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1.    Policy Definitions

 

1.1.                The insurer: Ayalon Insurance Company Ltd.

1.2.                The Policy holder: The Company that employees an employee and/or handles workers with foreign nationality and/or every other foreign resident as detailed in the preamble to the policy.

1.3.                The Insured: Every individual who is not an Israeli citizen and whose age does not exceed 65 years and who paid the relevant premium for it.

1.4.                The State of Israel: The area of the State of Israel including the areas of Judea, Samaria and the Gaza Strip, but excluding the areas controlled by the Palestinian Authority.

1.5.                Insurance period: As detailed in the preamble to the policy, but not before entry of the insured into Israel and not after his leaving Israel.

1.6.                Hospital: An institution recognized by the official competent authorities in Israel only as a hospital, including public hospitals, government hospitals and private hospitals that have and agreement with the insurer, but excluding sanatorium, clinics and hospitals for chronic illnesses.

1.7.                Hospitalization expenses: Payments for medical treatment expenses during hospitalization at the time the patient was hospitalized in a public or government hospital during the insured period.

1.8.                Medical expenses: Not in the context of hospitalization including: A visit to a doctor including a specialist, medical diagnostic tests due to an illness or accident, medical treatment, surgery or ambulatory surgical procedures, X-ray laboratories, imaging, medications and an ambulance in an emergency.

1.9.                Medical service center: A center operation 24 hours a day during the whole year, apart from Yom Kippur, that receives and provides information, directs insured to clinics and /or doctors, medical treatment, approval of hospitalization at a hospital, handling the return of injured to their country of origin, returning the body of a deceased person to its original place of residence abroad and providing other assistance required relating to the medical services covered by this policy.

1.10.              Doctor in the agreement: A doctor who has an agreement with the Insurer and/or another body that was authorized by the Insurer and empowered by the authorities in Israel to provide medical services.

1.11.              Accidents

1.11.1.              Personal Accident Bodily injury as a result of an unexpected event, caused during the period of insurance directly by an external factor by an observable random occurrence which is not dependent on any other cause and is the sole direct and immediate reason for invalidity and/or death of the insured.

1.11.2.              Permanent invalidity: Means the absolute and anatomical functional loss of an organ or limb or part thereof which occurred as a result of an accident within 12 months from the date of the occurrence of the accident.

1.11.3.              Death: An insured who, heaven forbid, dies as a direct result of an accident within 12 months from the date of the occurrence of the actual accident.

1.12.              Dollar: The representative rate of the U.S. Dollar.

2.                            The Insurer's liability: The Insurer will cover and compensate medical expenses up to an amount of $50,000 for the insurance period for the following items:

2.1.                Full expenses for hospitalization at hospitals for the patient registered as a hospitalized patient, up to a period not exceeding 90 days.

2.2.                Full medical expenses no in the framework of hospitalization through a service center will include the following services:

2.2.1.    Medical expenses connected with treatment, examination, service or diagnosis in the emergency room of a hospital for an insured event, also in those cases where this does not immediately require hospitalization in a hospital.

2.2.2.    Medical consultations with a doctor in the agreement, inclkuding a specialist and/or medical treatment given by a doctor in the agreement, including a speicialist, provided not at the time of hopsitalizion in a hospital, such as diagnostic tests, laboratory, X-ray, setting, fractures and removing them, endoscopies, E.C.G, radiology tests such as ultrasound, magnetic resonance, computerized tomography and every treatment or test required in accordance with medical criteria.

2.2.3.    Emergency treatment of teeth as first-aid only, required as a result of an insured event, and this by a doctor in the agreement up to a maximum of $500 for one insured during the insurance period.

2.2.4.    Expenses paid in order to transfer an injured or ill insured immediately after or as close as possible to the time of the occurrence to the hospital or event, by ambulance from the place of the occurrence to the hospital or to a Magen David Adom center, in view of his health condition, and all this as a direct result of the insured event, and this up to an amount of $500 per one insured during the insurance period.

2.2.5.    Receiving medical serviced at night clinics of the Service Center.

2.2.6.    Medications-registered and approved by a qualified doctor of the Service Center through a pharmacy in the agreement.

2.3.                Personal accidents - up to the amount of the maximum liability limit of the Insurer under this clause is up to an amount of $10,000.

2.3.1.    In the event of death from an accident, apart from those cases mentioned in the exclusion clause 3 below and if the age of the insured on the date of the death is between 18-65 years-the Insurer will pay an amount of $10,000 at the representative rte of the dollar on the date of payment to the beneficiary stated in the proposal form and if there is no beneficiary to the legal heirs.

