Agreement of compulsory medical and voluntary insurance. Mandatory and voluntary medical insurance in Russia

Treaty medical insurance. Each has the right to medical assistance in a guaranteed amount provided without charging the fee in accordance with the "Program" of state guarantees of free provision of medical care citizens, as well as to receive paid medical services and other services, including in accordance with the voluntary health insurance contract.

Right to medical care foreign citizensliving and staying on site Russian Federationis established by the legislation of the Russian Federation and the relevant international treaties of the Russian Federation. The stateless persons permanently residing in the Russian Federation enjoy the right to medical care on par with citizens of the Russian Federation, unless otherwise provided by international treaties of the Russian Federation.

Types of medical insurance contracts:
- compulsory medical insurance contract
- voluntary medical insurance contract

The right of the insured person for free medical care for compulsory health insurance is being implemented on the basis of prisoners in its favor between the participants of the compulsory medical insurance of the Treaty financial Security Compulsory medical insurance and contract for the provision and payment of medical care for mandatory health insurance.

Under the financial support contract, the insurance medical organization undertakes to pay for medical care provided to insured persons in accordance with the conditions established by the territorial program of compulsory medical insurance, due to targets.

"___" __________ 20__ years
Moscow

Insurance Company, referred to as "Insurance", in the face of ___________________________________________________________________________________________, on the one hand, and ___________________________, hereinafter referred to as the "Insurer", represented by ________________________, acting on the basis, on the other hand Together and individually, referred to as "Parties", concluded this agreement on the following:

1. The Subject of the Agreement
1.1. The insurer undertakes for the fee (insurance premium) due to this contract (insurance premium) upon the occurrence of an event provided for in the contract ( insurance case) To make a payment for medical services provided to the Insured person, in whose favor of the insurance contract, a medical institution, where the insured person received medical care and other assistance within the agreed agreement of the amount (sum insured).
1.2. The object of voluntary health insurance is the property interest of insured persons related to expenses caused by the appeal of the insured to medical facilities for medical services included in the insurance program (Appendix N 1).
1.3. Insurance case is the appeal of the insured for obtaining medical and other services during the period of action of the Treaty in the medical institution provided for by the insurance program in acute disease, the exacerbation of chronic disease, infection, during childbirth, injury, poisoning and other states requiring medical care provided for by the insurance program .
1.4. The total number of insured at the time of the conclusion of this Agreement is ___________ (__________) a person (Appendix N 2).

2. Insurance amount insurance premium and the order of it
2.1. Under the insurance amount under this Agreement it is understood as the limit amount of insurance coverage under the contract of medical insurance.
2.2. The insured amount for each insured is ___________.
Insurance amount for all insured is ____________________.
2.3. Insurance premiums for each insured are determined by the table:

2.4. The total insurance premium under this Agreement is _________ (____________________________________).
2.5. The insurance premium is paid by the insured in the following order: __________________________________________.
2.6. The moment of payment of the insurance premium is the date of receipt of the insurance premium to the account of the insurer.

3. Rights and obligations of the parties
3.1. The insurer must:
3.1.1. To organize the provision of medical services to the insured in accordance with the insurance program (Appendix N 1) and the conditions contained in this contract.
3.1.2. On the period no later than 10 (ten) working days from the moment of entry into force of this Agreement, to ensure the attachment of the insured to medical institutions, to issue each insured personal insurance medical Policy Voluntary medical insurance of the established form and pass to medical institutions (if any medical institutions).
3.1.3. Control the volume, timing and quality of the insured medical care provided.
3.2. The insurer has the right:
3.2.1. Check the accuracy of the data reported to him by the insured. If during the term of the contract of medical insurance it turns out that the insurer (insured) informed the insurer knowingly false or incomplete data affecting the degree of risk of an insured event, the Insurer has the right to demand additional insurance feecorresponding to the increased risk.
3.2.2. Request from the insured data on changes in the circumstances that are important to evaluate insurance risk.
3.2.3. When solving a question about the payment of insurance provisions to request additional documents.
3.2.4. Do not pay insurance if:
- Insured received medical serviceswhich are not provided for by the insurance contract (voluntary health insurance program);
- the insured received medical services in medical institutionsnot provided for in the insurance contract (voluntary health insurance program), except in cases pre-agreed with the insurer.
3.3. The insurer must:
3.3.1. Pay the insurance premium in the amount, order and the timing provided for by this insurance contract.
3.3.2. In case of amendments to the list of the insured issues an additional agreement. Until the entry into force of the Supplementary Agreement, this Agreement remains strength in relation to the insured specified in the previously submitted lists.
3.3.3. At the conclusion and during the period of the insurance contract, to inform the insurer about all the circumstances known to it that are important to assess the insurance risk.
3.3.4. If the insured under this Agreement is insured in the present agreement in excess of the amount of the sum insured, or not provided for by the insurance program, pay an additional insurance premium in the amount and time limits defined by the Supplementary Agreement between the Parties.
3.3.5. Inform the insurer during the days of refusals to provide insured medical care and medical services in the amount provided for by this Agreement.
3.4. The policyholder has the right:
3.4.1. In coordination with the insurer, make changes to the insurance program, change the amount of the sum insured, change the number of insured by issuing an additional agreement to this Agreement.
3.4.2. To replace the insured within the same program and an established contract of number during the term of the contract of medical insurance, taking into account the current legislation of the Russian Federation.

