- 554. Classes of sickness insurance
Sickness insurance may be provided as:
1) medical expenses insurance;
2) hospital insurance;
3) insurance against incapacity for work;
4) long-term care insurance;
5) insurance of another class.
- 555. Obligations of insurer
(1) In the case of medical expenses insurance, the insurer shall, to the extent of the sum insured, compensate the insured person for medical expenses which are incurred as a result of an illness or accident and are medically necessary and perform other contractual obligations. The costs of out-patient examinations conducted in order to establish and prevent illnesses shall also be compensated for.
(2) In the case of hospital insurance, the insurer shall pay the insured person the agreed hospital daily allowance agreed for in-patient treatment which is medically necessary.
(3) In the case of insurance against incapacity for work, the insurer shall compensate the insured person for loss of income or a reduction thereof due to incapacity for work caused as a result of an illness or accident by paying the insured person a daily allowance, making periodic payments or paying a lump-sum amount, as agreed.
(4) In the case of long-term care insurance and if the need to provide care arises, the insurer shall compensate for the costs of caring for the insured person to the extent agreed upon (long-term care expenses insurance) or pay an agreed daily allowance for the care (long-term care daily allowance insurance).
- 556. Application of non-life insurance provisions
If sickness insurance cover is provided pursuant to the principles of non-life insurance, the provisions concerning non-life insurance shall apply to sickness insurance accordingly. The provisions of §§ 443 to 447 and § 460 of this Act do not apply to sickness insurance.
- 557. Duration of sickness insurance contract
(1) Sickness insurance contracts are entered into for an unspecified term.
(2) An insurance contract against incapacity for work may be entered into for a specified term but not for less than three years.
(3) A sickness insurance contract may be entered into for a specified term if it is related to training, stay in a foreign state, travelling or the performance of work or an activity during a specified term.
- 558. Waiting periods
(1) If the parties agree that the obligations of the insurer commence after a certain period of time has passed from the insurance contract being entered into (waiting period), the waiting period shall not exceed five months in the case of medical expenses insurance, hospital insurance and insurance against incapacity for work and nine months in the case of childbirth and health services related thereto. In the case of long-term care insurance, the waiting period shall not exceed three years.
(2) If the insured event occurs before the end of the waiting period, the insurer shall be required to perform only if the policyholder proves that the illness occurred or that the child was conceived only after entry into the contract.
- 559. Insurance of born child
If, at the time of the birth of a child, at least one of the parents is covered by sickness insurance, the insurer shall enter into an insurance contract to insure the child as of his or her birth without any additional insurance premiums or waiting periods, provided that an application for the child to be insured is submitted not later than two months after his or her date of birth. The insurer has the obligation to insure the child to the extent that the insurance cover applied for the child does not exceed the scope of the insurance cover of the insured parent.
- 560. Change in size of insurance premium
(1) An agreement under which the insurer may, after entry into a sickness insurance contract, unilaterally increase the insurance premium or unilaterally change the scope of insurance cover, including establishing the excess which the policyholder has to pay, shall be valid only if agreement is reached to change the insurance premium or the scope of insurance cover if any of the following circumstances change:
1) circumstances which are specified in the insurance contract as basis for the calculation of the insurance premium and which are beyond the control of the parties;
2) the average life expectancy of the insured persons;
3) the frequency at which the insurer’s performance obligation is used by persons insured according to this insurance premium rate;
4) the scope of state compensation for sickness insurance services;
5) fees charged by providers of health care services for the use of their services;
6) legislation changing health care administration.
(2) Agreement shall not be reached on the right to increase the insurance premium unilaterally or to change the scope of insurance cover unilaterally solely on the grounds that the insured person is ageing or his or her state of health is deteriorating. The parties may, however, agree that, when the insured person attains a certain age, the initial insurance premium will be increased to an amount which, according to the relevant insurance premium rate, is payable with regard to an insured person who enters into an insurance contract at that age.
(3) Any declaration by the insurer which retroactively increases the insurance premium or changes the scope of insurance cover is void.
(4) An increase in the insurance premium and a change in the scope of insurance cover shall not take effect earlier than one month after the policyholder is notified of the increase or change.
- 561. Policyholder’s right to cancel
(1) The policyholder may cancel a sickness insurance contract by giving at least three months’ notice of the cancellation so that the contract terminates at the end of the year. The policyholder may cancel a sickness insurance contract which is entered into for a term of less than one year by giving at least three days’ notice of the cancellation.
(2) If the insurer increases the insurance premium or reduces its obligations, the policyholder may cancel the contract within one month as of receiving notice of the change. In such case, the contract terminates on the effective date of the increase of the insurance premium or reduction of obligations.
[RT I 2003, 78, 523 – entry into force 27.12.2003]
- 562. Restriction of ordinary cancellation by insurer
Ordinary cancellation of a contract of hospital insurance or medical expenses insurance by the insurer is only permitted within the first three years after entry into the contract and by giving at least three months’ notice of the cancellation.
- 563. Restriction on withdrawal from contract
If more than three years have passed since a sickness insurance contract was entered into, the insurer shall not withdraw from the contract on the grounds that the policyholder has violated the notification obligation upon entry into the contract.
- 564. Release of insurer from performance obligation
(1) The insurer shall be released from its performance obligation if the policyholder or the insured person intentionally caused his or her illness or an accident.
(2) If the policyholder intentionally caused the illness or accident of the insured person, the insurer’s performance obligation with respect to the insured person shall remain in force. Upon performance of the obligation, the claim of the insured person for compensation of damage against the policyholder shall transfer to the insurer.
- 565. Insurer’s obligation to provide information
The insurer shall, at the request of an insured person, grant access to the information concerning the state of health of the insured person obtained by the insurer upon entry into the insurance contract or during the period of validity of the insurance contract.
- 566. Death or dissolution of policyholder
(1) If an insurance contract terminates with the death of the policyholder or the dissolution of a policyholder who is a legal person, the insured person has the right to extend the insurance contract within two months after the death or dissolution of the policyholder if the insured person gives notice of the name of the new policyholder.
(2) The provisions of subsection (1) of this section apply accordingly if the policyholder cancels the insurance contract. The cancellation shall only be valid if the policyholder proves that the insured person is aware of the declaration of cancellation.
- 567. Group sickness insurance
(1) If a person is excluded from the circle of persons who are insured with group insurance, including on the grounds of the person’s retirement or the termination of a contract entered into between the policyholder and the insurer, the person who was insured under the group insurance may submit an application to the insurer to continue insurance of the same class separately for the person pursuant to insurance premium rates applicable to individual insurance without any waiting periods or additional charges besides the insurance premium being applied.
(2) The right of the insured person provided for in subsection (1) of this section shall expire if the person does not submit an application specified in subsection (1) of this section within one month as of being excluded from the circle of insured persons or termination of the group sickness insurance and performance of the notification obligation by the insurer.
(3) Upon the submission of an application specified in subsection (1) of this section, the insurance premium shall be determined based on the age of the person when the person entered into the group sickness insurance contract.
(4) The insured person shall not have the right provided for in subsection (1) of this section if the person is excluded from the circle of insured persons because of the extraordinary cancellation of the insurance contract by the insurer on the grounds of a violation of the insurance contract by the insured person.
(5) The insurer shall inform each person who is insured with a group insurance upon entry into the group sickness insurance contract or at the time the insurance cover extends to such person of the conditions under which the insurance is terminated and of the consequences regarding the size of the insurance premium if separate insurance were to be continued.
(6) Ordinary cancellation of a group sickness insurance contract by the insurer is only permitted if the insured persons may continue the insurance relationship in the form of individual insurance.