2.3.2.    In the event of permanent invalidity of the insured at a rate of 100%, and if the age of the insured on the date of the occurrence of the accident is between 18-65 years-the insurer will pay an amount of up to $10,000 at the representative rate of the dollar on the date of payment.

2.3.3.    In the event of permanent or partial invalidity of the insured due to an accident as mentioned above, the insurer will pay the insured for every loss as detailed below, but in no event more than 100%:


One eye

30%

Both eyes

100%

Hearing in one ear

20%

Hearing in both ears

50%

Leg above the knee

60%

Leg above the knee

70%

Leg below the knee to the ankle

60%

The foot

45%

Every toe on a leg

3%

 

 

Left hand from the shoulder and below

65%

Right hand from the shoulder and below

75%

Left arm and hand

55%

Right arm and hand

65%

Thumb of left hand

16%

Thumb of right hand

20%

Finger of left hand

12%

Finger of right hand

15%

Right third finger

12%

Left third finger

10%

Right ring finger

10%

Left ring finger

8%

Right little finger

12%

Left little finger

10%

Every disability existing before the accident will not be recognized and will be taken into account when determining the rate of invalidity


2.4.                Expenses spent by the insured relating to receipt of medical services covered by this policy not through the Service Center and subject to the approval of the Insurer and/or the Service Center will be compensated by a full/partial refund of the expenses against presentation of the following documents:

-                      Tax invoice of the provider of the service which states the amount of the payment

-                      A medical document which states the character of the medical service.

2.5.                Special expenses:

2.5.1.    Expenses for the transfer of the insured deceased to his country of origin or burial expenses in Israel up to a maximum of $5,000.

2.5.2.    A flight ticket expenses to the country of origin of the insured due to an illness or accident confirmed by medical documents which prevented and/or will prevent the insured leaving Israel on the original date planned for his return to his country of origin. The amount will be limited up to $2,500 provided that it was approved by the Insurer.

3.                            Limitations to the Insurer's liability: The insurer will not be liable and will not cover and/or compensate the insured for any claim resulting or connected with one of the following circumstances:

3.1.                For a worsening or sudden or unexpected change for the worse of an existing illness.

3.2.                Due to an existing illness or previous medical condition for which the insured received medical treatment or medications at the start of the insurance or six months prior to that.

3.3.                Hospitalization or treatment of patients those reason for coming to Israel was for therapy or medical treatment.

3.4.                Chronic illnesses or any malignant illnesses that started prior to the insurance period.

3.5.                Periodic checkups.

3.6.                Medical expenses due to pregnancy, itopic pregnancy, birth, surgery connected with fertility and/or infertility.

3.7.                Services and expenses for mental illnesses or disturbances, alcoholism, drugs, self injury or harm or attempted suicide or its sonsequences.

3.8.                Services and expenses for sexual diseases, acquired immune deficiency syndrome (AIDS), and all illnesses known as being caused and/or connected with this virus.

3.9.                Services and expenses for optometry, alternative medicine, chiropractic, medical expenses fro cosmetic and plastic surgery and treatment, experimental surgery, gum treatment and/or surgery, treatment of teeth apart from first aid as detailed in clause 2.2.3

3.10.              Any medical expenses and/or treatment outside the State of Israel.

3.11.              Road accident within the meaning of the National Insurance Law (Combined Version)-1968 or any other law replacing it.

3.12.              Work accident within the meaning of the National Insurance Law (Combined Version)-1968 or any other law replacing it.

3.13.              Earthquake, volcanic explosion, nuclear fusion or meltdown, or radioactive pollution.

3.14.              For medical expenses due to flight/sailing accidents, including in the event of a flight/sailing, and travel in a public or other ordinary service within the State of Israel approved by the authorities as a recognized public transporter.

3.15.              For the active participation of the insured in war or military action, underground, revolution, mutiny, public disturbance, strike, illegal activity, intentional body injury by the insured, medical treatment for rehabilitation from drugs.

3.16.              Any even connected with profession or competitive sport.

3.17.              Should there be a medical body or insurance or government body or other institution which covers the expenses covered by this policy-the Company will not cover or compensate and not indemnify for these expenses.

