Attachment 0008-Current Policy_Redacted.pdf

Contents

Some terms explained 4

Emergency treatment 4

In-patient, day-care and out-patient treatment 4

Your table of benefits 5

Network 5

Out-patient co-insurance 5

Member reimbursement claims co-insurance 5

Area of cover 5

Pre-existing conditions and chronic conditions 6

Plan annual maximum 6

In-patient benefits 7

Out-patient benefits 11

Other benefits 15

CCHI (Council of Cooperative Health Insurance) mandated benefits 19

Maternity benefits 22

Dental benefits 24

Vision benefits 25

Wellbeing benefits 26

International employee assistance programme 27

General exclusions 28

Your table of benefits

Benefits Clarifications

Network VIP Your assigned list of medical providers which you can visit to receive treatment on a direct billing basis.

Class VIP This is the employment class of the member

Pre-approval limit VIP 1,500 SAR

This is the monetary limit for treatment that would require prior approval. For treatment that meets or exceeds this limit, the network provider will contact us to seek approval for the required treatment.

Note:

Approved pre-authorisation is not guaranteed.

Request will be applied against benefits, policy wording, exclusions, local regulatory guidelines, and medical necessity.

Out-patient co-insurance

Covered Co-pay:

Nil

This is the percentage / amount payable per person, per out-patient consultation, and per service (e.g.

laboratory tests, x-ray).

Note:

The co-pay maximum within the minimum unified network is $20 / SAR 75.

Member reimbursement claims co-insurance

0% This is the percentage payable by the member when electing to receive treatment:

At a chosen out-of-network provider; or

In-network on a member re-imbursement basis, rather than availing direct billing.

Note:

The selected out-patient co-insurance applies in addition to any member re-imbursement claims co-insurance.

The member re-imbursement claims co-insurance will not apply in the following circumstances:

1. Treatment is not available within our network.

Area of cover Area: I Area I : Worldwide Area II: Worldwide excluding USA Area IV: Gulf Cooperation Council (GCC) countries (Saudi Arabia, UAE, Kuwait, Oman, Bahrain and Qatar), Pakistan, India, Egypt, Jordan, Lebanon, Syria, Yemen, Afghanistan, Africa Central Rep, Algeria, Angola, Benin, Botswana, Burkina Faso, Cameroon, Chad, Congo, Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea Republic, Guinea Bissau, Iran, Iraq, Ivory Coast, Kenya, Liberia, Libya, Madagascar, Malawi, Malaysia, Mali, Mauritania, Mauritius, Morocco, Mozambique, Namibia, Niger Republic, Nigeria, Philippines, Rwanda, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, Sri Lanka, Sudan, Swaziland, Tanzania, Thailand, Togo Republic, Tunisia, Uganda, Zambia and Zimbabwe, except where coverage and services (including payments) are illegal pursuant to and in compliance with applicable sanction laws.

Pre-existing conditions and chronic conditions

Covered Medical conditions or any related conditions for which one or more symptoms have been displayed at some point during your lifetime, irrespective of whether any medical treatment or advice was sought, and any such condition or related condition which you could reasonably have been assumed to have known.

Note:

Any drugs prescribed for use as an out-patient, are paid from your prescribed out-patient drugs and dressings benefit.

Plan annual maximum SAR 28,173,750 per year of insurance

Applies per insured person per year of insurance.

In-patient/day case healthcare benefits Clarifications

Hospital charges for:

Accommodation for in-patient treatment

Nursing for in-patient treatment

Day case treatment

Operating theatre and recovery room

Prescribed medicines, drugs and dressings for in-patients or day case patients

Covered Private Room

We pay charges for your hospital accommodation, including all hospital meals.

We do not pay for personal items such as but not limited to telephone calls, newspapers, guest meals or cosmetics.

We pay for the length of stay that is medically appropriate for the procedure that you are admitted for.

Examples:

Unless medically necessary, we do not pay for day-case accommodations for out-patient treatment (such as an MRI scan), and we do not pay for in-patient accommodations for day-case treatment (such as a biopsy) under this benefit.

Companion accommodation Covered We pay for the costs of accommodation for a person accompanying an in-patient member in the same room at the recommendation of the treating doctor, based on medical necessity.

Note:

This does not include costs for meals and personal items such as but not limited to telephone calls, newspapers, or guest meals.

Parental accommodation Covered We pay for hospital accommodations for each night you need to stay with your child in the same room.

This is limited to:

Only one parent each night.

Your child must be under 18, and a member of a plan that is administered by us receiving treatment for which he or she is covered under their plan.

Note:

This does not include costs for meals and personal items such as but not limited to telephone calls, newspapers, or guest meals.

Benefit is not applicable if child is in ICU or HDU ward, where parental accommodation is not available in the same room as the child.

In-patient cash benefit Not covered We will pay the specified amount to the employee or dependant for each night spent in hospital, up to a maximum of 25 nights per year of insurance.

The benefit is only payable where in-patient treatment is received completely free of charge and would have otherwise come at a cost to the member and in respect of treatment that is covered under the terms and conditions of the policy. For example, if a member received treatment at no charge from a governmental hospital or in an equivalent registered or licensed hospital under the laws of the country, state or other regulated area in which the treatment is provided rather than electing to receive treatment at a chargeable hospital/facility.

