RULES
OF VOLUNTARY MEDICAL INSURANCE
Baku 2009
RULES
OF VOLUNTARY MEDICAL INSURANCE
Voluntary Medical Insurance Rules of International Insurance Company OJSC, hereinafter referred
to as “Rules” in the text, have been developed in accordance with the Laws of the Azerbaijan
Republic “On Medical Insurance”, “Insurance Activity” and other legal and standard acts, and
shall be an integral part of all Voluntary Medical Insurance contracts concluded by International
Insurance Company under description “Insurance Contract”.
The type of insurance defined by these Rules shall be related to medical type of insurance.
DEFINITIONS
Voluntary medical insurance is a class of insurance intended to carry out insurance payment in
the amount sufficient to compensate, in full or in part, expenses arising in connection with
medical services provided to Insured person medical companies included in the insurance
program.
Medical insurance contract is a written agreement concluded between Insured and Insurer, as
provided for in the legislation, on defining organization of medical assistance to be provided to
Insured person in accordance with the chosen medical insurance program based on occurrence
of insured event against the relevant insurance premium paid by Insured person, making
insurance payment, as well as rights and obligations of the parties.
Insurance certificate is a document confirming the fact of making of an insurance contract
between Insurer and Insured, and reflecting the basic content of the same contract.
Insurer is a party to an insurance contract, which is responsible for the provision of insurance
payment in case of happening of insured event in the order provided for by legislation or the
insurance contract. For the purposes of these Rules, International Insurance Company OJSC shall
be considered as Insurer.
Insured is a party to an insurance contract, which has paid an insurance premium and has an
insurance interest in the subject of insurance being insured.
Insured person is a person being insured under an insurance contract and using rights arising
from the insurance contract in case of happening of an insured event.
Individual insurance is insurance of solely one person or together with husband/ wife, children,
father and mother, or persons under his/her guardianship.
Group insurance is the case of collective insurance of employees working at one and the same
legal entity.
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Territory of insurance is a territory mentioned in an insurance contract, within the boundaries of
which a subject of insurance shall be considered to have been insured.
Insurance premium is the amount of money to be paid by Insured to Insurer as provided in an
insurance contract in accordance with the insurance legislation against assuming or sharing the
relevant risks by Insurer.
Insurance amount expresses the maximum extent of the insurance payment to be carried out by
Insurer under an insurance contract, and responsibility for risks insured.
Insurance risk is the likelihood of occurrence of an event resulting in creation of expenses
associated with the receipt of medical service by Insured person at a medical establishment, as
well as obligation assumed by Insurer against such likelihood.
Insurance payment is the amount of money to be paid by Insurer to a medical establishment in
the order and within the term provided for in an insurance contract against services provided by
the medical establishment for damage caused to an Insured person’s health, and in case such
medical services have been paid by Insured person, such insurance amount shall be paid to
Insured person.
Deductible is a portion of the insurance payment to be assumed by Insured person within
proportions written in the insurance contract (certificate). In the event that deductible has been
provided for in the contract (certificate), such amount shall in each case be deducted from the
amount of damage.
Unconditional waiting term during this term insurance claim or insurance payment shall not
apply to damages created within the same term elapsed from the moment of occurrence of
insured event.
Existing illnesses are those illnesses that have shown their signs and symptoms before an
insurance contract (certificate) has gained its validity, and were known to Insured person.
Chronic illness or condition is such an illness or damage, which has at least one of the following
signs:
 lasts long and there is no treatment known;
 has a residue or there is likelihood to have residue (from time to time symptoms of the disease
return back);
 is a permanent disease (signs of the disease sometimes decrease, sometimes increase, but it
always exists);
 there is a need for rehabilitation in order to eliminate the disease;
 the disease requires long-lasting examinations, diagnostic tests, examination by a physician
and control of a doctor.
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Urgent and emergency cases are those cases that are not amongst standard exceptions
mentioned in the Rules, and arise as a consequence of a sudden illness or injury and pose threat
to life. Following cases shall be considered as urgent and emergency cases:
 Car accident;
 Myocardial [cardiac] infarction and rhythm
disturbances;
 Hypertonic crisis;
 Asthmatic status and severe failure of
breathing;
 Foreign substance in respiratory tracts;
 Strong and severe bleeding;




 Second and higher category burns;
 Severe damage to eye;
 Thermal shock
 Drowning;
 Fractures and dislocations;
 Severe
work
accidents,
traumatic
amputation of members;
Falling from height or fall of an item on;
 Meningitis, encephalitis;
Electrical shock;
 Intoxications;
Freezing;
 Severe abdominal colic;
Cases causing loss of consciousness (loss of  High temperature (38, 5 and higher).
consciousness happening as a result of
exclusive cases are outside the coverage);
Accident is an instant, unexpected event happening during the term of an insurance event, and
being beyond Insured person’s will.
