General terms and conditions of the Confido Health Plan

General terms and conditions of Confido Health Plan

The general terms and conditions of Confido Health Plan (hereinafter the terms and conditions) describe the principles and conditions of the health insurance offered by AS LHV Kindlustus (hereinafter the insurer) within the framework of the Confido Health Plan. If you would like to receive additional information about the conditions, please contact Tervisekindlustusagent OÜ (hereafter insurance agent, kindlustus@confido.ee, tel. 602 6795) or the insurance provider (kindlustus@lhv.ee, tel. 699 9111). The insurer has assigned to an insurance agent the right to market Confido Health Plan and to perform claims handling.

Definitions

Confido Health Plan is a non-life insurance service (hereinafter health insurance) developed by the insurer, within the framework of which AS Arstikeskus Confido (hereinafter Confido, registry code 12381384, address Veerenni 51, Tallinn, 10138 Harju County) itself or through its cooperation partners or other healthcare providers offers its healthcare services for employees (and, if applicable, also their close relatives) within the limits of the agreed health insurance risk.

Indemnity limit is the maximum amount compensated per insured event. The indemnity limit is reduced by the indemnity paid.

Claims handling includes receiving and processing of loss reports, customer service, proposing a decision on compensation of damage to the insurer, and making a disbursement on behalf of the insurer.

Insured object is the health of the insured person and the risk of incurring costs related to the provision of health services necessary to maintain it, that is, the insurance risk.

Insured person is the employee referred to as the insured person in the insurance contract or their close relative. On the basis of the insurance contract, the health insurance risk related to the insured person as a third party is insured. If the policyholder excludes an employee from the insurance contract, it is assumed that this person is no longer an insured person.

Insurance agent is Tervisekindlustusagent OÜ (registry code 16572262, address Veerenni 51, Tallinn, 10138 Harju County).

Insurer is AS LHV Kindlustus (registry code 14973611, address Tartu mnt 2, Tallinn, 10145 Harju County).

Insurance coverage is the insurer’s obligation, as defined by the terms of the insurance contract, to pay an insurance indemnity in the event of an insured event occurring during the insurance period, or to fulfil other obligations set out in the insurance contract.

Insurance contract is a health insurance contract concluded between an insurer and a policyholder, on the basis of which health insurance cover is provided based on the principles of non-life insurance. The insurance contract consists of the policyholder's statement, conditions, description of insurance coverage, insurance policy, information sheet, and other documents proving the agreements concluded between the policyholder and the insurer. The insurance contract makes it possible to provide insurance coverage to the policyholder's employees and, with an additional written agreement, also to the close relatives of the insured person. The conclusion of the insurance contract is intermediated by the insurance agent.

Insurance premium is the fee agreed in the insurance contract and paid by the policyholder or, if applicable, a close relative for insurance coverage.

Insurance period is the period of time specified in the insurance contract, during which the insurance coverage agreed with the insurance contract is in effect. If the insured person receives insurance coverage for the duration of the insurance period based on the insurance contract, then the insurance coverage applies to them from the time they join the insurance contract until the end of the insurance period unless the policyholder stops offering them insurance coverage under the insurance contract earlier.

Insurance policy is a document that confirms the conclusion and validity of an insurance contract and is communicated by an insurance agent to the policyholder after the conclusion of the insurance contract, amendment, or extension of the insurance period.

Sum insured or insurance amount is the maximum sum specified in the insurance contract, which is compensated for insured events per insured person during the insurance period. The sum insured is reduced by the benefits paid out.

Policyholder is a legal entity that wishes to provide health insurance to its employees and, if applicable, the close relatives of its employees and undertakes the obligation to pay the insurance premiums.

Close relatives are family members of the policyholder's employee. Family members are spouses or partners, parents, and children up to 18 years of age. A close relative is an insured person under the insurance contract if the close relative has given a relevant confirmation. Unless otherwise indicated by the context, the same applies to the close relative to the employee specified in the terms and conditions.

Deductible is the part of the damage specified in the insurance contract, the costs of which are borne by the insured person in the event of an insured event.

Information sheet is the standard form of the insurance product information document stipulated by the European Commission Implementing Regulation (EU) No. 2017/1469.

Healthcare service is the activity of a healthcare worker or institution to prevent and diagnose health problems and to restore health (including the sale of goods specified in these terms and conditions or in the insurance contract, such as glasses, contact lenses, orthopaedic aids, prescription medicines, or other such items).

Healthcare service provider is a healthcare provider registered in the Republic of Estonia who is entered into the Health Board registry, has a corresponding licence to provide healthcare services or has a valid professional certificate.

Marketing includes, among other things, the conclusion, amendment, and termination of insurance contracts, as well as the collection of insurance premiums.

Employee is a person who works on the basis of a valid employment contract, management board member agreement, or other service relationship contract for the benefit of the policyholder.

Supplementary insurance coverage is protection granted to the insured person by additional agreement, which is subject to the same principles and limitations as the primary insurance coverage, unless otherwise provided in the contract.

Authorized person is a person designated by the insurance agent and the policyholder whom they have authorized for data exchange in connection with the conclusion and execution of the insurance contract, including the transmission of encrypted data.