An overnight stay must commence before midnight.

The benefit will be payable upon discharge from hospital and submission of all invoices and supporting medical documentation.

Note:

We will not pay any amounts which are higher than the benefit detailed.

This benefit is available only on a reimbursement basis.

fees Covered We pay for the fees charged by surgeons and anaesthetists for the eligible treatment they deliver based on the complexity, time and skill required to perform a procedure.

Covered This benefit is paid in full for regular visits by a specialist physician during stays in hospital including intensive care for as long as is required by medical necessity.

Surgical procedures Covered This means a medical procedure involving incision with instruments, performed to repair damage or arrest disease in a living body.

Note:

This benefit does not include follow-up consultations with your consultant as these are paid from the out-patient benefit.

Intensive care Covered We pay for intensive care in an intensive care unit/ intensive therapy unit, high dependency or coronary care unit (or their equivalents) when:

It is an essential part of your treatment, and is required routinely by patients undergoing the same type of treatment as yours, or

It is medically necessary in the event of unexpected circumstances; for example if you have an allergic reaction during surgery, seizures, etc.

Radiology and pathology Covered We pay for the following when recommended by your consultant to help determine or assess your condition when carried out in a hospital.

Radiology: such as x-rays, magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography (PET), and diagnostic tests such as electrocardiograms (ECGs).

Pathology: such as checking blood and urine samples.

Home nursing charges Covered We pay for home nursing after eligible in-patient treatment:

If recommended by a specialist physician immediately after hospital treatment for as long as is required per medical necessity.

When home nursing is provided by a recognised nurse, licensed by the regulatory authority in the region.

On a full-time basis for as long as is required by medical necessity for treatment which would normally be provided in hospital; when recommended by a specialist physician.

Surgical appliance and/or medical appliance

Covered This means an artificial body part or appliance which is designed to form a permanent part of your body and is surgically implanted.

We pay for:

An artificial limb, prosthesis or device which is inserted during surgery; for example, to replace a joint or ligament.

An artificial prosthesis or device which is a necessary part of the treatment immediately following surgery for as long as is required by medical necessity; for example, heart pacemaker or heart valves.

A prosthesis or appliance which is medically necessary and is part of the recuperation process immediately following an in-patient treatment on a short-term basis.

Organ transplant Covered By this we mean the moving of an organ from one body to another, to replace the damaged or absent organ.

Organs most often transplanted include but are not limited to:

Kidney

Liver

Heart

Pancreas

Lung

Small intestine We pay for charges made for or in connection with approved organ transplant services, including immunosuppressive medications, organ procurement reduced by the amount payable for those costs from any other plan or source.

Certain transplants will not be covered based on general limitations (e.g. experimental procedures).

Note:

Any drugs prescribed for use as an out-patient, including anti-rejection drugs, are paid from your prescribed out-patient drugs and dressings benefit.

We do not pay for organ donor search.

Psychiatric care Covered We pay for in-patient non-emergency psychiatric conditions, other mental health disorders or addictive conditions.

International emergency services

Covered This benefit requires pre approval and arrangement by for the following services:

a) Emergency medical evacuation.

b) Medical repatriation.

c) Repatriation of mortal remains.

d) Reasonable transport costs for third parties.

Note:

All expenses incurred which is not been pre-approved and arranged by are not covered under the plan.

We do not pay for hotel accommodation costs for the accompanying person.

Local ambulance Covered This benefit is payable for transport to or from a hospital.

We pay for medically necessary travel by road ambulance when related to eligible in-patient treatment, day-case treatment or emergency treatment.

Rehabilitation Covered We pay for treatment in the form of a combination of therapies such as physical, occupational and speech therapy aimed at restoring full function after an acute event such as a stroke.

We only pay for rehabilitation where it starts within 30 days of in-patient treatment which is covered byyour plan (such as trauma or stroke).

Note:

We do not cover treatment for or in connection with speech therapy that is not restorative in nature, or if such therapy:

Is used to improve speech skills that have not fully developed.

Can be considered custodial or educational; or

Is intended to maintain speech communication.

*Please check the separate autism benefit for details on the rehabilitation services that are covered for autistic patients.

Physiotherapy Covered We pay for treatment provided by a physiotherapist if it is needed as part of your treatment in hospital.

Please note:

If you chose an out-patient co-insurance option, then the co-insurance will apply to all out-patient services ( i.e.

consultations, x-rays, laboratory, maternity, vision, etc). This out-patient co-insurance will not apply to prescribed drugs or dental which will have their own co-insurance.

Out-patient healthcare benefits Clarifications

Out-patient consultations Covered We pay for consultations with medical practitioners, family doctors and specialists.

Note:

No co-insurance applies on a follow-up visit if made within fourteen days unless new services have been requested during the follow up visit.

Prescribed medicines, drugs and dressings inside KSA

Branded medication

Covered

Co-pay of:

Nil

Generic medication

Covered

Co-pay of:

Nil

We pay for prescribed medications, drugs and dressings by a medical practitioner for eligible treatment. It also includes prescribed vitamins where they have been prescribed as treatment for a diagnosed vitamin deficiency condition.

Note:

This benefit excludes non-prescribed over-the-counter medications and vitamins.

