conditions_of_insurance_07 by yangxichun


									  Special Conditions of                     - Insurance scheme in the case of
                                            hospitalization  is  a   type  of
    Insurance for Group                     illness insurance and is governed
   Insurance of Persons                     by the VPP, these ZPP and the
        rev. 02/01.01.2005                  policy.

     1. General Provisions                  1.2 Policy period
                                            The insurance is provided for the
1.1 Basic information                       period agreed in the policy.
- Death insurance with refund of            1.3 Costs of indemnification
policy value and death insurance
with annuity payment are types of           The    Insurer     participates    in
life insurance and such insurance           expedient expenses relevant to the
types are governed by the General           application    for    indemnification
Conditions of Personal Insurance,           claim in the amount of CZK 100.
valid   from    January    1,    2005       The   Insurer     also    compensates
(hereinafter referred to as the             expedient          expenses        of
“VPP”),     by     these      Special       transportation to the place of the
Conditions        of       Insurance        medical examination requested by
(hereinafter referred to as the             the Insurer. Lost profit and/or
“ZPP”) and by the Group Insurance           wages for the duration of the trip
Policy (hereinafter referred to as          and examination are not refunded.
“policy”).                                  The Insurer is not obliged to
                                            refund the above expenses in the
- Permanent and total disability            case    of   no     entitlement    to
insurance with annuity payment is           indemnification.
a type of disability insurance and
is governed by the VPP, these ZPP           1.4  Procedure in case of death of
and the policy.                                  the insured
- Dread disease insurance is a              The death of the insured shall be
type of life insurance and is               reported     to      the     Insurer
governed by the VPP, these ZPP and          immediately by the policy holder,
the policy.                                 and a certified copy of the death
- Accident insurance with extended          certificate    forwarded   to    the
coverage (insurance scheme in the           former. The Insurer may request
case of death due to an injury or           further   documentation   from   the
death due to listed diseases,               policy    holder    necessary    for
insurance scheme in the case of             assessment of the claim and of the
permanent      injury       effects,        extent of indemnification.
insurance    scheme    with     daily       1.5 Surrender
allowance   payment    for    average       A policy pursuant to these ZPP may
duration of treatment of effects            not be surrendered.
of injury, insurance scheme with
daily allowance payment in the              1.6 Delivery of notices
case of hospitalization due to an           Notwithstanding the provision of
injury,   insurance    scheme    with       paragraph 1.19.2 of the VPP, for
annuity payment in the case of              the purpose of this insurance the
full disability ensuing from an             address of the branch, i.e. the
injury) is governed by the VPP,             address    of    the    territorial
these ZPP and the policy.                   directorate, is not considered as
- Insurance scheme in the case of           the domicile of the Insurer.
incapacity to work and insurance
scheme in the case of incapacity
to work ensuing from an injury are
types of illness insurance and are
governed by the VPP, these ZPP and
the policy.

       2. Special Provisions                The insured pays no premiums for
                                            this insurance during the period
2.1    Death insurance                      of   the  annuity   payments.   The
                                            annuity increases by 3 % annually.
2.1.1 Subject     of     insurance,
      insured risk                          2.3   Dread disease insurance
This insurance covers death during          2.3.1 Insured      risk,     form     of
the term of the insurance policy.                 indemnification,        premiums,
2.1.2 Forms of indemnification                    termination
Indemnification is provided:                An insured risk is any dread
 amounting to the agreed policy            disease or medical intervention
   value in the case of death               (hereinafter      referred      to    as
   insurance scheme with refund of          “serious illness”), specified in
   one-off compensation.                    paragraph 2.3.2. A dread disease
                                            of   the    insured,    specified     in
     in the form of annuity payments       paragraph 2.3.2, occurring within
      in the case of death insurance        six months of the date of the
      scheme with annuity payments;         policy,     shall    also      not    be
      the last annuity payment will         considered an insured event; the
      be paid in the year in which          dread disease insurance terminates
      the insured attains the age           in       this       case         without
      agreed in the insurance policy.       indemnification. The Insurer shall
                                            refund to the insured the premiums
2.2    Permanent and total                  paid.
       disability insurance with            In case of an insured event the
       annuity payment                      Insurer     shall     indemnify      the
2.2.1 Subject     of   insurance,           insured    by   the    agreed     policy
      insured risk                          value. In case of several insured
                                            risks    occurring     simultaneously,
An insured risk is permanent and            only     the     first      will      be
total disability of the insured,            indemnified.        The       insurance
as determined by the Insurer in             terminates     on     the     day     of
accordance with paragraph 5.3 of            occurrence of the insured risk.
the VPP.
                                            2.3.2 Definition      of      serious
2.2.2 Forms of indemnification                    illnesses and specification
Indemnification is provided in the                of insured risk conditions
form of an annuity. If the annuity          The insured becomes entitled to
exceeds CZK 50,000, it may be paid          indemnification for the following
in monthly instalments upon a               serious illnesses:
request from the insured.          Acute             myocardial
Notwithstanding the provisions of                  infarction    –    when    the
paragraph 5.4.1 of the VPP, the                    condition is diagnosed by a
insured    becomes   entitled    to                cardiological or internal
payments of annuity beginning from                 medicine    department      as
the   first   day  of   the   month                acute   necrosis    of   heart
following the month in which the                   muscle    tissue     due    to
permanent and total disability of                  interruption of the blood
the insured was determined by the                  supply to the given area.
Insurer. The last annuity payment                  The diagnosis requires the
will be provided no later than in                  presence of the following
the year in which the insured                      indicators: typical sharp
attains the age agreed in the                      pain behind the breastbone,
insurance policy as the final age                  fresh changes recorded on
for annuity payments, or in the                    the     ECG      with      the
year   in   which   the   insurance                development        of       an
terminates due to the death of the                 infarction   site,     typical
insured.                                           increase       in       enzyme