Insured event and insurance coverage
An insured event is the use of healthcare services or the purchase of prescription drugs, or aids by the insured person to the extent agreed in the insurance contract during the insurance coverage applicable to them. The insurance indemnity is paid out if the insured event meets the following conditions:
1. conforms to the volume and conditions agreed with the insurance contract;
2. the healthcare service is related to the insured person's insurance coverage;
3. the healthcare service has been provided during the insurance period;
4. the healthcare service has been provided by a service provider registered in the Republic of Estonia who is entered into the Health Board registry and holds a valid licence or professional certificate, as required by law, for the provision of that specific service. In the case of chiropractic, physiotherapy or osteopathy services, the specialist directly providing the service must hold a diploma in the relevant field;
5. the healthcare service has not been compensated by the Health Insurance Fund;
6. a claim for reimbursement has been submitted at the earliest opportunity, no later than within 30 days of receiving the healthcare service;
7. physician's referral (referral letter, digital referral letter, entry in the medical record, occupational health physician's decision, prescription) is issued to a specific healthcare service before receiving the healthcare service. The term of validity of the referral is considered to be one year from the date of issuance of the document, with the exception of the referral made by the occupational health physician, which is valid as stated in the decision but not more than three years.
The insurance contract may provide that the insurance coverage applies not only in the Republic of Estonia but also in other countries and to services provided by healthcare providers registered in those countries.
The insurer pays the insurance benefit through the insurance agent to the insured person if the insured person has paid the expenses themselves, or to the healthcare provider if the provider has rendered healthcare services to the insured person or covered the related costs. If the insurance benefit is paid to the healthcare provider, the insured person loses the right to the insurance benefits.
Outpatient insurance coverage
1. Outpatient treatment is a healthcare service in which the insured person's visit to the healthcare provider lasts only a few hours.
2. The following expenses are compensated on the basis of outpatient care insurance coverage:
  - general practitioner, specialist physician and nurse appointment and consultation fee;
  - remote consultation fee.
3. Under outpatient treatment insurance coverage, the following expenses are compensated only with a physician's referral:
  - tests;
  - examinations;
  - treatment procedures.
4. The following expenses are not covered on the basis of outpatient care insurance coverage:
  - costs related to dental treatment, mental health, special diagnostics, preventive health checkup, rehabilitation, hospital treatment, and services included in supplementary insurance coverage;
  - the cost related to the general exclusions referred to in clause 18.
Preventive health checkup insurance coverage
1. Preventive health checkup is a healthcare service for which there is no medical indication and which is performed by the healthcare service provider at the request and choice of the insured person in order to check their health condition, prevent diseases or issue a health certificate.
2. On the basis of preventive health checkup insurance coverage, the following expenses are compensated:
  - sports medicine physician’s appointment and consultation fee;
  - vaccination;
  - tests, examinations, examination and analysis packages, and audits, and appointment and consultation fees related to performing them;
  - birthmark examination, Dermtest, sports medicine examinations, and stress test and appointment and consultation fees related to performing them;
  - appointment and consultation fees related to testing (including testing for sexually transmitted diseases);
  - appointment and consultation fees related to issuing or renewing a prescription (including for a medicinal product or medical device);
  - appointment and consultation fees related to issuing a prescription for glasses or contact lenses and determining visual acuity;
  - examinations and appointment and consultation fees related to issuing a paid health certificate (including for applying for a firearm licence or driving licence, or for food handling);
  - medical checkup to monitor and treat a chronic disease or a disease contracted before the conclusion of the insurance contract.
3. The following costs are not compensated under preventive health checkup insurance coverage:
  - costs related to outpatient treatment, dental treatment, mental health, special diagnostics, rehabilitation, hospital treatment, and services included in supplementary insurance coverage;
  - costs related to the general exclusions referred to in clause 18.
Mental health insurance coverage
1. On the basis of mental health insurance coverage, the costs of the appointment and consultation fees of the following healthcare providers are compensated:
  - psychologist (including clinical psychologist);
  - psychotherapist;
  - psychiatrist;
  - family and couples therapist;
  - mental health nurse.
2. On the basis of mental health insurance coverage, the following expenses are compensated only upon referral by a physician:
  - mental health examinations and testing.
3. Costs of family and couples therapy are distributed proportionally to the number of participants and only the insured person’s share of the expense is compensated.
4. On the basis of mental health insurance coverage, the following costs are not compensated:
  - costs related to outpatient treatment, dental treatment, preventive health checkups, rehabilitation, hospital treatment, and services included in supplementary insurance coverage;
  - costs of psychedelic-assisted therapy;
  - costs of transcranial brain stimulation;
  - costs related to the general exclusions referred to in clause 18.
Insurance coverage for special diagnostics
1. On the basis of insurance coverage for special diagnostics, the costs of the following procedures and appointment and consultation fees related thereto are compensated only upon referral by a physician:
  - digital tomography;
  - magnetic resonance imaging;
  - anoscopy, hysteroscopy, cystoscopy, gastroscopy, colonoscopy and colposcopy;
  - ultrasound;
  - X-ray (including mammography);
  - computer tomography (CT).
2. The following costs are not compensated under the special diagnostics insurance coverage:
  - costs related to outpatient treatment, dental treatment, mental health, rehabilitation, hospital treatment, and services included in supplementary insurance coverage;
  - costs related to the general exclusions referred to in clause 18.
Insurance coverage for rehabilitation
1. Rehabilitation is a healthcare service that aims to restore impaired body functions.
2. On the basis of rehabilitation insurance coverage, the appointment and consultation fee for the following healthcare providers are compensated:
  - physiotherapist;
  - chiropractor;
  - rehabilitation physician.
3. On the basis of rehabilitation insurance coverage, the appointment and consultation fees for the following procedures and healthcare providers are compensated only upon referral by a physician:
  - device-assisted physiotherapy and kinesiology taping;
  - sports massage, therapeutic massage, classical massage, and lymphatic drainage massage;
  - lymphatic therapy;
  - myofunctional therapy;
  - manual therapy and osteopathy;
  - paraffin therapy;
  - speech therapy;
  - post-operative rehabilitation services.
4. The following costs are not compensated under rehabilitation insurance coverage:
  - costs related to inpatient rehabilitation, except for the post-operative rehabilitation services specified in clause 8.3; the rental or purchase of rehabilitation equipment, exercise equipment, and other rehabilitation products intended for home or independent use (including resistance bands, exercise balls, balance cushions, exercise equipment, massage devices, etc.), even if their use has been recommended by a physician or another healthcare professional;
  - passes to sports clubs, spas and swimming pools;
  - aquatherapy and mud treatment;
  - training sessions (including water aerobics and aquatic exercises);
  - types of massage not listed in clause 8.3 of these terms and conditions;
  - costs related to outpatient treatment, dental treatment, mental health, special diagnostics, preventive health checkup, and services included in supplementary insurance coverage;
  - costs related to the general exclusions referred to in clause 18.
Insurance coverage for hospital treatment
1. Insurance coverage for hospital treatment provides compensation for both day hospital treatment services and healthcare services for which it is necessary for the insured to be hospitalized for a longer term.
