kindlustus@confido.ee
1330
The general terms and conditions of the Confido Health Plan can be found at the link below. You can find the conditions applicable to the policy according to the start time of your company’s policy.
You can get answers to questions related to the insurance conditions by calling the short number 1330 or by writing to kindlustus@confido.ee.
General Terms and Conditions of the Confido Health Plan (applies to policies issued from 01.10.2023)
Appendix 2.3 Appendix 1 of the health insurance conditions: critical illness insurance
Appendix 2.4 Appendix 2 of the health insurance conditions: accident insurance conditions
General Terms and Conditions of Confido Health Plan partners (applies to policies issued from 01.10.2023)
General Terms and Conditions of the Confido Health Plan (applies to policies issued from 08.12.2022)
Appendix 2.3 Appendix 1 of the health insurance conditions: critical illness insurance
Appendix 2.4 Appendix 2 of the health insurance conditions: accident insurance conditions
General Terms and Conditions of Confido Health Plan partners (valid from 01.10.2022)
Confido Health Plan is a non-life insurance service (hereinafter health insurance) developed by the insurer, within the framework of which AS Arstikeskus Confido (hereinafter Confido, registry code 12381384, address Veerenni 51, Tallinn, 10138 Harju County) itself or through its cooperation partners or other health care providers offers its healthcare services for employees (and, if applicable, also their close relatives) within the limits of the agreed health insurance risk.
An authorized person is a person designated by the insurance agent and the policyholder whom they have authorized for data exchange in connection with the conclusion and execution of the insurance contract, including the transmission of encrypted data.
The close relatives are family members of the policyholder’s employee. Family members are spouses or partners, parents, and children up to 18 years of age. A close relative is an insured person under the insurance contract if the close relative has given a relevant confirmation. Unless otherwise indicated by the context, the same applies to the close relative to the employee specified in the terms and conditions.
Contact persons are people appointed by the parties to the contract to receive notifications related to the insurance contract and to resolve other current issues.
Deductible is the part of the damage specified in the insurance contract, the costs of which are borne by the insured person in the event of an insured event.
An employee is a person who works on the basis of a valid employment, board member, or other service relationship contract for the benefit of the policyholder.
Health care service is the activity of a health care worker or institution to prevent, diagnose and treat illness, injury or poisoning. The purpose of providing health care services is to relieve a person’s ailments, prevent deterioration of their health condition or exacerbation of the disease, and restore their health.
The indemnity limit is the largest indemnified amount per insurance cover for one insured person during the insurance period. The indemnity limit is reduced by the indemnity paid.
The information sheet is the standard form of the insurance product information document stipulated by the European Commission Implementing Regulation (EU) No. 2017/1469.
The insurance agent is Terviskindlustusagent OÜ (registration code 16572262, address Veerenni 51, Tallinn, 10138 Harju county).
An insurance card number is an electronic number issued by an insurance agent to an insured person, which confirms that the insured person is covered by insurance.
An insurance contract is a health insurance contract concluded between an insurance agent and a policyholder, on the basis of which health insurance cover is provided based on the principles of non-life insurance. The insurance contract consists of the policyholder’s statement, conditions, description of insurance coverage, insurance policy, information sheet, and other documents proving the agreements concluded between the policyholder and the insurance agent. The insurance contract makes it possible to provide insurance coverage to the policyholder’s employees and, with an additional written agreement, also to the close relatives of the insured person.
Insurance cover is the cover chosen by the policyholder when concluding an insurance contract, to the extent of which a person can be insured and with which, in the event of an insured event-related, the insured person can request indemnity. Additional insurance coverage is chosen by the policyholder on the basis of a separate agreement when concluding an insurance contract. Additional insurance coverage must be selected for all insured persons.
The insurance period is the period of time specified in the insurance contract, during which the insurance coverage agreed with the insurance contract is in effect and on the basis of which the insurance payments are calculated. If the insured person receives insurance coverage for the duration of the insurance period based on the insurance contract, then the insurance coverage applies to them from the time they join the insurance contract until the end of the insurance period unless the policyholder stops offering them insurance coverage under the insurance contract earlier.
The insurance premium is the fee agreed in the insurance contract and paid by the policyholder or, if applicable, a close relative for insurance coverage.
An insurance policy is a document that confirms the conclusion and validity of an insurance contract and is issued by an insurance agent to the policyholder after the conclusion of the insurance contract, amendment, or extension of the insurance period.
The insured object is the health of the insured person and the risk of incurring costs related to the provision of health services necessary to maintain it, that is, the insurance risk.
The insured person is the employee referred to as the insured person in the insurance contract or their close relative. On the basis of the insurance contract, the health insurance risk related to the insured person as a third party is insured. If the policyholder excludes an employee from the insurance contract, it is assumed that this person is no longer an insured person.
The insurer is AS LHV Kindlustus (registration code 14973611, address Tartu mnt 2, Tallinn, 10145 Harju county).
The policyholder is a legal entity that wishes to provide health insurance to its employees and, if applicable, the close relatives of its employees and undertakes the obligation to pay the insurance premiums unless the insured person pays the insurance premiums themselves.
The policy is a document in a form that enables written reproduction of the conclusion of the insurance contract and is issued by the insurance agent to the policyholder.
The health care service provider is the health care provider Confido and its cooperation partner or another health care service provider operating on the territory of Estonia who has a corresponding license to provide health care services or has a valid professional certificate.
The sum insured is the maximum sum specified in the insurance contract, which is indemnified for all insured events per insured person during the insurance period. The sum insured is reduced by the benefits paid out.
1.
An insured event is the use of healthcare services or the purchase of glasses, prescription drugs, or aids by the insured person to the extent agreed in the insurance contract during the insurance coverage applicable to them. The insurance indemnity is paid out if the insured event meets the following conditions:
1.1.
meets the volume and conditions agreed with the insurance contract;
1.2.
the healthcare service is related to the insured person’s insurance coverage;
1.3.
the healthcare service has been provided during the insurance period;
1.4.
the health care service has been provided by a service provider operating in the Republic of Estonia, who has a corresponding activity license or valid professional certificate for the provision of this service. The activity license can be checked on the website of the Estonian Health Board, and the professional certificate is available on the website of the Estonian Qualifications Authority;
1.5.
the healthcare service has been provided using such medical technology or methodology, the use of which is allowed in Estonia for the treatment of people;
1.6.
physician’s referral (referral letter, digital referral letter, entry in the medical record, occupational health physician’s decision, prescription) is issued to a specific healthcare service before receiving the healthcare service. The term of validity of the referral is considered to be one year from the date of issuance of the document, with the exception of the referral made by the occupational health physician, which is valid as stated in the decision but not more than three years.
2.
Insurance indemnity is paid by the insurance agent to the insured person if the costs were borne by the insured person themselves and to the healthcare service provider if the healthcare service provider has provided healthcare services to the insured person or borne related costs. If the insurance agent pays the insurance indemnity to the health care provider, the insured person loses the right to the insurance indemnity.
3.
Outpatient treatment insurance coverage
3.1.
Outpatient treatment is a healthcare service in which the insured person’s visit to the healthcare provider is limited to a few hours.
3.2.
On the basis of outpatient treatment insurance coverage, the following expenses are indemnified without a physician’s referral:
3.3.
On the basis of outpatient treatment insurance coverage, the following costs are indemnified only upon referral by a physician:
3.4.
The following are not indemnified under the insurance cover for outpatient treatment:
4.
Preventive health check-up insurance coverage
4.1.
Preventive health checkup is a health care service for which there is no medical indication and which is performed by the health care service provider at the request and choice of the insured person in order to check their health condition, prevent diseases or issue a health certificate.
4.2.
On the basis of preventive health checkup insurance coverage, the following expenses are indemnified without a physician’s referral:
4.3.
The following costs are not reimbursed under preventive health checkup insurance coverage:
5.
Mental health insurance coverage
5.1.
On the basis of mental health insurance coverage, the costs of the appointment and consultation fees of the following healthcare providers are indemnified without a physician’s referral:
5.2.
On the basis of mental health insurance coverage, the following expenses are reimbursed only upon referral by a physician:
5.3.
On the basis of mental health insurance coverage, the following costs are not reimbursed:
6.
Insurance coverage for special diagnostics
6.1.
On the basis of insurance coverage for special diagnostics, the costs of the following procedures are indemnified only upon referral by a physician:
6.2.
If the special diagnostic procedure, together with the physician’s appointment and consultation fee, is reflected as one service on the document certifying the cost, 50% of the costs are included under outpatient insurance coverage and 50% of the costs under special diagnostic insurance coverage.
6.3.
The following costs are not reimbursed under the special diagnostics insurance coverage:
7.
Outpatient rehabilitation insurance coverage
7.1.
Outpatient rehabilitation is a healthcare service that aims to restore impaired body functions.
7.2.
On the basis of outpatient rehabilitation insurance coverage, the following procedures and the appointment and consultation fees of healthcare providers are reimbursed only upon referral by a physician:
7.3.
The following costs are not indemnified under outpatient rehabilitation insurance coverage:
8.
Hospital treatment insurance coverage
8.1.
Hospital treatment is a healthcare service, the provision of which requires the stay of the insured person in a hospital. Day treatment is a healthcare service in which the insured person needs to be monitored in a hospital bed for a few hours due to treatment or examinations but is not kept in the hospital overnight.
8.2.
Before hospitalization, the insured person is obliged to coordinate it with the insurance agent.
8.3.
On the basis of hospitalization insurance coverage, the following costs of both daily and 24-hour treatment are reimbursed only upon referral by a physician
8.4.
The following are not reimbursed under the hospital treatment insurance coverage:
9.
Dental care insurance coverage
9.1.
On the basis of dental care insurance coverage, the following expenses are indemnified without a physician’s referral:
9.2.
The following are not indemnified on the basis of dental care insurance coverage:
10.
Prescription drugs
10.1.
On the basis of prescription drug insurance coverage, the following expenses are reimbursed only on the basis of a physician’s prescription:
10.2.
The following costs are not reimbursed under prescription drug insurance coverage:
11.
Orthopedic aids
11.1.
Under the insurance coverage of orthopedic aids, the following expenses are reimbursed only on the basis of a physician’s prescription:
11.2.
The cost of one aid of the same type during the insurance period is reimbursed.
12.
Optics
12.1.
The following expenses are reimbursed based on the optics insurance coverage:
12.2.
The purchase of one pair of glasses or contact lenses during the insurance period is reimbursed.
12.3.
The following costs are not reimbursed under the optics insurance coverage:
13.
Pregnancy and maternity
13.1.
On the basis of pregnancy and maternity insurance coverage, the following medically indicated expenses are reimbursed based on a physician’s referral:
14.
The insurance agent does not reimburse the cost related to the following cases:
14.1.
services not provided, including services reflected in advance invoices;
14.2.
cases related to an epidemic or pandemic or a state of emergency in the country, excluding cases related to Covid-19;
14.3.
if the insured person has caused damage to their health intentionally, including a suicide attempt, self-injury, or endangering their health;
14.4.
a case that occurred as a result of self-treatment and a case related to the use of a drug that was not recommended or prescribed by a physician;
14.5.
cases caused by the consumption of alcohol, narcotics, or psychotropic substances;
14.6.
a case that occurred when the insured person committed an act punishable pursuant to criminal procedure was detained by law enforcement bodies or was imprisoned in a custodian facility.
15.
The insurance agent does not reimburse any costs related to the services, procedures, visits, consultations, examinations, and diagnostics mentioned below and related to the following specialists:
15.1.
services of a coach, dietitian, occupational therapist, geneticist, hypnotist, narcologist, rehabilitation specialist, trichologist, technical orthopedist and prosthetist, and nutritionist;
15.2.
cosmetic and aesthetic services, cosmetic and plastic surgery (including benign skin tumor removal and treatment, aesthetic dermatology, cryotherapy, obesity treatment, weight loss program, skin laser treatment, ELOS technology and radio wave treatment services, pedicure and manicure services, including therapeutic and therapeutic manicure, treatment of ingrown nails and fungal treatment, acne and pimple treatment);
15.3.
surgery or procedure to correct visual acuity, dry eye treatment using laser technology;
15.4.
organ transplant surgery,
15.5.
consultation, treatment, surgery, and sclerotherapy related to varicose veins;
15.6.
genetic tests and studies, food intolerance and sensitivity tests (except for studies related to additional protection described in clause 13);
15.7.
sleep study and treatment;
15.8.
treatment of sexually transmitted diseases (including HIV and AIDS);
15.9.
purchase of medical aids (including orthopedic products such as corsets, orthosis, crutches, fixator, plaster, medical stockings, orthopedic insoles and shoes, and hygiene kit) (except for aids related to additional protection described in clause 11);
15.10.
endoprosthetic services;
15.11.
mandatory medical examination of the employee resulting from the law;
15.12.
immunoglobulin therapy, blood plasma, and hyaluronic acid therapy and intra-articular injections (including PRP injections, Kenalog, Synisc), barotherapy, orthokine therapy, and intraocular injection;
15.13.
alternative and complementary medicine services (including acupuncture, light therapy, sound therapy, aromatherapy, reflexology, holistic, iris examination, bioresonance diagnostics, electropuncture, homeopathy, and biofeedback method);
15.14.
services related to family planning and childbirth (including detection of pregnancy and fetus, prescription of contraceptives, infertility treatment, artificial insemination, abortion without medical indication, sperm analysis, vasectomy, and laparoscopic operations for the patency of the fallopian tubes and removal of appendages), except for studies related to additional protection described in clause 13, analyzes and procedures;
15.15.
treatment of congenital pathology, degenerative disease (including Alzheimer’s disease, Parkinson’s disease, multiple sclerosis), and mental illness;
15.16.
vacuummassage,cryo,Thaiandaromamassage,prostateorgynecologicalmassage;
15.17.
printing, saving of certificates, documents, etc., as a separate service;
15.18
palliative care and social care;
15.19.
the cost and expenses of smartphone applications, including their monthly fees;
15.20.
drugs, vitamins, and nutritional supplements and procedures with drugs (including infusion therapy), except prescription drugs related to the additional protection described in clause 10;
15.21.
training, lectures, and courses (including sexual counseling);
15.22.
convenience services, including home visits and transportation.
16.
The policyholder enters into an insurance contract with the aim of insuring insurance risks related to their employees and, if applicable, the close relatives of their employees in order to protect the health of employees and the close relatives of their employees and thereby increase the employees’ working capacity and productivity (insurance interest).
17.
The policyholder selects the appropriate insurance coverage for the employees and, if applicable, for the close relatives of their employees in cooperation with the insurance agent. The insurance coverages covered by the insurance, the sum insured, indemnity limits, and insurance premiums are specified in the insurance policy and in the terms and conditions.
18.
To add an employee to the insurance contract as an insured person, the policyholder submits an application to the insurance agent with the following information: employee’s name, social security number/date of birth and e-mail address, choice of insurance cover, insurance period.
19.
By transmitting data to the insurance agent, the policyholder confirms that they are the authorized person to transmit the employees’ data, that the employees agree to the transmission of their data, and to their inclusion in the insurance contract as insured persons under the terms of the insurance contract.
20.
A close relative is added to the insurance contract through an employee insured by the policyholder, and the addition to the insurance contract is confirmed by the close relative themselves.
21.
The insurance agent has the right to refuse to include the employee or their close relative as an insured person in the insurance contract if the person has provided false information or previously committed insurance fraud or failure to pay insurance premiums, or is not suitable to be an insured person for other compelling reasons.
22.
If an insured person is added to the insurance contract, the insurance agent provides the policyholder with the insurance policy, the information document, the terms and conditions, and, if necessary, other relevant information proving the insurance coverage. The insurance agent, using the contact details of the insured person, forwards to the insured person a confirmation letter proving the insurance coverage along with other relevant information.
23.
The policyholder is obliged to keep the list of insured persons up to date.
24.
The insurance contract is deemed concluded, and the rights and obligations arising from the insurance contract come into force at the moment of payment of the insurance premium but not earlier than the first date of the insurance period.
25.
The selected insurance cover applies to the insured person during the entire insurance period. During the insurance period, the policyholder has the right to exclude the insured employee from the insurance contract if the policyholder has terminated the employment or other service relationship with this person. Amendments to the insurance contract are made twice a month, taking into account the date when the employment or other service relationship with the employee was terminated and the date when the policyholder notified the insurance agent of the employee’s exclusion from the insurance contract. It is possible to exclude the employee’s close relative from the insurance contract during its validity only in exceptional cases and by agreement with the insurance agent.
26.
The insurance contract is concluded for an indefinite period, and the insurance period is one year.
27.
No later than 30 (thirty) days before the end of the current insurance period, the policyholder submits a new application to the insurance agent, on the basis of which the insurance agent draws up a new insurance policy for the next insurance period and forwards it to the policyholder. If the policyholder does not submit a new application by the specified deadline, the insurance agent will draw up an insurance policy based on the latest information known to the insurance agent and forward it to the policyholder.
28.
The terms of the insurance contract can be changed and/or supplemented (including termination) only with the written agreement of the insurance agent and the policyholder, which is formalized as an annex to the insurance contract. Regardless of this, the insurance agent has the right to unilaterally review and change the terms of the insurance contract in the following cases:
28.1.
The insurance agent may unilaterally and without prior notice change the terms of the insurance contract to be more favorable to the policyholder, including reducing insurance premiums and increasing insurance coverage and indemnity limits.
28.2.
The insurance agent may unilaterally increase insurance payments for the current insurance period and/or reduce the scope of insurance coverage, including reducing the volume of reimbursed health services and insurance amounts and indemnity limits if this is due to a change in the following circumstances:
29.
