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Care Amerika - Health insurance abroad for USA, Canada, Mexico

Care Amerika / Travel NAFTA - Health insurance abroad

General terms of insurance


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General Terms and Conditions (AVB-R) of medical and daily hospital benefits insurance during travels
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Extract from the German Insurance Contract Act (VVG):
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Designelement 1 zur Care Amerika/ Care Travel Versicherung Download Care Amerika/ Care Travel NAFTA condition and terms (PDF)
 § 1 Subject, scope and territory of insurance cover
  1. The insurer provides insurancecover for illnesses, accidents and other events specified in the policy. Where agreed, it shall also provide additional services directly relating to the above. In the event of the occurrence of an unforeseen insured event abroad, the insurer shall assume the costs of medical treatment incurred abroad and shall also provide other agreed benefits and services.
 § 2 Inception of insurance cover
  1. Insurance cover commences at the agreed point in time (inception of insurance), but not before the conclusion of the insurance policy, not before payment of the premium, not before crossing the border into a foreign country. The granting of an executable SEPA Direct Debit Mandate is deemed to be equivalent to payment of the premium.
  2. Trips abroad involving departure from the Federal Republic of Germany before the insurance takes effect are excluded from cover.
  3. Benefits are not paid for insured events which occur prior to commencement of the insurance cover.
 § 3 Nature and period of policy
  1. The insurance policy is concluded when the insurer accepts the application for insurance. The application for insurance must be submitted using the designated form. The application for insurance is accepted when the insurer delivers the certificate of insurance. If insurance is applied for using the paying – in form designated by the insurer, the policy is deemed to be effected on the date of payment of the premium (date stamp of post office, financial institute or accounting office is decisive), subject to the insurer receiving the duly completed application. The payment voucher handed over to the applicant by the post office, bank or the like is deemed to be the certificate of insurance.
  2. If the policy holder has stated a premium in the application for insurance which is inapplicable according to the tariff, the insurance application is deemed to have been submitted stating the applicable tariff premium if the premium is collected by SEPA Direct Debit Mandate (§8, para. (2)).
  3. The policy term is regulated by the tariff. In the event of the death of an insured person, the insurance arrangement shall end with regard to that person. In the event of the death of the policy holder , the insurance arrangements for the co-insured members shall remain unaffected.
 § 4 Scope of liability
  1. Insured persons are free to choose among the registered medical practitioners and dentists.
  2. Medicines, dressings and remedies are only reimbursable if prescribed by the practitioners specified in Section 1 above.
  3. In the case of medically necessary inpatient treatment, the insured person is free to choose among hospitals provided that these are permanently supervised by doctors, they have sufficient diagnostic and therapeutic facilities and also keep medical records.
  4. The type and amount of the insurance benefits are regulated by the tariff. Where the refund of evacuation or repatriation costs is agreed, the following applies:
    1. Unless otherwise agreed in the tariff, the evacuation of a person who has been taken ill must be deemed medically necessary, ordered by a medical practitioner and generally be carried out to the place where the patient had his permanent residence at the time of inception of the insurance policy, or to the nearest suitable hospital to such place of residence.
    2. Repatriation costs are the direct costs of repatriating an insured person who has died during a temporary trip abroad to the place of residence applicable at the time of inception of the insurance policy. Funeral expenses incurred abroad may be reimbursed instead of repatriation costs up to the sum specified in the tariff for repatriation costs. Repatriation costs and funeral expenses shall not be indemnified if the costs of treating the illness or accident causing death were not or would not have been reimbursable under this insurance.
  5. The insurer shall pay to the contractually agreed extent for types of examination or treatment and medicines which are predominantly recognised by traditional medicine in the Federal Republic of Germany or in the country of temporary residence. In addition, the insurer shall pay for methods of treatment and medicines which have proven to be just as successful in practice or which are applied because no traditional methods or medicines are available; however, the insurer is entitled to reduce payment to the amount which it would have cost to use traditional methods and medicines.
 § 5 Limitation of liability
  1. The insurer is not liable to pay
    1. for treatment for illnesses and consequences of an accident which was the purpose of travelling abroad, or for treatment which was known to be required during the scheduled trip unless the trip was undertaken due to the death of the spouse or a relative in the first degree;
