General terms and conditions of the Confido Health Plan

Valid from 01.10.2022

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).

DEFINITIONS USED
- Confido Health Plan – a non-life insurance service (health insurance) developed by the Insurer, within the framework of which AS Arstikeskus Confido (registration code 12381384, address Harju County, Tallinn, City Center district, Veerenni tn 51, 10138, hereinafter referred to as Confido) offers itself or through cooperation partners based on an agreement with Policyholders to their Employees (and, if applicable, to Employees' Relatives) Health services within the health insurance risk borne by the Insurer. This health insurance is offered only to Policyholders who have joined the Confido Health Plan service.
- Insurer - AS LHV Kindlustus (registration code 14973611, address Tartu maantee 2, 10145 Tallinn).
- Insurance agent - Terviskindlustusagent OÜ (registration code 16572262, Veerenni tn 51, 10138 Tallinn).
- Insurance Card - Individual insurance card number issued by the Insurer to the Insured Person, which confirms the validity of the Insurance Protection for the Insured Person. The Insurance Card number must not be shared with anyone. The Insurer, the Insurance Agent, and the Service Provider have the right to close the Insurance Card if it is established that the number of the Insurance Card is used by an unentitled person.
- Insured object - The object of health insurance is the health of the Insured persons and the risk of incurring costs related to the provision of Health Services necessary to maintain it (i.e., insurance risk).
- Insurance coverage - Risks against which the Insured Person is insured. Insurance coverage is determined according to the Health Services that are covered by the Insurance Contract.
- Insurance Contract - A health insurance contract concluded between the Insurer and the Policyholder, where health insurance coverage is provided in accordance with the principles of non-life insurance. The Insurance Contract consists of the Insurance Application, Terms and Conditions, Insurance Program, Insurance Policy, Information Sheet, and other documents concluded between the Policyholder and the Insurer. The Insurance Contract allows the Policyholder to include Employees and, if applicable, Relatives as Insured Persons in the Insurance Contract, in which case Employees and Relatives will be entitled to health insurance benefits from the Insurer in a situation where the Employee or Relatives needs treatment.
- Insurance Premium - The fee agreed in the Insurance Contract and paid by the Policyholder (or, if applicable, the Employee or Relative) for Insurance Protection.
- Insurance Policy - a document confirming the conclusion and validity of the Insurance Contract and which is forwarded to the Employee after the conclusion or extension of the Insurance Contract.
- Insurance program - insurance conditions that are an integral part of the insurance contract (Insurance protection, Insurance Premium, Sum Insured, Limit, etc.), which apply to a specific Insured Person or to all Insured Persons.
- Insurance period - the period of time specified in the Insurance Contract, during which the insurance coverage provided for in the Insurance Contract is in force and on the basis of which Insurance Premiums are calculated. If the Insured Person is added to the Insurance Contract during the Insurance Period, the Insurance Coverage applies to them from the time of addition until the end of the Insurance Period unless the Insured Person is removed earlier by the Policyholder.
- Sum Insured - Maximum amount to be reimbursed to the Insured Person within the framework of the Insurance Program selected by the Insurer (both as a whole and in terms of separately covered Health Services) during one Insurance Period.
- Insurance Application - A statement of desire to enter into an Insurance Contract submitted by the Policyholder to the Insurer or Insurance Agent. The Insurance Application contains a list of Employees and, if applicable, Relatives with the necessary personal data according to the Insurance Agent's form, who wish to join the Insurance Contract as Insured Persons, and the selection of Insurance Program for each Employee/Relative. When adding insured persons during the validity of the Insurance Contract, the Policyholder submits an additional Insurance Application to the Insurance Agent.
- Insured person - the Employee or their Relative who is named as the Insured Person in the Insurance Contract. On the basis of the Insurance Contract, the health insurance risk is insured related to the Insured Person as a third party. If the person is removed from the list of Insured Persons by the Policyholder, it is assumed that the person is no longer an Insured person.
- Policyholder - A legal entity that wishes to provide Health Insurance to its Employees and, if applicable, their Relatives and who undertakes the obligation to pay the insurance premiums (unless the Insurance Premium is paid by the Insured Persons themselves).
- Contact Person - Persons appointed by the parties to the Insurance Contract to receive notifications related to the Insurance Contract and to resolve current issues.
- Limit - The percentages resulting from the Insurance Contract to the extent that the Insurer pays for the service received by the Insured Person or the number of paid services, which do not exceed the Sums Insured specified in the Insurance Contract.
- A Family Member - A member of the Employee's family, which is considered to be the spouse or life partner, parents, and children who are Insured Persons under the Insurance Contract. For relatives, the provisions of the Terms and Conditions of the Employee shall apply unless the context otherwise requires.
- Information Sheet – the standard form of the information document for the insurance product provided by Commission Implementing Regulation (EU) No. 2017/1469.
- Service provider - Health service providers. The service providers are Confido and its cooperation partners.
