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Oman Table of Benefits.

This document provides a table of benefits for a healthcare insurance plan with three coverage categories. It summarizes the indemnity limits, covered territories, medical providers network, inpatient and outpatient benefits, and other benefits for each category. Category 1 provides the highest level of coverage, including a private room and premium network providers. Category 2 offers lower coverage levels than Category 1. Category 3 has the lowest coverage limits, including a shared room and access to signature and medcare network providers. The table details the reimbursement levels and coverage for elective treatment, emergency treatment, diagnostic services, accommodations and more within each category.

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0% found this document useful (0 votes)

523 views49 pages

Oman Table of Benefits.

Uploaded by

MOENES

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Download as PDF, TXT or read online on Scribd

You are on page 1/ 49

OIGM202100092674

24/07/2021 To 23/07/2022
Page No: 6

Table of Benefits
Healthcare Insurance
All amounts are in AED
General
Category 1 Category 2 Category 3
DOH Approval No. DOH Approval No. DOH Approval No.
45691 45692 45693
Indemnity Limit 2,500,000 1,000,000 500,000
UAE
Extended to Southeast
Basic Territory for Elective & Emergency Worldwide excluding Worldwide excluding
Asia, India Subcontinent
treatment USA & Canada. USA & Canada.
and Arab Country* for
inpatient treatment only
Extended Territory for Emergency treatment Worldwide excluding USA,
worldwide worldwide
only Canada & Europe.
Covered within basic
Covered within basic Covered within basic
Home Country territory * for inpatient
territory territory
treatment only
Pre-existing conditions (Subject to Exclusions
List)

If the waiting period is applicable, cover will be Covered Covered Covered

provided to pre-existing conditions that develop
into an emergency within the 6 month
exclusion period.
Chronic Conditions (Subject to Exclusions List) Covered Covered Covered

Elective Treatment
Inside UAE / Inside Network – (Direct Billing) Covered Covered Covered
Inside UAE / Outside Network –
Covered Covered Covered
(Reimbursement)
Reimbursement for IP
Outside UAE (Within covered Territory) Reimbursement Reimbursement
treatment only

Emergency Treatment
Inside UAE / Inside Network – (Direct Billing) Covered Covered Covered
Inside UAE / Outside Network –
Covered Covered Covered
(Reimbursement)
Outside UAE (Within covered Territory) Reimbursement Reimbursement Reimbursement

Medical Providers Network

Subject to ongoing changes.
Premium Network Edge Network Signature + Medcare
Available online at www.tameen.ae

Oman Insurance Company (P.S.C.), Paid up Capital 461,872,125, C.R. No. 41952, Insurance Authority No. 9 dated 24/12/1984 TRN
100258594900003
Head Office: P.O. Box 5209, Dubai, United Arab Emirates. Tel.: +971 4 233 7777, Fax: +971 4 233 7775, www.omaninsurance.ae
OIGM202100092674
24/07/2021 To 23/07/2022
Page No: 7

Inpatient Benefits – with PAR

Category 1 Category 2 Category 3
Room Accommodation Private room Private room Shared room
Diagnostic Investigations (Lab, Scan and X-ray)
and other prescribed medically necessary
Covered Covered Covered
diagnostic procedures e.g. endoscopy &
histopathology.
Accommodation Costs for one parent staying
300 per day AED 150 per day AED 100 per day
with a child up to the age of 18 years.
Accommodation Costs for one accompanying
family member in case of critical medical
300 per day AED 150 per day AED 100 per day
conditions.*1
Subject to treating doctor recommendation
Daycare treatment including out-patient minor
Covered Covered Covered
surgeries > 6 hours stay.
Internal Prosthetic devices implanted during
Covered Covered Covered
covered surgeries.*1
Outpatient Benefits
Category 1 Category 2 Category 3
Consultation. Follow up on same medical condition and at the same provider is free within 7 days from first consultation date.
General Practitioner – GP Covered Covered Covered
Specialist or Consultant – SP Covered Covered Covered
Pharmacy
Prescribed Pharmaceuticals Covered Covered Covered
ONLY Formulary products (Generic
No No No
Medication)
Vitamins prescribed as replacement Covered Covered Covered
therapy for known vitamin deficiency
conditions up to prescribed pharmaceutical
limit only.
Diagnostic Investigations & Procedures (Lab, Covered Covered
Covered
Scan, X-ray, endoscopy, etc.)
Outpatient procedures Covered Covered Covered
Physiotherapy *1 prescribed by respective Covered Covered
specialist doctor and administered by a qualified Covered
physiotherapist.
* For Abu Dhabi Policies: Only Generic medications can be prescribed and dispensed in line with DOH circular no (US/27/18) dated 23/07/2018

