Member Guide

Basic (Abu Dhabi Plan)

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Daman Headquarters Abu Dhabi Service Points
Next to Centro Rotana Hotel and Aloft Hotel Infinity Services – Moroor Street
ADNEC Area, Abu Dhabi Zones Corp. Mussafah
Telephone: 02 614 9555 Abu Dhabi Immigration
Fax: 02 614 9775
Dept. of Economic Development
P.O. Box 128888
Abu Dhabi Chamber of Commerce
Central Branch Marina Mall
Airport Road, Abu Dhabi Masdar City
Telephone: 02 417 3609 Al Shahama Municipality
P.O. Box 128888

Mussafah Branch Al Ain Service Points

Global Ascent Business Center Infinity Services
Al Musaffah 4, Abu Dhabi Al Wagan Municipality
Behind Mercedes-Benz Mazyad Municipality
Plot No. 12 behind SEHA Al Hayer Municipality
Telephone: 02 815 0209 Sweihan Municipality
P.O. Box 128888 Al Qoaa Municipality
Al Ain Immigration (Visit Visa Only)
Al Ain Branch Al Khaznah Municipality
G01-G02, Ground Flr, Al Wadi Trading Al Maqam Municipality
Centre, Khalifa Bin Zayed Al Awwat St.
Al Ain
P.O Box 69988 Western Region Service Points
Tel: 03-7011001/7011002/7011003 Madinat Zayed, Tamm Center
Ghayathi, Tamm Center
Western Region Branch Silaa, Tamm Center
Saeed Bin Humaid Complex - Block A – Delma, Tamm Center
Al Marfa’a, Tamm Center
1st Floor
Liwa, Tamm Center
Western Region, Abu Dhabi
Telephone: 02 894 4303
Sharjah Service Point
Sharjah Branch Sharjah Immigration
Ground Level, Crystal Plaza, Corniche Road
Sharjah
Telephone: 06 517 15 55 Ras Al Khaima Service Points
Ras Al Khaimah Immigration
Dubai Office
Al Barsha 1, Next to Sharaf DG Metro Station
Hassanicor bldg. (Roche Bobois Furniture
Shop),
5th Floor Room 501
Telephone: 04 436 0222

Dubai Direct Sales Office

Office#601 Capricorn Bldg,
Sheikh Zayed Road, Dubai
Telephone: 04 311 7911

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Table of Contents

Daman: Your Health Insurance Specialist ........................................................................4

Our Specialized Services ..............................................................................................5

What Is Covered? ........................................................................................................6

How To Obtain Your Plan Benefits? ................................................................................7

What Is Not Covered? ............................................................................................8

Important To Know .....................................................................................10

Your Rights and Responsibilities ..........................................................................12

Definitions ..................................................................................................13

Contact Us ...............................................................................................15

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Daman:
Your Health Insurance Specialists

Daman is the first specialized health insurer in the United Arab Emirates. Our strategic partnership with

Munich Re, one of the largest and most reputable reinsurer in the world, has helped us develop a renowned

stretch of competencies in the region, backed by the strong and reliable support of Abu Dhabi Government.

Our products are a result of industry knowledge, market research, and a deep understanding of our

customer’s health insurance needs. Basic Plan is an optimal health insurance plan, covering benefits like

hospital stays, treatments, and medicines within the Emirate of Abu Dhabi; as well as coverage for

emergency services in UAE. This plan offers you health insurance cover of AED 250,000 per person annually.

You can use your health insurance card (Emirates ID , digital insurance card or Daman card) to get direct

billing facility at health service providers across our plan’s Network which includes hospitals, clinics,

pharmacies and diagnostic centres.

