.

1000
. 6
.: (02) 902 70 00
: (02) 987 45 33

GENERAL TERMS AND CONDITIONS

of
MEDICAL INSURANCE
. SUBJECT AND PARTIES TO THE MEDICAL INSURANCE CONTRACT
1.
Pursuant to these General Terms and Conditions DZI Life Insurance JSC, on the grounds of a license
under Section II item 1 accident and item 2 illness of Appendix No. 1 of the Insurance Code, hereinafter referred
to as INSURER, shall conclude contracts for medical insurance against premium paid, whereby undertaking the
financial provision of the insured persons for health services and goods used by them during the duration of the
insurance contract and/or payment of fixed amounts in case of medical treatment.
2.
The financial provision shall include reimbursement of costs incurred by the insured persons and/or payment
of amounts to medical care providers that have conducted their treatment.
3.
Payment of fixed amounts shall be carried out upon the occurrence of cases of treatment of the insured
persons, provided for in the contract.
4.
Health services and goods shall be provided by certified providers of medical care.
5.
The medical insurance contract shall be valid on the territory of the Republic of Bulgaria, unless otherwise
agreed.
6.
Within the meaning of these General Terms and Conditions:
POLICYHOLDER/INSURING PERSON shall be a natural or legal person that concludes the contract for medical
insurance and undertakes to pay the premiums.
INSURED PERSON shall be the natural person who, upon the occurrence of an insured event shall have rights
under the contract.
The POLICYHOLDER and the INSURED may be the same person or different persons.
The relations between the parties shall be governed by these General Terms and Conditions, by the contract for
medical insurance and all appendices and supplements thereto.
. INSURED PERSONS
7.
Insured shall be Bulgarian citizens and foreign nationals, continuously or permanently residing in Bulgaria.
8.
The minimum and maximum insurance age of the person shall depend on the type of the medical insurance
contract:
8.1.
Persons aged 18 to 65 years shall be insured with individual contracts;
8.2.
Spouses aged 18 to 65 years and/or their children from 0 to 26 completed years of age who are not married
shall be insured with family contracts;
8.3.
Persons aged 0 to 65 years shall be insured with group contracts. Group within the meaning of General
Terms and Conditions shall be a community of 10 and more persons.
The age of the Insured Persons shall be determined in whole years at the beginning of the contract for medical
insurance. Less than 6 months shall not be taken into account, and completed 6 months or more shall be accepted
for a full year.
9. Insured shall be healthy persons.
10.
Special terms and conditions may:
10.1. exclude existing diseases of the insured persons. The Insurer shall not cover health services and goods for
these diseases or having a causal relationship thereto and shall not reimburse expenses or pay amounts.
10.2. exclude certain health services or goods from the insurance coverage, as expressly specified in the
contract.
. RISKS COVERED
11.
The contract for medical insurance shall be concluded for coverage of one or several groups of health
services and goods as follows:

11.1. Improvement of health and prevention of illness/health prophylaxis preventive activities previously agreed,
provided to insured persons according to a defined schedule in specified medical facilities;
11.2. Outpatient medical care examinations, tests, manipulations, etc., included in the contract, provided to the
insured persons in outpatient conditions;
11.3. Inpatient (hospital) medical care - health services for conservative and/or surgical treatment, manipulations,
etc., included in the contract, provided to the insured persons during treatment in hospital;
11.4. Dental care health services for therapeutic, surgical, orthopedic treatment and dental tests, included in the
contract;
11.5. Additional health services and goods medicinal products, sanitary transport, auxiliary aids, rehabilitation, etc.
12.
With the exception of health services for preventive health care item 11.1, the insurance coverage shall be
valid on:
12.1.
Cover - for cases of illness and accident of the insured persons;
12.2. Cover for cases of accident with the insured persons;
13.
The insurance coverage shall be provided as:
13.1.
Reimbursement of expenses for a freely selected Medical Care Provider. In this case, the insured persons
shall pay the medical care provided, and the Insurer shall refund the expenses incurred based on documentary
evidence presented.
13.2.