Other Benefits
Category 1 Category 2 Category 3
Local Emergency Transportation by Road
Covered Covered Covered
Ambulance
Birth Defects, Genetic Disorders & Congenital
Covered Covered Covered
Conditions*1
DHA minimum preventive services*1
Diabetes screening Not Covered Not Covered Not Covered

Hepatitis C Virus Screening and treatment Not Covered Not Covered Not Covered
Basmah Initiative Not Covered Not Covered Not Covered
Adult Pneumococcal Conjugate Vaccine
(as per DHA guidelines reference PD Not Covered Not Covered Not Covered
07/2018)
Basic Vaccination: Vaccines for Children (0-6)
Not Covered Not Covered Not Covered
as per MOH mandatory schedule*1
Medical Expenses related to Work Related Covered Covered Covered
Accidents, Injuries and Illness*1
Injuries related to Road Traffic Accidents*1 Covered Covered Covered
Only if medically Only if medically Only if medically
Immunotherapy & Immunomodulators necessary necessary necessary
Hepatitis A Covered Covered Covered
Hormone replacement therapy. (Excluding Covered Covered Covered
growth hormone and excluded medical
conditions)
Ophthalmology: Medical conditions related to it Covered Covered Covered
(Illness/Injury) of the eye excluding vision, sight
test & refraction error.
Recreational non-hazardous sports activities Covered Covered Covered
(professional and hazardous sports activities
even if recreational are not covered).

For Dubai policies, Hazardous activities if not

related to professional sports are covered
In emergency cases: Covered Covered Covered
i. Diagnostic and treatment services for
dental and gum treatments.
ii. Hearing and vision aids, and vision
correction by surgeries and laser.
Circumcision for new Muslims subject to the Covered Covered Covered
following:
i. The member is insured with OIC.
ii. The member declared Islam in the
Emirate of Abu Dhabi in line with all the
legal formalities in this aspect along with a
letter from Judicial Department in the
Emirate.
Air fare for outside UAE treatment (Limited to Covered Covered Covered
Geographical area specified) (Reimbursement)
Maternity and New Born
Category 1 Category 2 Category 3
A. Maternity (Limits & Coverage)
Covered
Inside UAE – Inside Network Covered Covered
Covered
Ante/Post Natal Consultation Covered Covered
Covered
Ante/Post Natal Investigations Covered Covered
Maternity complications Covered
(Life threatening maternity complications are Covered Covered
covered up to indemnity limit)

Covered
Normal Delivery*1 Covered Covered
Covered
Medically necessary C-Section*1 Covered Covered
Covered
Legal Abortion/Miscarriage*1 Covered Covered
Inside UAE – Outside Network & Abroad. Limit
specified is an aggregate for all services AED 10,000 AED 10,000 AED 8,000
(Subject to policy deductibles)
* For Dubai Policies: Visits to include reviews, checks & tests in accordance with DHA Antenatal Care

B. New born Cover (Covered services are as per MOHAP guidelines and protocols)
A New born delivered in UAE is covered up to
30 days as part of the mother’s insurance and
shall share the same indemnity limit. Continuity
Covered Covered Covered
of cover is subject to scheme opted for allows
dependents, addition notification within 30 days
and the newborn added to the policy.
If the scheme allows dependents addition, then
i. DOH: A New born will be enrolled to the
scheme from date of birth subject to the
notification within 30 days from that date.
ii. DHA: A New born will be enrolled to the
scheme from date of birth subject to the Covered Covered Covered
notification within 7 days from that date.
iii. When a baby is born outside UAE, he/she
will be enrolled to the scheme only
following their entry to the UAE, with a
valid entry permit and entry stamp.