Health information Form – An insurance contract (certificate) shall be concluded based on
information Form completed by Insured/ Insured person, and this form shall be considered to be
an integral part of the insurance contract (certificate).
Preliminary examination is an examination appointed by Insurer to determine whether or not a
person to be insured will be insured, or on what conditions he/she would be insured.
A medical establishment is a legal person providing medical assistance to Insured in case of
happening of an insured event in accordance with the contract concluded with Insurer and other
services provided for in the contract and receiving payment from Insurer for the services
provided, and having a special permission, also natural persons engaged in private business as
provided for in the legislation.
CHAPTER 1. GENERAL PROVISIONS
Article 1. Subjects of insurance relations
1.1
Subjects of medical insurance relations in accordance with these Rules shall mean Insurer,
Insured, Insured persons, medical establishments and persons (individuals) engaged in
private medical practice as established by the legislation.
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1.2
If Insured is a legal person, acts of its employees, officials and other representatives
authorized on its behalf in accordance with legislation, contract or a power of attorney shall
be considered to be the acts of Insured itself.
1.3
Conclusion of an insurance contract for the benefit of another person shall not release
Insured from obligations under the same contract.
1.4
If another Insured person was not mentioned in an insurance contract, in this case Insured
shall under the same contract be at the same time considered as Insured person.
Article 2.Subject of an insurance contract
An insurance subject under these Rules shall be a natural person, to whom property interests
insured under the insurance contract relate.
CHAPTER 2. INSURANCE COVERAGE
Article 3. Insured accident
3.1
Appeal of Insured person to medical establishments mentioned in an insurance contract to
receive medical assistance during the term of the insurance contract in connection with
injury as a result of his/her suffering from an illness with a sign of fortuity and not listed
among exceptions, or an injury as a result of accident shall be considered to be an insured
accident. Appeal of Insured person to medical establishments in connection with existing
illnesses shall not be considered as an insured accident.
3.2
Unconditional waiting term may be provided for in an insurance contract. During this term,
Insured person’s appeal to a medical establishment to receive medical assistance in
connection with accidents mentioned in an insurance contract and these Rules shall not be
considered as insured accident.
3.3
Insurer shall guarantee that medical expenses of Insured person incurred as a result of
insured accident happening during the term of the insurance contract shall be covered in
accordance with these Rules and to the extent of the amount mentioned in the insurance
contract (Certificate).
Article 4. Claims that may be included in the insurance coverage for additional insurance premium
payment and on conditions that it is shown in the insurance
contract
4.1.
Damages incurred in emergency cases (wars, military conflicts, revolutions, unrests, rebellions, natural
disasters, nuclear explosion, radioactive emanation etc.);
4.2.
examinations carried out with the aim of issuing certificates and other documents (to travel abroad, to be
hired, enter education establishments, carry a gun etc.);
4.3.
injury and damage suffered by Insured person as a consequence of his/her participation in highly dangerous
types of sports;
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4.4.
treatment of alcoholism, drug addiction, toxicomania, and tobacco addiction, or injury and illnesses caused
as a result of drinking alcohol, using drugs, being in toxic dizziness or smoking tobacco;
4.5.
venereal diseases, zoonosis infections, sexually transmitted infections, the examination of venereal diseases,
zoonosis infections, sexually transmitted infections in any case excluding in case of coverage of child birth,
AIDS, mental diseases or grave nervous disorders, epilepsy, their exacerbation, including injuries arising
from mental diseases and somatic diseases;
4.6.
tuberculosis, sarcoidosis, mucoviscidosis;
4.7.
professional diseases as defined by the Legislation of the Azerbaijan Republic;
4.8.
confirmed malignant tumours, new reproductions and blood cancer;
4.9.
severe and chronic radiation diseases, system and diffusive diseases of combining cell, all kinds of non
differentialed kolagenosis, autoimmun diseases;
4.10.
inherited and inborn pathologies;
4.11.
septoplastics, tonsilectomy with the exception of cases associated with danger to life, complications of
atrophic and hypertrophic rinits;
4.12.
childlessness, impotency, sexual disorders, contraceptive treatment;
4.13.
interruption of pregnancy, with the exception of cases associated with danger to life;;
4.14.
plastic surgery, all types of cosmetic services, including cosmetic stomatology;
4.15.