4. Term of the contract
4.1. This Agreement is concluded for a period of "__" _______________ on "___" 20__
4.2. In case of non-fulfillment by the insured, the obligation to pay the insurance premium The Insurer has the right to terminate this Agreement ahead of time. unilaterally and require damages.

5. Privacy
5.1. The parties undertake commitments to comply with the confidentiality regime regarding the information obtained in the execution of this Agreement, with the exception of cases provided for by the legislation of the Russian Federation.
5.2. Confidential under this Agreement is recognized by the information:
- on the form and content of the Agreement of Voluntary Health Insurance;
- information on the state of health of the insured, as well as cases of their appeal to medical care;
- information about the place of residence and home telephone insured.

6. Insurance payment procedure
6.1. Insurance fees are made by the insurer only on insurance cases specified in the Voluntary Medical Insurance Program (Appendix N 1).
6.2. The insurer makes the payment of insurance provision by transferring money In the medical institution to pay the insured medical services.
6.3. The amount of insurance fees in this Agreement for the entire period of its operation may not exceed the amount of the sum insured indicated in paragraph 2.2 of this Agreement.

7. Change and termination of the contract
7.1. The policyholder has the right to coordinate with the insurer during the term of the contract to make changes to the list of the insured. Amendments to the lists of the insured stops 2 months before the expiration of this Agreement.
7.2. When incorporating new persons to the list of the insured, the policyholder submits no later than 5 days before the expected date of making changes to the list of insured data on the new insured. The parties draw up an additional agreement to the contract containing changes to the list of insured, the sum of the insurance premium payable for these insured and the timing of its payment.
7.3. This Agreement may be terminated early at the initiative of the insured by written notice no later than 30 days before the date of the intended termination.
7.4. In the event of early termination of the insurance contract, the return of the insurance premium is carried out in accordance with the current legislation of the Russian Federation.
7.5. In case of early termination of the insurance contract, the insured is obliged to return the insurer of the insurance policy and skipping (a), the action of which is terminated since the end of the insurance period.

8. Responsibility of Party
8.1. In case of non-payment of insurance premiums in the manner prescribed by paragraph 2.7 of this Agreement, the insurer has the right to refuse to pay insurance compensation on insurance cases that happened during the delay period (do not organize medical service And not pay for the circulation of insured to medical institutions during the period of delay).
8.2. If it is impossible to provide medical services in a medical institution specified in insurance PolicyThe insurer organizes the provision of the above services in another medical institution of the appropriate level and profile at its discretion.
8.3. In the case of the guilty (intentional) causing a medical institution of damage to the insured, the Insurer assists the insured in negotiating with a medical facility about compensation for damage.
8.4. The presence of cases referred to in paragraph 8.3, as well as the amount of damage to the health of the insured must be confirmed by the competent commission formed as part of the representatives of the insurer, the insured, the medical institution, which makes a complaint with the participation of the insured.

9. The procedure for resolving disputes
Disputes arising under the insurance contract are resolved through negotiations. If it is impossible to achieve agreement, the dispute is transferred to the court in the manner prescribed by the current legislation of the Russian Federation.

10. Other conditions
10.1. This Agreement is drawn up in two copies of the same legal force - one for each of the parties.
10.2. All changes and additions to this Agreement are drawn up in writing, signed and fastened by the seals of the parties.
10.3. Appendices N No. 1, 2 are an integral part of this medical insurance contract.

