“GROUPAMA ZASTRAHOVANE” EAD is part of the French banking and insurance group Groupama. The company is on Bulgarian market since 2008 by acquiring two insurance companies “DSK Gar-ancia”. In 2009 was officially renamed “Groupama Insurance” EAD. The company has a license for insurance activity № 1-ОЗ/05.05.2005 of the Commission for Financial Supervision. Head office in Bulgaria: 47A “Tsarigradsko shosse” Blvd, Block V, 1124 Sofia
Direct line: 0700 123 32 for Bulgaria
+35929046400 outside Bulgaria
Report on solvency and financial condition of the Insurer is available at: www.groupama.bg.
Users of insurance service can complain against any action / inaction of the Insurer. The appeal shall be addressed to the Head office of insurance, at the same explicitly stated sender and the number of policy / claim number at which it is submitted. Insurer register each complaint received in register “Complaints” with the incoming number and date of receipt. In each Complaint, the Insurer shall decide within one month from the receipt and Users of insurance services have the opportunity to lodge complaints against the insurer before the Financial Supervision Commission – under the Insurance Code, as well as to other state bodies. Available to users of insurance services and all forms of out-of-court settlement in Bulgaria.
Article 1. Definitions
existence prior to the start of the insurance term.
Article 2. Subject of the insurance contract
(1) According these General Conditions for Medical insurance for foreigners in Bulgaria is provided insurance coverage for foreigners, residing on short-term or long-term basis in the Republic of Bulgaria, or transiting through the country, for the period of their stay in the country.
(2) In exchange for the paid by the Insured premium, the Insurer shall, upon occurrence of an insured event to indemnify the insured person for medical expenses actually incurred for urgent and emergency medical aid in case of a sudden, unforeseeable indisposition, illness or accident, arisen within the effective period of the insurance contract.
(3) Expenses for medical aid in urgent cases, expenses incurred for outpatient and hospital medical aid and expenses for dental aid under the provisions of the Ordinance shall be deemed expenses for treatment and hospital stay.
Article 3. Insured persons
(1) Insured are individuals (foreigners) in good physical and mental health.
(2) Under the insurance, persons who have lost their working capacity over 50% can be insured after approval from the HQ of the Insurer.
(3) Persons under par. 1 which have concluded abroad health insurance or medical insurance valid for the territory of the Republic of Bulgaria and / or when their medical insurance expires during their stay in the country are insured by compulsory health insurance under the Ordinance on general conditions, the minimum insurance amount, the minimum premium and procedures for the conclusion of compulsory medical insurance of foreigners residing in
Bulgaria short or transit through the country, hereinafter referred to as the Ordinance.
(4) Persons under par. 1 which have concluded abroad health insurance or medical insurance valid for the territory of the Republic of Bulgaria, shall be insured with a voluntary medical insurance.
(5) The Policyholder and the Insured can be one and the same person or different entities.
(6) The insurance can not be insured on the list of economic sanction , prohibition or restriction arising from resolutions of the UN and / or economic or trade sanctions , laws or regulations of the European Union , Bulgaria , the United States , or national law providing for such measures.
Article 4. Conclusion of the Insurance
(1) The insurance is effected on the basis of a proposal (written or spoken) by the Policyholder.
(2) Acceptance of the proposal by the Insurer shall be recorded in a specification, and then an insurance policy shall be issued and the Proposal, the General Conditions of the insurance, the additional agreements (endorsements), the lists of insured persons and other arrangements in writing between the parties, if any, shall be an integral part thereof.
(3) The data of the Insured person/s shall be indicated in the policy – name and ENG/or another personal identification number/. In addition, the Insurer may require in writing other information as well, which in his opinion is relevant to the risk evaluation of the insurance.
(4) In case the stay in Bulgaria is on business, the Insured person shall be obliged to inform in advance the Insurer about his occupation and the insurance shall be valid only in case an additional insurance premium is paid.
(5) The policy may be individual or group one:
(6) The Policyholder/ the Insured shall be obliged to notify about all circumstances relating to the risk assessment and shall be responsible for the truthfulness, accuracy and completeness of the information provided by him/her.