Co-Insurance/Deductible
Category 1 Category 2 Category 3
A. Inside UAE – Inside Network *2
Inpatient Services & Daycare cases/surgeries
Coinsurance Nil Nil Nil
Maximum copay amount per encounter N/A N/A N/A
Annual aggregate maximum copay amount N/A N/A N/A
Outpatient

Consultation Deductible/Coinsurance AED 50 AED 50 AED 50

Outpatient procedures Nil Nil Nil

Physiotherapy Nil Nil Nil
Diagnostic Services
i. Laboratory Nil Nil Nil
ii. Radiology Nil Nil Nil
Prescribed Pharmaceuticals
i. Co-Insurance Nil Nil Nil

ii. Maximum out of pocket limit N/A N/A N/A

Maternity
Inpatient Maternity Nil Nil Nil

Delivery Nil Nil Nil

Outpatient Ante/Post Natal Consultation AED 50 AED 50 AED 50
Deductible/Coinsurance
Outpatient Ante/Post Natal Investigations Nil Nil Nil
Coinsurance
Outpatient Ante/Post Natal Procedures Nil Nil Nil
Coinsurance
Outpatient Ante/Post Natal Prescribed Pharmaceuticals (including Ante Natal Vitamins)
i. Co-Insurance Nil Nil Nil
ii. Maximum out of pocket limit N/A N/A N/A
Additional Benefits (If opted)
Dental Co-Insurance (Opted level) 20% 20% 20%
Optical Co-Insurance (Opted level) 10% 10% 10%

Alternative Medicine Co-Insurance (Opted level) 10% 10% 10%

B. Inside UAE – Outside Network (Co-Insurance applies over and above Network Deductions)
Emergency in UAE. (In Emergency cases as defined by PD 02-2017, healthcare services outside the scope of health insurance must be covered until
stabilization at minimum)

Coinsurance (with or without PAR) 0% Coins 0% Coins 0% Coins

Basis of Claims Settlement Actual Actual Actual
Elective in UAE. (If treatment / service is not available within the network then cover is 100% at actual subject to PAR*1)
Coinsurance (with or without PAR) 20% Coins 20% Coins 80% Coins
Basis of Claims Settlement Actual Actual Network tariff
C. Abroad (within agreed territory) – Co-Insurance applies over and above network deductibles
Category 1 Category 2 Category 3
Emergency Abroad
Coinsurance 0% Coins 0% Coins 0% Coins
Basis of Claims Settlement Actual Actual Network tariff
Elective Abroad
80% Coins for IP treatment
Coinsurance 20% Coins 20% Coins
only
Basis of Claims Settlement Actual Actual Network tariff
LivFit - A free wellness program for a healthier workforce
LivFit is a turnkey comprehensive wellness solution that will help your employees to make positive lifestyle choices. It is a free program
that will allow your employees to take charge of their physical and mental wellbeing. Your employees will be able to enjoy the below
benefits.

Health Report Take the heath assessment to get the personal report

Checkups Discounts on general and disease specific checkups

Wellness Coach Discuss the health report with the coach, learn about lifestyle programs and get a personal fitness plan
Challenges Take part in different corporate challenges which can be tracked via the mobile app
Mobile App Track moves and follow the personal fitness plan
Gym Facilities Enjoy free trails and discounted gym packages
Group Classes Participate in free weekly fitness classes
Star Program Lose weight and get part of the cost sponsored
Tobacco Cessation Seminars to help people stop smoking
Stress Management Seminars to cope with pressure
Wellness Awareness Read articles on different health and wellness related topics
Offers and Discounts Enjoy discounts on various wellness products.
Visit www.livfit.ae to know more about the program. All terms and conditions of the program are available on the website.
Optional Benefits
Category 1 Category 2 Category 3
Patient treatment supplies (Reimbursement) Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered

Organ transplant (excluding donor’s expenses)*1

Optional Benefits (continued)

Category 1 Category 2 Category 3
Kidney Dialysis Treatment (Hemodialysis / Not Covered Not Covered Not Covered
Peritoneal Dialysis)*1
Not Covered Not Covered Not Covered
Hepatitis B and its complications*1
Elective Vitamins/Supplements prescribed by Not Covered Not Covered Not Covered
relevant physician
Home Nursing following inpatient treatment. Must Not Covered Not Covered Not Covered
be registered / licensed nurse and with doctor’s
recommendation (Reimbursement)
Enhanced Vaccination (All census) – MOH Not Covered Not Covered Not Covered
approved vaccines. Benefit does not include
vaccination against internationally or locally
recognized epidemics. (Reimbursement)
Psychiatric treatment other than mandated by Not Covered Not Covered Not Covered
DOH for Abu Dhabi schemes and DHA for Dubai
schemes (Reimbursement)
Allergy testing (Reimbursement) Not Covered Not Covered Not Covered

