Health insurance

The Insurer shall not pay the cost, unless otherwise provided for in the Insurance Program: medical and other services that do not comply with current treatment protocols (international clinical protocols in accordance with Order of the Ministry of Health of Ukraine No. 1422 dated December 29, 2016, which are available on the website: http://guidelines.moz.gov.ua/ or in accordance with the current Protocols and Standards of Medical Care posted on the website of the State Enterprise “State Expert Center of the Ministry of Health of Ukraine” mtd.dec.gov.ua);

medical care provided for any disease or injury that already existed or is the result of any disease or injury that existed before the commencement of this Agreement, except for exacerbation of chronic diseases, unless otherwise provided by the Insurance Program;
medical care provided by the HCI outside the place of the Agreement;
medical care (services) provided to the protected person for any illness or injury that occurred to the protected person as a result of military (combat) operations (even if the war has not been officially declared), participation in strikes, demonstrations, civil unrest, terrorist acts, participation in any military or military-type operations, anti-terrorist operations, operations aimed at establishing public order, etc;
medical care (services) provided by a healthcare organization as a result of diseases or conditions of the body or delayed consequences of a health disorder caused by exposure to ionizing radiation, radioactive, toxic, chemical substances, including in connection with the contamination of the territory with these substances and/or elimination of the consequences of such contamination by the healthcare organization, treatment of acute and chronic radiation injuries;
medical services provided in connection with the need to obtain a permit to drive a car, the right to use weapons, and other certificates (admission to educational/children’s institutions, etc.) not related to the treatment process, except for certificates for visiting the swimming pool. It also does not pay for the cost of vocational aptitude tests, dispensary examinations, and follow-up;
medical care as a result of an illness or accident related to flights in any aircraft, except when the HCP acts as a passenger of a civilian aircraft whose owner/carrier has a state license for air transportation of passengers;
medical care (services) provided by a health care organization for any disease or injury that occurred as a result of unlawful actions or inaction of the health care organization that provide for bringing a person to criminal or administrative liability;
staying in a hospital to receive nursing care;
services and goods that are not medically necessary for the diagnosis or treatment of a disease, including payment for 2 or more drugs with the same main active ingredient (for 1 nosology), except when prescribed in a hospital setting (of the same pharmacotherapeutic group (http://mozdocs.kiev.ua) for outpatient care);
receiving services, medications, treatment, including any period of inpatient stay or outpatient treatment, which were not recommended in writing by medical institutions, certified by the doctors of the medical center and/or the Assistance Company as prescribed in accordance with the protocols of the Ministry of Health;
treatment of injuries sustained by a person as a result of driving a vehicle under the influence of alcohol, drugs or other intoxication or under the influence of drugs that reduce attention and reaction time, as well as as a result of transferring control of the vehicle to a person who was in a state of such intoxication or under the influence of such drugs, or transferring control of the vehicle to a person who does not have the appropriate right to drive a vehicle, injuries sustained by a person as a result of a road traffic accident, provided that the person is aware of the
plastic and reconstructive surgeries (including planned hernioplasty, rhinoplasty, venectomy), cosmetic surgeries and procedures, surgeries on the heart, conduction system and blood vessels, except for cases related to restoration of functions impaired as a result of an accident occurred during the period of validity of the Agreement;
purchase of medical equipment, medical devices (medical devices) that replace and/or correct the functions of the affected organs, including temporary devices used in metal osteosynthesis operations, hernia mesh, stents, embolization kits, de-arterization kits, artificial ligaments, arthroscopic kits, prostheses, resolving bolts, screws, spokes, praline mesh, electrodes, cutting hinges, orthoses, denture retainers;
fixators and equipment for osteosynthesis;
use of medicines and other substances, as well as the use of treatment methods not prescribed by a doctor (self-medication);
medical care, the necessity of which arose in connection with suicide or suicide attempt, intentional self-inflicted bodily harm, except in cases where the Insured was brought to such a state by illegal actions of third parties;
treatment in medical institutions, in cases that are not urgent (non-emergency cases) and that are not agreed with the Assistance Company;

outpatient care: manual therapy, kinesitherapy, exercise therapy, acupuncture, massage.

