Insurances of the person

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Medical expenses insurance

Contents of insurance

The medical expenses policies reimburse the costs incurred for the examination and treatment of an illness or accident. There is a choice regarding the compensability of the expenses: in certain insurance companies, the customers can choose between the cover of illness only or both illness and accidents. The contents of the insurance company’s liability to indemnify is determined on the basis of the insurance contract terms, so when taking out the insurance, the customer should read its contents and estimate whether it suits their situation.

Granting of insurance

When applying for the medical expenses insurance, the applicant fills in the health declaration, which means that they give information on the insured person’s earlier state of health. Earlier illness or trauma may impact the granting of the insurance policy so that the insurance will contain exclusions related to the compensation for certain issues, or the insurance may be fully denied. The health information should be given correctly and in full since providing wrong or incomplete information may lead, for example, to the insurance contract being terminated and no compensation being paid. For example, if the health declaration form includes a question of symptoms in a certain area, the insured must mention the symptoms even if they have not seen a doctor for them.

The medical expenses insurance is normally granted to a person with permanent residence in Finland, covered by the Finnish health insurance system (Kela).

The medical expenses insurance can also be applied for infants. The medical expenses insurance can be applied for an unborn baby during pregnancy. In that case, the insurance will also cover expenses caused by various congenital illness, and the insurance policy will enter into force on the baby’s birthday, with no individual exclusions. When applying for the insurance for an unborn child, the insurance company will ask for a declaration of the mother’s health as well as copies of the child ante-natal clinic.

Insurance validity

The validity of medical expense insurance policies may be subject to various exceptions. The validity may have geographical limitations, in other words, it will not necessarily compensate for treatment other than that given in Finland.

Normally, medical expenses insurance policies also limit the types of activities and hobbies which, when resulting in illness or trauma, may entitle the person involved to receive treatment expense compensations.

The medical expenses may be tied to the validity of a home or farm insurance. If the so-called principal insurance policy expires, so may the medical expenses policy, or it may be subject to an increase in the premium. Therefore, when you change your insurance company, please check the impact of the change on your medical expenses insurance.

The validity of the medical expenses insurance is linked to the age of the insured. Children’s medical expenses policies may expire at the age of 15–25 years while those of adults may remain in force to the age of 60–65, for example. The insurance will also expertise when the maximum indemnity amount during the period of insurance has been paid out.

Coverable expenses

The policy terms of the medical expenses insurance always list the compensable treatment expenses as well as those that are not indemnified.  Likewise, the policies always contain some exclusions, with the related expenses not compensated, even if they were necessary for the treatment of the illness in question.

Normally, the medical expenses insurance covers the examination and treatment costs and medicines that are based on doctor’s prescription and indispensable and necessary according to the generally accepted medical opinion.  Moreover, the insurance may entitle to the compensation for daily hospital charges up to an eventual daily maximum. Normally, the medical expenses insurance covers the treatment and examinations provided by the private healthcare sector.

Policy terms vary as concerns the reimbursements payable for dental care, travelling costs, physical therapy, bandage, medical aids, rehabilitation, speech therapy or psychotherapy. Normally, nutritive products, basic creams, additional home care expenses or loss of income are not covered by the insurance.

Moreover, expenses due to pregnancy, infertility, vaccinations and health checks are not covered.

The sum total of the compensable expenses is reduced by the excess amount which may be specific to the illness or trauma in question or to the insurance application or insurance period. The insurance may sometimes be taken without the excess.

Applying for indemnity

The medical expenses insurance focuses on the expenses which are to be paid by the insured personally. Therefore, the Kela indemnities for the examination and treatment costs must first be applied, unless the treatment facility does not have a Kela direct indemnity facility or if the facility does not make the application directly.

In other respects, too, the medical expenses insurance is secondary to the statutory indemnities.  Therefore, the medical expenses insurance does not compensate for expenses that are reimbursed based on the legislation.

The insurance only pays for expenses incurred during the insurance validity time. Even if the illness had started during the validity period, it must also be in force when the expenses are incurred.

The indemnity claim must be made to the insurance company within a year from the date in which the expense is incurred.