AXIOM TELECOM L.L.C. POLICY NO

Transcription

1 SCHEDULE OF BENEFITS AXIOM TELECOM L.L.C. POLICY NO Subgroup Name Subgroup No. Plan No. Sub office No. AXIOM TELECOM L.L.C.-Abu Dhabi-C Plan 001 Sub office 005 BODY REPATRIATION AMOUNT OF INSURANCE Each Eligible Insured Up to age 65 years: AED 50,000 Age between years: AED 25,000 CRITICAL ILLNESS Critical Illness (Option 1) Each Eligible Insured Lump sum payment of AED 18,360 upon the diagnosis of Cancer MEDICAL BENEFITS Sub group No MetLife Alico s Medical Network Standard First: Total upper limit coverage 1. The annual upper limit for Healthcare Services AED 500,000 Second: Geographic Coverage 1. Health Insurance Services offered inside the Emirate of Abu Dhabi. inside METLIFE ALICO Network on direct billing on reimbursement basis inside UAE in Government Hospitals R&C inside UAE outside METLIFE ALICO Network Page 1 of 9

2 2 Health Insurance Services offered in other Emirates R&C charges outside METLIFE ALICO Network for emergency cases inside METLIFE ALICO Network on direct billing on reimbursement basis inside UAE in Government Hospitals R&C inside UAE outside METLIFE ALICO Network R&C charges outside METLIFE ALICO Network for emergency cases 3 Middle East R&C inside Middle East 4 International R&C on reimbursement basis outside UAE in GCC, ME ISC & SE ASIA R&C on reimbursement basis outside UAE Worldwide for emergency cases Third: Inpatient Healthcare Services at Authorized Hospitals 1. In-patient Healthcare Services, subject to prior approval. Private Room 2. Tests, diagnosis, treatments and surgeries in hospitals for non-urgent medical cases, subject to prior approval. 3. Healthcare services for emergency cases 4. Transportation services for medical emergencies inside the Emirate of Abu Dhabi by an authorized party. 5. Accommodation for a person accompanying an insured child up to 10 years of age. 6. Accommodation of an accompanying person in the same room in cases of critical conditions and as per recommendation of attending physician, subject to prior approval. 7. In-patient maternity services, subject to insurance prior approval. AED 200 per day AED 200 per day Covered in full inside the Emirate of Abu Dhabi Co-payment of AED 500 per delivery Page 2 of 9

3 8. Healthcare services for illness and injuries as per Federal Law No. 8 of 1980 concerning the Regulation of Work Relations, as amended and applicable laws in this respect. Fourth: Outpatient Healthcare Services 1. Examination, diagnostic and treatment services of clinics and health centers by general practitioners, and specialists provided that the Insured Person is referred to a specialist and/or consultant by a general practitioner. Follow ups are exempted from fees if made within a week from the date of first examination. 2. Laboratory tests services 3. X-ray diagnostic services. In cases of non-medical emergencies, the insurance company s prior approval is required for MRI, CT scans and endoscopies. 4. Physiotherapy treatment services, subject to insurance company prior approval. 5. Cost of medicine, subject to insurance company s prior approval for prescriptions which exceed AED Examination, diagnostic and treatment services for pregnancy and gynecology services in authorized health centers and clinics by general practitioners and specialists, provided that the Insured Person is referred to a specialist and/or consultant by a general practitioner. Follow ups are exempted from fees if made within a week from the date of first examination. Fifth: Other Benefits with copayment of AED Diagnostic and treatment services for dental and gum treatments. 2. Hearing and vision aids, and vision correction by surgeries and laser. 3. Treatments by X-ray and by radium or other radioactive substances; Artificial limbs and eyes when necessitated by accidental bodily injuries or diseases occurring while covered under this Rider; Casts, splints, trusses, braces and crutches; Rental of wheelchair, hospital bed or iron lung. 4. Vitamins for the following conditions Pernicious Anemia, Scurvey, Rickets, Pellagra, Malabsorption, Poly Neuritis, Covered in full for medical emergency cases Covered in full for medical emergency cases Medical cases Medical cases Page 3 of 9