        concentrations      (AST,      CK,               in       accordance           with
        CK-MB,    troponin),       and   a               international
        demonstration of impaired                        classification,                and
        contractibility        of      the               supplemented with a surgery
        heart muscle (hypokinesis                        protocol     if    surgery     has
        and akinesis) on an echo-                        been   performed.       A    dread
        cardiographic      examination.                  disease in terms of these
        None of the forms of angina                      ZPP does not include skin
        pectoris,              including                 cancer,     except     malignant
        unstable     heart      function                 melanoma, the initial stage
        without    the    presence      of               of Hodgkin’s disease, non-
        acute   infarction       or    so-               malignant                tumours,
        called silent infarction,                        premalignant conditions or
        shall    be    considered       an               micro-invasive, undeveloped
        insured risk.                                    malignant          developments, Cerebrovascular         accident                 tumours       developing        in
        (stroke)    –   upon      finding                connection          with       HIV
        intracerebral                   or               infection and non-invasive
        subarachnoidal bleeding or                       malignant tumours in situ,
        cerebral    ischemia,        which               surgically             removable
        are                 objectively                  without further effects.
        demonstrated          by         a Chronic renal failure to a
        neurological finding and CT                      substantial         degree      is
        (computer           tomography)                  considered a dread disease
        examination,         or        MRI               when there are medically
        (magnetic              resonance                 demonstrated           permanent
        imaging), while symptoms of                      changes    on     both    kidneys
        the condition pertain for                        requiring              permanent
        three    months     after      the               dialysis,          with        the
        occurrence of the accident.                      possibility                     of
        The    diagnosis       of     this               transplantation.               The
        condition must be found and                      condition is considered an
        demonstrated          by         a               insured risk after three
        specialised        neurological                  months       of       continuing
        centre.                Temporary                 dialysis treatment. Failure
        neurological symptomatology                      and/or    removal        of    one
        (TIA,     PRINT)       is      not               kidney or compensated renal
        considered       a        serious                insufficiency         are      not
        illness.                                         considered         a      serious Cancer – upon diagnosis of                       illness.
        a               histologically  A    vital      transplant      of
        demonstrated           malignant                 essential       organs,       i.e.
        tumour,    characterised        by               heart,       lungs,         liver,
        unruly        growth           and               kidneys, pancreas and bone
        proliferation       of      tumour               marrow    of      the     insured
        cells     into      surrounding                  becomes    a    dread     disease
        tissues       and         organs.                condition upon performance
        Sarcoma,     leukaemia,        and               of      the        corresponding
        malignant diseases of the                        operation.      An    indication
        lymphatic system are also                        for the operation must be
        considered             cancerous                 given    by     a    specialised
        conditions. Indemnification                      medical centre within the
        is also provided upon the                        territory      of    the     Czech
        diagnosis      of      a      non-               Republic.     Performance       of
        malignant brain tumour that                      the operation abroad must
        cannot      be       surgically                  be    consulted       with     and
        removed. The diagnosis must                      approved by the Insurer in
        be     determined         by     a               advance; failure to fulfil
        specialised medical centre                       this    obligation       relieves