The insurance agent may unilaterally change the documents of the insurance contract with the aim of specifying the conditions of the insurance contract to the extent that it is not dealt with in clause 28.2.
30.
Amendments to the insurance contract will not take effect until at least one month has passed after notifying the policyholder of the amendment.
31.
The insurance agent notifies the policyholder of changes to the insurance contract in accordance with the terms and conditions.
32.
The policyholder has the right to cancel the insurance contract by giving at least three months’ notice to the insurance agent, so that the contract terminates at the end of the year, i.e. the insurance period.
33.
The insurance agent has the right to cancel the insurance contract on a regular basis in cases provided by law.
34.
The insurance agent has the right to cancel the insurance contract exceptionally for the following reasons:
34.1.
the policyholder has not fulfilled the insurance contract by the term specified in the terms and conditions, i.e., has not paid the first or subsequent insurance installments;
34.2.
the policyholder or the insured person significantly violates the insurance contract and does not remedy the violation within the deadline set for this purpose;
34.3.
the policyholder has been declared bankrupt.
35.
The insurance agent may cancel the insurance contract in an emergency within one month of becoming aware of the violation.
36.
Insurance premiums for the employee as an insured person are paid by the policyholder. The policyholder pays the insurance premiums in quarterly installments.
37.
The insurance premium payment date is the day the insurance premium is received in the insurance agent’s bank account.
38.
An insurance agent issues invoices to receive insurance payments. If applicable, the insurance agent issues e-invoices through an e-invoicing operator.
39.
If the policyholder pays insurance premiums on the basis of an insurance policy issued for the current insurance period, the parties to the contract consider this as the policyholder’s acceptance of the insurance contract. If the insurance policy differs from the insurance offer, the information and agreements provided in the insurance policy are considered valid and correct.
40.
Insurance premiums must be paid for each insured person based on the insurance cover chosen for him.
41.
Insurance premiums must be paid for the insured person’s entire insurance period unless the insurance coverage is terminated based on the conditions before the end of the insurance period. If the policyholder terminates the employment or other service relationship with the insured person, the policyholder’s obligation to pay the insurance premium also ends from the quarter following the termination of the employment or other service relationship with the employee, if the policyholder notifies the insurance agent of the employee’s exclusion from the insurance contract. The policyholder will not be reimbursed for the insurance premium paid until the end of the quarter. The policyholder and the employee may agree that the insured person with whom the employment or other service relationship was terminated will be covered until the end of the insurance period (provided that the policyholder has paid insurance premiums for this) or that the policyholder will pay the following insurance premiums for this person even after the termination of the employment relationship.
42.
A close relative of the insured employee pays the insurance premiums for insurance coverage on behalf of the policyholder themselves unless otherwise agreed with the policyholder. The insurance premium must be paid at once for the entire insurance period. The insurance agent connects the employee to the close relative’s insurance contract after the close relative has paid the premium.
43.
If an employee is added to the contract as an insured person during the current insurance period, their indemnity limit and insurance premium are calculated based on the following proportion:
44.
The invoice payment term is indicated on the policy and on the invoice. If the invoice is not paid by the deadline, the insurance agent has the right to demand from the recipient of the invoice a late fee of 0.05% (zero point zero five percent) of the unpaid amount by the deadline for each day of delay in payment.
45.
Insurance premiums will not be reduced due to the taxes that apply to them, and they will be paid additionally as a result.
46.
If the policyholder has not paid the insurance premium or its first installment within 14 (fourteen) days after concluding the insurance contract, the insurance agent may withdraw from the contract until the payment is made. If the insurance agent does not file a lawsuit to collect the insurance premium within three months from the date the payment becomes due, it is assumed that they have withdrawn from the contract. If the insurance premium that has become due or its first installment has not been paid by the time the insured event occurs, the insurance agent is released from their performance obligation.
47.
If the policyholder does not pay the second or next installment of the insurance premium by the deadline, the insurance agent will give them a new deadline for payment. If the policyholder does not pay the installment by the new deadline and the insured event occurs after the new installment payment deadline, the insurance agent is released from the obligation to perform and also has the right to cancel the insurance contract.
48.
Obligation to provide information
48.1.
When concluding an insurance contract, the policyholder and the insured person must provide the insurance agent with all the information required by them, which is necessary for concluding and executing the insurance contract.
49.
Rights and obligations of the policyholder
49.1.
The policyholder has the right to:
49.2.
The policyholder is obliged to:
50.
Rights and obligations of the insured person
50.1.
The Insured Person has the right to:
50.2.
The insured person has an obligation to:
51.
Rights and obligations of an insurance agent
51.1.
The insurance agent has the right to:
51.2.
The insurance agent has the obligation:
52.
In the event of damage, the insured person is obliged to consult a physician as soon as possible, comply with their prescriptions and do everything possible to prevent the increase of injuries caused by the insured event.
53.
If the insured person paid the invoice presented by the health care provider themselves in order to receive insurance indemnity, they submit the following documents as soon as possible, no later than within 30 (thirty) days from receiving the service, by authenticating themselves at https://portal.terviselahendus.ee/#/kip or, if authentication is not possible, by sending the following documents to the e-mail address kahjud@terviselahendus.ee:
54.
The document proving the cost (invoice or payment receipt) must have the following information: name of healthcare service provider, name of the service recipient, name of service, price, and date of service provision. If the invoice does not show whether it has been paid for, the insured person must also provide a payment receipt or bank statement.
55.
If the insured person has not paid for health services themselves, the health care provider submits data and documents to the insurance agent in order to receive insurance indemnity based on the data volume agreed between the health care provider and the insurance agent.
56.
The insurance agent pays the employee health check-up indemnity to the policyholder or the health care provider who provided the employee health check-up service.
57.
If several insured events occur during the same insurance period, the insurance agent pays indemnity for all insured events covered by the respective insurance coverage, but not more than the insured amount specified in the insurance coverage.
58.
If the insured person has received a complaint from the insurance agent, they are obliged to return to the insurance agent within 10 (ten) working days at the latest the sums that the insurance agent has paid to the policyholder, health care provider, or directly to the insured person for the health services provided to the insured person:
58.1.
in case of exceeding the insurance amount specified in the insurance contract;
58.2.
in case of exceeding the limit specified in the insurance contract, including the number of paid services;
58.3.
to the extent of payments that are not stipulated in the insurance contract;
58.4.
in case of expiry of the insurance contract for any reason;
58.5.
in case the insured person commits fraud or has received insurance compensation for other unjustified reasons.
59.
The insurance agent has the right to refuse the payment of the insurance benefit if the policyholder or the insured person does not fulfill any obligation provided for in the legislation or the insurance contract, either intentionally (including for criminal purposes) or due to gross negligence.
60.
The insurance agent has the right to refuse the payment of the insurance benefit if the policyholder and/or the insured person does not comply with the written orders of the insurance agent, refuses to cooperate, or avoids it.
61.
The insurance agent has the right to refuse payment of the insurance indemnity in the event that the policyholder and/or the insured person prevents the insurance agent from ascertaining the circumstances, does not contribute to it, or provides misleading information or documents, as well as in the event that the policyholder and/or the insured person acts in a manner aimed at obtaining unfounded or higher insurance indemnity or part thereof.
62.
The insurance agent may reduce the insurance indemnity by up to 50% (fifty percent) in the event that the policyholder or the insured person, due to negligence, does not fulfill any condition stipulated in legislation or the insurance contract.
63.
The insurer, insurance agent and healthcare service provider process the data of insured persons, including special types of personal data, in accordance with legislation and the principles of processing customer data of the insurance provider, insurance agent and healthcare service provider, which are available on the insurer’s website at https://www.lhv.ee/et/kliendiandmete-tootlemise-pohimotted and on the insurance agent’s website at https://terviselahendus.ee//confido_privaatsuspoliitika and on the addresses of the websites of healthcare service providers, which can be found at https://terviselahendus.ee/koostoopartnerid.
64.
If the insurer or insurance agent deems it necessary, they have the right to receive information about the policyholder and the insured person from state authorities and the register of debtors.
65.
Priority of insurance contract documents
If there are contradictions in the documents of the insurance contract, the terms of the insurance coverage and the corresponding special conditions prevail for the parties to the contract.
66.
Transmission of notices
The parties to the contract transmit all notifications related to the insurance contract through authorized persons and contact persons.
67.
Submitting complaints about the activities of the insurance agent
67.1.
If it is relevant, the policyholder and the insured person have the right to file a complaint about the activities of the insurance agent in connection with the improper fulfillment of the obligations arising from the insurance contract.
67.2.
The complainant shall provide at least the following information in the complaint:
67.3.
The complaint can be sent to the postal address or e-mail address of the insurance agent.
67.4.
The insurance agent sends a reasoned written response to the complainant within 30 (thirty) days from the day of the complaint. If it is not possible to resolve the complaint within 30 (thirty) days due to its complexity or for other reasons, the insurance agent will inform the complainant of the reasons for the extension of the procedure and the new deadline for responding in a form that allows for written resubmission. The insurance agent may not extend this period beyond four months from the date of the complaint.
67.5.
If applicable, the policyholder, the insured person, and the beneficiary have the right to ask the insurance agent for additional information about the procedure for handling complaints.
67.6.
Complaints processing is free of charge for the complainant.
68.
Applicable law
The legislation in force in the Republic of Estonia is applied to regulate the contractual relations arising from insurance contracts.
69.
Settlement of disputes
69.1.
Disputes arising from insurance contracts are attempted to be resolved by agreement between the parties.
69.2.
If an agreement is not possible, disputes arising from the insurance contract will be settled in court on the basis of the legislation of the Republic of Estonia.
69.3.
The parties to the insurance contract do not have the right to transfer the rights arising from the insurance contract to third parties.
69.4.
If disagreements cannot be resolved, the parties to the insurance contract have the right to apply for the resolution of the dispute:
69.5.
The policyholder has the right to file a complaint about the activities of the insurer and the insurance agent to the Financial Supervision Authority (phone 668 0500, e-mail address info@fi.ee, address Sakala 4, 15030 Tallinn).
Indemnity is the amount which LHV will pay in the case of an insured event, based on what was agreed in the insurance contract.
Insured event is the initial contraction of the critical illness by the insured. A death resulting from a critical illness within 30 days of the diagnosis of the illness is not an insured event.
Insurance coverage is LHV’s obligation, specified in terms and conditions of insurance contracts, to pay an indemnity and pay for medical care for the critical illnesses in the case of the insured events specified in the policy. Coverage starts three months after the conclusion of the insurance contract and is valid in the Republic of Estonia.
Insurance period is the time period specified in the policy during which insurance coverage is in force. The insurance period is one year unless specified otherwise in the policy.
Insurance policy is the document, issued by LHV, which substantiates conclusion of insurance contract. The insurance policy is sent to the insurer after the insurance contract is concluded, amended or the Insurance Period extended.
Sum insured is the maximum amount agreed in the policy which LHV will pay the insured an indemnity in the case of an insured event.
Critical illness is an illness or pathological condition specified in the list of critical illnesses and the diagnosis of which completely meets the requirements set forth in the list. The list of critical illnesses is the list of critical illnesses agreed in the insurance contract and Annexes thereto.
ICD-10 is the 10th version of the International Classification of Diseases.
CMT is the international classification of malignant tumours.
1.1.
Annex 1 (“Terms and conditions of insurance for critical illnesses“) is in force only in conjunction with the valid LHV terms and conditions of health insurance. If not specified otherwise in a given provision, terms are defined the same way in both Annex 1 and the terms and conditions of health insurance.
2.1.
Insurance coverage is LHV’s obligation, specified in terms and conditions of the insurance contract, to pay an indemnity and pay for medical care for the critical illness in the case of the insured events specified in the policy.
2.2.
Coverage starts three months after the conclusion of the insurance contract and is valid in the Republic of Estonia.
2.3.
Insurance coverage expires in the following cases:
3.1.
Insured event is the initial contraction of the critical illness by the insured during the validity of the coverage.
3.2.
Critical illnesses are the following on the basis of the conditions herein.
3.2.1.
Myocardial infarction
Myocardial infarction is damage to heart muscle caused by an ischemic disorder. The ICD-10 code for the diagnosis is I21.
3.2.2.
Stroke
A stroke is a cerebrovascular event which results in a neurological damage lasting over 24 hours, manifested in motor and sensory function disorder and general symptoms. The ICD-10 diagnosis codes are I60–I64.
3.2.3.
Malignant tumours
A malignant tumour is an illness characterized by proliferation and spread of malignant cells into healthy tissues. In situ tumours, precancerous cells, cervical dysplasia, cervical abnormalities CIN1–CIN3, early prostate cancer (code T1 in the CMT), basal cell and squamous skin cancer and melanoma less than 1.5 mm according to the Breslow scale or smaller than level III on the Clark scale are not insured events. The ICD-10 diagnosis codes are C00–C97.
3.2.4.
Dementia before the age of 60
Dementia is a neurodegenerative disease characterized mainly degradation of intellectual capacities. Dementia caused by other brain or systemic illnesses or psychiatric conditions is not an insured event. The ICD-10 diagnosis codes are G30 and F00.
3.2.5.
Kidney failure
Kidney failure is an illness caused by damage to the functioning of both kidneys and the need for kidney transplant or chronic dialysis as substitutive renal therapy. The ICD-10 diagnosis codes are N18 and N19.
3.2.6.
Parkinson’s disease
Parkinson’s disease is a condition that causes permanent loss of physical capabilities. The illness must be diagnosed according to valid diagnostic and treatment guidelines. Insured events are cases where the neurological impairment is such that the person is unable to dress or wash oneself for six months and has developed difficulties walking. The ICD diagnosis code is G20.
3.2.7.
Multiple sclerosis (MS)
MS is a progressive central nervous system disease that damages the layer of myelin insulating brain and spinal cord neurons. The ICD-10 diagnosis code is G35.
3.2.8.
Organ or marrow transplant
Organ or marrow transplants are surgical operations where a heart, kidney, liver, lung, marrow, pancreas, small intestine, face, hand or foot are transplanted. Transplants of other organs, body parts, tissues or cells are not an insured event.
3.2.9.
Loss of an extremity or function of extremity
Loss of an extremity means loss of an entire limb or member. Loss of function of an extremity means a case that lasts over three months, which was diagnosed by a neurologist and which was caused by a brain or spinal cord disorder. The loss of an extremity or function of an extremity function due to self-injury or psychological disorder, and periodic or hereditary loss, is not considered an insured event.
3.2.10.
Loss of vision
Loss of vision means total and permanent blindness that has lasted at least six months.
3.2.11.
Loss of hearing
Hearing loss means the complete and irreversible damage to auditory capability in both ears as a result of the illness, and which cannot be restored by hearing aids. Hearing loss must be determined by audiometric examination and is characterized by hearing threshold of over 70 dB in the ear with better hearing at frequencies of 500, 1000 and 2000 Hz.
4.1.
Disbursement of indemnity and compensation of costs of medical care
4.1.1.
On the basis of the insurance contract, LHV pays the insured a one-time indemnity of 50% of the sum insured and compensates expenses on treatment of the critical illness to the health care service provider up to 50% of the sum insured. LHV does not compensate treatment costs that are subject to compensation or which are insured by the Estonian Health Insurance Fund.
4.1.2.
If the critical illness cannot be treated in the Republic of Estonia, LHV shall under exceptional procedure compensate the costs of treatment outside the Republic of Estonia as well. The costs of medical care must be coordinated with LHV prior to the start of the treatment.
4.1.3.
Following diagnosis of a critical illness, the insured shall submit the following documents in order to apply for the indemnity and compensation of costs of treatment:
4.1.4.
To decide on the disbursement of indemnity and to pay the costs of medical care, LHV is entitled to ask for additional data and documents, to make inquiries (such as to the attending physician and healthcare service providers) and if necessary to involve LHV’s medical expert.
4.1.5.
LHV makes the decision on indemnifying loss within 30 days of receiving all documents and data.
4.1.6.
LHV pays the one-time indemnity of 50% of the sum insured within 3 business days of the decision on indemnity.
4.1.7.
LHV is entitled to decline to pay the indemnity if it proves that the insured has intentionally submitted false or misleading information to LHV or failed to submit significant information related to important circumstances of the insured event.
4.1.8.
The compensation for costs of medical care shall be paid within 3 business days of the decision on indemnity in regard to the corresponding costs and the submission of the medical care invoice substantiating the amount of necessary treatment costs.
4.1.9.
An insurance indemnity paid out groundlessly must be refunded to LHV without delay.
5.1.
Insured event is the initial contraction of the critical illness by the insured. A death resulting from a critical illness within 30 days of the diagnosis of the illness is not an insured event.
5.2.
Persons who at the time of entering into the insurance contract had been diagnosed with the following illnesses are not covered by the insurance for critical illnesses:
5.2.1.
diabetes mellitus;
5.2.2.
AIDS or carrying HIV;
5.2.3.
a disease of the blood, kidneys or respiratory tracts liable to chronic flare-up;
5.2.4.
atherosclerosis;
5.2.5.
psychiatric and chronic severe disease of the nervous system
5.2.6.
hereditary disease if diagnosed prior to entering into the insurance contract.
In addition, the general exclusions specified in the Terms and Conditions of Health Insurance apply.
6.1.
Supervision over LHV’s activity is performed by the Financial Supervision Authority, Sakala 4, 15030 Tallinn. The insured is entitled to lodge a complaint against LHV to the Financial Supervision Authority (tel. 668 0500, email info@fi.ee, website www.fi.ee). The Financial Supervision Authority does not resolve contractual dispute between LHV and the insured.
6.2.
All disputes are resolved by agreement between the parties in accordance with the terms and conditions and the legal acts of the Republic of Estonia.
