Why Bulgarian medical insurance company can refuse your claim

People often buy medical insurance policies of Bulgarian insurance companies, but they are not aware of the reasons for which they will certainly obtain claim denial. Our task is to clarify the details. We shall explain this in the averaged form taking as a basis the conditions of medical insurance for foreigners in Bulgaria from different companies and the resolution on compulsory medical insurance for foreigners in Bulgaria.

In few words it means you shall not be paid for medical expenses, for example, if you break a limb being drunk (alcohol or drugs), or in case of injuries in a fight (if it is not self-defense). You are out of luck in case of injuries in the process of violation of criminal law. You shall pay on your own if you got sick before the insurance contract came into force. The dialysis, treatment of venereal diseases, conditions caused by chronic diseases and more, indicated in detail below, will not also be paid.

The policy holder shall not be liable and pay insurance compensation in the following cases:

1. The treatment began before the insurance contract came into force according to which the insured acquired the status of an insured person, or treatment continues after the expiration of the insurance contract;
2. The treatment, the necessity of which arose as a result of previous diseases and accidents existing before the entry into force of the insurance contract. In the event of a sudden crisis, as a result of previous diseases and accidents, only emergency medical care to save the insured from a life-threatening condition;
3. The treatment and hospitalization for existing chronic diseases of the insured. In the event of a sudden crisis due to a chronic disease, only the provision of emergency medical care to save the insured from a life-threatening condition.
4. For examinations and checkups without medical necessity. Expenses for examinations and checkups in cases where the insured person is apparently healthy according to a medical certificate;
5. Expenses for follow-up examinations, treatment and medical services that are not acute or emergency medical care;
6. Transplantation of organs, tissues and cells;
7. Various planned operations, inclusively, neurosurgical, cardiological and ophthalmologic operations;
8. Research and/or treatment of infertility, fertility, in vitro fertilization, treatment of venereal diseases and the reproductive system;
9. The treatment of chronic kidney disease, hemodialysis and blood transfusion;
10. The treatment, research and tests that are directly or indirectly related to the human immunodeficiency virus (HIV) or related diseases, including acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC), as well as any such infections, diseases, injuries or medical conditions resulting from these conditions, no matter how they are received;
11. Congenital anomalies;
12. The treatment and hospital stay of oncological patients and persons with mental disorders;
13. The treatment of alcoholism, drug addiction and any other addictions;
14. Any expenses for medical screening or research, diagnostic tests that are part of a routine physical examination or health check, including mandatory and voluntary immunizations, expenses for glasses, lenses, hearing aids, prostheses, medical supplies and equipment and other similar medical products and services;
15. Plastic cosmetic surgery and other cosmetic medical services;
16. The use of non-conventional methods for the beneficial effects on individual health;
17. Pregnancy, childbirth, abortion, contraception or sterilization measures, and any related complications. The insurer shall cover medical expenses incurred only in case of premature birth or spontaneous abortion, if they are not the result of an accident;
18. Surgeries and procedures carried out on the personal request of the insured person, treatment and / or surgeries that are not mandatory for medical reasons;
19. Reimbursement of expenses for treatment carried out by persons without permission to use the relevant medical activity in the required specialty;
20. Medical services, medicinal products not prescribed by a competent physician or for the purpose of rendering medical assistance to the insured person, as well as medicines purchased 3 days after release;
21. Experimental medical treatment, as well as medical services rendered regarding participation in medical and scientific research, or clinical trials of medicinal products;
22. The expenses in excess of the reasonable and ordinary expenses for appropriate treatment in Bulgaria. In this case, the Insurer has the right to partially refuse to reimburse expenses up to the generally accepted reasonable amount;
23. The expenses for the purchase of personal care products while in the hospital, as well as any expenses incurred for the purpose of ensuring personal comfort, such as a single bed ward, nurse supervision, food of choice, etc.;
24. The expenses for the choice of doctors in hospital treatment;
25. The expenses for rehabilitation, physiotherapy, kinesiotherapy, as well as any expenses caused by additional health care treatment or hospital stay for rehabilitation treatment, on mineral waters, in sanatoriums, health centers and other similar institutions;
26. The expenses for treatment carried out by persons without permission to practice medicine, as well as treatment carried out in institutions that are not registered under the Law on Medical Institutions;
27. The expenses for prescribed medicines and consumables such as: vitamins, homeopathic medicines, nutritional supplements; medicinal herbs, laxatives and medicines for weight loss, contraceptives, unregistered medicines in the Republic of Bulgaria, medical cosmetics, as well as all non-medical expenses;
28. The expenses for highly specialized studies: computed tomography, magnetic resonance diagnostics and positron emission tomography, if they are carried out without confirmation from the insurance company, unless the urgency of treatment does not allow to contact the insurance company;
29. The expenses for repatriation;
30. The expenses for medical transport crossing the border of the Republic of Bulgaria;
31. The expenses for dental treatment and the placement of dental implants, dentures, placement and replacement of fillings, repair of dental crowns and bridges;