       the     Insurer        of     the              balloon dilatation, laser
       liability to indemnify. A                      operation)     and     a    valve
       cornea transplant, auditory                    operation without the use
       ossicle transplant, auto-                      of    prosthesis      are     not
       transplant of bone marrow                      considered     dread      disease
       and transplants of organs                      conditions.
       other than specified in the    Blindness      is    a     dread
       first     clause      of     this              disease      in      case      of
       paragraph          are        not              irreversible loss of sight
       considered     dread      disease              in   both     eyes     (complete
       conditions.                                    blindness) ensuing from an An operation on coronary                      illness;      the      condition
       arteries due to myocardial                     becomes    an    insured     risk
       ischemia is considered a                       after three months from the
       dread      disease       if    it              day of diagnosis of the
       requires surgery resulting                     condition by a specialised
       in   at     least    a     double              medical centre. One-sided
       coronary      by-pass      (CABG,              blindness is not considered
       ACVB) using a transplant                       a dread disease condition.
       during open chest surgery         Deafness is a dread
       for       a        functionally                disease in case of the loss
       significant     condition      of              of hearing in both ears
       the     coronary       arteries.               (complete        deafness       –
       Surgery without opening the                    incapacity to hear sound
       chest cavity (angioplasty)                     and understand speech even
       and                  functional                with    the    most     powerful
       insufficiency of a single                      hearing aid) ensuing from
       coronary     artery     are   not              an illness. Deafness must
       considered     dread      disease              be     confirmed         by     a
       conditions.                                    comprehensive       examination Operation on the aorta due                    by     tone       and      verbal
       to     a      life-threatening                 audiometry,            objective
       dissecting aortic aneurysm                     audiometry                (BERA),
       using an aortic prosthesis                     tympanometry                  and
       of     the     thoracic       and              examination of the middle
       abdominal         aorta        is              ear musculature reflexes.
       considered        a       serious    Complete and permanent
       illness. However, a medical                    paralysis of two or more
       intervention              without              limbs due to an illness or
       opening the chest cavity                       injury    is     considered     a
       (angioplasty,             balloon              dread disease condition if
       dilatation,                 laser              persisting     for    at    least
       operation) and operation of                    three months. Paralysis of
       branches of the aorta (e.g.                    a single limb (monoplegia),
       carotid       artery,       renal              partial       paralysis        or
       artery) are not considered                     temporary paralysis is not
       dread disease conditions.                      considered a dread disease A cardiac valve operation                     condition.
       is a dread disease if the         Multiple      sclerosis    –
       insured     receives      through              the condition becomes an
       surgery a mitral, pulmonary                    insured risk upon diagnosis
       or    tricuspid      valve     or              by        a         specialised
       aortic valve due to an                         neurological centre and if
       acquired       hemodynamically                 persistent     for    at    least
       significant                 heart              three months, or after the
       condition.       However,       a              second acute attack of the
       medical            intervention                condition.     The     condition
       without opening the chest                      must be demonstrated by the
       cavity           (angioplasty,                 results of a CT examination

       (computer    tomography)     or          daily    allowance   for    the
       MRI examination (magnetic                 duration of hospitalization due
       resonance     imaging).     The           to an injury;
       first acute attack or vague
       neurological diagnoses are               annuity from the permanent and
       not   considered    as    dread           total disability insurance with
       disease conditions.                       annuity payment;    Encephalitis            is       2.4.2 Indemnification       from    the
       considered a dread disease                  insurance scheme in the case
       if        a        specialised              of death due to an injury of
       neurological             centre             the insured or the insurance
       diagnoses inflammation of                   scheme in the case of death
       the brain tissue caused by                  due to listed diseases
       a       viral        infection
       propagated by ticks; the     Should     the   insured    die
       condition    must    last    at               within one year of the day
       least three months from the                   of   injury,     the    Insurer
       date of the diagnosis and                     provides       indemnification
       must result in a degree of                    amounting    to   the    policy
       handicap    of   the    insured               value    agreed    for    death
       preventing       them      from               ensuing from an injury. The
       performing at least three                     amount of indemnification
       common   daily     activities,                is   decreased    by    amounts
       such as washing, dressing,                    already      paid     as     an
       independent eating, use of                    indemnification or advance
       the   toilet    and    use   of               towards the indemnification
       medical drugs, or confining                   of permanent consequences
       the    insured      to     bed,               of the injury. Should the
       rendering them dependent on                   insured die due to the
       outside assistance.                           injury within three years
                                                     of the expiry of one year
2.4    Accident insurance with                       from   the     date    of   the
       extended coverage                             injury, the provisions of
                                                     paragraph apply.
2.4.1 Forms of indemnification      The      Insurer       provides
For the agreed accident insurance,                   indemnification also if the
the Insurer shall indemnify the                      insured    dies   during    the
insured upon the occurrence of an                    policy period due to any
insured risk, by payment of:                         disease listed in paragraph
 the agreed policy value of the            If the insured is
   insurance scheme in the case of                   a person under 18, the
   death due to an injury of the                     Insurer                provides
   insured or the insurance scheme                   indemnification      amounting
   in the case of death due to                       to CZK 20,000; in other
   listed diseases;                                  cases the indemnification
                                                     provided    by   the    Insurer
     the respective percentage of
                                                     amounts to CZK 50,000. The
      the   policy   value   of   the
                                                     Insurer                provides
      insurance scheme in the case of
                                                     indemnification for death
      permanent injury effects with
                                                     of   the    insured    due   to
      linear indemnity;
                                                     listed    diseases    also   in
     the respective percentage of                   case     the     disease     is
      the   policy   value   of   the                diagnosed during the policy
      insurance scheme in the case of                period,    but   the    insured
      permanent injury effects with                  dies after termination of
      progressive indemnity;                         the insurance.
     daily allowance for the average Listed diseases:
      duration of the treatment of                    Leptospirosis         (Weil's
      injury effects;                                   disease) – death due to

