DENTAL INSURANCE TERMS AND CONDITIONS HRK-3/2019
Valid from 10.12.2019
Dental insurance plan ’Bronze’ terms and conditions are the part of the insurance contract and a basis for the indemnification of claims. Please take the time to carefully read these terms and conditions through and make sure you understand all these terms, conditions, exclusions and limitations.
EXCHANGE OF INFORMATION
Information related to the insurance contract, including the policy confirming the start or extension of the contract, notices about premium payment, insurance indemnity claims or amendments to the insurance contract shall be transmitted only by e-mail. Therefore, it is important that when you sign up for dental insurance, you provide us with an email address that is actively in use and will inform us immediately if you have changed your email address. The valid dental insurance terms and conditions are always available on the website www.inpro.ee/hambaravikindlustus
CONTENTS
1. Purpose of insurance contract
2. Persons whom the insurance contract concerns
3. Definitions of these insurance terms and conditions
4. General terms and conditions of insurance contract
5. Rights and obligations of insurance contract parties
6. Indemnification rules
7. Claims
8. Exclusions
9. Complaints procedure
10. Fair processing notice Annex A.
1. PURPOSE OF INSURANCE CONTRACT
• The purpose of this dental insurance contract is to indemnify, on the basis of the insurance terms of conditions, the policyholder’s possible arising expenses on treatment.
• The cover is valid if in the dentist’s or doctor’s opinion the dental treatment was clinically necessary, the premium or part of it has been paid by the time of the claim and the claim takes place or starts during the policy period.
• Any issues not regulated in these dental insurance terms and conditions will be governed by Estonian law. Dental Insurance Terms and Conditions HRK-3/2019
2. PERSONS WHOM THE INSURANCE CONTRACT CONCERNS
• The policyholder (you, your) is the insured person stated on the insurance policy who is responsible for paying the premium or instalments of premium, who has a right for cover and ensuring that the policy terms and conditions are adhered to.
• The insurer (we, our, us) is XL Insurance Company SE (reg.no 641686, address 8, St. Stephen’s Green, Dublin 2, Ireland, www.axaxl.com) is part of AXA XL, a division of AXA and who is in the insurance providers’ list kept by the Estonian Financial Supervision and Resolution Authority (www.fi.ee).
• The insurance broker is Inpro Insurance Brokers OÜ (reg. no. 14778803, address Raua 32, 10152 Tallinn, www.inpro.ee), who is in the insurance intermediaries’ list kept by the Estonian Financial Supervision and Resolution Authority (www.fi.ee) and who engages, for a remuneration and based on a brokerage contract, in insurance distribution.
• The insurance distributor (distributor) is Northern1 International Insurance Brokers OÜ (reg. no. 12806139, address Tartu mnt 84A-M302, 10112 Tallinn, www.northern1.eu), who is in the insurance intermediaries’ list kept by the Estonian Financial Supervision and Resolution Authority (www.fi.ee) and who engages, for a remuneration and based on a brokerage contract, in insurance distribution.
• The claims administrator is Denis UK Limited (reg. no. 06399615, seat at 603 Network House Basing View, Basingstoke, Hampshire, RG21 4HG United Kingdom, www.denisglobal.com).
3. DEFINITIONS OF THE INSURANCE CONTRACT
The terms and definitions have the same meanings in the terms and conditions and the insurance policy. Any other words and phrases not listed here are used in their ordinary meanings.
• The insurance contract is an agreement concluded between the insurer and the policyholder in compliance with these terms and conditions, on the basis of which the policyholder undertakes to pay premium to the extent and pursuant to the procedure stipulated in the contract, and the insurer undertakes to indemnify to policyholder, within the limits of the amount of sum insured and in compliance with Annex A to these terms and conditions, the medically required dental treatment costs and other agreed costs that were incurred as a result of an illness or accident.
Please note: The insurance contract includes the insurance application, the insurance policy, the terms and conditions and special conditions if agreed.
• Insurance application is the application form policyholder submits to insurer via distributor.
• Insurance policy is an insurance contract document that proves the conclusion of the insurance contract.
• The cover is the insurer’s obligation to pay the indemnity for treatment listed in Annex A, within the limits of the maximum sums insured after the claim. The cover will take effect immediately but for regular and oral cancer treatment a waiting period is applied.
Please note: The cover for regular treatment and oral cancer treatment is applicable only to treatments by dental practices or other health care practices in Estonia. In the event of treatment following an accident, the cover is applicable with respect to the services provided by dental practices in Estonia and by licensed dentists abroad.
• The insurance benefit plan is the insurance indemnity plan marked on insurance policy and in Annex A of the terms and conditions.
Please note: Change of the insurance benefit plan can be done only at the renewal date.
• The sum insured is the maximum amount of indemnity in one policy period specified for each type of treatment (regular treatment, accident treatment and oral cancer treatment) indicated in Annex A. Dental Insurance Terms and Conditions HRK-3/2019 Please note: The maximum sum insured for regular treatment is divided between subgroups (Xrays, minor treatments and major treatments).
• Reference price is the maximum amount to be reimbursed per procedure written in Annex A.
• The claim is when you incur expense to be indemnified according to Annex A as a result of your dental treatment or oral cancer treatment.
• The insurance indemnity is the amount to be paid as compensation for the loss resulting from the claim.
• The premium is the amount agreed in the insurance contract to be paid by the policyholder for the annual cover.
• The policy period is the period of time on the basis of which premiums are calculated and during which the cover specified in the contract is valid.
• The start date of insurance contract is the first day of the policy period, as also stipulated on the insurance policy. It is usually the day when the insurance application was submitted.
• The renewal date of insurance contract is the day when 12 calendar months have passed from the start date of insurance contract.
• The waiting period is a certain period of time from the start date of insurance contract. The insurance indemnity will not be paid for the claim that take place during this period. The exact duration of the waiting period (in days) is specified for each type of treatment in Annex A.
• The dentist is a duly qualified and licensed dentist who practices in the state where the treatment is provided. In Estonia, the dentists with the requisite professional skills are registered by the Health Board. The dentist’s license code issued by the Health Board must be on the invoice of the dental practice.
• The dental practice is any dental practice in Estonia where the policyholder wants to receive the dental treatment to be indemnified and any dental practice abroad where the policyholder can turn to receive accident treatment. Please note: A contracted practice is a dental practice which adopts the dental insurance treatment or state coding system and tooth numbering for use on the practice invoice to enable faster and more accurate claim processing or a dental practice which submits insurance claims directly to the claims administrator in the name of the policyholder if such service is activated.
• The invoice by the dental practice is an electronically compiled and, where necessary, printed invoice for dental treatment. It must include the requisite data of the dental practice and the insured person, the dentist’s license code, the treatment, the number of the treated tooth, the full price of the service and the rate of the national benefit if applicable.
• The treatment is the dental or medical procedure that is listed in Annex A and clinically necessary to maintain and/or restore the oral health of the policyholder on the condition that the services are provided: a) by a licensed dentist, a physician or any other specialist in the respective field; b) in compliance with the generally acceptable medical standards; c) during the policy period.
• Dentures are the false teeth that replace the missing teeth and can be removed from the mouth.
• Orthodontic treatment is treatment by a dentist to prevent or correct uneven teeth.
• Cosmetic treatment is dental treatment that is not necessary to maintain tooth health; its sole purpose is correction of the policyholder’s appearance.
• The accident is an injury caused by direct impact outside of the oral cavity that results in fracture of tooth structure and or the bone and gums around the teeth. To qualify as an accident in terms of this insurance the nature of the injury should require treatment by a dentist within Dental Insurance Terms and Conditions HRK-3/2019 one week of the incident. Damage to dentures whilst being worn is included. Damage due to chewing is regarded as an internal injury and therefore specifically excluded from the accident category of cover.
• Physical contact sports are rugby, hockey, boxing, wrestling, lacrosse, ice hockey, Gaelic football or any other type of sports where it is common to wear a mouth, gum or head protection.
4. GENERAL TERMS AND CONDITIONS OF THE INSURANCE CONTRACT
4.1 Validity and taking of effect of the insurance contract
4.1.1 The insurance contract is concluded on the basis of the insurance application.
4.1.2 The insurance contract and the cover will take effect on the start date of the policy period if the premium or its first instalment has been paid and the respective amount is deposited on the distributor’s bank account and distributor confirms conclusion of the contract by issuing an insurance policy.
4.1.3 The insurance contract is concluded for an unspecified term. The policy period shall be for the period running from the start date to the subsequent renewal date. If the insurance contract has not been cancelled by either of the parties 30 days before renewal date, it will renew for another 12 months at each renewal date for an unspecified term. For each policy period, the distributor issues a new policy of insurance unless otherwise agreed in the insurance contract.
4.2 Payment of the insurance premium
4.2.1. The insurance premium or the first premium instalment must be paid at the moment of contracting as per policyholder’s choice and the manner of payment enabled by the distributor.
4.2.2. For collecting the insurance premium or premium instalments the distributor uses the authorized processors (incl. the factor).