The length of prescription allowed is up to 90 days.

This is subject to prescription by the treating physician and approval by us.

The benefit covers diabetes testing strips & lancets.

Any drugs related to pregnancy including prescribed multivitamins and prescribed mineral supplements are covered under the routine out-patient maternity benefit; this excludes Omega 3 supplements, even if prescribed, (e.g. Pregnacare plus is not covered).

Prescribed vitamins are covered in cases of:

i. Vitamin deficiency conditions (there should be a medical test confirming the vitamin deficiency).

ii. Pregnancy state.

iii. Immune compromised.

iv. If prescribed with antibiotics.

v. For neuropathy.

vi. For diabetic patients.

*Vitamin IV infusions are not covered unless medically necessary.

Herbal products are not covered.

Infertility medications are not covered unless specified in this table of benefits.

Compound medication is not covered unless there is no alternative.

Dental prescribed medicines, drugs and dressings are not covered under this benefit.

Co-pay would be deducted as applicable.

Prescribed medicines, drugs and dressings outside KSA

Covered

Co-pay of:

Nil

We pay for prescribed medications, drugs and dressings by a medical practitioner for eligible treatment. It also includes prescribed vitamins where they have been prescribed as treatment for a diagnosed vitamin deficiency condition.

Note:

This benefit excludes non-prescribed over-the-counter medications and vitamins.

The length of prescription allowed is up to 90 days.

This is subject to prescription by the treating physician and approval by us.

The benefit covers diabetes testing strips & lancets.

Any drugs related to pregnancy including prescribed multivitamins and prescribed mineral supplements are covered under the routine out-patient maternity benefit; this excludes Omega 3 supplements, even if prescribed, (e.g. Pregnacare plus is not covered).

Prescribed vitamins are covered in cases of:

i. Vitamin deficiency conditions (there should be a medical test confirming the Vitamin deficiency).

ii. Pregnancy state.

iii. Immune compromised.

iv. If prescribed with antibiotics.

v. For neuropathy.

vi. For diabetic patients.

*Vitamin IV infusions are not covered unless medically necessary.

Herbal products are not covered.

Infertility medications are not covered unless specified in this table of benefits.

Compound medication is not covered unless there is no alternative.

Dental prescribed medicines, drugs and dressings are not covered under this benefit.

Co-pay would be deducted as applicable.

X-rays, laboratory tests and pathology

Covered We pay for x-rays, laboratory tests (including some allergy testing) and pathology.

Non-surgical and minor surgical procedure and treatment

Covered We pay for a treatment or a surgery that does not require an overnight hospital stay, with shorter medical procedure duration.

Complementary and alternative treatment

Covered We pay for acupuncture, chiropody/ podiatry, chiropractic, osteopathy, ayurvedic and homeopathy, when administered by a licensed practitioner.

Note:

This benefit is covered where it is recognised as an alternate treatment and meets the medically necessary criteria for the diagnosed condition.

This benefit only applies to conditions that are covered under the table of benefits and in line with clinical guidelines and local regulations.

We do not cover alternative treatment at a fitness centre unless the fitness centre is registered as a health care provider with the local authorities.

Acupuncture for temporomandibular joint disorders is not covered.

Physiotherapy Covered We pay for the cost of both the consultation and treatment:

The first 5 sessions do not require pre-approval;

after 5 sessions, approval is required.

This treatment must be administered by a licensed physiotherapist; and when referred by a specialist physician.

Treatment given by a physiotherapist must be under the medical supervision of a medical practitioner.

Medical supervision means that the reason for referral has been initiated by the medical practitioner who has defined a diagnosis.

There must be a clear treatment program from the physiotherapist with an end point and expected outcome.

Any further treatment/sessions needed will require review and further referral by the supervising medical practitioner and approval by us.

Speech therapy and occupational therapy

Covered This benefit will be paid if recommended by a specialist and is intended to restore function which has been lost as a result of an accident or an acute medical condition, such as a stroke.

Note:

Acute medical condition refers to a type of medical condition that occurs suddenly without any existing symptoms but improves over a short period of time.

The below conditions are excluded from this benefit:

Children with developmental conditions, e.g. autism spectrum disorder, selective mutism, language delay, learning difficulty, stammering.

Adults with a degenerative condition, e.g.

Speech delay even if medically necessary that is a result of a congenital/hereditary/genetic condition (example: cerebral palsy).

*Please check the separate autism and Alzheimer's benefit for details on the services that are covered for these patients.

Hearing and vision tests Covered We pay for one annual eye test and hearing test for dependent children under the age of 15.

Well child tests Covered We pay for:

Well child consultation as per the appropriate age intervals.

All mandated immunisation for children up to the age of 18.

Note:

This benefit covers vaccines that must be given as per the vaccination schedules mandated by the regional regulatory authorities (MOH/WHO).

Adult travel vaccinations Covered We pay for adult vaccinations related to travel and other medically necessary vaccinations when prescribed by a licensed physician.

Travel vaccinations include (but are not limited to):

Tetanus - every 10 years

Hepatitis A & B

Meningitis

Rabies

Cholera

Yellow fever

Japanese encephalitis

Polio booster

Typhoid

Malaria - tablet form, daily or weekly

Note:

Some providers might ask you for a proof of travel such as air tickets, as per their internal process.