2. Before using the hospital treatment coverage, the insured person is required to obtain prior approval from the insurance agent.
3. On the basis of hospitalization insurance coverage, the following costs are compensated without referral by a physician:
  - fees for physician and nurse visits and consultations related to the hospital treatment.
4. On the basis of hospitalization insurance coverage, the following costs are compensated only upon referral by a physician:
  - bed-day fee;
  - the cost of hospital treatment (including surgery, minor surgery, treatment at hospital);
  - tests, examinations, and treatment procedures related to the hospital treatment;
  - medications prescribed and consumed during hospitalization;
  - additional costs of a paid hospital room (including the cost of a postnatal room even if the person giving birth is the insured person’s spouse or partner who is listed as a parent on the child’s birth certificate).
5. The following are not compensated under the hospital treatment insurance coverage:
  - the costs associated with a relative or a person close to the insured person staying with the insured person in hospital;
  - the insured person’s stay in hospital due to another person’s illness or treatment (including as a caregiver or accompanying person), as well as any related hospital stay, bed-day, and other costs;
  - costs related to outpatient treatment, dental treatment, mental health, special diagnostics, preventive health checkup, rehabilitation, and services included in supplementary insurance coverage;
  - costs related to the general exclusions referred to in clause 18.
Dental care insurance coverage
1. On the basis of dental care insurance coverage, the following expenses are compensated:
  - fees for dental appointments and consultation fees (including the preparation of a treatment plan);
  - dental treatment;
  - oral hygiene services (including professional oral hygiene, removal of dental calculus, subgingival calculus removal, polishing with prophylaxis paste, and curettage);
  - oral surgery;
  - general and local anaesthesia;
  - endodontics and periodontal treatment;
  - expenses related to dentures, crowns and implants.
2. The following are not compensated on the basis of dental care insurance coverage:
  - cosmetic and aesthetic dental and oral cavity services (including teeth whitening, dental jewellery, and veneers or dental prostheses placed solely for aesthetic purposes);
  - professional dental cleaning, including pearl polishing, soda blasting, and AirFlow treatment;
  - orthodontics;
  - mouthguards and other devices not related to dental treatment (including anti-snoring, sports, and bruxism mouthguards), as well as any associated costs;
  - products purchased for home use (including toothpaste, mouthwash, and toothbrushes);
  - costs related to outpatient treatment, mental health, special diagnostics, preventive health checkup, rehabilitation, hospital treatment, and services included in supplementary insurance coverage;
  - costs related to the general exclusions referred to in clause 18.
Supplementary insurance coverage
Insurance coverage for prescription drugs
1. On the basis of prescription drug insurance coverage, the following expenses are compensated only based on a valid prescription issued by a physician or other healthcare professional authorised to prescribe medication:
  - purchase of a prescription drug if the prescription drug is registered in the European Union, and the cost of the prescription drug is greater than 10 euros.
2. The following costs are not compensated under prescription drug insurance coverage:
  - OTC medicines;
  - vaccines;
  - medications related to mental health (including antidepressants, sedatives, stimulants, and psychostimulants);
  - medications for the treatment of addiction;
  - sleeping pills;
  - medications and devices related to pregnancy or contraception;
  - tests (including pregnancy tests);
  - food supplements;
  - vitamins;
  - medications related to obesity and weight loss;
  - medical devices and assistive devices (including syringes, blood pressure monitors, blood glucose meters, hearing aids, and assistive devices required for rehabilitation as specified in clause 12.1);
  - costs related to outpatient treatment, mental health, special diagnostics, preventive health checkup, rehabilitation, hospital treatment, dental care and other services included in supplementary insurance coverage;
  - costs related to the general exclusions referred to in clause 18.
Insurance coverage for orthopaedic aids
1. Under the insurance coverage of orthopaedic aids, the following expenses are compensated only on the basis of a physician's prescription:
  - rental or purchase of assistive aids required for rehabilitation (orthoses, medical corsets, orthopaedic insoles, crutches, wheelchairs, support bandages, and medical compression products, including compression stockings) and related assessments.
2. The cost of one assistive aid of the same type during the insurance period is compensated.
3. Under the insurance coverage of orthopaedic aids, the following expenses are not compensated:
  - costs related to outpatient treatment, mental health, special diagnostics, preventive health checkup, rehabilitation, hospital treatment, dental care and other services included in supplementary insurance coverage;
  - the rental or purchase of medical devices and assistive aids not listed as compensable assistive aids in clause 12.1, including syringes, blood pressure monitors, blood glucose meters, and hearing aids;
  - costs related to the general exclusions referred to in clause 18.
Insurance coverage for vision care
1. The following expenses are compensated based on the vision care insurance coverage:
  - the purchase of prescription glasses or contact lenses if the visual acuity has changed during the current insurance period, provided that the prescription was issued before the purchase of the glasses/contact lenses and the previous prescription on which the change is based was issued no more than three years ago.
2. Purchase of contact lenses and/or one pair of glasses shall be compensated during the insurance period.
3. The following costs are not compensated under vision care insurance coverage:
  - the purchase of glasses without prescription lenses;
  - costs related to the repair of glasses;
  - costs related to glasses cases and cleaning and storage products for glasses and contact lenses;
  - costs related to outpatient treatment, mental health, special diagnostics, preventive health checkup, rehabilitation, hospital treatment, dental care and other services included in supplementary insurance coverage;
  - costs related to the general exclusions referred to in clause 18.
Insurance coverage for pregnancy and maternity
1. On the basis of pregnancy and maternity insurance coverage, the following expenses are compensated only upon referral by a physician or midwife and where medically indicated:
  - fees for appointments and consultations related to pregnancy.
2. On the basis of pregnancy and maternity insurance coverage, the following expenses are compensated only upon referral by a physician or midwife and where medically indicated:
  - analyses, examinations, and procedures during pregnancy and after childbirth.
3. The following expenses are not compensated on the basis of pregnancy and maternity insurance coverage:
  - costs related to outpatient treatment, mental health, special diagnostics, preventive health checkup, rehabilitation, hospital treatment, dental care and other services included in supplementary insurance coverage;
  - costs related to the general exclusions referred to in clause 18.
Insurance coverage for vein treatment
1. On the basis of insurance coverage for vein treatment, the following costs are compensated when medically indicated:
  - physician’s appointment and consultation fee.
2. On the basis of insurance coverage for vein treatment, the following costs are compensated only with a referral from a physician and when medically indicated:
  - tests, examinations and procedures related to vein treatment and sclerotherapy;
  - vascular surgery.
3. The following expenses are not compensated on the basis of insurance coverage for vein treatment:
  - aesthetic vein treatment and sclerotherapy services;
  - costs related to outpatient treatment, mental health, special diagnostics, preventive health checkup, rehabilitation, hospital treatment, dental care and other services included in supplementary insurance coverage;
  - costs related to the general exclusions referred to in clause 18.
Insurance coverage for post-accident dental care
1. An accident is an unexpected event caused by an external factor and beyond the control of the insured person, resulting in broken teeth and/or gum injuries.
2. The following costs are compensated under post-accident dental care insurance coverage:
  - treatment of dental damage resulting from an accident.
3. The following costs are not compensated under post-accident dental care insurance coverage:
  - injuries caused by biting and chewing;