4.2.3. The distributor as the factoring client has the right to transfer an insurance premium claim that has fallen due to AS Inbank (SliceIn3 payment method) on the basis of a factoring contract specified in § 256 of the Law of Obligations Act as a result of which the distributor’s right to claim the insurance premium based on subsection 4 of § 78 of the Law of Obligations Act from the client transfers to Inbank (the factor) and the client is required to make all the subsequent payments to a respective bank account of Inbank. The client is required to make the payments by their due dates. The occurrence of an insured event or any other events (except for the final payment of all the instalments) do not release the customer from the obligation to pay instalments to the factor. The client has the right to pay all the instalments to Inbank before the due dates specified in the payment schedule.
4.2.4. The distributor as the collector of the insurance premium (EveryPay payment method) follows § 458 of the Law of Obligations Act upon collecting insurance premium in instalments.
4.3 Age limit
4.3.1 According to the terms and conditions of the insurance contract, the cover is applicable to persons who are 19–70 years old on the start date of the insurance contract. Dental Insurance Terms and Conditions HRK-3/2019
4.5 Waiting period
4.5.1 Pursuant to the terms and conditions of the insurance contract, a waiting period for indemnification of treatment expenditure will be applicable after the contract is concluded. The waiting periods for each type of treatment are specified in Annex A.
4.5.2 No waiting period is applicable to the treatment after an accident nor after renewal of the contract for a consecutive policy period.
4.5.3 If you have entered into a dental insurance contract with another insurer and want our cover to be effective immediately as of the day that other insurance contract ends, no waiting period is applied, and the cover will take effect on the first day of the policy period. To be able to receive that cover immediately after the previous contract, you must inform the distributor of your previous dental insurance thereof before submitting the insurance application. The distributor has the right to ask you to provide proof of the previous dental insurance.
4.6 Other insurance
4.6.1 If you have similar cover under another insurance contract, you must inform the distributor thereof before signing our contract or immediately after entering into the other insurance contract.
4.6.2 Upon a claim, the insurer has no obligation to pay a higher indemnity than is proportionate compared to the cover under the other insurance contract.
5. RIGHTS AND OBLIGATIONS OF INSURANCE CONTRACT PARTIES
5.1 Policyholder rights and obligations
5.1.1 The policyholder has the right to receive the insurance indemnity in accordance with the terms and conditions of the insurance contract.
5.1.2 To sign a dental insurance contract the policyholder is obliged to submit an application via webpage www.inpro.ee and ensure accuracy of the information provided.
5.1.3 Should the information provided by the policyholder turn out or become inaccurate or inadequate or should significant changes take place, the policyholder must inform the distributor thereof as soon as possible.
5.1.4 The policyholder has an obligation to pay premiums as agreed in the contract.
5.1.5 The policyholder can cancel this policy within 14 days of the start date of this policy, unless they have made or intend to make a claim and shall be entitled to a refund of any premium paid.
5.1.6 The policyholder shall have the right to terminate the insurance contract for an unspecified term by notifying the distributor thereof 1 month before the end of the current insurance period.
5.1.7 If the insurer increases or decreases its premium, the policyholder may cancel the contract within one month after receipt of the notice of amendment. The contract will then terminate at the time of the entry into force of the premium increase or reduction of the liability.
5.2 Insurer’s rights and obligations
5.2.1 In the event of a claim, the insurer is obliged to pay the policyholder insurance indemnity in accordance with the terms and conditions of the insurance contract. Dental Insurance Terms and Conditions HRK-3/2019
5.2.2 The insurer has the right to cancel the insurance contract if the policyholder has: a) misled the insurer by submitting false information or withholding information; b) knowingly claimed indemnity for purposes not allowed in the insurance terms and conditions; c) consented to a third person’s attempt to obtain unreasonable financial gain to the detriment of the insurer; d) violated the insurance terms and conditions or other contractual obligations in any other material way due to negligence.
5.2.3 Should the insurer terminate the contract, it must be done by informing the policyholder 30 days in advance. The respective notice must be sent to the most up-to-date e-mail address the policyholder has given the insurer. The policyholder will have the right to receive the remaining proportional amount of the premium for the unused policy period if no indemnity has been paid.
5.2.4 The insurer has no right to declare some clauses of the insurance contract null and void or change these to your detriment, unless upon renewal of the insurance contract.
5.2.5 Should the insurer not apply any clause of the insurance contract in certain circumstances or cases, this does not mean the insurer cannot apply the clause in another circumstance or case.
5.2.6 The insurer may change the premium rates, terms and conditions and indemnity rates, but the changes cannot take effect before the date of renewal of the contract and must be notified at least 30 days in advance.
5.2.7 The insurer may at its own expense take proceedings in your name to recover its losses from any third party in respect of any loss or damage covered by this insurance, and any amount so recovered shall belong to the Insurer.
6. INDEMNIFICATION RULES
6.1 Regular dental treatment
6.1.1 The indemnity and the limits for what we will pay under this policy for regular treatments are set out in Annex A.
6.1.2 The filling indemnity per the tooth is valid for 2 years. The filling for the same tooth is reimbursed again in year 3 if the policyholder renews the insurance contract for subsequent periods of insurance.
6.1.3 The crown or bridge indemnity per tooth is valid for 5 years. The crown or bridge for the same tooth is reimbursed again in year 6 if the policyholder renews the insurance contract for subsequent periods of insurance. 6.1.4 The indemnity for the denture is valid for 2 years. The denture is reimbursed again in year 3 if the policyholder renews the insurance contract for subsequent periods of insurance.
6.1.5 Bridge and dentures are only covered if the tooth or teeth being replaced were extracted after the appropriate waiting period for removal of the tooth. This rule is not applicable where a tooth is lost due to an accident.
6.1.6 Crown and bridge are only covered if the diagnosis to place the crown or bridge was made after insurance contract start date.
6.3 Accident treatment
6.3.1 If the accident meets the criteria defined in these insurance terms and conditions, the emergency treatment necessary for immediate alleviation of the accidental injury and any Dental Insurance Terms and Conditions HRK-3/2019 following treatment necessary to restore the damaged tooth or teeth will be indemnified within the limits of the maximum sum insured specified for accident treatment in Annex A, irrespective whether the treatment was done in Estonia or abroad.
6.4 Oral cancer treatment
6.4.1 Pursuant to the insurance contract, the oral cancer treatment expenditure will be indemnified once in the insured person’s lifetime in compliance with the terms and conditions of the insurance contract and within the limits of the maximum sum insured set out in Annex A.
6.4.2 The indemnity will be paid only if the oral cancer was diagnosed and treated by a specialist, physician or dentist who is licensed in Estonia and has the respective qualifications.
6.4.3 Oral cancer treatment like hospital treatment (outpatient or inpatient), surgery and anesthesia (outpatient or inpatient), ambulatory care specialist consult and services, pathology tests and X-rays, radiology and chemotherapy expenditure will be indemnified.
7. CLAIMS
7.1 Claim
7.1.1 All claims where indemnification is claimed must be clinically necessary and incurred only for treatment purposes.
7.1.2 The insurance indemnity will be paid only if the treatment services have been provided: a) by a licensed dentist in Estonia; b) in the event of accident treatment, by a licensed dentist in Estonia or abroad; c) by a physician having a licence to treat oral cancer or the respective specialist in Estonia.
7.2 Submitting a claim
7.2.1 Claims (invoices from dental practices) must be submitted to claims administrator either: a) by you by uploading these via webpage www.inpro.ee section “Claim” directly to claims handler portal https://hambaravikindlustus.denisglobal.com/ or b) by the contracted practice if this service has been made available.
7.2.2 All claims (including additional documents where necessary) must be submitted within 180 days of the end of the treatment. We do not indemnify any claims that we will receive later.
7.2.3 In any claim where the claims administrator suspects that the treatment might fall outside of the policy rules, the claims administrator may request clinical records to substantiate such a claim from policyholder, health care provider or other third party. Clinical records must include a set of x-rays which displays the date taken and the name of the patient. The x-rays should show the status of the tooth or teeth before the claimed treatment was rendered. Dental Insurance Terms and Conditions HRK-3/2019
7.3 Payment of indemnity
7.3.1 The insurance indemnity will be paid out to you or contracted practice (see point 7.2.1/b) within 5 working days from the moment the claims administrator has sent a notice of claim payment to your e-mail address confirming that the claim has been completed.
7.3.2 Upon treatment after an accident abroad, you will be paid the indemnity in euros (€) on the basis of the exchange rate of the day of the treatment.
7.4 Notifying about the claim upon accident
7.4.1 If you run into an accident that requires accident treatment in Estonia or abroad, you must inform thereof by writing to kindlustusjuhtum@denisglobal.com.
7.4.2 You must cover the costs of possible translations of the dentist’s invoices, claims and proof documents should these be not in Estonian or English. This will be deducted from the indemnity.