    leptospirosis   must   be                   to tuberculosis must be
    evidenced              by                   evidenced             by
    demonstrating         the                   demonstrating        the
    presence   of    specific                   presence      of     the
    Leptospira antibodies.                      bacterium
   Meningococcal                               (Mycobacterium)       in
    meningitidis or sepsis -                    affected tissue or by
    death        due        to                  any    of   the   modern
    meningococcal                               examination      methods
    meningitidis or sepsis                      (PCR).
    must   be   evidenced   by       2.4.3 Indemnification      from    the
    demonstrating          the             insurance scheme in the case
    presence       of      the             of permanent injury effect
    etiological          agent
    (Neisseria meningitidis) Should the insured suffer
    by        microbiological               permanent         consequences
    examination                             ensuing from an injury, the
    (cultivation).                          Insurer shall pay the ratio
                                            of    the     policy      value
   Streptococcal sepsis -                  corresponding to the ratio
    death        due        to              of    disability      of    the
    streptococcal       sepsis              insured due to the injury,
    must   be   evidenced   by              in accordance with tables
    demonstrating          the              for    the    assessment     of
    presence       of      the              permanent         consequences
    etiological          agent              (hereinafter referred to as
    (Streptococcus pyogenes)                the “Tables”), which are
    by        microbiological               available to the insured
    examination                             upon request. The Insurer
    (cultivation).                          shall        provide         no
   Meningoencephalitis      -              indemnification for other
    death        due        to              effects not listed in the
    encephalitis     must   be              Tables.    The     extent    of
    evidenced               by              permanent injury effects is
    demonstrating          the              assessed                  after
    presence   of     specific              stabilisation thereof. In
    antibodies in serum or                  case   the   injury     effects
    by               examining              fail to stabilise within
    cerebrospinal fluid.                    three years of the date of
                                            the   injury,    the    Insurer
   Actinomycosis    –  death               shall       indemnify        in
    due   to    actinomycosis               accordance       with       the
    must be evidenced by a                  condition upon expiry of
    histological microscopic                the three-year period.
    examination             In cases when the Tables
    demonstrating         the               specify a percentage range,
    presence      of      the               the Insurer determines the
    etiological         agent               exact value in accordance
    (Actinomyces bacteria).                 with the nature and extent
   Acute viral hepatitis A,                of bodily harm incurred by
    B, C – death due to                     the injury. The Insurer may
    hepatitis A, B or C with                amend and modify the Tables
    acute   course  must   be               in       accordance        with
    evidenced              by               developments     in     medical
    demonstrating         the               science    and/or     practice.
    presence    of   specific               The Insurer determines the
    agent antibodies.                       amount of indemnification
   Tuberculosis – death due                in   accordance      with   the
                                            Tables valid at the time of

       the     reporting       of     the              single injury may be equal
       permanent injury effects.                       to   a   maximum      of     100 % The degrees of limitation                      extent        of       permanent
       of    joint     mobility       are              consequences according to
       specified relative to the                       the Tables.
       normal physiological extent     Should     the     extent      of
       of     the     movement,        as              permanent consequences of
       follows:                                        the injury exceed 25 %, the
           Light      limitation       –              indemnification       from     the
       limitation       of      mobility               insurance     scheme     in    the
       within the interval of 10                       case of permanent injury
       to 33 % from the norm in                        effects     with     progressive
       all     planes      of      normal              indemnification        increases
       movement;                                       progressively in accordance
           Medium      limitation      -              with      the       table       of
       limitation       of      mobility               progressive indemnification
       within the interval of 34                       for      permanent         injury
       to 66 % from the norm in                        effects for a policy value
       all     planes      of      normal              of CZK 100,000 (hereinafter
       movement;                                       referred to as “Table No.
           Severe      limitation      –
                                       Should an injury result in
       limitation       of      mobility
                                                       the loss of a limb or a
       exceeding     66 %     from    the
                                                       part thereof requiring a
       norm    in   all     planes     of
                                                       prosthesis, or the loss of
       normal movement.
                                                       a limb or a part thereof or The insured is entitled to                     bodily disability requiring
       request     an     annual      re-              the use of a wheelchair,
       examination of the extent                       the           amount            of
       of         the          permanent               indemnification        for     the
       consequences, until three                       permanent      injury     effects
       years from the date of the                      increases      by    10 %;     the
       insured risk, if there has                      claim           shall           be
       been a marked deterioration                     substantiated          by        a
       of the condition. Should a                      certificate      issued     by   a
       greater         extent          of              specialised medical centre
       limitation      due      to    the              confirming the medical need
       permanent consequences of                       for    a   prosthesis      or    a
       the injury be found, the                        wheelchair.
       Insurer must provide the        Should     several     separate
       new                     increased               effects of a single injury
       indemnification within 15                       or more injuries affect the
       days in accordance with the                     same limb, organ or parts
       provisions      of      paragraph               thereof, the Insurer shall
       1.13.4 of the VPP.                              assess the condition as a Should the injury affect a                     whole,         and        provide
       body    part    or    an     organ              indemnification        according
       previously      damaged,       the              to        the         percentage
       Insurer will decrease the                       determined      in    accordance
       indemnification                for              with          the          Tables
       permanent consequences of                       corresponding to the actual
       the latter injury by the                        anatomical      or    functional
       ratio corresponding to the                      loss of a limb, organ or
       degree of previous damage,                      parts thereof.
       in   accordance       with     the    Should the insured die
       Tables.                                         within one year of the day The total indemnification                      of the injury of causes
       provided by the Insurer for                     unrelated to the injury, or
       permanent consequences of a                     should the same die within