    2. for such illnesses including their consequences and for consequences of accidents and of death caused by acts of war abroad if the German Foreign Office had issued a warning against travel to the country in question prior to the insured person entering the country inquestion. This also applies if the insured person is already in the country in question at the time the German Foreign Office issues the warning against travel or at the time war breaks out and he fails to leave the country immediately following the announcement of the travel warning or the outbreak of war.
    3. for illnesses and accidents caused deliberately, including their consequences, or for the treatment of addictions;
    4. for the treatment of mental and psychological disorders and illnesses including hypnosis and psychotherapy;
    5. for examinations and treatment due to pregnancy, childbirth, miscarriage and abortion or any consequences thereof. However, costs are indemnified if medical attendance is necessary due to acute complications in pregnancy, including miscarriage, in the country where the insured person is staying;
    6. for dental prosthesis, including crowns and orthodontic surgery;
    7. for medical aids;
    8. for health resort and sanatorium treatment and for rehabilitation measures;
    9. for outpatient medical treatment in a spa or health resort. This limitation shall not apply if medical treatment becomes necessary during a temporary stay due to an illness or accident which is not connected to the purpose of the stay;
    10. for treatment administered by the spouse, parents or children. Material costs are reimbursed.
    11. for accommodation necessitated by nursing-care or custody requirements;
    12. for treatment due to sterility or artificial insemination.
  2. If medical treatment or an alternative measure, for which benefits have been agreed, exceeds the extent of treatment deemed medically necessary, or if the invoiced amount is excessive, the insurer is entitled to reduce its payments to an acceptable amount. If the costs of medical treatment or other services are strikingly disproportionate to the services provided, the insurer is not obliged to pay such costs.
  3. If an insured person is eligible to claim benefits from a statutory health, accident or pension insurance provider, from a statutory medical care provider or accident care provider, the insurer shall be liable to reimburse only those costs which still qualify for reimbursement after benefits have been paid by the other entities.
 § 6 Payment of insurance benefits; submission of supporting documents
  1. The insurer is only liable to pay if it is presented with original invoices and any required supporting evidence; such documents then become the property of the insurer. If the original invoices are submitted to another insurer for reimbursement (e. g. To those referred to under §5, para. 3), duplicates of the invoices shall suffice, provided that the other insurance company has noted the benefits it has paid on the invoices.
  2. All supporting documents must contain the first name, surname and date of birth of the person treated, a description of the illness and treatment data; prescriptions must clearly state the prescribed medication, the price and the note of dispensation. In the case of dental treatment, the documents must contain a description of the teeth treated and the treatment performed in each case. Benefits or the refusal to pay them by the insurance providers specified in § 5, para. 3 must be substantiated.
  3. A doctor’s certificate confirming medical necessity must be submitted as evidence of the medical necessity of an evacuation.
  4. If claims are made for the reimbursement of repatriation costs or funeral expenses, an official or medical certificate confirming the cause of death must be submitted.
  5. The insurer is obliged to pay the insurance benefits to the insured person if the policy holder has named the person as the beneficiary, in writing, to the insurer. If this requirement is not fulfilled, then only the policy holder can demand to receive the benefit.
  6. Costs incurred in a foreign currency are converted into euro at the exchange rate valid on the date the insurer receives the documents. The daily rate is the official EUR exchange rate at the European Central Bank. In the case of non-traded currencies, for which no reference rates are set, the rate applied is in accordance with the "Exchange Rate Statistics" publications of the Deutsche Bundesbank, Frankfurt/Main in the most recent version, unless the insured person can prove in the form of a bank slip that the currency purchased for the purpose of settling the invoices was purchase data less favourable rate of exchange.
  7. The cost of transferring insurance benefits to a foreign account or of special types of remittance chosen upon the insured person’s instructions may be deducted from the benefits.
  8. Rights to insurance benefits can neither be sub rogated nor pledged.
  9. For the rest, the conditions governing the insurer’s liability to pay a reset down in § 14 VVG (German Insurance Contract Act; see Appendix).
 § 7 Expiry of insurance cover
  1. Insurance cover ends, also for pending insured events, at the agreed point in time, at the end of the trip at the latest.
  2. If, due to medical reasons, an insured person is incapable of making there turn journey by the agreed time, the insurer’s liability to pay indemnifiable claims shall continue beyond the agreed time, until the insured person is capable of being transported.