8. EXCLUSIONS
8.1 Benefits are not available for:
8.1.1 any dental treatment which took place on or prior to the start date and treatment received after the policy period ceases;
8.1.2 services or supplies which are not described in Annex A or which are specifically excluded in terms and conditions;
8.1.3 treatment that exceeds maximum number of treatments and/or maximum sum insured per treatment group, subgroup and/or per procedure (reference price);
8.1.4 treatments to replace teeth which were missing on or prior to the start date or where the diagnosis to remove the teeth was made before policy start date or where the teeth were removed during waiting period;
8.1.5 treatment to replace any existing crowns or bridges;
8.1.6 preventive treatment (scaling, polishing, fluoride treatments and similar);
8.1.7 cosmetic treatments and treatments not clinically necessary;
8.1.8 cost of hospitals, anaesthesiologists and pathologists except in the case of oral cancer treatment;
8.1.9 orthognathic surgery (surgery designed to alter the position of the jaws and teeth);
8.1.10 services or supplies which are experimental in nature, or not normally supplied by a dental practice, or which are not clinically necessary;
8.1.11 reimbursement for travelling expenses or telephone calls in connection with any treatments or charges for completing the claim form;
8.1.12 any claims for the replacement of dentures damaged whilst not being worn;
8.1.13 any Treatment relating to damage or injury caused whilst participating in any physical contact sports when the appropriate tooth, mouth or head protection was not being worn;
8.1.14 injuries sustained while engaged in illegal, unlawful or anti-social activities;
8.1.15 oral cancer diagnosed, suspected, or for which tests were conducted or planned or for which a referral to a specialist had been made prior to the Insured Person joined the plan;
8.1.16 oral Cancer resulting from smoking or chewing tobacco products (including betel nut juice);
8.1.17 adult orthodontic treatment; Dental Insurance Terms and Conditions HRK-3/2019
8.1.18 any Treatment charges which qualify for reimbursement under state dental provision or any other form of insurance, regardless of whether or not the insured person claims these benefits from the state or other insurance provider;
8.1.19 war and terrorism mass destruction exclusion clause: Notwithstanding any provision to the contrary within this insurance or any endorsement thereto it is agreed that this insurance shall exclude war, invasion, acts of foreign enemies, hostilities (whether war be declared or not), civil war, rebellion, revolution, insurrection, or military or usurped power or terrorism but only as the sole result of the utilisation of nuclear, chemical or biological weapons of mass destruction howsoever these may be distributed or combined. For the purpose of this clause: a) terrorism means an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorism can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorism can either be acting alone, or on behalf of, or in connection with any organisation(s) or governments(s). b) utilisation of nuclear weapons of mass destruction means the use of any explosive nuclear weapon or device or the emission, discharge, dispersal, release or escape of fissile material emitting a level of radioactivity capable of causing incapacitating disablement or death amongst people or animals. c) utilisation of chemical weapons of mass destruction means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing incapacitating disablement or death amongst people or animals. d) utilisation of biological weapons of mass destruction means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) microorganism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesised toxins) which are capable of causing incapacitating disablement or death amongst people or animals. 8.1.20 We will not be deemed to provide cover and shall not be liable to pay any claim or provide any benefit to the extent that the provision of such cover, payment of such claim or provision of such benefit would expose us to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, law or regulations of the European Economic Union, United Kingdom or United States of America.
9. COMPLAINTS PROCEDURE
We are committed to treating customers fairly. However, there may be times when things go wrong. Any complain must be submitted no later than 3 years after concluding an insurance contract. In case of complaints about insurance contract or distributor activities written complaint must be sent to email kaebus@northern1.com by using Complaint form available on website https://hambaravikindlustus.ee/northern1. In case of complaints about claims written complaint must be sent to email: kindlustusjuhtum@denisglobal.com. Dental Insurance Terms and Conditions HRK-3/2019 We aim to answer your complaint within 3 working days of receiving it. If we are unable to resolve your complaint with this time, we will issue the final decision within 8 weeks of receiving it. If, having received the answer to your complaint, you are still not satisfied, you can take your complaint to either the: a) Estonian Financial Supervision and Resolution Authority (Sakala 4, 15030 Tallinn www.fi.ee), or b) The Estonian Consumer Protection Board (Pronksi 12, 10117 Tallinn www.tarbijakaitseamet.ee), or c) Kindlustuse lepitusorgan (Mustamäe tee 46, 10621 Tallinn www.eksl.ee) The Online Dispute Resolution website https://webgate.ec.europa.eu/odr is an official website managed by the European Commission dedicated to helping consumers and traders resolve their disputes out-of-court. If you have had a problem with something that you have bought on line, you can use this site if you live in the EU and the trader is based in the EU.
10. FAIR PROCESSING NOTICE
This Privacy Notice describes how the insurer collects and uses the personal information of insureds, claimants and other parties when they are providing our insurance and reinsurance services. The information provided to the insurer, together with medical and any other information obtained from you or from other parties about you in connection with this policy, will be used by them for the purposes of determining your application, the operation of insurance (which includes the process of underwriting, administration, claims management, analytics relevant to insurance, rehabilitation and customer concerns handling) and fraud prevention and detection. They may be required by law to collect certain personal information about you, or as a consequence of any contractual relationship they have with you. Failure to provide this information may prevent or delay the fulfilment of these obligations. Information will be shared by the Insurer for these purposes with group companies and third party insurers, reinsurers, insurance intermediaries and service providers. Such parties may become data controllers in respect of your personal information. Because they operate as part of a global business, they may transfer your personal information outside the European Economic Area for these purposes. You have certain rights regarding your personal information, subject to local law. These include the rights to request access, rectification, erasure, restriction, objection and receipt of your personal information in a usable electronic format and to transmit it to a third party (right to portability). If you have questions or concerns regarding the way in which your personal information has been used, please contact: legalcompliance@axaxl.com. The insurer is committed to working with you to obtain a fair resolution of any complaint or concern about privacy. If, however, you believe that they have not been able to assist with your complaint or concern, you have the right to make a complaint to the Irish Data Protection Commission. For more information about how the insurer processes your personal information, please see their full privacy notice at: http://axaxl.com/privacy-and-cookies.
DENTAL INSURANCE TERMS AND CONDITIONS HRK-3/2019
Valid from 10.12.2019
Dental insurance plan ’Silver’ terms and conditions are the part of the insurance contract and a basis for the indemnification of claims. Please take the time to carefully read these terms and conditions through and make sure you understand all these terms, conditions, exclusions and limitations.
EXCHANGE OF INFORMATION
Information related to the insurance contract, including the policy confirming the start or extension of the contract, notices about premium payment, insurance indemnity claims or amendments to the insurance contract shall be transmitted only by e-mail. Therefore, it is important that when you sign up for dental insurance, you provide us with an email address that is actively in use and will inform us immediately if you have changed your email address. The valid dental insurance terms and conditions are always available on the website www.inpro.ee/hambaravikindlustus
CONTENTS
1. Purpose of insurance contract
2. Persons whom the insurance contract concerns
3. Definitions of these insurance terms and conditions
4. General terms and conditions of insurance contract
5. Rights and obligations of insurance contract parties
6. Indemnification rules
7. Claims
8. Exclusions
9. Complaints procedure
10. Fair processing notice Annex A.
1. PURPOSE OF INSURANCE CONTRACT
• The purpose of this dental insurance contract is to indemnify, on the basis of the insurance terms of conditions, the policyholder’s possible arising expenses on treatment.
• The cover is valid if in the dentist’s or doctor’s opinion the dental treatment was clinically necessary, the premium or part of it has been paid by the time of the claim and the claim takes place or starts during the policy period.
• Any issues not regulated in these dental insurance terms and conditions will be governed by Estonian law. Dental Insurance Terms and Conditions HRK-3/2019
2. PERSONS WHOM THE INSURANCE CONTRACT CONCERNS
• The policyholder (you, your) is the insured person stated on the insurance policy who is responsible for paying the premium or instalments of premium, who has a right for cover and ensuring that the policy terms and conditions are adhered to.
• The insurer (we, our, us) is XL Insurance Company SE (reg.no 641686, address 8, St. Stephen’s Green, Dublin 2, Ireland, www.axaxl.com) is part of AXA XL, a division of AXA and who is in the insurance providers’ list kept by the Estonian Financial Supervision and Resolution Authority (www.fi.ee).
• The insurance broker is Inpro Insurance Brokers OÜ (reg. no. 14778803, address Raua 32, 10152 Tallinn, www.inpro.ee), who is in the insurance intermediaries’ list kept by the Estonian Financial Supervision and Resolution Authority (www.fi.ee) and who engages, for a remuneration and based on a brokerage contract, in insurance distribution.
• The insurance distributor (distributor) is Northern1 International Insurance Brokers OÜ (reg. no. 12806139, address Tartu mnt 84A-M302, 10112 Tallinn, www.northern1.eu), who is in the insurance intermediaries’ list kept by the Estonian Financial Supervision and Resolution Authority (www.fi.ee) and who engages, for a remuneration and based on a brokerage contract, in insurance distribution.