        three years of the expiry                    the time of reporting the
        of one year from the date                    injury.
        of the injury due to any     In case a specific bodily
        cause,   and    should   there               harm caused by an injury is
        exist      a      right     to               not      listed      in     the
        indemnification            for               Evaluation       Table,     the
        permanent consequences of                    Insurer shall specify the
        the injury which has not                     duration of treatment for
        been   provided,    then   the               which the daily allowance
        amount of indemnification                    will be provided, according
        shall   be    equal   to   the               to a bodily harm specified
        extent       of      permanent               in   the    Evaluation    Table
        consequences at the time of                  which corresponds closest
        the death, but not higher                    to the claimed bodily harm.
        than         the        agreed Should the insured suffer
        indemnification for death                    several bodily harms from
        due to an injury of the                      the same injury, a daily
        insured.                                     allowance will be provided
                                                     in   accordance      with   the
2.4.4 Daily    allowance     for    the
                                                     longest period of treatment
      average       duration         of
                                                     required for any of the
      treatment of injury effects
                                                     bodily harms. The   right    to    a    daily The daily allowance for
        allowance for the average                    the   average     duration   of
        duration of treatment of                     treatment in case of the
        injury effects arises if                     dislocation of a joint is
        the actual time necessary                    provided     only     if    the
        for   treatment    of    injury              treatment consists of the
        effects is at least equal                    repositioning of the joint
        to 18 days. In such a case                   by a medical doctor.
        the   insured    receives     a Should    the    duration   of
        daily                allowance               treatment of a bodily harm
        corresponding to the daily                   exceed        the       average
        indemnification     multiplied               treatment duration as given
        by the average duration of                   in the Evaluation table,
        treatment specified for the                  the Insurer shall provide
        given bodily harm in the                     the daily allowance for the
        evaluation table of average                  longer period only if the
        treatment times for effects                  actual     treatment     period
        of   injuries    (hereinafter                exceeds the average period
        referred     to      as     the              by at least 18 days and if
        “Evaluation Table”), which                   the prolongation is caused
        is available to the insured                  by   complications     due   to
        upon request. The Insurer                    protracted healing of the
        may amend and modify the                     corresponding bodily harm
        Evaluation       Table       in              due to:
        accordance                 with             A basic illness (diabetes
        developments     in     medical              mellitus,          hepatopathy,
        science    and/or     practice               haematological        diseases,
        should    such    development                etc.);
        result in a marked change
        in the time required for                    Latent illnesses diagnosed
        treatment of bodily harms                    only    in    relation   to
        specified in the Evaluation                  treatment of the injury;
        Table.       The        Insurer             Any of the causes specified
        determines the amount of
        indemnification              in
        accordance       with       the              -   infection  –   bacterial
        Evaluation Table valid at                    inflammation,    local    or

general, infection entering                     complications.
through the wound;                              The Insurer shall specify
- osteomyelitis – bacterial                     the period of treatment for
inflammation         of       bone              the purposes of the daily
marrow;                                         allowance      in    case    of
- osteoporosis – loss of                        complications in accordance
bony tissue;                                    with medical documentation
- osteomalacia – softening                      or medical examination of
of bones;                                       the insured.
-     Sudeck      syndrome       – The   daily     allowance   is
symptoms include pain and                       provided within a period of
inflammation of limbs, or                       one year of the date of the
even osteoporosis, aseptic                      injury. If treatment of the
necrosis,               following               injury is commenced in such
fixation of limbs;                              a way that the average
-    Phlebitis        in     lower              period    of    treatment    as
extremities             following               specified in the Evaluation
fixation in plaster or in                       table    or     the    extended
another manner;                                 treatment     period    expires
-   Pulmonary       embolism     –              after this term, the daily
during phlebitis caused by                      allowance is provided until
pressure and fixation;                          the day of expiry of one
- Skin necrosis – due to                        year from the date of the
fixation;                                       injury.      In     case     of
-      pseudo-arthritis          –              treatment of fractures by
fracture healed by a so-                        osteosynthesis the average
called “false joint”, not                       period    of    treatment    is
mended;                                         extended     by     14    days.
-    fistula      –     following               Removal of the mechanical
osteosyntheses, as well as                      device      and      subsequent
osteomyelitis;                                  treatment may fall outside
-   Infected      hematomas      –              the period specified in the
occurring      in      connection               previous sentence.
with the injury;                Should the insured claim
- swellings – in connection                     the daily allowance, the
with the injury, following                      former   shall     notify   the
extensive contusion of soft                     Insurer of the occurrence
tissues, can cause pressure                     of the injury and submit
on nervous and circulatory                      the    corresponding       form
bundles;                                        after the expiry of 18 days
-   any    damage      to    nerve              from   conclusion      of   the
fibres in connection with                       actual period of treatment,
the    injury    requiring      an              but no later than one month
extended period of time for                     from the conclusion of the
restoration of function –                       treatment.     Injuries    with
regeneration.                                   treatment periods up to 28
The insured shall notify                        days can be reported using
the      Insurer        of     the              a special form without the
occurrence          of        such              medical report. In case of
complications        within     18              the    late      delivery    of
days    of   expiry       of   the              notification of injury, the
average        duration         of              Insurer may decrease the
treatment as specified in                       allowance provided by up to
the      Evaluation         Table;              one half.
failing that, the Insurer
                                         2.4.5 Daily    allowance     during
shall be relieved of the
                                               hospitalization    due     to
liability     to    honour     the
claim of extended treatment
allowance           due         to An agreed amount of daily

