An insured event of medical assistance insurance is the following event starting in a foreign country that has occurred to the insured person:
Medical expenses and medicines
Examination and treatment costs resulting from the insured event of the medical assistance insurance and incurred during the trip and prescribed by a doctor. Costs of medicines and treatment procedures caused by the insured event of the medical assistance insurance and incurred during the trip and prescribed by a doctor.
If expenses occur due to the treatment of unexpected tooth pain in a foreign country and/or emergency dental treatment expenses due to an accident (e.g. a fall) during the trip, including examinations and medicines in the amount of up to € 500. LHV shall not compensate scheduled dental treatment.
Pregnancy-related medical care
Compensation for the emergency medical care expenses due to unexpected complications of pregnancy within the first 35 weeks of pregnancy. LHV shall not compensate the costs of pregnancy complications if the pregnancy has lasted for more than 35 weeks. LHV shall not cover the cost of childbirth, related complications, postnatal care and treatment, except in the case of childbirth during the first 35 weeks of pregnancy.
The costs of repairing or replacing the prosthesis, hearing aid, or glasses of the insured person which were broken as a result of the insured event of medical assistance insurance in an extent of up to € 200 per insured event. Expenses for medical aids (e.g. glasses, hearing aids, wheelchairs, crutches) abroad due to the insured event of medical assistance insurance, if prescribed by a doctor, up to €200 per insured event.
Burial or cremation costs
Burial or cremation costs of the insured person abroad and/or costs of bringing his or her corpse or cremated remains home. Arranging for burial or cremation abroad or the method of transporting the corpse or cremated remains must be agreed with LHV in advance.
- Reasonable expenses for the insured person’s travel to a medical institution if this was absolutely necessary to receive medical treatment abroad.
- Repatriation expenses of a seriously ill or injured insured person to Estonia. The time and method of his/her transport must be agreed upon with LHV in advance.
- If, due to an insured event of the medical assistance insurance, the insured person needs assistance to return to Estonia, LHV will reimburse the transport and accommodation expenses of the person accompanying him/her.
- If, due to an insured event of the medical assistance insurance, the insured minor cannot return to Estonia on his/her own, LHV will reimburse the transport and accommodation costs of the person accompanying him/her.
Additional travel and accommodation costs for the insured person to return to Estonia, if he or she is unable to return from the trip as planned due to an insured event of medical assistance insurance. LHV will not reimburse these costs for the period during which the insured person was sufficiently recovered to make it medically possible for him/her to return to or be brought back to Estonia.
Costs of drafting, reproducing, and sending of medical documents, if this is necessary to handle the claim. LHV shall not reimburse travel and accommodation expenses related to sending the documents.
Costs incurred by the family member travelling to the insured person or by the travelling companion to the insured person
- Travel, accommodation and food expenses of one member of the insured person’s family to and from the place of sickness, injury and/or death of the insured person if there are no travelling companions left or if the insured person cannot be transported to Estonia within seven days of the insured event. The costs are reimbursed from the sum insured of the medical assistance insurance of the insured person. LHV will not reimburse the above costs for the period during which the insured person was sufficiently recovered to make it medically possible for him/her to return to or be brought back to Estonia.
- Reasonable additional costs of accommodation abroad for one travelling companion staying with an injured or deceased insured person and his/her travel expenses to return to Estonia, if this is absolutely necessary (e.g. for the mother to stay with the child). The costs are reimbursed from the sum insured of the medical assistance insurance of the insured person.
Activity upon an insured event of medical assistance insurance
If an insured person needs non-hospital medical treatment abroad in the case of an insured event, he or she can go directly to a licensed medical institution.
If the treatment of the insured person continues after the notification to LHV, LHV has the right to designate the medical institution where the treatment will continue.
If the insured person needs hospital treatment abroad in the case of an insured event, he/she must inform LHV as soon as possible.
In the case of an insured event, LHV will help arrange for the insured person’s hospitalisation abroad, repatriation to Estonia, or burial or cremation abroad. LHV will only reimburse the aforementioned costs if they have been agreed upon with LHV in advance.
If the insured event is the result of a crime committed against the insured person, the local police or other competent authority must be informed.
In order to apply for an insurance benefit, you must submit the following documents to LHV:
- notification of the occurrence and circumstances of the insured event and application for the insurance benefit;
- a medical certificate with the date of the insured event of medical assistance insurance and the insured person’s diagnosis;
- bills for medicines, medical treatment, accommodation and transport;
- if necessary, additional evidence to establish the circumstances of the loss event (e.g. proof of length of stay abroad, and health data such as a medical certificate or a transcript of medical records).