  - costs related to outpatient treatment, mental health, special diagnostics, preventive health checkup, rehabilitation, hospital treatment, dental care and other services included in supplementary insurance coverage;
  - costs related to the general exclusions referred to in clause 18.
Insurance coverage for aesthetic medicine and well-being
1. The following costs are compensated under aesthetic medicine and well-being insurance coverage:
  - diagnosis and treatment of rosacea, acne, and pimples;
  - treatment of ingrown toenails and fungal nail infections;
  - diagnosis and removal of benign skin tumors when medically indicated;
  - food intolerance and sensitivity tests;
  - sleep studies and treatment of sleep disorders, including sleep apnoea and snoring.
2. The following costs are not compensated under aesthetic medicine and well-being insurance coverage:
  - costs related to outpatient treatment, mental health, special diagnostics, preventive health checkup, rehabilitation, hospital treatment, dental care and other services included in supplementary insurance coverage;
  - costs related to the general exclusions referred to in clause 18.
Exclusions
The following expenses are not compensated, including appointment fees, procedure fees, and other expenses related to the exclusions listed below:
1. services not received, including services for which the insured person failed to attend the scheduled appointment, and services included in prepayment invoices;
2. cases related to an epidemic or pandemic, or to a state of emergency or emergency declared in the country;
3. cases where the insured person has intentionally caused harm to their own health, including by attempting suicide, self-harm, or knowingly putting their health at risk;
4. cases resulting from self-treatment and cases related to the use of medication that has not been recommended or prescribed by a physician;
5. cases resulting from the use of alcohol, narcotic substances, or psychotropic substances;
6. treatment of addictions;
7. cases occurring while the insured person was committing a criminal offence, was detained by law enforcement authorities, or was held in a detention facility;
8. appointments with a coach, dietitian, occupational therapist, geneticist, hypnotherapist, narcologist, rehabilitation specialist, trichologist, orthopaedic technician, prosthetist, foot care specialist or nutritionist, and related services;
9. services provided for the purposes of preventive medicine, lifestyle medicine, anti-aging medicine, health support or life extension (longevity), as well as related consultations, laboratory tests, microbiological tests, functional examinations, diagnostic imaging, health assessments and other diagnostic or treatment procedures;
10. cosmetic and aesthetic services, except when covered under the supplementary insurance described in clause 17;
11. aesthetic dermatology, scar treatment and therapy, treatment of hair loss, acne, pimples, and rosacea; cryotherapy, salt therapy, laser skin treatment, services using ELOS technology, radiofrequency treatment, treatment of excessive sweating and related services, cosmetic and plastic surgery, except when covered under the supplementary insurance described in clause 17;
12. diagnosis and removal of benign skin tumours and lesions, except when covered under the supplementary insurance described in clause 17;
13. breast reduction and augmentation surgeries and related services;
14. treatment of obesity, weight-loss-related services, bariatric surgeries, and related services;
15. podiatry, foot care, pedicure, and manicure services (including therapeutic and medical manicures and pedicures, treatment of ingrown nails and corns, treatment of fungal nail infections, etc.), except when covered under the supplementary insurance described in clause 17;
16. services related to vision correction and the treatment of dry eye;
17. services related to sex reassignment, circumcision, and gender transition;
18. services related to organ transplantation;
19. services related to varicose veins, except when covered under the supplementary insurance described in clause 15;
20. genetic tests and diagnostic investigations; sleep studies and treatment of sleep disorders, including sleep apnoea and snoring; food intolerance and sensitivity tests and related services, except when covered under the supplementary insurance described in clause 17;
21. treatment of sexually transmitted diseases;
22. purchase and rental of medical assistive aids (including medical corsets, orthoses, crutches, support braces, casts, medical compression products, including compression stockings, orthopaedic insoles and footwear, hygiene kits, and hearing aids), except when covered under the supplementary insurance described in clause 12;
23. services related to endoprosthetic replacement;
24. mandatory employee health examinations required by law;
25. immunoglobulin therapy, plasma therapy, hyaluronic acid therapy, intra-articular injections (including PRP injections, Kenalog, and Synvisc), barotherapy, orthokine therapy, and intraocular injection-related services;
26. alternative and complementary medicine services (including acupuncture, light therapy, sound therapy, aromatherapy, reflexology, holistic, iris examinations, bioresonance diagnostics, electropuncture, homeopathy, and biofeedback methods);
27. services related to family planning, pregnancy, and childbirth (including confirmation of pregnancy and fetal assessment, purchase, insertion, and removal of contraceptive devices, infertility treatment, assisted reproduction, abortion without a medical indication, semen analyses, vasectomy, and laparoscopic procedures for the assessment of fallopian tube patency and removal of adhesions), except when covered under the supplementary insurance described in clause 14;
28. treatment of congenital pathology, degenerative disease (including Alzheimer's disease, Parkinson's disease, sclerosis multiplex), and mental disorders;
29. procedures involving medications (including infusion therapy and injection procedures);
30. travel medicine consultations;
31. printing and saving of certificates, documents, etc., as a separate service;
32. palliative care and social care;
33. expenses related to smartphone applications and platforms;
34. training, lectures and courses (including sexual counselling);
35. convenience services, including home visits and transportation;
36. loss, expenses, or illnesses directly or indirectly caused by:
  - war, acts of war, or armed conflict (whether or not war has been officially declared), invasion, hostilities, or acts of a foreign enemy;
  - civil war, rebellion, revolution, coup d’état, civil unrest, martial law, or a state of emergency;
  - acts of terrorism or military or police operations undertaken to prevent such acts;
  - military service, mobilisation, or participation in the activities or exercises of any armed forces.
Payment and recovery of insurance indemnity
In the event of damage, the insured person is obliged to consult a physician as soon as possible, comply with their prescriptions and do everything possible to prevent the increase of injuries caused by the insured event.
If the insured person paid the invoice presented by the healthcare provider themselves in order to receive insurance indemnity, they submit the following documents as soon as possible, no later than within 30 (thirty) days from receiving the service, by authenticating themselves at portal.terviselahendus.ee or, if authentication is not possible, by sending the following documents to the e-mail address kahjud@terviselahendus.ee:
- physician's appointment and consultation – a document proving the cost (invoice or receipt);
- tests, analyses and medical procedures (including special diagnostics) – a document proving the cost (invoice or receipt) and a document proving the physician's referral;
- examinations and tests of preventive health checkups – a document proving the cost;
- vision care – certificate(s) of the change in visual acuity (an earlier certificate of previous acuity, up to three years old, and certificate of change in visual acuity recorded during the insurance period, issued before purchase of glasses/lenses) and a document proving the cost of buying glasses or contact lenses;
- dental care – a document proving the cost;
- rehabilitation – a document proving the cost and the document proving the physician's referral specified in clause 8.3;
- hospital treatment – a document proving the cost, and document proving the physician’s referral;
- prescription drugs and orthopaedic aids – a document proving the cost and a physician's prescription;
- other documents are required by the insurer and/or insurance agent regarding the services provided to the insured person in order to clarify the circumstances related to the insured event and/or to determine the amount of insurance compensation to be paid.
The document evidencing the expense (invoice or payment receipt) must contain the following information: the name of the healthcare provider, the name of the recipient of the service, the name of the service, its price, and the date on which the service was provided. If the invoice does not indicate whether it has been paid, the insured person must also submit a payment receipt or bank statement.