- Healthcare Service - The activity of a healthcare worker/facility to prevent, diagnose and treat illness, injury or poisoning. The purpose of a health care service is to alleviate a person's ailments, prevent the deterioration of his or her state of health or exacerbation of the disease, and restore health. Healthcare service can be either outpatient or inpatient.
- Health insurance - Health insurance service provided by the Insurer to the extent stipulated in these Terms and Conditions (LOA § 554 and Insurance Activities Act § 12 (1) p. 2) within the scope of which the Insurer insures the insurance risk arising from the need to provide Health Services to the Insured Person and bear the associated costs.
- Employee - A person who works for the Policyholder on the basis of a valid employment contract, a board member contract, or other service-related contract.
- Authorized person - persons, designated by the Insurance Agent and the Policyholder whom the parties have appointed for data exchange in connection with the conclusion and execution of the Insurance Contract, including the transmission of encrypted data.
INSURED EVENT AND INSURANCE COVER
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:
  1. which is related to the Insured Person's health;
  2. In accordance with and within the limits of the Insurance Coverages provided for in the Insurance Contract;
  3. to the extent of the Sum Insured and the Limit;
  4. which is provided during the Insurance Period, except for the waiting period;
  5. which is indicated by Service providers operating in the territory of Estonia;
  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;
  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;
  8. which are not excluded under the Terms and Conditions and which are not subject to indemnification.
2. The Insurer pays the Insurance Indemnity:
  1. To the Insured Person, if the costs of Health Services were borne by the Insured Person themselves; or
  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.
3. Outpatient treatment insurance coverage
  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. 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.
  3. The following costs are reimbursed without a doctor's referral:
    - Visit fee of the Insured Person;
    - remote consultations;
    - renewing prescriptions in remote consultations.
  4. Only the costs of the following procedures with the referral of a doctor are reimbursed:
    - tests;
    - examinations
    - treatment procedures;
    - medical specialist consultations.
  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.
  6. The following are not covered under the insurance cover of Outpatient Treatment:
    - the cost of dental services;
    - the cost of maternity care;
    - Covid tests;
    - the cost of prescription drugs;
    - the cost of glasses and contact lenses;
    - the cost of outpatient rehabilitation;
    - the cost of rehabilitation with a hospital stay;
    - the cost of preventive examinations.
    - examinations related to pregnancy;
    - a regular appointment with the gynecologist;
    - birthmark examinations;
    - home visits;
    - occupational health inspection;
    - medical certificates.
4. Mental health insurance coverage
  1. The following costs are reimbursed without a doctor's referral:
    - services of a psychologist;
    - services of a psychotherapist;
    - services of a psychiatrist;
    - services of a clinical psychologist;
    - services of a mental health nurse.
5. Insurance coverage for special diagnostics
  1. Only the costs of the following procedures with the referral of a doctor are reimbursed:
    - digital tomography;
    - magnetic resonance examination;
    - anesthesia;
    - specific diagnostic technologies, e.g., gastroscopy and colonoscopy;
    - ultrasound;
    - x-ray;
    - computed tomography;
    - colposcopy.
  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.
6. Inpatient treatment insurance coverage
  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. 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.
  3. The Insurer shall indemnify the costs for paid services in the 24-hour and day inpatient care.
  4. The following costs are reimbursed:
    - inpatient stay;
    - surgeries;
    - medical consultations;
    - tests, examinations, and treatment procedures;
    - treatment under conditions of enhanced service for up to 10 days, if the medical institution provides such services
  5. The following are not covered under the Insurance Cover of Inpatient Treatment:
    - the cost of dental services;
    - the cost of maternity care;
    - the stay of a relative or close person with the Insured Person in a hospital;
    - preoperative and post-operative care services.
7. Insurance coverage for prophylactic health check-ups
  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. The following are reimbursed without a medical indication:
    - health examination to monitor a chronic or pre-existing illness;
    - vaccination;
    - medical certificates;
    - appointments to the doctor regarding prescription drug renewals;
    - optometrist consultations, including issuing a prescription for glasses;
    - a regular appointment with the gynecologist;
    - gynecological and midwifery consultations;
    - buying glasses (if visual acuity has changed during the Insurance Period);
    - STD tests;
    - birthmark examinations;
    - derm test;
    - health check-up packages (except occupational health check-ups);
    - andrologist consultation;
    - Covid tests.
  3. The following are not eligible for compensation on the basis of prophylactic health check-up insurance coverage:
    - food intolerance tests;
    - dentistry;
    - genetic tests;
    - glasses without optical lenses;
    - contact lenses;
    - sunglasses with optical lenses;
    - blue light glasses;
    - the cost of medicines.
8. Stomatology insurance coverage
  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. 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.