Validity of medical assistance insurance during sport and other activities
Medical assistance insurance always covers the following activities:
- recreational and health sports, including running, roller-skating, cycling, golf, yoga and fishing;
- swimming, snorkelling and diving to a maximum depth of 10 metres;
- sailing (except windsurfing) in inland and coastal waters;
- hiking up to 2,500 metres.
Medical assistance insurance for high-risk activities
(valid only if the Policy includes a note on sports cover)
- snowboarding, alpine skiing and slalom on the marked trails of the winter sports centre;
- competitive sport: participation in cycling, skiing, running (including marathons) and triathlon, as well as participation in training camps and preparation for competitions in these sports;
- mountain biking;
- diving to a maximum depth of 40 metres, if the diver has a licence;
- boating on a river with rapids;
- water-skiing, surfing, kitesurfing and windsurfing;
- sailing on the high seas and the ocean, if returning to port every seven days;
- trekking up to 4,500 metres;
- hiking in the wild, including desert, taiga and jungle;
- participation in an organised, guided safari;
- rock-climbing on well-equipped tracks and using safety equipment;
- participation in sports competitions and training as a professional athlete..
Medical assistance insurance is always excluded for the following activities:
- snowboarding, alpine skiing, and slalom outside the marked trails of winter sports centres;
- high-speed downhill and snowboarding, which includes getting out of a helicopter;
- diving alone and at night, in a wreck and in an underwater cave;
- boating down the rapids and boating alone in a remote area;
- water sports (jet skiing and towing of any kind) and rafting;
- air sports such as hang gliding, paragliding, gliding, and ballooning;
- trekking at altitudes of more than 4,500 metres, rock climbing outside equipped trails;
- hiking alone in a remote area;
- down-hill cycling, bicycle tricks, BMX riding, skateboard tricks, freeride;
- parachute and bungee jumps;
- tobogganing, ski jumping, and speed skiing;
- martial arts or sports related to self-defence, such as karate, judo, boxing, kickboxing, and Thai boxing, wrestling, etc.;
- car or motor sports, incl. driving ATVs and participating in training for driving with motor vehicles, rally, kart racing, driving snowmobiles, and participation in motorbike sports.
Physical paid work (optional additional protection)
Medical assistance insurance is also valid in the case of physical work and service, provided that the Policy includes a note on physical work cover.
Physical work is defined as work that generally requires physical effort, including work as a driver or bus driver, forestry, agricultural or construction worker, caterer, hotel attendant and cleaner.
Medical assistance insurance is always excluded for the following activities:
- professional stunt man or woman;
- mine worker, derrick worker;
- a member of the crew of a ship or aircraft;
- policeman, security guard, rescuer, mine expert;
- conscript in military service or border guard service;
- participant in any military activities, drills or exercises, military missions, incl. an observer or person engaged in other works;
- any work, job or activity, during the performance of which the insured person carries or uses a weapon or handles explosives.
Exclusions from medical assistance insurance
Expenditure incurred in Estonia
LHV will not reimburse you for expenses incurred in Estonia, even if the expenses were caused by an insured event abroad.
Costs related to illness or injury that appeared or was sustained before the start of the trip
LHV shall not reimburse treatment costs, the cause of which is an illness or an injury that appeared before the trip. The exemption shall not apply to the first aid for life-threatening exacerbations of chronic illness.
Costs of scheduled treatments
LHV shall not cover the cost of scheduled treatment, including planned cosmetic surgery.
Pregnancy and childbirth
LHV shall not reimburse any costs resulting from pregnancy, childbirth, abortion, and related complications, post-natal treatment or care, except for emergency medical care for unexpected complications during the first 35 weeks of pregnancy when abroad. The exclusion is applied to the costs related to both the mother and the baby.
Travel expenses of other persons
- LHV shall not compensate the travel and accommodation expenses of a travel companion and or family member accompanying the insured person within the extent to which the latter should have incurred costs even if no insured event had occurred.
- LHV shall not compensate the travel and accommodation expenses (travel, staying overnight, etc.) of persons attending the funeral or cremation ceremony of the insured person or the expenses of a funeral banquet.
Exclusions related to the insured person returning to Estonia
- LHV will not reimburse the cost of returning to Estonia if the insured person returned from the trip without prior coordination with LHV or disregarded the instructions of LHV or the doctor when returning to Estonia.
- LHV will not reimburse any further costs if a doctor approved by LHV considers it possible to bring the sick or injured insured person back to Estonia, but the insured person refuses to do so.
- LHV will not reimburse the cost of repatriating the insured person to Estonia if the doctor approved by LHV shall not consider the repatriation to Estonia to be medically justified.
