Settlement of claims
INTERNAL RULES FOR CLAIM SETTLEMENT ON INSURANCE CONTRACTS AND PAYMENT OF SURRENDER VALUE
(Amended 01.11.2010) The present Rules regulate the procedures under which NN Insurance – Sofia Branch, named shortly here below the Insurer or NN Life, shall register claims for payment of insurance benefits and provision of insurance benefit under concluded insurance contracts, shall collect proofs in order to determine the grounds and amount of submitted claims, shall perform assessment of the level of injuries incurred, shall determine the amount of insurance payments, shall effect payments to clients and shall consider complaints related to submitted claims by clients.
I. Registration of claims for payment
1.1 (Amended 01.11.2010) Upon claiming payment of insurance benefit or provision of insurance benefit an application as per a sample of the insurer shall be filled in. Each beneficiary, if more than one, shall fill in a separate form. Upon claiming payment of surrender payment the policy holder shall fill in an application as per a sample of the insurer.
1.2 (Amended 01.11.2010) The application and all supporting documentation as per Section II shall be presented by the applicant at the Head Office of NN Insurance - Sofia Branch with address: 1404, Sofia, 49B Bulgaria Blvd., Floor 10, or at any other NN office.
1.3. When the application is filled in at an Insurer’s office, the signature of the applicant has to be laid before the officer, who accepts the application after presenting a personal identity card.
When sending documents they should be sent by a registered mail or courier to the above address of the Insurer’s head office. In that case the application should bear the notary certified signature of the applicant.
1.4. The Insurer shall put a stamp containing the number and the date of receipt on each incoming insurance claim, thus certifying the registration of the claim.
1.5 When the applicant submits original documents and wishes to have them back, the Insurer’s officer makes a copy of the presented originals certifying by his/ her signature the identity of the copy with the original and returns the originals to the applicant.
II. Documents ascertaining the grounds and amount of submitted claims
2.1 Submission of documents by the applicant
2.1.1. (Amended 01.11.2010) Upon submitting the application for payment of insurance benefit, the applicant has to provide the following documents:
a) Documentation evidencing occurrence of the insurance event and any circumstances related thereof:
- In case of death of the insured:
- death certificate (an original, a notary certified copy or an official duplicate);
- copy of the death notice certified by the holder of the original document;
- questionnaire as per a sample of the insurer filled in by the insured’s general practitioner;
- autopsy protocol (an original, a notary certified copy or an official duplicate).
- In case of survival – a declaration from the policyholder or from the beneficiary
- In case of accident - traffic police report in the event of traffic accident (an original, a notary certified copy or an official duplicate);
- In case of occupational (employment) accident:
- declaration for occupational accident (an original, a notary certified copy or an official duplicate)
- investigation report for the occupational accident (an original, a notary certified copy or an official duplicate)
- decision from The National Social security Institute for accepting/non-accepting the accident for occupational (an original, a notary certified copy or an official duplicate).
- In case of permanent disability – decision of the Territorial Board of Health Experts (TBHE) or the National Board of Health Experts (NBHE) (an original, a notary certified copy or an official duplicate);
- In case of hospitalization:
- epicrisis/s (case history/ies) evidencing the hospital stay (an original, a notary certified copy or an official duplicate) and
- copy of patient’s sick leave form and
- questionnaire as per a sample of the insurer, filled in by the insured’s general practitioner
- In case of surgical treatment:
- epicrisis/s (case history/ies) evidencing the sustained surgical treatment (an original, a notary certified copy or an official duplicate) and
- a copy of the declaration of informed consent, concerning sustained surgical treatment, and
- a questionnaire as per a sample of the insurer, filled in by the doctor performed or managed the surgery, and
- a questionnaire as per a sample of the insurer, filled in by the insured’s general practitioner
- In case of dread disease:
- questionnaire as per a sample of the insurer, filled in by the insured’s general practitioner and/or by the insured’s attending doctor
- epicrisis/s (case history/ies) of the dread disease diagnosed if the insured has been admitted to hospital (an original, a notary certified copy or an official duplicate)
In case of fracture:
- questionnaire as per a sample of the insurer, filled in by an orthopedic surgeon;
- X-ray with an interpretation
b) In the event of investigation carried out by the competent authorities related to the insurance event – an official duplicate of the prosecutor’s decree for suspension or termination of the criminal proceeding or of other provided by the law act, from which acts the applicant may request an official duplicate to be issued;
c) Documentation evidencing beneficiary’s entitlement to the insurance benefit such as: Certificate of inheritance when the designated beneficiaries under the insurance contract are legal heirs, an identification document of the beneficiary/ies in all cases.
d) In case of surrendering the contract the policy holder presents an identification document.
e) Copy of a document issued by a bank for each beneficiary/ policy holder stating the number and bank account’s holder name.
f) Other documents that insurer can require in order to clarify the occurrence of the insurance event, the circumstances related thereof, and the entitlement of the beneficiary to the insurance payment.
g) If the insurance event has occurred in a foreign country and some of the documents are prepared/issued in the foreign country, these documents have to be legalized, or apostilled respectively (depending on the case), and accompanied by officially translated versions into Bulgarian.
h) Expenses related to collection and submission of the documentation listed above shall be incurred by the respective applicants / beneficiaries.
i) In case the beneficiary is a third person, upon submission of a claim he/she will be notified by the Insurer for the documents which are required. The claim shall be registered when it is supported by the documents relevant to the specific case. In this case the deadline is to be counted as from the date when the documents are presented at the Insurer’s office.