11. Addresses and details of the parties
Insurer ______________________
Insured ____________________


Voluntary medical insurance in Russia has no sustainable legislative soil. This in turn means that the DMS Agreement is paper "on trust", provided not so much legal responsibility as the reputation of the insurance company and the attentive attitude of the client. What should be in insurance contract And how should he look like the insured person to defend his interests and get the required services when an insured event occurs?

The basis of the relationship between the insurer and the insured person in voluntary medical insurance is a DMSA agreement. It determines the basic rights and obligations of the parties, the list and the procedure for providing services, helps to resolve controversial situations.

What is the contract of DMS?

The voluntary health insurance contract is a document that provides the client with the opportunity to receive medical care in the amount specified in the contract, and the insurer is charged for this one-time (or regular) fee (insurance premium).

If we talk simple language, the policyholder buys the PMC policy for a certain agreement, and insurance Company Pays medical services to the insured person in accordance with the insurance program and upon the occurrence of insured events. Most Russians are accustomed to using medical institutions on OMS, therefore consider DMS unjustified luxury, but it is not. In fact, the policies are similar to each other only typical titleAnd here are very different:

From the comparative table it becomes clear that the PMC policy complements the mandatory medstrash, opening the door to the medical world without queues, problems and surcharges.

Sometimes OMS and DMS programs can work in parallel and in combination with each other. For example, the insured falls into the clinic at the place of residence on the OMS, receiving treatment in the hospital at the expense of the state. If the insurer has a contract with the same clinic, then in the PMD policy, the patient can set up in a paid chamber (high comfort), while the treatment will also be compensated for by the CHI policy.

When concluding a contract, the client independently with insurance agent, "Can collect" a suitable policy or choose the standard, provided SC. In any case, in treaty of DMS. Be sure to be spelled out the following items:

  • Full name, passport and contact details of the insured;
  • Information about the insurer: name, contacts, details;
  • Full name and position of the responsible representative of the insurance organization signed by the Agreement;
  • Selected insurance program;
  • Medical centers for help and consultation;
  • List of insured persons and their personal data;
  • Insurance conditions;
  • Contract time;
  • Insurance premiums and payment procedure;
  • Insurance amount (polis cover);
  • Rights and obligations of the parties;
  • Terms of termination of the contract;
  • Fors major and other information.

In the annex to the DMS Agreement, a list of insurance cases and exclusion from them must be registered. Otherwise, the insurer may refuse to pay, recognizing any problem without an insured event.

The term of the contract is negotiated by the parties separately, most often it is 1 year. If the insurance period is less than 12 months, the amount of insurance premium is set as a percentage of the annual value. The contract without specifying the term is invalid. The policy begins its work immediately after signing the contract by the parties, however, sometimes the contract shall enter into force from the date defined in the document. Most often, these conditions are prescribed in the DMS, which provides insurance abroad.

Rights and obligations of Parties in DMS Insurance

DMS should be distinguished for organizations and for individuals. In the first case, the Insured has the right to receive medical care (or verify its provision to the Insured person) according to insurance conditions, as well as to change the insured people and their number in agreement with the SC. The physically has the right only for medical services in accordance with the terms of the contract - to freely change the person in the policy will not work. Also, the insurer may, according to its own solution, terminate the agreement or make changes to it (as agreed with SC). At the same time, he is reimbursed by a part of payments for a non-delicent period. Everything else, the insured may apply for advice or help to the insurer, get a duplicate policy with his loss. The obligations of the insured and insured persons are described in the standard contract fairly accurately. Here are the main of them:

  • In time to carry out insurance payments;
  • Inform the insured people about the terms of the contract and the insurance program, the procedure for obtaining assistance. Also, in the case of corporate DMS, the employer is obliged to transfer the Policy of the DMS to employees;
  • Inform the insurer on any changes regarding the insured;
  • Perform the appointments of doctors;
  • Keep documents not to transmit them to third parties;
  • Return the insurance company policy when early termination contract.

The insurer, in turn, has the right to terminate the treaty in violation of the terms of the payment of insurance payments or, in the situation provided for by the contract, refuse to pay and / or provide services. And the SC can check the accuracy of the data transferred by the insured, any in a convenient way. The obligations of the insurer are also clearly spelled out in the DMS contract:

  • Pass the PMD policy;
  • Ensure the provision of medical care in accordance with the insurance program;
  • Timely pay for services rendered;
  • Do not disclose confidential data;
  • Protect the interests of insured persons.