Diseases of organs and tissues requiring transplantation or prosthetics, including endoprosthesis [prosthesic]
replacement, endosynthesis;
4.16.
tooth replacement, placement of pin, including all types of preparation to prosthetics works;
4.17.
treatment of ocular refraction (short-sightedness, farsightedness and astigmatism), detachment of retina;
4.18.
medical devices, hearing aids, glasses, contact lenses, wheelchairs;
4.19.
pancreatic [insular] diabetes, hypertension diseases excluding of hypertension stroke;
4.20.
hepatitis B, hepatitis C;
4.21.
obesity;
4.22.
cardio surgery, angiography, koronography, all kinds of venous failure, varix dilatation of lower extremities
veins, varicosele;
4.23.
chronic diseases, injuries, with the exception of cases of complication;
4.24.
pregnancy and aid to birth giving;
4.25.
chronic kidney and liver disorder, including treatment on conducting haemodialysis and hemosorption,
plasmapheresis;
4.26.
circumcision, with the exception of cases generated as a result of harmful diseases according to medical
indices;
4.27.
treatment of psoriasis, papilloma, erosion, kandiloma, blotches and warts;
4.28.
dandruff and baldness (falling of hair);
4.29.
services provided by a psychoanalyst and psychotherapist;
4.30.
medicines not licensed by the Ministry of Health of Azerbaijan Republic, homoeopathic preparations, all
biological additions, immunostimulants, cosmetic preparations (drugs), tooth pastes, shampoos etc.;
4.31.
physical therapy, massotherapy etc. more than 10 (ten) session during the period covered by the insurance;
4.32.
appointment of surgical operations on plan during last 14(fourteen) days of the term of an insurance
contract;
4.33.
other types of vaccinations, with exception of urgent vaccinations;
4.34.
medical services not provided by the program of services.
illnesses, treatment of which is entrusted by standard acts to state-owned establishments
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Article 5.Exceptions
5.1
Expenses associated with medical assistance and other services provided to Insured person
in connection with below-mentioned, or diseases, complication, accident and other cases
resulted directly from them shall not be included in the insurance coverage:
5.1.1. diseases and injuries generated before the commencement of the insurance term;
5.1.2. suicide attempt, as well as illnesses and injuries being the result of wilfully causing injury
to himself/ herself;
5.1.3. illnesses and injuries arising as a result of Insured person’s acts of criminal nature,
Insured person’s conscientiously jeopardizing his life and health, except in cases where
this is done to safe a human life or property being in danger;
5.1.4. medical examination and treatment not recognized by science or considered to be as
experimental;
5.1.5. medical services provided at medical establishments having no insurance contract with
Insurer or not included in the list of medical establishments of Insurer, and by physicians
working at such establishments, including diagnostics and provision with medicines;
5.1.6. expenses associated with receiving a repeated medical advice on Insured person’s
initiative from another specialist on the same insured accident without the consent of
Insurer.
Article 6.Territory covered by Insurance
6.1
If a specific territory of insurance is shown in an insurance contract, then the insurance
contract shall be enforce only within the boundaries of that specific territory.
6.2
In the event that no specific territory of insurance is shown in an insurance contract, then
the insurance contract shall be effective only within the Republic of Azerbaijan.
CHAPTER 3. INSURANCE CONTRACT (CERTIFICATE)
Article 7.Conclusion of an insurance contract
7.1
Medical insurance shall be carried out in the form of contracts concluded between its
subjects.
7.2
A medical insurance contract shall be concluded in writing as follows:
7.2.1. by means of mutually signing by Insurer and Insured of an insurance contract
drawn up based on these Rules (if Insured is a legal person, should be approved by
its seal);
7.2.2. by means of issuing by Insurer an insurance certificate to Insured, provided it
confirms that Insured agrees to these Rules;
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7.2.3. Unless otherwise is provided for in an insurance contract, an insurance contract
shall enter into force after the first portion of or all insurance premium has been
paid.
Article 8. Insurance certificate’s precedence over the Rules
8.1
Upon concluding an insurance contract, Insured and Insurer may come to agreement on
change or exclusion of certain provisions of these Rules, as well as making certain
amendments thereto, provided that if such modifications do not conflict with the
legislation and State insurance authorities have no objection to them.