The insured shall not be liable if the insured event occurs:

1. as a result of war, assault, hostilities, military operations, terrorist actions, civil war, sabotage, terrorism and vandalism, insurrections, revolutions, uprisings, military or other coup, and as a result of the active participation of insured persons in disorderly or committing a criminal offense;
2. as a result of damage to health with a conscious risk (other than an attempt to save a person’s life), intentionally harming himself, in the event of suicide or attempted suicide (regardless of responsible or mentally disturbed state), also when fighting or in case of physical violence without court (except in cases of proven self-defense);
3. due to non-compliance with medical recommendations;
4. as a result of treatment of any dependencies, as well as diseases and accidents (consequences of accidents) occurred or progressed as a result of the abuse of alcohol, drugs, intoxicants, stimulants, anabolic hormones or other substances that are doping or treatment that is ineffective and the patient’s condition worsens due to abuse, as well as measures and treatment for its cessation;
5. when participating in activities carrying a high degree of risk and danger: for example (but not limited to), in such sports as: auto racing, motor sports, air sports, underwater sports, hunting, acrobatics, cave exploration, mountaineering, work with pyrotechnic means, fireworks, ammunition and explosives, ski jumping, bobsleigh, free skiing, bungee jumping, etc.
6. with the participation of the insured person as a professional or amateur in sports competitions and in preparation for such competitions, if the insurance policy is acquired without such additional coverage.
7. as a result of natural disasters (for example, volcanic eruptions, earthquakes, etc.);
8. as a result of ionizing radiation or radioactive contamination with another type of radioactive waste from nuclear fuel, that is, exposure to the radioactive, toxic, explosive or other hazardous qualities of nuclear facilities and their components.
9. as a result of the execution of the death sentence against the insured person;
10. as a result of damage to health during the detention by the authorities of the insured person;
11. as a result of damage to health when the insured person is in prison;
12. as a result of other events occurring as a result of ignoring the danger, deliberate action or gross negligence on the part of the insured person;
13. as a result of damage to health against the permanent or chronic use of alcohol, drugs, painkillers or drug dependence;
14. as a result of medical care by family members;

Other reasons for refusal to pay besides mentioned:

1. failure to meet the time limit for the notification of the occurrence directly to the insurance company or assisting company.
2. the provision of incorrect, not accurate or incorrectly specified data of the insured person in the insurance contract, as well as in documents justifying the expenses;
3. if the insurance contract with the Bulgarian insurance company is concluded for a period of more than 90 days, while the insured person has no right to stay for more than 90 days in Bulgaria;
4. the insurance contract is concluded in the name and without notification of the insured person;
5. the treatment of the insured person was made after the expiration of the insurance contract, even if the treatment began within the validity period of the insurance contract;