The procedure for concluding a contract of DMS

Get the policy of DMS is quite simple, especially if the insured has a financial opportunity and understanding what he is waiting for a voluntary medstrash. To do this, it is enough to contact the selected insurance company, presenting a passport, and fill model statement. At the request of the insurer, to determine the value of contributions and the degree of risk, it may be necessary to filling out a medical questionnaire with a reliable information and the provision of supporting documents.

Next, appropriate is selected insurance programThe list of medical institutions is drawn up, the contract is negotiated. Based on the tariffs of the insurance company and the LPU, the health status of a potential insured person, the selected insurance program is calculated by the amount of insurance premium; The designated sample agreement is issued and signed by both parties.

After that, the Insurer issues the Insured History polis DMS., giving the right to receive services under a voluntary health insurance contract, and insurance comes into effect.

What moments need to be considered when signing the contract?

Voluntary medical insurance is a kind of "designer", from the quality of the assembly of which the timeliness and completeness of the services provided by the insured person depends. Here are the basic rules that will help avoid problems when buying a DMS policy:

  • License to work in the field of insurance should be confirmed by the SC until signing the contract. This will help avoid problems when receiving services on the PMS policy;
  • It is impossible to provide the insurer with false information about health or incorrect data insured, this will cancel the contract and services will not be rendered on legal basis;
  • It is necessary to prescribe in the documents that the solution of all disputed cases between the insured (insured person) and the LPU should take on the insurer;
  • It is worth a clearly indicate the actions of the insured and the insurer in case of delay in the payment of insurance premiums. Some SCs stop servicing the PMC policies after 1 day of non-payment, which is not very convenient if the proceedings, for example, happened due to the wine bank;

To date, in our country, voluntary medical insurance is the only opportunity to receive medical care at the proper quality level. Numerous problems of district polyclinic, queues, rudeness, lack of motivation from workers, outdated clinical and laboratory bases lead to the need to use the insurance policy of the DMS.

This service has been introduced from October 1, 1992 and includes additional medical and other services in excess of installed compulsory health insurance programs.

It is possible to become the owner of the PMC policy, concluding the appropriate agreement with the insurance company.

The voluntary health insurance contract may include one or more medical services:

  • Ambulatory and polyclinic service. Primary and repeated examinations of doctors in the clinic. Therapeutic and diagnostic manipulations aimed at the relief and diagnosis of acute or exacerbation of chronic disease. Tool and laboratory research methods. Procedural Cabinet services. Recoveful manipulations. Registration and issuance of medical records.
  • Help at home. Departure of the doctor at home, if the patient for health can not visit the clinic
  • Emergency medical care. Implementation of the necessary emergency medical and diagnostic measures, in accordance with the existing pathology.
  • Hospital. Accommodation and treatment in the department of intensive therapy, carrying out resuscitation, operational activities for individual medical testimony.
  • Dentistry. Therapeutic and surgical dentistry.

The insurer can only be a legal entity exercising medical insurance on the basis of a special state permit (license) on the right to do medical insurance.

The voluntary health insurance contract is an agreement between the insured and the insurance medical organization, in accordance with which the latter undertakes to organize and finance the provision of the insured contingent of medical care for a certain amount and quality or other services for voluntary health insurance programs.

The voluntary health insurance contract must contain:

  • name of the parties;
  • terms of action of the contract;
  • the number of insured;
  • size, deadlines and procedure for making insurance premiums;
  • a list of medical services that meet voluntary health insurance programs;
  • rights, duties, responsibility of the parties and other non-contrary to the legislation of the Russian Federation conditions.

The DMS Treaty begins with the provision of an insurance statement by the insured. The application may be drawn up on the insured itself, on the members of his family or with collective insurance - on employees.

In the statement, the policyholder provides the following information:

  • age
  • marital status
  • profession
  • place of residence
  • health condition at the time of filling out the application
  • the presence of chronic diseases, injury, physical indicators, a list of transmitted diseases.

In the case of concluding agreements with high guarantees, the application may ask to indicate the presence of hereditary diseases, the life expectancy of parents, the data of the main laboratory analyzes, predisposition to certain diseases, as well as demand to pass an additional medical examination or provide extracts from the history of the disease.