Article 9. Essential (special) conditions
9.1.
Performance by Insured of other duties and requirements associated with the subject of
insurance and existing risks may be provided for in an insurance contract as special
conditions.
9.2.
Failure of Insured (Insured person) to meet these conditions shall be the ground for
Insurer to refuse to make insurance payment or terminate the insurance contract earlier.
Article 10. Commencement and expiry of insurance coverage term
10.1
Unless otherwise is provided for in the insurance contract, term of the insurance coverage
shall commence at 24:00 on the date of concluding the insurance contract and expire at
24:00 on the date, on which the term of the insurance contract expires.
Article 11. Increase of insured risk
11.1
Insured shall inform Insurer of all circumstances associated with the increase of insured
risks (generation of circumstances that would cause arising of diseases, or could damage
insured persons’ health condition, or increase of such circumstances etc.) arising after
concluding the insurance contract that my affect Insurer’s decision on whether not to sign
the contract or sign it with a modified content.
11.2
After receiving information about circumstances affecting the increase of insurance risk,
Insurer shall have the right to make change to the conditions of the insurance contract or
require payment of additional insurance premium in proportion to the increased risk.
11.3
If Insured did not agree to changes made to the insurance contract, or refused to pay
additional insurance premium, the insurance contract may be terminated by Insurer in the
order established by the legislation.
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Article 12. Termination of the insurance contract
12.1
If Insured failed to inform Insurer in writing of extension of the insurance contract earlier,
the insurance contract shall lose its force upon the expiry of the term.
12.2
Insurance contract shall be terminated earlier in the following circumstances:
12.2.1
12.2.2
12.2.3
12.2.4
12.2.5
12.2.6
12.2.7
12.2.8
12.2.9
decease of Insured person;
valid court decision invalidating the contract;
liquidation of Insurer as established by current legislation;
if an Insured – legal person is liquidated, Insured person’s refusal to assume the
obligation to pay the insurance premium;
in case if Insured failed to pay insurance premium as provided for in the legislation
and the insurance contract;
at the request of Insurer, if Insured did not accept the request with regard to making
change to the insurance contract in connection with the increase of insured risks, or
payment of additional insurance premium in proportion to the increased risk;
at the request of Insurer or Insured or upon mutual agreement of the parties. A party
wiling to terminate the contract shall, at least 30 days in advance (60 days if the
insurance contract was concluded for longer than five years, 5 business days, if the
contract was concluded for less than 3 months), send a written notice to the other
party substantiating the request.
if Insurer has performed its obligations before Insured (Insured person), i.e. total
amount of payments made by Insurer for accidents occurred during the term of the
contract has amounted to the amount of the sum insured;
in other cases provided for by the legislation.
Article 13. Return of insurance premium upon termination of an insurance contract
13.1
13.2
If an insurance contract is terminated earlier at the request of Insured (in case of group
insurance, also in relation to any subject of insurance), with the exception of cases
provided for in the insurance legislation, Insurer shall, having deducted costs associated
with carrying out works under this contract (in case of group insurance, also in relation to
any subject of insurance), return the portion of the insurance premium for the reaming
term to Insured; if this request is associated with failure of Insurer to perform its
obligations under the insurance contract, Insurer shall return insurance premiums (in case
of group insurance, also insurance premium paid on any subject of insurance of the
contract) to Insured in full.
In the event that the insurance contract (in case of group insurance, also in relation to any
insurance subject of the contract) is terminated earlier at Insurer’s request, Insurer shall
return the insurance premium in full (in case of group insurance, also in relation to any
insurance subject of the contract); if this request was associated with failure of Insured to
perform its obligations under the insurance contract, Insurer shall, having deducted costs
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13.3
13.4
13.5
13.6
on carrying out works under the contract, return insurance premiums (in case of group
insurance, also insurance premiums paid on any one insurance subject) for the remaining
portion of the term to Insured.
In case of early termination of the insurance contract (in case of group insurance, also in
relation to any insurance subject of the contract), if until such termination Insurer had
carried out insurance payment to Insured equal to or over the amount of the insurance
premium paid by Insured (in case of group insurance, also insurance premiums paid on
any insurance subject of the contract), no insurance premium (in case of group insurance,
also insurance premiums paid on any insurance subject of the contract) shall be returned
to Insured.
