Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1698058477861.pdf (Georgia)
Internal Travel Insurance Terms ICG/INT/TR 2017 The Insurance is carried out under Legislation of Georgia and in accordance with below stated provisions.

1.
DEFINITIONS Insurer - Insurance Company IC group, (hereinafter Insurer); Policyholder – the person who concludes the insurance contract with Insurer; Insured – the person, who enjoys a short-term (not more than 30 days) stay within the coverage territory – “Territory of Insurance”, and is indicated in the Policy as Insured; Territory of Insurance – Territorial scope, indicated in the Policy, where the cover provided by this insurance is in force; Insurance Policy (Policy) – document confirming the signing of the agreement between Policyholder and Insurer and defining the terms and conditions of this agreement; Insurance Event – event, on occurrence of which Insurer is liable to perform Insurance Indemnification; Insurance Period – period of time indicated in the Policy, within which the Insurance is in force; Insurance Premium – sum indicated in the Policy, which represents the price for insurance services provided by Insurer; Deductible - the amount specified in the insurance contract by which the total indemnity for each and every loss or damage resulting from a single occurrence shall be reduced.
[Type text] Page 1 Reported Claim – a claim for indemnification made in written against Insurer as per form provided by Insurer; Limit – maximal aggregate amount of indemnity payable under the insurance by Insurer, is indicated in the Policy; Insurance Indemnity – the amount payable by Insurer on the satisfaction of the Claim.

Accident – a sudden, unexpected, unusual, bodily injury or deterioration of health caused by an external (mechanic, thermal, chemical, physical) force.
No health deterioration caused by the contracting of any disease and/or illness (heart attack, cancer, stroke), nor the injection or ingestion of any substance, shall be considered as Accident.
Bodily injury or health deterioration that directly or indirectly is related to the health conditions existed on the moment of application for insurance shall also not be treated as Accident; Medical Expenses – expenses incurred for inpatient and outpatient treatment, medical examinations and medicines; Sudden Illness – an instance of illness occurring suddenly that requires immediate medical assistance, delay of which will inevitably cause either Insured’s death, disability or serious deterioration of health; Urgent Condition – worsening of health condition due to an Accident or Sudden Illness, which appears to be life threatening and needs urgent medical care; Emergency Medical Care – on occurrence of Accident or Sudden Illness urgent medical service rendered by ambulance crew to Insured and/or transportation of Insured to the nearest hospital for further appropriate treatment; Urgent Outpatient Treatment – medical treatment of Insured being in Urgent Condition that does not require staying in clinic/hospital for more than 24 hours; Urgent Hospital Treatment – inpatient treatment of Insured being in Urgent Condition lasting more than 24 hours; Urgent Dental Treatment – Relief of acute dental pain and urgent tooth extraction according to diagnosis; [Type text] Page 2 Urgent Ophthalmology Treatment – medical treatment, provided to Insured in case of acute traumatic injury of an eye; Medical Evacuation – If Insured is not a resident of Georgia, Insurer at his own discretion may offer her/him reimbursement of travel expenses to the country of residence instead of the medical treatment in Georgia.
In this case Insurer will cover transportation costs within the Limit of Liability for Evacuation and initial medical care necessary for preparation for Evacuation.

Repatriation - In case of death of the Insured Person, Insurer shall indemnify expenses for transportation of the body or ashes to the Insured’s home country.
High risky Nonprofessional Sport Activities – Following types of nonprofessional sport activities: ricing (automotive, motorcycle, water scooter), paragliding, hang-gliding, gliding, parachute jumping, bungee jumping, diving, mountain skiing.

Policy Validity Period – A single trip within Insurance Period, which starts and finishes in Georgia and embraces the Territory of Insurance as defined in the Policy.

2.

INSURANCE COVERAGE 2.1.


The cover is in force only with respect to Accident/ Sudden Illness that occur within the Territory of Insurance and within the Policy Validity Period.

2.2.
On occurrence of Insurance Event Insurer provides within the Limit of Liability as per Policy the indemnification of the Medical/ Repatriation costs incurred within the Territory of Insurance namely : • Costs for 24 H call center - unlimited • Costs for Emergency Medical Care;- unlimited • Costs for Urgent Inpatient Treatment for max EURO 300 per each day of inpatient treatment, EURO 15 000 in the aggregate; • Costs for Urgent Outpatient Treatment - Limit 3 000 EURO • Costs for Urgent Ophthalmology Treatment for max EURO 1 000 in the aggregate; • Costs for Urgent Dental CARE for max EURO 1 000 in the aggregate; • Costs for Medical Evacuation for max EURO 10 000 in the aggregate; [Type text] Page 3 • Costs for Repatriation of Insured (body or ashes) for max EURO 20 000 in the aggregate.
Deductible for Urgent Outpatient Treatment is 80 EURO.

2.3.

The decision on medical evacuation to be taken by Insurer’s medical expert on the basis of consultation with the doctor in charge with Insured’s medical treatment, should the group decide in favor of Insured’s Repatriation, but Insured be against the Repatriation, this Policy will be considered terminated and Insurer will be exempted from any liability to indemnify any further costs in connection with Insured’s medical treatment/ repatriation.
Insurance Indemnification Insurer shall be notified on Accident/ Sudden Illness within 24 hours from its occurrence, on IC group 24 hours assistance service phone number: +995 (32) 220 33 33 .