External Prosthetic devices and medical Not Covered Not Covered Not Covered
equipment (Reimbursement)
Infertility treatment. (Reimbursement) Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered

Medically indicated Deviated Nasal Septum *1
Cash indemnity benefit (Reimbursement) Not Covered Not Covered Not Covered

Passive War Risk (Reimbursement) Not Covered Not Covered Not Covered

TruDoc Telehealth
− Free consultation Covered
− No booking of appointments is required Covered Covered

doc
Chronic Disease Management via Trudoc – CDM
Covered Covered Covered
− Applicable to 10% of the total
population
Assist America Package. All services must be arranged and provided through Assist America.
No claims for reimbursement will be accepted.

Category 1 Category 2 Category 3

Activated at 120 Activated at 120
Emergency Medical Evacuation Activated at 120 Kilometers Kilometers Kilometers

Activated at 120 Activated at 120

Medical Repatriation Activated at 120 Kilometers Kilometers Kilometers

Activated at 0 Activated at 0
Repatriation of Mortal Remains Activated at 0 Kilometers Kilometers Kilometers
Second Medical Opinion Covered Covered Covered

Wellness Benefit (Reimbursement at actual within specified limits and coinsurance) Options Available
Wellness Health Check-Up AED 2,000 AED 1,000 AED 1,000

Alternative Medicine (Reimbursement at actual within specified limits and coinsurance) Options Available
Basic Alternative Medicine AED 5,000 AED 5,000 AED 5,000

Enhanced Alternative Medicine Not Covered Not Covered Not Covered

Dental Benefit Options Available

Routine Dental*1 Refer to below Refer to below Refer to below
Enhanced Dental*1 AED 3,500 AED 3,500 AED 2,500
Optical Benefit (Reimbursement at actual within specified limits and coinsurance) Options Available
Basic Optical Refer to below Refer to below Refer to below
Enhanced Optical AED 1,500 AED 1,500 AED 1,500

∗ 1 PAR = Prior Authorization request (please refer to claim administrative & prior approval procedures)
∗ 2 Treatment taken inside the network if submitted on reimbursement basis will be settled at the agreed tariff of the medical provider and subject
to policy deductibles/coinsurance. Policy must support reimbursment for the claim to be considered.
LivFit - A free wellness program for a healthier workforce
LivFit is a turnkey comprehensive wellness solution that will help your employees to make positive lifestyle choices. It is a free program
that will allow your employees to take charge of their physical and mental wellbeing. Your employees will be able to enjoy the below
benefits.
Health Report Take the heath assessment to get the personal report
Checkups Discounts on general and disease specific checkups

Glossary
1. If Opted: Cash indemnity benefit of AED 200/- per night for a maximum of 30 nights for inpatient
hospitalization against free, covered treatment received and/or not being claimed from any insurance
company. Original discharge summary to be submitted.

2. DHA minimum preventive services:

− Diabetes screening: this benefit is covered once a year for members 30 years and above. For
high risk individuals entitlement age for this benefit is 18 years.
− Hepatitis C Virus Screening and treatment: To be followed as per the guidelines laid out in the
Hepatitis C support program
− Cancer Screening and treatment: To be followed as per the guidelines laid out in the Cancer
support program
− Adult Pneumococcal Conjugate Vaccine followed as per DHA adult Pneumococcal Vaccination
guidelines

3. If Opted: Wellness – Basic Routine Health Checkup shall include the following tests: Blood
examination (CBC, Blood Sugar, Lipid profile, HIV, Hepatitis B), Electrocardiogram ECG, Fundoscopy,
Chest X ray, Urine routine, Stool OP/OB Consultation with General Practitioner/Internal Medicine
Specialist). This benefit can be claimed only once a year for members 30 years and above.

4. If Opted: Wellness – Enhanced Health Checkup shall include Basic Routine Health Checkup along
with the following cancer screening
i. Breast Cancer for females 30 years and above: Clinical exam, Mammogram, Pelvic
sonogram, if medically indicated and CA 15.3, if medically indicated.
ii. Prostate Cancer for males 30 years and above: Clinical exam, PSA, Rectal sonogram.
iii. Colon Cancer for adults 30 years and above: FIT (Fecal Immunochemical Test) every 2
years. Colonoscopy every 10 years or according to findings.