In case of early termination of the insurance contract, if until such termination Insurer had
carried out insurance payment to Insured being less than the amount of the insurance
premium paid by Insured (in case of group insurance, also insurance premiums paid on
any insurance subject of the contract), payment of the difference between the insurance
premium paid and the amount of insurance payment actually made shall accordingly be
carried out in the order provided for in paragraphs 13.1 and 13.2 of this article.
In case the insurance contract is deemed to have been terminated as provided for in the
relevant legislation of the Azerbaijan Republic, Insurer shall, having deducted costs
incurred in connection with carrying out works under the contract, return the insurance
premiums for the remaining portion of the term (in case of group insurance, also in
relation to any insurance subject of the contract) taking into consideration the
requirements of paragraphs 13,3 and 13.4 of this Article, to the legal representative of
Insured.
Unless other case has been provided for in the insurance contract, cost of carrying out
work shall be understood to be administrative expenses and insurance payment.
CHAPTER 4. SUM INSURED AND INSURANCE PREMIUM
Article 14. Sum insured
14.1
Sum insured shall be determined according to an insurance contract, in compliance with
the medical program independently chosen by Insured.
Article 15. Insurance premium
15.1.
15.2.
Insurance premium shall be calculated taking into account the term of an insurance
contract, result of the medical inquiry, sex and age of Insured person, medical services
chosen by Insured person, medical establishments, and other circumstances provided for
in the insurance contract.
Unless otherwise is provided for in the contract, insurance premium to be paid for
Insured persons added to the insurance contract during the term of insurance shall be
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calculated according to a schedule (Schedule 1), which is an integral part of these Rules,
and shall be shown in an appendix to the insurance contract. Insurance premiums on
contracts concluded for less than a year shall be calculated based on that schedule
(Schedule 1).
Article 16. Payment of insurance premium
16.1.
Insurance premium shall be calculated by Insurer based on information provided by
Insured and shall be shown in Insurance Certificates and Appendices to the insurance
contract.
16.2.
In the event that insurance premium or its first portion was not paid within the term
mentioned in the insurance contract, Insurer may establish additional payment term in
accordance with the legislation for the payment of insurance premium. If insurance
premium was not paid during the established term, Insurer shall gain the right to stop
providing medical services to Insured persons, and the insurance contract shall be
considered to have been terminated upon the expiry of the period, for which insurance
premium had been paid.
16.3.
If, in case of payment of insurance premium by instalments, time for payment of the next
portion of the insurance premium was delayed and an insured accident happened during
this period of delay, Insurer may ask for the payment of unpaid portion of the insurance
premium. Insurer may also deduct such unpaid insurance amount from the insurance
payment upon making such insurance payment.
16.4.
In the event that insurance premium or its first part was not paid within the payment
period mentioned in the instance contract, Insurer may establish additional payment in
accordance with the legislation to ensure payment of the insurance premium. If the
insurance premium was not paid within the established term, Insurer may refuse to make
insurance payment if an insured accident had happened.
16.5.
Termination of the insurance contract by Insurer due to Insured’s failure to pay insurance
premium shall not release Insured from his obligation to pay the portion of the insurance
premium to Insurer for the appropriate term of obligations.
16.6.
Any other person may pay insurance premium by Insured’s instruction, provided that
Insurer is notified thereof in advance, however the person, who has made such payment,
shall not gain any right under the insurance contract.
16.7.
Following shall be considered to be the day of payment of insurance premium:
a) in case of payment by cash – the day of payment of the insurance premium to Insurer’s
cash office, or its authorized representative or broker;
b) in case of non-cash payment (transfer) – the day, on which the monetary funds have
entered the bank account of Insurer, or insurance agency or a broker.
CHAPTER 5. RULES OF ORGANIZATION OF MEDICAL SERVICE
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Article 17. Obligation to provide information
17.1.
In case of occurrence of an insured accident, Insured (Insured person) shall call the
supervisory service using the phone number mentioned on the insurance card and shall
be sent to one of the medical establishments mentioned in the document attached to the
insurance contract.
17.2.
Any diagnostics, prophylactic or treatment actions shall only be carried out on doctor’s
order.
17.3.
Insurer shall pay charges for medical services provided to Insured person in accordance
with the insurance contract to medical establishments (provided that, if deductible has
been provided for in the contract, the deductible should be deducted).
17.4.
In the event that Insured person has, after having agreed with Insurer, paid the fees for
the medical services provided:
17.4.1. Upon provision of the application by Insured person showing the medical
establishment, having attached the original of the invoice paid, list and prices of
services provided, receipt, appointment card, extract from outpatient’s or inpatient’s
medical card, Insurer shall reimburse the appropriate medical services (if such service
has been organized or agreed by Insurer) paid by Insured person.
