Existing_Table_of_Benefits__.pdf

HEALTH INSURANCE PLAN

LOCALLY EMPLOYED STAFF

EMBASSY OF THE UNITED STATES OF AMERICA

SCHEDULE OF BENEFITS

MEDICAL BENEFITS

Maximum Policy Year Benefit Per Insured

Dhs. 300,000 Per Insured Per Policy Year

Insured’s are Employees, Spouses and Unmarried children up to the age of 19 years

Geographical Scope

UAE, extended out of UAE for employees and dependents when:

A life threatening condition occurs when the individual is out of the UAE and treatment is medically necessary before the individual returns home; or

The individual’s attending physician certifies in advance that such treatment is medically necessary and unavailable locally.

On vacation or business trips for a maximum of 60 days (as per UAE Network rates on a reasonable and customary basis)

Alico’s Medical Network

Executive

Deductible Nil

Co-Insurance

In-Patient Treatment: covered at 100% for all expenses Out-Patient Treatment: covered at 100% except:

Routine immunizations and prescribed drugs are covered with 80%. Prior approval is required for any medication that exceeds 500 Dh.

Suppressant Medication:

For employees; covered at 100% (i.e. tuberculosis and toxoplasmosis) for employees who have HIV/AIDS.

For employee & employee’s covered spouse: 100% reimbursement for brief course of anti-retroviral drugs during childbirth to prevent the transmission of HIV to the employee’s child.

Suppressant medication is covered up to US$ 10,000 per patient per policy year.

Physical therapy and Prescription drugs

100%

Routine Annual Physical Examination

100% covered for routine physical examination ( the coverage is limited to a General Consultation, ECG, Chest X-Rays, CBC, FBS, Urea, Creatinine, ESR, Cholesterol, Tryglycerides, HDL/LDL, Routine Urinalysis, Stool Analysis, Peripheral Smear/Pap Smear).

Room and Board Limit for In-Patient Admissions

100% for Semi-Private room or 80% of Private Room not to exceed 100% of the cost of a semi-private room.

Parent Accommodation

Covered for one parent accompanying an insured child under the age of 10 up to a maximum of Dhs 100 per day

Maternity benefits 100% covered (obstetrical medical care including prenatal and postnatal care)

Optical Benefits 100% reimbursement for eye examinations, prescribed medicines, tests. Eye glasses and lenses are not covered.

Psychiatric Treatment

50% reimbursement for routine care 100% reimbursement for emergency psychiatric treatment

Ambulance Services 100% reimbursement

Hearing Aids Not covered

Dental Benefit Not covered

Family Planning

80% including prescribed contraceptive devices and drugs, voluntary sterilization, and diagnosis and treatment of infertility.

Does not include reversal of voluntary sterilization, infertility treatment after voluntary sterilization, genetic counseling, fertility drugs, and assisted reproductive technology.

CBD Life Threatening only

Immunizations For children only – up to 80% (BCG, DT, DTwP, DTwPHibHep, Hib, Measles, MMR, OPV, Rubella and Td).

Pre-existing conditions

Covered

Chronic conditions Covered

HIV/Aids treatment Covered as per the ALICO and DOS pooling agreement, and up to a limit of Dhs 36,730 per policy year applicable to employees only.

Dependents will not be eligible for this benefit.

Passive War and Terrorism

Covered

Benefits Pre- Determination

Applicable

Governmental Hospitals

Direct Settlement of Bills

Reimbursement Claims

Covered on reimbursement basis only – insured members wishing to get treatment at governmental hospitals are covered at 100%.

Out-Patient: Available at ALICO’s Medical Provider’s Network in

UAE.

In-Patient: Available worldwide with limitations and with prior notification.

Settled in 14 working days upon receipt of complete documents.

ELIGIBILITY

Employees / Spouses Min : 18 Years and Max : 65 Years

Children

Minimum Zero days; Maximum 19th birthday (A newborn eligible child will be deemed eligible for insurance coverage on the date of birth when the birth is reported within 30 days time.

