What are the General Terms and Conditions of Health Insurance?

Article 1 – Definitions

• Illness: An abnormal condition that arises after the policy commencement and is medically diagnosed by a physician.

• Accident: A sudden, external event that occurs outside the control of the insured.

• Medical Expenses: Examination, tests, imaging, laboratory, surgery, hospital, medication, medical supplies, rehabilitation, and medical transportation expenses (subject to policy limits/coverage).

• Network Institution: An institution included in the list of healthcare providers contracted with the insurer.

• Provision: Confirmation with the insurer whether pre-treatment/post-treatment expenses are covered under the policy.

• Deductible/Contribution: The portion (percentage or amount) undertaken by the insured.

• Waiting Period: The period excluded from coverage as stipulated in the specific terms and conditions, starting from the policy commencement.

• Pre-existing condition: A condition that existed before the policy commencement and can be proven with medically verifiable findings.

Article 2 – Principle of Interpretation
In case of doubt, the principle of interpretation in favor of the consumer (if the consumer status exists within the scope of the Turkish Commercial Code and Law No. 6502) shall be observed; however, the special condition explicitly narrows the scope of risk, the provisions of the special condition shall apply.

---

SECTION II – COVERAGE AND EXCEPTIONS

Article 3 – Coverage Scope The insurance covers medically necessary and reasonable treatment expenses incurred by the insured due to illness and/or injury resulting from an accident during the policy period ; and, if agreed upon , daily allowance/disability compensation, within the scope of the coverage types, plan, limit, lower limit, deductible and co-payment stated in the policy/insurance certificate .

• Types of Coverage (Examples):
  a) Outpatient Treatment: Examination, tests, imaging, prescription medication.
  b) Inpatient Treatment: Surgery, intensive care, room-companion, operating room, medical supplies.
  c) Emergency Situations: Life-threatening situations (List in Appendix 2).
  d) Medical and Burial Transportation: Medically necessary transportation; burial transportation (if applicable under special conditions).
  e) Maternity Coverage: Subject to waiting periods and limits (under special conditions).
  f) International Coverage: Subject to geographical limitations and currency conversion rules (Articles 5 and 19).

Article 4 – Exclusions (Extended)
The following are not covered under this policy (subject to mandatory public order provisions):

1. War, similar operations, rebellions, uprisings and resulting internal disturbances; nuclear risks.

2. Committing or attempting to commit a crime intentionally , attempted suicide , knowingly exposing oneself to grave danger (excluding rescue situations).

3. Earthquake, flood, volcanic eruption, landslide (coverage can be provided with a special clause).

4. Conditions arising from drug/psychotropic substance use ; conditions related to alcohol abuse (unless otherwise stipulated in specific conditions)

5. Pre-existing illnesses and complications (unless specifically covered; waiting period and declaration principle reserved).

6. Cosmetic/aesthetic procedures; dental health (excluding emergency trauma) – performed if a specific plan is available.

7. Treatments within the scope of experimental/clinical research ; practices whose medical necessity has not been proven

8. professional sports activities under an athlete's license (unless otherwise specified).

9. Pregnancy screening packages/delivery (if no private coverage exists); infertility investigations and treatments (if no private plan exists).

10. Alternative/complementary medicine practices (unless there is a specific plan).

11. Expenses incurred without provision at non-network locations (may be exceptionally refundable under special terms and conditions).

12. Injuries resulting from actions that warrant criminal or administrative sanctions (excluding rescue operations)

Article 5 – Geographical Limits and Foreign Currency The geographical scope shall be clearly stated in the policy (e.g., Turkey / Europe / Worldwide). For overseas payments, the policy currency shall be used. Currency conversion shall be based on the Central Bank of Turkey's (TCMB) foreign exchange selling rate as of the date of the payment documents (special conditions may stipulate otherwise).

---

SECTION III – DURATION, START DATE, PREMIUM AND DECLARATION

Article 6 – Commencement and Termination of Insurance Unless otherwise agreed, the policy commences at 12:00 on the commencement date stated thereon and terminates at 12:00 on the termination date (Turkish time)

Article 7 – Obligation to Disclose Information (When the Contract is Formed) The insurer relies on the disclosures contained in the proposal/policy and its annexes . The policyholder/insured is obligated to provide accurate and complete disclosures .

• In case of intentional false/incomplete information , the insurer may withdraw from the contract within ……… months from the date it becomes aware of the situation ; if the risk has materialized, it will refrain from payment ; and will be entitled to the premium .

