DIASPORA SPECIAL ASSISTANCE

PRODUCT BENEFITS & LIMITATIONS

A. WHILE THE BENEFICIARY IS VISITING ETHIOPIA* FOR SHORT TIME

Medical expenses in case of illness or accident for a

B. IN CASE OF DEATH OF THE BENEFICIARY IN THE COUNTRY OF RESIDENCE

(*) Maximum 90 consecutive days per trip to ETHIOPIA.

POLICY TERMS & CONDITIONS

1. DEFINITIONS

“Insurer” or “The Company” means:

NYALA INSURANCE S.C. With their Head Office at; Protection House, Mickey Leland Street, P.O. Box 12753, Addis Ababa, Ethiopia., registered and authorized in the country in which this insurance policy is issued and subscribed.

“The Assistance Company” means:

The company provided by the Insurer for the purpose of supplying the covers of this policy, directly or by means of its network, on the Insurer’s behalf.

“Policyholder” means:

All physical persons with their residence established in Ethiopia, taking the policy on behalf of the beneficiary resident outside Ethiopia. The Policyholder can also be a foreigner with their residence established in Ethiopia, taking the policy for his own behalf and/or for other relatives living in the same country. Maximum insured age is 80 years old.

“Beneficiary” or “Insured Person” means:

All physical persons with their residence established inside or outside Ethiopia that have been designated by the Insured while purchasing the policy and fulfil the requirements as per the full definition of “beneficiary” set in the policy wording and that fulfil the following requirements:

1. To be of Ethiopian nationality or having their original family established in Ethiopia;
2. To have their usual place of residence in Zone I or Zone II, excluding Ethiopia;
3. To be designated as beneficiary of a policy taken out with NYALA INSURANCE S.C. whose holder is a relative resident in Ethiopia;
4. To have a current residence permit or, where appropriate, proof of application for the same in the event of being in the process of awaiting its issue.

The beneficiary status also extends to the spouse and to the first degree ascendants and descendants if they each fulfil the foregoing requirements and having their individual premium paid.

Not eligible:

1. Persons over 80 years of age at the moment of the insurance underwriting.
2. Minors may only be insured if there is a written authorization signed by their legal tutors. In any case, the Accidental Death guarantee cannot be taken out for children under 14 years of age or for the disabled.
3. Those who have not given their written consent, except where their interest in the policy may be assumed for some other reason.
4. Insured travelling for work reasons (paid or otherwise), undertaking physical or manual hazardous activities such as: driving commercial vehicles or any other kind of vehicle over 3500Kg, use of machinery, loading and unloading, working at heights or in confined spaces, assembly of machinery, working on floating or underwater platforms, mines or quarries, use of chemical substances, laboratory work of any kind and any other hazardous activities.

“Manual Labour” means: unskilled, semi-skilled, and/or skilled labour involving working with your hands and/or operation of mechanical and/or non-mechanical machinery

“Immediate Family Member” of the Insured, means:

Spouse, children, parents, grandparents and siblings.

“Close Relative” of the Insured, means:

Spouse, parents, children, grandparents, grandchildren, siblings, mother and father in law and brothers and sisters in law.

“Children” means:

Persons from 3 months to 18 years old.

“Spouse” means:

Person officially registered as wife or husband of the Insured.

“Usual Country of Residence” means:

The country where the beneficiary has established its permanent residence that must be in one of the following geographical areas defined as Zone I and Zone II:

ZONE I: Beneficiaries with their residence established in Africa – excluding Ethiopia, Europe and Middle East

ZONE II: Beneficiaries with their residence established in America, Asia and Oceania.

“Illness” means:

Any change in health diagnosed and confirmed by a legally recognised doctor during the life of the policy and which is not comprised or derived from either of the following two groups:

  Congenital disease: the disease that exists at the moment of birth as a consequence of hereditary factors or complaints acquired during pregnancy.

  Pre-existing disease: the disease that the Insured suffered prior to the date of taking out this Policy, even if it wasn’t diagnosed.

“Serious Illness” means:

Any illness that requires admission to hospital and which, in the opinion of the Assistance Company's medical team, prevents the Insured from continuing travel on the date planned, or which involves the risk of death.

“Injury” means:

A medical problem caused by a sudden and severe external cause or reason beyond the control of the Insured, within the validity period of this Policy.

“Serious Injury" means:

An injury which, in the opinion of the Assistance Company's medical team, prevents the Insured from continuing travel on the date planned or involves the risk of death.

“Emergency Dental Care” means:

Any natural dental treatment covered by the policy due to a condition suddenly started up at travel and that it does not occur by reason of any pre-existing situation has been documented by dentist’s report.