If both reimbursable and non-reimbursable expenses are shown as a single amount on the document evidencing the expense and their respective proportions cannot be determined, the insurance agent, acting on behalf of the insurer, has the right to deem up to 50% of the amount reimbursable.
If an insurance indemnity has been refused because the service specified in the document evidencing the expense is not reimbursable under the insurance contract, a subsequent change to the name or description of the service does not constitute grounds for changing the original decision. The insurance agent, acting on behalf of the insurer, has the right to rely on the original document evidencing the expense and other documents evidencing the provision of the service and to uphold the decision to refuse the indemnity.
If the insured person has not paid for the healthcare services themselves, the healthcare provider shall submit the information and documents required for the payment of the insurance indemnity to the insurance agent, based on the scope of data agreed between the healthcare provider and the insurance agent.
The insurance agent shall pay the indemnity for employees’ health examinations to the policyholder or to the healthcare provider that performed the employees’ health examinations.
If several insured events occur during the same insurance period, the insurance agent shall pay an insurance indemnity for all insured events covered by the relevant insurance coverage, but not beyond the indemnity limit and the sum insured specified for that insurance coverage.
If the insured person has received a complaint from the insurance agent, they are obliged to return to the insurance agent within 10 (ten) working days at the latest the sums that the insurance agent has paid to the policyholder, healthcare provider, or directly to the insured person for the health services provided to the insured person:
1. if the insurance amount specified in the insurance contract is exceeded;
2. if the limit specified in the insurance contract, including the number of paid services, is exceeded;
3. to the extent of payments that are not stipulated in the insurance contract;
4. if the insured person commits fraud or has received insurance compensation for other unjustified reasons.
Release of the insurer from the obligation to perform
The insurer has the right to refuse to pay the insurance indemnity or to reduce the amount of the insurance indemnity if:
- the policyholder or the insured person has intentionally breached an obligation arising from the insurance contract or applicable legislation;
- the policyholder or the insured person has knowingly submitted misleading information or documents for the purpose of obtaining an insurance indemnity without justification;
- the circumstances of the insured event cannot be sufficiently established on the basis of the information and/or documents submitted by the policyholder and/or the insured person;
- the policyholder and/or the insured person refuses to provide the information and/or documents necessary to establish the circumstances of the insured event;
- the person entitled to receive the insurance indemnity, or the ultimate recipient of the insurance indemnity is subject to an Estonian national or international sanction;
- there are other legal grounds for refusing to pay or reducing the insurance indemnity.
The insurer does not have the right to refuse to pay or to reduce the insurance indemnity if the breach of the obligation had no effect on the occurrence of the insured event, the occurrence or amount of the loss, or the establishment of the circumstances of the insured event.
The health insurance contract: conclusion, amendments, and termination
The policyholder selects the appropriate insurance coverage for the employees and, if applicable, for the close relatives of their employees in cooperation with the insurance agent. The insurance coverages covered by the insurance, the sum insured, indemnity limits, and insurance premiums are specified in the insurance policy and in the terms and conditions.
To add an employee to the insurance contract as an insured person, the policyholder submits an application to the insurance agent with the following information: employee's name, social security number/date of birth and e-mail address, telephone number, selection of insurance cover and insurance period.
By transmitting data to the insurance agent, the policyholder confirms that they are the authorized person to transmit the employees' data, that the employees agree to the transmission of their data, and to their inclusion in the insurance contract as insured persons under the terms of the insurance contract.
Close relatives are added to the insurance contract through an employee insured by the policyholder, and the addition to the insurance contract is confirmed by the close relatives themselves.
The insurance agent has the right to refuse to include the employee or their close relative as an insured person in the insurance contract if the person has provided false information or previously committed insurance fraud or failure to pay insurance premiums, or is not suitable to be an insured person for other compelling reasons.
If an insured person is added to the insurance contract, the insurance agent provides the policyholder with the insurance policy, the information document, the terms and conditions, and, if necessary, other relevant information proving the insurance coverage. The insurance agent, using the contact details of the insured person, forwards to the insured person a confirmation letter proving the insurance coverage along with other relevant information.
The policyholder is obliged to keep the list of insured persons up to date.
The insurance contract is deemed concluded, with the rights and obligations arising from the insurance contract coming into force, at the moment of payment of the insurance premium but no earlier than the start date of the insurance period.
The selected insurance cover applies to the insured person during the entire insurance period. During the insurance period, the policyholder has the right to exclude the insured employee from the insurance contract if the policyholder has terminated the employment or other service relationship with this person. Amendments to the insurance contract are made twice a month, taking into account the date when the employment or other service relationship with the employee was terminated and the date when the policyholder notified the insurance agent of the employee's exclusion from the insurance contract. It is possible to exclude an employee’s close relative from the insurance contract during its validity only in exceptional cases and by agreement with the insurance agent.
The insurance contract shall be concluded for a fixed term. The insurance period shall be one year unless otherwise agreed in the insurance contract.
The insurance agent may submit an offer to the policyholder for the subsequent insurance period no later than 30 (thirty) days before the expiry of the current insurance period.
The terms of the insurance contract can be changed and/or supplemented (including termination) only with the written agreement of the insurance agent and the policyholder, which is concluded as an annex to the insurance contract.
Amendments to the insurance contract will not take effect before at least one month has passed since the policyholder was notified of the amendment.
The insurance agent notifies the policyholder of changes to the insurance contract in accordance with the terms and conditions.
The insurance agent has the right to cancel the insurance contract on a regular basis in cases provided by law.
The insurance agent has the right to cancel the insurance contract exceptionally for the following reasons:
1. the policyholder has not performed the insurance contract by the term specified in the terms and conditions, i.e., has not paid the first or subsequent insurance premium instalments;
2. the policyholder or the insured person significantly violates the insurance contract and does not remedy the violation within the deadline set for this purpose;
3. the policyholder has been declared bankrupt.
Under extraordinary circumstances, the insurance agent may cancel the insurance contract within one month of becoming aware of the violation.
Insurance premiums and the consequences of non-payment
Insurance premiums for the employee as an insured person are paid by the policyholder. The policyholder pays the insurance premiums in quarterly instalments, unless agreed otherwise with the agent.
The insurance premium payment date is the day the insurance premium is received in the insurance agent's bank account.
An insurance agent issues invoices to receive insurance payments. If applicable, the insurance agent issues e-invoices through an e-invoicing operator.
If the policyholder pays insurance premiums on the basis of an insurance policy issued for the current insurance period, the parties to the contract consider this as the policyholder's acceptance of the insurance contract. If the insurance policy differs from the insurance offer, the information and agreements provided in the insurance policy are considered valid and correct.