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Our Specialized Services
We offer you a distinctive set of world class services as listed below:

 Network of more than 600 health service providers in the Emirate of Abu Dhabi
 24/7 in-house Customer Service Centre staffed with bilingual representatives
 24/7 access to medical authorizations (pre-approvals required to receive specific medical
treatments)
 Automated systems for effective management of your pharmacy benefits
 Efficient claims processing
 Easy access to information on your network directory (including hospitals, pharmacies, clinics,
doctors etc.) through our online portal www.damanhealth.ae
 Wide geographical representation of branches and service points across the United Arab Emirates
offering you convenience and choice
 Easy and safe access to our online portal to submit and track your claims, search for health
services providers, and ask questions through your “My Daman” account
 Access to ActiveLife Program, a community engagement platform designed to give our members
and the community at large a platform to support them in leading a healthier, more active life.

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What is covered?
Main Cover-Your Benefit Summary

Covered at
Network Notes
Providers

Inpatient benefits
Including room, meals, nursing, drugs and
Hospital Charges 
dressings.

Surgeries, day procedures, radiotherapy,

Inpatient Treatments 
chemotherapy, etc.

Medical appliances, Used as part of inpatient procedures.


diagnostic tests

Specialist’s or Consultant’s

Fee

Outpatient Benefits

Including General Physician consultation and

Doctor’s consultation 
Specialist consultation on referral basis.

Prescribed medicines  Covered as per your Drug Formulary.

Including X-rays, blood tests, ultrasounds, CT

Diagnostic tests 
Scans and MRI.

Physiotherapy sessions 

Maternity Benefits

Including childbirth, complications of pregnancy

Inpatient Maternity 
or delivery, newborn accommodation and care.

Doctor’s Consultation,

Prescribed medicines

Additional Benefits

Including Ambulance Services, Dental or Vision

Correction treatments in case of medical
Any emergency treatments 
emergency. Emergency treatments or services
or services within UAE
will also be covered outside Daman’s Network
within UAE.

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How to obtain your plan benefits?

Within Daman’s Network: Use your health insurance card

You will have direct billing access at our Network Providers for health services covered under
your policy. Just remember to carry your health insurance card (Emirates ID , digital
insurance card or Daman card) when going to the network provider and comply with the
administrative procedures there.

Some health services may have deductibles or co-insurance charges that you will have to
pay for. Such charges will be clearly mentioned on your Schedule of Benefits and will be due
and payable to the provider on the date that the service is provided.

Outside Daman’s Network: Get your bills reimbursed (incase of

Emergency only)

If you go to a Health Services provider that is not part of Daman’s Provider Network, you
will have to pay directly for the services provided. Only in case it is a medical emergency,
and if such services are covered in your plan, you will be eligible to reimburse the cost of the
health service from Daman.

For reimbursement, you have to submit a claim form, along with the documents like original
itemized bills, medical or investigational reports, etc. The claim form and details of our
reimbursement requirements are available on our website. These documents must be
submitted to Daman within 180 days from the date of service received. You can apply for
reimbursement through our website or by visiting any of our branches or service points.

Coverage for Emergencies

We are committed to provide you the best coverage for health care services,
especially when it matters the most. In case of a medical emergency within the
United Arab emirates, you will be eligible to get coverage for your medical bills,
whether you were treated at a Network or Non-network Provider. Prior approval
is not required in case of emergency or services. However, you must notify us
within 24 hours of the services received so that we can help you with the
claims process. You can reach us on the Customer Service toll free number
mentioned on Daman website, digital app or Daman card in case you need
further information.

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What is not covered?