2.2.1 (New 01.11.2010) Terms for notification
In case of hospitalization the Insured (or his representative) is obliged to inform the insurer within 72 hours after entering in a hospital. A telephone call to the insurer’s call centre shall be considered as a notification.
2.2.2 (New 01.11.2010) Terms for claiming an insurance payment and accompanying documents related to submission
In case of hospitalization – within 15 days after the insured has been discharged from hospital.
Claims for payment in case of survival shall be submitted on date specified as expiry date of the main insurance coverage, on the earliest.
2.2.3 If a claim is submitted after more than 5 years from date of insurance event or from the date of the policy has matured, the insurer shall not pay.
2.3. Collection of evidence for substantiating the claim and its amount
2.3.1. The Insurer shall collect proofs on the basis of documents, specified in Item 2.1.1.
2.3.2. When on the assessment of the Insurer as per Item 2.2. additional proofs are necessary the Insurer may request such from:
a) third persons beneficiaries, within a period of up to forty-five days as of the date of submission of the proofs, which are demanded upon the registration of the claim, except in the case where the necessity of such additional proofs may not have been envisaged as of the date of registration the claim.
b) from a party under an Insurance Contract, within a period of forty-five days following the submission of the proofs specified by the Contract, if such additional proofs have not been envisaged under the Insurance Contract at the moment of its conclusion.
2.3.3. The insurer may independently collect information in order to elucidate the claim. Upon occurrence of the insurance event the insurer may require all medical documentation concerning the state of health of the insured from all persons responsible for keeping such information. Upon conclusion of the insurance contract the insured shall give his/ her consent such information to be provided to the insurer. All expenses for collection of the information under this Item shall be borne by the insurer.
2.3.4. The Insurer shall not demand proofs, which the insurance service consumer may not obtain due to existing legal obstacles or due to lack of legal possibility to secure these, as well as such proofs that may be reasonably considered as having no substantial importance for the establishment of the claim’s grounds and amount.
ІІІ. (Amended 01.11.2010) Review of claim. Determination of insurance payment amount in case of insurance event
3.1 Upon considering the submitted insurance claims and supporting documents, the Insurer verifies whether the policyholder/ insured has performed his/ her obligation for disclosure of information and for reporting on new circumstances.
3.2 If on the basis of provided documentation it is proved that upon conclusion of the insurance contract the insured has not disclosed to the insurer his/ her actual age, then the insurance benefit shall be changed in accordance with the ratio between the amount of premiums paid and the premiums that should have been paid taking into account the actual age of the insured.
3.3 (New 01.11.2010) In case of death under “NN One” insurance contract the insurer pays out the risk part and the investment part of the basic coverage using the last available investment units price valid for the day before the date of decision of the claim.
3.4 (Amended 13.03.2015) The insurance payment in case of permanent disability due to accident is determined on the basis of the percent of permanent disability, determined in the expert decision of TBHE/NBHE. If an insurance event under this rider occurs to the main insured, leading to payment of 100% of the sum insured, the rider shall be terminated after paying the insurance benefit. If an insurance event under this rider occurs to a co-insured, after paying 100% of the sum insured, the rider shall be terminated for the respective co-insured but shall remain in force for the rest of the co-insured and the main insured.
3.5 In case of additional coverage for waiver of premium in the event of permanent disability on the basis of the medical documents submitted and on the basis of results from a medical examination of the insured, the Insurer may determine a disablement rate which is different from the rate determined in the decision of TBHE/NBHE, and a different start date of the disablement.
3.6. (Amended 01.11.2010) The payment of insurance benefits in case of death (incl. death resulted from accident) and in case of survival do not have an indemnity character, i.e. their amount does not depend on the level of the damage. Payment amount depends on the sum insured, and in case of death, the payment may also depend on the reason of death (for example an accident, a road accident).
3.7 (New 01.11.2010) Insurance payment in case of dread disease is 100% from the sum insured under dread disease rider.
3.8 (New 13.03.2015) In case of additional coverage for surgical treatment the Insurer classifies the operation depending on the complexity and the risk for the health of the insured and pays out 10, 25, 50, 75 or 100% from the sum insured depending on the category of the operation. The five surgery categories are explicitly described in the List of surgeries that is part of the Special terms (appendices 1 and 2), which is part of the Special regulations on the additional coverage for surgical treatment.
3.9 (New 01.11.2010) The insurance payment in case of hospitalization depends on the total number of hospitalization days and the sum insured under this rider for the respective additional coverage. The insurer shall not cover a hospitalization that is equal to or shorter than 3 days.
3.10. (Amended 01.11.2010) In case of additional coverage for waiver of premium, the Insurer does not perform an insurance payment. The insurance benefit is in the form of an waiver of the policyholder from his/ her obligation to pay premium under the insurance contract, starting from the date of the first due premium right after the date stated as a beginning date of disability for the period of disablement but maximum until the end of the term of the rider.
3.11 (New 01.11.2010) Upon payment of the insurance benefit in case of insurance contracts “Perspective” or “Protection” with periodic premium it shall be assumed that the last premium due shall refer to the policy month of the occurrence of the insurance event. The insurer shall refund, together with the sum insured, the unearned part of the insurance premium referring to the period following the month of the occurrence of the insurance event.
3.12 (New 01.11.2010) Upon payment of the insurance benefit on “NN One” contracts it shall be assumed that the last premium due for the risk part of the main and additional coverages and the administration fee shall refer to the policy month during which the insurance event has occurred.
3.13 (New 01.11.2010) Upon payment of the insurance benefit the insurer shall withhold the overdue premiums, the unsettled loans and interests on them, as well as all taxes and fees due which are payable by the beneficiary receiving the payment and which the insurer is obliged to withhold.