• The claims administrator is Denis UK Limited (reg. no. 06399615, seat at 603 Network House Basing View, Basingstoke, Hampshire, RG21 4HG United Kingdom, www.denisglobal.com).
3. DEFINITIONS OF THE INSURANCE CONTRACT
The terms and definitions have the same meanings in the terms and conditions and the insurance policy. Any other words and phrases not listed here are used in their ordinary meanings.
• The insurance contract is an agreement concluded between the insurer and the policyholder in compliance with these terms and conditions, on the basis of which the policyholder undertakes to pay premium to the extent and pursuant to the procedure stipulated in the contract, and the insurer undertakes to indemnify to policyholder, within the limits of the amount of sum insured and in compliance with Annex A to these terms and conditions, the medically required dental treatment costs and other agreed costs that were incurred as a result of an illness or accident.
Please note: The insurance contract includes the insurance application, the insurance policy, the terms and conditions and special conditions if agreed.
• Insurance application is the application form policyholder submits to insurer via distributor.
• Insurance policy is an insurance contract document that proves the conclusion of the insurance contract.
• The cover is the insurer’s obligation to pay the indemnity for treatment listed in Annex A, within the limits of the maximum sums insured after the claim. The cover will take effect immediately but for regular and oral cancer treatment a waiting period is applied.
Please note: The cover for regular treatment and oral cancer treatment is applicable only to treatments by dental practices or other health care practices in Estonia. In the event of treatment following an accident, the cover is applicable with respect to the services provided by dental practices in Estonia and by licensed dentists abroad.
• The insurance benefit plan is the insurance indemnity plan marked on insurance policy and in Annex A of the terms and conditions.
Please note: Change of the insurance benefit plan can be done only at the renewal date.
• The sum insured is the maximum amount of indemnity in one policy period specified for each type of treatment (regular treatment, accident treatment and oral cancer treatment) indicated in Annex A. Dental Insurance Terms and Conditions HRK-3/2019 Please note: The maximum sum insured for regular treatment is divided between subgroups (Xrays, minor treatments and major treatments).
• Reference price is the maximum amount to be reimbursed per procedure written in Annex A.
• The claim is when you incur expense to be indemnified according to Annex A as a result of your dental treatment or oral cancer treatment.
• The insurance indemnity is the amount to be paid as compensation for the loss resulting from the claim.
• The premium is the amount agreed in the insurance contract to be paid by the policyholder for the annual cover.
• The policy period is the period of time on the basis of which premiums are calculated and during which the cover specified in the contract is valid.
• The start date of insurance contract is the first day of the policy period, as also stipulated on the insurance policy. It is usually the day when the insurance application was submitted.
• The renewal date of insurance contract is the day when 12 calendar months have passed from the start date of insurance contract.
• The waiting period is a certain period of time from the start date of insurance contract. The insurance indemnity will not be paid for the claim that take place during this period. The exact duration of the waiting period (in days) is specified for each type of treatment in Annex A.
• The dentist is a duly qualified and licensed dentist who practices in the state where the treatment is provided. In Estonia, the dentists with the requisite professional skills are registered by the Health Board. The dentist’s license code issued by the Health Board must be on the invoice of the dental practice.
• The dental practice is any dental practice in Estonia where the policyholder wants to receive the dental treatment to be indemnified and any dental practice abroad where the policyholder can turn to receive accident treatment. Please note: A contracted practice is a dental practice which adopts the dental insurance treatment or state coding system and tooth numbering for use on the practice invoice to enable faster and more accurate claim processing or a dental practice which submits insurance claims directly to the claims administrator in the name of the policyholder if such service is activated.
• The invoice by the dental practice is an electronically compiled and, where necessary, printed invoice for dental treatment. It must include the requisite data of the dental practice and the insured person, the dentist’s license code, the treatment, the number of the treated tooth, the full price of the service and the rate of the national benefit if applicable.
• The treatment is the dental or medical procedure that is listed in Annex A and clinically necessary to maintain and/or restore the oral health of the policyholder on the condition that the services are provided: a) by a licensed dentist, a physician or any other specialist in the respective field; b) in compliance with the generally acceptable medical standards; c) during the policy period.
• Dentures are the false teeth that replace the missing teeth and can be removed from the mouth.
• Orthodontic treatment is treatment by a dentist to prevent or correct uneven teeth.
• Cosmetic treatment is dental treatment that is not necessary to maintain tooth health; its sole purpose is correction of the policyholder’s appearance.
• The accident is an injury caused by direct impact outside of the oral cavity that results in fracture of tooth structure and or the bone and gums around the teeth. To qualify as an accident in terms of this insurance the nature of the injury should require treatment by a dentist within Dental Insurance Terms and Conditions HRK-3/2019 one week of the incident. Damage to dentures whilst being worn is included. Damage due to chewing is regarded as an internal injury and therefore specifically excluded from the accident category of cover.
• Physical contact sports are rugby, hockey, boxing, wrestling, lacrosse, ice hockey, Gaelic football or any other type of sports where it is common to wear a mouth, gum or head protection.
4. GENERAL TERMS AND CONDITIONS OF THE INSURANCE CONTRACT
4.1 Validity and taking of effect of the insurance contract
4.1.1 The insurance contract is concluded on the basis of the insurance application.
4.1.2 The insurance contract and the cover will take effect on the start date of the policy period if the premium or its first instalment has been paid and the respective amount is deposited on the distributor’s bank account and distributor confirms conclusion of the contract by issuing an insurance policy.
4.1.3 The insurance contract is concluded for an unspecified term. The policy period shall be for the period running from the start date to the subsequent renewal date. If the insurance contract has not been cancelled by either of the parties 30 days before renewal date, it will renew for another 12 months at each renewal date for an unspecified term. For each policy period, the distributor issues a new policy of insurance unless otherwise agreed in the insurance contract.
4.2 Payment of the insurance premium
4.2.1. The insurance premium or the first premium instalment must be paid at the moment of contracting as per policyholder’s choice and the manner of payment enabled by the distributor.
4.2.2. For collecting the insurance premium or premium instalments the distributor uses the authorized processors (incl. the factor).
4.2.3. The distributor as the factoring client has the right to transfer an insurance premium claim that has fallen due to AS Inbank (SliceIn3 payment method) on the basis of a factoring contract specified in § 256 of the Law of Obligations Act as a result of which the distributor’s right to claim the insurance premium based on subsection 4 of § 78 of the Law of Obligations Act from the client transfers to Inbank (the factor) and the client is required to make all the subsequent payments to a respective bank account of Inbank. The client is required to make the payments by their due dates. The occurrence of an insured event or any other events (except for the final payment of all the instalments) do not release the customer from the obligation to pay instalments to the factor. The client has the right to pay all the instalments to Inbank before the due dates specified in the payment schedule.
4.2.4. The distributor as the collector of the insurance premium (EveryPay payment method) follows § 458 of the Law of Obligations Act upon collecting insurance premium in instalments.
4.3 Age limit
4.3.1 According to the terms and conditions of the insurance contract, the cover is applicable to persons who are 19–70 years old on the start date of the insurance contract. Dental Insurance Terms and Conditions HRK-3/2019
4.5 Waiting period
4.5.1 Pursuant to the terms and conditions of the insurance contract, a waiting period for indemnification of treatment expenditure will be applicable after the contract is concluded. The waiting periods for each type of treatment are specified in Annex A.
4.5.2 No waiting period is applicable to the treatment after an accident nor after renewal of the contract for a consecutive policy period.
4.5.3 If you have entered into a dental insurance contract with another insurer and want our cover to be effective immediately as of the day that other insurance contract ends, no waiting period is applied, and the cover will take effect on the first day of the policy period. To be able to receive that cover immediately after the previous contract, you must inform the distributor of your previous dental insurance thereof before submitting the insurance application. The distributor has the right to ask you to provide proof of the previous dental insurance.
4.6 Other insurance
4.6.1 If you have similar cover under another insurance contract, you must inform the distributor thereof before signing our contract or immediately after entering into the other insurance contract.
4.6.2 Upon a claim, the insurer has no obligation to pay a higher indemnity than is proportionate compared to the cover under the other insurance contract.
5. RIGHTS AND OBLIGATIONS OF INSURANCE CONTRACT PARTIES
5.1 Policyholder rights and obligations
5.1.1 The policyholder has the right to receive the insurance indemnity in accordance with the terms and conditions of the insurance contract.
5.1.2 To sign a dental insurance contract the policyholder is obliged to submit an application via webpage www.inpro.ee and ensure accuracy of the information provided.
5.1.3 Should the information provided by the policyholder turn out or become inaccurate or inadequate or should significant changes take place, the policyholder must inform the distributor thereof as soon as possible.
5.1.4 The policyholder has an obligation to pay premiums as agreed in the contract.
5.1.5 The policyholder can cancel this policy within 14 days of the start date of this policy, unless they have made or intend to make a claim and shall be entitled to a refund of any premium paid.
5.1.6 The policyholder shall have the right to terminate the insurance contract for an unspecified term by notifying the distributor thereof 1 month before the end of the current insurance period.