This benefit does not cover vaccination campaigns or mass vaccination events.

Emergency dental treatment

SAR 5,635 We pay for treatment received at a hospital or a licensed dental clinic; for the first emergency visit immediately or within 24 hours maximum after accidental damage to sound, natural teeth at the time of accident.

Psychiatric care SAR 50,000 This benefit is covered when a psychiatric condition exists. We pay for treatment of non-emergency out-patient psychiatric conditions or other mental disorders or addictive conditions.

Note:

Counselling is covered under this benefit only when an underlying psychiatric condition has been diagnosed.

Oncology treatment in-patient and out-patient

Covered

Wigs are covered up to SAR 940 per year of insurance

Once cancer is diagnosed, we pay fees that are related specifically to planning and carrying out treatment for cancer.

This includes consultation, laboratory & radiological investigations, prescribed medications, chemotherapy and radiotherapy.

Note:

Wigs for hair loss due to cancer treatment are covered up to the limit shown in the benefit on reimbursement basis.

Other benefits Clarifications

AIDS/HIV Covered We pay for treatment in connection with human immunodeficiency virus (HIV) related illness including acquired immune deficiency syndrome (AIDS).

Congenital and/or hereditary disorders

Covered We pay for any disorder or illness acquired during conception or the foetal stage of development as a result of the genetic make-up of the parents or environmental factors, whether or not it is manifested or diagnosed before birth, at birth, after birth, or years later.

Note: This benefit excludes:

Any dental treatment related to congenital jaw deformities, surgical removal of impacted teeth, the surgical removal of cysts and orthognathic surgeries for the correction of malocclusion are not covered unless a dental plan has also been selected.

Treatment for autism, and treatment for or in connection with speech therapy that is not restorative in nature, or if such therapy is:

a) Used to improve speech skills that have not fully developed.

b) Can be considered custodial or educational; or

c) Intended to maintain speech communication.

Treatment for or in connection with developmental disorders, including but not limited to:

i. Developmental reading disorders

ii. Developmental arithmetic disorders

iii. Developmental language disorders

iv. Developmental articulation disorders

*Please check the separate autism benefit for details on the services that are covered for autistic patients.

Medically necessary reconstructive surgery

Covered We pay for medically necessary reconstructive surgeries which are related to an injury, sickness or congenital anomaly when the primary purpose is to improve physiological functioning of the involved part of the body and appearance after a disfiguring accident, or as a result of surgery for cancer, if the accident or surgery occurs during your membership of the scheme.

Hepatitis and associated complications

Covered We pay for any healthcare services, investigations and treatments related to hepatitis and associated complications.

Hospice and palliative care Covered We pay for palliative care for in-patient, day case or out-patient treatment following the diagnosis that the condition is terminal with a life expectancy of less than six

(6) months, and treatment can no longer be expected to cure the condition; will pay for the physical care, psychological care as well as hospital or hospice accommodation, nursing care andprescription drugs.

Please note:

If you chose an out-patient co-insurance option, then the co-insurance will apply to all out-patient services ( i.e.

consultations, x-rays, laboratory, maternity, vision etc). This out-patient co-insurance will not apply to prescribed drugs or dental which will have their own co-insurance.

occurring menopause. However, treatment involving unproven or experimental methods or procedures will not be covered.

Injuries resulting from natural disasters

Covered We pay for injuries due to but not limited to: floods, hurricanes, tornadoes, volcanic eruptions, earthquakes, tsunamis, and any other type of natural disaster.

Injuries resulting from attempted suicide or self-inflicted injuries

Covered We pay for treatment for, or arising from, an injury that you have intentionally inflicted on yourself, for example, during a suicide attempt.

Sleep disorders such as obstructive sleep apnoea diagnosis

Covered We pay for a sleep study upon recommendation of a specialist physician, subject to medical necessity, for the diagnosis of suspected obstructive sleep apnoea (OSA) when specific criteria are met.

Passive war risk Covered We pay for injuries sustained due to an act of war provided the member is not participating.

Prosthetic devices and medical equipment

Covered We pay for this benefit when determined as medically necessary on a short-term basis and approved by us.

Examples of durable medical equipment (different from a surgical appliance):

Wheelchairs

Walkers Prosthetic devices and medical equipment must be prescribed by a licensed physician and must meet all of the following criteria:

-approved for the purpose being prescribed.

intermediate nursing facility.

treatment of your illness or injury, or to improve the functioning of a malformed body part.

an illness or injury.

For mobility equipment, it is used to help a patient in daily living activities such as toileting, feeding, dressing, grooming, and bathing in a home.

Electric wheelchairs will only be covered when medically necessary and no other option is available.

Note:

Hearing aids are covered under a separate benefit.

Breast pumps are not covered under this policy.

Road traffic accident Covered We pay for treatment of injuries sustained during a road traffic accident.

Work-related injuries Covered We pay for bodily injury sustained at the insured injury to a body part.

Note: we will not pay for work-related diseases.

Infertility investigation Covered We pay for the investigation of infertility to the point of diagnosis.

Note:

We will not pay for any investigation into the cause of infertility.

Developmental disorders Not covered We pay for all expenses related to the treatment including behaviour training & behaviour management, speech therapy, occupational therapy, physical therapy and medicine.