6.3.
The extrajudicial bodies for resolving disputes are the conciliation body of the Association of Estonian Insurance Companies Mustamäe tee 46, 10621 Tallinn (tel. 667 1800, email lepitus@eksl.ee), and the Consumer Protection and Technical Regulatory Authority, Endla 10a, 10122 Tallinn (tel. 667 2000, email info@ttja.ee).
6.4.
If agreement is not reached the parties have the right to turn to Harju County Court.
Insured event is an accident taking place during the insurance period, due to an injury as a consequence of which the insured develops a permanent disability within one year. Death resulting from an accident is not an insured event.
Insurance coverage is LHV’s obligation as delimited by the terms and conditions of the insurance contract to pay an indemnity in the event of insured events specified in the policy. The insurance coverage applies 24 hours a day and in the Republic of Estonia.
Insurance period is the time period specified in the policy during which insurance coverage is in force. The insurance period is one year unless specified otherwise in the policy.
Insurance policy is the document substantiating conclusion of the insurance contract. It is issued by LHV. The insurance policy is sent to the insurer after the insurance contract is concluded, amended or the insurance period extended.
Sum insured is the maximum amount agreed in the policy which LHV will pay the insured an indemnity in the case of an insured event. The percentage of the payment of the sum insured depends on the degree of severity of the permanent disability. Degrees of severity are described in the terms and conditions of accident insurance.
Accident is an unexpected bodily injury caused by an external influence, due to an injury sustained as a consequence of which the insured person develops a permanent disability within one year.
1.1.
Annex 2 (“Terms and conditions of accident insurance“) is in force only in conjunction with the valid LHV terms and conditions of health insurance. If not specified otherwise in a given provision, terms are defined the same way in both Annex 2 and the terms and conditions of health insurance.
2.1.
Insurance coverage is LHV’s obligation, specified in terms and conditions of the insurance contract, to pay an indemnity in the case of the insured events specified in the policy. Insurance coverage is valid 24 hours a day and in the Republic of Estonia.
Insurance coverage expires in the following cases:
3.1.
An insured event is an unexpected accident that occurs during the validity of the insurance period and caused by an external influence, causing an injury that results in the insured developing a permanent disability within one year.
3.2.
Poisoning caused by e.g. chemical, gas, steam or toxic plants and occurring independently of the intent of the insured is also considered an insured event.
3.3.
The basis for determining the existence and magnitude of the permanent disability is the state of the insured person’s health at a point when one year has passed since the accident.
3.4.
An insured event is not death occurring due to an accident or the occurrence of a permanent disability later than one year after the accident.
3.5.
In the case of an insured event, LHV pays an indemnity to the insured as a one-time payment, the amount of the payment being calculated as a percentage of the sum insured.
3.6.
An indemnity is paid by LHV on the basis of a permanent disability caused by accident.
3.7.
If the degree of severity of the permanent disability sustained by the insured is not described in the terms and conditions of Health Insurance or Annex 2 thereto, LHV shall make the decision on indemnity based on descriptions for similar kinds of injuries and degrees of severity.
3.8.
The total insurance indemnity paid out for multiple insured events within an insurance year can amount to 100% of the sum insured. The amount of indemnity paid out for several injuries sustained in the context of a single insured event may be up to 100% of the sum insured.
3.9.
The insured shall submit the following documents for applying for the indemnity:
3.10.
To decide on the disbursement of indemnity, LHV is entitled to ask for additional data and documents, to make inquiries (such as to the attending physician and healthcare service providers) and if necessary to involve LHV’s medical expert.
3.11.
LHV makes the decision on indemnity within 30 days of receiving all documents and data. Disbursements of indemnity are made by LHV within 3 business days of the decision on indemnity.
3.12.
LHV is entitled to decline to pay indemnity if it proves that the insured has intentionally submitted false or misleading information to LHV or failed to submit significant information related to important circumstances of the insured event.
3.13.
An insurance indemnity paid out groundlessly must be refunded to LHV without delay.
4.1.
It is not an insured event if the accident befell the insured due to an activity specified in the following list or having a similar level of risk as any of said activities or if the insured works in any of the high-risk professions specified in clause 14.3.
4.1.1.
Competitive sport and professional sport activity
Competitive sport does not include public running races and other comparable mass sport events.
4.1.2.
High-risk activity:
4.1.3.
High-risk professions:
4.1.4.
Other:
In addition, general exclusions specified in the Terms and Conditions of Health Insurance apply.
Percentage of the sum insured specified in the insurance contract
Nervous system
| Monoparesis (upper, lower) | 30% |
| Hemiparesis and/or paraparesis | 40% |
| Tetraparesis, loss of coordination, dementia | 70% |
| Monoplegia | 60% |
| Hemiplegia, paraplegia or tetraplegia; decortication syndrome | 100% |
| Disorders of pelvic organs | 70% |
| Severed radial, ulnar or median nerve at forearm and/or wrist level; severed tibial or peroneal nerve at lower leg or ankle | 10% |
| Two or more severed nerves at forearm and/or wrist joint level; severed tibial nerve or peroneal nerve at lower leg and/or ankle joint level | 20% |
| One severed nerve at humeral or femoral level l | 25% |
| Two or more severed nerves at humeral or femoral level | 50% |
Visual organs*
| Paralysis of accommodation in one eye | 15% |
| Hemianopsia, traumatic strabismus caused by injury to the eye muscles, ptosis, diplopia, tunnel vision | 15% |
| Pulsating exophthalmos of one eye | 20% |
| Total loss of vision in one eye | 50% |
| Total loss of vision in sole eye | 100% |
Auditory organs*
| Absence of at least half of earlobe or change in earlobe’s external shape by at least one-half due to trauma | 10% |
| Complete absence of earlobe | 20% |
| Loss of auditory acuity (threshold over 70 dB) | 10% |
| Deafness in one year | 25% |
| Deafness in both ears | 50% |
Respiratory organs
| Partial pneumonectomy (lobe or part of lung) | 20% |
| Pneumonectomy, one lung | 35% |
| Injuries to larynx and trachea with constant need for tracheotomy intubation | 20% |
Digestive tract
| Lingulectomy, distal 1/3 | 15% |
| Lingulectomy, distal 2/3 | 30% |
| Full lingulectomy | 60% |
| Oesophageal stricture (only liquid food) | 40% |
| Oesophageal obstruction (gastrostomy) | 60% |
| Oesophageal colostomy | 75% |
| Partial hepatectomy (resection) | 15% |
| Splenectomy | 10% |
| Gastrectomy | 60% |
Reproductive and urinary organs
| Renectomy, one kidney | 10% |
| Nephrectomy, one kidney | 40% |
| Reduction in bladder volume | 10% |
| Toxic glomerulonephritis, urinary stricture | 25% |
| Traumatic toxicosis, crush syndrome, chronic kidney failure | 30% |
| Urinary obstruction, fistulas of urinary/reproductive organs | 40% |
| Hysterectomy in a patient 50 and younger | 50% |
| Hysterectomy in a patient 51 and older | 10% |
| Penectemy and bilateral orchiectomy | 50% |
| Bilateral ovariotomy, salpingectomy | 30% |
| Bilateral orchiectomy, partial penectomy | 30% |
Spinal column
| Total immobilization of cervical vertebrae due to fracture | 25% |
Shoulder joint
| Ankylosis of shoulder joint | 25% |
| Non-union after fracture of upper arm | 30% |
| Amputation of upper arm | 75% |
| Amputation of sole upper limb | 100% |
Elbow joint
| Ankylosis of elbow joint | 20% |
| Amputation of lower arm | 65% |
| Amputation of lower arm of sole limb | 100% |
| Ankylosis of wrist joint | 20% |
| Amputation of all fingers or hand | 55% |
| Amputation of sole hand | 100% |
Fingers
| Ankylosis of thumb | 10% |
| Ankylosis of finger | 5% |
| Amputation of thumb | 20% |
| Amputation of index finger | 15% |
| Amputation of third, fourth or fifth finger | 5% |
| Amputation of metacarpal | 5% |
Pelvis and hip
| Hemipelvectomy | 75% |
| Ankylosis of hip joint | 30% |
Thigh
| Non-union after femoral fracture | 25% |
| Amputation of thigh | 65% |
| Amputation of thigh of sole limb | 100% |
Knee
| Ankylosis of knee joint | 15% |
| Amputation of lower leg | 50% |
| Amputation of lower leg of sole limb | 100% |
Ankle
| Ankylosis of ankle | 20% |
| Amputation from the ankle | 40% |
Foot
| Ankylosis of foot | 10% |
| Amputation of foot | 20% |
Toes
| Amputation of big toe | 10% |
| Amputation of 1st, 2nd ,3rd or 4th toe | 5% |
*The magnitude of the injury is determined three months after the insured event on the basis of a medical certificate completed in follow-up examination
6.1.
Supervision over LHV’s activity is performed by the Financial Supervision Authority, Sakala 4, 15030 Tallinn. The insured is entitled to lodge a complaint against LHV to the Financial Supervision Authority (tel. 668 0500, email info@fi.ee, website www.fi.ee). The Financial Supervision Authority does not resolve contractual dispute between LHV and the insured.
6.2.
All disputes are resolved by agreement between the parties in accordance with the terms and conditions and the legal acts of the Republic of Estonia.
6.3.
The extrajudicial bodies for resolving disputes are the conciliation body of the Association of Estonian Insurance Companies Mustamäe tee 46, 10621 Tallinn (tel. 667 1800, email lepitus@eksl.ee), and the Consumer Protection and Technical Regulatory Authority, Endla 10a, 10122 Tallinn (tel. 667 2000, email info@ttja.ee).
6.4.
If agreement is not reached the parties have the right to turn to Harju County Court.
Confido Health Plan is a non-life insurance service (hereinafter “health insurance”) developed by the insurer, within the framework of which AS Arstikeskus Confido (hereinafter Confido, registry code 12381384, address Veerenni 51, 10138, Tallinn, Harju County) itself or through its cooperation partners or other service providers offers its health services for employees (and, if applicable, also their close relatives) within the limits of the agreed health insurance risk.
The indemnity limit is the largest indemnified amount per insurance cover for one insured person during the insurance period. The indemnity limit is reduced by the insurance indemnity paid.
A co-policyholder is an insured person.
The insured object is the health of the insured person and the risk of incurring costs related to the provision of health services necessary to maintain it, that is, the insurance risk.
The insured person is the person named as a co-policyholder in the insurance contract. On the basis of the insurance contract, the health insurance risk related to the insured person is insured.
The insurance agent is Terviskindlustusagent OÜ (registration code 16572262, address Veerenni 51, 10138, Tallinn, Harju county).
The insurer is AS LHV Kindlustus (registration code 14973611, address Tartu mnt 2, 10145, 1 Tallinn, Harju county).
Insurance cover is the cover chosen by the policyholder when concluding an insurance contract, to the extent to which a person can be insured, and in the case of an insurance event related to which the insured person can apply for insurance indemnity.
An insurance contract is a contract between the policyholder and the insurer, which enables the insured person to voluntarily join the health insurance plan. The insurance contract consists of the insured person’s application, conditions, insurance offers, insurance policy, information sheet, and other documents certifying the agreements concluded between the insured person, the policyholder, and the insurance agent.
An insurance premium is the fee paid by the policyholder for insurance coverage agreed upon in the insurance contract. The policyholder and the insured person agree that the insured person pays the insurance premium to the insurance agent on behalf of the policyholder.
The insurance period is the period of time specified in the insurance contract, during which the insurance coverage agreed with the insurance contract is in effect and on the basis of which the insurance payments are calculated.
An insurance policy is a document that confirms the conclusion and validity of an insurance contract. Insured persons are added to the insurance policy concluded by the policyholder on the basis of their own application.
The sum insured is the largest sum specified in the insurance contract, which is indemnified for all insured events per insured person during the insurance period. The sum insured is reduced by the paid-out insurance indemnities.
The policyholder is Terviskindlustusagent OÜ, which has concluded an insurance contract with the insurer.
Contact persons are people appointed by the parties to the contract to receive notifications related to the insurance contract and to resolve other current issues.
A deductible is part of the damage specified in the insurance contract, the costs of which are borne by the insured person in the event of an insured event.
The information sheet is the standard form of the insurance product information document stipulated by the European Commission Implementing Regulation (EU) No. 2017/1469.
Health care service is the activity of a health care worker or institution to prevent, diagnose and treat illness, injury, or poisoning. The purpose of providing health care services is to relieve a person’s ailments, prevent deterioration of their health condition or exacerbation of the disease, and restore their health.
The healthcare service provider is Confido and its cooperation partner or another healthcare service provider operating in the territory of Estonia.
An authorized person is a person authorized by the insurance agent and the policyholder to exchange data with the cooperation partner in connection with the conclusion and execution of the insurance contract, including the transmission of encrypted data.
1.
The insured event is the use of healthcare services (including the purchase of glasses) by the insured person during the insurance coverage valid for them and to the extent agreed in the insurance contract. The insurance benefit is paid out if the insured event meets the following conditions:
1.1.
meets the volume and conditions agreed with the insurance contract;
1.2.
the healthcare service is related to the insured person’s insurance coverage;
1.3.
the healthcare service has been provided during the insurance period;
1.4.
the health care service has been provided by a service provider operating in the Republic of Estonia, who has a corresponding activity license or valid professional certificate for the provision of this service. The activity license can be checked on the website of the Estonian Health Board, and the professional certificate is available on the website of the Estonian Qualifications Authority;
1.5.
the healthcare service has been provided using such medical technology or methodology, the use of which is allowed in Estonia for the treatment of people;
1.6.
physician’s referral (referral letter, digital referral letter, entry in the medical record, occupational health physician’s decision, prescription) is issued to a specific healthcare service before receiving the healthcare service. The term of validity of the referral is considered to be one year from the date of issuance of the document, with the exception of the referral made by the occupational health physician, which is valid as stated in the decision but not more than three years.
2.
Insurance indemnity is paid by the insurance agent to the insured person if the costs were borne by the insured person themselves and to the healthcare service provider if the healthcare service provider has provided healthcare services to the insured person or borne related costs. If the insurance agent pays the insurance indemnity to the health care provider, the insured person loses the right to the insurance benefit.
3.
Outpatient treatment insurance coverage
3.1.
Outpatient treatment is a healthcare service in which the insured person’s visit to the healthcare provider is limited to a few hours.
3.2.
On the basis of outpatient treatment insurance coverage, the following expenses are indemnified without a physician’s referral:
3.3.
On the basis of outpatient treatment insurance coverage, the following costs are indemnified only upon referral by a physician:
3.4.
The following are not indemnified under the insurance cover for outpatient treatment:
4.
Preventive health checkup insurance coverage
4.1.
A preventive health check-up is a health care service for which there is no medical indication and which is performed by the health care service provider at the request and choice of the insured person in order to check their health condition, prevent diseases or issue a health certificate.
4.2.
On the basis of preventive health checkup insurance coverage, the following expenses are indemnified without a doctor’s referral:
4.3.
The following costs are not reimbursed under preventive health check-up insurance coverage:
5.
Mental health insurance coverage
5.1.
On the basis of mental health insurance coverage, the costs of the appointment and consultation fees of the following healthcare providers are indemnified without a
5.2.
On the basis of mental health insurance coverage, the cost of mental health examinations is reimbursed only when referred by a physician.
5.3.
On the basis of mental health insurance coverage, the following costs are not reimbursed:
6.
Insurance coverage for special diagnostics
6.1.
On the basis of insurance coverage for special diagnostics, the costs of the following procedures are indemnified only upon referral by a physician:
6.2.
If the special diagnostic procedure, together with the physician’s appointment and consultation fee, is reflected as one service on the document certifying the cost, 50% of the costs are included under outpatient insurance coverage and 50% of the costs under special diagnostic insurance coverage.
6.3.
The following costs are not reimbursed under the special diagnostics insurance coverage:
7.
Outpatient rehabilitation insurance coverage
7.1.
Outpatient rehabilitation is a healthcare service aimed at restoring or maintaining impaired body functions.
7.2.
On the basis of outpatient rehabilitation insurance coverage, the following procedures and the appointment and consultation fees of healthcare providers are reimbursed only upon referral by a physician:
7.3.
The following costs are not indemnified under outpatient rehabilitation insurance coverage:
8.
Hospital treatment insurance coverage
8.1.
Hospital treatment is a healthcare service, the provision of which requires the stay of the insured person in a hospital. Day treatment is a healthcare service in which the insured person needs to be monitored in a hospital bed for a few hours due to treatment or examinations but is not kept in the hospital overnight.
8.2.
Before hospitalization, the insured person is obliged to coordinate it with the insurance agent.
8.3.
On the basis of hospital treatment insurance coverage, the following costs of both daily and 24-hour treatment are reimbursed only upon referral by a physician:
8.4.
On the basis of hospital treatment insurance coverage, the following costs are indemnified only upon referral by a physician:
8.5.
The following costs are not reimbursed under the hospital treatment insurance coverage:
9.
Dental care insurance coverage
9.1.
On the basis of dental care insurance coverage, the following expenses are indemnified without a physician’s referral:
9.2.
The following are not indemnified on the basis of dental care insurance coverage:
10.
Prescription drugs
10.1.
On the basis of prescription drug insurance coverage, the following expenses are reimbursed only on the basis of a physician’s prescription:
purchase of a prescription drug if the prescription drug is entered in the European Medicines Agency register, and the cost of the prescription drug is greater than 10 euros.
10.2.
The following costs are not reimbursed under prescription drug insurance coverage:
11.
Orthopedic aids
11.1.