5.1.7 If the insurer increases or decreases its premium, the policyholder may cancel the contract within one month after receipt of the notice of amendment. The contract will then terminate at the time of the entry into force of the premium increase or reduction of the liability.
5.2 Insurer’s rights and obligations
5.2.1 In the event of a claim, the insurer is obliged to pay the policyholder insurance indemnity in accordance with the terms and conditions of the insurance contract. Dental Insurance Terms and Conditions HRK-3/2019
5.2.2 The insurer has the right to cancel the insurance contract if the policyholder has: a) misled the insurer by submitting false information or withholding information; b) knowingly claimed indemnity for purposes not allowed in the insurance terms and conditions; c) consented to a third person’s attempt to obtain unreasonable financial gain to the detriment of the insurer; d) violated the insurance terms and conditions or other contractual obligations in any other material way due to negligence.
5.2.3 Should the insurer terminate the contract, it must be done by informing the policyholder 30 days in advance. The respective notice must be sent to the most up-to-date e-mail address the policyholder has given the insurer. The policyholder will have the right to receive the remaining proportional amount of the premium for the unused policy period if no indemnity has been paid.
5.2.4 The insurer has no right to declare some clauses of the insurance contract null and void or change these to your detriment, unless upon renewal of the insurance contract.
5.2.5 Should the insurer not apply any clause of the insurance contract in certain circumstances or cases, this does not mean the insurer cannot apply the clause in another circumstance or case.
5.2.6 The insurer may change the premium rates, terms and conditions and indemnity rates, but the changes cannot take effect before the date of renewal of the contract and must be notified at least 30 days in advance.
5.2.7 The insurer may at its own expense take proceedings in your name to recover its losses from any third party in respect of any loss or damage covered by this insurance, and any amount so recovered shall belong to the Insurer.
6. INDEMNIFICATION RULES
6.1 Regular dental treatment
6.1.1 The indemnity and the limits for what we will pay under this policy for regular treatments are set out in Annex A.
6.1.2 The filling indemnity per the tooth is valid for 2 years. The filling for the same tooth is reimbursed again in year 3 if the policyholder renews the insurance contract for subsequent periods of insurance.
6.1.3 The crown or bridge indemnity per tooth is valid for 5 years. The crown or bridge for the same tooth is reimbursed again in year 6 if the policyholder renews the insurance contract for subsequent periods of insurance. 6.1.4 The indemnity for the denture is valid for 2 years. The denture is reimbursed again in year 3 if the policyholder renews the insurance contract for subsequent periods of insurance.
6.1.5 Bridge and dentures are only covered if the tooth or teeth being replaced were extracted after the appropriate waiting period for removal of the tooth. This rule is not applicable where a tooth is lost due to an accident.
6.1.6 Crown and bridge are only covered if the diagnosis to place the crown or bridge was made after insurance contract start date.
6.3 Accident treatment
6.3.1 If the accident meets the criteria defined in these insurance terms and conditions, the emergency treatment necessary for immediate alleviation of the accidental injury and any Dental Insurance Terms and Conditions HRK-3/2019 following treatment necessary to restore the damaged tooth or teeth will be indemnified within the limits of the maximum sum insured specified for accident treatment in Annex A, irrespective whether the treatment was done in Estonia or abroad.
6.4 Oral cancer treatment
6.4.1 Pursuant to the insurance contract, the oral cancer treatment expenditure will be indemnified once in the insured person’s lifetime in compliance with the terms and conditions of the insurance contract and within the limits of the maximum sum insured set out in Annex A.
6.4.2 The indemnity will be paid only if the oral cancer was diagnosed and treated by a specialist, physician or dentist who is licensed in Estonia and has the respective qualifications.
6.4.3 Oral cancer treatment like hospital treatment (outpatient or inpatient), surgery and anesthesia (outpatient or inpatient), ambulatory care specialist consult and services, pathology tests and X-rays, radiology and chemotherapy expenditure will be indemnified.
7. CLAIMS
7.1 Claim
7.1.1 All claims where indemnification is claimed must be clinically necessary and incurred only for treatment purposes.
7.1.2 The insurance indemnity will be paid only if the treatment services have been provided: a) by a licensed dentist in Estonia; b) in the event of accident treatment, by a licensed dentist in Estonia or abroad; c) by a physician having a licence to treat oral cancer or the respective specialist in Estonia.
7.2 Submitting a claim
7.2.1 Claims (invoices from dental practices) must be submitted to claims administrator either: a) by you by uploading these via webpage www.inpro.ee section “Claim” directly to claims handler portal https://hambaravikindlustus.denisglobal.com/ or b) by the contracted practice if this service has been made available.
7.2.2 All claims (including additional documents where necessary) must be submitted within 180 days of the end of the treatment. We do not indemnify any claims that we will receive later.
7.2.3 In any claim where the claims administrator suspects that the treatment might fall outside of the policy rules, the claims administrator may request clinical records to substantiate such a claim from policyholder, health care provider or other third party. Clinical records must include a set of x-rays which displays the date taken and the name of the patient. The x-rays should show the status of the tooth or teeth before the claimed treatment was rendered. Dental Insurance Terms and Conditions HRK-3/2019
7.3 Payment of indemnity
7.3.1 The insurance indemnity will be paid out to you or contracted practice (see point 7.2.1/b) within 5 working days from the moment the claims administrator has sent a notice of claim payment to your e-mail address confirming that the claim has been completed.
7.3.2 Upon treatment after an accident abroad, you will be paid the indemnity in euros (€) on the basis of the exchange rate of the day of the treatment.
7.4 Notifying about the claim upon accident
7.4.1 If you run into an accident that requires accident treatment in Estonia or abroad, you must inform thereof by writing to kindlustusjuhtum@denisglobal.com.
7.4.2 You must cover the costs of possible translations of the dentist’s invoices, claims and proof documents should these be not in Estonian or English. This will be deducted from the indemnity.
8. EXCLUSIONS
8.1 Benefits are not available for:
8.1.1 any dental treatment which took place on or prior to the start date and treatment received after the policy period ceases;
8.1.2 services or supplies which are not described in Annex A or which are specifically excluded in terms and conditions;
8.1.3 treatment that exceeds maximum number of treatments and/or maximum sum insured per treatment group, subgroup and/or per procedure (reference price);
8.1.4 treatments to replace teeth which were missing on or prior to the start date or where the diagnosis to remove the teeth was made before policy start date or where the teeth were removed during waiting period;
8.1.5 treatment to replace any existing crowns or bridges;
8.1.6 preventive treatment (scaling, polishing, fluoride treatments and similar);
8.1.7 cosmetic treatments and treatments not clinically necessary;
8.1.8 cost of hospitals, anaesthesiologists and pathologists except in the case of oral cancer treatment;
8.1.9 orthognathic surgery (surgery designed to alter the position of the jaws and teeth);
8.1.10 services or supplies which are experimental in nature, or not normally supplied by a dental practice, or which are not clinically necessary;
8.1.11 reimbursement for travelling expenses or telephone calls in connection with any treatments or charges for completing the claim form;
8.1.12 any claims for the replacement of dentures damaged whilst not being worn;
8.1.13 any Treatment relating to damage or injury caused whilst participating in any physical contact sports when the appropriate tooth, mouth or head protection was not being worn;
8.1.14 injuries sustained while engaged in illegal, unlawful or anti-social activities;
8.1.15 oral cancer diagnosed, suspected, or for which tests were conducted or planned or for which a referral to a specialist had been made prior to the Insured Person joined the plan;
8.1.16 oral Cancer resulting from smoking or chewing tobacco products (including betel nut juice);
8.1.17 adult orthodontic treatment; Dental Insurance Terms and Conditions HRK-3/2019
8.1.18 any Treatment charges which qualify for reimbursement under state dental provision or any other form of insurance, regardless of whether or not the insured person claims these benefits from the state or other insurance provider;
8.1.19 war and terrorism mass destruction exclusion clause: Notwithstanding any provision to the contrary within this insurance or any endorsement thereto it is agreed that this insurance shall exclude war, invasion, acts of foreign enemies, hostilities (whether war be declared or not), civil war, rebellion, revolution, insurrection, or military or usurped power or terrorism but only as the sole result of the utilisation of nuclear, chemical or biological weapons of mass destruction howsoever these may be distributed or combined. For the purpose of this clause: a) terrorism means an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorism can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorism can either be acting alone, or on behalf of, or in connection with any organisation(s) or governments(s). b) utilisation of nuclear weapons of mass destruction means the use of any explosive nuclear weapon or device or the emission, discharge, dispersal, release or escape of fissile material emitting a level of radioactivity capable of causing incapacitating disablement or death amongst people or animals. c) utilisation of chemical weapons of mass destruction means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing incapacitating disablement or death amongst people or animals. d) utilisation of biological weapons of mass destruction means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) microorganism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesised toxins) which are capable of causing incapacitating disablement or death amongst people or animals. 8.1.20 We will not be deemed to provide cover and shall not be liable to pay any claim or provide any benefit to the extent that the provision of such cover, payment of such claim or provision of such benefit would expose us to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, law or regulations of the European Economic Union, United Kingdom or United States of America.