  3. Costs of cosmetic whitening or cosmetic operations are not reimbursed under the Insurance Contract.
  4. The following costs of services related to dental treatment are subject to coverage :
    - consultation with a specialist and preparation of a treatment plan;
    - dental care;
    - oral hygiene procedures;
    - outpatient surgical and dental services;
    - local anesthesia;
    - prosthetics, and costs related to implants.
  5. The following are not subject to compensation:
    - the cost of cosmetic surgery on the teeth and mouth;
    - the cost of cosmetic teeth whitening;
    - orthodontic costs;
    - installation of sealants and dental decorations.
9. Outpatient rehabilitation insurance coverage
  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. Only the following services related to outpatient rehabilitation prescribed by a doctor are covered by compensation:
    - physiotherapy;
    - therapeutic massage;
    - manual therapy;
    - chiropractic;
    - speech therapist service;
    - magnetic therapy.
EXCLUSIONS
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.
1. The following events are not considered insured events, and expenses are not indemnified:
  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);
  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. if the Insured Person has intentionally caused damage to their health, including by attempting suicide;
  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;
  5. events that occurred during the commission of criminally punishable acts by the Insured Person;
  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;
  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;
  8. laser vision correction surgery, organ transplant surgery, venous surgery, sclerotherapy, and paid services;
  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);
  10. diagnosis, treatment, and genetic testing for viral hepatitis C and chronic hepatitis, as well as Hansen's disease;
  11. diagnosis and treatment of sexually transmitted diseases, including ureaplasma, HIV and AIDS, spirochetes, and chlamydial infections;
  12. diagnosis and treatment of fungal diseases, avian and swine flu virus;
  13. early health checks on drivers;
  14. immunoglobulin therapy, intravenous laser therapy, laser organ therapy (e.g., incontinence therapy), autohemotherapy (e.g., PRP injections), barotherapy, orthokine injection, intraocular injections;
  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;
  16. alternative medicine services (e.g., acupuncture, iridodiagnosis, biomagnetic resonance, electropuncture), complementary medicine services, use of the biofeedback method;
  17. paid services relating to pregnancy, fetal diagnosis, and childbirth;
  18. family planning, contraceptive measures, infertility treatment, artificial insemination, abortions without medical indications;
  19. diagnosis or treatment of congenital pathologies, degenerative diseases, and mental illness;
  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;
  21. treatment of diseases included in the public health program to the extent of paid services;
  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;
  23. medical services provided without medical indications, as well as the costs of regular health check-ups, etc., palliative care, social welfare;
  24. educational information sessions, lectures, or courses;
  25. the stay of a relative or close person with the Insured Person in a hospital;
  26. preoperative and post-operative care services;
  27. convenience services such as home visits and transportation.
RELIEF OF THE INSURER FROM PERFORMANCE OBLIGATION
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.
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.
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. 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.
CONCLUSION, AMENDMENT, AND TERMINATION OF THE HEALTH INSURANCE CONTRACT
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.
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).
In cooperation with the Insurance Agent, the Policyholder selects the Insurance Programs suitable for his or her Employees and, if applicable, Relatives.
To include employees as Insured Persons in the Insurance Contract, the Policyholder submits an Insurance Application to the Insurance Agent.
The Policyholder's Authorized Person shall submit the specified data in encrypted form by forwarding them to the Insurance Agent's Authorized Person.
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.
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
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.
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.
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.
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.
The Insurance Contract is concluded for an indefinite period, and the Insurance Period is 1 (one) year.
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.
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.
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.
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:
  - A circumstance independent of the parties specified in the Insurance Contract as the basis for calculating the Insurance Premium;
  - Average life expectancy of insured persons;
  - frequency of use of the Insurer's performance obligation by the Insured Person according to this premium rate;
  - the extent of state compensation for health insurance services;
  - Service provider fees for using Health Services;
  - legislation amending healthcare management;
  - Insurance losses significantly exceed insurance premiums.
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.
4. Amendments to the Insurance Contract shall enter into force no earlier than 1 (one) month after notifying the Policyholder of the amendment.
5. The Insurer or Insurance Agent will notify changes to the Insurance Contract in accordance with the procedure provided in the Terms and Conditions.
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.