       allowance                    for                consequences     (as        per
       hospitalization due to an                       paragraph 2.4.3);
       injury is provided for each                        Full disability of the
       day of medically necessary                     insured declared during the
       hospitalization       of     the               policy period, but no later
       insured    for   purposes     of               than four years after the
       treatment of the effects of                    injury.
       injury. The total number of
       days   considered      for   the The annuity is provided
       purposes          of         the               yearly,       unless       agreed
       indemnification is equal to                    otherwise. The last annuity
       the number of nights spent                     payment will be provided no
       in hospital.                                   later than in the year in A daily allowance during                      which the insured attains
       hospitalization is provided                    the   age     agreed     in   the
       for a maximum period of one                    insurance     policy     as   the
       year from the day of the                       final    age      for     annuity
       injury.      In      case     of               payments, or in the year in
       hospitalization       for    the               which        the       insurance
       purposes     of   removal     of               terminates due to the death
       metal supports of fractures                    of the insured.
       treated by osteosynthesis,                     Unless     agreed      otherwise
       the     Insurer         provides               with    the      Insurer,     the
       indemnification              for               insured shall demonstrate
       hospitalization            after               continuing      disability     no
       expiry    of    the     one-year               later than one month before
       period,     for    a     maximum               the    due     date     of    the
       duration of 14 days.                           annuity, and the Insurer A daily allowance for stay                    shall be entitled to review
       in       nursing          homes,               the    existence       of    full
       convalescence             homes,               disability of the insured.
       rehabilitation centres and                     The Insurer is entitled to
       spas is not provided.                          cease     payment       of    the
                                                      annuity     upon    failure    to
2.4.6 Indemnification     from     the                fulfil the above liability
      permanent       and        total                of the insured. In case of
      disability    insurance     with                termination         of       full
      annuity payment (hereinafter                    disability the entitlement
      referred     to      as      the                to     the     annuity       also
      “annuity”)                                      terminates on the last day The insured is entitled to                    of the month in which the
       the agreed annuity from the                    full disability ceased to
       first day of the month                         exist.
       following    the    month    in The        insured         shall
       which   the   permanent     and                demonstrate the existence
       total   disability     of   the                of    full     disability      by
       insured was determined by                      medical documentation, the
       the       Insurer,         upon                Insured being entitled to
       fulfilment of the following                    review the disability by
       conditions:                                    means      of      a      medical
           The sole cause of the                     examination performed by a
       full    disability     is    an                medical doctor appointed by
       injury suffered no sooner                      the Insurer.
       than on the first day of       Should the Insurer receive
       the   commencement     of   the                a full disability pension
       insurance;                                     from a government body or
                                                      should     such    pension     be
           The injury has clearly                    withdrawn,       the      insured
       caused            permanent                    shall notify the Insurer of