• If there is no malicious intent , the insurer will either terminate the contract within ……… months or continue the contract with a claim for the premium difference ; if the claimed difference is not accepted within ……… days, termination will occur

• If the cancellation/termination/premium difference request is not made within the specified period, it will be forfeited.

• If the risk materializes before the insurer becomes aware of the situation or within the termination period/notice period , a proportional reduction will be applied to the compensation (premium accrued / premium due).

Article 8 – Notification of Changes During the Policy Period Changes that worsen the risk must be notified to the insurer in writing within ……… days at the latest . The insurer may terminate the policy or request a premium difference within ……… days ; if the difference is not accepted, the policy will be terminated. Unused rights lapse .

Article 9 – Premium and Commencement of Liability The premium is payable in advance or in installments ; liability does not commence until the first installment is paid (as stated on the front of the policy). For premiums not paid on time, the insurer will give a period of ……… months via registered mail/notary public notice ; if not paid, the contract will be terminated ; the premium for the elapsed period will be collected on a daily basis

---

CHAPTER IV – RISK OCCURRENCE AND CLAIMS PROCESS

Article 10 – Notification, Provision and Medical Process

1. Notification: A written notification must be given to the insurer within ……… days from the date the risk is learned ; the location/date/cause of the event and a medical report must be submitted.

2. Provision: Obtaining provision is essential in network institutions . If emergency services need to be provided without provision, notification and documentation must be submitted at the earliest opportunity

3. Initiation of Treatment and Care: Immediate treatment; permission to be examined by physician(s) appointed by the insurer ; obligation to follow medical advice .

4. Documentation: Invoice, medical summary, test results, prescription, payment receipts, referrals/reports, and Social Security Institution/other insurance payment statements must be submitted.

5. Failure to comply: Intentional breach results in loss of rights ; negligent breach and aggravated consequences result in no liability for the aggravated part of the consequences .

Article 11 – Determination of Costs and Dispute Resolution (Arbitration-Expert Witness)
If the parties cannot agree on the amount of costs, the arbitration-expert witness procedure shall be applied:

• If an agreement cannot be reached with a single arbitrator, each party shall choose an arbitrator; 7 days ; if no agreement is reached, in the place of treatment shall make the appointment.

• The third arbitrator only decides on matters where the arbitrators of the parties disagree

• The decisions are final and binding on the parties; if there is a clear and significant deviation from the actual situation , an appeal for annulment may be filed within 1 week of notification

• Fees: Each party pays their own arbitrator's fee, and the third arbitrator's fee split equally between .

• Unless otherwise agreed, the claim becomes due upon the decision of the arbitrator-expert ; the statute of limitations begins to run from the date of notification of the final report (Turkish Commercial Code Article 1420 reserved)

Article 12 – Payment Method and Exceptions

• Direct payment (network institution): The insurer can make direct payments to the contracted institution.

• Refund (non-network): The insured pays first; applies with documents; refund is made after deducting the policy limit, deductible, and co-payment

• SGK/other insurance schemes will be deducted; duplicate payments will not be made.

• Expenses that are not reasonable or medically necessary will not be reimbursed

Article 13 – Subrogation and Co-insurance The insurer shall be subrogated to liability with respect to third parties to the extent of the compensation paid (Turkish Commercial Code). If there is more than one insurer, the principle of sharing in proportion to the coverage shall apply; in case of double insurance , the provisions of the relevant legislation shall apply.

---

SECTION V – SPECIAL ARRANGEMENTS

Article 14 – Waiting Periods and Pre-existing Conditions Waiting periods may be stipulated under special conditions (e.g., 30 days for outpatients; 12 months for childbirth). Pre-existing conditions are excluded from coverage unless they are covered by a special clause or medical declaration assessment

Article 15 – Exemptions and Contributions An exemption (e.g., 1,000 TL annually) and/or a contribution (e.g., 20%) may be determined for each insurance item . These amounts will be deducted from the net compensation

Article 16 – Compliance with Network Rules Higher limits/lower co-payments may apply to network-internal institutional usage . Special terms and conditions apply to off-network usage . In emergency situations, the nearest healthcare facility is the primary option.

Article 17 – Assistance Services: 24/7 call center, emergency organization, medical transport/repatriation, and escort arrangements are managed through the assistance company (Appendix-3 Service Brochure)

Article 18 – Taxes, Fees and Charges
Taxes, fees and charges relating to policy issuance and compensation payments shall be collected/paid in accordance with the applicable legislation.