Your policy does not cover you for:

 Health Services, including treatments and supplies, not medically necessary

 Health Services including pharmaceuticals not prescribed by a physician
 Health Services received outside the plan Network, except in case of an Emergency
 Dental and gum treatment, Vision and Hearing Correction treatments and Aids, except in case
of medical emergency
 Assistance in activities of daily living which do not change the medical condition of the
member (for example-custodial care, private duty nursing, etc.)
 Vitamins
 Personal comfort and convenience items or service (fro example-beauty services)
 Cosmetic procedures, surgeries which are not incidental to any injury, sickness or congenital
deformities
 Treatment or obesity and weight management programs
 Experimental, investigational or Unproven services, treatments, drug and supplies or devices
 Outpatient medical supplies including prosthetic devices and durable medical equipment (for
example- bandages, syringes , wheel chair)
 Any services for hair fall (for example- alopecia)
 All cases resulting from alcoholism , use of drugs and hallucinatory substances
 Smoking cessation programs
 Health Services related to sex transformation operations, fertility or infertility
 Hazardous activities or professional sports (for example- bungee jumping)
 Treatment as a result of war, riots, military operation, etc. where a member participates in
such acts
 Treatment as a result of nuclear risk, natural peril or any terrorist or criminal activities
 Mental health diseases or disorders unless it is transient mental disorder
 Preventive care including any associated test and investigation (for example- vaccinations)
 Alternative treatments (for example- herbal or Chinese treatments)
 Any Health Services and associated for HIV, AIDS, sexually transmitted diseases and all
related medical conditions. Birth defects or Congenital Anomalies for newborn unless
representing a life threat
 All cases related to Maternity in respect of unmarried females

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 Any test which is not related to a specific symptom/disease. This includes examinations required
for employment, travel, immigration, licensing or insurance and related reports
 More than one physician consultation in a day or during free follow up period unless medically
necessary and referred by the initial treating doctor
 Lesions resulting from attempted suicides or self infliction
 All substances which are not considered as medicines and all equipment not primarily intended
to improve a medical condition or injury (for example-food supplements, air purifying systems)
 Growth hormone therapy unless medically necessary
 Enteral feeding and other nutritional and electrolyte supplement, unless medically necessary
 Services related to musculoskeletal treatments except for treatment of fracture and dislocation
of extremities
 Nasal septum deviation, nasal concha resection
 Chronic conditions requiring hemodialysis or peritoneal dialysis including related investigations
 Viral hepatitis and related complications except hepatitis A
 Air ambulance transportation and terrestrial transportation in non-emergency cases or by non-
licensed ambulance services
 Circumcision and any related complications, except for newly converted Muslims
 Any pharmaceutical products, which is not considered as specific treatment for a particular
disease or not prescribed by an approved Physician
 All cases where appropriate pre-authorization or notification was not carried out as per policy
terms and conditions
 Officially recognized epidemics or pandemics
 Complications directly arising from services not covered
 Education programs or learning disabilities treatments
 Any treatment or services rendered by a family member or any person with the same legal
residence
 Any inpatient treatment, tests and other procedures, which can be carried out on Outpatient
basis without jeopardizing the insured ‘s health
 Organ and tissue transplants

Note: This is only an extract from the General Exclusions list that applies to your plan. Please
refer to the Policy Wording for the complete list and details of exclusions, definitions, terms and
conditions.

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Important To Know
Pharmacy Benefit Management
Pharmacy Benefit Management (PBM) is an internet-based interface between Daman and your
pharmacy within Daman’s Network in Abu Dhabi. It is designed to mange your pharmaceutical benefits
better.

PBM will help us enhance our service quality by following established frameworks and best practices
related to drug prescription and dispensing. We will be able to review every drug prescribed for
consistency with your diagnosis, age, gender and previous medical history. We can avoid any potential
health hazard by rejecting clinically inappropriate drugs or where we suspect negative drug-to-drug
interaction.

PBM will further help us with automated checks for cases like a particular drug is not covered in your
policy (Drug Formulary) or you have already consumed your pharmacy benefit limit or the drug is not
medically necessary or you requested for a prescription refill too soon.

However, you may get a refill approved on an exceptional basis. You may contact our Customer
Service Centre (by calling the toll free number mentioned on Daman website, digital app or Daman
card if you require further information or wish to file for an appeal in case for exceptional
circumstances.

Pre-Authorization
Your policy may contain specific services that require prior-approvals or pre-authorizations. This is
necessary to ensure that your Health Services Provider has appropriate information on services
covered under your policy.