Insurance premiums must be paid for each insured person based on the insurance cover chosen for them.
Insurance premiums must be paid for the insured person's entire insurance period unless the insurance coverage was terminated on the basis of the terms and conditions before the end of the insurance period. If the policyholder terminates the employment or other service relationship with the insured person, the policyholder's obligation to pay the insurance premium also ends from the quarter following the termination of the employment or other service relationship with the employee, if the policyholder notifies the insurance agent of the employee's exclusion from the insurance contract. The policyholder will not be compensated for the insurance premium paid until the end of the quarter. The policyholder and the employee may agree that the insured person with whom the employment or other service relationship was terminated will be covered until the end of the insurance period (provided that the policyholder has paid insurance premiums for this) or that the policyholder will pay the following insurance premiums for this person even after the termination of the employment relationship.
A close relative of the insured employee pays the insurance premiums for insurance coverage through the policyholder themselves unless otherwise agreed with the policyholder. The insurance premium must be paid at once for the entire insurance period. The insurance agent adds the relative to the insurance contract after the relative has paid the premium.
If an employee is added to the contract as an insured person during the current insurance period, their indemnity limit and insurance premium are calculated based on the following proportion:
- during the first quarter after the conclusion of the insurance contract – 100% of the insurance premium and indemnity limit;
- during the second quarter after the conclusion of the insurance contract – 75% of the insurance premium and indemnity limit;
- during the third quarter after the conclusion of the insurance contract – 50% of the insurance premium and indemnity limit;
- during the fourth quarter after the conclusion of the insurance contract – 25% of the insurance premium and indemnity limit.
The policyholder and insurance agent can also agree in conditions different from the ones in clause 54.
The payment due date for the invoice is shown on the policy and the invoice. If the invoice is not paid by the deadline, the insurance agent has the right to demand from the recipient of the invoice a late fee of 0.05% (zero point zero five percent) of the unpaid amount by the deadline for each day of delay in payment.
Insurance premiums will not be reduced due to the taxes that apply to them, and they will be paid additionally as a result.
If the policyholder has not paid the insurance premium or its first instalment within 14 (fourteen) days after concluding the insurance contract, the insurance agent may withdraw from the contract until the payment is made. If the insurance agent does not file a lawsuit to collect the insurance premium within three months from the date the payment becomes due, it is assumed that they have withdrawn from the contract. If the insurance premium that has become due or its first instalment has not been paid by the time the insured event occurs, the insurance agent is released from their performance obligation.
If the policyholder does not pay the second or next instalment of the insurance premium by the deadline, the insurance agent will give them a new deadline for payment. If the policyholder does not pay the instalment by the new deadline and the insured event occurs after the new instalment payment deadline, the insurance agent is released from the obligation to perform and also has the right to cancel the insurance contract.
Rights and obligations of the parties
Obligation to provide information
1. When concluding an insurance contract, the policyholder and the insured person must provide the insurance agent with all the information required by them, which is necessary for concluding and executing the insurance contract.
Rights and obligations of the policyholder
1. The policyholder has the right to:
  - receive information about the insurance contract from the insurance agent;
  - file a complaint to the insurance agent regarding the performance of the insurance contract in accordance with the procedure stipulated in the terms and conditions.
2. The policyholder is obliged to:
  - inform the insured person that the insurance contract has been concluded with them as a beneficiary and introduce to them the insurance contract, including the insurance coverage and conditions, as well as explain the rights and obligations arising from the insurance contract;
  - pay insurance premiums in the amount and by the term indicated in the insurance contract;
  - keep the data of the insured persons up to date and immediately notify the insurance agent of changes thereto and provide new data;
  - to ensure that the insured persons give their consent to transfer their personal data to the insurance agent for the conclusion and execution of the insurance contract and to add themselves to the insurance contract as insured persons. The consent must be provided at least in a form that allows reproduction and is available to the insurance agent upon their request.
Rights and obligations of the insured person
1. The insured person has the right to:
  - receive information and advice about the insurance contract concluded in relation to them;
  - receive the healthcare services agreed upon in the insurance contract concluded in relation to them;
  - receive insurance indemnity for the services agreed upon in the insurance contract concluded and which they have paid for;
  - receive a reasoned written decision from the insurance agent on denial of insurance indemnity in full or in part.
2. The insured person has an obligation to:
  - take care of maintaining their health, follow the instructions of the attending physician in case of illness, and not increase the risk situations related to themselves;
  - not to allow third parties to use their insurance coverage;
  - before receiving a service covered by insurance coverage from the healthcare provider, submit an identity document to the healthcare provider;
  - monitor the extent of the insurance benefit, if necessary, also contact the insurance agent for information so as not to exceed the insurance amount or indemnity limit specified in the insurance contract;
  - comply with the conditions and obligations prescribed by any other document of the insurance contract, including the conditions of insurance coverage.
Rights and obligations of insurer and insurance agent
1. The insurer and agent have the right to:
  - receive information about the insured person from healthcare service providers, government authorities or the register of debtors if necessary for claims handling and the insurance agent deems it necessary;
  - process the insured person's personal data in accordance with the applicable legal acts.
2. The insurance agent has the obligation to do the following on behalf of the insurer:
  - forward the information and documents of the insurance contract about the insured persons to the policyholder;
  - submit invoices for insurance payments to the policyholder or insured person by the deadline;
  - collect necessary information from the policyholder to conclude an insurance contract and to add employees and their close relatives to the insurance contract;
  - in the event of an insured event, ensure efficient and quick damage handling;
  - pay insurance indemnity based on the terms and conditions of the insurance contract in the event of an insured event;
  - at the request of the insured person, inform them of the amount of the remaining insurance amount or indemnity limit;
  - at the policyholder's request, issue them the data and copies of documents that affect the policyholder's rights and obligations arising from the insurance contract if such activity does not contradict the requirements arising from legal acts;
  - at the policyholder's request, to issue replacement policies and copies of declarations of intent submitted by the policyholder in a form that enables written reproduction.
Processing of personal data
The insurer, insurance agent and healthcare service provider process the data of insured persons, including special types of personal data, in accordance with legal acts and the principles of processing customer data of the insurance provider, insurance agent and healthcare service provider, which are available on the insurer's website at https://www.lhv.ee/en/principles-of-processing-customer-data and on the insurance agent’s website at https://terviselahendus.ee//confido_privaatsuspoliitika and on the addresses of the websites of healthcare service providers, which can be found at https://terviselahendus.ee/koostoopartnerid.
Other terms and conditions
Priority of insurance contract documents