Subscription service by Providers of Medical Care that have concluded a contract with the Insurer. In these
cases, the insured persons shall receive health services within the sum insured/limit free of charge. The existence of
coverage shall be certified by a valid card. The Insurer shall pay directly to the Provider the cost of the health
services provided.
13.3.
A fixed amount for cases as specified in the contract.
14.
The manner of providing insurance coverage and health services to which it refers, shall be defined in the
contract for medical insurance.
A health service may be provided either under item 13.1 or under item 13.2.
V. EXCLUDED RISKS
15.
There shall be no payment and reimbursement of amounts for costs, borne by other Insurers, a state or
private medical program or an employer.
16.
There shall be no reimbursement of costs or payment of amounts for health services and goods in case of:
16.1.
Hostilities, civil unrest, radioactive incidents and outbreaks on a local or nationwide scale, announced by
the Ministry of Health (MH) and/or the Ministry of the Emergency Situations;
16.2. Treatment of alcoholism, narcomania, addiction to medicinal substances and diseases caused by them,
damage to health due to systematic use of these substances, self-harm, mental illness, psychotherapy sessions,
treatment of bulimia and anorexia, unless the Insurer has accepted them eplicitly upon the conclusion of the contract.
16.3.
Programs and treatment for overweight, obstipation, smoking, alopecia, sleep apnea, testing and treatment
of impotence, placing, removal and adjustment of contraceptive devices, including such containing hormones, sterility
and in vitro, gender reassignment, treatment of menopause.
16.4.
Ttreatment of the following dermatological diseases nail fungus (onychomycosis), vitiligo, seborrhea,
acne, treatment and removal of benign skin formations lipomas and other fatty formations; nevi, warts;
16.5.
Cosmetic and plastic corrections or other cosmetic services, including laser vision correction;
16.6.
Each medical condition of the teeth and the oral cavity, unless it is a part of the agreed coverage of dental
care;
16.7.
Prophylactic examinations, examinations without any specific complaints or symptoms of a disease,
immunizations and vaccinations, performance of tests for AIDS and syphilis, unless they are part of the agreed
coverage or have been conducted as part of the preoperative preparation;
16.8.
Acupuncture, iris diagnostics, balneotherapy, kinesitherapy and massages, rehabilitation, spa procedures,
diagnostics and treatment with unconventional and unapproved methods (according to the Medical Standards
published by the Ministry of Health) and means and any treatment that has not been recommended and conducted
by a diplomaed doctor or has been conducted in facilities that are not registered as medical under the Law on
Medical Establishments;
16.9.
Pregnancy /normal and pathological/, childbirth and complications, resulting from them, unless the Insurer
has explicitly accepted them at the conclusion of the contract with separate sublimits. Voluntary termination of
pregnancy, placing and removal of intrauterine spirals, including such containing hormones.

16.10. Examinations and tests for work, driving courses, contracting a civil marriage, acceptance for insurance, for
admission to kindergarten, for presentation to MCC committees and TEMC, selection of a team/doctor, unless the
Insurer has accepted them explicitly at the conclusion of the contract;
16.11. Examinations and tests relating to forensic medical expert examination of the person.
16.12. Transplantation of organs and tissues, hemodialysis, blood transfusion, radiotherapy, chemotherapy, as well
as photodynamic therapy.
16.13. Purchase of medicines in quantities exceeding 30-day period of treatment for chronic diseases and 10-day
period of treatment in case of acute diseases.
16.14. Administrative fees for issue of documents and copies of documents, issued by the medical institutions; fees
for receiving copies (records) of performed tests CD (DVD), as well as fees for the sending of materials for testing
from one medical institution to another.
16.15. Accommodation in hospices and nursing homes, unless this is the subject of coverage of a special package.
16.16. Prepaid healthcare packages in medical establishments for outpatient or inpatient health care.
16.17. Health services not directly related to the diagnosis recorded in the medical documentation;
16.18. Chronic and previous diseases of the insured persons, as well as consumables used in laparoscopic and
arthroscopic operations and artificial joints in individual, family and group contracts for up to 30 persons, unless the
Insurer has accepted them explicitly upon the conclusion of the contract.