9. COMPLAINTS PROCEDURE
We are committed to treating customers fairly. However, there may be times when things go wrong. Any complain must be submitted no later than 3 years after concluding an insurance contract. In case of complaints about insurance contract or distributor activities written complaint must be sent to email kaebus@northern1.com by using Complaint form available on website https://hambaravikindlustus.ee/northern1. In case of complaints about claims written complaint must be sent to email: kindlustusjuhtum@denisglobal.com. Dental Insurance Terms and Conditions HRK-3/2019 We aim to answer your complaint within 3 working days of receiving it. If we are unable to resolve your complaint with this time, we will issue the final decision within 8 weeks of receiving it. If, having received the answer to your complaint, you are still not satisfied, you can take your complaint to either the: a) Estonian Financial Supervision and Resolution Authority (Sakala 4, 15030 Tallinn www.fi.ee), or b) The Estonian Consumer Protection Board (Pronksi 12, 10117 Tallinn www.tarbijakaitseamet.ee), or c) Kindlustuse lepitusorgan (Mustamäe tee 46, 10621 Tallinn www.eksl.ee) The Online Dispute Resolution website https://webgate.ec.europa.eu/odr is an official website managed by the European Commission dedicated to helping consumers and traders resolve their disputes out-of-court. If you have had a problem with something that you have bought on line, you can use this site if you live in the EU and the trader is based in the EU.
10. FAIR PROCESSING NOTICE
This Privacy Notice describes how the insurer collects and uses the personal information of insureds, claimants and other parties when they are providing our insurance and reinsurance services. The information provided to the insurer, together with medical and any other information obtained from you or from other parties about you in connection with this policy, will be used by them for the purposes of determining your application, the operation of insurance (which includes the process of underwriting, administration, claims management, analytics relevant to insurance, rehabilitation and customer concerns handling) and fraud prevention and detection. They may be required by law to collect certain personal information about you, or as a consequence of any contractual relationship they have with you. Failure to provide this information may prevent or delay the fulfilment of these obligations. Information will be shared by the Insurer for these purposes with group companies and third party insurers, reinsurers, insurance intermediaries and service providers. Such parties may become data controllers in respect of your personal information. Because they operate as part of a global business, they may transfer your personal information outside the European Economic Area for these purposes. You have certain rights regarding your personal information, subject to local law. These include the rights to request access, rectification, erasure, restriction, objection and receipt of your personal information in a usable electronic format and to transmit it to a third party (right to portability). If you have questions or concerns regarding the way in which your personal information has been used, please contact: legalcompliance@axaxl.com. The insurer is committed to working with you to obtain a fair resolution of any complaint or concern about privacy. If, however, you believe that they have not been able to assist with your complaint or concern, you have the right to make a complaint to the Irish Data Protection Commission. For more information about how the insurer processes your personal information, please see their full privacy notice at: http://axaxl.com/privacy-and-cookies.
DENTAL INSURANCE TERMS AND CONDITIONS HRK-3/2019
Valid from 10.12.2019
Dental insurance plan ’Gold’ terms and conditions are the part of the insurance contract and a basis for the indemnification of claims. Please take the time to carefully read these terms and conditions through and make sure you understand all these terms, conditions, exclusions and limitations.
EXCHANGE OF INFORMATION
Information related to the insurance contract, including the policy confirming the start or extension of the contract, notices about premium payment, insurance indemnity claims or amendments to the insurance contract shall be transmitted only by e-mail. Therefore, it is important that when you sign up for dental insurance, you provide us with an email address that is actively in use and will inform us immediately if you have changed your email address. The valid dental insurance terms and conditions are always available on the website www.inpro.ee/hambaravikindlustus
CONTENTS
1. Purpose of insurance contract
2. Persons whom the insurance contract concerns
3. Definitions of these insurance terms and conditions
4. General terms and conditions of insurance contract
5. Rights and obligations of insurance contract parties
6. Indemnification rules
7. Claims
8. Exclusions
9. Complaints procedure
10. Fair processing notice Annex A.
1. PURPOSE OF INSURANCE CONTRACT
• The purpose of this dental insurance contract is to indemnify, on the basis of the insurance terms of conditions, the policyholder’s possible arising expenses on treatment.
• The cover is valid if in the dentist’s or doctor’s opinion the dental treatment was clinically necessary, the premium or part of it has been paid by the time of the claim and the claim takes place or starts during the policy period.
• Any issues not regulated in these dental insurance terms and conditions will be governed by Estonian law. Dental Insurance Terms and Conditions HRK-3/2019
2. PERSONS WHOM THE INSURANCE CONTRACT CONCERNS
• The policyholder (you, your) is the insured person stated on the insurance policy who is responsible for paying the premium or instalments of premium, who has a right for cover and ensuring that the policy terms and conditions are adhered to.
• The insurer (we, our, us) is XL Insurance Company SE (reg.no 641686, address 8, St. Stephen’s Green, Dublin 2, Ireland, www.axaxl.com) is part of AXA XL, a division of AXA and who is in the insurance providers’ list kept by the Estonian Financial Supervision and Resolution Authority (www.fi.ee).
• The insurance broker is Inpro Insurance Brokers OÜ (reg. no. 14778803, address Raua 32, 10152 Tallinn, www.inpro.ee), who is in the insurance intermediaries’ list kept by the Estonian Financial Supervision and Resolution Authority (www.fi.ee) and who engages, for a remuneration and based on a brokerage contract, in insurance distribution.
• The insurance distributor (distributor) is Northern1 International Insurance Brokers OÜ (reg. no. 12806139, address Tartu mnt 84A-M302, 10112 Tallinn, www.northern1.eu), who is in the insurance intermediaries’ list kept by the Estonian Financial Supervision and Resolution Authority (www.fi.ee) and who engages, for a remuneration and based on a brokerage contract, in insurance distribution.
• The claims administrator is Denis UK Limited (reg. no. 06399615, seat at 603 Network House Basing View, Basingstoke, Hampshire, RG21 4HG United Kingdom, www.denisglobal.com).
3. DEFINITIONS OF THE INSURANCE CONTRACT
The terms and definitions have the same meanings in the terms and conditions and the insurance policy. Any other words and phrases not listed here are used in their ordinary meanings.
• The insurance contract is an agreement concluded between the insurer and the policyholder in compliance with these terms and conditions, on the basis of which the policyholder undertakes to pay premium to the extent and pursuant to the procedure stipulated in the contract, and the insurer undertakes to indemnify to policyholder, within the limits of the amount of sum insured and in compliance with Annex A to these terms and conditions, the medically required dental treatment costs and other agreed costs that were incurred as a result of an illness or accident.
Please note: The insurance contract includes the insurance application, the insurance policy, the terms and conditions and special conditions if agreed.
• Insurance application is the application form policyholder submits to insurer via distributor.
• Insurance policy is an insurance contract document that proves the conclusion of the insurance contract.
• The cover is the insurer’s obligation to pay the indemnity for treatment listed in Annex A, within the limits of the maximum sums insured after the claim. The cover will take effect immediately but for regular and oral cancer treatment a waiting period is applied.
Please note: The cover for regular treatment and oral cancer treatment is applicable only to treatments by dental practices or other health care practices in Estonia. In the event of treatment following an accident, the cover is applicable with respect to the services provided by dental practices in Estonia and by licensed dentists abroad.
• The insurance benefit plan is the insurance indemnity plan marked on insurance policy and in Annex A of the terms and conditions.
Please note: Change of the insurance benefit plan can be done only at the renewal date.
• The sum insured is the maximum amount of indemnity in one policy period specified for each type of treatment (regular treatment, accident treatment and oral cancer treatment) indicated in Annex A. Dental Insurance Terms and Conditions HRK-3/2019 Please note: The maximum sum insured for regular treatment is divided between subgroups (Xrays, minor treatments and major treatments).
• Reference price is the maximum amount to be reimbursed per procedure written in Annex A.
• The claim is when you incur expense to be indemnified according to Annex A as a result of your dental treatment or oral cancer treatment.
• The insurance indemnity is the amount to be paid as compensation for the loss resulting from the claim.
• The premium is the amount agreed in the insurance contract to be paid by the policyholder for the annual cover.
• The policy period is the period of time on the basis of which premiums are calculated and during which the cover specified in the contract is valid.
• The start date of insurance contract is the first day of the policy period, as also stipulated on the insurance policy. It is usually the day when the insurance application was submitted.
• The renewal date of insurance contract is the day when 12 calendar months have passed from the start date of insurance contract.
• The waiting period is a certain period of time from the start date of insurance contract. The insurance indemnity will not be paid for the claim that take place during this period. The exact duration of the waiting period (in days) is specified for each type of treatment in Annex A.
• The dentist is a duly qualified and licensed dentist who practices in the state where the treatment is provided. In Estonia, the dentists with the requisite professional skills are registered by the Health Board. The dentist’s license code issued by the Health Board must be on the invoice of the dental practice.
