Brief overview
Medical insurance is designed to cover specified medical expenses that arise during the period of cover. It does not cover every health issue or every expense. This article explains the most common grounds on which a Bulgarian insurer may refuse or limit a claim under compulsory medical insurance for foreigners in Bulgaria.
In simple terms, cover can be refused, for example, where an injury occurs while the insured person is under the influence of alcohol or drugs, during a fight other than proven self-defence, or while committing a criminal offence. Expenses may also be excluded where treatment began before the policy came into force, continued after it expired, or relates to an exclusion listed in the policy terms.
This is an explanatory summary, not a legally binding insurance document. The final decision always depends on the policy, its applicable terms and the facts of the particular claim. The exclusions below are compiled from the conditions of Bulgarian insurers and from the rules on compulsory medical insurance for foreigners in Bulgaria. The wording and scope of individual policies may differ.
Medical expenses that may be excluded
Under the policy terms, the insurer may refuse to pay insurance compensation for the following types of treatment or expense:
- Treatment that began before the insurance contract came into force, or that continues after the contract has expired.
- Treatment needed because of illnesses or accidents that existed before the policy took effect. In the event of a sudden crisis caused by a previous illness or accident, cover may be limited to emergency medical care needed to save the insured person from a life-threatening condition.
- Treatment and hospitalisation for pre-existing chronic diseases. In the event of a sudden crisis caused by a chronic disease, cover may be limited to emergency medical care needed to save the insured person from a life-threatening condition.
- Examinations and check-ups without medical necessity, including examinations where the insured person is apparently healthy according to a medical certificate.
- Follow-up examinations, treatment and medical services that are not acute or emergency medical care.
- Organ, tissue or cell transplantation.
- Planned operations, including neurosurgical, cardiological and ophthalmological operations.
- Investigation or treatment of infertility, fertility treatment, in-vitro fertilisation, treatment of venereal diseases and treatment of the reproductive system.
- Treatment of chronic kidney disease, haemodialysis and blood transfusion.
- Treatment, investigations and tests directly or indirectly related to HIV, AIDS, AIDS-related complex (ARC), or related infections, diseases, injuries or medical conditions, regardless of how they were acquired.
- Congenital anomalies.
- Treatment and hospital stays for oncology patients and persons with mental disorders.
- Treatment of alcoholism, drug addiction and other addictions.
- Medical screening, routine physical examinations, health checks, mandatory or voluntary immunisations, and expenses for glasses, lenses, hearing aids, prostheses, medical supplies, equipment and similar products or services.
- Plastic, cosmetic and other cosmetic medical procedures.
- Non-conventional methods intended to improve individual health.
- Pregnancy, childbirth, abortion, contraception, sterilisation and related complications. Medical expenses may be covered only in cases of premature birth or spontaneous abortion where these are not the result of an accident.
- Procedures and operations performed at the insured person’s request, or treatment and operations that are not medically necessary.
- Treatment provided by persons who are not authorised to carry out the relevant medical activity in the required specialty.
- Medical services and medicines that have not been prescribed by a competent physician for the purpose of assisting the insured person, as well as medicines purchased more than three days after discharge.
- Experimental medical treatment, medical services connected with medical or scientific research, and clinical trials of medicinal products.
- Expenses above the reasonable and customary cost of appropriate treatment in Bulgaria. The insurer may partially refuse reimbursement above the generally accepted reasonable amount.
- Personal-care products used during a hospital stay, as well as expenses intended to provide personal comfort, such as a single room, private nursing, food of choice and similar items.
- Expenses for choosing a particular doctor during hospital treatment.
- Rehabilitation, physiotherapy, kinesitherapy, additional healthcare and hospital stays for rehabilitation treatment, mineral-water treatment, sanatoriums, health centres and similar institutions.
- Treatment provided by persons without authorisation to practise medicine, or in institutions not registered under the Medical Institutions Act.
- Vitamins, homeopathic medicines, nutritional supplements, medicinal herbs, laxatives, weight-loss medicines, contraceptives, medicines not registered in the Republic of Bulgaria, medical cosmetics and all non-medical expenses.
- Highly specialised examinations, including CT, MRI and PET scans, carried out without confirmation from the insurance company, unless the urgency of treatment makes it impossible to contact the insurer.
- Repatriation expenses.
- Medical transport crossing the border of the Republic of Bulgaria.
- Dental treatment, dental implants, dentures, placement or replacement of fillings, and repair of dental crowns and bridges.
Events and circumstances that may be excluded
Cover may also be refused where an insured event occurs in the following circumstances:
- War, armed conflict, hostilities, military operations, terrorist acts, civil war, sabotage, terrorism, vandalism, riots, revolutions, uprisings, military or other coups, or the insured person’s active participation in disorder or the commission of a criminal offence.
- Deliberate exposure to danger, except when attempting to save a person’s life; intentional self-harm; suicide or attempted suicide; fighting or physical violence, except in cases of proven self-defence.
- Failure to follow medical recommendations.
- Treatment of addictions, or illnesses and accidents caused or worsened by the abuse of alcohol, drugs, intoxicants, stimulants, anabolic hormones, doping substances or other substances. This also includes treatment that is ineffective because the patient’s condition worsens through such abuse, and measures or treatment intended to stop it.
- Participation in high-risk or dangerous activities, including but not limited to motor racing, air sports, underwater sports, hunting, acrobatics, cave exploration, mountaineering, work with pyrotechnics, fireworks, ammunition or explosives, ski jumping, bobsleigh, free skiing and bungee jumping.
- Participation as a professional or amateur in sports competitions, or preparation for them, where the policy was issued without the required additional cover.
- Natural disasters, such as volcanic eruptions or earthquakes.
- Ionising radiation, radioactive contamination or exposure to the radioactive, toxic, explosive or other hazardous properties of nuclear facilities, nuclear fuel or radioactive waste.
- Execution of a death sentence against the insured person.
- Injury while the insured person is detained by the authorities or is in prison.
- Events resulting from disregard of danger, deliberate action or gross negligence by the insured person.
- Injury caused by the permanent or chronic use of alcohol, drugs, painkillers or drug dependence.
- Medical care provided by family members.
Other reasons why a claim may be refused
- Failure to notify the insurer or assistance company within the time limit set out in the policy.
- Incorrect, inaccurate or falsely stated personal information in the insurance contract or in documents supporting the expenses.
- A policy issued for a period longer than 90 days where the insured person has no right to remain in Bulgaria for more than 90 days.
- A policy concluded in the insured person’s name without notifying that person.
- Treatment received after the insurance contract has expired, even if treatment began during the period of cover.
What to do if you need medical assistance
Before arranging non-urgent treatment, contact the assistance company using the telephone number shown on your policy. Keep the policy, medical records, invoices, receipts and all documents connected with the claim. For urgent treatment, seek medical help first and contact the assistance company as soon as possible afterwards.
For the full wording of available policies, see our Insurance Documents page. The policy terms and the facts of the individual case remain decisive.