When concluding collective insurance contracts, it does not require data on the state of the health of potential insured.

The DMSA is considered concluded from the date of payment of the first insurance premium, if the terms of the contract is not established otherwise.

During the period of the DMS agreement, when recognizing by the Court of the Insured, an incapable or limited in the capacity of his rights and obligations to go to the guardian or a trustee acting in the interests of the insured.

Every citizen, with respect to which a voluntary health insurance contract was concluded or who concluded such a contract independently, receives an insurance medical policy. The insurance medical policy is in the hands of the insured.

If the insurance contract is concluded individualThe insurance policy indicates:

  • surname, first name, patronymic of the insured (insured);
  • home address and telephone policy (insured);
  • insurance conditions;
  • the list of medical institutions in which the insured has the right to seek medical care or services;
  • the order and form of payment.

If the insurance contract lies with a legal entity, then in the insurance policy indicates:

  • name, legal address and details of the bank account of the insured;
  • insurance conditions;
  • medical insurance program;
  • a list of medical facilities in which the provision of services is guaranteed;
  • the term of the insurance contract;
  • the number of insured;
  • the amount of the insurance premium payable under the insurance contract;
  • the order and form of payment.

The DMS object is an insurance risk associated with the cost of providing medical care in the event of an insured event.

Insurance case is the appeal of the insured to the medical institution from among the insured disease provided for in the acute disease agreement, the exacerbation of chronic disease, injury, poisoning and other accidents for receiving advisory, preventive and other assistance requiring medical services within their list provided for by the insurance contract.

Insurance case recognizes the appeal of the insured to the medical institution during the term of the insurance contract.

The sum insured is the limiting level of insurance coverage under the medical insurance contract, determined on the basis of the list and the cost of medical services provided for by the Health Insurance Treaty.

The insurance premiums paid by the Insured under the insurance contract are established depending on the insurance conditions chosen by the insured list of medical services and the level of insurance coverage under the insurance contract, the term of insurance and other conditions provided for by the insurance contract.

Under the voluntary health insurance contract, the insured must:

  • in a timely manner and in full, to pay insurance premiums due to the insurance contract;
  • provide the insurer the information necessary for the conclusion of an insurance contract, as well as other necessary informationassociated with the action of the insurance contract;
  • ensure the preservation of documents under the insurance contract.

At the same time, the insured must:

  • comply with the prescriptions of the attending physician, obtained during the provision of medical care, to comply with the procedure established by a medical institution;
  • take care of the safety of insurance documents and not to transmit them to other persons in order to receive medical services.

The insurer under the insurance contract must:

  • introduce the insured with insurance rules;
  • give the insurance policy (contract) of the established form;
  • at the occurrence insurance event produce insurance payment in the manner prescribed in the insurance contract;
  • privacy in relations with the insured (insured).

The insurance contract is terminated in cases:

  • the expiration of the period on which the contract was concluded;
  • fulfillment by the insurer of obligations to the insured under the insurance contract in full;
  • elimination of the Insured - legal entity in established by law order (the death of the insured - an individual);
  • the liquidation of the insurer in the manner prescribed by the current legislation of the Russian Federation;
  • in other cases provided for by the current legislation of the Russian Federation.

In accordance with legislative Base Of the Russian Federation, medical insurance has two forms: mandatory and voluntary. Mandatory medical insurance (OMS) is based on monthly payments of a single social tax and applies to all citizens of Russia. Voluntary medical insurance (DMS) provides additional acquisition of medical services in excess of the OMS program.

The relations of medical insurance participants are governed by the medical insurance contract, which lies between the insurance subjects. In accordance with the terms of the medical insurance contract, the parties are committed to the laws by the legislation of the Russian Federation.

Medical insurance contract is an agreement between the insurer (insurance medical organization) and the insured. In accordance with the terms of the contract, the medical organization assumes the obligation to organize and finance the provisions of the insured persons under the Voluntary and Mandatory Medical Insurance Program.

Mandatory Medical Insurance

Insured persons (Citizens of the Russian Federation) guaranteed the right to receive free medical services for OMS (compulsory medical insurance), which is implemented on the contracts concluded in their favor between the participants in compulsory medical insurance.