Article 19 – Exchange Rate, Inflation and Indexing (If Applicable) Premiums and limits may be indexed according to medical inflation and claims/premium performance during annual renewal (to be formulated in a special condition).

Article 20 – Personal Data Protection Law and Confidentiality
The insurer and its designated service providers Law No. 6698 on the Protection of Personal Data; the Information Text and Explicit Consent (if necessary) are included in Annex 4. The obligation to maintain confidentiality (General Terms and Conditions Article 12) and professional confidentiality are essential.

---

CHAPTER VI – NOTIFICATION, DISPUTE, STATUTE OF LIMITATIONS

Article 21 – Notification and Communication
The insured's notifications and communications in writing/via the UETS system to the insurer's headquarters or authorized agent. The insurer's notifications the last address/electronic address.

Article 22 – Dispute Resolution and Insurance Arbitration Negotiation and expert arbitration procedures shall be applied first . If this is not possible, the right to apply to the Insurance Arbitration Commission pursuant to Article 30 of Law No. 5684 is reserved. If arbitration is not pursued, the competent court shall be the commercial courts (the following jurisdiction provision is reserved).

Article 23 – Competent Court
In disputes arising from this policy;

• In lawsuits to be filed by the policyholder/insured: The courts of the place where the insurer's headquarters or the agent who brokered the contract is located, or the courts of the place where the risk occurred, shall have jurisdiction ;

• In lawsuits filed by the insurer: The commercial courts located where the defendant resides have jurisdiction.

Article 24 – Statute of Limitations Claims arising from insurance contracts are subject to a statute of limitations of 2 years in accordance with Article 1420 of the Turkish Commercial Code ; for claims relating to the injured party's right of recourse in liability insurance, the limitation period is 10 years (subject to the relevant provisions for this type of policy). Longer/shorter periods stipulated in special laws are reserved.

---

CHAPTER VII – MISCELLANEOUS PROVISIONS

Article 25 – Entry into Force, Transfer and Termination The policy enters into force upon payment of the premium/first installment. It cannot be transferred in favor of the insured (unless specifically approved). It terminates automatically at the end of its term; the parties may negotiate the renewal terms

Article 26 – Special Conditions and Clauses Special conditions that do not conflict with the general conditions and (if any) clauses may be included in the policy:

• Maternity coverage clause (waiting period/limit),

• Foreign coverage clause (geographical region/limit/currency),

• Sports clause, dental/filling/orthodontics clause,

• Pre-existing disease coverage clause (premium difference/special exemption),

• Medical device and rehabilitation clause, etc.

Article 27 – Force Majeure
In cases of force majeure that are beyond the control of the parties and make performance of the obligation impossible (war, natural disasters, widespread epidemics, etc.), obligations shall be suspended for the duration of the force majeure event; termination/adaptation mechanisms may be applied.

Article 28 – Integrity and Priority
The policy, insurance certificate, annexes, and general/special conditions constitute a whole. In case of conflict, special conditions take precedence; written clause, the general conditions apply.

---

APPENDICES (Sample List)

• Appendix 1: List of Participants/Insured Persons (for group policies)

• Appendix 2: Emergency Situations List and Guide

• Appendix 3: Assistance Service Brochure and Contact Information

• Appendix 4: Personal Data Protection Law (KVKK) Information Text and Explicit Consent, if Required

• Appendix 5: Network (Partner Institutions) List

• Appendix 6: Guarantee-Limit-Exemption-Participation Fee Table

• Appendix 7: Principles for International Use and Currency Conversion

• Appendix 8: Claim and Documentation Checklist (Damage File)

---

BLANKS TO FILL IN / PARAMETER TABLE (Practical Diagram)

---

Notes (Practical Advice – From a Lawyer's Perspective)

• Declaration and health declaration forms must be attached; the concept of pre-existing illness should be substantiated with references to epicrisis and examination results .

• The refund rate for off-network usage (e.g., "80% refund on off-network bills, 20% participation") should be clearly stated.

• The waiting period for maternity coverage , the distinction between cesarean and vaginal delivery, and newborn coverage should be regulated in separate paragraphs.

• The exchange rate conversion and the date (invoice/payment) should be clearly defined; the Central Bank of Turkey's selling rate reference works well.

• The definition of urgency in assistance processes (Annex-2) should not be narrowed; otherwise, there is a risk of consumer disputes.

• The statute of limitations (Turkish Commercial Code Article 1420) is two years – this should be clear and visible in the text; furthermore, of arbitration and opinion should be explained in a user-friendly manner.