V. SUM INSURED AND LIMIT OF LIABILITY
17.
The limit of liability shall represent the maximum amount of payments per one insured person or group of
persons during the term of the medical insurance contract for one or more health services and goods, included
therein.
18.
The sum insured shall be equal to the liability limit. The sum insured shall be agreed, and its minimum and
maximum amount shall be determined by the Insurer.
19.
Treatment costs above the sum insured or for health services and goods outside the agreed in the medical
insurance contract shall be at the expense of the insured persons.
20.
Upon conclusion of the medical insurance contract a deductible may be agreed upon of the insured person,
as a percentage or a fixed amount of the amounts payable by the Insurer as a reimbursement. The deductible shall
be the portion of each payment due for health services and goods, which shall remain at the expense of the Insured
Person.
21.
The limit of liability shall be preserved regardless of the agreed amount of deductible of the insured person.
V. INSURANCE PREMIUM
22.
Insurance premium shall be the payment, which the Policyholder/Insured Person owes to the Insurer.
23.
The insurance premium shall be calculated according to the effective tariff of the Insurer.
24.
The insurance premium shall be annual and shall be prepaid for the insurance year, unless agreed
otherwise. For fixed-term contracts for a period longer than one year, upon payment of the annual premium for the
second and any following year, the Insurer shall be entitled to recalculate the premium according to the changes in
the tariff or the result of the development of risk during the previous one or more years.
25.
The Policyholder/Insured Person shall be obliged to take care of the regular payment of the insurance
premiums prior to or on maturity.
26.
The method of payment of the insurance premium shall be determined at the conclusion of the medical
insurance contract. Change in the method of payment of premium during its period of validity shall be allowed with an
additional written agreement (annex) between the parties to the contract.
27.
The premium shall be paid by bank transfer, in a lump-sum payment or in instalments, according to the tariff
of the Insurer.
28.
If in case of agreed deferred payment of the premium, the Policyholder/Insured fails to pay the instalment
due within the agreed term (maturity date), the coverage of the insurance contract shall be terminated at 24:00 hours
on the 15th day after the maturity date.
29.
If in individual and family contracts deferred payment of premium has been agreed, upon occurrence of
insured event the unpaid deferred installments shall become callable and the Policyholder shall be obliged to pay
them in full before payment by the Insurer of the claims filed with it, unless expressly agreed otherwise.
30.
Insurance premium may be prepaid for more than one year after the current one or until the end of the
duration of the medical insurance contract /prepaid premiums/. In case of termination of the medical insurance
contract prepaid annual premiums following the year of termination shall be returned, less the costs incurred.

31.
In case of death of the Insured Person prior to expiry of the term of the medical insurance contract, the
unused portion of the annual premium shall not be subject to a return.
32.
For group medical insurance contracts, provided that this is stated in the contract, equalization of the
insurance premium shall be made in accordance with the actual change in the personnel during the insurance year,
resulting in additional collection or return of premiums.
V. CONCLUSION, BEGINNING AND DURATION OF THE MEDICAL INSURANCE CONTRACT
33.
Insurance shall be carried out on the basis of a written contract, specifying the agreed one or several groups
of health services and goods, the conditions of their use, the sum insured /limit of liability/, duration of the contract,
the amount and method of payment of the insurance premium, as well as the persons that will be insured.
34.
The medical insurance contract shall be concluded for a period of one year unless otherwise agreed, as
from the date specified as the start date.
35.
The medical insurance contract shall be concluded for a period in accordance with the age of the Insured
Person and with the conditions of the Tariff so that by its expiration the Insured Person must not be older than the
maximum age specified in item 8.
36.
Prior to concluding the contract the person willing to insure shall complete a Personal Health Declaration by
form of the Insurer, and shall be obliged to answer in good faith, thoroughly and accurately the questions therein and
provide true information.
37.
Based on the information from the Personal Health Declaration the Insurer shall be entitled to require
additional tests, interim medical report from the personal GP, containing information about past and current diseases
and medical examination. The medical examination shall conclude with a conclusion medical report by a doctor of
the Insurer. The costs for the performed tests shall be at the expense of the person.
38.