Under the insurance coverage of orthopedic aids, the following expenses are reimbursed only on the basis of a physician’s prescription:
rental or purchase of aids necessary for rehabilitation (orthoses, orthopedic insoles, crutches, wheelchairs, support bandages).
11.2.
The cost of one aid of the same type during the insurance period is reimbursed.
12.
Optics
12.1.
The following expenses are reimbursed based on the optics insurance coverage:
the purchase of glasses or contact lenses if the visual acuity has changed during the current insurance period, and the previous document certifying the visual acuity, which is the basis of the change, was issued no more than three years ago.
12.2.
The purchase of one pair of glasses or contact lenses during the insurance period is reimbursed.
12.3.
The following costs are not reimbursed under the optics insurance coverage:
13.
Pregnancy and maternity
13.1.
On the basis of pregnancy and maternity insurance coverage, the following medically indicated expenses are reimbursed based on a physician’s referral:
14.
The insurer does not reimburse the cost related to the following cases:
14.1.
services not provided, including services reflected in advance invoices;
14.2.
cases related to an epidemic or pandemic or a state of emergency in the country, excluding cases related to Covid-19;
14.3.
if the insured person has caused damage to their health intentionally, including a suicide attempt, self-injury, or endangering their health;
14.4.
a case that occurred as a result of self-treatment and a case related to the use of a drug that was not recommended or prescribed by a physician;
14.5.
cases caused by the consumption of alcohol, narcotics, or psychotropic substances;
14.6.
a case that occurred when the insured person committed an act punishable pursuant to criminal procedure was detained by law enforcement bodies or was imprisoned in a custodian facility.
15.
The insurer does not reimburse any costs related to the services, procedures, visits, consultations, examinations, and diagnostics mentioned below and related to the following specialists:
15.1.
services of a coach, dietitian, occupational therapist, geneticist, hypnotist, narcologist, rehabilitation specialist, trichologist, technical orthopedist and prosthetist, and nutritionist;
15.2.
cosmetic and aesthetic services, cosmetic and plastic surgery (including benign skin tumor removal and treatment, aesthetic dermatology, cryotherapy, obesity treatment, weight loss program, skin laser treatment, ELOS technology and radio wave treatment services, pedicure and manicure services, including therapeutic and therapeutic manicure, treatment of ingrown nails and fungal treatment, acne and pimple treatment);
15.3.
surgery or procedure to correct visual acuity, dry eye treatment using laser technology;
15.4.
organ transplant surgery,
15.5.
consultation, treatment, surgery, and sclerotherapy related to varicose veins;
15.6.
genetic tests and studies, food intolerance and sensitivity tests (except for studies related to additional protection described in clause 13);
15.7.
sleep study and treatment;
15.8.
treatment of sexually transmitted diseases (including HIV and AIDS);
15.9.
purchase of medical aids (including orthopedic products such as corsets, orthosis, crutches, fixator, plaster, medical stockings, orthopedic insoles and shoes, and hygiene kit) (except for aids related to additional protection described in clause 11);
15.10.
endoprosthetic services;
15.11.
mandatory medical examination of the employee resulting from the law;
15.12.
immunoglobulin therapy, blood plasma, and hyaluronic acid therapy and intra-articular injections (including PRP injections, Kenalog, Synisc), barotherapy, orthokine therapy, and intraocular injection;
15.13.
alternative and complementary medicine services (including acupuncture, light therapy, sound therapy, aromatherapy, reflexology, holistic, iris examination, bioresonance diagnostics, electropuncture, homeopathy, and biofeedback method);
15.14.
services related to family planning and childbirth (including detection of pregnancy and fetus, prescription of contraceptives, infertility treatment, artificial insemination, abortion without medical indication, sperm analysis, vasectomy, and laparoscopic operations for the patency of the fallopian tubes and removal of appendages), except for studies related to additional protection described in clause 13, analyzes and procedures;
15.15.
treatmentofcongenitalpathology,degenerativedisease(includingAlzheimer’sdisease, Parkinson’s disease, multiple sclerosis), and mental illness;
15.16.
vacuum massage, cryo, Thai and aroma massage, prostate or gynecological massage;
15.17.
printing, saving of certificates, documents, etc., as a separate service;
15.18.
palliative care and social care;
15.19.
the cost and expenses of smartphone applications, including their monthly fees;
15.20.
drugs, vitamins, and nutritional supplements and procedures with drugs (including infusion therapy), except prescription drugs related to the additional protection described in clause 10;
15.21.
training, lectures, and courses (including sexual counseling);
15.22.
convenience services, including home visits and transportation.
16.
The insurer and the policyholder enter into an insurance contract with the aim of ensuring the health insurance risks of the insured persons related to the policyholder’s cooperation partner. If the insured person submits an application to join the insurance contract after reviewing the pre-contractual information, based on this, the insured person’s insurance interest is deemed to have been established.
17.
The insured person chooses the appropriate insurance coverage in cooperation with the insurance agent and the policyholder. Insurance coverage, insurance amounts, indemnity limits, and insurance premiums are specified in the insurance offer, confirmation letter, and terms and conditions.
18.
To add an insured person to the insurance contract, the insured person submits an application to the insurance agent with their desire to join, along with the following information: affiliation with the cooperation partner, first and last name, social security code or date of birth, e-mail address, phone number and choice of insurance coverage.
19.
The policyholder has the right to refuse to include the insured person in the insurance contract if the person has provided false information or previously committed insurance fraud or failure to pay insurance premiums, or is not suitable to be an insured person for other compelling reasons.
20.
If an insured person is added to the insurance contract, the insurance agent provides the policyholder with the insurance policy, the information document, the terms and conditions, and, if necessary, other relevant information certifying the insurance coverage.
21.
The insurance contract is deemed concluded, and the rights and obligations arising from the insurance contract come into force at the moment of payment of the insurance premium but not earlier than the start date of the insurance period.
22.
The selected insurance cover applies to the insured person during the entire insurance period. The insured person can be excluded from the insurance contract during its validity only in exceptional cases and by written agreement with the insurer and the policyholder.
23.
The insurance contract is concluded for a fixed term, and the insurance period is one year unless otherwise stated in the insurance policy. The insurance contract is concluded between the insurer and the policyholder, who is a legal entity, which is why the insurance contract is not automatically extended for the policyholder and insured persons at the end of the insurance period.
24.
The terms and conditions of the insurance contract can be changed and/or supplemented (including termination) only by written agreement with the insurer, which is formalized as an annex to the insurance contract. Regardless of this, the insurance agent has the right
to unilaterally review and change the terms and conditions of the insurance contract in the following cases:
24.1.
The insurer may unilaterally and without notice change the terms of the insurance contract to be more favourable to the policyholder and/or the insured person, including reducing insurance premiums and increasing insurance coverage and indemnity limits.
24.2.
The insurer may unilaterally increase the insurance premiums for the current insurance period and/or reduce the scope of insurance coverage, including reducing the volume of indemnified healthcare services and insurance amounts and indemnity limits, if this is due to a change in the following circumstances:
25.
The insurer may unilaterally change the documents of the insurance contract with the aim of specifying the conditions of the insurance contract to the extent that it is not addressed in clause 24.2.
26.
Amendments to the insurance contract do not enter into force until at least one month has passed after notifying the policyholder and the insured person of the respective amendment.
27.
The insurer informs the policyholder and the insured person of changes to the insurance contract in accordance with the procedure specified in the terms and conditions.
28.
The insurer has the right to cancel the insurance contract exceptionally for the following reasons:
28.1.
The policyholder and/or the insured person has not fulfilled the insurance contract by the term specified in the conditions, including not having paid the first or subsequent insurance installment;
28.2.
The policyholder and/or the insured person significantly violate the insurance contract and do not remedy the violation within the term given for that purpose.
29.
The insurer may cancel the insurance contract in an extraordinary manner within one month of becoming aware of the violation.
30.
The insured person pays the insurance premiums for insurance coverage themselves unless otherwise agreed with the policyholder. The insured person generally pays the insurance premium for the entire insurance period at the same time according to the selected insurance coverage unless otherwise stated in the insurance offer and/or insurance policy.
31.
In order to receive the insurance payment, the insurer issues an invoice to the policyholder and the insured person through the insurance agent. If it is relevant, the insurer issues a payment link via the insurance agent or an e-invoice via an invoice operator.
32.
If the insured person is added to the insurance contract during the current insurance period, their compensation limit and insurance premium are calculated based on the following proportion:
33.
The invoice payment term is indicated on the invoice. If the invoice is not paid by the due date, the insurer has the right to demand from the recipient of the invoice a late payment of up to 0.066% of the amount not paid by the due date for each day of delay in payment.
34.
Insurance premiums will not be reduced due to the taxes that apply to them, and they will be paid additionally as a result.
35.
If the policyholder and/or the insured person has not paid the insurance premium within 14 (fourteen) days after concluding the insurance contract, the insurer may withdraw from the contract until the payment is made. If the insurer does not file a lawsuit to collect the insurance premium within three months from the time the payment becomes recoverable, it is assumed that they have withdrawn from the contract. If the insurance premium that has become recoverable has not been paid by the time the insured event occurs, the insurer is released from their performance obligation.
36.
If the policyholder and/or the insured person does not pay the second or next installment of the insurance premium by the deadline, the insurer will give them a new deadline for payment. If the policyholder and/or the insured person does not pay the installment by the new deadline and the insured event occurs after the new installment payment deadline, the insurer is released from the obligation to perform and also has the right to cancel the insurance contract.
37.
Obligation to provide information
37.1.
When concluding an insurance contract, the policyholder and the insured person must provide the insurance agent with all the required information necessary for concluding and executing the insurance contract.
38.
Rights and obligations of the policyholder
38.1.
The policyholder has the right to:
38.2.
The policyholder has an obligation to:
39.
Rights and obligations of the insured person
39.1.
The insured person has the right to:
39.2.
The insured person has an obligation to:
40.
Rights and obligations of the insurer and/or insurance agent
40.1.
The insurer and/or the insurance agent has the right to:
40.2.
The insurer and/or the insurance agent has an obligation to:
41.
In the event of damage, the insured person is obliged to consult a physician as soon as possible to comply with their prescriptions and to do everything possible to prevent an increase in injuries caused by the insured event.
42.
If the insured person paid the invoice presented by the health care provider themselves in order to receive insurance indemnity, they submit the following documents as soon as possible, no later than within 30 (thirty) days from receiving the service, by authenticating themselves at https://portal.terviselahendus.ee/ or, if authentication is not possible, by sending the following documents to the e-mail address kahjud@terviselahendus.ee:
43.
The document proving the cost (invoice or payment receipt) must have the following information: name of healthcare service provider, name of the service recipient, name of service, price, and date of service provision. If the invoice does not show whether it has been paid for, the insured person must also provide a payment receipt or bank statement.
44.
If the insured person has not paid for the health care themselves, the health care provider submits data and documents to the insurance agent in order to receive insurance indemnity based on the amount of data agreed between the health care provider and the insurance agent.
45.
If several insured events occur during the same insurance period, the insurer pays indemnity for all insured events covered by the respective insurance coverage, but not more than the insured amount specified in the insurance coverage.
46.
If the insured person has received a claim from the insurer and/or agent in connection with health care services unjustly indemnified to him, the insured person is obliged to return the insurance indemnity to the insurer within 10 (ten) working days at the latest, which the insurer has paid to the health care service provider or directly to the insured person in the course of indemnification:
46.1.
in case of exceeding the insurance amount specified in the insurance contract;
46.2.
in case of exceeding the indemnity limit specified in the insurance contract, including the number of paid services;
46.3.
to the extent of payments that are not stipulated in the insurance contract;
46.4.
in case of expiry of the insurance contract for any reason;
46.5.
in case the insured person commits fraud or has received insurance compensation for other unjustified reasons.
47.
The insurance agent has the right to refuse the payment of the insurance benefit if the policyholder or the insured person does not fulfill any obligation provided for in the legislation or the insurance contract, either intentionally (including for criminal purposes) or due to gross negligence.
48.
The insurer has the right to refuse the payment of the insurance benefit if the policyholder and/or the insured person does not comply with the insurer’s written orders, refuses to cooperate, or avoids it.
49.
The insurer has the right to refuse payment of the insurance compensation in the event that the policyholder and/or the insured person prevents the insurer from ascertaining the circumstances, does not contribute to it, or provides misleading information or documents, as well as in the event that the policyholder and/or the insured person acts in a manner that aims to obtain unfounded insurance indemnity or insurance indemnity or a part thereof is higher than the prescribed amount.
50.
The insurer may reduce the insurance indemnity by up to 50% (fifty percent) if the policyholder or the insured person fails to fulfill any condition stipulated in legislation or the insurance contract due to negligence.
51.
The insurance provider and the insurance agent process the data of the policyholder and the insured persons, including special types of personal data, in accordance with the legislation and the principles of customer data processing of the insurance provider and the insurance agent, which are available on the insurance provider’s website at https://www.lhv.ee/et/kliendiandmete-tootlemise-pohimotted on the website of the insurance agent at https://terviselahendus.ee/confido_privaatsuspoliitika.
52.
If the insurer or insurance agent deems it necessary, they have the right to receive information about the policyholder and the insured person from state authorities and the register of debtors.
53.
Priority of insurance contract documents
If there are contradictions in the documents of the insurance contract, the terms of the insurance coverage and the corresponding special conditions prevail for the parties to the contract.
54.
Transmission of notices
The parties to the contract transmit all notifications related to the insurance contract through authorized persons and contact persons.
55.
Submission of complaints about the activities of the insurer and insurance agent
55.1.
If it is relevant, the policyholder and the insured person have the right to file a complaint about the activities of the insurer and/or insurance agent in connection with the improper fulfillment of the obligations arising from the insurance contract.
55.2.
The complainant shall provide at least the following information in the complaint:
55.3.
Complaints can be submitted to the postal address or e-mail address of the insurer and/or agent.
55.4.
The insurer and/or agent shall send a reasoned written response to the complainant within 30 (thirty) days from the day of receipt of the complaint. If it is not possible to resolve the complaint within 30 (thirty) days due to its complexity or for other reasons, the insurance agent will inform the complainant of the reasons for the extension of the procedure and the new deadline for responding in a form that allows for written resubmission. The insurance agent may not extend this period beyond four months from the date of the complaint.
55.5.
If applicable, the policyholder and the insured person have the right to ask the insurer and/or agent for additional information about the complaint-handling procedure.
55.6.
Complaints processing is free of charge for the complainant.
56.
Applicable law
Legal acts in force in the Republic of Estonia apply to the regulation of relations arising from the insurance contract.
57.
Settlement of disputes
57.1.
Disputes arising from the insurance contract are tried to be resolved by agreement of the contracting parties.
57.2.
If an agreement is not possible, disputes arising from the insurance contract will be settled in court on the basis of the legislation of the Republic of Estonia.
57.3.
The parties to the insurance contract do not have the right to transfer the rights arising from the insurance contract to third parties.
57.4.
If disagreements cannot be resolved, the parties to the insurance contract have the right to apply for the resolution of the dispute:
57.5.
The policyholder and the insured person have the right to submit a complaint about the activities of the insurer and/or insurance agent to the Financial Supervision Authority (phone 668 0500, e-mail address info@fi.ee, address Sakala 4, 15030 Tallinn.
Confido Health Plan is a non-life insurance service (hereinafter health insurance) developed by the insurer, within the framework of which AS Arstikeskus Confido (hereinafter Confido, registry code 12381384, address Veerenni 51, Tallinn, 10138 Harju County) itself or through its cooperation partners or other health care providers offers its health services for employees (and, if applicable, also their close relatives) within the limits of the agreed health insurance risk.
An authorized person is a person designated by the insurance agent and the policyholder whom they have authorized for data exchange in connection with the conclusion and execution of the insurance contract, including the transmission of encrypted data.
The close relatives are family members of the policyholder’s employee. Family members are spouses or partners, parents, and children up to 18 years of age. A close relative is an insured person under the insurance contract if the close relative has given a relevant confirmation. Unless otherwise indicated by the context, the same applies to the close relative to the employee specified in the terms and conditions.
Contact persons are people appointed by the parties to the contract to receive notifications related to the insurance contract and to resolve other current issues.
Deductible is the part of the damage specified in the insurance contract, the costs of which are borne by the insured person in the event of an insured event.
An employee is a person who works on the basis of a valid employment, board member, or other service relationship contract for the benefit of the policyholder.
Health care service is the activity of a health care worker or institution to prevent, diagnose and treat illness, injury or poisoning. The purpose of providing health care services is to relieve a person’s ailments, prevent deterioration of their health condition or exacerbation of the disease, and restore their health.
The indemnity limit is the largest indemnified amount per insurance cover for one insured person during the insurance period. The indemnity limit is reduced by the indemnity paid.
The information sheet is the standard form of the insurance product information document stipulated by the European Commission Implementing Regulation (EU) No. 2017/1469.
The insurance agent is Terviskindlustusagent OÜ (registration code 16572262, address Veerenni 51, Tallinn, 10138 Harju county).
An insurance card is an electronic card issued by an insurance agent to an insured person, which confirms that the insured person is covered by insurance.
An insurance contract is a health insurance contract concluded between an insurance agent and a policyholder, on the basis of which health insurance cover is provided based on the principles of non-life insurance. The insurance contract consists of the policyholder’s statement, conditions, description of insurance coverage, insurance policy, information sheet, and other documents proving the agreements concluded between the policyholder and the insurance agent. The insurance contract makes it possible to provide insurance coverage to the policyholder’s employees and, with an additional written agreement, also to the close relatives of the insured person.
Insurance cover is the cover chosen by the policyholder when concluding an insurance contract, to the extent of which a person can be insured and with which, in the event of an insured event-related, the insured person can request indemnity. Insurance coverages that are possible are for outpatient treatment, preventive health check-ups, mental health, special diagnostics, outpatient rehabilitation, and hospitalization.