4 Kwashiorkor 5. Nasal septum deviation and nasal concha Medical cases resection where medically necessary 6. All chronic conditions requiring Medical cases haemodialysis or peritoneal dialysis, and related test/treatment or procedure. 7. Treatments and services related to viral Medical cases hepatitis and associated complications 8. Alzheimer s disease Medical cases 9. Health services and associated expenses for organ and tissue transplants, When Medical cases the Insured Person is a recipient 10. Venereal sexually transmitted diseases excluding AIDS/HIV Medical cases Daily Room and Board Limit (Average Private Room) Intensive Care Unit Out-Patient Consultation Max per Out-Patient Limit 14. Chronic Conditions (If not Pre-existing otherwise as per the inside METLIFE ALICO Network inside UAE Up to AED 650 outside the Network inside UAE Up to AED 650 inside UAE in Government Hospitals Up to AED 650 outside UAE, within GCC, ME ISC & SE ASIA Up to AED 1,300 outside UAE, Worldwide for emergency cases inside the Emirate of Abu Dhabi inside METLIFE ALICO network Outside METLIFE ALICO Network double the daily room and board limit per disability for 21 days, standard room and board limits to apply thereafter inside UAE within METLIFE ALICO Network Up to AED 300 & 400 per visit inside UAE in Government Hospitals for General Practitioner & Specialist respectively Up to AED 300 & 400 per visit inside UAE,outside METLIFE ALICO Network for General Practitioner & Specialist respectively Up to AED 300 & 400 outside UAE, within GCC, ME ISC & SE ASIA for General Practitioner & Specialist respectively Covered in full Page 4 of 9

5 Pre- existing waiver) 15. In-Hospital Reimbursement Cash Benefit (per night for free hospitalization up to Maximum of AED 650 maximum 20 days) 16. Companion room accommodation Covered (For a Child under the age of 18 years) 17. Organ Transplant Covered (Cost of surgery in respect of the Insured person as recipient and the organ donor at the time of transplant surgery) 18. Renal Dialysis Covered 19. Nursing at home (Immediately after or instead of Covered hospitalization) 20. Acts of Terrorism (Passive exposure) Covered Maternity / Obstetrical (Private room) Alternative Medicine On cash reimbursement basis Psychiatric treatment (other than acute cases) Inside the Emirate of Abu Dhabi: Covered in full inside the Emirate of Abu Dhabi Deductible : AED 500 per delivery Co-Insurance: Waiting period: Nil Outside the Emirate of Abu Dhabi: Deductible : Nil Co-Insurance: Waiting period: Nil Normal Delivery up to AED 20,000 Caesarian Section / Ectopic / Extra- Uterine Pregnancy up to AED 20,000 Miscarriage / Legal Abortion up to AED 20,000 Maternity Complications up to AED 20,000 Limit: AED 1,600 Recommended by Doctor for respective branch of alternative medicine Co-insurance: 90% Inclusion: Ayurvedic treatment, Homeopathy treatment, Chriropathy /reflexology treatment, Herbal treatment including herbal medicines. Co-Insurance : 80% Page 5 of 9

6 In-Patient: AED 8,500 Covers In-Patient Psychiatric treatment following an accident or hospitalization up to a maximum of 20 days per Insured per year 24. Medical Evacuation Out-Patient: AED 1, 500 Per Insured Per Year Covers up to a maximum of 15 visits per year (including expenses for one accompanying family member) up to a maximum of AED 140,000 per insured per policy year 25. Assistance Program Available 26. Benefits Predetermination Review / Second Opinion Hospitalization Program Applicable PRE-EXISTING CONDITIONS EXCLUSION Shall be waived in full for all Insureds under the plan. ELIGIBILITY Minimum 18 years; Maximum 65 years. Employees / Spouses For CMM: Coverage shall be extended up to 70 years of age subject to double the premium (without EOI). For BR: Coverage shall be extended up to 70 years of age subject to half the existing annual limit & double the premium (without EOI) Children Minimum 0 days; Maximum 19 th birthday. Coverage shall be extended up to age 25 years subject to full-time student in an accredited College or University. Unmarried dependent daughters coverage shall be extended up to age 30. Page 6 of 9