You would need pre-authorization before availing any of the following health services:

• Inpatient and day treatment services

• Outpatient Physiotherapy
• MRI, CT Scans and Endoscopies
• Prescription Drugs above AED 500 or medication to be consumed for more than 60 days

Your Network Provider, along with Daman, will carry out the pre-authorization process (where
necessary) and notify you once the approval is granted. If the authorization is not granted, you have
the right to ask for an explanation by calling our Customer Service Centre at the toll free number
mentioned on Daman website, digital app or Daman card.

Coverage for Specific Conditions

Your policy covers this listed conditions after a waiting period for 6 months. The waiting period applies
to inpatient treatment only for the following medical conditions:

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Diabetes mellitus, Arterial diseases, COPD (Chronic Obstructive Pulmonary Disease), all cancer cases,
Neurosurgery, Cerebro Vascular Diseases all delivery cases (Maternity). The waiting period is not
applicable if you were continuously covered without any break for atleast 6 months under a health
insurance plan approved by Health Authority Abu Dhabi (HAAD).

Member Cost Sharing

For health services covered within Daman’s Network, there maybe some services where a deductible
or co-insurance is payable. Such charges will be clearly mentioned on your Schedule of Benefits and
will be due and payable to the provider on the date that the service is provided.

Network Directory
Before going for a treatment or service, we recommend that you refer to your Network Directory and
confirm if the provider is listed in Daman’s Network. Our Network Directories are continuously
updated as we establish new agreements with health service providers within the territories specified
in your plan. Going to a Network Provider would ensure that you can enjoy the direct billing facility and
avail cashless benefits for Health Services covered in your policy. You can check the Provider details
on our website or call our Customer Service Centre on the toll free number mentioned on Daman
website, digital app or Daman card for any assistance.

Drug Formulary
If your policy covers outpatient prescription drugs, these drugs will be subjected to a Drug Formulary.
A Drug Formulary details the pharmaceuticals covered under your policy as decided by Health
Authority-Abu Dhabi (HAAD). Your Drug Formulary covers both brand-name and generic drugs.
Generic drugs have the same active ingredients as brand-name drugs and are equally safe and
effective. In case the prescribed drug is not covered in your Drug Formulary, you will have to pay the
drug bill directly to the Provider. You can refer to our website to check if the medicines prescribed for
you are covered in the Drug Formulary of your policy.

Complaints and Appeals

Daman is committed to address members’ coverage issues, complaints and problems. For any general
inquires related to your policy benefits, or specific complaints concerning your pharmacy benefits such
as adjudication of your claims (declining the pre-authorization request for a drug) , dispensing
oversight or provider related issues (access, quality and safety), you can call our Customer Service
toll free number mentioned on Daman website, digital app or Daman card.

For cases where a drug cannot be found with your Network Provider, you have the option to request
exceptional consideration for coverage. If your request is declined, you may further approach us
through our appeal process. Daman will discuss the merits of your case internally and externally and
will communicate the decision to you within 30 calendar days from the date of appeal. Details of
appeals process and the Appeals/Exception Request Form are available on our website. You can submit
your Appeal/Exception request Form along with all supporting documents at any of the Daman
Branches or via email to [email protected].

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Your Right and Responsibilities
As a Daman member you have the Right to:

1. Receive information about Daman’s health insurance plans and services including but not limited
to health insurance plan benefits, exclusions, policy terms and conditions, Pharmacy Benefit
Management (PBM) services, details of network providers (including hospital, pharmacy, dental
clinic etc), online services, list of medications covered under your health insurance plan (Drug
List) and your Rights and Responsibilities.

2. Be treated with respect and dignity and have the right to privacy.

3. Preserve the confidentiality of your treatment records to the extent protected by Federal and
Emirate laws in the UAE. You are also entitled to receive an explanation regarding exceptions to
confidentiality.