17.4.2. Application of Insured person shall be presented to Insurer not later than within one
month from the moment of provision of the medical services. Payment shall be made
within 15 days from the date of provision of all necessary documents by Insured
person. Amount of the payment shall be determined taking into account the average
price of similar services at the medical establishments mentioned in the list attached to
the insurance contract.
Article 18. Rights and obligations of the parties during the term of the contract
18.1
Rights of Insured:
18.1.1 Check compliance by Insurer with the conditions of the insurance contract, as well as
obtain non-confidential information from Insurer about its financial stability;
18.1.2 Request that medical services are provided to Insured persons at medical
establishments in accordance with the medical program and in the order agreed in the
conditions of the insurance contract;
18.1.3 Order Insurer to organize medical services mentioned in the insurance program,
provided that their costs are either paid in advance or after the services have been
provided.
18.2
Obligations of the Insured:
18.2.1. to pay insurance premium in the amount and within the term established by the
insurance contract;
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18.2.2 provide information required for the conclusion of an insurance contract, as well as
other information associated with the insurance contract;
18.2.3 while making an insurance contract, Insured should provide Insurer with information
known to him, which could affect Insurer’s decision as to whether not to conclude the
contract or conclude it with a modified content;
18.2.4 to ensure safeguarding of documents related to the insurance contract;
18.2.5 to familiarize Insured persons with the insurance contract and appendices enclosed
thereto;
18.2.6 to immediately inform Insurer in writing (letter, email, fax) of any changes made to the
list of Insured persons within the term of validity of the insurance contract;
18.2.7 upon expiry of the insurance term, or when any Insured person is excluded from the
list of insured persons, to return the relevant insurance card (or cards) within 7(seven)
calendar days from the date of expiry of insurance coverage.
18.3
Rights of Insured person:
18.3.1 to choose one of the medical establishments mentioned in the appendix made to the
insurance contract;
18.3.2 to choose any physician among physicians involved in the implementation of the
medical insurance program;
18.3.3 to appeal to Insurer, of which telephone numbers are shown on the insurance card, in
order to receive explanations about the characteristics of the medical coverage, as well
as medical and organizational assistance;
18.3.4 except for Sundays and holidays, to appeal for outpatient – polyclinic services every
day from 09:00 to 18:00;
18.3.5 in case of arising disputable circumstances in connection with providing medical
assistance, to appeal to Insurer;
18.3.6 in case of decease of Insured- a natural person, or if Insured being a legal entity is
liquidated as provided for in the legislation, as well as if Insured and Insurer have
come to agreement on this, to perform the obligations of Insured and obtain all rights
of Insured under the contract;
18.4
Obligations of Insured person:
18.4.1 Insured person should receive consent from Insurer by having contacted Insurer
beforehand in order to receive medical assistance. In the event that Insured person was
hospitalized in urgent and emergency conditions and there was no chance to contact
Insurer, Insurer should be informed of the case as soon as possible after the patient
was placed in the hospital, and in any case not later than 48 hours from the moment of
placement in the hospital.
18.4.2 comply with the instructions of a physician while providing medical assistance, and
observe the rules of the medical establishment;
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18.4.3 treat insurance documents with care and prevent from transfer of these documents to
other persons with the objective of receiving medical services. If the fact of transfer of
the insurance card to another person in order to receive medical assistance under the
insurance contract is confirmed, the insurance contract’s validity in relation to Insured
person will be stopped from that very moment;
18.4.4 to pass preliminary medical examination, if provided for in the conditions of the
insurance contract;
18.4.5 provide all necessary information to supervisor (dispatcher).
18.4.6 in the event that deductible has been provided by the insurance contract, to pay the
deductible to the medical establishment, which has provided medical assistance;
18.5
Obligations of Insurer:
18.5.1. to provide Insured (Insured person) with Insurance Certificate and insurance card
within the established time;
18.5.2. to carry out payment, based on the relevant documents, of medical services in
accordance with the contract made between Insurer and medical establishment on
provision of medical services in case of occurrence of insured accident;
18.5.3. to ensure confidentiality in the relations with Insurer;
18.5.4. to defend Insured persons’ rights in relations with medical establishments within the
frame of the insurance contract;
18.5.5. In accordance with the legislation, Insurer shall be responsible for dissemination by its
own employees of information associated with the insurance contract, including secret
of a physician.