5. If Opted: Organ Transplant benefit will cover the incurred charges on transplantation surgery for the
beneficiary being the recipient of the transplant of an organ. The covered amount includes doctor’s
fees, hospital accommodation and other beneficiary’s related medical expenses during hospital stay.
The organ transplants covered are as follows: Heart, Heart/Lung, Lung, Kidney, Kidney/Pancreas,
Liver, Allogeneic bone marrow and Autologous bone marrow. Cover will exclude costs related to
search for donor, cost of acquisition of organ and costs incurred for removal of organ from donor.

6. Expenses related to Immunomodulators and Immunotherapy will be covered if used as an

effective therapeutic strategy for radical therapy.

7. If Opted: External Prosthetic devices and medical equipment cover should mean any medical
equipment used externally from the human body which: (1) can withstand repeated use; (2) is not
designed to be disposable; (3) is used to serve a medical purpose; (4) is generally not useful to a
person in the absence of a Sickness or Injury; and (5) is used outside of the Hospital. These are
subject to recommendation of the treating doctor and are on reimbursement basis.

8. If Opted: Patient treatment supplies shall be limited to lancets, pens, needles, pen needles &
syringes. These are subject to recommendation of the treating doctor and are on reimbursement
basis.

9. If Opted: Alternative medicines – Basic to be performed only by a licensed practitioner. Services are
limited to: Chinese medicine, Ayurveda and Homeopathic treatments.

10. If Opted: Alternative medicines – Enhanced to be performed only by a licensed practitioner.

Services are limited to: Acupuncture, Acupressure, Osteopathy, Chiropody, Lymphatic drainage
(cupping), Magneto therapy, Chiropractic on top of Basic Alternative medicines cover.

11. If Opted: Psychiatric services/treatments will not include psychotherapists and/or psychologists
treatment or services. Only MOH licensed psychiatrist’s consultation/treatment will be paid for.

12. If Opted: Passive war and terrorism benefit extends to cover accidental injuries suffered by the
insured member as an innocent bystander only and excludes if the person insured is training or
serving in any capacity as a member of the Armed Forces or whilst engaging in any war, invasion,
acts of foreign enemies, hostilities or war-like operations whether declared or not, civil war, rebellion,
revolution, insurrection, military or usurped power or martial law; an act of terrorism. “Passive War”
cover is excluded if an insured is traveling to a country, (unless otherwise to his/her home country),
after war has been declared in that country or after it has been recognized as a war zone by the United
Nations or where there are war like operations.

13. Air Ticket fare if listed as covered in the Table of Benefits, will be subject to
i. Treatment within the member’s eligible geographical area for elective treatments as per
policy.
ii. Inpatient treatments.
iii. Cost of treatment is less than 70% of the applicable network customary tariff of the country of
policy issuance.
iv. Airfare class: Economy.
v. Reimbursement for the patient’s airfare (no airfare for companions).
vi. Reimbursement will be limited to AED 2000/- maximum per treatment.
vii. Maximum overall cost inclusive of the airfare does not exceed 90% of the OIC applicable
network tariff.

14. If Opted: Routine Dental, covers the following services: Dental consultation, Lesions of Oral Cavity,
Endoperio Surgery, Scaling, Filling, Curettage & Gum Problems, Root Canal and Pulp Treatment and
Extraction (Removal, Simple & Surgical), x-rays & prescribed drugs for the mentioned services.
However, General Dental Inspection (Check-up), Maintenance of Appearance, Crown, Bridges, Posts,
Dentures, Pins, Prosthesis, Orthodontic Treatment and Cosmetic Treatment & Surgery is not covered.
Toothpastes, Mouth Wash, Mouth Sprays etc. are not covered. Covered services done by oral
hygienist are covered excluding consultation.

15. If Opted: Enhanced Dental on top of Routine Dental covers the following services: General Dental
Inspection (Check-up), Crowns, Bridges, Posts, Dentures, Pins, Prosthesis, Orthodontic Treatment.

Cosmetic Treatment & Surgery is not covered. Toothpastes, Mouth Wash, Mouth Sprays etc. are not
covered. Covered services done by oral hygienist are covered excluding consultation.