If there are contradictions in the documents of the insurance contract, the terms of the insurance coverage and the corresponding special conditions prevail for the parties to the contract.
Transmission of notices

The parties to the contract transmit all notifications related to the insurance contract through authorized persons and contact persons.
Submitting complaints about the activities of the insurance agent
1. If relevant, the policyholder and the insured person have the right to file a complaint about the activities of the insurance agent in connection with the improper fulfilment of the obligations arising from the insurance contract and obligations assigned to the agent by the insurer.
2. A person lodging a complaint shall, in the complaint, include at least the following information:
  - information about the person lodging the complaint:
    - if it is an individual, their first and last name, address, telephone number and email address (if applicable);
    - if it is a legal person, its name, registry code, address, telephone number and email address (if applicable);
  - date complaint was lodged;
  - an overview of the circumstances and reasons for dissatisfaction with as clear and comprehensive a description as possible; if possible, documents proving the circumstances referred to in the complaint are attached.
The complaint can be sent to the postal address or e-mail address of the insurance agent.
The insurance agent sends a reasoned written response to the complainant within 30 (thirty) days from the day of the complaint. If it is not possible to resolve the complaint within 30 (thirty) days due to its complexity or for other reasons, the insurance agent will inform the complainant of the reasons for the extension of the procedure and the new deadline for responding in a form that allows for written resubmission. The insurance agent may not extend this period beyond four months from the date of the complaint.
If applicable, the policyholder, the insured person, and the beneficiary have the right to ask the insurance agent for additional information about the procedure for handling complaints.
Processing of complaints is free of charge for the person lodging the complaint.
Applicable law