Mandatory Medical Insurance Treaty

Contracts between medical organizations included in the register of medical organizations and participating in the implementation of the territorial programs of the OMS, and insurance medical organizations, which are also involved in the implementation of territorial OMS programs.

Medical organizations, guided by the Health Insurance Treaty, guarantee provision within the framework of the territorial OMS programs to provide medical assistance to insured persons. Insurance medical organizations undertake to pay such medical services provided within the framework of territorial programs.

The provisions of the OMS contract

The contract necessarily health insurance contains provisions that provide for the obligations of insurance medical organizations:

  • receive all the necessary information from medical organizations rendered and planned medical care to insured persons;
  • conduct control in terms of volumes, deadlines, quality and conditions for the provision of medical services in medical organizations;
  • organize medical care for insured persons in other medical organizations.

Mandatory provisions for medical organizations:

  • provide information for insurance medical organizations about the insured person and the volumes, timing and quality of medical care provided to him;
  • submit a register of accounts for medical services rendered;
  • represent reporting on the use of funds for compulsory health insurance for the Federal Fund;
  • perform other duties provided for by federal legislation.

Important!

The insured person has the right to independently choose a medical organization to conclude with it a compulsory health insurance contract with an insurance medical organization.

Financial Side of Health Insurance

Payment of medical care is carried out in accordance with the tariffs for the payment of medical care and the procedure for payment of medical services provided by the OMS established by the rules of the OMS.

Neo-payment or late payment of medical care is paid to a fully insurance medical organization on the requirements (taking into account the penalties for each overdue day) at the expense of its own funds.

For late rendering (provision of improper quality) or non-appearance of medical care under the medical insurance contract, a medical organization pays a penalty in the amount specified in the insurance contract. For medical organizations (in accordance with federal legislation), penalties for non-purpose use Received funds.

The compulsory medical insurance contract is considered terminated in the following cases:

  • termination (suspension) of the license or liquidation of the insurance medical organization;
  • loss by the medical organization of its right to the implementation of medical activities.

Form of a typical contract

The form of a compulsory medical insurance contract is approved by special authorized federal authorities.

Voluntary health insurance contract

With voluntary health insurance, the insurance facility is the risk that is carrying out the costs of providing medical care in the occurrence of the insurance case.

The health insurance contract must contain the following conditions:

  • medical insurance subjects;
  • list of medical services included in medical care program;
  • the total number of insured persons;
  • insurance amount;
  • insurance premium (order, size and deadlines for insurance premiums);
  • the rights and obligations of participants in insurance legal relations;
  • contract time.

The medical insurance contract comes into force from the date of payment of the first insurance premium. The term of the contract is established in coordination of the parties, but can not be for a period of less than one year. The rights and obligations of the policyholder can go to the trustee or guardian acting in the interests of the insured person if the insured during the term of the insurance period is recognized as limited in legal capacity or incapable.

DMSA is one of the most common types of insurance contract. To conclude a contract, you need to contact a specialized company that has a license for the right to engage in medical insurance (Art. 938 of the Civil Code of the Russian Federation).

The DMSA must necessarily be concluded in writing (clause 1, 2, Article 940 of the Civil Code of the Russian Federation). The standard form of the contract is usually its own insurer (paragraph 3 of Art. 940 of the Civil Code of the Russian Federation).

It remains only to carefully study how far the conditions offered for you are insurer.

The terms of the contract are determined by the rules of the DMS established in insurance companies. The main conditions in any DMS contract are as follows.

1. Term of the contract

Without an indication of the term, the contract will be invalid.

In most cases, the DMS contract is considered concluded from the moment of signing the text of the contract. However, it can provide another. This means that two options are possible:

  • the contract may provide for the condition according to which it is considered concluded from the moment of its signing. In practice, this option is the most common;
  • the contract may come into force from the date of payment of the first insurance premium (clause 1 of Art. 957 of the Civil Code of the Russian Federation).

Note!

In practice, the term of the contract of DMS and the term of insurance, that is, the period during which you have the right to seek medical care that the Insurer is obliged to pay, often do not coincide. This means that, first of all, the parties to the DMSA agreement may foresee what is paid, including medical assistance, which was provided until the conclusion of this transaction. Secondly, the contract may also provide an inverse situation, namely the payment of only those medical services that will be provided with a later point than the moment of concluding the contract. For example, in the DMSU, which was concluded on December 20, it is indicated that medical care is paid from January 1 next year.