Note:

Please check the separate autism benefit for details on the services that are covered for autistic patients.

Emergency psychiatric conditions

Covered We pay for in-patient and out-patient emergency psychiatric conditions, other mental disorders or addictive conditions.

Note:

An emergency is defined as urgent medical treatment required by the medical condition of the insured as a result of an accident or a case requiring prompt medical attention, depending on the following levels of urgent medical care (1.

Resuscitation, 2. Emergency, 3. Urgent condition that may be resulting in death, loss of one or more organs, or the occurrence of an accidental or permanent disability situation) as described by the private health institutions law and regulations approved by the ministry of health, which determines how to dispatch emergency cases.

Council of Cooperative Health Insurance (CCHI) mandated benefits

Clarifications

Circumcision for newborn baby boys

Up to

SAR 500

per year of insurance

We pay for the cost of circumcision for newborn boys.

Acquired heart valve damage

Up to SAR 150,000 per year of insurance

We pay for the costs of acquired heart valve damage.

Up to SAR 15,000 per year of insurance

We pay for any treatments and some associated expenses for the treatment once diagnosed.

Disability Up to SAR 100,000 per year of insurance

We pay for the cost of disability cases.

Autism Up to SAR 50,000 per year of insurance

We pay for the costs of the services available for autistic patients, including:

1. Diagnosis of autism spectrum disorder.

2. Medical diagnostic procedures magnetic resonance, analysis of genes and metabolic diseases and others.

3. Psychological evaluation and psychometric testing - IQ, autism, and autism scale CAROS, ADOS, VINLAND.

4. Medical rehabilitation - speech therapy, functional therapy, and behaviour modification therapy.

5. Early intervention program - for children less than 6 years, minimum 3 hours per day three times a week for two years.

6. Medical and psychological counselling.

Hearing aids Up to SAR 6,000 per year of insurance

We pay for the cost of hearing aids.

Renal dialysis Up to SAR 180,000 per year of insurance

We will pay for renal dialysis-related investigations, treatments or procedures.

Ear piercing for newborn baby girls

Up to SAR 300 per year of insurance

We will pay for ear piercing for newborn baby girls.

A newborn is a child under 2 months of age.

National programme of newborns early examination to reduce disability

Up to SAR 100,000 Per year of insurance

We will pay for the national programme of newborns early examination to reduce disability.

Please note:

If you chose an out-patient co-insurance option, then the co-insurance will apply to all out-patient services (i.e.

consultations, x-rays, laboratory, maternity, vision etc). This out-patient co-insurance will not apply to prescribed

Early hearing screening programme and critical congenital heart disease programme for all newborn babies

Covered We will pay for early hearing screening and critical congenital heart disease for all newborn babies.

Immunization programme from RSV for children.

Covered We will pay for the immunization program from RSV for children.

Baby formula up to age of 24 months

Covered We will pay for baby formula up to the age of 24 months when prescribed by a treating doctor.

This benefit will cover the following cases/conditions:

i. Metabolic disorders.

ii. Diseases of the national programme of newborns.

iii. Early examination to reduce disability.

iv. Allergy to milk or sugar.

v. Malabsorption issues.

vi. Babies which are premature or underweight or understrengthened due to gestational age which milk.

vii. Metabolic diseases.

Psoriasis treatment Covered We will pay for psoriasis treatment.

Obesity SAR 15,000 per year of insurance

We will pay for bariatric and metabolic approved treatment options only when the member meets the inclusion criteria for bariatric surgery as defined in the bariatric surgery guidelines - basic health insurance policy

Sexually transmitted diseases

Covered We will pay for the treatment of sexually transmitted diseases (whatever the way the infection occurs).

Includes cover for nongonococcal urethritis, trichomoniasis, HIV, syphilis, human papillomavirus (genetic warts), Neisseria gonorrhoeae, genetic herpes, chancroid.

Mammograms for breast cancer screening

Covered We will pay for:

One baseline mammogram for asymptomatic women aged 35-39.

A mammogram for asymptomatic women aged 40-49 every two years.

A mammogram every year for women aged 50 and over.

Pap smear to detect cervical cancer

Covered We will pay charges for an annual papanicolaou screening for women aged 21-65 years old.

Colon cancer screening Covered We will pay for a fecal immunochemical test (FIT) or colonoscopy as per the medical necessity and best clinical practice to detect colon cancer. (Fecal immunochemical test) or colonoscopy according to medical need and best medical practices.

Costs for contraception SAR 1,500 per year of insurance

We will pay for temporary contraception that includes hormonal contraceptives therapy and intrauterine devices according to the approved guidelines with the contraception clinical practice guidelines.

Bone densitometry (DEXA) to detect osteoporosis

Covered We pay for one DEXA scan for women every 1.5 to 2 years, when they meet the below criteria:

Women 65 years and older.

or

Postmenopausal women younger than 65 years increased risk of:

i. Osteoporotic fractures

ii. Parental history of hip fracture

iii. Smoking

iv. Excessive alcohol consumption

v. Low body weight

Telemedicine Covered We shall provide, within the minimum network, a telemedicine service according to the classification of service providers approved by the council to provide this service.