The insurance period is the period of time specified in the insurance contract, during which the insurance coverage agreed with the insurance contract is in effect and on the basis of which the insurance payments are calculated. If the insured person receives insurance coverage for the duration of the insurance period based on the insurance contract, then the insurance coverage applies to them from the time they join the insurance contract until the end of the insurance period unless the policyholder stops offering them insurance coverage under the insurance contract earlier.
The insurance premium is the fee agreed in the insurance contract and paid by the policyholder or, if applicable, a close relative for insurance coverage.
An insurance policy is a document that confirms the conclusion and validity of an insurance contract and is issued by an insurance agent to the policyholder after the conclusion of the insurance contract, amendment, or extension of the insurance period.
The insured object is the health of the insured person and the risk of incurring costs related to the provision of health services necessary to maintain it, that is, the insurance risk.
The insured person is the employee referred to as the insured person in the insurance contract or their close relative. On the basis of the insurance contract, the health insurance risk related to the insured person as a third party is insured. If the policyholder excludes an employee from the insurance contract, it is assumed that this person is no longer an insured person.
The insurer is AS LHV Kindlustus (registration code 14973611, address Tartu mnt 2, Tallinn, 10145 Harju county).
The policyholder is a legal entity that wishes to provide health insurance to its employees and, if applicable, the close relatives of its employees and undertakes the obligation to pay the insurance premiums unless the insured person pays the insurance premiums themselves.
The policy is a document in a form that enables written reproduction of the conclusion of the insurance contract and is issued by the insurance agent to the policyholder.
The health care provider is the health care provider Confido and its cooperation partners or another health service provider operating on the territory of Estonia.
The sum insured is the maximum sum specified in the insurance contract, which is indemnified for all insured events per insured person during the insurance period. The sum insured is reduced by the benefits paid out.
1.
The insured event is the use of healthcare services (including the purchase of glasses) by the insured person during the insurance coverage valid for them and to the extent agreed in the insurance contract. The insurance benefit is paid out if the insured event meets the following conditions:
1.1.
the healthcare service is related to the insured person’s insurance coverage;
1.2.
it meets the volume and conditions agreed upon in the insurance contract;
1.3.
the healthcare service has been provided during the insurance period;
1.4.
health care service has been provided by health care providers operating in the Republic of Estonia who have a professional certificate for the provision of the corresponding service or an activity license prescribed by legislation (visible in the information system of the Health Administration Information System. or on the website of the Estonian Qualifications Authority);
1.5.
the physician’s referral (referral letter, digital referral letter, entry in the medical record, occupational health physician’s decision) was issued before the performance of a test, examination, or treatment procedure of the insured person, and the referral was made less than a year ago (except for the occupational health physician’s decision);
1.6.
the healthcare service has been provided using such medical technology or methodology, the use of which is allowed in Estonia for the treatment of people;
1.7.
is not excluded based on the insurance conditions.
2.
The insurance agent would pay the insurance indemnity to the insured person if the costs were borne by the insured person themselves or to the health care provider if the health care provider has provided health services to the insured person or borne related costs. If the insurance agent pays the insurance indemnity to the health care provider, the insured person loses the right to the insurance indemnity.
3.
Outpatient treatment insurance coverage
3.1.
Outpatient treatment is a non-stationary health care service in which the insured person’s visit to the health care provider is limited to a few hours.
3.2.
The following costs are indemnified without a physician’s referral:
3.3.
The following costs are indemnified only upon referral by a physician:
3.4.
The following are not covered under the insurance cover of insurance cover for outpatient treatment:
4.
Preventive health check-up insurance coverage
4.1.
A preventive health check-up is a physician’s appointment and consultation, health examination, examination package, or test for which there is no medical indication and which the physician performs at the request and choice of the insured person to check their health condition, prevent diseases, or issue a health certificate.
4.2.
The following costs are indemnified without a physician’s referral:
4.3.
On the basis of preventive health check-up insurance, the following are not indemnified:
5.
Mental health insurance coverage
5.1.
Without a physician’s referral, the appointment and consultation fees of the following healthcare providers are indemnified:
5.2.
The cost of mental health examinations is indemnified only upon referral by a physician.
5.3.
On the basis of mental health insurance coverage, couple and family counseling and therapy is not indemnified.
6.
Insurance coverage for special diagnostics
6.1.
The costs of the following procedures are indemnified only upon the doctor’s referral:
7.
Outpatient rehabilitation insurance coverage
7.1.
Outpatient rehabilitation is a healthcare service aimed at restoring or maintaining impaired functions.
7.2.
Only when referred by a physician the following procedures and appointment and consultation fees of healthcare providers are indemnified:
7.3.
The following are not indemnity under outpatient rehabilitation insurance coverage:
8.
Hospital treatment insurance coverage
8.1.
Hospital treatment is a healthcare service, the provision of which requires the stay of the insured person in a hospital. The insured person is obliged to consult with the insurance agent before using hospital treatment services.
8.2.
Day treatment is a health care service in which the insured person needs to be monitored in a hospital bed for a few hours due to treatment or examinations but is not left in the hospital overnight.
8.3.
The insurance agent indemnifies the costs of the paid services of both inpatient treatment and day treatment.
8.4.
The following costs are indemnified only upon referral by a physician:
8.5.
The following are not indemnified on the basis of hospital treatment insurance coverage:
9.
Dental insurance coverage
9.1.
The following costs are reimbursed without a physician’s referral:
9.2.
The following are not indemnified on the basis of hospital treatment insurance coverage:
10.
The insurance agent does not reimburse the cost related to the following cases:
10.1.
services not provided;
10.2.
cases related to an epidemic or pandemic or a state of emergency in the country, except for cases related to Covid-19;
10.3.
if the insured person has caused damage to their health intentionally, including a suicide attempt, self-harm, or endangering their health;
10.4.
a case that occurred as a result of self-treatment and a case related to the use of a drug that was not recommended or prescribed by a physician;
10.5.
Cases caused by the consumption of alcohol, narcotics, or psychotropic substances;
10.6.
a case that occurred when the insured person committed an act punishable pursuant to the criminal procedure, was detained by law enforcement bodies or was imprisoned in a custodian facility.
11.
The insurance agent does not reimburse the costs of services, procedures, appointments, consultations, examinations, and diagnostics related to the following specialists referred to below:
11.1.
services of a coach, dietitian, occupational therapist, geneticist, hypnotist, narcologist, rehabilitation specialist, sexual pathologist, sports doctor, a trichologist, technical orthopedist and prosthetist, and nutritionist;
11.2.
cosmetic and aesthetic services, including cosmetic and plastic surgery (including benign skin tumor removal and treatment, aesthetic dermatology, surgical treatment of obesity, weight loss program, skin laser treatment, including ELOS technology, radio wave treatment, pedicure and manicure services);
11.3.
vision correction surgery using laser technology;
11.4.
organ transplant surgery,
11.5.
consultation, treatment, surgery, and sclerotherapy related to varicose veins;
11.6.
genetic tests and research;
11.7.
sleep research and treatment;
11.8.
treatment of sexually transmitted diseases, including HIV and AIDS;
11.9.
purchase of medical aids (including contact lenses, orthopedic products, e.g., corset, orthosis, crutches, fixator, cast, medical stockings, orthopedic insoles and shoes, hygiene kit);
11.10
endoprosthetic services;
11.11.
mandatory medical examination of the employee resulting from the law;
11.12.
immunoglobulin therapy, blood plasma and hyaluronic acid therapy (e.g., PRP injections), barotherapy, orthokine therapy, and intraocular injection;
11.13.
alternative and complementary medicine services (including acupuncture, light therapy, sound therapy, aromatherapy, reflexology, iris examination, bioresonance diagnostics, electropuncture, homeopathy, and biofeedback method);
11.14.
services related to family planning and childbirth (including detection of pregnancy and fetus, prescription of contraceptives, infertility treatment, artificial insemination, abortion without medical indication, sperm analysis, vasectomy, and laparoscopic operations to remove fallopian tubes and appendages);
11.15.
treatment of congenital pathology, degenerative disease (including Alzheimer’s disease, Parkinson’s disease, multiple sclerosis), and mental illness;
11.16.
vacuum, cryo, Thai and aroma massage, massage of the prostate, or gynecological massage;
11.17.
printing of medical examination documents and other medical documents as a separate service;
11.18.
palliative care and social care;
11.19.
costs of medicines, vitamins, and nutritional supplements;
11.20.
training, lectures, and courses;
11.21.
convenience services, including home visits and transportation.
12.
The policyholder enters into an insurance contract with the aim of insuring insurance risks related to their employees and, if applicable, the close relatives of their employees in order to protect the health of employees and the close relatives of their employees and thereby increase the employees’ working capacity and productivity (insurance interest).
13.
The policyholder selects the appropriate insurance coverage for the employees and, if applicable, for the close relatives of their employees in cooperation with the insurance agent. The insurance coverages covered by the insurance, the sum insured, indemnity limits, and insurance premiums are specified in the insurance policy and in the terms and conditions.
14.
To add an employee to the insurance contract as an insured person, the policyholder submits an application to the insurance agent with the following information: employee’s name, social security number/date of birth and e-mail address, choice of insurance cover, insurance period.
15.
By transmitting data to the insurance agent, the policyholder confirms that they are the authorized person to transmit the employees’ data, that the employees agree to the transmission of their data, and to their inclusion in the insurance contract as insured persons under the terms of the insurance contract.
16.
A close relative is added to the insurance contract through an employee insured by the policyholder, and the addition to the insurance contract is confirmed by the close relative themselves.
17.
The insurance agent has the right to refuse to include the employee or their close relative as an insured person in the insurance contract if the person has provided false information or previously committed insurance fraud or failure to pay insurance premiums, or is not suitable to be an insured person for other compelling reasons.
18.
If an insured person is added to the insurance contract, the insurance agent provides the policyholder with the insurance policy, the information document, the terms and conditions, and, if necessary, other relevant information proving the insurance coverage. The insurance agent, using the contact details of the insured person, forward the insurance card and, if necessary, relevant information to the insured person.
19.
The policyholder is obliged to keep the list of insured persons up to date.
20.
The insurance contract is deemed concluded, and the rights and obligations arising from the insurance contract come into force at the moment of payment of the insurance premium but not earlier than the first date of the insurance period.
21.
The selected insurance cover applies to the insured person during the entire insurance period. During the insurance period, the policyholder has the right to exclude the insured employee from the insurance contract if the policyholder has terminated the employment or other service relationship with this person. Amendments to the insurance contract are made twice a month, taking into account the date when the employment or other service relationship with the employee was terminated and the date when the policyholder notified the insurance agent of the employee’s exclusion from the insurance contract. It is possible to exclude the employee’s close relative from the insurance contract during its validity only in exceptional cases and by agreement with the insurance agent.
22.
The insurance contract is concluded for an indefinite period, and the insurance period is one year.
23.
No later than 30 (thirty) days before the end of the current insurance period, the policyholder submits a new application to the insurance agent, on the basis of which the insurance agent draws up a new insurance policy for the next insurance period and forwards it to the policyholder. If the policyholder does not submit a new application by the specified deadline, the insurance agent will draw up an insurance policy based on the latest information known to the insurance agent and forward it to the policyholder.
24.
The terms of the insurance contract can be changed and/or supplemented (including termination) only with the written agreement of the insurance agent and the policyholder, which is formalized as an annex to the insurance contract. Regardless of this, the insurance agent has the right to unilaterally review and change the terms of the insurance contract in the following cases:
24.1.
The insurance agent may unilaterally and without prior notice change the terms of the insurance contract to be more favorable to the policyholder, including reducing insurance premiums and increasing insurance coverage and indemnity limits.
24.2.
The insurance agent may unilaterally increase insurance payments for the current insurance period and/or reduce the scope of insurance coverage, including reducing the volume of reimbursed health services and insurance amounts and indemnity limits if this is due to a change in the following circumstances:
25.
The insurance agent may unilaterally change the documents of the insurance contract with the aim of specifying the conditions of the insurance contract to the extent that it is not dealt with in clause 24.2.
26.
Amendments to the insurance contract will not take effect until at least one month has passed after notifying the policyholder of the amendment.
27.
The insurance agent notifies the policyholder of changes to the insurance contract in accordance with the terms and conditions.
28.
The policyholder has the right to cancel the insurance contract by giving at least three months’ notice to the insurance agent, so that the contract terminates at the end of the year.
29.
The insurance agent has the right to cancel the insurance contract on a regular basis in cases provided by law.
30.
The insurance agent has the right to cancel the insurance contract exceptionally for the following reasons:
30.1.
the policyholder has not fulfilled the insurance contract by the term specified in the terms and conditions, i.e., has not paid the first or subsequent insurance installments;
30.2.
the policyholder or the insured person significantly violates the insurance contract and does not remedy the violation within the deadline set for this purpose;
30.3.
the policyholder has been declared bankrupt.
31.
The insurance agent may cancel the insurance contract in an emergency within one month of becoming aware of the violation.
32.
Insurance premiums for the employee as an insured person are paid by the policyholder. The policyholder pays the insurance premiums in quarterly installments.
33.
The insurance premium payment date is the day the insurance premium is received in the insurance agent’s bank account.
34.
An insurance agent issues invoices to receive insurance payments. If applicable, the insurance agent issues e-invoices through an e-invoicing operator.
35.
If the policyholder pays insurance premiums on the basis of an insurance policy issued for the current insurance period, the parties to the contract consider this as the policyholder’s acceptance of the insurance contract. If the insurance policy differs from the insurance offer, the information and agreements provided in the insurance policy are considered valid and correct.
36.
Insurance premiums must be paid for each insured person based on the insurance cover chosen for him.
37.
Insurance premiums must be paid for the insured person’s entire insurance period unless the insurance coverage is terminated based on the conditions before the end of the insurance period. If the policyholder terminates the employment or other service relationship with the insured person, the policyholder’s obligation to pay the insurance premium also ends from the quarter following the termination of the employment or other service relationship with the employee; if the policyholder notifies the insurance agent of the employee’s exclusion from the insurance contract. The policyholder will not be reimbursed for the insurance premium paid until the end of the quarter. The policyholder and the employee may agree that the insured person with whom the employment or other service relationship was terminated will be covered until the end of the insurance period (provided that the policyholder has paid insurance premiums for this) or that the policyholder will pay the following insurance premiums for this person even after the termination of the employment relationship.
38.
A close relative of the insured employee pays the insurance premiums for insurance coverage on behalf of the policyholder themselves unless otherwise agreed with the policyholder. The insurance premium must be paid at once for the entire insurance period. The insurance agent connects the employee to the close relative’s insurance contract after the close relative has paid the premium.
39.
If an employee is added to the contract as an insured person during the current insurance period, their indemnity limit and insurance premium are calculated based on the following proportion:
40.
The invoice payment term is indicated on the policy and on the invoice. If the invoice is not paid by the deadline, the insurance agent has the right to demand from the recipient of the invoice a late fee of 0.05% (zero point zero five percent) of the unpaid amount by the deadline for each day of delay in payment.
41.
Insurance premiums will not be reduced due to the taxes that apply to them, and they will be paid additionally as a result.
42.
If the policyholder has not paid the insurance premium or its first installment within 14 (fourteen) days after concluding the insurance contract, the insurance agent may withdraw from the contract until the payment is made. If the insurance agent does not file a lawsuit to collect the insurance premium within three months from the date the payment becomes due, it is assumed that they have withdrawn from the contract. If the insurance premium that has become due or its first installment has not been paid by the time the insured event occurs, the insurance agent is released from their performance obligation.
43.
If the policyholder does not pay the second or next installment of the insurance premium by the deadline, the insurance agent will give them a new deadline for payment. If the policyholder does not pay the installment by the new deadline and the insured event occurs after the new installment payment deadline, the insurance agent is released from the obligation to perform and also has the right to cancel the insurance contract.
44.
Obligation to provide information
44.1.
When concluding an insurance contract, the policyholder and the insured person must provide the insurance agent with all the information required by them, which is necessary for concluding and executing the insurance contract.
45.
Rights and obligations of the policyholder
45.1.
The policyholder has the right to:
45.2.
The policyholder is obliged to:
46.
Rights and obligations of the insured person
46.1.
The Insured Person has the right to:
46.2.
The insured person has an obligation to:
47.
Rights and obligations of an insurance agent
47.1.
The insurance agent has the right to:
47.2.
The insurance agent has the obligation:
48.
In the event of damage, the insured person is obliged to consult a physician as soon as possible, comply with their prescriptions and do everything possible to prevent the increase of injuries caused by the insured event, as well as to notify the insurance agent in writing of the need for treatment in order to receive a letter of guarantee from them in case the insured person is provided with a service other than the contractual partner of Confido Health Plan.
49.
If the insured person paid the invoice presented by the health care provider themselves in order to receive insurance indemnity, they submit the following documents as soon as possible, no later than within 30 (thirty) days from receiving the service, by authenticating themselves at www.tervisehalendus.ee or, if authentication is not possible, by sending the following documents to the e-mail address kahjud@tervisehalendus.ee:
50.
If the insured person has not paid for health services themselves, the health care provider submits data and documents to the insurance agent in order to receive insurance indemnity based on the data volume agreed between the health care provider and the insurance agent.
51.
The insurance agent pays the employee health check-up indemnity to the policyholder or the health care provider who provided the employee health check-up service.
52.
If several insured events occur during the same insurance period, the insurance agent pays indemnity for all insured events covered by the respective insurance coverage, but not more than the insured amount specified in the insurance coverage.
53.