If the insured person objects to medically acceptable and reasonable repatriation (evacuation) to his country of permanent residence once he is fit for transportation, the insurer's obligation to pay shall cease on the day the insured person objects to repatriation.

 § 8 Premium payment
  1. The premium is a single premium. It is derived from the tariff and payable at the time of conclusion of the insurance policy at the latest.
  2. The tariff can prescribe that the premium is payable by SEPA Direct Debit Mandate. In this case, the legally valid direct debit authorisation is deemed to be equivalent to payment of the premium if the insurer was subsequently able to debit the premium.
 § 8a Premium adjustment

Within the scope of the contractual confirmation of benefits, benefits paid by the insurer can change, e. g. Due to increasing medical treatment costs, more frequent availment of medical services or due to increasing life expectancy. Accordingly, foreach tariff where the insurer’s right of ordinary cancellation is ruled out contractually or by law, the insurer compares the required insurance benefits with the insurance benefits and mortalities calculated in the actuarial bases for the calculation of premiums at least once a year.

Depending on the outcome of there view, premiums are adjusted where required on the basis of the applicable statutory provisions. The premium adjustments take effect at the beginning of these cond month following notification of the policy holder.

In the event of an increase in premium, the policy holder can cancel the insurance policy with in two months of receiving notification of the increase, and such cancellation will take effect on the date when the premium is due to increase. The policy holder may cancel the insurance policy up to the date when the adjustment takes effect, even if the deadline has already expired.

 § 8b Amendments to the General Terms and Conditions of Insurance
  1. The General Terms and Conditions of Insurance may, if the insurer’s right of cancellation is ruled out contractually or by law, be amended with effect for existing insurance policies, for the remainder of the current insurance year as well (see tariff), on the basis of the applicable legal provisions if such amendment appears necessary in order to sufficiently safeguard the interests of the insured persons
    1. in the event of a change in the state of the health service not only of a temporary nature,
    2. in the event of terms and conditions being pronounced invalid in court, if the replacement thereof is necessary in order to continue the policy,
    3. in case of amendments to laws upon which the terms and conditions of the insurance policy are based,
    4. in case of amendments of supreme court rulings, of administrative practices of the Bundesanstalt für Finanzdienstleistungsaufsicht (German) Federal Institute for the Supervision of Financial Services – or the cartel offices, which affect the insurance policy directly.
    With regard to the letters c and d, an amendment is only permissible where it relates to §§ 1, 2, 3, 4, 5, 7, 8, 9, 10, 13, 14 para. 2, AVB-R.

  2. Amendments pursuant to paragraph 1 shall become effective at the beginning of the second month after the policy holder has received notification thereof.
  3. In the event of an amendment in the terms and conditions, the policy holder can cancel the insurance policy with in one month of receiving notification of the amendment, and cancellation shall take effect on the date when the amendment is scheduled to come into effect. The policy holder may cancel the insurance policy up to the date when the adjustment takes effect, even if the deadline of one month has already expired.

 § 9 Obligations
  1. The policy holder or the insured person specified as the beneficiary (cf. §6, para. 5) must submit all documents by the end of the third month after the end of the trip at the latest; any hospital treatment must be reported within 10 days of its commencement.
  2. At there quest of the insurer, the policy holder or the insured person specified as the beneficiary ( cf. §6, para. 5) shall be required to provide each and every kind of information necessary to determine an insured event or an obligation to perform on the part of the insurer and the scope there of.
  3. At there quest of the insurer, the insured person shall be obliged to under go a medical examination by a doctor appointed by the insurer.
 § 10 Consequences of any breach of obligations
In accordance with the limitation prescribed by §28, sections 2-4 of the German Insurance Contract Act (VVG: see appendix), the insurer shall be released from its obligation to perform if any of the obligations specified under § 9 above are breached. The knowledge and negligence of the insured person shall be put on a par with the knowledge and negligence of the policyholder.
 § 11 Obligations and consequences of breaches of obligations in the event of claims against third parties
  1. If the policy holder or an insured person is entitled to claim against third parties, he is obliged, notwithstanding the statutory assignment of claims according to § 86 VVG (see Appendix) , to subrogate such claims in writing to the insurer up to the amount of those costs (reimbursement of costs, material costs and services) reimbursed under the insurance policy.
  2. The policy holder or the insured person must protect his claim to compensation or any right which serves to safeguard any such claim in compliance with the applicable formal and temporal requirements and contribute towards its enforcement by the insurer where necessary.
  3. Should the policy holder or an insured person deliberately violate the obligations specified in sections 1 and 2, then the insurer shall not be required to perform to the extent that it cannot obtain any compensation from the third party as a result thereof. In the case of any breach of obligation due to gross negligence, the insurer is entitled to reduce the amount of compensation it awards in relation to the severity of the breach.
  4. If the policy holder or an insured person is entitled to claim against a provider of services for there payment of fees paid without legal grounds, which the insurer has reimbursed on the basis of the insurance policy, then paragraphs 1 to 3 shall be applied accordingly.
 § 12 Offsetting claims
The policyholder can only offset claims asserted by the insurer in as much as the counter claim is uncontested or has been established as final and absolute.
 § 13 Notifications and declarations of intent
Notifications and declarations of intent to the insurer must be in textform.
 § 14 Place of jurisdiction
  1. Legal action taken against the policy holder arising from the insurance policy shall be subject to the jurisdiction of the court at the policy holder’s permanent place of residence or, failing this, his usual place of residence.
  2. Legal proceedings against the insurer may be brought before the court at the policy holder's permanent or usual place of residence or before the court at the domicile of the insurer.
  3. If, after conclusion of the policy, the policy holder moves its permanent or usual place of residence to a state which is not a memberstate of the European Union or contracting state of the Treaty on the European Economic Area, or if its permanent or usual place of residence is not known at the time the proceedings are brought, the court at the domicile of the insurer has jurisdiction.