The Personal Health Declaration must be obligatory checked by a doctor of the Insurer who shall give
conclusion for:
38.1. Insurance under standard terms and conditions;
38.2. Insurance under special terms and conditions;
38.3. Refusal to insure.
39.
Individual and family medical insurance contracts shall be concluded with a Personal Health Declaration,
filled in by the insurance applicant. Personal Health Declarations of children up to 14 years shall be filled in by
parents.
40.
Group medical insurance contracts shall be concluded with a List of the insured persons and personal
health declarations. For groups of over 30 persons conclusion of medical insurance contract shall be allowed without
presentation of personal health declarations.
41.
Within 10 days after conclusion of the medical insurance contract the Insurer shall provide to the Insuring
person a valid card for medical insurance for each insured person, with which rights under the contract shall be used.
Where the medical insurance contract is concluded only as reimbursement of expenses, a card shall not be issued.
42.
The liability of the Insurer shall start on condition that premium /first instalment/ has been paid, unless
otherwise agreed in the terms and conditions of the concluded contract.
42.1. For cases of illness under individual and family medical insurance contracts the liability of the Insurer shall
start from 24:00 hours on the date of expiry of one month from the date specified in the contract as the liability start
date;
42.2. For all other cases the liability of the Insurer shall start from 24:00 hours of the day specified in the medical
insurance contract as starting date.
43.
For new incoming persons under group medical insurance contracts:
43.1. The liability of the Insurer shall be from 24:00 hours of the day, on which for them additional premium has
been paid;
43.2. When new incoming persons replace persons who have left, the liability of the Insurer shall start from 24:00
hours of the day of entry into the group, without payment of additional premium, on condition that the Insurer has
given consent;
44.
For persons who have left the group of the insured the liability of the Insurer under group medical insurance
contracts at the expense of the employer shall be terminated from 24:00 hours of the day of exit, unless otherwise
agreed. The Policyholder shall collect and return to the Insurer the issued cards of the individuals who have quit, for
whom insurance is terminated.
45.
In medical insurance contracts, concluded at the expense of the employer, for entering/leaving the group
shall be considered the day of entering/leaving work by the Insured Person, provided that the Insurer is notified in
writing.

46. If the medical insurance contract has been concluded with untrue information about age and/or health status of
the Insured Person, for which the Insurer has placed a question in writing, the Insurer shall be entitled:
46.1. To terminate the contract and refuse payment of amounts under it, if deliberately declared inaccurate or
concealed circumstances are of such nature that the Insurer would not have concluded the contract. The Insurer
shall have the right within one month after learning about the circumstance, to terminate the contract. In this case the
premium paid shall not be refundable.
46.2. To propose a change in the medical insurance contract if the deliberately declared inaccurate or concealed
circumstances allow conclusion of the contract, but under different conditions within one month after becoming aware
of them. If the Policyholder does not accept the proposed change within two weeks from receipt of the proposal, the
contract shall be terminated and premiums paid shall not be refundable.
47.
The contract for medical insurance shall be renewed upon payment of the premium for the next period,
before the expiry of the current one. Upon renewal of individual and family contracts the one-month term under item
42.1 shall not apply. On renewing the contract for medical insurance the Insurer shall require the completion of a new
health declaration. Renewal of contracts shall take into account the result under the prior contract, resulting in a
possible adjustment of the insurance premium.
48. The Insurer shall be entitled to refuse renewal of the medical insurance contract.
V. USE OF HEALTH SERVICES AND GOODS AND REIMBURSEMENT OF INCURRED EXPENSES
49. Insured persons shall be entitled to use the contracted health services and goods anywhere in the country, to
choose freely the treating doctor and medical institution among the providers of medical care, in the manner agreed
for the provision of insurance coverage.
50. The contracted health services and goods may be provided by a limited number of providers of medical care
with which the Insurer has concluded a contract, which is stated in the health insurance contract.
51. Where health services and goods are provided by medical care providers, with which the Insurer has
concluded a contract:
51.1. The Insured Person, prior to use, shall contact the coordinator from the list of the Provider, who shall guide
the treatment and shall compile the necessary medical and insurance documents. A list with the names of the
coordinators shall be presented by the Insurer to the Policyholder upon conclusion of the medical insurance contract
along with the list of the medical institutions, with which the Insurer has concluded a contract.