Insured shall provide the relevant medical institution with this Policy, and Insurer will pay his part of the costs for the medical services as provided herein directly to the Health Care Provider via wire transfer.
To collect the payment, the following documentation to be presented by the Healthcare provider: invoice, patient history, medical treatment rendered, copies of Insured’s passport and the Policy.

If Insured pays the costs of medical treatment by himself/herself, he/she shall provide Insurer with the diagnosis, records on medical treatment received, medical services’ payment proving documents, own passport and Policy within 15 working days upon completion of the medical treatment.
On expiration of the abovementioned period Insurer is entitled to refuse Insurance Indemnification.

List of required documents: 1.

In case of Urgent Outpatient Treatment: • Passport or it’s copy; • Policy or it’s copy; • Medical Form #IV-100/a (other documents upon request); • Detailed calculation; • Cash bill; • Originals of receipts.

[Type text] Page 4 Insurance Policy or it’s copy; 2.
In case of Urgent Inpatient Treatment: • Passport or it’s copy; • • Medical Form #IV-100/a (other documents upon request); • Cash bill/calculation; • Originals of receipts.

3.

In case of Urgent Dental/Ophthalmological Treatment: • Passport or it’s copy; • • Medical Form #IV-100/a (other documents upon request); • Cash bills/calculations & receipts.
Insurance Policy or it’s copy; Exclusions This Insurance does not cover:  Expenses arising from diseases which do not represent Urgent Condition and which do not prevent Insured from continuing the trip ;  Any expenses born without obtaining the approval of Insurer;  Accidents occurring during war, civil war, riots, strikes, civil commotions, acts of terrorism or sabotage;  All damage or expenses caused by a source of radioactivity;  All damage or expenses caused by pandemic, epidemic, pollution and natural disasters;  Injuries caused by influence of narcotic and psychotherapeutic drugs or from toxic effect of drugs not prescribed by a certified medical practitioner;  Commitment of any criminal act, as well as the consequences of acts of self-injury, suicide or attempts of suicide by Insured;  Diseases that are chronic or existing before the trip , except the expenses for first five days of Emergency Medical Care provided by Intensive care department; Insured’s congenital physical or mental defects;   Psychic diseases;  Pregnancy, child’s delivery or any complications therefrom;   All diseases having manifested and not cured or not definitely cured before the departure;  Sexually transmitted diseases, AIDS, B and C Hepatitis;  Events occurring due to Insured’s unnecessary exposure to the risk (other than as an attempt Infertility examination and treatment, contraception; to save other person’s life); [Type text] Page 5  Spa treatment, medical massage, sanatorium-resort treatment and treatment
 for cosmetic purposes;  Prosthesis and transplantation;  Vaccination or immunization;  Consultations and treatment at non-licensed medical institutions and by non-certified practitioners;  Medical treatment or consultation if the trip is undertaken for the purpose of receiving such services;  Costs incurred for selection and purchase of eye glasses, lenses, contact lenses, and hearing aids;   Indemnification of Insured’s Medical or Repatriation Expenses arising from injuries received in air or train crash; Injuries received while Insured’s participation in any maneuvers or training exercises of the armed forces;  Any kind of cardio surgery, cardio invasive treatment inclusive: CABG-Coronary Artery Bypass Graft, PTCA-Per Coetaneous Trans-luminal Coronary Angioplasty and Stenting;  No cover is provided for Repatriation should the medical care costs related to Accident/ Sudden Illness be outside of insurance cover;  Failure of Insured to provide satisfactory proofs for the cause of her/his Claim;  Any Professional sport activities and Non professional High risk sport activities 3.
SPECIAL CONDITIONS 3.1.

Should Insurer consider it necessary Insurer’s authorized physician-expert shall be allowed to examine Insured and shall be acquainted with her/his treatment history.

3.2.

Insured shall be within the Territory of Insurance for not more than 24 hours at the moment of the Policy issuance.

3.3.

Nonperformance of conditions listed in 3.1 – 3.2 releases Insurer of any liability to pay Insurance Indemnification under the Policy.

3.4.
3.4.

Irrespective of the Limits provided by the Policy and in 2.2 Section of these conditions , should Insured be older than 65 years, Insurer shall reimburse only 50% of medical/Repatriation costs otherwise covered, while for the person who becomes 70 within the Insurance Period only Urgent Hospital/Outpatient Treatment costs are covered and for 50% only.

Persons over 75 years are not entitled to cover.

[Type text] Page 6 3.5.


If Insured has declared (in a written form) about the Insurance Event, but has not provided all required documentation within 15 calendar days from the date of medical treatment’s termination, Insurer is entitled to deny the Insurance Indemnification.

4.

TERMINATION AND CANCELLATION OF THE PRESENT POLICY 4.1.

The Policy is terminated in the following cases: • Expiration of the Policy Validity Period; • Exhaustion of the Limit of Liability as per Policy.

4.2.
4.2.

Should the Policy be cancelled after commencement of Insurance Period no refund of Insurance Premium or its part would be made.

5.

DISPUTE SETTLEMENT Any dispute and differences, which may arise between the parties in respect of this Insurance, are to be settled on the basis of mutual agreement, should no amicable settlement be reached - at the Court of Georgia.

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