(7) In case of learning about circumstances, which have existed at the moment of the insurance conclusion or have occurred during its validity, which is relevant to the risk under the insurance, for the Insured and for the Insurer, of importance are the decree of the Insurance Code.
Article 5. Term the insurance contract period of coverage , the insurance period and termination of the insurance contract
(1) The contract term is defined and mentioned in the insurance policy.
(2) The period of coverage is the period in which the insurer bears insurance risk.
(3) The insurance period is the period for which premium is determined.
(4) The term of the contract and the beginning and end of the period of insurance coverage and the insurance period specified in the policy and match the dates specified in the policy as the ” Period of insurance ” with a definite beginning and end.
(5) The insurance is effected for a period, ranging from one day to one year, depending on the period of stay.
(6) The insurance is concluded for the period specified in the policy and shall take effect from 00.00 hours on the day stated in the policy for a start, but only on condition that the insurance premium is paid, unless otherwise agreed between the parties.
(7) The insurance contract is terminated premature in the following cases:
(8) Early termination of the insurance contract terminated early the insurance coverage.
(9) Upon premature termination of the insurance contract, by which are not paid and are not due insurance indemnities, upon written request, the Insurer shall reimburse the Insured / legal heirs the corresponding of the unexpired portion of the term of the insurance coverage of the insurance premium, after deduction of the planned technical – insurance costs.
(10) If the insurance contract is terminated premature in accordance with Art. 5 par. 7, p. 1 because by fault of the Insured, the Insurer did not return the unused premium for the remaining period of the insurance coverage, unless otherwise agreed.
(11) In the event that the term of the insurance policy limit is exhausted for dental care insurance remains in force for other risks of the coating.
(12) The coverage of this insurance is valid only for the territory of the Republic of Bulgaria.
Article 6. Insurance cover
(1) The Insurer shall pay to the Insured the following medical expenses in case of accident and/or acute illness, occurring during his/her stay in the territory of the Republic of Bulgaria:
1.1. expenses for medical aid in emergency cases, expenses incurred for outpatient and hospital medical aid;
1.2. transport expenses – the necessary and appropriate transportation expenses, substantiated by documents for admission in or moving of the Insured to a hospital establishment;
1.3. Dental aid expenses – the risk comprises emergency cases occurring suddenly in relation to:
1.3.1. Incision of abscesses and phlegmons in the oral cavity;
1.3.2. Extraction of suddenly broken or deeply destroyed tooth, including anaesthesia;
1.3.3. Control medical check-up for services under items 1.3.1 and 1.3.2;
1.3.4. Urgent conditions after use of dental procedures.
(2) The insurer covers the risks referred to in para. 1 when the accident, acute illness or dental condition occurred and were diagnosed during the period of insurance and the costs incurred during the course of the insurance and occurred during the stay of the Insured in the Republic of Bulgaria.
Article 7. Exceptions to the insurance coverage
(1) The liability of the Insurer shall not cover expenses of the Insured for:
(2) Insurance coverage does not include, and the Insurer does not owe compensation insurance for bodily injury or death of the insured due to:
14.1. the Insurer shall reimburse any medical expenses incurred in case of premature birth or abortion, if they have been caused by an accident, covered under these terms and conditions;
(3) The insurer does not pay health services, rendered to the insured due to participation in medical research or clinical trials of medicinal products.
(4) The insurer does not cover health services, the necessity of which has arisen from pre-existing illnesses.
Article 8. Sum Insured and Insurer’s responsibility
(1) The sum insured is agreed between the Insurer and the Policyholder and written in the Insurance policy in Bulgarian lev.
(2) Under the compulsory insurance the sum insured for one person shall not be less than the minimum sum insured determined as per the Ordinance on the general conditions, the minimum sum insured, the minimum insurance premium and the order for conclusion of compulsory medical insurance for foreigners on short-term or long-term stay in the Republic of Bulgaria, or transiting through the country.