       any      such     decision                    or a medical certificate of
       immediately.                                  incapacity    to    work    for The annuity increases by                     their Insurer (insured not
       3 % annually.                                 entitled to health benefits
                                                     as per the Health Benefits
2.5       Insurance scheme in case of
          incapacity to work
                                     The beginning and end of
2.5.1 Forms   of   indemnification,                  the incapacity to work must
      subject of insurance                           be demonstrated by means of
                                                     a    medical     report     and
     Insurance scheme in case of                    certificate of incapacity
      incapacity to work                             to work. A certificate of
       The Insurer shall pay to the                  incapacity to work issued
       insured daily benefits in the                 by a medical doctor who is
       extent     specified  in    the               the spouse, parent, child
       insurance policy in case of                   of the insured or any other
       loss    of    profit   due   to               closely related person of
       incapacity to work ensuing from               the   same   shall     not   be
       an illness or injury.                         sufficient for the purposes
       Insurance scheme in case of                  of     demonstrating        the
        incapacity to work ensuing                   incapacity to work.
        from an injury               In cases when the duration
                                                     of incapacity to work for
      The Insurer shall pay to the                   the   given    diagnosis     is
      insured daily benefits in the                  considerably    longer     than
      extent     specified  in    the                the   average    duration    of
      insurance policy in case of                    treatment of the particular
      loss    of    profit   due    to               illness or injury, and such
      incapacity to work ensuing from                prolongation        is      not
      an injury. Incapacity to work                  sufficiently    substantiated
      ensuing from an illness does                   in medical documentation,
      not represent an insured risk                  the duration of incapacity
      within this insurance scheme.                  to work for the purposes of
                                                     indemnification      shall   be
2.5.2 Termination of insurance
                                                     determined by the Insurer
The insurance terminates no later                    in accordance with medical
than on the anniversary of the                       documentation or a medical
commencement   of   the   insurance                  examination of the insured.
cover in the year when the insured   The Insured shall exert
reaches the age of 65 or on the                      all   reasonable      care   to
day of partial or full disability.                   regain their capacity to
2.5.3 Incapacity to work                             work; in particular they
                                                     must follow recommendations Incapacity to work for the
                                                     of the medical staff and
       purposes    of    these   ZPP
                                                     adopt      all         measures
       occurs when the insured is
                                                     beneficial       to       their
       medically            declared
       temporarily unfit for work
       due to an illness or injury            2.5.4 Amount of daily benefits
       and the insured does not      The daily benefits can be
       perform their work, and has                   provided   in   the   amount
       received       a      medical                 specified by the Insurer,
       certificate (sick note) in                    who determines the amounts
       accordance with Decree of                     in accordance with the net
       the Ministry of Health Care                   income of the insured. The
       No. 31/1993      Coll.,    as                 sum of the daily benefits,
       amended (insured entitled                     health             benefits,
       to health benefits as per                     compensations    for    lost
       the Health Benefits Act),                     profit      from       other

       commercial    Insurers,    and                deduction          of        the
       for profit lost due to                        appropriate      income     tax,
       incapacity to work received                   social security deductions,
       ensuing from occupational                     and       general         health
       disease or injury must not                    insurance deductions; the
       exceed – when expressed as                    net income is demonstrated
       a per day value – 100 % of                    by a certificate from the
       the   net   income    of   the                employer for the preceding
       insured.                                      fiscal     year       or     the In case of an insured                        preceding               quarter,
       risk, the sum of the daily                    converted       to       average
       benefits, health benefits,                    monthly income.
       old-age and/or disability    For income from a business
       allowance,      compensations                 undertaking     (in    case   of
       for lost profit from other                    entrepreneurs), all incomes
       commercial    Insurers,    and                specified    in    Section    7,
       for profit lost due to                        paragraphs 1 and 2 of the
       incapacity to work received                   Income Tax Act, after the
       ensuing from occupational                     deduction       of       amounts
       disease or injury must not                    expended    to    achieve    and
       exceed – when expressed as                    maintain      the       profits,
       a per day value – 100 % of                    deduction          of        the
       the   net   income    of   the                appropriate      income     tax,
       insured.                                      social security deductions, In case of an insured                        and       general         health
       risk,       the        Insurer                insurance           deductions,
       determines     the     maximum                unless      the       insurance
       amount of the daily benefit                   expenditures        had     been
       from the actual net income                    included     in     the    above
       of the insured for the last                   expended      amounts;       the
       quarter or the last fiscal                    subsequent        income      is
       year preceding the day of                     demonstrated by a copy of
       the   insured    risk.    When                the tax return for the
       determining the amount of                     previous       fiscal       year
       the   daily    benefit,    the                verified (stamped) by the
       Insurer   shall    take   into                relevant fiscal authority.
       account the period which is           In   case   of   a    combination     of
       more   favourable    for   the        incomes of the insured as per
       insured.                              paragraphs     and Should      the       Insured        above, the net incomes are added
       discover that the agreed              up only in case the insured pay
       daily    benefit     of    the        the     insurance       premiums      as
       insured does not reflect              entrepreneurs.
       the subsequent income of              The insured shall demonstrate the
       the   latter,   the    Insurer        amount of net incomes in the
       shall    be    entitled     to        manner    specified       above     upon
       terminate the insurance.              request from the Insurer; the
                                             Insurer    shall   relieve      of   the
2.5.5 Net income and demonstration
                                             obligation     of      confidentiality
                                             those    institutions       which    can
Net income for the purposes of               provide     necessary       information
this insurance policy is, and the            (employers,    fiscal      authorities,
insured   shall   demonstrate, the           Social Security Bureau and its
following:                                   branch offices, other Insurers). For wages and salaries (in
        the case of employees) all           2.5.6 Decrease   of    net income
        incomes as per Section 6,                  during the policy term and
        paragraphs 1 and 10 of the                 consequences thereof
        Income Tax Act, after the   In case of a long-term