“Doctor” or “Physician” means:

An officially registered medical practitioner according to the law of the place where the claim happens.

“Osteosynthesis material” means:

Parts or pieces of metal or of any other kind used to join together the ends of a fractured bone, or to knit together the tips of joints, by surgical operation and which can be reused.

Orthopaedic material or orthesis means:

Anatomical parts or items of any kind used to prevent or correct temporary or permanent deformations of the body (walking sticks, cervical collar, wheelchair, etc.).

“Prosthesis” means:

These are deemed to be any item of any kind that temporary or permanently replaces the lack of an organ, tissue, organic fluid, member or part of any of them. By way of an example, mechanical or biological items such as cardiac valve parts, joint replacements, synthetic skin, intraocular lenses, biological materials (cornea), fluids, gels and synthetic or semisynthetic liquids that replace organic humours or liquids, medicine reservoirs, mobile oxygen therapy systems, etc.

“Limit” means:

The amounts set forth in the Conditions of this Policy, Schedules of Covers and Economic Limits of each different Plan, and which represents the maximum benefit (financial, temporary or another kind) covered under each guarantee.

“Fraudulent Claims” means:

When the Insured, beneficiary or someone acting on their behalf, uses any fraudulent means or devices in order to obtain any of the benefits of this policy, consequently, any payment of any amount in respect of such claim shall be cancelled.

“Deductible” or “Excess” means:

The amount of expenses or the number of days which are not covered by the Insurer, and that are to be paid or supported by the Insured Person before the Policy benefits become payable.

“Mandatory Excess” means:

An excess period of 30 days is mandatory for all beneficiaries, except while renewing automatically their policy after the initial one is expired.

“Premium” means:

The price of the insurance that the Policyholder must pay the Insurer in consideration for the coverage of the risks provided for the Insured by the latter, the receipt for which will include, moreover, the surcharges and taxes legally applicable.

“Period of Insurance” or “Effective Date of Coverage” means:

The period that commences and ends on the dates stated on the Certificate of the Policy contracted. Such period of Insurance is in any case not renewable.

“Territory” means:

Geographic area where the travel object of the contract takes place, and in which the events that occur there have coverage.

“Cover” means:

The Company will immediately provide the Insured, the assistance specified under the “Coverage” clause of this Insurance Policy for mishaps that occur due to unforeseen incidents, provided that this occurrence does not take place outside the specified geographical boundaries and does not take place out of the prescribed validity dates of this Policy. Period of Cover granted under this Policy for journeys taken by the Insured to his/her Country of Origin (ETHIOPIA) shall not exceed 90 consecutive days each travel.

II.  GUARANTEES COVERED

The Insurer, where appropriate, shall be responsible for the rendering of the services shown below.

WHILE THE BENEFICIARY IS VISITING ETHIOPIA FOR SHORT TIME

A. Medical expenses in case of illness or accident for a maximum period of 90 consecutive days:

Medical expenses are covered in Ethiopia for a maximum of 90 consecutive days per trip, except for beneficiaries with their residence established in Ethiopia. For these beneficiaries living in Ethiopia, the medical expenses will be covered while visiting their country of origin (outside Ethiopia) for a maximum of 90 consecutive days. In the event of illness or injury of the insured occurring while the insured is visiting Ethiopia, The Company will meet the usual, customary, necessary and reasonable costs of hospitalization, surgery, medical fees and pharmaceutical products, prescribed by the attending doctor.

The Company's medical team will maintain the telephone contacts necessary with the centre and with the doctors attending to the Insured to supervise the provision of proper health care.

This cover is subject to a limit of 10000 EUROS. 50 EUROS excess is applicable per claim.

IN CASE OF DEATH OF THE BENEFICIARY IN THE COUNTRY OF RESIDENCE

B. Repatriation of mortal remains of the beneficiary to Ethiopia:

In the event of death of the insured party, the Insurer shall organize and take charge of the transport or repatriation of the body from the place where death has occurred to the place of burial in its country of origin.

The repatriation of mortal remains is covered in case of death of the beneficiary within the usual country of residence located either in Zone I or Zone II.

Payment of expenses for interment, cremation or funeral ceremony is excluded from this guarantee.

C. Transport of a relative to accompany the deceased:

In the event of repatriation for death, the Insurer shall reimburse a close relative (spouse, first degree ascendant or descendent, brother or sister) the price of a return ticket – Economy Class - in the most suitable means of transport to accompany the mortal remains from the place where death has occurred to the place of burial.

