Optional medical insurance against disease
Optional medical insurance against disease is a form of protecting the Insured’s proprietary interests against expenses associated with payment for the insured’s treatment.
According to the optional disease insurance agreement the Insurer guarantees arrangement and financing of medical services from the specified list and of the specified quality, provided by the insured within the range of the insurance program attached to the insurance agreement and forming an integral part thereof.
Territory of the agreement – Republic of Kazakhstan.
Event insured according to this Agreement is reference of the insured to a medical institution during the term of the Agreement, specified in the Insurance agreement. A reason for reference can be acute disease, flare-up of a chronic disease, trauma, poisoning, etc. requiring consultative, diagnostic, therapeutic, rehabilitation, and other assistance specified by the insurance program.
Insured according to this Agreement can be any person in relation to which the Insurance agreement has been concluded. However, children younger than 1 year, persons older than 65, persons registered with drug rehabilitation, psychiatric, tuberculosis, dermatovenerologic, oncologic dispensaries, and HIV-positive persons are not accepted for insurance.
Upon conclusion of an Insurance agreement the Insurer shall give each insured a plastic card containing the following information: the Insured’s full name, Insurer’s name, insurance program title, term of insurance coverage, round-the-clock medical assistance Call- center telephone number, medical coordinator and family physician telephone numbers. The card shall be valid on presentation of the personal ID.
Delivery and provision of medical care under the Agreement shall be performed by engagement of medical assistance (the Insurer’s agents) with a staff of family doctors and a net of accredited healthcare facilities (the List of family doctors and clinics of the Insurer’s agent).
Upon occurrence of an event insured the insured shall act in accordance with the Algorithm of reference to a family doctor, described in this section below. The insured can get out-patient and policlinic care in the clinics that are on the Insurer’s List (Insurer’s Agent’s), on a family doctor’s appointment. If the insurance program provides for a limit on medicines the insured gets them on the family doctor’s prescription in pharmacies that are on the Insurer’s List (Insurer’s Agent’s).
In case of urgent admission to a clinic that is not on the Insurer’s List (Insurer’s Agent’s), as well as to a clinic from the List, the insured (or a relative and a colleague of his) shall notify the medical coordinator, the family doctor, or the insurance company employee about it within 3 working days. Otherwise, the Insurer reserves a right to refuse payment for the medical care got in this clinic. In case of the insured’s admission to hospital, the medicines necessary for in-patient treatment shall be covered by the insurance program.
Dental services are provided to the insured by doctors of dental clinics that are on the Insurer’s List, within the limits for dental care included in the insurance program.
If the insured exceeds the limits included into the insurance program on one or another option, the Insurance agreement with this insured ceases to be effective until payment of the excess expenditure. The insured shall be notified about the overlimit and payment order by the medical coordinator.
The Policy-holder’s (Insured’s) actions on occurrence of an event insured
(Algorithm of reference to a family doctor)
On occurrence of an event insured the Insured shall refer to a coordinating doctor – the Insurer’s Agent in the established reception hours or call the Insurer’s Agent’s call-center to get consultation and arrangement of medical care.
Timely notification of the Insurer’s Agent’s coordinating doctor about occurrence of an event insured is a mandatory condition of getting medical care.
When necessary the Policy-holder (Insured) shall provide information about the event insured to the Insurer (Insurer’ Agent) upon their request.
Provision of medical care to the insured in medical institutions from the Insurer’s Agent’s List shall be arranged by the Insurer’s Agent’s coordinating doctor in accordance with the Attachment to the Agreement.
In case of urgent admission to a clinic that is not on the Insurer’s Agent’s List (as well as to a clinic from the List) and also in view of an urgent event insured, the insured or an authorized representative of his shall advise the Insurer’ Agent medical coordinator of the following:
•personal medical history No, organization name, full personal name of the Insured.
•the Insured’s location, contact telephone numbers;
•brief description of what has happened and what medical care he needs or has already been provided.
If the insured needs out-patient care, he shall refer to the Insurer’s Agent’s coordinating doctor for arrangement and provision of such care.
Admission of the insured to hospital on medical indications shall be performed only on prescription of a doctor from the Insurer’s Agent’s List and his written consent.
Purchasing of medicines shall only be performed on the Insurer’s Agent’s prescription.