4. Voice complaints or to appeal to Daman on benefits offered, claim settlement, services offered,
PBM services or any other grievance.

5. Be provided, upon request, with information about your plan’s benefits including limitations and
exclusions applicable and details related to your health plan Drug List.

6. Receive services in English and Arabic when contacting Daman Customer service.

7. Make suggestions and give comments on ways Daman can improve its services.

8. Exercise your rights in accordance with the Health Insurance Law of the Emirate of Abu Dhabi.

As a Daman member, your Responsibilities are:

1. To read your insurance policies for the details of benefits, exclusions, other terms and conditions
applicable under your health insurance plan. If you do not understand the information, you
should contact Daman Customer Service for explanations on the covered benefits, limitations
and authorization procedures.

2. To present your health insurance card (Emirates ID, digital insurance card or Daman card) when
accessing covered health services from our Network Providers.

3. To know how to access covered health services and pharmacy benefit you are entitled to as part
of your health insurance plan benefits.

4. To pay any applicable co-insurance and deductible at the time of availing a health service.

5. To demonstrate mutual respect and courtesy towards providers (including hospitals, pharmacies,
dental clinics etc.) and Daman personnel.

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Definitions

Co-insurance - the percentage of eligible expenses that you need to pay for specified medical
services availed under your policy.

Deductible - the defined fixed amount that you need to pay for the specified medical services
received under your policy.

Eligible Expenses - Reasonable and Customary Charges for Covered Health Services, incurred
while the Policy is in effect.

Emergency - A sudden development of a medical or surgical condition where lack of immediate

medical treatment at a health service provider might result in a life threatening situation or
seriously affect member’s bodily functions.

Drug Formulary - A list of medications or drugs covered under your policy

Health Insurance Card - the identification card (Emirates ID or Daman digital insurance card or
Daman Card) that Eligible Person must show every time they request Health Services from
Network Providers.

Health Services - the health care services and supplies covered under the Policy, unless such
health care services and supplies are not limited or not excluded in the policy.

Inpatient Benefit - Hospitalization or Day Treatment or observation or treatment in an

Emergency room or facility which cannot be carried out on an outpatient basis.

Network - Used to describe a Health Services Provider, which holds an agreement in effect with
Daman to provide Health Services to members.

Non-Network Benefits - Coverage available for Health Services obtained from the Non-
Network Providers. Coverage for the Non-Network Benefits is only provided if the services are
assured in Schedule of Benefits.

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Outpatient Benefit - are those services which do not require Hospitalization or Day treatment or
necessitate specialized medical attention and care in a Hospital before, during or after the delivery of
the service.

Pre-authorization - a prior approval or official permission, granted by Daman to the Network

Provider, before initiating certain medical procedures.

Pre-Existing Condition - any known or unknown injury, sickness, disease or other medical, mental
or nervous condition, disorder or ailment that with reasonable medical certainty that existed at the
time of applying for
this policy.

Provider - a Physician, Hospital, group practice, pharmacy or any facility, individual or group of
individuals that provides a health care service.

Refill-too-soon - Replenishment or dispensing of a prescribed medicine before the previous

dispense of the same pharmaceutical is consumed.

Appeal - A request contesting a denial or reduction of coverage for services which have been
availed or are intended to be availed.

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 Contact Us
For any product related queries or general inquiries,
kindly contact us on:
Toll Free: 800 4 DAMAN (32626)
Website: www.damanhealth.ae
Fax: +971 2 614 9775
P.O. Box 128888, Abu Dhabi, UAE
PM/E/0007/E002/010417/V1R2/P

Disclaimer
This document is for information purposes only and does not form part of the Policy. The
complete list of benefits, definitions, exclusions, terms and conditions are set out in the Policy.
While every effort is made to ensure the accuracy of the content, Daman cannot be held liable for
any typographical errors, errors of fact or any other error or inconsistency found in this
document.

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