(3) Under the voluntary medical insurance the sum insured shall be at the choice of the Policyholder.
(4) The liability of the Insurer shall be up to the agreed limit for the respective risk, irrespective of the number of insured occurrences in the operative period of the insurance.
(5) Upon payment of indemnity the sum insured under the respective insured risk shall be reduced by the amount of the indemnity paid.
Article 9. Insurance premium
(1) Insurance premium is fixed in Bulgarian leva, determined based on the tariffs of the Insurer and written in the Insurance policy.
(2) The insurance premium shall be paid by the Policyholder once and entirely, at the conclusion of the insurance. In case of non-payment or incorrect payment of the insurance premium, the insurance contract is not entry into force and the incorrect amount paid is refundable.
(3) All additions to the premium to be borne by the Insured shall be paid together with the premium.
(4) The insurance contract comes into force after payment of the total premium due.
(5) Upon payment via bank transfer, the date of payment shall be the date on which the account of the Insurer is credited with the sum due.
Article 10. Obligations of the insured on occurrence of insurance event. Payment of insurance indemnity
(1) The insured is obliged to take measures to prevent ago to comply with instructions of the insurer and the competent authorities to remove sources of danger for causing damage and allow the insurer to inspect
2) In case of occurrence of an insured event the Insured or the medical service provider, which provides a medical aid to him/her shall be obliged:
(3) Obligations under par. 2, p. 1 and. 2 is a condition precedent to any liability of the Insurer to pay insurance indemnity.
(4) To prove the occurrence of an insured event and determining the amount of the indemnity insured or the beneficiary must submit:
(5) All medical documents should be issued by licensed health care establishments.
(6) In the case that the Insured has other valid insurance covering risks referred to in these General Conditions, it shall declare in written form that fact. In this case, the responsibility of the Insurer is proportional to the limit specified in the policy for the risk and the total limit on all insurance.
(7) If the Insured or his proxy or the beneficiaries fail to fulfill their obligations as described above, or present false information, declarations or use fraud in order to receive insurance indemnity, the Insurer shall have the right to terminate the effect of the insurance, and in case of occurrence of insurance event – to refuse in full the payment or to reduce the amount of the insurance indemnity, and he shall not reimburse the insurance premium.
Article 11. Insurer’s decision on presented claim. Execution of insurance payments
(1) The Insurer shall make a decision on every claim presented to him for an execution of insurance payment under the insurance contract and in 15-days period from submitting a claim:
(2) The Insurer shall pay the expenses for rendered medical services for treatment and hospitalization, as follows:
(3) In case the determined indemnity is remitted abroad, the sum due shall be recalculated in the respective currency according to the exchange rate of the Bulgarian National Bank on the day of the remittance.
(4) If the Insurer cannot take a decision under para. 1, because there is a need to submit additional documents, in 45-days period the Insurer/Assistance company shall notify the beneficiary of the document he/she must additionally submit. After receiving the necessary documents, the Insurer shall decide within 15 working days of the date of submission of the documents required.
(5) The insurer is not required to provide coverage or pay compensation or other amount under this contract if such coverage, compensation or payment would expose the Insurer to sanction, prohibition or restriction stemming from the UN resolutions or trade or economic sanctions laws or regulations of the European Union, France, the United States, its member states, or national law providing for such measures.
(6) Users of insurance service can complain against any action / inaction of the Insurer. The appeal shall be addressed to the Head office of insurance, at the same explicitly stated sender and the number of policy / claim number at which it is submitted. Insurer register each complaint received in register “complaints” with the incoming number and date of receipt. In each Complaint, the Insurer shall decide within no later than thirty days from the receipt and
(7) Users of insurance services have the opportunity to lodge complaints against the insurer before the Financial Supervision Commission – under the Insurance Code, as well as to other state bodies. Available to users of insurance services and all forms of out-of- court settlement in Bulgaria.
Report on solvency and financial condition of the Insurer is available at: www.groupama.bg.
Article 12. Recourse, prescription period, right to dispute
(1) The Insurer has the right to claim with recourse to third parties liable for occurrence of certain insured event to the amount of the indemnity paid and the expenses for its determination.