51.2. The medical documents for the used health services and goods shall be signed by the insured person.
51.3. Payment of the costs of health services and goods shall be carried out by the Insurer up to the amount of the
sum insured and the limit of liability specified in the contract for medical insurance, without the participation of the
Insured Person. Where deductible has been agreed for subscription service, the Insured Person shall pay the
amount of the deductible with the Provider of medical care.
51.4. For provided health services and goods, due to insurance exclusion/ excluded risk or disease, excluded as
special condition under item 10, the Insurer shall not make payment and treatment shall be at the expense of the
insured person.
51.5. The insured person shall owe reimbursement of the costs to the Insurer for the use of health services outside
the agreed. The Insurer shall notify the insured person of the amount, term for reimbursement and the bank account.
52.
Where health services and goods are provided by Medical Care Providers with which the Insurer has not
concluded a contract, they shall be paid by the Insured Person and on the basis of documents submitted the Insurer
shall reimburse the costs incurred up to the amount of the agreed sum insured or limit of liability for the respective
group of health services.
53.
For reimbursement of incurred expenses or payment of fixed amounts, within 15 days from the provision of
the health services and goods, the Insured Person shall submit the following documents:
53.1. General documents for each health service and goods:
Application by form of the Insurer;
Ambulatory sheet completed with all available requisites or Information about the performed health service
by form of the Insurer from the examination with explicitly specified duration of the disease;
Detailed invoice /with a description of the health services by type and price/ for the costs incurred in the
original, in the name of the insured person and attached fiscal (cash) receipt. For payment of fixed amounts, invoice
and cash receipt shall not be presented.
53.2. Additional documents depending on the used health services and goods:
copy of the results from medical tests (in cases of performed tests) and a medical document with their
appointment;
prescriptions for medicines, corrective glasses or auxiliary aids,
epicrisis (in cases of hospital stay);

in case of accident a document for medical care provided with mandatory indication of the date and
circumstances of the accident, etc.
54.
Provision of the necessary documents shall be at the expense of the insured persons. Failure to submit
some of the necessary documents or the submission of documents with incomplete content shall represent grounds
for refusal to pay amounts.
55.
The Insurer shall pay the amounts not later than 15 days from the submission of all required documents for
healthcare services and goods used or shall notify in writing of refusal to pay, stating the reasons.
55.1. The Insurer shall be entitled to refuse the payment of amounts for health services and goods that are not
related to the diagnosis made and the prescribed treatment.
55.2. The Insurer may require additional (control) examination of the person with a view to diagnostic clarification
and assessment of the prescribed therapy. This type of examination shall be conducted by exception, after notifying
the person of the time and place of the examination and shall be at the expense of the Insurer. In the absence of
confirmation of diagnosis and therapy the Insurer shall be entitled to refuse the payment of amounts for health
services and goods.
55.3. The Insurer shall have the right to check the circumstances stated by the insured regarding the occurrence
of the insured event and the use of health services, to require medical documentation from all persons storing such
information, and also preparation of an expert opinion.
56.
The Insurer shall reimburse the amount of health services and goods according to a price list of the
providers of outpatient, inpatient medical or dental care, as reflected in the submitted expense documents /invoice
and cash receipt/.
57.
The Insured Person shall be obliged to:
57.1. Observe the procedures and manner of use of health services and goods specified in the present General
Terms and Conditions;
57.2. Provide access and information to the Insurer in relation to his/her health condition;
57.3. Shall not create conditions for unlawful and malicious use of the health services and goods, included in the
medical insurance contract.
58.
In case of death of the Insured Person after having received health services and goods, the Insurer shall
reimburses the costs or pay the due amounts for them to the persons entitled medical institutions or legal heirs on
the basis of submitted evidencing documents.
. TERMINATION AND MODIFICATION OF THE CONTRACT FOR MEDICAL INSURANCE
59.