• The dental practice is any dental practice in Estonia where the policyholder wants to receive the dental treatment to be indemnified and any dental practice abroad where the policyholder can turn to receive accident treatment. Please note: A contracted practice is a dental practice which adopts the dental insurance treatment or state coding system and tooth numbering for use on the practice invoice to enable faster and more accurate claim processing or a dental practice which submits insurance claims directly to the claims administrator in the name of the policyholder if such service is activated.
• The invoice by the dental practice is an electronically compiled and, where necessary, printed invoice for dental treatment. It must include the requisite data of the dental practice and the insured person, the dentist’s license code, the treatment, the number of the treated tooth, the full price of the service and the rate of the national benefit if applicable.
• The treatment is the dental or medical procedure that is listed in Annex A and clinically necessary to maintain and/or restore the oral health of the policyholder on the condition that the services are provided: a) by a licensed dentist, a physician or any other specialist in the respective field; b) in compliance with the generally acceptable medical standards; c) during the policy period.
• Dentures are the false teeth that replace the missing teeth and can be removed from the mouth.
• Orthodontic treatment is treatment by a dentist to prevent or correct uneven teeth.
• Cosmetic treatment is dental treatment that is not necessary to maintain tooth health; its sole purpose is correction of the policyholder’s appearance.
• The accident is an injury caused by direct impact outside of the oral cavity that results in fracture of tooth structure and or the bone and gums around the teeth. To qualify as an accident in terms of this insurance the nature of the injury should require treatment by a dentist within Dental Insurance Terms and Conditions HRK-3/2019 one week of the incident. Damage to dentures whilst being worn is included. Damage due to chewing is regarded as an internal injury and therefore specifically excluded from the accident category of cover.
• Physical contact sports are rugby, hockey, boxing, wrestling, lacrosse, ice hockey, Gaelic football or any other type of sports where it is common to wear a mouth, gum or head protection.
4. GENERAL TERMS AND CONDITIONS OF THE INSURANCE CONTRACT
4.1 Validity and taking of effect of the insurance contract
4.1.1 The insurance contract is concluded on the basis of the insurance application.
4.1.2 The insurance contract and the cover will take effect on the start date of the policy period if the premium or its first instalment has been paid and the respective amount is deposited on the distributor’s bank account and distributor confirms conclusion of the contract by issuing an insurance policy.
4.1.3 The insurance contract is concluded for an unspecified term. The policy period shall be for the period running from the start date to the subsequent renewal date. If the insurance contract has not been cancelled by either of the parties 30 days before renewal date, it will renew for another 12 months at each renewal date for an unspecified term. For each policy period, the distributor issues a new policy of insurance unless otherwise agreed in the insurance contract.
4.2 Payment of the insurance premium
4.2.1. The insurance premium or the first premium instalment must be paid at the moment of contracting as per policyholder’s choice and the manner of payment enabled by the distributor.
4.2.2. For collecting the insurance premium or premium instalments the distributor uses the authorized processors (incl. the factor).
4.2.3. The distributor as the factoring client has the right to transfer an insurance premium claim that has fallen due to AS Inbank (SliceIn3 payment method) on the basis of a factoring contract specified in § 256 of the Law of Obligations Act as a result of which the distributor’s right to claim the insurance premium based on subsection 4 of § 78 of the Law of Obligations Act from the client transfers to Inbank (the factor) and the client is required to make all the subsequent payments to a respective bank account of Inbank. The client is required to make the payments by their due dates. The occurrence of an insured event or any other events (except for the final payment of all the instalments) do not release the customer from the obligation to pay instalments to the factor. The client has the right to pay all the instalments to Inbank before the due dates specified in the payment schedule.
4.2.4. The distributor as the collector of the insurance premium (EveryPay payment method) follows § 458 of the Law of Obligations Act upon collecting insurance premium in instalments.
4.3 Age limit
4.3.1 According to the terms and conditions of the insurance contract, the cover is applicable to persons who are 19–70 years old on the start date of the insurance contract. Dental Insurance Terms and Conditions HRK-3/2019
4.5 Waiting period
4.5.1 Pursuant to the terms and conditions of the insurance contract, a waiting period for indemnification of treatment expenditure will be applicable after the contract is concluded. The waiting periods for each type of treatment are specified in Annex A.
4.5.2 No waiting period is applicable to the treatment after an accident nor after renewal of the contract for a consecutive policy period.
4.5.3 If you have entered into a dental insurance contract with another insurer and want our cover to be effective immediately as of the day that other insurance contract ends, no waiting period is applied, and the cover will take effect on the first day of the policy period. To be able to receive that cover immediately after the previous contract, you must inform the distributor of your previous dental insurance thereof before submitting the insurance application. The distributor has the right to ask you to provide proof of the previous dental insurance.
4.6 Other insurance
4.6.1 If you have similar cover under another insurance contract, you must inform the distributor thereof before signing our contract or immediately after entering into the other insurance contract.
4.6.2 Upon a claim, the insurer has no obligation to pay a higher indemnity than is proportionate compared to the cover under the other insurance contract.
5. RIGHTS AND OBLIGATIONS OF INSURANCE CONTRACT PARTIES
5.1 Policyholder rights and obligations
5.1.1 The policyholder has the right to receive the insurance indemnity in accordance with the terms and conditions of the insurance contract.
5.1.2 To sign a dental insurance contract the policyholder is obliged to submit an application via webpage www.inpro.ee and ensure accuracy of the information provided.
5.1.3 Should the information provided by the policyholder turn out or become inaccurate or inadequate or should significant changes take place, the policyholder must inform the distributor thereof as soon as possible.
5.1.4 The policyholder has an obligation to pay premiums as agreed in the contract.
5.1.5 The policyholder can cancel this policy within 14 days of the start date of this policy, unless they have made or intend to make a claim and shall be entitled to a refund of any premium paid.
5.1.6 The policyholder shall have the right to terminate the insurance contract for an unspecified term by notifying the distributor thereof 1 month before the end of the current insurance period.
5.1.7 If the insurer increases or decreases its premium, the policyholder may cancel the contract within one month after receipt of the notice of amendment. The contract will then terminate at the time of the entry into force of the premium increase or reduction of the liability.
5.2 Insurer’s rights and obligations
5.2.1 In the event of a claim, the insurer is obliged to pay the policyholder insurance indemnity in accordance with the terms and conditions of the insurance contract. Dental Insurance Terms and Conditions HRK-3/2019
5.2.2 The insurer has the right to cancel the insurance contract if the policyholder has: a) misled the insurer by submitting false information or withholding information; b) knowingly claimed indemnity for purposes not allowed in the insurance terms and conditions; c) consented to a third person’s attempt to obtain unreasonable financial gain to the detriment of the insurer; d) violated the insurance terms and conditions or other contractual obligations in any other material way due to negligence.
5.2.3 Should the insurer terminate the contract, it must be done by informing the policyholder 30 days in advance. The respective notice must be sent to the most up-to-date e-mail address the policyholder has given the insurer. The policyholder will have the right to receive the remaining proportional amount of the premium for the unused policy period if no indemnity has been paid.
5.2.4 The insurer has no right to declare some clauses of the insurance contract null and void or change these to your detriment, unless upon renewal of the insurance contract.
5.2.5 Should the insurer not apply any clause of the insurance contract in certain circumstances or cases, this does not mean the insurer cannot apply the clause in another circumstance or case.
5.2.6 The insurer may change the premium rates, terms and conditions and indemnity rates, but the changes cannot take effect before the date of renewal of the contract and must be notified at least 30 days in advance.
5.2.7 The insurer may at its own expense take proceedings in your name to recover its losses from any third party in respect of any loss or damage covered by this insurance, and any amount so recovered shall belong to the Insurer.
6. INDEMNIFICATION RULES
6.1 Regular dental treatment
6.1.1 The indemnity and the limits for what we will pay under this policy for regular treatments are set out in Annex A.
6.1.2 The filling indemnity per the tooth is valid for 2 years. The filling for the same tooth is reimbursed again in year 3 if the policyholder renews the insurance contract for subsequent periods of insurance.
6.1.3 The crown or bridge indemnity per tooth is valid for 5 years. The crown or bridge for the same tooth is reimbursed again in year 6 if the policyholder renews the insurance contract for subsequent periods of insurance. 6.1.4 The indemnity for the denture is valid for 2 years. The denture is reimbursed again in year 3 if the policyholder renews the insurance contract for subsequent periods of insurance.
6.1.5 Bridge and dentures are only covered if the tooth or teeth being replaced were extracted after the appropriate waiting period for removal of the tooth. This rule is not applicable where a tooth is lost due to an accident.
6.1.6 Crown and bridge are only covered if the diagnosis to place the crown or bridge was made after insurance contract start date.
