ANNEXURE : 1 FLEXI - DUBAI PLANS - OPTION 1

Transcription

1 ANNEXURE : 1 FLEXI - DUBAI PLANS ( OPTION 1 ) Applicable only for (DXB visa holders) with Gross Salary Above AED 4,000. Preexisting & chronic conditions will be covered only for declared cases: - New membership- 6 months waiting period for Pre-existing & Chronic conditions/ and no continuity of coverage. - Nil waiting period for members who have continuity of coverages. - Pre-existing & Chronic conditions will not be covered for undeclared cases even after 6 months waiting period. - Maternity coverage- Non -working spouses who are confirmed pregnant after time of enrollment will be subject to 9 months waiting period. - No waiting period for maternity for Working females and non-working females with continuity of cover. Aggregate Limit Under the terms and conditions of the plan, we will pay necessary, customary and reasonable expenses up to an overall maximum, per insured member per year. 1 AED 500,000/- AED 350,000/- AED 250,000/- AED 150,000/- AED 150,000/- AED 150,000/- 2 Area of Cover 3 Eligibility Worldwide including USA & Canada UAE, GCC, ME, SEA including Indian Subcontinent 4 Network GN + AH GN network + 20% co-insurance on ALL OP services in Saudi German hospital Mediclinic Group & Al Zahra Group UAE, GCC, ME, SEA including Indian Sub-continent UAE, GCC, ME, SEA including Indian Subcontinent All UAE residents (UAE Nationals & Expatriates having a Valid Residence Visa) UAE, Indian Sub-continent and Philippines RN RN2 RN3 (Outpatient restricted to clinics only) UAE Only *Outpatient: Nextcare's PCP network (specialist visits from RN3 network is allowed after referral from PCP GPs only) *Inpatient: RN3 hospitals (referral from PCP doctors only) 5 Age Limit 0 to unlimited 0 to unlimited 0 to unlimited 0 to unlimited 0 to unlimited 0 to unlimited Treatment Outside the Network within Geographical scope 6 If is taken outside the network for eligible medical condition covered under the policy, reimbursement would be allowed subject to 20% Co-insurance based on Usual, Customary and Reasonable ( UCR ) Network Charges. ( UCR charges are as per the discretion of the insurer ) 20% Co-insurance subject to UCR Network Charges 20% Co-insurance subject to UCR Network Charges * Treatment out-side the Network is not allowed and will not be reimbursed. * Emergency within UAE covered in full ( Life threatening cases) 7 Claims Settlement Basis ( as per Usual, Customary and Reasonable Charges of the Network in UAE ). Within the Network on Direct Billing Basis Outside the Network on Reimbursement Basis within the Network on Direct Billing Basis -Outside Network(within UAE) is allowed For Life threatening cases on Reimbursement Basis only * For emergency within UAE covered in full ( For Life threatening cases only )

2 In-Patient Treatment a Accidents and emergencies, intensive care and theatre costs b Hospital Accommodation ( Room Charges ) in Full in Full in Full in Full in Full in Full Private Room Private Room Private Room up to aed 750 per day Semi Private Room up to aed 450 per day Semi Private Room up to aed 450 per day Semi Private Room up to aed 450 per day c Nursing Fees, medical expenses and ancillary charges in Full in Full in Full in Full in Full in Full d Surgeons', consultants, anaesthetist', specialists', General Practitioners' fees in Full in Full in Full in Full in Full in Full e Prescribed Medicine and drugs in Full in Full in Full in Full in Full in Full f Reconstructive surgery following an accident or following surgery for an eligible medical condition in Full in Full in Full in Full in Full in Full g Prostheses: artificial body parts surgically implated to form permanent parts of an in Full in Full in Full in Full in Full in Full insured member's body h MRI, PET, CT Scans in Full in Full in Full in Full in Full in Full i X-Rays, Pathology, diagnostic tests and procedures in Full in Full in Full in Full in Full in Full j Oncology tests, drugs and consultants' fees including cover for chemotherapy and radiotheraphy in Full in Full in Full in Full in Full in Full k l m n Parent accommodation Hospital accomodation cost in respect of a parent or legal guardian staying with an Insured member who is under 18 years of age and is admitted to a Hospital as an In-Patient. Ground transportation services in the UAE provided by an authorized party for medical emergencies Accidental Damage to Teeth Treatment recevied in an Emergency room in a Hospital within 48 hours of incurring Accidental damage caused to sound, natural teeth as a result of an Accident. Hospital Cash Benefit When is received as an In-Patient for an eligible Medical Condition in a Government Hospital, where no costs were incurred for accommodation and/or for, then this benefit pays for a daily cash benefit for In- Patient stay more than 3 days. This benefit is not applicable for Accident & Emergency admissions. up to AED 100/= per day in Full in Full in Full in Full in Full in Full in Full in Full in Full in Full in Full in Full up to AED 300/= per day up to AED 200/= per day up to AED 200/= per day o Deductible for ( In-Patient Services ) ( Applicable if is taken in a facility in-side/outside the Network of providers ) NIL 20% coinsurance With a cap of 500 AED payable per encounter and an annual aggregate cap of 1000 AED. Above these caps the insurer will cover 100% of