Functional vision corrective intervention that prevent vision loss

Covered We pay for functional vision corrective: interventions to improve vision that are important for vision preservation amblyopia procedures for children less than 14 years and keratoconus, cataract, glaucoma for all age groups.

Coverage is based on local regulations.

Complications resulting from a benefit treatment covered in the policy

Covered We will pay for any complications arising from treatment relating to a benefit covered under this policy.

Maternity Benefits Benefit Limit Clarifications

Routine in-Patient Covered We pay for eligible females covered under this plan. In-patient and day-case normal maternity and childbirth.

Normal maternity and childbirth as in-patient or day-case treatment.

These benefits include medically necessary costs, for example:

Antenatal care such as ultrasound scans.

fees for pregnancy and childbirth.

Post-natal care required by the mother immediately following normal childbirth, such as stitches.

baby.

Birth and therapy of premature babies.

Note:

Eligible female means a person who is a female employee or a female spouse of an employee.

Treatment for abnormal cell growth in the womb (hydatidiform mole) is not covered under this benefit but may be covered by your other in-patient benefits.

Routine out-Patient Covered This benefit is payable to eligible females covered under this plan.

Out-patient ante-natal services.

We pay for out-patient examination, diagnostic tests and out-patient treatment services for pregnancy and gynaecology services, including consultation fees by general practitioners, a family doctor and/or consultants.

Pregnancy Benefits and services include:

Antenatal care such as ultrasound scans.

for pregnancy.

Note:

Prescribed multivitamins and prescribed mineral supplements are covered under this benefit. We do not pay for Omega 3 supplements, even if prescribed.

Eligible female means a person who is a female employee or a female spouse of an employee.

Complications of pregnancy and childbirth

Covered This benefit is payable to eligible females covered under this plan, and includes medically necessary elective and non-elective caesarean sections. By this we mean where a caesarean section is either planned (elective) for known complications (e.g. placenta previa, eclampsia, cephalopelvic disproportion, etc.) or

Please note:

If you chose an out-patient co-insurance option, then the co-insurance will apply to all out-patient services (i.e.

consultations, x-rays, laboratory, maternity, vision etc). This out-patient co-insurance will not apply to prescribed emergency (non-elective) where a caesarean section becomes necessary after labour has started. (e.g. non-progression during labour (dystocia), foetal distress, haemorrhage, etc.).

Note:

This benefit is subject to review as per clinical coverage guidelines.

Eligible female means a person who is a female employee or a female spouse of an employee.

Birth and therapy of premature babies is covered.

Newborn care Covered up to 30 days under

We pay for newborns up to 30 days from birth under policy.

This includes BCG, Hepatitis B and neo-natal screening test (Phenylketonuria (PKU), congenital hypothyroidism, sickle cell screening, congenital adrenal hyperplasia).

Note:

Please review your member guide on to add your dependant to the insurance

If the mother is not insured under the plan, the coverage will start after the baby is officially enrolled on to the plan.

Legal abortion Covered We pay for the medical costs for the treatment of legal abortion upon recommendation by the treating physician in cases of medical necessity.

International Employee Assistance programme (IEAP Level 2)

Telephonic and face to face counselling - 6 visits per event

This benefit provides telephone counselling which is available 24/7 through a toll-free line. The multilingual questions, assesses the problem, whether big or small, discusses and develops an action plan together with them.

Members have unlimited access to telephonic support.

Dental benefits Option 3 Clarifications

Annual maximum SAR 22,500 per year of insurance

Annual table of benefits maximum per member or dependant.

Note:

1. Examinations and scale and polish will both be limited to 2 visits per year of insurance.

2. Full case assessment will be limited to one per year of insurance.

3. X-rays will be limited to four bitewings and six intra oral per year of insurance and OPG every 3 years.

4. Prolonged periodontal treatment limit of one course per year of insurance.

5. Please refer to the full dental exclusion list for non-covered services.

6. Dental prescribed medicines, drugs and dressings are covered under this benefit and the co-insurance applied will be the lowest of the dental treatment classes.

Class one Investigative and preventative treatment

Covered up to the dental annual maximum

Benefits include:

X-rays, scale and polish.

Class two Basic restorative treatment, periodontal treatment and treatment of dental injury

Covered up to the dental annual maximum

Benefits include:

Root canal treatment, fillings including the composite types (e.g. amalgam filling), extractions, surgical procedures, occasional treatment, anaesthetics, periodontal treatment.

Class three Major restorative treatment

Covered up to the dental annual maximum

Benefits include:

Dentures acrylic/synthetic, metal and metal/acrylic.

Crowns, bridge , inlays, mouthguard or occlusal splint.

For molars, we only cover porcelain fused to metal crowns/bridges where medically necessary.

Orthodontic treatment Covered up to the dental annual maximum

We pay for orthodontic treatments only for members under the age of 18 years old.

Please note:

If you chose an out-patient co-insurance option, then the co-insurance will apply to all out-patient services (i.e.

consultations, x-rays, laboratory, maternity, vision etc). This out-patient co-insurance will not apply to prescribed

Vision benefits Benefit Clarifications

One eye examination per year of insurance

SAR 2,813

per year of insurance

The examination must be done by a registered optometrist or an ophthalmologist.