3.18.              The Company will not compensate or indemnify in the event of a fraud, deception, or concealment regarding any matter which affects this insurance, or regarding submitting a claim under this policy. In the event of a fraud, deception of misleading act regarding this insurance, this will cause the policy to be null and void and any such claim will be rejected.

4.                            General conditions:

4.1.                Every claim under this policy will be paid to the insured in JIS at the representative rate of the dollar prevailing in Israel at the time of payment, or in the event of death, to the legal heirs or administrators of the estate of the insured, as a Court rules.

4.2.                For every accident, loss, damage or occurrence whose results are likely to result in a claim under this policy, the Service Center and/or the Insurer must be immediately informed. In addition to the above notice the insured and/or the policy holder must submit to the Insurer at the said address, within 60 days from the date of the accident damage, in writing, any information, proof, certificates and documents from qualified factors such as: the police, the hotel management, the hospital management, doctor, a pharmacy, and airline, a shipping line, etc. and every other material required from the insured and/or the holder of policy by the Insurer. This clause is a specific precondition to any liability of the Insurer.

4.3.                In the event of submitting a claim the insurer will be entitled to carry out an investigation and in particular to have the insured checked by a doctor or doctors on its behalf, and this as a condition for approving the claim.

4.4.                In the event of insured's death the Insurer will have the right to demand a postmortem which will be carried out on the account of the Insurer. Moreover, the insured and /or the holder of the policy will undertake to submit to the Insurer at its demand all the details required in order to enable the Insurer to check the insured's past medical history.

4.5.                Every act of fraud, or deception or concealment regarding any matter which affects this insurance, or regarding submitting any claim under this policy, will cause the policy to be null and void and any such claim will be rejected.

4.6.                In any event the Insurer will not be responsible for loss or damage or for any payment under this policy from the time of the occurrence of the damage or loss or event which entitles payment under this policy as mentioned in the Insurer, as appears in the proposal form for the insurance and its appendices.

5.                            This insurance policy is subject to the Insurance Contract Law-1981.

6.                            Claims and disputes resulting from this policy will be submitted only to the competent court in Israel in Tel Aviv-Jaffa.

 

 

Addendum to Insurance Policy - expanded coverage for preexisting conditions

 

This addendum is an integral part of the "Medical Insurance" Policy and is only valid for UTS club members. In addition to the coverage detailed in the Policy, the Policy shall be expanded in the following manner:

 

1.    Coverage of a medical transport from the insured person's country of origin shall be at the insurance company's discretion.

2.    The total medical expenses covered by the Policy in accordance with section 2, shall be raised to $100,000.

3.    The maximum age for this program is 75.

4.    Travel expenses back to the insured person's country of origin shall be covered in the event that the person's trip is cut short due to sickness or accident. This coverage is capped at $5,000.

5.    The coverage shall be expanded to include a preexisting condition, and full medical services shall be provided in the event that the condition worsens during the person's stay in Israel.

6.    The coverage of section 5 does not include the following situations:

 

-       Medical treatment that was planned as part of the visit.

-       It was known in advance that there would be a need for hospitalization, medical treatment, or a checkup in Israel.

-       There has been a change / worsening of the condition during the last six months.

-       The person has been hospitalized during the last six months/

-       The person suffers from cancer that was treated by radiation / chemotherapy during the last 12 months.

-       The person suffers from either AIDS, Multiple Sclerosis, a lung disease in which an oxygen balloon is required, a disease in which dialysis is required, Myasthenia Gravis, Organ transplantees, Cystic Fibrosis.



Ambulance

 

In the event of transport by ambulance (either by the customer's decision or because of a doctor's advice), the customer shall pay for the full price of the service and shall not be eligible for reimbursement, to the exclusion of the following detailed cases.

 

Case

Amount reimbursed

Responsible for payment

Transport by ambulance ending in hospitalization of policy holder or death

Full

FEMI

Transport by ambulance not ending in hospitalization of the policy holder

None

 

Transport by intensive care ambulance ending in hospitalization

Full

FEMI

Transport by intensive care ambulance not ending in hospitalization or ending in death of the policy holder in their home

50%

FEMI

Transport by ambulance from a branch of FEMI to a hospital not ending in hospitalization of the policy holder (at the behest of a kupah doctor)

Full

FEMI

Transport by ambulance after a car accident

Full

Perpetrator's car insurance

Transport by ambulance after a terrorist attack

Full

Social Security (Bituach Leumi)

Transport by ambulance to hospital following a work accident, first transport

No payment necessary

Social Security  to MADA

Transport from a hospital to rehabilitation center

No reimbursement - turn to the district center

Transport from rehabilitation center back to the hospital

50% of actual expenses / MADA rate - lower of the two

District Center

Transport from one emergency room to another since the first emergency room cannot provide the required services.