III. THE COMPANY’S LIABILITY CONDITIONS

1. In the event of any claim the liability of the Company shall be conditional on the insured claiming indemnity or benefit having complied with and continuing to comply with the terms of this Policy.
2. In the event of a claim under this Policy the Insured shall:
   1. Take all reasonable precautions to minimize the loss.
   2. As soon as possible telephone the Company to notify the claim stating the Benefits required.
   3. Freely provide the Company with all relevant information.
   4. Make no admission of liability or offer promise or payment of any kind.
3. The Assistance Company will not reimburse or consider reimbursing any expenses which were not previously approved.

   Previously approved expenses will have to include the claim number obtained from The Assistance Company prior to sending the official receipts and/or letter explaining the reason and circumstances of why the Travel Assistance Services for which expenses are claimed were not obtained from The Assistance Company directly

IV. VALIDITY OF THE CONTRACT

This insurance shall be valid as long as NYALA INSURANCE S.C. maintains the insurance policy which has been contracted for this purpose in force.

Coverage shall take effect as from 0 hours of the day following the day on which the requirements established for the INSURED to acquire BENEFICIARY status are met, in accordance with the provisions of this policy. Likewise, this coverage shall terminate at 0 hours of the first day of the month following that in which the INSURED party is no longer insured, in accordance with the aforementioned definition, or on the date of cancellation of the policy.

Despite this, this coverage shall be valid as long as NYALA INSURANCE S.C. maintains the insurance policy which has been contracted for this purpose in force.

In the event of any or all of the guarantees of the policy being annulled or limited, NYALA INSURANCE S.C. shall communicate said circumstance with sufficient notice.