(2) The rights of the Insured person shall be prescribed within three years, starting on the date of occurrence of the insurance event.
(3) Insured person/The beneficiary has the right to dispute the decision of the Insurer on a claim by lodging a complaint in which they declare their wish for a reconsideration of the claim. The complaint shall be lodged with the Insurer. It shall contain documents proving that the decision taken by the Insurer on the claim is not founded.
(4) Within 15 days of the submission of the complaint, on the basis of the submitted documents, the Insurer shall rule on it. If the documents submitted reveal new facts and circumstances, proving beyond doubt that the claim is founded, the Insurer may cancel his decision, declare the claim as founded and execute the insurance payment in line with the procedure, agreed upon in the contract.
Article 13. Taxes and fees
All taxes, fees or others, which exist or shall be established on the received insurance payment, shall be covered by the person receiving the insurance payment. Article 14. Concluding provisions
(1) The users of insurance services shall provide the insurer with data, which are personal data within the meaning of the Law on the protection of personal data and General Data Protection Regulation (EU) 2016/679 of the Еuropean Parliament and of the Council of 27.04.2016 will be collected and processed for the purposes of and by the persons listed in the “Privacy Notice”, an integral part of the General Terms and Conditions of Insurance and available at www.groupama.bg. Without this data, the insurer could not conclude an insurance contract.
(2) In order to establish legal claims the Insurer “Groupama Zastrahovane” EAD, EIK 131421443 may also request and receive from health, medical, authorities, institutions and persons, data, medical and other documents concerning the health status and the health insurance status of the Insured persons, as well as processing the received data in connection with their insurance. The Policyholder is obliged to bring this information to the knowledge of the Insured persons.
(3) The Insurer undertakes to use and process the personal data provided only in connection with the conclusion and execution of insurance contracts.
(4) With the explicit consent of the users, the insurer may also process their personal data for other purposes. Consent is a separate ground for the processing of personal data and the purpose of the processing is specified therein.
(5) Every user of insurance services shall be obliged to notify the Insurer in the event that he is listed or included in a list of economic sanctions, prohibitions or restrictions stemming from UN resolutions and / or economic or commercial sanctions, laws or regulations of the European Union, the Republic of Bulgaria, the United States of America, or a national law providing for such measures. In case of non-fulfillment of this obligation, the insurer has the right not to make an insurance payment.
(6) With the conclusion of the insurance, the Insurer and the Assisting Company shall be deemed authorized to receive the entire necessary information with regard to the insurance event by any third parties /medical establishments, medical experts and others /, including for the cases when the information is personal information about the Insured, as well as such, representing company or professional secret.
(7) It is considered that the Insured by signing the policy has authorized the Insurer and any person designated by the Insurer to make on behalf of the Insured decisions related to providing emergency medical care, emergency dental care, and repatriation, if the insured is in a condition, in which he cannot make decisions by himself.
(8) The present General Conditions and each insurance policy are drawn up in Bulgarian and English. In case of discrepancy between the Bulgarian and English text, the Bulgarian wording shall prevail.
(9) The present General conditions, all annexes, endorsements and lists of insured persons shall be an integral part of the insurance policy.
(10) In case of discrepancy between the insurance policy and the General Conditions the provisions of the policy shall have effect.
(11) Internal rules for the organization of work on settlement of insurance claims found on the Internet at: www.groupama.bg Article 15. Disputes between the parties. Jurisdiction
All disputes arising from these General Conditions and from the Insurance Contract, or related to it, including the disputes arising from or referring to its interpretation, invalidity, execution or termination, shall be settled by the competent Bulgarian court. The Bulgarian legislation shall apply.
These General Conditions for Medical Insurance for foreigners in Bulgaria have been approved by the Board of Directors of the Insurer by Protocol from 17.10.2014, amended by Decisions of the Board of Directors, noted in Protocol from 16.12.2015 amended by Decisions of the Board of Directors, noted in Protocol from 11.04.2018, in force from 25.05.2018.
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