2. Number and names of insured persons

Most often, this information is made in the form of annex to the contract. Medical insurance can be individual and collective. The DMS Treaty begins with the submission of an insurance statement by the insured. The application may be drawn up:

  • on the insured itself, on his family members (individual insurance);
  • on employees of the organization (collective insurance).

When concluding a DMS contract by an employer with respect to employees, the employer is an insured, and employees are insured persons.

3. Types of Insurance Cases

The DMS contract should indicate the types of insurance cases and the exceptions of them, which does not apply to insurance.

Insurance case on DMS, as a rule, is the appeal of the insured person for the provision of medical services provided for by the DMS program, a medical institution, which is included in the list of medical facilities included in this dMS program.

In particular, the contract may provide for outpatient polyclinic assistance, dental care, home assistance, emergency and emergency care, emergency and planned inpatient care. A detailed list of such services can be given in the annex to the Agreement.

An exception to the insurance claims may be, for example, an appeal to medical care in obtaining injury in a state of alcoholic or drug intoxication.

Start the selection of the PMC policy from determining the composition of the services that should be included in the insurance contract. Choose the DMS program depending on the health, place of residence and the possibility of accessing the medical institutions of the appropriate level, as well as the age of the insured person.

4. Size, deadlines and procedure for making an insurance premium

The size of the insurance premium (i.e. fees for insurance) is determined in accordance with the established insurance facilities.

Terms and procedure for making an insurance premium are established by the insurance contract. Thus, the insurance contract may be provided for the introduction of an insurance premium in installments. It should be borne in mind that the contract is also envisaged for non-payment set time insurance premiums (Art. 954 of the Civil Code of the Russian Federation).

In addition, from 02.03.2016, within 90 days, insurance companies appear a duty to provide for the condition for returning the insured of the paid insurance premium on newly concluded contracts voluntary insurance. So, the condition for the return of the paid insurance premium is assumed as mandatory in the event of a refusal of the contract within five working days from the date of its conclusion (or more long time - By decision of the insurance company), provided that this period did not occur at an insured case (paragraph 1 -, instructions of the Bank of Russia of 20.11.2015 N 3854-y).

If the policyholder refused the contract within the specified period, but before the start date of the insurance, the paid insurance premium shall be returned in full.

If the policyholder refused the contract within the specified period, but after the start of the insurance, the insurance company has the right to keep part of the insurance premium in proportion to the term of the contract (paragraph 5 - instructions).

The return of the insurance premium must be made in a period not exceeding ten working days from the date of receipt of the written statement of the Insured on the refusal of the contract (paragraph 8 of the instructions).

5. Size of the Insurance amount (insurance compensation)

The right to receive an insurance amount belongs to a person in whose favor a contract is concluded (paragraph 1 of Art. 934 of the Civil Code of the Russian Federation). When an insured event comes, the insured should receive medical care, and the medical institution - the payment for services established in the Tariff contract.

In practice, often during the action of the DMSA agreement, the intended volume of services for the insured person may vary, so it is desirable to provide the insured right to change the amount of the insurance amount by signing an additional agreement with the insurer.

For example, a situation may arise when the amount of medical services provided by a medical institution exceeds the amount specified in the contract, and in connection with this, the insurer may require additional insurance premiums from the insured.

6. Rights, duties and responsibilities of the parties

The main responsibilities of the insurer under the contract of DMS:

  • issue an insurance policy to the insured persons;
  • organize the provision of medical services to insured persons in accordance with the insurance program, concluding contracts with medical institutions;
  • make payment of medical services to the agreed terms;
  • do not disclose information about the insured persons, if this does not contradict the law.

The insurer under the DMSA agreement is entitled:

  • check the accuracy of the data specified by the insured at the conclusion of the contract;
  • check the composition and validity of medical services provided by a medical institution;
  • refuse to pay for medical services in the cases provided for by the Treaty.

The insurer must:

  • to pay the insurance premium in a timely manner;
  • report when concluding an agreement on all circumstances known to him affecting the assessment of insurance risk;
  • in the case of unwise of medical services on the DMS, it is informed of the insurer.

The policyholder is entitled to demand from the insurer to provide medical services to insured persons in medical institutions provided for by the DMS Treaty.

Knowing the main conditions that should be in any DMS contract, you can always independently examine the draft treaty you have been offered and, if necessary, to make changes or additions to it.

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