Valid from 07.2016


For the settlement of disputes arising from the insurance policy the policyholder can contact the ombudsman for private health and long-term care insurance to settle the dispute out of court.

OMBUDSMANN Private Kranken- und Pflegeversicherung
Postfach 060222
10052 Berlin
www.pkv-ombudsmann.de

The insurer participates in the procedure with the ombudsman for private health and long-term care insurance.

Extract from the German Insurance Contract Act(VVG):
 § 14 Due date of cash benefit
  1. The insurer shall be liable to pay a cash benefit when enquiries necessary to establish the occurrence of the insured event and the extent of the insurer's liability have been concluded.
  2. If these enquiries have not been concluded one month after notification has been given of the occurrence of the insured event, the policyholder may demand part payment in the amount which the insurer will at least be expected to pay. The time limit shall be suspended for as long as the enquiries cannot be concluded on account of the fault of the policyholder.
  3. An agreement on account of which the insurer is released from the obligation to pay interest on arrears shall be void.
 § 28 Nonobservance of an incidental obligation
  1. Where the contract provides that the insurer is not obligated to effect payment in the event of the non-observance of an incidental obligation on the part of the policyholder, he shall be released from the liability if the policyholder intentionally breached the obligation. In the case of grossly negligent non-observance of the obligation, the insurer shall be entitled to reduce any benefits payable commensurate with the severity of the policyholder's fault; the burden of proof that there was no gross negligence is on the policyholder.
  2. Notwithstanding subsection (2), the insurer shall be liable insofar as the non-observance of the obligation neither caused the occurrence or the establishment of the insured event nor the establishment or the extent of the insurer's obligation to effect payment. The first sentence shall not apply if the policyholder fraudulently breached the obligation.
  3. The condition on which the insurer's entire or partial release from liability in accordance with subsection (2) is based shall, in the event of a violation of an existing duty to provide information or duty of disclosure after the occurrence of an insured event, be the fact that the insurer instructed the policyholder in separate correspondence and in writing of this legal consequence.
 § 82 Loss avoidance and minimisation
  1. The policyholder must, upon the occurrence of the insured event, ensure that the loss is avoided or minimised wherever possible.
  2. The policyholder must follow the instructions of the insurer, where reasonable, and obtain instructions, circumstances permitting. If several insurers involved in the contract of insurance issue different instructions, the policyholder must act at his own proper discretion.
  3. In the event of the breach of an incidental obligation under subsections (1) and (2), the insurer shall not be obligated to effect payment if the policyholder intentionally breached the incidental obligation. In the event of a grossly negligent breach, the insurer shall be entitled to reduce his benefits payable commensurate with the severity of the policyholder's fault; the burden of proof that there was no gross negligence is on the policyholder.
  4. Notwithstanding subsection (3), the insurer shall be liable insofar as the breach of the incidental obligation is the cause neither of the establishment of the occurrence of the insured event, nor of the establishment of the extent of the liability. The first sentence shall not apply if the policyholder fraudulently breached the obligation.
 86 Assignment of claims
  1. If the policyholder is entitled to claim damages from a third party, this claim shall be assigned to the insurer insofar as the insurer compensates for the loss. The claim may not be assigned to the detriment of the policyholder.
  2. The policyholder shall safeguard his claim for damages or a right serving to safeguard this claim in accordance with the applicable form and time requirements, and shall assist the insurer wherever necessary in asserting them. If the policyholder intentionally breaches this obligation, the insurer shall not be obligated to effect payment insofar as he cannot as a result claim compensation for it from a third party. In the case of grossly negligent non-observance of the obligation, the insurer shall be entitled to reduce any benefits payable commensurate with the severity of the policyholder's fault; the burden of proof that there was no gross negligence is on the policyholder.
  3. If the policyholder claims compensation from a person with whom he is sharing a common household when the loss occurs, assignment in accordance with subsection (1) cannot be asserted, unless that person intentionally caused the loss.
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Please note that the English translation is for convenience only. The legally binding version is the German one.


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