If the insured person has received a complaint from the insurance agent, they are obliged to return to the insurance agent within 10 (ten) working days at the latest the sums that the insurance agent has paid to the policyholder, health care provider, or directly to the insured person for the health services provided to the insured person:
53.1.
in case of exceeding the insurance amount specified in the insurance contract;
53.2.
in case of exceeding the limit specified in the insurance contract, including the number of paid services;
53.3.
to the extent of payments that are not stipulated in the insurance contract;
53.4.
in case of expiry of the insurance contract for any reason;
53.5.
in case the insured person commits fraud or has received insurance compensation for other unjustified reasons.
54.
The insurance agent has the right to refuse the payment of the insurance benefit if the policyholder or the insured person does not fulfill any obligation provided for in the legislation or the insurance contract, either intentionally (including for criminal purposes) or due to gross negligence.
55.
The insurance agent has the right to refuse the payment of the insurance benefit if the policyholder and/or the insured person does not comply with the written orders of the insurance agent, refuses to cooperate, or avoids it.
56.
The insurance agent has the right to refuse payment of the insurance indemnity in the event that the policyholder and/or the insured person prevents the insurance agent from ascertaining the circumstances, does not contribute to it, or provides misleading information or documents, as well as in the event that the policyholder and/or the insured person acts in a manner aimed at obtaining unfounded or higher insurance indemnity or part thereof.
57.
The insurance agent may reduce the insurance indemnity by up to 50% (fifty percent) in the event that the policyholder or the insured person, due to negligence, does not fulfill any condition stipulated in legislation or the insurance contract.
58.
The insurer and the insurance agent process the data of the policyholder and the insured persons, including special types of personal data, in accordance with legislation and the principles of processing customer data of the insurer and the insurance agent, which are available on the insurer’s website at https://www.lhv.ee/et/kliendiandmete-tootlemise-pohimotted and on the insurance agent’s website at https://terviselahendus.ee//confido_privaatsuspoliitika.
59.
If the insurer or insurance agent deems it necessary, they have the right to receive information about the policyholder and the insured person from state authorities and the register of debtors.
60.
Priority of insurance contract documents
If there are contradictions in the documents of the insurance contract, the terms of the insurance coverage and the corresponding special conditions prevail for the parties to the contract.
61.
Transmission of notices
The parties to the contract transmit all notifications related to the insurance contract through authorized persons and contact persons.
62.
Submitting complaints about the activities of the insurance agent
62.1.
If it is relevant, the policyholder and the insured person have the right to file a complaint about the activities of the insurance agent in connection with the improper fulfillment of the obligations arising from the insurance contract.
62.2.
The complainant shall provide at least the following information in the complaint:
62.3.
The complaint can be sent to the postal address or e-mail address of the insurance agent.
62.4.
The insurance agent sends a reasoned written response to the complainant within 30 (thirty) days from the day of the complaint. If it is not possible to resolve the complaint within 30 (thirty) days due to its complexity or for other reasons, the insurance agent will inform the complainant of the reasons for the extension of the procedure and the new deadline for responding in a form that allows for written resubmission. The insurance agent may not extend this period beyond four months from the date of the complaint.
62.5.
If applicable, the policyholder, the insured person, and the beneficiary have the right to ask the insurance agent for additional information about the procedure for handling complaints.
62.6.
Complaints processing is free of charge for the complainant.
63.
Applicable law
The legislation in force in the Republic of Estonia is applied to regulate the contractual relations arising from insurance contracts.
64.
Settlement of disputes
64.1.
Disputes arising from insurance contracts are attempted to be resolved by agreement between the parties.
64.2.
If an agreement is not possible, disputes arising from the insurance contract will be settled in court on the basis of the legislation of the Republic of Estonia.
64.3.
The parties to the insurance contract do not have the right to transfer the rights arising from the insurance contract to third parties
64.4.
If disagreements cannot be resolved, the parties to the insurance contract have the right to apply for the resolution of the dispute:
64.5.
The policyholder has the right to file a complaint about the activities of the insurer and the insurance agent to the Financial Supervision Authority (phone 668 0500, e-mail address info@fi.ee, address Sakala 4, 15030 Tallinn).
Indemnity is the amount which LHV will pay in the case of an insured event, based on what was agreed in the insurance contract.
Insured event is the initial contraction of the critical illness by the insured. A death resulting from a critical illness within 30 days of the diagnosis of the illness is not an insured event.
Insurance coverage is LHV’s obligation, specified in terms and conditions of insurance contracts, to pay an indemnity and pay for medical care for the critical illnesses in the case of the insured events specified in the policy. Coverage starts three months after the conclusion of the insurance contract and is valid in the Republic of Estonia.
Insurance period is the time period specified in the policy during which insurance coverage is in force. The insurance period is one year unless specified otherwise in the policy.
Insurance policy is the document, issued by LHV, which substantiates conclusion of insurance contract. The insurance policy is sent to the insurer after the insurance contract is concluded, amended or the Insurance Period extended.
Sum insured is the maximum amount agreed in the policy which LHV will pay the insured an indemnity in the case of an insured event.
Critical illness is an illness or pathological condition specified in the list of critical illnesses and the diagnosis of which completely meets the requirements set forth in the list. The list of critical illnesses is the list of critical illnesses agreed in the insurance contract and Annexes thereto.
ICD-10 is the 10th version of the International Classification of Diseases.
CMT is the international classification of malignant tumours.
1.1.
Annex 1 (“Terms and conditions of insurance for critical illnesses“) is in force only in conjunction with the valid LHV terms and conditions of health insurance. If not specified otherwise in a given provision, terms are defined the same way in both Annex 1 and the terms and conditions of health insurance.
2.1.
Insurance coverage is LHV’s obligation, specified in terms and conditions of the insurance contract, to pay an indemnity and pay for medical care for the critical illness in the case of the insured events specified in the policy.
2.2.
Coverage starts three months after the conclusion of the insurance contract and is valid in the Republic of Estonia.
2.3.
Insurance coverage expires in the following cases:
3.1.
Insured event is the initial contraction of the critical illness by the insured during the validity of the coverage.
3.2.
Critical illnesses are the following on the basis of the conditions herein.
3.2.1.
Myocardial infarction
Myocardial infarction is damage to heart muscle caused by an ischemic disorder. The ICD-10 code for the diagnosis is I21.
3.2.2.
Stroke
A stroke is a cerebrovascular event which results in a neurological damage lasting over 24 hours, manifested in motor and sensory function disorder and general symptoms. The ICD-10 diagnosis codes are I60–I64.
3.2.3.
Malignant tumours
A malignant tumour is an illness characterized by proliferation and spread of malignant cells into healthy tissues. In situ tumours, precancerous cells, cervical dysplasia, cervical abnormalities CIN1–CIN3, early prostate cancer (code T1 in the CMT), basal cell and squamous skin cancer and melanoma less than 1.5 mm according to the Breslow scale or smaller than level III on the Clark scale are not insured events. The ICD-10 diagnosis codes are C00–C97.
3.2.4.
Dementia before the age of 60
Dementia is a neurodegenerative disease characterized mainly degradation of intellectual capacities. Dementia caused by other brain or systemic illnesses or psychiatric conditions is not an insured event. The ICD-10 diagnosis codes are G30 and F00.
3.2.5.
Kidney failure
Kidney failure is an illness caused by damage to the functioning of both kidneys and the need for kidney transplant or chronic dialysis as substitutive renal therapy. The ICD-10 diagnosis codes are N18 and N19.
3.2.6.
Parkinson’s disease
Parkinson’s disease is a condition that causes permanent loss of physical capabilities. The illness must be diagnosed according to valid diagnostic and treatment guidelines. Insured events are cases where the neurological impairment is such that the person is unable to dress or wash oneself for six months and has developed difficulties walking. The ICD diagnosis code is G20.
3.2.7.
Multiple sclerosis (MS)
MS is a progressive central nervous system disease that damages the layer of myelin insulating brain and spinal cord neurons. The ICD-10 diagnosis code is G35.
3.2.8.
Organ or marrow transplant
Organ or marrow transplants are surgical operations where a heart, kidney, liver, lung, marrow, pancreas, small intestine, face, hand or foot are transplanted. Transplants of other organs, body parts, tissues or cells are not an insured event.
3.2.9.
Loss of an extremity or function of extremity
Loss of an extremity means loss of an entire limb or member. Loss of function of an extremity means a case that lasts over three months, which was diagnosed by a neurologist and which was caused by a brain or spinal cord disorder. The loss of an extremity or function of an extremity function due to self-injury or psychological disorder, and periodic or hereditary loss, is not considered an insured event.
3.2.10.
Loss of vision
Loss of vision means total and permanent blindness that has lasted at least six months.
3.2.11.
Loss of hearing
Hearing loss means the complete and irreversible damage to auditory capability in both ears as a result of the illness, and which cannot be restored by hearing aids. Hearing loss must be determined by audiometric examination and is characterized by hearing threshold of over 70 dB in the ear with better hearing at frequencies of 500, 1000 and 2000 Hz.
4.1.
Disbursement of indemnity and compensation of costs of medical care
4.1.1.
On the basis of the insurance contract, LHV pays the insured a one-time indemnity of 50% of the sum insured and compensates expenses on treatment of the critical illness to the health care service provider up to 50% of the sum insured. LHV does not compensate treatment costs that are subject to compensation or which are insured by the Estonian Health Insurance Fund.
4.1.2.
If the critical illness cannot be treated in the Republic of Estonia, LHV shall under exceptional procedure compensate the costs of treatment outside the Republic of Estonia as well. The costs of medical care must be coordinated with LHV prior to the start of the treatment.
4.1.3.
Following diagnosis of a critical illness, the insured shall submit the following documents in order to apply for the indemnity and compensation of costs of treatment:
4.1.4.
To decide on the disbursement of indemnity and to pay the costs of medical care, LHV is entitled to ask for additional data and documents, to make inquiries (such as to the attending physician and healthcare service providers) and if necessary to involve LHV’s medical expert.
4.1.5.
LHV makes the decision on indemnifying loss within 30 days of receiving all documents and data.
4.1.6.
LHV pays the one-time indemnity of 50% of the sum insured within 3 business days of the decision on indemnity.
4.1.7.
LHV is entitled to decline to pay the indemnity if it proves that the insured has intentionally submitted false or misleading information to LHV or failed to submit significant information related to important circumstances of the insured event.
4.1.8.
The compensation for costs of medical care shall be paid within 3 business days of the decision on indemnity in regard to the corresponding costs and the submission of the medical care invoice substantiating the amount of necessary treatment costs.
4.1.9.
An insurance indemnity paid out groundlessly must be refunded to LHV without delay.
5.1.
Insured event is the initial contraction of the critical illness by the insured. A death resulting from a critical illness within 30 days of the diagnosis of the illness is not an insured event.
5.2.
Persons who at the time of entering into the insurance contract had been diagnosed with the following illnesses are not covered by the insurance for critical illnesses:
5.2.1.
diabetes mellitus;
5.2.2.
AIDS or carrying HIV;
5.2.3.
a disease of the blood, kidneys or respiratory tracts liable to chronic flare-up;
5.2.4.
atherosclerosis;
5.2.5.
psychiatric and chronic severe disease of the nervous system
5.2.6.
hereditary disease if diagnosed prior to entering into the insurance contract.
In addition, the general exclusions specified in the Terms and Conditions of Health Insurance apply.
6.1.
Supervision over LHV’s activity is performed by the Financial Supervision Authority, Sakala 4, 15030 Tallinn. The insured is entitled to lodge a complaint against LHV to the Financial Supervision Authority (tel. 668 0500, email info@fi.ee, website www.fi.ee). The Financial Supervision Authority does not resolve contractual dispute between LHV and the insured.
6.2.
All disputes are resolved by agreement between the parties in accordance with the terms and conditions and the legal acts of the Republic of Estonia.
6.3.
The extrajudicial bodies for resolving disputes are the conciliation body of the Association of Estonian Insurance Companies Mustamäe tee 46, 10621 Tallinn (tel. 667 1800, email lepitus@eksl.ee), and the Consumer Protection and Technical Regulatory Authority, Endla 10a, 10122 Tallinn (tel. 667 2000, email info@ttja.ee).
6.4.
If agreement is not reached the parties have the right to turn to Harju County Court.
Insured event is an accident taking place during the insurance period, due to an injury as a consequence of which the insured develops a permanent disability within one year. Death resulting from an accident is not an insured event.
Insurance coverage is LHV’s obligation as delimited by the terms and conditions of the insurance contract to pay an indemnity in the event of insured events specified in the policy. The insurance coverage applies 24 hours a day and in the Republic of Estonia.
Insurance period is the time period specified in the policy during which insurance coverage is in force. The insurance period is one year unless specified otherwise in the policy.
Insurance policy is the document substantiating conclusion of the insurance contract. It is issued by LHV. The insurance policy is sent to the insurer after the insurance contract is concluded, amended or the insurance period extended.
Sum insured is the maximum amount agreed in the policy which LHV will pay the insured an indemnity in the case of an insured event. The percentage of the payment of the sum insured depends on the degree of severity of the permanent disability. Degrees of severity are described in the terms and conditions of accident insurance.
Accident is an unexpected bodily injury caused by an external influence, due to an injury sustained as a consequence of which the insured person develops a permanent disability within one year.
1.1.
Annex 2 (“Terms and conditions of accident insurance“) is in force only in conjunction with the valid LHV terms and conditions of health insurance. If not specified otherwise in a given provision, terms are defined the same way in both Annex 2 and the terms and conditions of health insurance.
2.1.
Insurance coverage is LHV’s obligation, specified in terms and conditions of the insurance contract, to pay an indemnity in the case of the insured events specified in the policy. Insurance coverage is valid 24 hours a day and in the Republic of Estonia.
Insurance coverage expires in the following cases:
3.1.
An insured event is an unexpected accident that occurs during the validity of the insurance period and caused by an external influence, causing an injury that results in the insured developing a permanent disability within one year.
3.2.
Poisoning caused by e.g. chemical, gas, steam or toxic plants and occurring independently of the intent of the insured is also considered an insured event.
3.3.
The basis for determining the existence and magnitude of the permanent disability is the state of the insured person’s health at a point when one year has passed since the accident.
3.4.
An insured event is not death occurring due to an accident or the occurrence of a permanent disability later than one year after the accident.
3.5.
In the case of an insured event, LHV pays an indemnity to the insured as a one-time payment, the amount of the payment being calculated as a percentage of the sum insured.
3.6.
An indemnity is paid by LHV on the basis of a permanent disability caused by accident.
3.7.
If the degree of severity of the permanent disability sustained by the insured is not described in the terms and conditions of Health Insurance or Annex 2 thereto, LHV shall make the decision on indemnity based on descriptions for similar kinds of injuries and degrees of severity.
3.8.
The total insurance indemnity paid out for multiple insured events within an insurance year can amount to 100% of the sum insured. The amount of indemnity paid out for several injuries sustained in the context of a single insured event may be up to 100% of the sum insured.
3.9.
The insured shall submit the following documents for applying for the indemnity:
3.10.
To decide on the disbursement of indemnity, LHV is entitled to ask for additional data and documents, to make inquiries (such as to the attending physician and healthcare service providers) and if necessary to involve LHV’s medical expert.
3.11.
LHV makes the decision on indemnity within 30 days of receiving all documents and data. Disbursements of indemnity are made by LHV within 3 business days of the decision on indemnity.
3.12.
LHV is entitled to decline to pay indemnity if it proves that the insured has intentionally submitted false or misleading information to LHV or failed to submit significant information related to important circumstances of the insured event.
3.13.
An insurance indemnity paid out groundlessly must be refunded to LHV without delay.
4.1.
It is not an insured event if the accident befell the insured due to an activity specified in the following list or having a similar level of risk as any of said activities or if the insured works in any of the high-risk professions specified in clause 14.3.
4.1.1.
Competitive sport and professional sport activity
Competitive sport does not include public running races and other comparable mass sport events.
4.1.2.
High-risk activity:
4.1.3.
High-risk professions:
4.1.4.
Other:
In addition, general exclusions specified in the Terms and Conditions of Health Insurance apply.
