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GENERAL
CONDITIONS - PERSONAL
ACCIDENTS
1.
Insurance contract
(insurance policy)
1.1.
1.1.
This insurance contract
between Insurer: Insurance
Company “SIGKOS” JSC, and
the Insured or his
representative (Contractor)
named in the police provided
that the insurance premium
is being paid from the
Insured oblige the Insurer
that in case the insured
event is confirmed, pay in
the interest of the Insured
or his representative
benefitions specified in
this contract.
1.2.
I 1.2. Isurance
contract is contracted for
one year period and can be
renewed after the end of the
insured year. Insurer signs
Contract of Insurance after
studying written
declarations for the
physical conditions of the
Insured and after the
insurance premium is paid.
Incorrect and intentional
declarations done by the
Insured or Contractor could
be as cause to revoke the
contract or release the
Insurer from the obligations
to pay the benefitions.
1.3.Insurance contract
enters into force at the
24:00h on the day the
premium is
paid,
but not before the date
noted in the police.
1.4.
1.4.
According to these
conditions can be insured
persons from 16 to 65 years
old. Persons younger than 16
years old and older than 65
can be insured under the
additional and specific
Conditions.
1.5.
1.5.
Coverage in the insurance
will be suspended or be
invalid in the cases below:
(a) a) End of the deadline
set in the insurance policy;
(b) b) When unilaterally
one of the contracted
parties does not fill the
obligations. When liability
falls into the Insurer, he
is obliged to get back
the paid premium for the
rest of the insurance
period;
(c)
c) One of the parties
resigns from the insurance
contract;
(d)
d) When the Insured moves
his residence out of the territory of Kosova;
(e) e) With the
paid rate after the
insurance event which
consumes all remained
amount of insurance.
2.
insured ammount
2.1.
2.1.The insured amount is
set in the insurance policy
according to the request of
the Insured and Insurer
approval.
2.2.
2.2. Maximal insurance
amount from the Insurance
Branches is 5000 Euro for
pupils and 10.000 Euro for
students. For the higher
insurance amounts an
authorization from Central
Directorate of “SIGKOS” in
Pristine is needed.
3.
Insurance Premium
3.1.
3.1.
Insurance premium is to be
set on percentage on the
insured amount and is to be
paid on a annual rate. In
case that the Insured moves
his residence out of
the territory of Kosova or
dies from the causes not
subject of the insurance,
than Insurer reimburse to
the beneficiary the part of
the premium for the
remained period.
3.2. In case that the
Insured gets involved in a
professional activity during
the vacation period, a
written notice must
immediately be done to the
Insurer, who has right to do
the commensurable raise of
the premium for the period
of engagement of the
Insurer.
4.
Beneficiary
4.1.
4.1.The Insured must
immediately nominate the
beneficiary in the insurance
contracted moment.
Restitution, by the case, is
to be paid to the Insured or
the representative he
nominated.
4.2.
4.2.
In case there is no
nominated beneficiary
appointed by the Insured,
and the Insured dies, the
beneficiary rights belongs
to parents or legal tutors
of the Insured.
5.
Residence
5.
All insured persons must be
residents of Kosova. If the
Insured moves out of Kosova
to reside in another state,
he is obliged to inform the
Insurer within 15 days
before moving.
6. Policy benefit
6.1. Benefitions in case of
accident event
In case of the accident
insured according to the
police conditions, to the
Insured or his beneficiary
will be paid one of the benefitions below pendent of
the accidents consequences:
a)
In case that accident causes
with the death of the
Insured, the Insurer pays
the Insurance Amount
specified in the police, but
discounting benefitions paid
previously.
b) Benefitions for the
permanent disability caused
by the accident. When the
accident causes permanent
disability, the Insurer
pays:
-
The full amount of insurance
set in police when there is
permanent and total
disability.
-
Percentages of the insurance
amount when the permanent
disability is partial are
given in the table for the
designation of
disabilities which is
constituent part of the
insurance conditions:
Note: If the Insured is
leftist, percentages of the
left will be applied for the
right.
-
If different parts of the
body are damaged,
percentages collect, but
total disability can not be
over 100 % of the insurance
amount. All payments done
can not exceed the insurance
amount.
d)
Remuneration of daily
hospitalization
¾
is paid to the Insured every
day of stay at the hospital
because of the insured
accident, up to 180 days
within a year. Daily
hospital remuneration is
0.05 % of the insured amount
for every day of stay at the
hospital provided that the
Insured stayed more than
three days hospitalized.
¾
Hospitalization for
fractures will not be
subject of the remuneration
of daily hospitalization,
but as in the point 6/1/c
above.
e)
Medical hospital and
ambulatory treatment
This payment includes
medical costs described in
the point 8/5.
6.2.
Benefition for the natural
death
The Insurer will cover the
natural death only for the
critical illness up to
liability, respectively up
to the insurance amount
presented in the police.
6.3.
Benefitons for the death of
a parent or tutor.
Will be paid to the Insured
in case of the accidental
death of the parent or tutor
this benefition is equal to
the insurance amount
discounting benefitions used
previously. In case that at
the same accident both
parents will die, the
Insurer pays double amount
of insurance. After the
payment of the parents or
tutor death, the insurance
contract will be considered
as done.
7.