The Insurer does not pay for the costs of treatment of chronic diseases (diagnostics and treatment) (except for exacerbations that threaten the life of the Insured), including:

chronic allergic diseases (allergic rhinitis, allergic dermatitis, allergic conjunctivitis, etc.), except in cases of decompensation states that threaten the life of the person with disabilities (for example, Quincke’s edema, anaphylactic shock, pulmonary edema);
The Insurer shall not pay medical expenses in case of the following diseases and health disorders (diagnostics and treatment), unless otherwise provided by the Insurance Programcervical dysplasia, any medical care directly or indirectly related to male or female infertility or birth control, artificial termination of pregnancy (except for termination of pregnancy for medical reasons), artificial insemination, sexual dysfunctions, menopause, depleted ovary syndrome, menstrual disorders polycystic ovaries, galactorrhea, as well as contraceptive operations (intrauterine device insertion, sterilization operations), sex reassignment surgery, determination of reproductive panel hormones, as well as diagnosis and treatment of dyshormonal conditions (prostate adenoma, endometriosis, fibroid, mastopathy, hyperprolactinemia, hyperandrogenism);
providing pregnancy detection tests;
treatment of human immunodeficiency virus (HIV) infection and related diseases, including acquired immunodeficiency syndrome (AIDS), AIDS complex, as well as their derivatives or varieties of diseases, regardless of the cause, any other immunodeficiency conditions;
treatment of alcoholism, drug addiction, substance abuse or other addictive condition of any kind, as well as treatment of any diseases or injuries directly or indirectly caused by such addiction, use of alcohol, drugs or toxic substances, or which directly or indirectly result from alcohol or drug intoxication;
Medical care provided in connection with mental illnesses, mental disorders and their complications. Various injuries and somatic diseases that have arisen in connection with mental illnesses;
cosmetic surgeries (including dental) and treatment of the consequences of any cosmetic surgeries, treatment courses for obesity;
surgical interventions related to transplantation of organs and tissues of the body (except for tissue transplantation as a stage of treatment of traumatic injuries), prosthetics, endoprosthetics;
medical services related to donor operations when the donor or recipient is a healthcare organization, as well as the consequences of these operations;
rehabilitation, except in cases of necessary rehabilitation after inpatient treatment of acute illnesses or injuries for a period not exceeding 14 (fourteen) days;
prosthetics of limb and eye defects;
preventive treatment, sanatorium treatment;
treatment of any congenital defects or anomalies;
hereditary diseases (including those with chromosomal abnormalities);
treatment of speech defects;
treatment of dry eye syndrome;
eye pathology requiring the use of “artificial tears”;
consultations, diagnostics and treatment of invasive diseases of the gastrointestinal tract (amoebiasis, giardiasis, ascariasis, etc.) and other organs;
rheumatism, sarcoidosis, and cystic fibrosis, regardless of the clinical form and stage of the process;
Age-related and degenerative-dystrophic changes and diseases (cardio- and pneumosclerosis, atherosclerosis, deforming osteoarthritis, osteoporosis, encephalopathy, etc.);
systemic connective tissue diseases (OA, rheumatoid arthritis, gout, systemic lupus erythematosus, etc.) and their consequences;
blood diseases, chronic peripheral vascular diseases (obliterative endarteritis, obliterative atherosclerosis, Raynaud’s disease, chronic venous insufficiency);
varicose veins, except for acute conditions, namely: acute thrombophlebitis, phlebothrombosis, hemorrhoidal thrombosis, acute hemorrhoids, hemorrhoidal bleeding);
vertebral hernia, spondyloarthrosis, spondylolisthesis, osteochondrosis, except in cases of acute pain relief (pain, muscle-tonic and edema syndromes);
autoimmune and demyelinating diseases;
Dermatological diseases (including psoriasis, neurodermatitis, eczema, seborrhea, sunburn, mycoses, scabies, vitiligo, pediculosis, atopic dermatitis, acne, corns, warts, papillomas, alopecia, contagious molluscum, demodicosis), and other parasitic skin diseases;
irritable bowel syndrome, dysbiosis, dysbiosis, dyspancreatitis;
inpatient treatment that continues after the expiration of the Agreement and lasts more than 14 days;
especially dangerous infections (smallpox, plague, cholera, anthrax, etc.) if the government or other competent authorities declare an epidemic situation for this infection;
tumors of benign and malignant diseases, oncological diseases, unless otherwise provided by the Insurance Program;