Percentage of the sum insured specified in the insurance contract
Nervous system
| Monoparesis (upper, lower) | 30% |
| Hemiparesis and/or paraparesis | 40% |
| Tetraparesis, loss of coordination, dementia | 70% |
| Monoplegia | 60% |
| Hemiplegia, paraplegia or tetraplegia; decortication syndrome | 100% |
| Disorders of pelvic organs | 70% |
| Severed radial, ulnar or median nerve at forearm and/or wrist level; severed tibial or peroneal nerve at lower leg or ankle | 10% |
| Two or more severed nerves at forearm and/or wrist joint level; severed tibial nerve or peroneal nerve at lower leg and/or ankle joint level | 20% |
| One severed nerve at humeral or femoral level l | 25% |
| Two or more severed nerves at humeral or femoral level | 50% |
Visual organs*
| Paralysis of accommodation in one eye | 15% |
| Hemianopsia, traumatic strabismus caused by injury to the eye muscles, ptosis, diplopia, tunnel vision | 15% |
| Pulsating exophthalmos of one eye | 20% |
| Total loss of vision in one eye | 50% |
| Total loss of vision in sole eye | 100% |
Auditory organs*
| Absence of at least half of earlobe or change in earlobe’s external shape by at least one-half due to trauma | 10% |
| Complete absence of earlobe | 20% |
| Loss of auditory acuity (threshold over 70 dB) | 10% |
| Deafness in one year | 25% |
| Deafness in both ears | 50% |
Respiratory organs
| Partial pneumonectomy (lobe or part of lung) | 20% |
| Pneumonectomy, one lung | 35% |
| Injuries to larynx and trachea with constant need for tracheotomy intubation | 20% |
Digestive tract
| Lingulectomy, distal 1/3 | 15% |
| Lingulectomy, distal 2/3 | 30% |
| Full lingulectomy | 60% |
| Oesophageal stricture (only liquid food) | 40% |
| Oesophageal obstruction (gastrostomy) | 60% |
| Oesophageal colostomy | 75% |
| Partial hepatectomy (resection) | 15% |
| Splenectomy | 10% |
| Gastrectomy | 60% |
Reproductive and urinary organs
| Renectomy, one kidney | 10% |
| Nephrectomy, one kidney | 40% |
| Reduction in bladder volume | 10% |
| Toxic glomerulonephritis, urinary stricture | 25% |
| Traumatic toxicosis, crush syndrome, chronic kidney failure | 30% |
| Urinary obstruction, fistulas of urinary/reproductive organs | 40% |
| Hysterectomy in a patient 50 and younger | 50% |
| Hysterectomy in a patient 51 and older | 10% |
| Penectemy and bilateral orchiectomy | 50% |
| Bilateral ovariotomy, salpingectomy | 30% |
| Bilateral orchiectomy, partial penectomy | 30% |
Spinal column
| Total immobilization of cervical vertebrae due to fracture | 25% |
Shoulder joint
| Ankylosis of shoulder joint | 25% |
| Non-union after fracture of upper arm | 30% |
| Amputation of upper arm | 75% |
| Amputation of sole upper limb | 100% |
Elbow joint
| Ankylosis of elbow joint | 20% |
| Amputation of lower arm | 65% |
| Amputation of lower arm of sole limb | 100% |
| Ankylosis of wrist joint | 20% |
| Amputation of all fingers or hand | 55% |
| Amputation of sole hand | 100% |
Fingers
| Ankylosis of thumb | 10% |
| Ankylosis of finger | 5% |
| Amputation of thumb | 20% |
| Amputation of index finger | 15% |
| Amputation of third, fourth or fifth finger | 5% |
| Amputation of metacarpal | 5% |
Pelvis and hip
| Hemipelvectomy | 75% |
| Ankylosis of hip joint | 30% |
Thigh
| Non-union after femoral fracture | 25% |
| Amputation of thigh | 65% |
| Amputation of thigh of sole limb | 100% |
Knee
| Ankylosis of knee joint | 15% |
| Amputation of lower leg | 50% |
| Amputation of lower leg of sole limb | 100% |
Ankle
| Ankylosis of ankle | 20% |
| Amputation from the ankle | 40% |
Foot
| Ankylosis of foot | 10% |
| Amputation of foot | 20% |
Toes
| Amputation of big toe | 10% |
| Amputation of 1st, 2nd ,3rd or 4th toe | 5% |
*The magnitude of the injury is determined three months after the insured event on the basis of a medical certificate completed in follow-up examination
6.1.
Supervision over LHV’s activity is performed by the Financial Supervision Authority, Sakala 4, 15030 Tallinn. The insured is entitled to lodge a complaint against LHV to the Financial Supervision Authority (tel. 668 0500, email info@fi.ee, website www.fi.ee). The Financial Supervision Authority does not resolve contractual dispute between LHV and the insured.
6.2.
All disputes are resolved by agreement between the parties in accordance with the terms and conditions and the legal acts of the Republic of Estonia.
6.3.
The extrajudicial bodies for resolving disputes are the conciliation body of the Association of Estonian Insurance Companies Mustamäe tee 46, 10621 Tallinn (tel. 667 1800, email lepitus@eksl.ee), and the Consumer Protection and Technical Regulatory Authority, Endla 10a, 10122 Tallinn (tel. 667 2000, email info@ttja.ee).
6.4.
If agreement is not reached the parties have the right to turn to Harju County Court.
This document (hereinafter the Terms and Conditions) sets out the principles and conditions of health insurance offered by AS LHV Kindlustus (hereinafter the Insurer) within the framework of the Confido Health Plan. If you do not understand something while reading the Terms and Conditions, please contact Terviskindlustusagent OÜ (hereinafter: Insurance agent, kindlustus@confido.ee; +372 602 6795) or the Insurer (kindlustus@lhv.ee; +372 699 9111).
Confido Health Plan is a non-life insurance service (hereinafter “health insurance“) developed by the insurer, within the framework of which AS Arstikeskus Confido (hereinafter Confido, registry code 12381384, address Veerenni 51, 10138, Tallinn, Harju County) itself or through its cooperation partners or other service providers offers its health services for employees (and, if applicable, also their close relatives) within the limits of the agreed health insurance risk.
The indemnity limit is the largest indemnified amount per insurance cover for one insured person during the insurance period. The indemnity limit is reduced by the insurance indemnity paid.
A co-policyholder is an insured person.
The insured object is the health of the insured person and the risk of incurring costs related to the provision of health services necessary to maintain it, that is, the insurance risk.
The insured person is the person named as a co-policyholder in the insurance contract. On the basis of the insurance contract, the health insurance risk related to the insured person is insured.
The insurance agent is Terviskindlustusagent OÜ (registration code 16572262, address Veerenni 51, 10138, Tallinn, Harju county).
The insurer is AS LHV Kindlustus (registration code 14973611, address Tartu mnt 2, 10145, Tallinn, Harju county).
Insurance cover is the cover chosen by the policyholder when concluding an insurance contract, to the extent to which a person can be insured, and in the case of an insurance event related to which the insured person can apply for insurance indemnity.
An insurance contract is a contract between the policyholder and the insurer, which enables the insured person to voluntarily join the health insurance plan. The insurance contract consists of the insured person’s application, conditions, insurance offers, insurance policy, information sheet, and other documents certifying the agreements concluded between the insured person, the policyholder, and the insurance agent.
An insurance premium is the fee paid by the policyholder for insurance coverage agreed upon in the insurance contract. The policyholder and the insured person agree that the insured person pays the insurance premium to the insurance agent on behalf of the policyholder.
The insurance period is the period of time specified in the insurance contract, during which the insurance coverage agreed with the insurance contract is in effect and on the basis of which the insurance payments are calculated.
An insurance policy is a document that confirms the conclusion and validity of an insurance contract. Insured persons are added to the insurance policy concluded by the policyholder on the basis of their own application.
The sum insured is the largest sum specified in the insurance contract, which is indemnified for all insured events per insured person during the insurance period. The sum insured is reduced by the paid-out insurance indemnities.
The policyholder is Terviskindlustusagent OÜ, which has concluded an insurance contract with the insurer.
Contact persons are people appointed by the parties to the contract to receive notifications related to the insurance contract and to resolve other current issues.
A deductible is part of the damage specified in the insurance contract, the costs of which are borne by the insured person in the event of an insured event.
The information sheet is the standard form of the insurance product information document stipulated by the European Commission Implementing Regulation (EU) No. 2017/1469.
Health care service is the activity of a health care worker or institution to prevent, diagnose and treat illness, injury, or poisoning. The purpose of providing health care services is to relieve a person’s ailments, prevent deterioration of their health condition or exacerbation of the disease, and restore their health.
The healthcare service provider is Confido and its cooperation partner or another healthcare service provider operating in the territory of Estonia.
An authorized person is a person authorized by the insurance agent and the policyholder to exchange data with the cooperation partner in connection with the conclusion and execution of the insurance contract, including the transmission of encrypted data.
2.1.
The occurrence of the Insurance Protection event selected in the insurance policy is considered an insurance event. When the insured event occurs, the insurance benefit is paid out (all of the following conditions must be met at the same time), reimbursing the costs of the Insured Person to the Health Service:
2.1.1.
which is related to the Insured Person’s health;
2.1.2.
In accordance with and within the limits of the Insurance Coverages provided for in the Insurance Contract;
2.1.3.
to the extent of the Sum Insured and the Limit;
2.1.4.
which is provided during the Insurance Period, except for the waiting period;
2.1.5.
which is indicated by Service providers operating in the territory of Estonia;
2.1.6.
obtained from medical institutions registered in the register of medical institutions and persons registered in the register of medical staff, sports facilities, a point of purchase of optical equipment, or a pharmacy;
2.1.7.
performed with the help of medical technology registered in the state database of technology used for the provision of health care services of the Republic of Estonia, as well as the acquisition of optics or medicines;
2.1.8.
which are not excluded under the Terms and Conditions and which are not subject to indemnification
2.2.
The Insurer pays the Insurance Indemnity:
2.2.1.
To the Insured Person, if the costs of Health Services were borne by the Insured Person themselves; or
2.2.2.
To a Service Provider who has provided Health Services to the Insured Person or has borne the costs related to the said service. In such case, the Insured Person loses the right to claim the Insurance Indemnity.
NB! The Insurance coverage covered by the Insurance Contract is determined by the Insurance Programs selected by the Policyholder for all or each Insured Person separately.
2.3.
Outpatient treatment insurance coverage
2.3.1.
Outpatient treatment – outpatient healthcare service, in which the Insured Person’s visit to the healthcare facility is limited to a few hours, and a 24-hour stay in the hospital is not necessary.
2.3.2.
The Insurer shall reimburse the appointment and consultation fee of the Service Provider, including the family doctor if the contact with the Health Care Service Provider is due to the Insured Event
2.3.3.
The following costs are reimbursed without a doctor’s referral:
2.3.4.
Only the costs of the following procedures with the referral of a doctor are reimbursed:
2.3.5.
A doctor’s referral, a digital referral, an entry in the medical record, an occupational health doctor’s decision, etc., must be issued before the reimbursable test, examination, treatment procedure, or specialist consultation is carried out.
2.3.6.
The following are not covered under the insurance cover of Outpatient Treatment:
2.4.
Mental health insurance coverage
2.4.1.
The following costs are reimbursed without a doctor’s referral:
2.5.
Insurance coverage for special diagnostics
2.5.1.
Only the costs of the following procedures with the referral of a doctor are reimbursed:
2.5.2.
A doctor’s referral, a digital referral, an entry in the medical record, an occupational health doctor’s decision, etc., must be issued before the test, examination, treatment procedure, or specialist medical consultation is carried out.
2.6.
Inpatient treatment insurance coverage
2.6.1.
Inpatient or hospital treatment – Health Care Service, the provision of which requires the Insured Person to stay in a hospital. In the case of Inpatient Services, the Insured Person is obliged to consult with the Insurer in advance.
2.6.2.
Daycare – Health care service in which the Insured Person needs to be monitored in a hospital bed for a few hours due to treatment or examinations but leaves for home in the evening/night.
2.6.3.
The Insurer shall indemnify the costs for paid services in the 24-hour and day inpatient care.
2.6.4.
The following costs are reimbursed:
2.6.5.
The following are not covered under the Insurance Cover of Inpatient Treatment:
2.7.
Insurance coverage for prophylactic health check-ups
2.7.1.
Prophylactic or preventive health examination – a prophylactic health examination is a medical health examination at the request and choice of the Insured Person and for which there is no medical indication.
2.7.2.
The following are reimbursed without a medical indication:
2.7.3.
The following are not eligible for compensation on the basis of prophylactic health check-up insurance coverage:
2.8.
Stomatology insurance coverage
2.8.1.
Stomatology or dentistry – in the narrower sense, dentistry is the correction of dental defects with various filling materials (composite materials, glass ionomers, gold or porcelain inlays).
2.8.2.
On the basis of the insurance contract, expenses related to dental treatment are reimbursed to the extent of the Sum insured specified in the insurance policy.
2.8.3.
Costs of cosmetic whitening or cosmetic operations are not reimbursed under the Insurance Contract.
2.8.4.
The following costs of services related to dental treatment are subject to coverage :
2.8.5.
The following are not subject to compensation:
2.9.
Outpatient rehabilitation insurance coverage
2.9.1.
Outpatient rehabilitation is a type of treatment aimed at restoring, maintaining, or adapting to disability. It is a treatment that restores the ability to work or cope. Rehabilitation applies treatment and operations to comprehensively restore the impaired functions of the Insured Person from the medical, physical, mental, and social aspects.
2.9.2.
Only the following services related to outpatient rehabilitation prescribed by a doctor are covered by compensation:
NB! The exclusion referred to in this clause does not apply if the Health Service covered by the exclusion or the reason for the exclusion is insured under the Insurance Program chosen by the Policyholder with the main and/or supplementary Insurance Protection in accordance with the provisions of clause 2.
3.1.
The following events are not considered insured events, and expenses are not indemnified:
3.1.1.
events caused by force majeure, i.e., an extraordinary event that the Insured Person could not foresee or prevent (e.g., natural disasters, acts of terrorism, riots, strikes and other mass disturbances, war);
3.1.2.
cases emerged as a result of self-medication, use of drugs or narcotics, the use of which is not medically necessary and which, in this case, have not been prescribed by the treating physician;
3.1.3
if the Insured Person has intentionally caused damage to their health, including by attempting suicide;
3.1.4.
cases of alcohol, narcotic drugs, or psychotropic substances. Expenses for the treatment and diagnosis of alcoholism, drug addiction, and toxic addiction, as well as expenses for the detection of alcohol, drugs, and toxic substances in the body;
3.1.5.
events that occurred during the commission of criminally punishable acts by the Insured Person;
3.1.6.
events caused by the Insured Person in connection with a pandemic. A pandemic is considered to be the spread of infectious diseases to the extent that exceeds the usual morbidity or occurrence of the disease for a specific territory and intensive spread in a territory where it has not been recorded before, that covers a large geographical area or a continent, and which has been reported by the responsible institution of the Republic of Estonia;
3.1.7.
cosmetic care and treatment, aesthetic surgery operations and services, including treatment of non-malignant skin tumors (such as birthmarks, papillomas, warts, keratosis), plastic, reconstructive and bariatric surgery, weight loss programs, lymphatic drainage, vacuum massage, radio wave therapy services, pedicure services;
3.1.8.
laser vision correction surgery, organ transplant surgery, venous surgery, sclerotherapy, and paid services
3.1.9.
the cost of purchasing optical products and aids (e.g., corsets, fixators, elastic bandages, plaster, stockings, orthopedic insoles, hygiene kits); the cost of replacement materials used in tissue surgery (e.g., implants, prostheses, meshes);
3.1.10.
diagnosis, treatment, and genetic testing for viral hepatitis C and chronic hepatitis, as well as Hansen’s disease;
3.1.11.
diagnosis and treatment of sexually transmitted diseases, including ureaplasma, HIV and AIDS, spirochetes, and chlamydial infections;
3.1.12.
diagnosis and treatment of fungal diseases, avian and swine flu virus;
3.1.13.
early health checks on drivers;
3.1.14.
immunoglobulin therapy, intravenous laser therapy, laser organ therapy (e.g., incontinence therapy), autohemotherapy (e.g., PRP injections), barotherapy, orthokine injection, intraocular injections;
3.1.15.
services of a narcologist, hypnologist, andrologist, geneticist, a trichologist, technical orthopedist and prosthetist, occupational therapist, sports physician, physiotherapist, rehabilitation specialist or physician of physical and rehabilitation medicine, chiropractor, dietician, nutritionist, homeopath, dentist, cosmetologist, and beautician;
3.1.16.
alternative medicine services (e.g., acupuncture, iridodiagnosis, biomagnetic resonance, electropuncture), complementary medicine services, use of the biofeedback method;
3.1.17.
paid services relating to pregnancy, fetal diagnosis, and childbirth;
3.1.18.
family planning, contraceptive measures, infertility treatment, artificial insemination, abortions without medical indications;
3.1.19.
diagnosis or treatment of congenital pathologies, degenerative diseases, and mental illness;
3.1.20.
general massage, herbal massage, aroma massage, acupuncture, prostate or gynecological massage; whole body diagnostics, polysomnography, examination and treatment of sleep disorders, ambulatory rehabilitation services in a day hospital or rehabilitation centers, overnight stay in a day hospital;
3.1.21.
treatment of diseases included in the public health program to the extent of paid services;
3.1.22.
preparation of medical documents and printing of medical examinations, documents, and other communications as a separate service, including 3D and 4-dimensional examinations related to pregnancy;
3.1.23.
medical services provided without medical indications, as well as the costs of regular health check-ups, etc., palliative care, social welfare;
3.1.24.
educational information sessions, lectures, or courses;
3.1.26.
the stay of a relative or close person with the Insured Person in a hospital;
3.1.26.
preoperative and post-operative care services;
3.1.27.
convenience services such as home visits and transportation.
4.1.
If the Policyholder or the Insured Person does not fulfill any obligation stipulated in the legislation or the Insurance Contract intentionally (including for criminal purposes) or due to gross negligence, the Insurer has the right to refuse payment of the insurance indemnity.
4.2.
The Insurer has the right to refuse payment of the insurance indemnity if the Policyholder and/or the Insured Person does not comply with the Insurer’s written orders, refuses to cooperate, or avoids it.
4.3.
The Insurer has the right to refuse payment of the insurance indemnity if the Policyholder and/or the Insured Person prevents the Insurer from ascertaining the circumstances, does not contribute to it, or provides misleading information or documents, as well as acts in a way to receive an unjustified or larger insurance indemnity or part of it.
4.4.
The Insurer may reduce the indemnity, but not more than 50% (fifty percent), if the Policyholder or the Insured Person fails to comply with any condition prescribed by legislation or the Insurance Contract due to negligence.
6.
Insurance Coverages covered by health insurance, applicable Sums Insured, Limits, and Insurance Premiums covered by the Health Insurance are provided in the Insurance Programs from which the Policyholder can choose and in these Terms and Conditions.
7.
The Policyholder enters into the Insurance Contract for the purpose of insuring the insurance risks related to the Employees and, if applicable, Relatives in order to protect their health and increase the Employees’ ability to work and productivity (insurance interest).