At the beginning of each insurance year the Policyholder shall be entitled to amendments to the medical
insurance contract. In these cases the Insurer shall be entitled to require the submission of a new Personal Health
Declaration and performance of a medical examination.
60.
The amendments shall be executed on the basis of a written request by the Policyholder with the signing of
an annex to the contract of medical insurance.
61.
When the Policyholder and the Insured are different persons, the Policyholder shall be entitled to
amendments.
62.
The Insurer shall be entitled to accept or reject the request for amendment.
63.
The medical insurance contract shall be terminated:
63.1. With expiration of the term for which it has been concluded;
63.2. With the written consent of the parties;
63.3. With the death of the Insured Person;
63.4. Under the conditions and procedure of item 28 and/or item 46 hereof.
. DEFINITIONS
Within the meaning of these General Terms and Conditions:
64.
INSURED EVENT shall be the provision of health services and goods to the Insured during the validity of
the contract, as a result of illness or accident, leading to diagnostics and treatment with qualified medical care
providers, as well as costs incurred prior to the date, specified as end of the liability of the Insurer.
65.
ACCIDENT shall be a sudden and accidental event of external origin to the insured, occurring during the
period of insurance and not by the will of the insured, which had caused his/her death or other bodily injury of
different severity (of the skin and subcutaneous layer, locomotory system, internal organs and systems, central and
peripheral nervous system).
LABOUR (OCCUPATIONAL) ACCIDENT shall be an accident which has occurred during and in relation to or in
connection with the work performed, as well as any work carried out in the interest of the company. An accident shall

be recognized as labour accident if it has occurred during the usual way of going to or returning from the workplace
to: the principal place of residence, the place where the insured takes his/her meals during the working day, the
place of receiving remuneration.
Casualties SHALL NOT BE CONSIDERED AS ACCIDENTS when they have occurred as a result of:
a)
occupational diseases;
b) proven existing illnesses or suddenly occurring medical conditions, physical or mental;
c) bodily injury caused by natural temperature influences (freezing, sunburn, sunstroke or heatstroke), except in the
management of the consequences of an accident;
d) injections, operations, general and local anaesthesia, chemotherapy, radiotherapy and other therapeutic
procedures;
e) use of alcohol, narcotics, opiates, stimulants, doping and other psychotropic substances;
f) sprain, strain and tearing of tissues, joints, ligaments and muscles, resulting from a sudden exertion of ones own
powers;
g) immunizations, vaccinations, leading to incapacity for work and/or death;
h) diseases that are a direct consequence of an accident.
66.
DISEASE (ILLNESS), within the meaning of these General Terms and Conditions, shall be the combination
of complaints and clinical symptoms that have been diagnosed in a registered medical institution, requiring related
medical measures, as reflected in official medical records.
67.
ACUTE DISEASE (ILLNESS) shall be a disease with an acute onset and progressive course, requiring
urgent testing and treatment because of its nature of pain and direct threat to the patients life. Within the meaning of
these General Terms and Conditions acute illnesses shall be: pulmonary embolism, spontaneous pneumothorax,
recent myocardial infarction, acute cardiac rhythm and conduction disorders (evidenced by ECG recording),
perforation of duodenal or gastric ulcer, acute pancreatitis, mesenteric thrombosis, obturation ileus, volvulus, acute
appendicitis, acute peritonitis, acute renal colic, acute biliary colic, acute bleeding from organs of the digestive tract
(without oral cavity and haemorrhoidal plexus), anuria, macrohematuria, recent ischaemic or hemorrhagic cerebral
insultus, non-traumatic (spontaneous) subarachnoid hemorrhage, acute encephalitis or meningitis (bacterial, viral),
rupture of aortic aneurysm, acute purulent otitis media, retinal detachment.
68.
MEDICAL/SANITARY TRANSPORT shall be the transportation of the Insured Person when necessary from
medical point of view from the place of the accident to a medical institution or from a medical institution to another
medical institution, carried out by means of a specialized transport vehicle with accompanying medical team/person.
69.
INSURANCE YEAR shall be the period from the day, specified as starting date in the medical insurance
contract until the day of expiry of 12 /twelve/ months.
70.