The Insurer shall not pay the cost unless otherwise provided for in the Insurance Program:
general stimulants (Bitner’s Balm, Biovital, etc.), biologically active additives (dietary supplements) and food additives (additives), general enzymes (wobenzyme, phlogensyme, etc.), hypolipidemic drugs (including statins, except in cases of acute myocardial infarction within 2 months), prostaglandins;
Immunomodulators, biostimulants, bacteriophages, adaptogens, psychotropic drugs (neuroleptics, tranquilizers, antidepressants), sleeping pills and sedatives (Persen, etc.), cytostatics, ursodeoxycholic acid preparations (ursophalk, etc.) agonists and antagonists of gonadotropin-releasing hormones, materials for allografting and xenoplasty, allergy screening, allergy panels, immunograms, lipidograms, systemic immunotherapy of allergic diseases;
disinfectants, medical instruments, hygiene and care products, shampoos, creams, pastes, etc;
drugs for vaccination, except for influenza vaccination;
carrying out vision correction procedures, including those for computer syndrome, myopia, hyperopia, astigmatism, cone, strabismus, amblyopia, glaucoma (including hardware treatment). The use of laser treatment technologies, including preventive laser coagulation of the retina;
diagnostics and treatment of functional disorders, dystonias of various genesis (including vegetative-vascular dystonia (VVD, NCD), periods of adaptation of the body, except for the period of emergency care;
complex treatment of diseases and conditions requiring the use of permanent replacement therapy. complex treatment of conditions requiring the use of long-term therapy for more than 30 days (hormonal, enzyme, antihypertensive drugs, etc.);
Medicines (drugs) required for long-term or continuous use in case of chronic diseases (conditions) (except for the stage of severe exacerbation, during which medicines are covered until the health condition is stabilized) for a period of more than 30 days and no more than one exacerbation during the term of the contract, unless otherwise provided by the program;
purchase, rental, repair of auxiliary medical devices (crutches, canes, glasses, contact lenses, eyeglass frames, hearing aids, wheelchairs, prostheses, Chance collar, bandages, etc.).The Insurer shall not pay the cost of the following medical services (expenses), unless otherwise provided by the selected Insurance Program:examination and treatment of any chronic diseases in remission and/or compensation;
dental prosthetics and implantation;
surgical operations using a heart-lung machine, coronary surgery (stenting, bypass surgery), prosthetic heart and joint valves;
scheduled eye surgeries (including laser vision correction);
provided for diseases for which treatment is provided by state programs, such as tuberculosis, diabetes mellitus, bronchial asthma, pediatric care in the first three years after the birth of a child (patronage, vaccinations, etc.), except for cases of treatment of acute states of decompensation of these diseases (for example, diabetic coma, pulmonary edema, etc.);
any operations or treatment that are not completed or are expected to be completed before the entry into force of this Agreement, as well as operations that are scheduled (scheduled operations);
treatment of diseases, including injuries, acquired as a result of professional sports (during training and competitions), or practicing and competing in extreme sports at the amateur level (mountaineering, caving, hang gliding, equestrian sports, downhill skiing, skiing, parachuting, diving, bobsleigh, rally, etc;)
regular scheduled (preventive) examinations (examinations) if there is no deterioration in health, including diagnostics, examinations at the MSEC, medical commissions (for admission to educational institutions, drivers, obtaining a permit to carry weapons, etc;)
vaccinations and vitaminization of schools;
any examinations, treatment and preventive measures, the need for which is directly or indirectly related to pregnancy, childbirth or childbirth;
alternative medicine (acupuncture, manual therapy, hypnosis, psychotherapy, iridodiagnostics, biocorrection, reflexology, hirudotherapy, etc.), homeopathic and herbal treatment;
wellness procedures (swimming pool, massage, etc.);
diagnostics, prescription of treatment regimens and direct treatment of classical sexually transmitted diseases (infections transmitted mainly through sexual contact), according to the WHO classification, such as gonorrhea, syphilis venereal lymphogranulomatosis, gardnerellosis, genital herpes, cytomegalovirus infection, mycoplasmosis, papillomavirus infection, trichomoniasis, ureaplasmosis, chlamydia, herpes virus type 2, papillomavirus;
diagnosis and treatment of TORCH infections (toxoplasmosis, cytomegalovirus, rubella virus, herpes virus, Epstein-Barr virus);
Hepatitis of any etiology (except hepatitis A), fatty degeneration, cirrhosis;
diagnostics and treatment of occupational diseases in accordance with the orders of the Ministry of Health of Ukraine;
consultations of a neuropsychiatrist, psychotherapist, psychoanalyst;
medical manipulations at home (massage, injections, taking tests, etc.), except for seriously ill patients and patients with bed rest prescribed by a doctor;
provision of additional comfort, namely air conditioning, humidifier, hairdresser, cosmetologist services;
medicines for the period after the expiration of the Agreement, even if the medicines were prescribed during the Agreement.