18.6. Rights of Insurer:
18.6.1
18.6.2
18.6.3
18.6.4
18.6.5
18.6.6
to check information provided by Insured, as well as compliance by Insured and
Insured person with the conditions of the insurance contract;
in cases provided for in the Rules, including in the event that the insurance card was
given by Insured person to a third person with the view of receiving medical
assistance, to refuse to carry out insurance payment, if such payments have already
been carried out, to ask for return by Insured or Insured person of such amounts;
if it is discovered that Insured (Insured person) had provided to Insurer false
information about circumstances known to him/it being essential in the assessment
of the risk, and about insured accident, to refuse to carry out insurance payment;
in the event that there has been raised criminal proceeding on the accident and facts
that have led to traumatic injury caused to Insured person or otherwise disorder of
his/her health condition, to postpone payments on medical services until the relevant
decision is made by authorized bodies;
to terminate the insurance contract in the order and on conditions provided for in
these Rules;
to suspend providing services to Insured persons or terminate the Insured contract, if
unpaid amount of the insurance premium was not paid within the term mentioned
in the insurance contract;
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18.6.7
not to accept Insured’s (Insured person’s) request concerning the change of a
treating doctor or medical establishment if there was not sufficient ground;
18.6.8 to require that Insured person be examined as to whether or not Insured person was
under the influence of alcohol, drug or toxic substances, if Insured person had
applied for provision of medical service in connection with his/her injury;
18.6.9 in the event that Insured person refused to undergo examination to check whether or
not he/she was under the influence of alcohol, drug or toxic substances, Insurer may
refuse to carry out payment of medical services associated with the damage caused;
18.6.10 to bring an action to court in the order provided for in the legislation to insure
payment of damage caused to Insured person due to the fault of the medical
establishment and/ or medical person.
Article 19. Supervision by Insurer
19.1.
Insurer shall, in accordance with the conditions of the insurance contract, have the right
to carry out control over the volume, term and quality of services provided to Insured
person.
CHAPTER 6. INSURANCE PAYMENT
Article 20. Insurance payment and the rule of carrying out such payment
20.1
Insurer shall pay cost of medical services provided to Insured person under the insurance
contract concluded on the basis of these Rules to a medical establishment (in the event
that there has been provided deductible in the insurance contract, deducting the
deductible ).
20.2
The sum of all payments carried out by Insurer during the term of validity of the
insurance contract may not exceed the sum insured shown in the insurance contract.
20.3
Rule of reimbursement of costs of medical services provided to Insured person shall be
determined by a relevant contract made between Insurer and a medical establishment or a
person practicing private medical activity.
20.4
In case Insured person had wilfully organized provision of medical assistance without a
written consent of Insurer, Insurer shall not be responsible for the quality of the medical
service and for expenses incurred by Insured person.
20.5
With the exception of emergency circumstances, Insurer shall not be responsible to
reimburse costs incurred for the provision of medical service at medical establishments
not agreed upon in the insurance contract without written consent of Insurer. In the event
that there is written consent of Insurer, payment for such medical services provided at
such medical establishments shall be carried out based on the price lists of medical
establishments provided for in the insurance contract.
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20.6
In case Insured person did not comply with the medical prescriptions, recommendations
of medical staff and the rules and regulations established at the medical establishment,
and if the medical establishment has stopped provision of outpatient services or in-patient
assistance having notified Insurer thereof, Insurer may refuse to cover the expenses for
medical services provided so far and as well as other additional expenses incurred as a
result of this. In this case, obligation for payment of medical services provided so far shall
relate to Insured.
20.7
In case Insured person refused to be placed in a hospital under doctor’s order, Insurer
may refuse to provide coverage for medical services directed to Insured person’s
treatment due to complications of the illness.
20.8
In the event that after Insured person is placed in a hospital or after applying to receive
outpatient medical service it is established that the accident occurred was not an insured
accident under the insurance contract, then obligation for payment of medical services
provided at the medical establishment shall relate to Insured person.
20.9
If provision of medical service as a result of insured accident occurred during the term of
validity of the insurance contract shall be necessary to continue after the expiry of the
insurance contract, then insurance payments for medical services shall be carried out as
follows:
20.9.1 in severe period of illness during outpatient treatment – until medical certificate is
closed, provided that it is not longer than 3 (three) days from the date of expiry of the
insurance term;
20.9.2 during emergency placement in a hospital – until the patient leaves the hospital,
provided that it is not longer than 5 (five) days from the date of expiry of the insurance
term;
20.9.3 during planned placement of a patient in a hospital – until the insurance contract loses
its force.