Exceptions
There will not be taken
under insurance and not be
paid benefitions foreseen in
the police for the cases
below:
a)
Surgeon interventions,
visits or treatments for the
causes not linked to the
police conditions;
b)
Deliberate acts done or
attempt from the Insured;
c)
Drunk, over used of
psiko-farmaceuticals, use of
drugs or other narcotics;
d)
War operations, outbreaks,
land displacements,
earthquake, volcanic
eruptions;
e)
Radioactive eruptions of the
atomic energy,
irrespectively from the
origin of their cause;
f)
Participation of the
contractor or his
beneficiary on the
deliberate crime against the
Insured;
g)
Any physical or health
anomaly, or any other
illness which does not fit
with the term “Critical
Illness”;
h)
Any damage which results
from the suicide, suicide
tentative or intentional
self damage;
i)
Persons suffering from
alcoholism, narcotics, or
mental illness or who
require permanent care from
other members of the family
or tutor;
j)
Preexisting critical
illnesses;
k)
Driving any vehicle if the
Insured does not posses the
necessary oarsman ship
document;
l)
Participation in the
different sport
competitions, training
competitions.
8.
Determination of terms used
in the police
8.1.
Accident.
Accident means any event
caused with no will
and reluctantly, violent and
external, which causes
physical damages objectively
confirmed in the Insured
body and as consequence
causes temporary, permanent
disability or death of the
Insured. As accidents will
be considered also:
Total poison from the
absorption of fume or devour
or poison substances;
a)
strangulation
b)
freezing;
c)
burn;
d)
sun or warm attacks;
e)
damages caused by physical
outputs (except rupture)
f)
asphyxia with non
pathological origin;
g)
accidents caused in a
immediate illness state or
unaware;
h)
lack of experience or
negligence;
i)
first 14 days of the massive
civil outbreaks or war acts,
terrorist acts provided that
the Insured does no actively
participated on it.;
j)
enter of bacterial bodies
through wounds taken in the
insured accident;
8.2.
Natural Death
For
the effect of the insurance
coverage, natural death or
critical illness will be
considered:
a)
heart attack;
b)
cerebral attack;
c) surgery or coronary
arteries;
d)
cancer;
e)
damage of one or two
adrenal;
f)
paralyze of both legs;
Limit of coverage for
natural death will be:
3.000,00 €
8.3.
Permanent disability.
For
the purposes of the
insurance coverage a
permanent disability will be
considered total permanent
disability caused fro a
critical illness (except
accident).
8.4. The Insured
is the person nominated in
the insurance policy who in
the moment of binding the
contract is pupil or student
in the correspondent
educational system in an
education institution within
the
territory
of
Kosova.
8.5.
Costs for the medical
treatment
This term includes medical
and ambulant costs, costs of
the surgery treatments,
pharmaceutical costs,
analyses and radiographies,
costs for the
physiotherapeutic treatments
and rehabilitation as well
as costs for the transport
in the special conditions
all these recommended by the
doctor in the event of
insured accident or of the
critical illness. General
amount of costs is limited
on amount of 10% of the
insured amount.
When the insured amount is
not less than 5.000 EURO for
pupils and 10.000 EURO for
students, insurer get
engaged sending of the
insured in a clinic outside
the country when it appears
necessary from the credible
authority, covering all
costs up to the insured
amount.
8.6
Evacuation/Repatriation
Insurer will compensate the
Insured in case of an
accident out of the territory of Kosova
for the evacuations costs
and/or of repatriation
provided that the Insured
have contracted this kind of
insurance and paid the
premium.
Limit of this coverage will
be: 3.000,00 €.
9. Notice of the insured
event
Insured or the beneficiary
is obliged to inform
immediately the Insurer for
accident or the critical
illness incur since the
written notice must send not
later than within three
10.
Request for taking the
restitution
10.1.
The Insured or the
beneficiary for taking the
restitution makes a written
request accompanied with a
list of documents set by the
insurer dependant on the
insured event and their
consequences on the insured
as: filled form of the
accident notice, insurance
police, clinical card of the
insured, medical
certificate, death
certificate and death file
stamped by the forensic,
medical expertise, document
of the hospitalization and
hospital costs, medical
recommendations for the
medical treatment, bill of
the pharmaceutical costs,
confirmation of the
transport costs and so on.
10.2. The
Insured or the beneficiary
has to prepare all documents
for taking the restitution
on his own costs.
11.
evaluation of the medical
condition
11.1. The
evaluation of the medical
conditions is to be done on
the basis of documentation
presented by the insured,
from the expert or the group
of experts set by the
insurer. The insured is
obliged to present to the
insurer within three days
the accident or critical
illness notice since all
other required documents
within 30 days from the date
of the insured event.
11.2.
Expert or the group of
experts is obliged to draft
the expertise-act within 10
days from the day of taking
the request for expertise,
except when the level of
injuries incurred can not be
determined within such
period of time.
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Class of the insured
risk noted in the
Policy
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Class of the risk
where personal
accident happened
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Indemnity rate in %
according to the
class of risk
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Class I
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Class II
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Class III
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Class I
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100.00
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55.00
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35.00
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Class II
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100.00
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100.00
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70.00
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Class III
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100.00
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100.00
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100.00
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14.
Other provisions
14.1. In this
insurance contract the
insured does not enjoy the
cession right, mortgage or
block the insured amounts.
14.2. As it is
foreseen on these insurance
conditions, all requirements
from the Civil Code and
Insurance Law in the territory of Kosova
will be respected.
15.
Disagreements resolution
Disagreements which might
rise between the Insurer and
the Insured which can not be
resolved by understanding
will be subject to the
competent court.
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