Note:

We will not pay benefit for the following treatment and extras:

More than one eye examination in any one year of insurance.

Medical or surgical treatment of the eye (this is covered when it is not cosmetic in nature and medically necessary only under your medical plan).

Expenses for:

Prescribed lenses to correct vision

Eyeglass frames (once per year of insurance)

Prescription sunglasses

We will pay for Lenses / Eyeglass frames where prescribed by a registered optometrist or an ophthalmologist.

Note:

We will not pay benefit for the following treatment and extras:

Lenses/eyeglass frames/ sunglasses which are not supported by a prescription from a registered optometrist or ophthalmologist.

More than one pair of prescribed eyeglass frames/ sunglasses in a policy year.

Please note:

If you chose an out-patient co-insurance option, then the co-insurance will apply to all out-patient services (i.e.

consultations, x-rays, laboratory, maternity, vision etc). This out-patient co-insurance will not apply to prescribed

Wellbeing benefits Clarifications

Routine adult physical examinations

SAR 1,690 per year of insurance

We pay for routine physical examinations for members/dependants over the age of 18 years old.

This benefit includes reimbursement for the initial consultation with a general or specialist physician.

Examples would include full physical examination; health assessment (e.g. body mass, blood pressure, ECG, cholesterol check, urinalysis, etc.); health questionnaire (e.g. diet, exercise, work, lifestyle, etc.).

The routine adult physical examinations benefit includes but is not limited to:

LFT lung function test

RFT renal function test

LFT liver function test

CBC complete blood count

ECG electrocardiogram

X-ray

Fasting blood sugar for glucose

Vitamin D test

Note:

This benefit is subject to review as per clinical coverage guidelines.

Prostate cancer screening We will pay charges for an annual prostate cancer screening for eligible males over 50 years old.

Please note:

If you chose an out-patient co-insurance option, then the co-insurance will apply to all out-patient services ( i.e.

consultations, x-rays, laboratory, maternity, vision etc). This out-patient co-insurance will not apply to prescribed

Optional benefits

General exclusions

Medical expenses for the treatment of below items or consequences as a result of it are not covered unless specifically mentioned as covered in the table of benefits and in line with the clinical guidelines for medical necessity and local regulations.

We will not pay benefit for the following treatment and extras:

1. Speech therapy We do not cover treatment for or in connection with speech therapy that is not restorative in nature, or if such therapy is:

Used to improve speech skills that have not fully developed.

Can be considered custodial or educational; or

Intended to maintain speech communication.

2. Harmful or hazardous use of alcohol, drugs and/or medicine(s) treatment for or arising from the harmful, hazardous or addictive use of any substance including alcohol, drugs and/or medicine(s), whether prescribed or not excluding the costs of treating emergency cases (life-threatening injuries) as described by the private health institutions law and regulations approved by the ministry of health, which determines how to dispatch emergency cases.

3. Sterilization and sexual dysfunction

We do not cover investigations into, treatment of and complications arising from sterilization, sexual dysfunction (unless this condition is as a result of total prostatectomy following surgery for cancer).

4. Hair loss and hair replacement

We do not cover investigations into, treatment for and associated expenses of loss of hair and any hair replacement (alopecia, baldness, hair falling out, dandruff orwigs) unless otherwise is specified in your table of benefits.

5. Other treatments including but not limited to: Health hydros, nature cure clinics, spas and gyms

We do not cover treatment or services which do not seek to improve or which do not result in a change in the medical condition of the patient received in a health hydro, nature cure clinic, health spa, nursing home or any similarestablishment that is not a hospital.

6. Residential stays in a hospital

We do not cover charges for residential stays in a hospital that is arranged wholly or partly for domestic reasons or where treatment is not required or where the hospital has effectively become the place of domicile or permanent abode.

7. Growth hormone therapy We do not cover treatment that uses growth hormones to stimulate growth and cellreproduction, often given as prescribed medication.

8. Infertility treatment Unless otherwise specified in your table of benefits, we do not cover any treatment neededbecause of or relating to infertility or any type of fertility treatment, including complications arising out of such treatment, such as:

In-vitro fertilisation (IVF)

Gamete intrafallopian transfer (GIFT)

Zygote intrafallopian transfer (ZIFT)

Artificial insemination (AI)

Prescribed drug treatment

Embryo transport (from one physical location to another), or

Donor ovum and/or semen and related costs

We will pay for the investigation of infertility to the point of diagnosis.

9. Termination of pregnancy We do not cover treatment by way of the intentional termination of pregnancy, unless two medical practitioners certify in writing that the pregnancy were to endanger the life or mental stability of the mother, and provided it is a legal abortion/ termination of pregnancy where maternity benefit has been selected.

21. Hospital accommodation costs

We do not cover hospital accommodation costs that are more expensive than those of astandard private room unless mentioned in the table of benefits.

22. Sex change We do not cover sex change operations or any treatment needed to prepare for or recoverfrom these operations (for example, psychological counselling), including complications arising out of such treatment.

23. Self-inflicted injuries We do not cover complications from self-inflicted injury, excluding the costs of treating emergency cases (life-threatening injuries) as described by the private health institutions law and regulations approved by the ministry of health, which determines how to dispatch emergency cases.