V. GENERAL EXCLUSIONS

1. Loss, damage, illness and/or injury directly or indirectly caused by, arising out of and/or in consequence of the following are excluded from the guarantee/cover granted under this Policy:
   1. The bad faith of the Insured, by his/her participation in criminal acts, or as a result of his/her fraudulent, seriously negligent or reckless actions including those actions of the Insured in a state of derangement or under psychiatric treatment costs for which are themselves excluded;
   2. Extraordinary natural phenomena such as floods, earthquakes, landslides, volcanic eruptions, atypical cyclonic storms, falling objects from space and aerolites, and in general any extraordinary atmospheric, meteorological, seismic or geological phenomenon any other type of natural disaster;
   3. Events arising from terrorism, mutiny or crowd disturbances, unless specifically expressed in the Benefits schedule of the commercialized product ;
   4. Events or actions of the Armed Forces or Security Forces in peacetime, unless specifically expressed in the Benefits schedule of the commercialized product;
   5. Costs and/or damages caused by baggage that is not sufficiently well packaged or identified, as well as fragile baggage or perishable products
   6. Wars, with or without prior declaration, and any conflicts or international interventions using force or duress or military operations of whatever type, unless specifically expressed in the Benefits schedule of the commercialized product;
   7. Those caused by or resulting from radioactive materials and nuclear energy;
   8. Those caused when the Insured takes part in bets, challenges or brawls, save in the case of legitimate Defense or necessity;
   9. Illness or injuries existing prior to the claim, unless expressly included in the Private or Special Conditions and subject to payment of the relevant surcharge premium;
   10. Those that occur as a result of the participation by the Insured in competitions, sports, and preparatory or training tests;
   11. Engaging in the following sports: motor racing or motorcycle racing in any of its modes, big game hunting outside European territory, underwater diving using artificial lung, navigation in international waters in craft not intended for the public transport of passengers, horse riding, climbing, pot holing, boxing, wrestling in any of its modes, martial arts, parachuting, hot air ballooning, free falling, gliding and, in general, any sport or recreational activity that is known to be dangerous;
   12. Participation in competitions or tournaments organised by sporting federations or similar organisations.
   13. Hazardous winter and/or summer sports such as skiing and/or similar sports unless expressly included in the Private or Special Conditions and subject to payment of the relevant surcharge premium;
   14. Permanent residents of the Country where the sinister causing a claim has occurred unless expressly included in the Private or Special Conditions and subject to payment of the relevant surcharge premium;
   15. Claims under a “Students” policy occurred in a different country than the one where the courses are taking place.
   16. The use, as a passenger or crew, of means of air navigation not authorised for the public transport of travellers, as well as helicopters; and,
   17. The accidents deemed legally to be work or labour accidents, consequence of a risk inherent to the work performed by the Insured.
   18. Internationally and locally recognized epidemics.
   19. Illnesses or injuries arising from chronic ailments or from those that existed prior to the inception date of the policy;
   20. Death as a result of suicide and the injuries or after-effects brought about by suicide and/or attempted suicide or any self-inflicted injuries.
   21. Illness, injuries or pathological states caused by the voluntary consumption of alcohol, drugs, toxic substances, narcotics or medicines acquired without medical prescription, as well as any kind of mental illness or mental imbalance;
   22. Illness or injuries resulting from refusal and/or delay, on the part of the Insured or persons responsible for him/her, in the transfer proposed by the Company and agreed by its medical service;
   23. Illness or injuries caused by pregnancy and childbirth or any complication therefore or voluntary termination of pregnancy;
   24. Mental Health diseases.
   25. Venereal sexually transmitted diseases.
   26. All pre-existing, congenital and/or Chronic Medical Conditions
   27. Any cardiac or cardio vascular or vascular or cerebral vascular illness or conditions or after-effects thereof or complications that, in the opinion of a medical practitioner appointed by the Company, can reasonably be related thereto, if the insured person has received medical advice or treatment (including medication) for hypertension 2 years prior to the commencement of the Protected Journey.
   2. In addition to the foregoing General Exclusions, the following benefits are not covered by this insurance:
   28. The services arranged by the Insured on his/her own behalf, without prior communication or without the consent of The Assistance Company, except in the case of an extreme emergency/urgent necessity. In that event, the Insured shall furnish the Company with the vouchers and original copies of the invoices;
   29. Assistance or medical services, which are not medically necessary and all Elective and/or non-Emergency medical condition and its complications.
   30. Rehabilitation treatments;
   31. Prostheses, orthopaedic material or thesis and osteosynthesis material, as well as spectacles.
   32. Assistance or compensation for events that occurred during a trip that had commenced, in any of the following circumstances:
   1. Before this insurance comes into force;
   2. With the intention of receiving medical treatment;
   3. After the diagnosis of a terminal illness;
   4. Without prior medical authorisation, after the Insured had been under treatment or medical supervision during the twelve months prior to the start of the trip;
   33. Expenses that arise beyond the scope of application of the guarantees of the insurance, and, in any case, after the dates of validity of the policy have elapsed or after 90 days have elapsed since the start of a covered journey to the Country of Origin of the Insured.
   34. Any Health Services that are received as Out-of-Hospital benefits.
   35. All expenses relating to dental treatment, dental prostheses, and orthodontic treatments.
   36. Services that do not require continuous administration by specialized medical personnel.
   37. Personal comfort and convenience items (television, barber or beauty service, guest service and similar incidental services and supplies).
   38. Medical Services that are not performed by Authorized Healthcare Service Providers, apart from medical Services rendered in a Medical Emergency.
   39. Prosthetic devices and consumed medical equipment.
   40. Treatments and services arising as a result of hazardous activities, including but not limited to, any form of aerial flight, any kind of power-vehicle race, water sports, horse riding activities, mountaineering activities, violent sports such as judo, boxing, and wrestling, bungee jumping and any professional sports activities.
   41. Costs associated with hearing tests, vision corrections, prosthetic devices or hearing and vision aids.
   42. Patient treatment supplies (including elastic stockings, ace bandages, gauze, syringes, diabetic test strips, and like products, non-prescription drugs and treatments, excluding such supplies required as a result of Healthcare Services rendered during a Medical Emergency).
   43. Services rendered by any medical provider relative of a patient for example the Insured person and the Insured member’s family, including spouse, brother, sister, parent or child.
   44. All Healthcare Services & Treatments for In-Vitro Fertilization (IVF), embryo transport, ovum and male sperms transport.
   45. Treatments and services related to viral hepatitis and associated complications, except for treatment and services related to Hepatitis A.
   46. Air or Terrestrial Medical evacuation except for Emergency cases or unauthorized transportation services.
   47. Medical services and associated expenses for organ and tissue transplants, irrespective of whether the Insured Person is a donor or recipient.
   48. Any test or treatment not prescribed by a doctor.
   49. Diagnosis and treatment services for complications of excluded illnesses.

3. The Company is exempt from liability when, as a result of force majeure, it is unable to put into effect any of the benefits specifically envisaged in this policy.

VI. HOW THE INSURED SHOULD APPLY FOR ASSISTANCE?

Since the appearance of an event that could be included in any of the guarantees described previously, the beneficiary or any person acting in his place will necessarily contact, in the shortest possible time, in every case, the Alarm Centre mentioned below, which will be available to help any person 24h/24 7d/7.

Assistance Email     afrcosiam@mapfre.com

Refunds Email:     refund@mapfre.com