The legal acts in force in the Republic of Estonia are applied to regulate the contractual relations arising from insurance contracts.
Settlement of disputes
An attempt shall be made to resolve disputes arising from insurance contracts by agreement between the parties.
If an agreement is not possible, disputes arising from the insurance contract will be settled in court on the basis of the legal acts of the Republic of Estonia.
The parties to the insurance contract do not have the right to transfer the rights arising from the insurance contract to third parties.
If disagreements cannot be resolved, the parties to the insurance contract have the right to apply for the resolution of the dispute to:
- to the conciliation body operating at the Estonian Insurance Association (phone 667 1800, e-mail address lepitus@eksl.ee, address Mustamäe tee 46, 10621 Tallinn);
- in case of violation of consumer rights, to the Consumer Protection and Technical Regulatory Agency (phone 620 1707, e-mail address info@ttja.ee, address Sõle 23a, 10614 Tallinn);
- in case of data protection disputes, to the Data Protection Inspectorate (phone 562 02341, e-mail address info@aki.ee, address Tatari 39, 10134 Tallinn).
The policyholder has the right to file a complaint about the activities of the insurer and the insurance agent to the Financial Supervision Authority (phone 668 0500, e-mail address info@fi.ee, address Sakala 4, 15030 Tallinn).

General terms and conditions of the Confido Health Plan

General terms and conditions of Confido Health Plan

Definitions

Insured event and insurance coverage

Supplementary insurance coverage

Exclusions

Payment and recovery of insurance indemnity

Release of the insurer from the obligation to perform

The health insurance contract: conclusion, amendments, and termination

Insurance premiums and the consequences of non-payment

Rights and obligations of the parties

Processing of personal data

Other terms and conditions