7 Travel and Medical Assistance How to contact when you need help Call SOS at any time at any of SOS Alarm Centres around the world. Simply provide SOS with: Your name Your company name Your member account number (as printed on your card) The telephone number from which you re calling For 24/7 assistance, please contact SOS on the number appearing on the front of your card. You can also call any Alarm Center on the numbers listed on next page. Medical assistance i. Telephone medical advice SOS will arrange for the provision of medical advice to the Insured over the telephone. ii. iii. iv. Medical Service Provider referral SOS shall provide to the insured, upon request, the name, address, telephone number and, if available, office hours of physicians, hospitals, clinics, dentists and dental clinics (collectively Medical Service Provider(s) ). SOS shall not be responsible for providing medical diagnosis or treatment. Although SOS may make such referrals, it cannot guarantee the quality of the Medical Service provided and the final selection of a Medical Service Provider shall be the decision of the Insured. Arrangement of hospital admission If the medical condition of the Insured necessitates hospitalisation, SOS will assist such Insured in the hospital admission. Evacuation and Repatriation SOS, will arrange for the air and/or surface transportation, medical care during transportation, communications and all usual and customary ancillary charges incurred in moving and transporting an Insured to the nearest hospital where appropriate medical care is available, which may be a location other than the Insured s Home Country or Country of Assignment. Page 7 of 9

8 i. SOS will arrange for the transport of the Insured to his/her Home Country or Country of Assignment following a medical evacuation for subsequent in-patient hospitalization or rehabilitative treatment. ii. SOS reserves the right, at its sole discretion, to determine the location to which the Insured will be evacuated and the means or method by which such evacuation or repatriation will be carried out. In making such arrangements, SOS may consider all relevant circumstances including, but not limited to the Insured s medical condition, the degree of urgency, the Insured s fitness to travel, airport availability, weather conditions and travel distance in determining whether transportation will be provided by private medically equipped aircraft, helicopter, regular scheduled flight, rail or land vehicle. Transportation shall be carried out under constant medical supervision, unless otherwise approved by the Company physician. v. Arrangement of transportation of mortal remains SOS will arrange for the transportation of the Insured s mortal remains to the Home Country or Usual Country of Residence, or arrange, as requested by the Insured s family or legal representative, for local burial at the place of death. Page 8 of 9

9 Alarm Centers contact details: AZERBAIJAN Baku Tel: +994 (0) AUSTRALIA Sydney Tel: +61 (0) CAMBODIA Phnom Penh Tel: +855 (0) CHAD N Djamena Tel: CHINA Beijing Tel: +86 (0) Guangzhou Tel: +86 (0) Nanjing Tel: +86 (0) Shekou Tel: +86 (0) Tianjin Tel: +86 (0) CZECH REPUBLIC Prague Tel: FRANCE Paris Tel: +33 (0) GERMANY Stuttgart Tel: +49 (0) INDIA New Delhi Tel: +91 (0) INDONESIA Jakarta Tel: +62 (0) Jakarta (2) Tel: +62 (0) Bali Tel: +62 (0) JAPAN Tokyo Tel: +81 (0) KAZAKHSTAN Almaty Tel: +7 (0) Atyrau Tel: +7 (0) MYANMAR Yangon Tel: +95 (0) MALAYSIA Kuala Lumpur Tel: +60 (0) MYANMAR Yangon Tel: +95 (0) NEW ZEALAND Auckland Tel: +64 (0) NIGERIA Lagos Tel: +234 (0) Port Harcourt Tel: +234 (0) Warri Tel: +234 (0) PHILIPPINES Manila Tel: +63 (0) RUSSIA Moscow Tel: +7 (095) SINGAPORE Tel: SOUTH AFRICA Johannesburg Tel: +27 (0) SOUTH KOREA Seoul Tel: +82 (0) SPAIN Madrid Tel: +34 (0) SWITZERLAND Geneva Tel: +41 (0) TAIWAN (ROC) Taipei Tel: +886 (0) THAILAND Bangkok Tel: +66 (0) UNITED KINGDOM London Tel: +44 (0) USA Philadelphia Tel: +1 (0) VIETNAM Ho Chi Minh City Tel: +84 (0) Hanoi Tel: +84 (0) 4 934