20.10 Insured shall return the amount spent for medical services provided to a person who had
used the insurance card illegally directly by Insured’s fault (or of Insured person’s).
20.11 In case Insured person failed to visit a doctor at the time of appointment without having
notified Insurer, or if Insured person was not at the mentioned address at the time of
calling urgent and emergency medical assistance team, Insured(Insured person) shall
reimburse Insurer the expenses paid by Insurer to a medical establishment.
Article 21. Payment term and required documents
21.1
Depending on the type of payment, from the moment when the following documents
have to be presented by the parties to Insurer, Insurer shall make decision within 15
business day with regard to whether to make insurance payment or refuse to make such
payment:
- register of services reflecting information such as insured person, type of service, number,
cost of services, etc.;
- invoice;
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- medical documents confirming Insured person’s diagnosis (copy of the outpatient card,
epacris etc.);
- copy of the insurance card;
- copy of Insured person’s identity card;
- other documents associated with the essence of the insured accident.
Article 22. Grounds for refusal to make insurance payment
22.1.
Insurer shall refuse to make insurance payment in the following cases:
22.1.1 If the accident occurred can not be considered as an insured accident under the
legislation, these Rules and the insurance contract;
22.1.2 Subject to item 18.2.3, Insurer is deprived completely or partially of a possibility to
assess the insured risk, as well as determine the causes of happening of the insured
accident or the volume of damage caused as a result of wilfully provision by Insured
and/ or Insured person of false information to Insurer about Insured person and/ or
insured accident;
22.1.3 If interests of Insurer were damaged in connection with complete or partial
deprivation of the possibility to determine the causes of the accident and/ or the
damage caused as a result of failure to meet the requirements of item18.4.1;
22.1.4 Preventing by Insured or Insured person Insurer from carrying out investigation of
causes of the insured accident;
22.1.5 In other cases provided for in the legislation.
Article 23. Subrogation right
23.1
After insurance payment has been made, the right to raise a claim in the order of
subrogation against a third person, who is responsible for damage caused to Insured
person, shall be transferred to Insurer to the extent of the amount paid.
23.2
Insured (Insured person) should assist Insurer within their capabilities to ensure that
Insurer’s subrogation right is secured, and shall provide Insurer with all documents,
evidences and information being necessary to raise a claim.
23.3
Amounts of coverage received by Insured(Insured person) from any court based on
outside agreement or from persons being responsible under a court decision will first be
spent to reimburse the insurance payments carried out by Insurer under the insurance
contract.
23.4
With the exception of cases when there is such agreement between Insured and Insurer
and such agreement is mentioned in the insurance contract, if Insured (Insured person)
refused to raise claim against the person, who had caused the damage, or exercise the
rights securing the claim, or to present necessary documents to Insurer, Insurer shall be
released from making insurance payment to the extent Insurer could have received in the
order of subrogation from the person who had caused the damage, and shall gain the
right to return the whole insurance payment paid, or its relevant portion.
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23.5
If payment of the damage has been carried out by the persons who had caused the
damage, Insurer shall only pay the difference between the amount of damage to be paid
and the amount paid by third persons (that have caused damage). Insured (Insured
person) or a beneficiary shall promptly inform Insurer of any payments actually made or
would be paid by persons who had caused the damage.
Article 24. Consideration of unpaid insurance premium
If the relevant insurance premium (or its portion) has not been paid in full until insurance
payment is given, Insurer shall have the right to deduct the amount of unpaid insurance
premium when making the insurance payment.
25. Responsibilities of the parties
25.1. This contract has been drawn up in accordance with the legislation of the Azerbaijan
Republic and shall be executed by the parties properly.
25.2. If one of the parties hereto failed to perform the obligations arising from the contract, or
performed them insufficiently, such party shall compensate the damage caused to the other
party as a result of such failure as provided for by the current legislation of the Azerbaijan
Republic.
25.3. None of the parties hereto shall have the right to assign the relevant obligations to a third
party without the consent of the other.
Article 26. Settlement of disputes
All disputes arising from the insurance contract concluded on the basis of these Rules shall first
be settled through negotiations between the parties, in the order of complaint, and if no
settlement was possible to reach by this way, they shall be solved at courts in accordance with
the current legislation of the Azerbaijan Republic.
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