24. Smoking cessation programmes

We do not cover supplies, treatment and services for smoking cessation programmes andthe treatment of nicotine addiction.

25. Stem cells We do not pay for harvesting or storage of stem cells. For example, ovum, cord blood or sperm storage.

Note:

We pay for stem cell transplants when carried out as part of the treatment for cancer. This is covered under the cancer treatment benefit.

26. Professional sports We do not cover treatment that arises from or is any way connected with injury, sickness ordisablement as a result of:

Taking part in a sporting activity on a professional basis; or

Solo scuba-diving or scuba diving at depths below 30 metres unless the diver is PADI qualified (or equivalent) for that depth.

27. Experimental, investigational or unproven treatment

We do not cover any form of experimental treatment (or procedure) that does not amount to orthodox treatment or does not adhere to the commonly accepted, customary or traditional practice of medicine in the country where the services were rendered and which meet minimum international standards of medicine.

We do not pay for any treatment or medicine which in our reasonable opinion is not effective based on acceptable current clinical evidence and practice.

28. Illegal claim payments We do not cover payments that are illegal under applicable law; in particular, where claimpayment contravenes any applicable sanction laws as more specifically stated in the preamble.

29. Activities of daily living We do not cover assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other custodial services or self-care activities,homemaker services and services primarily for rest, domiciliary or convalescent care.

30. Obesity treatment Unless mentioned in your table of benefits, we do not cover medical and surgical services, e.g. gastric sleeve. Initial and repeat, intended for the treatment or control of obesity, including medical and surgical services to alter appearance or physical changes that are the result of any surgery performed for the management of obesity and weight loss programmes or treatments, whether prescribed or recommended by a medical practitioner or under medical supervision.

31. Medical services that are not required for health reasons

We do not cover for reports, evaluations, physical examinations, or hospitalization not required for health reasons including, but not limited to, employment, insurance or government licenses, and court-ordered, forensic or custodial evaluations.

32. Routine foot care We do not cover routine foot care, including the paring and removing of corns and callusesor trimming of nails or thickened or misshapen nails.

33. Membership costs or fees We do not cover membership costs or fees associated with health clubs, weight loss programmes and smoking cessation programmes.

34. Genetic screening We do not cover genetic screening or pre-implantations genetic screening when such screenings are solely performed to determine whether or not you may be genetically likely to develop a medical condition.

35. Cosmetic treatment We do not cover any treatment carried out by a plastic surgeon (plastic, cosmetic or reconstructive surgery), whether or not for medical/psychological purposes and any cosmetic or aesthetic treatment to enhance your appearance, even when medically prescribed and any related complications.

The only exception is reconstructive surgery necessary to restore function or appearance after a disfiguring accident, or as a result of surgery for cancer, if the accident or surgery occurs during your membership in the scheme.

Note:

All cosmetic healthcare services and services associated with replacement of an existing breast implant will be excluded, in addition to abdominoplasty or treatment related to or arising from the removal or addition of non-diseased or surplus or fat tissue.

Nose surgeries for cosmetic purposes are not covered.

The deviated nasal septum surgery requires pre-approval and review as per clinical guidelines.

36. Hearing tests We do not cover hearing tests unless medically necessary.

37. Chinese medicine We do not cover any form of chinese medicine, including but not limited to:

Herbal medicine(s)

Dietary therapy

Joint manipulation

Meditation

38. Organ transplant Unless otherwise stated in your table of benefits, we do not cover treatment costs for, or as a result of the following:

Transplants involving mechanical or animal organs, except where a mechanical appliance is temporarily used to maintain bodily function whilst awaiting transplant.

The removal of an organ from you for purposes of transplantation into another person.

The harvesting and storage of stem cells, when this is carried out as a preventive measure against future possible diseases or illness.

Certain transplants will not be covered based on general limitations (e.g.

experimental procedures).

Reimbursement of costs incurred due to donor search.

39. Appliances We do not cover appliances unless otherwise stated in your table of benefits.

40. Incidental costs We do not cover incidental costs including newspapers, taxi fares, telephone

41. Non-medical treatments and supplies

We do not cover all supplies which are not considered as medical treatments, including but not limited to: Mouthwash, toothpaste, lozenges, antiseptics, milk formulas (except as covered under the baby a formula benefit), 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.

42. Vitamins or minerals We do not cover products classified as vitamins or minerals (except during pregnancy or to treat diagnosed, clinically significant vitamin deficiency syndromes) and supplements including, but not limited to, special infant formula (except as covered under the baby formula benefit), and cosmetic products, even if medically recommended, prescribed or acknowledged as having therapeutic effects. Costs incurred as a result of nutritional or dietary consultations are not covered, unless as specified under your table of benefits.

43. Routine exams and tests We do not cover routine examinations or tests including health screens and medical examinations except for child wellness tests and/or adult wellnessbenefit(s), where those benefit(s) have been selected.

44. Health-related services which do not seek to improve or which do not result in a change in the medical condition of the patient

We do not pay non-medical treatment or artificial life maintenance including mechanical ventilation, where such treatment will not or is not expected to result in your recovery or restore you to your previous state of health.

Example:

We will not pay for artificial life maintenance when you are unable to feed or breathe independently and require percutaneous endoscopic gastrostomy (PEG) or nasal feeding except in the cases of cancer.