Charitable contributions made by the Insured person to medical institutions shall not be indemnified by the Insurer

The insurer does not pay:

the cost of medicines (their analogues), medical devices available on the day of treatment in a medical institution according to the website https://eliky.in.ua or other official website that contains information on the state of supply, available balances of medicines in accordance with the Order of the Ministry of Health of Ukraine No. 509 of June 2, 2016 (as amended), orders of regional state administrations;

payment for consultative-diagnostic and therapeutic-prophylactic specialized outpatient medical care, provision and/or organization of necessary laboratory tests, if such care is provided for by the State Medical Guarantees Program “Prevention, Diagnosis, Monitoring and Treatment in Outpatient Settings”, which is paid by the NHSU upon referral by a family doctor, a course of treatment for one and each insured event for more than 30 (thirty) days from the date of commencement of treatment.

The insurance coverage and obligations to pay claims or services are possible to the extent and as long as it does not contradict economic, trade or financial sanctions or embargoes imposed by the United Nations, the United States of America, the United Kingdom of Great Britain and Northern Ireland, Switzerland in relation to: the Russian Federation, the Republic of Belarus, the Islamic Republic of Iran, Cuba, Syria, Afghanistan, the Democratic People’s Republic of Congo, Iraq, the Democratic Republic of Korea, Liberia, Lebanon, Somalia, Sudan, Sierra Leone, Côte d’Ivoire.

The insurance contract may provide for additional or other exclusions from insurance payments than those specified in these General Terms and Conditions, which are agreed with the Insured and do not contradict the law.

The grounds for denial of insurance indemnity (payment) are:

– intentional actions of the Insured or the person in whose favor the insurance contract is concluded, aimed at occurrence of the insured event, except for actions committed in a state of emergency or necessary defense, or cases determined by law or international customs; commission of an intentional criminal offense by the Insured or the person in whose favor the insurance contract is concluded, which led to occurrence of the insured event;
– submission by the Insured of false information about the object of insurance, circumstances of material importance If the loss is partially indemnified, the insurance payment shall be made after deduction of the amount received from the said person as compensation for losses;
– untimely notification by the Insured (person specified in the insurance contract or legislation) of the insured event without good reason or failure to fulfill other obligations specified in the insurance contract or legislation, if this resulted in the Insurer’s inability to establish the fact, causes and circumstances of the insured event or the amount of damage (losses).
– existence of circumstances that are exceptions to insured events and insurance limitations provided for in the insurance contract;
– existence of other grounds established by law or the insurance contract.

The decision to refuse payment of insurance indemnity shall be made by the Insurer within 10 working days from the date of receipt of all required documents under the Contract or General Insurance Terms, unless another term is provided for by the terms of the Contract. The decision to refuse payment of insurance indemnity shall be notified to the Insured in writing within 5 business days from the date of such decision with justification of the reasons for refusal, unless otherwise provided by the terms of the Contract.

The insurer’s decision to make or refuse to make an insurance payment may be appealed by the insured in court.