The Insurer has the right to cancel the Insurance Contract in a regular manner in cases provided by law.
The Insurer has the right to cancel the Insurance Contract in an emergency for the following reasons:
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;
2. The Policyholder/Insured Person materially violates the Insurance Contract and does not eliminate the violation additionally within the given term;
3. in case of bankruptcy of the Policyholder.
The Insurer can cancel the Insurance Contract in an extraordinary manner within 1 (one) month after becoming aware of the violation.
INSURANCE PREMIUMS AND THE CONSEQUENCES OF FAILURE TO PAY THEM
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.
2. The Insurer authorizes the Insurance Agent to accept Insurance Premiums.
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.
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.
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.
6. Insurance premiums are payable for each Insured Person according to the Insurance Program selected for the said Insured Person.
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.
8. Insurance premiums are paid by the Policyholder on behalf of the Insured Person.
9. The Policyholder pays the Insurance Premiums in quarterly payments according to the invoices presented by the Insurance Agent.
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.
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.
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:
  - 1-90 days after signing the insurance contract, 100% of the insurance premium;
  - 91-180 days after signing the insurance contract, 75% of the insurance premium;
  - from 181 days after signing the insurance contract, 50% of the insurance premium.
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.
14. Insurance premiums are not subject to reduction due to the taxes applicable to them and, as a result, additionally payable.
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.
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.
THE SUM INSURED, LIMITS, AND DEDUCTIBLES
1. The Sum Insured is the maximum amount to which the Insurer compensates the loss.
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.
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.
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.
RIGHTS AND OBLIGATIONS OF THE PARTIES
1. Obligation to provide information
  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.
2. Rights and obligations of the Policyholder
  1. The Policyholder has the right to:
    - receive information about the Insurance Contract from the Insurance Agent and the Insurer;
    - submit claims to the Insurance Agent and the Insurer in connection with the performance of the Insurance Contract pursuant to the procedure provided in the Terms and Conditions.
  2. The Policyholder is obliged to:
    - inform the Insured about the conclusion of the Insurance Contract in their favor and acquaint them with the terms and conditions of the Insurance Contract, including the Insurance Program, as well as explain to them the rights and obligations arising from the Insurance Contract;
    - pay Insurance premiums in the amount indicated and by the term specified in the Insurance Contract;
    - keep the data on the Insured Persons up-to-date and immediately inform the Insurance Agent of changes in the data and submit new data;
    - ensure that the Insured Persons give their consent for the transfer of personal data of the Insured Persons to the Insurance Agent and the Insurer for the conclusion and execution of the Insurance Contract and their inclusion as Insured Persons in the Insurance Contract. These consents must be at least in a reproducible form and available to the Insurance Agent and the Insurer upon request.
3. Rights and obligations of the Insured Person
  1. The Insured Person has the right to:
    - receive information and consultations regarding his or her Insurance Contract;
    - receive the services agreed in the Insurance Contract;
    - receive Insurance Indemnity for the services agreed in the Insurance Contract, for which the Insured has paid from his or her own funds;
    - receive a motivated written decision regarding refusal to pay the Insurance Indemnity in full or in part.
  2. The Insured Person is obliged to:
    - pay the Insurance Premiums to the extent that, in accordance with the Terms and Conditions, they are not payable by the Policyholder;
    - take care of maintaining their health and follow the instructions of the attending physician in case of illness and not increase the risk circumstances related to the Insured Person;
    - not to allow another person to use his/her Insurance Card and to notify the Insurer or the Insurance Agent immediately in case of loss of the Insurance Card;
    - to submit an identity document and the Insurance Card before receiving the service covered by the Insurance Cover from the Service Provider;
    - to monitor the extent of the Insurance Indemnity, if necessary, by contacting the Insurer or the Insurance Agent, inter alia, in order not to exceed the Sum Insured or the Limit provided in the Insurance Contract;
    - to comply with the terms and conditions set forth in any other document of the Insurance Contract, such as the terms and conditions of the Insurance Programs.
4. Rights and obligations of an Insurance Agent:
  1. The Insurance Agent is obliged to:
    - Provide the Insurer with relevant information and documents about the Employees and, if applicable, Relatives who wish to join the Insurance Contract;
    - Transmit to the Policyholder the relevant Insurance Contract information and documents about the Insured Persons;
    - Transmit to the Policyholder/Insured Person on time the Insurance Premium invoices;
    - Collect the necessary information from the Policyholder to conclude the Insurance Contract and to join the Employees and, if applicable, their Relatives to the Insurance Contract.
    - In the event of an Insured Event, carry out effective and quick damage handling.