Full

FEMI

Transport by ambulance from one hospital to another at the request of the patient

None

 

Transferring a work related accident victim to another hospital

Full

FEMI

Transport of a woman in labor, above the regular MADA tarrif

The difference

Social Security

Transport to a psychiatric hospital

Ministry of Health's responsibility

Addendum C

REFUND FOR LOSS OF DEPOSIT AS A RESULT OF THE CANCELLATION OF THE JOURNEY PRIOR TO ITS COMMENCEMENT
THE COVER - The insurer will indemnify the insured for the loss of non-refundable deposits or advance payments or payments due in the event of an unavoidable and vital cancellation of the journey prior to its commencement, due to the causes detailed hereunder:

  1. The hospitalisation or death of the insured or an * "immediate family member".
  2. A serious accident which renders the insured bedridden on the date of the journey.
  3. An epidemic which prevents the insured from travelling overseas or to return due to the closure of the airport/s in the destination country to which the flight / shipping ticket has been purchased.


The indemnity payments in accordance with this appendix are up to $2,000 USD.

The compensation payable to the insured in accordance with this section will not exceed the amount of the deposit actually paid, less the amount by which the insured is credited and not exceeding the total sum insured stated above.


*Immediate family member: Spouse, father, mother, son, daughter, brother, sister, parent in law, nephew, niece, grandparent, grandchild, brother or sister in law, sole Business partner solely in a two-man business partnership.
Exclusions to Appendix C

The insurer will not pay any claims arising or connected to the following events and/or causes:
  1. Illness, accident or medical condition in respect of which the insured received medical treatment in the 6 month period prior to the inception date of this policy and/or in respect of which the insured should have received medical treatment in accordance with a documented directive prior to the inception date of the policy, unless underwriting information was submitted to the insurer prior to the journey and the insurer confirmed the cover.
    • 1.1 Any heart and blood vessel disease including: heart rhythm disorders, heart valve disorders, heart disease within the past 6 months.
    • 1.2 If the ratio of the weight to the height [BMI ] of the insured is greater than 40.
  2. Medical treatment which is provided for a medical problem which existed prior to the journey and in respect of which the attending doctor recommended that the insured refrain from travelling overseas as long as it exists.
  3. Malignant diseases unless if they have been declared by the insured and the insurer has agreed to provide the cover at the special conditions determined by the insurer.
  4. AIDS, dialysis, multiple sclerosis or cystic fibrosis which the insured suffered from prior to making the journey.
  5. The cover in respect of these sections is subject to the insured and/or immediate relative not being hospitalised in any hospital or being on a waiting list for surgery or hospitalisation.
  6. The insurer will not be obliged to make indemnity payments in accordance with this section if the cancellation of the journey is caused due to a governmental law or regulation, error in the provision of information regarding the holiday, the unwillingness of the insured to make the journey, the insured being summoned to provide testimony in court due to a financial situation, cancellation of the journey due to an illegal act or criminal proceeding including the insured being summoned to provide testimony in court.
CLAIMS HANDLING
  1. Claims: On the occurrence of an insured event, the insured is obliged to act as follows:
      1.1 To immediately notify the insurer of the event and provide all of the original documents required by the insurer for the settlement of the claim, as soon as possible.
      1.2 In event of Cancellation Due to Medical reasons the insured should provide all medical reports and medical documents to the Insurer.
      1.3 In event of Cancellation Due to Death of the insured or an "immediate family member" The insured or family member should provide Death certification to the Insurer.
Addendum "D"

LUGGAGE INSURANCE
  1. THE COVER - The insurer will indemnify the insured for direct loss or damage to his personal luggage accompanying the insured which occurs during the period of insurance in respect of luggage, commencing from the moment that the insured leaves his home for the overseas journey or, if the luggage is handed-over to a transporter prior to the journey, from the moment of the hand-over, expiring on his return to home land directly to his home, all during the period of insurance and as stated below:
      A. The total indemnity payments in accordance with this clause will not exceed above $1,500 USD.
      B. The total indemnity payments in respect of * valuables will not exceed the amount stated below:

      Maximum sum insured for all expenses in accordance with this section US$ 1,500
      Maximum per item US$ 300
      Restoration of documents US$ 150
      Valuables US$ 500
      Theft of luggage from a vehicle or from a glove compartment US$ 400
      Handbag, wallet or suitcase US$ 200


      * Valuables: Silverware and items of gold, jewellery, furs, wristwatches, spectacles, cameras, camcorders including their accessories, tapes, electrical appliances, optic equipment and electronic equipment of any type, leatherwear and perfumery, professional sports equipment such as: diving, skiing or water sports equipment, musical instruments, religious and sacramental artefacts contained in the luggage.