Health Insurance Exclusions:

This Schedule sets out the non basic (excluded) healthcare services:

1. Healthcare services, which are not medically necessary.

2. All expenses relating to dental treatment, dental prostheses, and orthodontic treatments.

3. Domiciliary care; private nursing care; respite care.

4. Custodial care includes:

(1) non-medical treatment services; or

(2) health-related services which do not seek to cure or which do not result in a change in the medical condition of the patient.

5. Services which do not require continued administration by trained medical personnel.

6. Personal comfort and convenience items (television, telephone, barber or beauty services, guest services and similar incidental services and supplies).

7. Healthcare services and associated expenses for cosmetic procedures and replacement of an existing breast implant. Cosmetic procedures are those procedures which improve physical appearance and which are not incidental to an injury, sickness or congenital anomaly when the primary purpose is to improve physiological functioning of the involved part of the body. Breast reconstruction following a mastectomy for cancer is covered.

8. Surgical and non-surgical treatment for obesity (including morbid obesity), and any other weight control programs, services, or supplies.

9. Medically non-approved experimental, research, investigational healthcare services, treatments, devices and pharmacological regimens.

10. Healthcare Services that are not performed by Authorized Healthcare

Service Providers, apart from Healthcare Services rendered in a Medical

Emergency.

11. Healthcare services, treatments & associated expenses for alopecia, baldness, hair falling, dandruff or wigs.

12. Non-medically necessary Amniocentesis

13. Treatment, services and surgeries for sex transformation.

14. Prosthetic devices and durable medical equipments, unless approved by the insurance company.

15. 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.

16. Growth hormone therapy.

17. Costs associated with hearing tests, vision corrections, prosthetic devices and hearing and vision aids.

18. Patient treatment supplies (including elastic stockings, ace bandages, gauze and the like products; non-prescription drugs and treatments, excluding such supplies required as a result of Healthcare Services rendered during a

Medical Emergency).

19. Services rendered by any medical provider relevant of an Insured Person or who is a member of an Insured Person's family, including spouse, brother, sister, parent or child.

20. Healthcare services for an analysis and adjustment of spinal subluxation, diagnosis and treatment by manipulation of the skeletal structure, by any means, except treatment of fractures and dislocations of the extremities.

21. Healthcare services and treatments by acupuncture; acupressure, hypnotism, Rolfing, massage therapy, aromatherapy, homeopathic treatments, and other forms of alternative treatment.

22. All Healthcare services & treatments for in-vitro fertilization (IVF), embryo transport; ovum and male sperms transport.

23. Elective diagnostic services and medical treatment for correction of vision.

24. Nasal septum deviation and nasal concha resection.

25. All chronic conditions requiring hemodialysis or peritoneal dialysis, and related test/treatment or procedure.

26. Birth defects, congenital disease &/or deformities unless life-threatening.

27. Healthcare services for senile dementia and Alzheimer's disease.

28. Terrestrial or air transportation in cases other than medical emergencies or unauthorized transportation services.

29. Circumcision healthcare services.

30. Inpatient treatment received without prior approval from the insurance company which were not notified within 24 hours from the date of admission.

31. Any test or treatment, which is not related to a specific symptom and/or disease, examinations required for employment, travel, licensing or insurance purposes.

32. All supplies which are not considered as medical treatments including but not limited to: mouthwash, toothpaste, lozenges, antiseptics, milk formulas, food supplements, skin care products, shampoos and multivitamins (unless prescribed as replacement therapy for known vitamin deficiency conditions) and all equipment not primarily intended to improve a medical condition or injury, including but not limited to air conditioners or air purifying systems, arch supports, convenience items/ options, exercise equipment and sanitary supplies.

33. More than one consultation or follow up with a medical specialist in a single day unless referred by a physician.

34. Health services and associated expenses for organ and tissue transplants, irrespective of whether the insured person is a donor or recipient.

35. All kinds of education programs and/or learning disabilities treatments.

36. Injuries resulting from criminal acts or resisting authority by the insured person.

37. All cases resulting from the use of alcohol, non-prescribed narcotic drugs and hallucinatory substances by the insured person.

38. Any examination or treatment not prescribed by a doctor.

39. Injuries resulting from attempted suicide or self-inflicted injuries.