple neurological deficit is present for more than 6 (six)

months; and

– The disease is confirmed by magnetic resonance imaging

findings showing at least 2 (two) lesions of demyelination in the

brain or spinal cord indicative of multiple sclerosis.


– Possible multiple sclerosis and neurologically or radiologically

isolated syndromes suggestive but not diagnostic of multiple

sclerosis;

– Isolated optic neuritis and/or neuromyelitis optica.

14.4.1.10. Parkinson's disease (under 65 years old) shall mean

the definite initial Parkinson's disease diagnosed to the Insured

by a neurologist before the Insured reaches the age of 65 (sixty

five).

The Insurance Indemnity shall be paid provided that all the

following conditions are met:

a) At least 2 (two) following clinical manifestations are

diagnosed:

– Muscle stiffness (rigidity);

- Trembling (tremor);

– Bradykinesia (abnormal slowness of movement, sluggishness

of the physical and mental response).

b) Total inability to perform, by oneself, at least three out of six

activities of daily living for a continuous period of at least 3

(three) months:

– Washing: the ability to take a bath or shower (including

getting into/out of a bath or shower) or satisfactory washing by

other aids;

– Getting dressed and undressed: the ability to put on, take off,

secure or fasten all garments, if necessary – braces, artificial

limbs or other orthopedic aids;

– Feeding oneself : the ability to feed oneself when food has

been prepared and made available;

– Maintaining personal hygiene: the ability to maintain a

satisfactory level of personal hygiene by using the toilet or

otherwise managing bowel and bladder function;

– Getting between rooms: the ability to get from room to room

on a level floor;

– Getting in/out of bed: the ability to get up/get out of bed into a

chair or wheelchair and back.

The implantation of a neurostimulator to control symptoms by

deep brain stimulation is, independent of the Activities of Daily

Living, covered under this definition of Critical Illnesses. The

implantation must be determined to be medically necessary by

a neurologist or neurosurgeon.


– Secondary parkinsonism (including drug- or toxin-induced

parkinsonism);

– Essential tremor;

– Parkinsonism related to other neurodegenerative disorders.

21

14.4.1.11. Alzheimer's disease(under 65 years old) shall mean

the Alzheimer's disease diagnosed by a neurologist to the

Insured before the Insured reaches the age of 65 (sixty five)

provided that the following needs for care of the Insured are

identified and approved.



– The disease is supported by typical neuropsychological and

nervous system imaging findings (e.g., computed tomography,

magnetic resonance imaging);

– Loss of intellectual capacity involving impairment of memory

and cognitive functions (sequencing, organizing, abstracting,

and planning), which results in a significant deterioration of

mental and social function;

– Diagnosed personality disorder;

– Gradual onset and continuing decline of cognitive functions;

– No disturbance of consciousness;

– Need for constant supervision 24 hours daily confirmed by a

neurologist.

The Insurance Indemnity shall not be paid for other forms of

mental handicap (dementia) due to brain, systemic or mental

diseases.

14.4.1.12. Third-degree burns shall mean the burns of the

Insured's body, which destroy all layers of the skin, cover at least

20% of the body surface area and are approved by a medical

surgeon.

The body surface area can be determined either by the “Rule of

Nines” or the “Lund and Browder Chart”, or the “Rule of Palms”

(1% of the body surface area is equal to the palm surface of the

Insured's hand, i.e. both the palm and fingers).

14.4.1.13. Benign brain tumour shall mean non-malignant

growth of tissue located in the cranial vault (brain, meninges, or

cranial nerves) diagnosed by a neurologist and neurosurgeon

and supported by imaging examination findings.

The Insurance Indemnity shall be paid provided that:

a) The tumour is treated in at least one of the following ways:

– Complete or incomplete surgical removal;

– Stereotactic radiosurgery;

– External beam radiation; or

b) None treatment options indicated in item a) are possible due

to medical reasons, but the tumour causes a persistent

neurological deficit, which has to be documented for at least 3

months following the date of diagnosis.


– Diagnosis or treatment of any cyst, granuloma, hamartoma or

malformation of the arteries or veins of the brain;

– Diagnosis of tumors of the pineal gland (pituitary gland).

14.4.1.14. Blindness shall mean total and irreversible loss of

vision in both eyes as a result of injury or illness which cannot be

treated by refractive correction, pharmaceuticals or surgery The

diagnosis must be supported by the findings of objective tests

and the conclusion of the commission of medical experts on

vision loss after the expiry of 6 (six) months after diagnosis.

Profound vision loss is evidenced by either a visual acuity of 3/60

or less (0.05 or less in the decimal notation) in the better eye

after correction or a visual field is less than 10° diameter in the

better eye after correction. The Insurance Indemnity shall not be

paid for:

– Loss of vision in one eye only;

– Different reversible vision disorders.

14.4.1.15. Deafness shall mean a permanent and irreversible loss

of hearing of the Insured in both ears as a result of sickness or

physical injury. The diagnosis must be confirmed by an

otolaryngologist and supported by an auditory threshold (at

least 90 db at 500, 1000 and 2000 hertz in the better ear using a

pure tone audiogram).

14.4.1.16. Loss of speech shall mean a definite diagnosis of the

total and irreversible loss of the ability of the Insured to speak

confirmed by an otolaryngologist and resulting from physical

injury or disease not subject to correction by any medical

treatment means provided that this condition persists for a

continuous period of at least 6 months. The Insurance

Indemnity shall not be paid for the loss of speech due to

psychiatric disorders or diseases.

14.4.1.17. Loss of limb function shall mean Total and irreversible

loss of two or more limbs or their function due to injury or illness

of spinal marrow and brain. Loss of limb function shall mean

loss of limbs above the elbow or knee joints

The Insurance Indemnity shall be paid provided that the loss of

the limb function persists for more than 3 (three) months and is

confirmed by a neurologist and supported by clinical

symptoms and diagnostic findings.


– Paralysis due to self-harm or psychological disorders;

– Guillain-Barre syndrome;

– Periodic (reversible) or hereditary paralysis..

14.4.1.18. Coma shall mean a state of unconsciousness

diagnosed by a neurologist provided that all the following

conditions are satisfied:

– No response from the Insured to exogenous irritants (results in

a score of 8 or less on the Glasgow coma scale) or no response to

needs of nature for at least 96 (ninety six) hours;

– Need for the use of life support systems;

– Results in a persistent neurological deficit which must be

assessed at least 30 (thirty) days after the onset of the coma. The

Insurance Indemnity shall not be paid for:

– Medically induced coma;

– Any coma due to self-inflicted injury, alcohol or drug use.

14.4.1.19. Viral encephalitis shall mean a diagnosis of brain

(cerebral hemispheres, cerebral trunk, cerebellum) fever

induced by viral infection. The diagnosis must be confirmed by

a neurologist after stationary examination indicating typical

cl in ical symptoms, changes in cerebrospinal fluid ,

immunological/serological indicators.



– Neurological deficit; and

– Neurological deficit is documented for at least 3 months

following the date of diagnosis. . The Insurance Indemnity shall

not be paid for:

– Encephalitis induced by HIV;

– Encephalitis caused by bacterial or protozoal infections;

– Paraneoplastic encephalomyelitis.

health insurance rules no. 010

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