3 p Medical emergencies on Hearing and vision aids, and vision correction by surgeries and laser. Cover : Emergency Treatment required to save or alleviate danger to life q Accidental damage to teeth & Gum Treatment recevied in an emergency room in a hospital within 48 hours of incurring accidental damage caused to sound, nutural teeth as a result of an accident. Cover : Emergency Treatment required to save or alleviate danger to life r Maternity - In patient services. Waiting Period: Nil. For (Non -working spouses who are confirmed pregnant after time of enrollment will be subject to 9 months waiting period). 10% coinsurance payable by the insured Maximum benefit 15,000 AED per normal delivery, 20,000 AED for medically necessary C- section, complications and for medically necessary termination (All limits include coinsurance) 10% coinsurance payable by the insured Maximum benefit 10,000 AED per normal delivery, 15,000 AED for medically necessary C-section, complications and for medically necessary termination (All limits include coinsurance) 10% coinsurance payable by the insured Maximum benefit 7,000 AED per normal delivery, 10,000 AED for medically necessary C-section, complications and for medically necessary termination (All limits include coinsurance) Where any condition develops which becomes an emergency, the medically necessary expenses will be covered up to -Maximum limit AED 150,000 PPPY 1 2 Out-Patient & Day-care Deductible /Co insurance for ( Out-Patient Services ) Free follow up with the same doctor for the same ailment within seven days. Primary Consultation and to include General Practitioners' fees, prescribed medicines, drugs and dressings 20% coinsurance on OP consultation or AED 50/- on all OP consultation whichever is lower. 3 X-ray, pathology, diagnostic tests and procedures 4 Prescribed Medicine and drugs 5 Physiotherapy recommended / referred by a General Practitioner or a Specialist, 30% Coinsurance Maximum Limit AED 2,000 up to 6 sessions per ailment/condition per person per year 30% Coinsurance Maximum Limit AED 1,500 up to 6 sessions per ailment/condition per person per year with 20% coinsurance 6 Oncology tests, drugs and consultants' fees including cover for chemotherapy and radiotheraphy 7 MRI, PET, CT Scans 8 Out-Patient Surgical Operations 9 Post - Hospitalization Treatment Other Benefits up to 7 sessions per ailment/condition per person per year

4 ab Pre-existing Conditions & Chronic Medical Conditions ( Where any condition develops which becomes an emergency, the medically necessary expenses will be covered up to the annual aggregate limit. ) - For declared cases only -Maximum limit AED 150,000 PPPY - Treatment for chronic Or pre-existing conditions excluded for first 6 months of first membership. Included thereafter

5 ac Maternity - Out patient services. Waiting Period: Nil. For ( Non -working spouses who are confirmed pregnant after time of enrollment will be subject to 9 months waiting period). 10% Copay, Maximum 8 visits checks and tests in accordance with DHA Antenatal Care Protocols ad New born cover _Cover for 30 days from birth. _BCG, Hepatitis and neo-natal screening tests. (Phenylketonuria (PKU), Congenital Hypothyroidism, sickle cell screening, congenital adrenal hyperplasia) ae Life threatening congenital conditions - Maximum limit AED 150,000 PPPY ( life - threatening birth defects, deformities and congenital diseases for new born children only ) af Nursing at Home Immediately following Hospital discharge on the recommendation of a specialist and must be provided by a qualified nurse. All s under this benefit must be preauthorized by us. upto a limit of AED 5,000/= upto a limit of AED 4,000/= upto a limit of AED 2,500/= upto a limit of AED 1,000/= upto a limit of AED 1,000/= upto a limit of AED 1,000/= ag ah Reconstructive Surgery Reconstructive surgery following an Accident or following surgery for an eligible medical conditions, which is not preexisting and the incident has not occurred prior to commencing this cover under the policy. Dental Cover Below dental procedures excluding any surgeries. Root Canal, Fillings, Extractions, Antibiotics for Infection of Gums Consultation and X- ray. in Full in Full in Full in Full in Full in Full up to a limit of AED 2,000/= with AED 100/= as deductible. Reimbursement basis only Not Not Not Not Not ai Optical Cover Cover for a pair of lenses only. up to a limit of AED 200/= for a pair of lenses. on Reimbursement basis only Not Not Not Not Not aj Preventive services *Preventive services as stipulated by DHA to include initially diabetes and Papanicolaou test. Diabetes: Every 3 years from age 30 High risk individuals annually from age 18 Papanicolaou: Every 3 years for married female *Frequency restricted to: ak Vaccines and immunizations Essential vaccinations and inoculations for newborns and children as stipulated in the DHA s policies and its updates in the assigned facilities from age 0-6 years. - according to DHA price list with 10% Copay on Reimbursement basis only

6 al am Return Air Fare to Patient for Surgery in Home Country ( if is not available in the country of residence or the expense is up to 50% of the cost in UAE ). Pre-approval from ASNIC required Global Emergency services - Assist America Key services: Medical Consultation, Evaluation & Referral, Hospital Admission Assistance, Emergency Medical Evacuation, Medical Monitoring, Medical Repatriation, Prescription Assistance, Compassionate Visit, Care of Minor Children, Return of Mortal Remains, Lost Luggage or Document Assistance, Interpreter & Legal Referrals, Pre-trip Information. AED 2,000/= Plus AED 2,000/= for accompanying Family Member AED 2,000/= Insured patient only Not Not an Second Medical Opinion (International Medical Consultation) - Confirmation of Diagnosis diagnosis has not been appropriate course of - Confirmation of Diagnosis - Confirmation of Diagnosis - Confirmation of Diagnosis - Confirmation of Diagnosis Not Not ao Death due to accident ( for Principal only ) (Refer to addendum for complete information on Max AED 25,000. Max AED 20,000. Max AED 15,000. Max AED10,000. Not Not ap (Cancer & Hep - c ) : Patient support Program - according to - according to - according to - according to - according to - according to