      C. In any case, the indemnity payments per item or set of items or pair of items will not exceed the amounts stated above.

  2. The policy covers expenses for the restoration of documents up to US$ 150.
  3. Loss assessment: It is hereby noted and agreed that the basis of compensation in the event of loss or damage is as follows: A. In the event that the damaged property was new and the insured is in possession of purchase receipts proving the same, the loss will be assessed by the insurer (without deduction for wear and tear) however the applicable VAT in the country in which the product was purchased will be deducted from the compensation amount. B. In the event that the insured is not in possession of purchase receipts the value of the damaged property will be assessed by the insurer, however in any case the maximum amount payable in respect of loss or damage to luggage will be the new replacement value of the item, less a deduction for wear and tear of at least 35%.
  4. The insurer will complete the handling of the claim in accordance with this section within 14 business days from the date on which all of the documents and information required for proving the loss have been submitted.
Exclusions to Appendix D
  1. The insurer will not pay for loss or damage to luggage arising from or connected to theft from a motor vehicle (other than public transportation) other than for the amount stated in the Schedule of Covers and on the express condition that at the time of the theft the doors, the windows and all other openings of the vehicle are closed and properly locked and that the locks or windows or closing devices were broken into by force and violence with evident signs of the same.
  2. The insurer will not pay f or loss of damage of any types of documents, travellers' cheques, flight tickets and travel tickets (which cannot be rest or ed), cash, cheques, postage stamps, photography films, contact lenses, hearing aids, false teeth, medication (as luggage), medical and/ or other access or ies which have been purchased overseas, spectacles, fragile items, food and beverages, mobile telephones, palm top computers, mobile computers of any type. F or the avoidance of doubt the insurer will pay f or or thopaedic access or ies which are installed overseas following an accident.
  3. The insurer will not pay for loss or damage to saleable business samples.
  4. The insurer will not pay any indemnity or compensation in respect of consequential loss of any type.
  5. The insurer will not pay for normal wear and tear, attrition, gradual deterioration, mechanical or electrical breakdown, damage caused by moth, worms, confiscation or requisition of suitcases or travel bags other than in the event of theft or fire.
  6. The insurer will not pay any indemnity or compensation in respect of damage as a result of confiscation, requisition, seizure or destruction of property by the government, the military, a local authority or individual acting in accordance with law.
CLAIMS HANDLING
  1. Claims: On the occurrence of an insured event, the insured is obliged to act as follows:
      1.1 To immediately notify the insurer of the event and provide all of the original documents required by the insurer for the settlement of the claim, as soon as possible.
      1.2 To provide a police certificate from the overseas police and from the airline company and/or shipping company and/or railway company attesting to the provision of a notification of loss or damage. The provision of the certificate to the insurer is a precondition for the handling of the claim.
      1.3 In the event of damage to luggage which occurs whilst the airline or shipping company was liable for it, the insured is obliged to lodge a claim against the carrier and is obliged to provide all of the documents to the insurer after h avi ng exhausted all of the procedures, including details of the compensation received from the carrier in which case the insurer will compensate him after h avi ng deducted the amount paid or due from the carrier.
      1.4 In the event that damage to luggage occurs whilst it is in the custody of a hotel, the insured is obliged to lodge a claim against the hotel and in such a case the insurer will compensate him after h avi ng deducted the amount paid or due from the hotel.
      1.5 Insurance cover with other companies (other than insurance cover provided free of charge or as a benefit without payment): The insured is obliged to notify the insurer in writing immediately upon becoming aware of any other insurance arranged for the perils covered in accordance with this policy. This policy does not cover any loss or damage if at the time of the occurrence of the loss or damage there was any other insurance/s in force regardless as to whether such insurance was arranged by the insured or by another party, other than if the insured notifies the insured of the same and the insurer agrees to the existence of this additional insurance. In such a case, in the event of loss or damage the insurer will be liable to indemnify the insured for the surplus amount between the actual loss and the indemnity payments made by the other insurer/s.