8.
In cooperation with the Insurance Agent, the Policyholder selects the Insurance Programs suitable for his or her Employees and, if applicable, Relatives.
9.
To include employees as Insured Persons in the Insurance Contract, the Policyholder submits an Insurance Application to the Insurance Agent.
10.
The Policyholder’s Authorized Person shall submit the specified data in encrypted form by forwarding them to the Insurance Agent’s Authorized Person.
11.
By transmitting the data to the Insurance Agent, the Policyholder confirms that they are entitled to transmit the data of the Employees (and, if applicable, Relatives) to the Insurance Agent and the Insurer and that the Employees (and, if applicable, Relatives) agree to their inclusion in the Insurance Contract as Insured Persons under the terms of the Insurance Contract.
12.
The Insurer has the right to refuse to include the Employee (or, if applicable, their Relative) as an Insured Person in the Insurance Contract if the person has provided false information or has previously committed insurance fraud or failure to pay insurance premiums in the past or is unsuitable to be an Insured Person for other compelling reasons
13.
In the case of adding the Insured Person to the Insurance contract, the Insurer, through the Insurance Agent, will forward to the Policyholder the Insurance Policy proving the Insurance Coverage, the number of the Insured Person’s Insurance card, and other relevant information. If appropriate, the Insurance Agent, using the Insured Person’s contact details, also transmits information about the Insurance Coverage to the Insured Persons themselves. The Policyholder is obliged to inform the Insured Person of the entry into force of the Insurance Coverage for them and to acquaint them with the terms and conditions of the Insurance Contract.
14.
The Policyholder is bound by the Insurance Application from the moment it is submitted in signed form to the Insurance Agent. Employees (and, if applicable, Relatives) are covered by Insurance from the moment they are entered into the Insurance Contract as Insured Persons. After that, it is possible to deduct the Insured Persons from the Insurance Contract only in accordance with the procedure stipulated in the Terms and Conditions.
15.
The Policyholder is obliged to keep the list of Insured Persons up-to-date and, if necessary, update it immediately. The Policyholder bears the risk if the list of Insured Persons is not up-to-date or the information provided in it is incorrect.
16.
The chosen Insurance Program applies to the Insured Person during the entire Insurance Period. During the Insurance Period, the Policyholder has the right to deduct the Insured Person from the list if the Policyholder has terminated the employment or other service relationship with the Employee. In order to deduct the Insured Person from the Employee list, the Policyholder submits the relevant Employee data to the Insurance Agent. The Employee is considered removed from the list from the date of termination of the employment or other service relationship with the Employee or from another later date specified by the Policyholder, but not earlier than 14 (fourteen) days after the Policyholder informs the Insurance Agent about the Employee’s removal from the list of Insured Persons. Removal of a Relative of the Insured Person from the list of Insured Persons during the Insurance Period is possible only by agreement with the Insurer.
17.
The Insurance Contract is concluded for an indefinite period, and the Insurance Period is 1 (one) year.
18.
No later than 30 (thirty) days before the end of the current Insurance Period, the Policyholder submits a new Insurance Application to the Insurance Agent, on the basis of which the Insurance Agent issues a new Insurance Policy for the following Insurance Period. If the Policyholder does not submit a new Insurance Application, the Insurance Agent shall draw up the Insurance Policy on the basis of the latest available information and forward it to the Policyholder.
19.
The terms of the Insurance Contract can be changed and/or supplemented (including termination) only with the written agreement of the Insurer and the Policyholder, which is formalized as an annex to the Insurance Contract. Regardless of this, the Insurer has the right to unilaterally review and change the terms and conditions of the Insurance Contract in the following cases.
19.1.
The Insurer can unilaterally and without prior notice always changes the terms of the Insurance Contract to be more favorable to the Policyholder/Insured Persons, including reducing the Insurance Premiums, increasing the Insurance Coverage, increasing the Limits, etc.
19.2.
During the current Insurance Period, the Insurer can unilaterally increase the Insurance Payments and/or reduce the scope of the Insurance Coverage, including reducing the Health Services to be reimbursed, reducing the Sum Insured, reducing the Limits, etc., if this is due to a change in the following circumstances:
19.3.
The Insurer can unilaterally change the documents of the Insurance Contract to the extent that is not discussed in the previous point with the aim of specifying the terms of the Insurance Contract.
19.4.
Amendments to the Insurance Contract shall enter into force no earlier than 1 (one) month after notifying the Policyholder of the amendment.
19.5.
The Insurer or Insurance Agent will notify changes to the Insurance Contract in accordance with the procedure provided in the Terms and Conditions.
20.
The Policyholder has the right to cancel the insurance Contract in an orderly manner by notifying the Insurer or the Insurance Agent at least 3 (three) months in advance such that the Insurance Contract ends at the end of the current year.
21.
The Insurer has the right to cancel the Insurance Contract in a regular manner in cases provided by law.
22.
The Insurer has the right to cancel the Insurance Contract in an emergency for the following reasons:
22.1.
The Policyholder is in arrears with the payment of the first or subsequent financial obligation arising from the Insurance Contract beyond the terms provided for in the Terms and Conditions;
22.2.
The Policyholder/Insured Person materially violates the Insurance Contract and does not eliminate the violation additionally within the given term;
22.3.
in case of bankruptcy of the Policyholder.
23.
The Insurer can cancel the Insurance Contract in an extraordinary manner within 1 (one) month after becoming aware of the violation.
24.1.
The Insurance Cover enters into force as of the inclusion of the Insured Person in the Insurance Contract pursuant to the procedure provided in the Terms and Conditions and the date of payment of the first part of the Insurance Premium
24.2.
The Insurer authorizes the Insurance Agent to accept Insurance Premiums.
24.3.
The date of payment of the Insurance Premium is the day when the respective amount of money is received in the current account of the Insurance Agent.
24.4.
In order to pay the Insurance Premiums, the Insurance Agent submits invoices. If applicable, the Insurance Agent submits e-invoices through the e-invoice operator.
24.5.
If the Policyholder pays the Insurance Premiums on the basis of the Insurance Policy issued for the current Insurance Period, the parties shall consider this as the Policyholder’s consent to the insurance contract. If the Insurance Policy differs from the insurance offer, the information and agreements specified in the Insurance Policy are considered valid and correct.
24.6.
Insurance premiums are payable for each Insured Person according to the Insurance Program selected for the said Insured Person.
24.7.
Insurance Premiums are payable for the time when the Insured Person is included in the Insurance Contract and until the end of the Insurance Period, except when the Insurance Coverage is terminated before the end of the Insurance Period in accordance with the Terms and Conditions. Upon termination of the employment or other service relationship between the Insured Person and the Employee by the Policyholder, the Policyholder’s obligation to pay the Insurance Payment ends from the date of termination of the employment or other service relationship with the Employee, but not earlier than 14 (fourteen) days after the Policyholder notifies the Insurance Agent of the Employee’s deduction from the list of Insured Persons. The Policyholder and the Employee may agree that the Insurance Coverage of the departed Employee is valid until the end of the Insurance Period (provided that the Policyholder has paid the Insurance Premiums) or that the Policyholder pays the following Insurance Premiums on the Employee even after termination of employment. The departed Employee can inform the Insurer of the wish to continue using the health insurance service within 1 (one) month from the date of deducting the Employee from the list of Insured Persons. In such a case, the Insurer shall separately assess whether and under what conditions the Insurer can offer similar insurance cover to the Employee.
24.8.
Insurance premiums are paid by the Policyholder on behalf of the Insured Person.
24.9.
The Policyholder pays the Insurance Premiums in quarterly payments according to the invoices presented by the Insurance Agent.
24.10.
Unless otherwise agreed with the Policyholder, the Employee/Relative shall pay the Insurance Premiums for the Relative’s Insurance Coverage, as well as the Employee’s Insurance Coverage, which is not paid for by the Policyholder themselves. In this respect, the Insurance Agent invoices the Relative/Employee directly, and the Insurance Premium is payable at once for the entire Insurance Period. In such a case, the Insurance Premium is deemed to be paid in accordance with the procedure provided for in subsection 1 of § 455 of the Law of Obligations Act. Before payment of the Invoice by the Relative/Employee, the Insurer will not include the Relative/Employee as an Insured Person in the Insurance Contract.
24.11.
If the Insured Person is added to the Insurance Contract or deducted from the Insurance Contract in the middle of the Insurance Period, the Insurance Premium is calculated proportionally to the number of quarters when the Insured Person is added to the Insurance Contract. Invoicing takes place once in 90 days based on the number of employees of the Insured Persons.
24.12.
If an Insured Person additionally joins during the valid insurance contract, their insurance limit and insurance premium are calculated based on the following proportionality:
24.13.
The term for payment of the Invoice is the term indicated on the Invoice, which is not shorter than 14 (fourteen) calendar days. If the Invoice is not paid on time, the Insurance Agent has the right to demand from the payer of the invoice interest on arrears of 0.05% (zero point zero five percent) of the amount not paid on time for each day of delay in payment.
24.14.
Insurance premiums are not subject to reduction due to the taxes applicable to them and, as a result, additionally payable.
24.15.
If the Policyholder has not paid the insurance premium or the first insurance premium within 14 days after the conclusion of the Insurance Contract, the Insurer may withdraw from the Contract until the payment is made. It is assumed that the Insurer has withdrawn from the Contract if they do not file a lawsuit to collect the insurance premium within three months of the payment becoming due. If the Insurance Premium has become due or the first Insurance Payment has not been paid by the time the insured event occurs, the Insurer is released from its obligation to perform.
24.16.
If the second or subsequent installment of the Insurance Premium is not paid on time, the Insurer will grant an additional term for payment (among other things, the Insurance Agent is authorized to grant an additional term). If the installment is not paid for the additional term and the Insured Event occurs after the term for payment of the additional installment, the Insurer shall be released from the obligation to perform. The Insurer also has the right to cancel the Insurance Contract in such a case.
25.1.
The Sum Insured is the maximum amount to which the Insurer compensates the loss.
25.2.
The Sum insured for each Insured Person is indicated in the Insurance Contract for each Insurance Program and Insurance Coverage, and this is the maximum amount paid out by the Insurer in the event of an Insured Event.
25.3.
If several Insured Events occur during the same Insurance Period, the expenses will be indemnified up to the Sum Insured indicated in the Insurance Program/Insurance Coverage.
25.4.
The deductible is the part of the loss specified in the Insurance Contract that is borne by the Insured Person. The deductible is the part of the loss that exceeds the Insurance Indemnity Limit according to the specific Insurance Program. The Insurance Indemnity can never exceed the Sum Insured.
26.1.
Obligation to provide information
26.1.1.
On the day of concluding the Insurance Contract, the Policyholder and the Insured Person must submit to the Insurance Agent and the Insurer all the information required by them, which is necessary for concluding and performing the Insurance Contract.
26.2.
Rights and obligations of the Policyholder
26.2.1.
The Policyholder has the right to:
26.2.2.
The Policyholder is obliged to:
26.3.
Rights and obligations of the Insured Person
26.3.1.
The Insured Person has the right to:
26.3.2.
The Insured Person is obliged to:
26.4.
Rights and obligations of an Insurance Agent:
26.4.1.
The Insurance Agent is obliged to:
26.5.
Rights and obligations of the Insurer
26.5.1.
The Insurer is obliged to:
28.
In the event of damage, the Insured Person is obliged to: consult a doctor as soon as possible, follow the doctor’s prescriptions, and do everything possible to prevent the increase of injuries caused by the insured event and notify the Insurer in writing of the need for treatment in order to obtain a guarantee letter from the Insurer, if the service is provided elsewhere than by a contractual partner of Confido Health Plan.
29.
In case of damage, the Insured Person can turn to the contractual partners of Confido Health Plan ( the list of partners can be found at: www.terviselagendus.ee) or to a suitable healthcare institution for treatment, fulfilling the obligations stipulated in these terms and conditions.
30.
Claim applications can be submitted digitally at www.terviselahendus.ee, by authenticating oneself, if there is no authentication option, one can submit a claim digitally to the e-mail: kahjud@terviselahendus.ee.
31.
The occupational health inspection indemnity is paid to the Policyholder or the Service Provider who provided the occupational health inspection service.
32.
In order to receive Insurance Indemnity, if the Insured Person has paid the bill themselves, the latter must submit the following documents to the Insurer or Insurance Agent as soon as possible, but no later than within 90 (ninety) days of receiving the service:
32.1.
a written statement in a form that can be reproduced in writing;
32.2.
the original Invoice or a certified copy thereof, in which the following information is indicated: service provider, recipient of the service, name of the service, quantity, price, date of provision;
32.3.
other documents required by the Insurer/Insurance Agent regarding the services received by the Insured Person in order to find out the circumstances related to the Insurance Event or to determine the amount of Insurance Indemnity to be paid.
33.
In order to receive insurance indemnity if the insured person has not paid for the Health Services, the Service Provider submits data and documents to the Insurer in accordance with the data volume agreed between the Service Provider and the Insurer.
34.
Upon receipt of the relevant claims from the Insurer, the Insured Person is required to return to the Insurer within 10 (ten) working days at the latest the sums of money that have been paid by the Insurer to the Policyholder, the Service Provider or directly to the Insured Person for the Health Services received by the Insured Person:
34.1.
In case of exceeding the Sum Insured provided for in the Insurance Contract;
34.2.
In case of exceeding the limit provided for in the Insurance Contract, including exceeding the number of paid services;
34.3.
to the extent of payments not provided for in the Insurance Contract;
34.4.
Upon termination of the Insurance Contract or Insurance Card for any reason;
34.5.
If the Insured Person commits fraud or receives Insurance Indemnity for other unjustified reasons.
35.1.
The Insurer processes the data of the Policyholder and the Insured Persons, including special types of personal data, in accordance with the relevant legislation and the Insurer’s customer data processing principles, which are available on the Insurer’s website.
35.2.
The Insurer has the right to obtain information about the Policyholder and the Insured Person from state authorities or the Creditinfo if the Insurer deems it necessary.
36.1.
Priority of insurance contract documents
36.1.1.
In the event of any discrepancies between the documents of the Insurance Contract, the terms and special conditions of the Insurance Program and the Insurance Coverages covered by it shall prevail for the parties.
36.2.
Confidentiality
36.2.1.
The Contracting Parties undertake not to disclose confidential information received within the framework of the Insurance Contract about the participants in the Insurance Contract or third parties, except in the cases provided for in the current legislation of the Republic of Estonia.
36.2.2.
The Insurer has the right to submit information related to the Insurance Contract to experts and reinsurers.
36.2.3.
The Insurer and the Insurance Agent have the right to store information related to the Insurance Contract in the databases of the Insurer and the Insurance Agent, respectively.
36.2.4.
The Insurer and the Insurance Agent have the right to submit the information obtained in connection with the conclusion and execution of the Insurance Contract about the participants in the Insurance Contract to the Service Providers to the extent necessary for the provision of Health Services.
36.3.
Notifications
36.3.1.
The Parties shall forward all notices related to the Insurance Contract through Authorized Persons and Contact Persons.
36.4.
Submitting complaints about the Insurer’s or Insurance Agent’s actions
36.4.1.
The Policyholder, the Insured Person, and the beneficiaries, if appropriate, have the right to file a complaint with the Insurer against the Insurer’s or Insurance Agent’s actions in connection with improper fulfillment of the obligations arising from the Insurance Contract.
36.4.2.
When submitting a complaint, the complainant must provide at least the following information:
36.4.3.
The complaint can be submitted:
36.4.4.
Upon forwarding the complaint to the Insurance Agent, the Insurance Agent shall forward the complaint to the Insurer immediately, but not later than within five (5) business days from the date of receipt of the complaint, and shall notify the complainant thereof.
36.4.5.
Upon receiving a complaint, the Insurer registers the complaint and informs the complainant of the complaint registration number and the deadline for responding in a form that can be reproduced in writing.
36.4.6.
The Insurer shall submit a reasoned written response to the complaint to the complainant within 30 (thirty) days from the day when the complainant has submitted the complaint to the Insurer or the Insurance Agent. In the event that the complaint cannot be resolved within 30 (thirty) days due to its complexity or other reasons, the Insurer shall inform the complainant in writing of the reasons for the extension of the procedure and the additional deadline for responding. The Insurer may extend the term by no more than 4 (four) months from the date of submission of the complaint.
36.4.7.
The Insurer always responds to complaints concerning the activities of the Insurance Agent.
36.4.8.
The Policyholder, the Insured, and the beneficiaries, if applicable, have the right to request (in writing or electronically) from the Insurer additional information on the procedure for handling complaints.
36.4.9.
Complaints processing is free of charge for the complainant.
36.5.
Applicable law
36.5.1.
The legislation in force in the Republic of Estonia is applied to regulate the contractual relations arising from insurance contracts.
36.6.
Settlement of disputes:
36.6.1.
Disputes arising from Insurance Contracts shall be sought to be resolved by agreement of the parties.
36.6.2.
If an agreement is not possible, disputes arising from the Insurance Contract shall be settled in court in accordance with the legislation of the Republic of Estonia.
36.6.3.
The parties to the insurance contract do not have the right to transfer the rights arising from the Contract to third parties.
36.6.4.
The parties to the insurance contract have the right to contact the Insurer for the settlement of the dispute if the differences cannot be resolved:
36.6.5.
The Policyholder has the right to submit a complaint about the activities of the Insurer or the Insurance Agent to the Financial Supervision Authority at Sakala 4, 15030 Tallinn, info@fi.ee.
Call 1330 or write to
kindlustus@confido.ee
Call 1330, write to kindlustus@confido.ee
or book minu.confido.ee