An insured event of accident insurance is an accident which occurred with the insured person when travelling abroad within the area covered by the insurance, as a result of which:
- the insured person dies within three years of the occurrence of an accident;
- the insured person develops a permanent disability within three years of the occurrence of an accident.
The sum insured for accident insurance is:
- in the case of permanent disability up to € 50,000;
- In the case of death (person over 16 years of age) up to € 50,000;
- in the event of death (up to the age of 16), € 2,000.
LHV pays a death benefit to the heirs of the insured person if the insured person dies as a result of the insured event of accident insurance within one year of the date of the insured event.
- The amount of the death benefit is the sum insured of accident insurance.
- If the insured person dies more than one year after the occurrence of the insured event of accident insurance, no death benefit will be paid.
- Death benefit is reduced by the permanent disability indemnity previously paid for the same insured event.
Permanent disability indemnity
LHV pays a permanent disability indemnity to the insured person if his or her health condition has permanently deteriorated due to the insured event. The permanent disability indemnity is paid as a percentage of the sum insured of the accident insurance, based on the condition of the insured person one year after the occurrence of the insured event.
- The permanent disability benefit is 25% of the sum insured of the accident insurance if, one year after the occurrence of the insured event, the insured person shall not need assistance most of the time, but his/her general capacity is noticeably reduced: memory impairment, speech and communication difficulties, loss of accuracy of movements, balance problems, rapid fatigue and other conditions that make daily activities difficult or impossible.
- The permanent disability benefit is 50% of the sum insured of the accident insurance if, one year after the insured event, the insured person is able to perform only light and short-term activities, has a significant loss of capacity and is therefore substantially dependent on the assistance of another person for some activities of daily living (including eating, washing, dressing, moving around the home or outside it).
- The permanent disability benefit is 100% of the sum insured of the accident insurance if, one year after the insured event, the insured person unavoidably needs the assistance of another person for all daily activities (including eating, washing, dressing, moving around the room).
The existence and degree of permanent disability caused by the insured event will be determined at the latest within one year of the occurrence of the insured event, on the basis of the insured person’s state of health at that time. If the permanent disability is the result of the loss of a part of the body or an organ which shall not recover its function (e.g. amputation), the existence and extent of the permanent disability will be determined as soon as possible after the insured event.
Permanent disability is determined by comparing the insured person’s state of health with that of a healthy person of the same age, taking into account only the severity and nature of the disability and not the insured person’s individual characteristics, including lifestyle, occupation or hobbies. The existence and degree of permanent disability is established on the basis of medical documentation. In addition, the condition of the insured person prior to the insured event of the accident insurance is taken into account.
Loss of capacity for work and loss of income are not accounted for when establishing permanent disability. The degree of disability established by a national expert’s decision is not binding on LHV when determining permanent disability.
LHV shall not pay permanent disability indemnity:
- in the case of damage to the insured person’s teeth or dental prostheses;
- if the permanent disability appears later than within one year after the insured event;
- if the insured person dies as a result of the insured event within one year from the date of the insured event. In such case LHV pays a death benefit.
Exclusions from accident insurance
LHV shall not pay compensation if the death or permanent disability was caused or aggravated by:
- the insured person’s illness (the insured event is not death or the development of a permanent disability due to illness);
- any medical procedure, including surgery (the exemption shall not apply if the cause of the medical procedure is the insured event that occurred abroad during the validity of the conditions);
- miscarriage or childbirth, complications due to miscarriage or childbirth;
- an accident which occurred while the insured person was in a detention centre as an inmate, prisoner or detainee;
- tick or insect bites;
- high-risk activities excluded under clause 2.17 (unless the Policy has a note on a sports cover, in which case the activities listed in clause 2.18 are excluded);
- high-risk activities excluded in clause 2.18;
- physical work (unless the Policy has a note on paid physical work).
Other exclusions from medical assistance insurance
LHV shall not compensate the following costs:
- that are avoidable;
- procedures and services not prescribed by a doctor;
- medicines purchased without medical prescription;
- therapeutic food products intended for medical purposes;
- food supplements;
- non-medical treatments or alternative medicine;
- treatment provided by an unlicensed person;
- getting or removing a tattoo and complications thereof;
- the diagnosis and treatment of psychiatric and behavioural disorders, including depression;
- the diagnosis and treatment of sexually transmitted diseases, HIV and AIDS;
- vaccination, except for vaccination for the treatment of an insured event of medical assistance insurance.
In addition to the exclusions listed in clause 2.34, the restrictions mentioned in the clause "General Exclusions" also apply.