5. Rights and obligations of the Insurer
  1. The Insurer is obliged to:
    - In the event of an Insured Event, pay the Insurance Indemnity in accordance with the terms and conditions of the Insurance Contract;
    - At the request of an Insured person, inform them of the remaining Sum Insured or Limit;
    - to forward to the Policyholder the information and documents of the relevant Insurance Contract regarding the Insured Person if the Policyholder so requests;
    - to issue replacement policies to the Policyholder upon request, as well as copies of the statements of intent submitted by the Policyholder in a form that can be reproduced in writing;
    - Upon receipt of the relevant request of the Policyholder, issue to the Policyholder data and copies of documents in the Insurer's possession that affect the Policyholder's rights and obligations arising from the Insurance Contract if such action does not contradict the imperative requirements arising from legislation;
    - process the Insured Person's personal data in accordance with the applicable legislation. The Insurer also has the right to obtain information about the Insured Person from state authorities or the Creditinfo if the Insurer deems it necessary.
PAYMENT AND RECOVERY OF INSURANCE INDEMNITY
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.
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.
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.
The occupational health inspection indemnity is paid to the Policyholder or the Service Provider who provided the occupational health inspection service.
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:
1. a written statement in a form that can be reproduced in writing;
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;
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.
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.
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:
1. In case of exceeding the Sum Insured provided for in the Insurance Contract;
2. In case of exceeding the limit provided for in the Insurance Contract, including exceeding the number of paid services;
3. to the extent of payments not provided for in the Insurance Contract;
4. Upon termination of the Insurance Contract or Insurance Card for any reason;
5. If the Insured Person commits fraud or receives Insurance Indemnity for other unjustified reasons.
PROCESSING OF PERSONAL DATA
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.
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.
OTHER TERMS AND CONDITIONS
1. Priority of insurance contract documents
  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.
2. Confidentiality
  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.
  2. The Insurer has the right to submit information related to the Insurance Contract to experts and reinsurers.
  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.
  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.
3. Notifications
  1. The Parties shall forward all notices related to the Insurance Contract through Authorized Persons and Contact Persons.
4. Submitting complaints about the Insurer's or Insurance Agent's actions
  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.
  2. When submitting a complaint, the complainant must provide at least the following information:
    - information about the complainant:
      - private person — first and last name, address, telephone number, and e-mail address (if any);
      - legal entity — company/business name, registration code, address, telephone number, and e-mail address (if any);
    - the date on which the complaint was lodged;
    - an overview of the circumstances and reasons for the dissatisfaction with as clear and comprehensive a description as possible and, if possible, attach documents proving the circumstances referred to in the complaint.
  3. The complaint can be submitted:
    - by mail :
      - to the address of the Insurance Agent;
      - to the address of the Insurer;
    - by e-mail :
      - to the Insurance Agent's e-mail;
      - to the Insurer's e-mail.
  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.
  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.
  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.
  7. The Insurer always responds to complaints concerning the activities of the Insurance Agent.
  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.
  9. Complaints processing is free of charge for the complainant.
5. Applicable law
  1. The legislation in force in the Republic of Estonia is applied to regulate the contractual relations arising from insurance contracts.
6. Settlement of disputes:
  1. Disputes arising from Insurance Contracts shall be sought to be resolved by agreement of the parties.
  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.
  3. The parties to the insurance contract do not have the right to transfer the rights arising from the Contract to third parties.
  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:
    - To the conciliation body operating at the Estonian Insurance Association (phone. +372 6 67 18 00, lepitus@eksl.ee, Mustamäe tee 46, Tallinn 10621);
    - In case of violation of consumer rights, to the Consumer Protection and Technical Regulatory Authority (phone. +372 6 20 17 07, info@ttja.ee, Sõle 23a, 10614 Tallinn);
    - in case of data protection disputes, to the Data Protection Inspectorate (+372 5 62 02 341, info@aki.ee, Tatari 39, Tallinn 10134).
  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.

General terms and conditions of the Confido Health Plan

DEFINITIONS USED

INSURED EVENT AND INSURANCE COVER

EXCLUSIONS

CONCLUSION, AMENDMENT, AND TERMINATION OF THE HEALTH INSURANCE CONTRACT

INSURANCE PREMIUMS AND THE CONSEQUENCES OF FAILURE TO PAY THEM

THE SUM INSURED, LIMITS, AND DEDUCTIBLES

RIGHTS AND OBLIGATIONS OF THE PARTIES

PAYMENT AND RECOVERY OF INSURANCE INDEMNITY

PROCESSING OF PERSONAL DATA

OTHER TERMS AND CONDITIONS

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