School Insurance

TJSS Personal Accident Insurance Summary – Medical Expense Reimbursement

• Medical Expense Reimbursement for Accidents

The company will reimburse the insured for medical, pharmaceutical, and hospital expenses incurred as a result of an accident, up to an annual amount of 60 UF (Unidades de Fomento, a Chilean unit of account), provided that such expenses are for care received within ninety (90) days following the date of the accident and are a consequence of the injuries sustained.

As a condition for processing the reimbursement, the insured must present original receipts, invoices, and other documents, as applicable, along with copies of vouchers, service orders, medical programs, or other documents issued in the insured’s name that demonstrate the expenses incurred and their payment. The insured must also present to the company any documents demonstrating contributions, compensation, reimbursements, or bonuses received from their affiliated health insurance provider.

What is an accident?

For the purposes of this insurance contract, an accident is defined as any unforeseen, involuntary, sudden, and fortuitous event, duly documented, caused by external means and in a violent manner, that affects the insured’s body, resulting in one or more injuries manifested by visible bruises or wounds, as well as cases of drowning or internal injuries revealed by the corresponding examinations.

Suicide, heart attacks, epileptic seizures, vascular diseases, cerebrovascular accidents, peripheral vascular accidents, strokes, mental disorders, fainting or sleepwalking, viral or bacterial infections, or any other illness, nor the events or consequences thereof that affect the insured’s body, are considered accidents. Events occurring as a result of medical, physiotherapy, surgical, or anesthetic treatments are also not considered accidents.

• Medical Expense Reimbursement Exclusions

No reimbursement will be made under the various coverage options of this insurance contract when the insured’s medical expenses arise from or are caused by:

Below are the most relevant exclusions and/or those that may be most common.

• War, civil war, or acts that the law classifies as crimes against the State’s internal security. Fights or brawls, except in cases where a final and unappealable court judgment establishes that it was a case of self-defense.
• Commission of acts classified as crimes, self-inflicted injuries, attempts on one’s own life.
• Driving any vehicle or means of transport while intoxicated and/or under the influence of narcotics or psychotropic substances. Treatments for drug addiction or alcoholism
• The practice or performance of any sport that objectively constitutes a flagrant increase in risk, such as: skydiving, hang gliding, paragliding, bump jump, mountaineering, rock climbing, motorcycling, boxing, wrestling, rodeo. The practice or performance of any clearly risky activity, profession, or trade, such as the following: i. The handling of explosives or corrosive chemicals. The handling of mechanical, reciprocating, band, or circular saws used in industries or factories. Motorcycling, whether as driver or passenger.
• Hearing aids, eyeglasses, prostheses, orthoses, artificial limbs, and the supply of orthopedic devices or equipment.
• Care provided by a private clinic at the insured’s home and home hospitalizations of any kind. Private nursing care outside of a hospital setting.

• Air transfers of the insured or transfers over a distance greater than 50 kilometers from the accident site to a hospital or clinic, regardless of the means of transport.

• Psychiatric and/or psychological medical care.

• Cosmetic plastic surgery, dental, orthodontic, orthopedic, and other treatments for cosmetic purposes or to correct malformations caused by accidents occurring before the insured’s policy effective date.

The insurance will not be effective when:

• The policy has expired.

• The accident occurs after the policy has expired.

• The claim is filed after the deadline.

• The claim is filed without the necessary documentation (supporting evidence).

• The claim is not an accident.

• A claim is made for eyeglasses, prostheses, orthoses, etc.

Recursos