6.3 Accident treatment
6.3.1 If the accident meets the criteria defined in these insurance terms and conditions, the emergency treatment necessary for immediate alleviation of the accidental injury and any Dental Insurance Terms and Conditions HRK-3/2019 following treatment necessary to restore the damaged tooth or teeth will be indemnified within the limits of the maximum sum insured specified for accident treatment in Annex A, irrespective whether the treatment was done in Estonia or abroad.
6.4 Oral cancer treatment
6.4.1 Pursuant to the insurance contract, the oral cancer treatment expenditure will be indemnified once in the insured person’s lifetime in compliance with the terms and conditions of the insurance contract and within the limits of the maximum sum insured set out in Annex A.
6.4.2 The indemnity will be paid only if the oral cancer was diagnosed and treated by a specialist, physician or dentist who is licensed in Estonia and has the respective qualifications.
6.4.3 Oral cancer treatment like hospital treatment (outpatient or inpatient), surgery and anesthesia (outpatient or inpatient), ambulatory care specialist consult and services, pathology tests and X-rays, radiology and chemotherapy expenditure will be indemnified.
7. CLAIMS
7.1 Claim
7.1.1 All claims where indemnification is claimed must be clinically necessary and incurred only for treatment purposes.
7.1.2 The insurance indemnity will be paid only if the treatment services have been provided: a) by a licensed dentist in Estonia; b) in the event of accident treatment, by a licensed dentist in Estonia or abroad; c) by a physician having a licence to treat oral cancer or the respective specialist in Estonia.
7.2 Submitting a claim
7.2.1 Claims (invoices from dental practices) must be submitted to claims administrator either: a) by you by uploading these via webpage www.inpro.ee section “Claim” directly to claims handler portal https://hambaravikindlustus.denisglobal.com/ or b) by the contracted practice if this service has been made available.
7.2.2 All claims (including additional documents where necessary) must be submitted within 180 days of the end of the treatment. We do not indemnify any claims that we will receive later.
7.2.3 In any claim where the claims administrator suspects that the treatment might fall outside of the policy rules, the claims administrator may request clinical records to substantiate such a claim from policyholder, health care provider or other third party. Clinical records must include a set of x-rays which displays the date taken and the name of the patient. The x-rays should show the status of the tooth or teeth before the claimed treatment was rendered. Dental Insurance Terms and Conditions HRK-3/2019
7.3 Payment of indemnity
7.3.1 The insurance indemnity will be paid out to you or contracted practice (see point 7.2.1/b) within 5 working days from the moment the claims administrator has sent a notice of claim payment to your e-mail address confirming that the claim has been completed.
7.3.2 Upon treatment after an accident abroad, you will be paid the indemnity in euros (€) on the basis of the exchange rate of the day of the treatment.
7.4 Notifying about the claim upon accident
7.4.1 If you run into an accident that requires accident treatment in Estonia or abroad, you must inform thereof by writing to kindlustusjuhtum@denisglobal.com.
7.4.2 You must cover the costs of possible translations of the dentist’s invoices, claims and proof documents should these be not in Estonian or English. This will be deducted from the indemnity.
8. EXCLUSIONS
8.1 Benefits are not available for:
8.1.1 any dental treatment which took place on or prior to the start date and treatment received after the policy period ceases;
8.1.2 services or supplies which are not described in Annex A or which are specifically excluded in terms and conditions;
8.1.3 treatment that exceeds maximum number of treatments and/or maximum sum insured per treatment group, subgroup and/or per procedure (reference price);
8.1.4 treatments to replace teeth which were missing on or prior to the start date or where the diagnosis to remove the teeth was made before policy start date or where the teeth were removed during waiting period;
8.1.5 treatment to replace any existing crowns or bridges;
8.1.6 preventive treatment (scaling, polishing, fluoride treatments and similar);
8.1.7 cosmetic treatments and treatments not clinically necessary;
8.1.8 cost of hospitals, anaesthesiologists and pathologists except in the case of oral cancer treatment;
8.1.9 orthognathic surgery (surgery designed to alter the position of the jaws and teeth);
8.1.10 services or supplies which are experimental in nature, or not normally supplied by a dental practice, or which are not clinically necessary;
8.1.11 reimbursement for travelling expenses or telephone calls in connection with any treatments or charges for completing the claim form;
8.1.12 any claims for the replacement of dentures damaged whilst not being worn;
8.1.13 any Treatment relating to damage or injury caused whilst participating in any physical contact sports when the appropriate tooth, mouth or head protection was not being worn;
8.1.14 injuries sustained while engaged in illegal, unlawful or anti-social activities;
8.1.15 oral cancer diagnosed, suspected, or for which tests were conducted or planned or for which a referral to a specialist had been made prior to the Insured Person joined the plan;
8.1.16 oral Cancer resulting from smoking or chewing tobacco products (including betel nut juice);
8.1.17 adult orthodontic treatment; Dental Insurance Terms and Conditions HRK-3/2019
8.1.18 any Treatment charges which qualify for reimbursement under state dental provision or any other form of insurance, regardless of whether or not the insured person claims these benefits from the state or other insurance provider;
8.1.19 war and terrorism mass destruction exclusion clause: Notwithstanding any provision to the contrary within this insurance or any endorsement thereto it is agreed that this insurance shall exclude war, invasion, acts of foreign enemies, hostilities (whether war be declared or not), civil war, rebellion, revolution, insurrection, or military or usurped power or terrorism but only as the sole result of the utilisation of nuclear, chemical or biological weapons of mass destruction howsoever these may be distributed or combined. For the purpose of this clause: a) terrorism means an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorism can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorism can either be acting alone, or on behalf of, or in connection with any organisation(s) or governments(s). b) utilisation of nuclear weapons of mass destruction means the use of any explosive nuclear weapon or device or the emission, discharge, dispersal, release or escape of fissile material emitting a level of radioactivity capable of causing incapacitating disablement or death amongst people or animals. c) utilisation of chemical weapons of mass destruction means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing incapacitating disablement or death amongst people or animals. d) utilisation of biological weapons of mass destruction means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) microorganism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesised toxins) which are capable of causing incapacitating disablement or death amongst people or animals. 8.1.20 We will not be deemed to provide cover and shall not be liable to pay any claim or provide any benefit to the extent that the provision of such cover, payment of such claim or provision of such benefit would expose us to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, law or regulations of the European Economic Union, United Kingdom or United States of America.
9. COMPLAINTS PROCEDURE
We are committed to treating customers fairly. However, there may be times when things go wrong. Any complain must be submitted no later than 3 years after concluding an insurance contract. In case of complaints about insurance contract or distributor activities written complaint must be sent to email kaebus@northern1.com by using Complaint form available on website https://hambaravikindlustus.ee/northern1. In case of complaints about claims written complaint must be sent to email: kindlustusjuhtum@denisglobal.com. Dental Insurance Terms and Conditions HRK-3/2019 We aim to answer your complaint within 3 working days of receiving it. If we are unable to resolve your complaint with this time, we will issue the final decision within 8 weeks of receiving it. If, having received the answer to your complaint, you are still not satisfied, you can take your complaint to either the: a) Estonian Financial Supervision and Resolution Authority (Sakala 4, 15030 Tallinn www.fi.ee), or b) The Estonian Consumer Protection Board (Pronksi 12, 10117 Tallinn www.tarbijakaitseamet.ee), or c) Kindlustuse lepitusorgan (Mustamäe tee 46, 10621 Tallinn www.eksl.ee) The Online Dispute Resolution website https://webgate.ec.europa.eu/odr is an official website managed by the European Commission dedicated to helping consumers and traders resolve their disputes out-of-court. If you have had a problem with something that you have bought on line, you can use this site if you live in the EU and the trader is based in the EU.
10. FAIR PROCESSING NOTICE
This Privacy Notice describes how the insurer collects and uses the personal information of insureds, claimants and other parties when they are providing our insurance and reinsurance services. The information provided to the insurer, together with medical and any other information obtained from you or from other parties about you in connection with this policy, will be used by them for the purposes of determining your application, the operation of insurance (which includes the process of underwriting, administration, claims management, analytics relevant to insurance, rehabilitation and customer concerns handling) and fraud prevention and detection. They may be required by law to collect certain personal information about you, or as a consequence of any contractual relationship they have with you. Failure to provide this information may prevent or delay the fulfilment of these obligations. Information will be shared by the Insurer for these purposes with group companies and third party insurers, reinsurers, insurance intermediaries and service providers. Such parties may become data controllers in respect of your personal information. Because they operate as part of a global business, they may transfer your personal information outside the European Economic Area for these purposes. You have certain rights regarding your personal information, subject to local law. These include the rights to request access, rectification, erasure, restriction, objection and receipt of your personal information in a usable electronic format and to transmit it to a third party (right to portability). If you have questions or concerns regarding the way in which your personal information has been used, please contact: legalcompliance@axaxl.com. The insurer is committed to working with you to obtain a fair resolution of any complaint or concern about privacy. If, however, you believe that they have not been able to assist with your complaint or concern, you have the right to make a complaint to the Irish Data Protection Commission. For more information about how the insurer processes your personal information, please see their full privacy notice at: http://axaxl.com/privacy-and-cookies.