MATURITY DATE shall be the date for payment of the insurance premium.
71.
PROVIDERS OF MEDICAL OR DENTAL CARE may be medical establishments for outpatient medical and
dental care and hospitals, registered under the Medical Establishments Act.
72.
OUTPATIENT MEDICAL CARE shall include specific medical services, provided by the respective Providers
in ambulatory conditions.
Providers of OUTPATIENT care shall be natural and legal persons, having the right to carry out medical activities.
73.
INPATIENT (HOSPITAL) MEDICAL CARE shall be the stay in hospital and the entire range of medical and
other services, provided according to the health condition of the insured persons by the Providers of Hospital Medical
Care, with the purpose of recovering the health of the Insured Persons.
Providers of HOSPITAL Care shall be legal entities, licensed under the Medical Establishments Act, which include in
their activities active treatment, additional treatment or rehabilitation of the insured persons.
74.
HOSPITAL STAY shall be the overall process of treatment and stay in hospital for at least 24 hours on
medical prescription.
75.
Provided that it is included in the contract, DAILY ALLOWANCE for hospital stay shall be an agreed amount
payable to the insured for each day of hospitalization.
76.
Within the meaning of these General Terms and Conditions, medical institutions for treatment of chronically
and mentally ill, alcoholics, drug addicts, prophylactic centres, dispensaries, hospices and medical and social care
homes shall not be Medical Care Providers.
77.
SURGICAL TREATMENT shall be the immediate medical process, where by means of operative
intervention a correction is performed of pathological conditions of organs or systems, as well as the overall variety of
operative interventions, carried out once or repeatedly but interrelated at a fixed time, as reported in the operating
journal of the ambulatory or hospital units, including operating activity in the treatment.
78.
Provided that it is included in the contract, AMOUNTS FOR THE SURGICAL TREATMENT OF ORGANS
OR SYSTEMS shall be a percentage of the sum insured, equal to the percentage specified for the operation
performed in the surgical table of the Insurer.

79.
DOCTOR COORDINATOR/ COORDINATOR shall be member of the staff of Medical Care Providers, who
performs initial reception of the insured person, registers and guides his/her further treatment by himself or by
another expert. The doctor coordinator processes the medical and insurance documents for payments by the
Insurer to the Provider.
80.
MEDICAL EXAMINATION shall include all methods of examining the patient for diagnosis and prescribing a
treatment. Medical examinations shall be prophylactic and by indications.
Within the meaning of these General Terms and Conditions medical examinations shall not include examinations,
conducted by psychics, folk healers and unqualified medical and civil persons. A medical examination may also be
conducted in the patients home in case of urgent indications, after prior consultation with the Insurer.
81.
MEDICAL TESTS shall be methods for the detection of pathological deviations from normal physiological
characteristics of the organism. Medical tests results must be reflected in an official medical document. Medical tests
shall be prophylactic and by indications.
82.
MEDICINAL PRODUCT shall be any end product, which represents a substance or a combination of
substances, intended for treatment on doctors prescription of diseases in humans, manufactured or officially allowed
for import into Bulgaria and registered at the Bulgarian Drug Agency (BDA) under the Law on Medicinal Products in
Human Medicine (SG, issue 31/2007).
Within the meaning of these General Terms and Conditions the following shall not be medicines: all herbs,
synthesized herbal preparations, vitamins and homeopathic products, immunostimulants, preparations with
preventive action, nutritional supplements, contraceptives where leading is their contraceptive effect, specialized
foods, biostimulants, vaccines, laxatives and medical cosmetics.
Medicinal products must be prescribed by a doctor in connection with the diagnosed accident or illness of the insured
persons.
83.
PRECEDING DISEASES shall be all health complications that the Insured Person has had prior to or at the
conclusion of the medical insurance contract.
84.
CHRONIC DISEASES shall be those diseases with progressive course and frequent exacerbations,
included in the List of Chronic Diseases of the Ministry of Health (MH) and the World Health Organisation (WHO) and
diagnosed before the conclusion of the insurance contract.
85.