       decrease of the net income                     the    Insurer       of     their
       by more than 25 %, unless                      becoming        incapable      of
       caused by an insured risk,                     working within three days
       the    insured,      plus    the               of the agreed commencement
       policy holder in case they                     of     indemnification         if
       are   different      from    the               objectively            possible.
       Insurer, shall notify the                      Should         the         agreed
       Insurer.      The     following                commencement                   of
       shall be considered a long-                    indemnification fall within
       term     decrease      of    net               the waiting period, then
       income:                                        the    notification        period
    Decrease      exceeding      three               extends    to     within    three
      months in duration in the                       days   of    expiry      of   the
      case of employees;                              waiting period.
    Decrease       exceeding       one In      case        of      late
      fiscal    year   in     case   of               notification of incapacity
      entrepreneurs.                                  to work, the daily benefits Should the Insurer learn                      shall be provided from the
       of a decrease in income of                     day following the day of
       the insured during the term                    receipt of the notification
       of the policy below the                        by the Insurer.
       level of the amount of         After       notifying        the
       benefits, the former shall                     Insurer of incapacity to
       be         entitled           to               work,    the     insured    shall
       correspondingly         decrease               forward to the Insurer an
       the amount of the daily                        insured risk report form,
       benefit and the premiums,                      duly filled in with all
       regardless of whether an                       enquiries             truthfully
       insured risk has already                       answered.       In    case     of
       occurred,     effective     from               incapacity to work shorter
       the   month    following     the               than one month from the
       discovery of the decreased                     date    of    entitlement      to
       income.                                        indemnification,              the Should the insured cease                      insured shall submit the
       to receive any income as                       form after recovery. Should
       per these ZPP in accordance                    the     duration        of    the
       with paragraph 2.5.5 during                    incapacity to work exceed
       the policy term, then the                      one month from the date of
       insured    and     the    policy               entitlement                    to
       holder    shall    notify    the               indemnification,              the
       Insurer     of     this     fact               insured shall submit the
       immediately but no later                       form after one month. In
       than by the end of the                         case        of         prolonged
       corresponding month. Unless                    incapacity,       the     Insured
       agreed    otherwise      between               shall    provide     the    daily
       the     Insurer      and     the               benefits always after one
       insured,       the        policy               month,          against         a
       terminates        with      such               certificate of incapacity
       notification.      Should    the               to    work       and/or     other
       insured fail to notify of                      documentation requested by
       the loss of income, the                        the Insurer.
       policy terminates on the       The insured shall ensure
       day following the day when                     that     all      reports     and
       the Insurer learned of the                     medical        opinions       are
       loss.                                          provided       as     soon     as
2.5.7 Procedure upon occurrence of    The insured and the policy
      an insured risk                                 holder        shall        enable The insured shall notify                      employees of the Insured to

       check   the    observance    of                corresponding    field    of
       provisions of the rider, in                    medicine, or in a hospital.
       particular     observance    of
                                              2.5.8 Change     of    occupation,
       obligations related to the
                                                    employment or other earning
       incapacity to work.
                                                    activity Should employees of the
       Insurer    be    refused    the        The   insured  shall  notify   the
       right of inspection as per             Insurer    of   any   change    of
       the previous sentence, it              occupation, employment or other
       shall    be     considered    a        earning activity.
       breach of the policy and               2.6   Insurance scheme in the case
       the      Insurer        becomes              of hospitalization
       entitled to terminate the
       provision        of       daily        2.6.1 Subject of insurance, form
       benefits.                                    of indemnification Should the amount of daily            This        insurance       covers
       benefits    increase     during        hospitalization of the insured due
       the    policy      term,    the        to an illness or injury. The
       Insurer shall indemnify for            Insurer indemnifies in the form of
       insured     risks     occurring        a daily allowance.
       before such an increase by
       the amount of the daily                       3. Common and Final
       benefit valid before such                           provisions
       an increase. Should the amount of daily            These   ZPP   become   valid   on    1
       benefits    decrease     during        January 1005.
       the    policy     term,    this
       decreased amount of daily
       benefits     will    apply   to
       insured     risks     occurring
       before such a decrease. Daily       benefits       are
       provided on condition the
       insured    receives     medical
       treatment from a medical
       doctor duly licensed in the

                                Table No. 1
                    Table         of         progressive
                    indemnification      for   permanent
                    injury effects (policy value of CZK
                     Extent of Indemnificati Indemnific
                     permanent on percentage    ation
                    consequenc in accordance
                         es          with
                                  table for
                                of an injury
                        1 %           1 %     CZK 1,000
                        5 %           5 %     CZK 5,000
                        10 %         10 %     CZK 10,000
                        15 %         15 %     CZK 15,000

20   %   20 %    CZK   20,000
25   %   25 %    CZK   25,000
30   %   45 %    CZK   45,000
35   %   65 %    CZK   65,000
40   %   85 %    CZK   85,000
45   %   105 %   CZK   105,00
50 %     125 %   CZK   125,00
55 %     150 %   CZK   150,00
60 %     175 %   CZK   175,00
65 %     200 %   CZK   200,00
70 %     225 %   CZK   225,00
75 %     250 %   CZK   250,00
80 %     300 %   CZK   300,00
85 %     350 %   CZK   350,00
90 %     400 %   CZK   400,00
95 %     450 %   CZK   450,00
100 %    500 %   CZK   500,00


To top