MEDICAL CONSUMABLES shall be the specific supplies and materials used in the course of prophylaxis,
diagnostics and treatment in accordance with the medical prescription given for them. These shall include all
bandages, surgical needles and sutures, surgical meshes, systems for transfusion, cannula, injection syringes,
needles, artificial joints, catheters, etc.
86.
AUXILIARY AIDS shall be the aids used to support and correct vital functions, prescribed by a doctor and
purchased during the validity period of the contract for medical insurance.
86.1. Auxiliary aids shall be: prostheses, crutches, walking sticks, wheelchairs and strollers, orthosis, compression
socks and stockings, elastic bandage dressings and urinators.
86.2. Corrective devices shall be: contact lenses, spectacle glasses and hearing devices (aids).
87.
Monitoring of PREGNANCY within the meaning of these General Terms and Conditions shall include all
examinations and tests of the insured persons carried out during the insurance year with the purpose of monitoring
pregnancy evolution up to a specified amount of the agreed sum insured.
88.
CHILDBIRTH within the meaning of these General Terms and Conditions shall include an additional volume
of medical care, health cares and living conditions provided to the insured persons in hospital conditions up to a
specified amount of the agreed sum insured.
. GENERAL PROVISIONS
89.
When the Policyholder and the Insured Person are different persons, the Policyholder shall be obliged to
explain to the Insured his/her rights and obligations under the medical insurance contract and the procedures for the
use of health services and goods and their payment by the Insurer, and to acquaint them with these General Terms
and Conditions.
90.
The Insurer shall be entitled during the duration of the medical insurance contract to perform a verification
through its own or independent experts and to require additional information about the health status of the Insured
from the Providers of medical and other services.
91.
All relationships between the parties in connection with the execution of the provisions of these General
Terms and Conditions shall be carried out in writing.
92.
Any changes in these General Terms and Conditions shall be valid for medical insurance contracts,
concluded after the date of the change.
93.
The Insurer shall not owe interests on amounts unduly paid and amounts received untimely.

94.
In case of destruction or loss of the insurance contract or talon/card the insured persons shall be obliged to
inform the Insurer within 7 days for the issue of a duplicate.
95.
Any disputes between the parties to the medical insurance contract shall be resolved by negotiation or by
the competent Bulgarian court.
96.
Prior to bringing a claim before the court the Insured Person shall be obliged to appeal the decision before
the Head Office of DZI Life Insurance JSC.
97.
DZI Life Insurance JSC declares:
97.1.
DZI Life Insurance JSC is registered as a personal data controller Certificate of the Commission for
Personal Data Protection (CPDP) 0000425 dated 05.05.2004;
97.2. Personal data are collected, stored and processed by DZI Life Insurance JSC in its capacity as personal
data controller with a view to the lawful performance of its activities in strict compliance with the requirements of the
Personal Data Protection Act (PDPA);
97.3. Persons whose data are processed by DZI Life Insurance JSC shall have the right to:
access to relevant to them personal data processed by the insurance company, and also to request the
correction of such data;
object to the processing of their personal data pursuant to Article 34, paragraph 2 of the PDPA.
97.4.
Personal data collected and processed by DZI Life Insurance JSC in its capacity as personal data
controller may be provided to the following categories of third parties:
persons rendering assistance with regard to the service and collection of receivables of the controller, as
well as assignees;
banks for the purpose of administration of insurance products/services related to banking products;
persons to whom the controller has assigned the processing of personal data;
marketing agencies for the purpose of market research and direct marketing of banking and insurance
products/services;
other institutions, belonging to KBC Group;
authorities, institutions and persons to which the controller is obliged to provide personal data under the
applicable legislation in the Republic of Bulgaria (Association of Health Insurance Companies, Commission for
Personal Data Protection; National Revenue Agency; National Social Security Institute; Financial Supervision
Commission; National Statistical Institute; Financial Intelligence Agency; the Court; the Prosecutors Office;
Investigation Service; Ministry of the Interior; External Auditors).)
These General Terms and Conditions together with the Personal Health Declaration shall form an integral part of the
medical insurance contract and have been adopted at a meeting of the Management Board of DZI Life Insurance
JSC, held on December 4, 2012.