16. Emergency Dental: Treatment is covered to restore or replace sound natural teeth lost or damaged in
an accident and for which medical treatment is provided within 72 hours following the accident. These
expenses are covered under general treatment and do not fall under the dental limit if applicable.

17. If Opted: Basic Optical: the benefit provides for the fees charged for only refraction test carried out by
a qualified and registered Ophthalmologist/Optometrist. A coinsurance/ deductible will apply as
mentioned in TOB to all eligible charges incurred. This amount will be payable by the member. Claims
settlement would be on reimbursement basis. (Covered only for applicable category).

18. If Opted: Enhanced Optical with Lenses & Frames: The benefit provides for the fees charged for
refraction test carried out by a qualified and registered Ophthalmologist/Optometrist, the cost of
spectacle frames once a year and corrective lenses (including Contact Lenses) prescribed by the
Ophthalmologist/Optometrist (excluding tinted/reactive lenses and sunglasses, whether prescribed or
not). A coinsurance/ deductible will apply as mentioned in TOB to all eligible charges incurred. This
amount will be payable by the member. Claims settlement would be on reimbursement basis.

19. Emergency as defined by Law is “A situation which calls for immediate medical intervention by a
health services provider for the rescuing of a person’s life/organ or the elimination of the danger
threatening that person's life/organ.”

20. Arab countries include: Algeria, Bahrain, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco,
Oman, Palestine, Qatar, Saudi Arabia, Sudan, Syria, Tunisia, and Yemen.

21. South East Asia countries include: Afghanistan, Bangladesh, Bhutan, Burma, India, Indonesia, Iran,
Malaysia, Nepal, Pakistan, Philippines, Sri Lanka, Thailand and Vietnam.

22. Indian Subcontinent countries includes: Nepal, India, Pakistan, Bhutan, Bangladesh & Sri Lanka.

23. Extended territory if offered is covered only for medical necessitated emergency while insured
member is traveling (vacation/business trip) subject to maximum aggregate period of 60 days in a
policy year.

24. The following benefits, if listed in the Table of Benefits as covered, shall be on reimbursement basis
unless specifically agreed otherwise in writing: Air ticket fare, Alternative treatments, Optical
Lenses/Frames under Optical Benefit, Wellness Benefits, Vaccination, Nursing at Home, Work related
accidents (for Non-Abu Dhabi region only), Psychiatric treatment, and Infertility treatment.

SECTION 1
DEFINITIONS
Member eligibility definitions

The eligibility for enrollment under this medical insurance Policy shall be defined as per the definitions
outlined hereunder:

Employee

The term Employee shall be deemed to refer to any regular, full-time, permanent employee of the
Policyholder working under direct management and supervision of the Policyholder, the latter being
registered and regulated in the UAE.

Eligible Employees

The class of employees eligible for Insurance under this insurance Policy shall be as per selection criteria
mentioned in the Schedule who have not reached the age of sixty-five (65) in the service of the Policyholder
on the inception date of this Policy as declared by the Policyholder, unless otherwise specifically accepted.
Subsequent new employees who have not reached their sixty- fifth birthday shall be eligible on the date of
joining with Policyholder of such new Employee. The additional premium shall be calculated as from the date
of joining with Policyholder of such new employee.

Insured Employees

Each Employee eligible for the insurance under this Policy shall become insured for the full benefits
corresponding to his classification by the Policyholder, on the day he becomes eligible, provided that he is
actively at work on full time at the date of inception of this insurance Policy.
In any instance when an Employee is not actively at work on full-time on the date, he would become insured
in accordance with the above provisions, however the commencement of the such Employee’s insurance
shall be deferred until return to active work on full-time basis with the Policyholder.

Dependant

If mentioned in the Policy Schedule as covered, this term shall be deemed to refer only to:

1. The legal wife or husband of an Employee (not including those legally separated) who is registered as
such in the records of the Policyholder and,

2. Any Employee’s unmarried children, stepchildren and children legally adopted, who are:

2.1. Within the age of cover as specified in the Policy Schedule and living in the Employee’s household
as United Arab Emirates resident or absent there from only to attend an academic institution as a
full-time student.

2.2. 18 years and over but under 25 years of age, having the same permanent residence as the
Employee, and who are full-time students at an accredited college or university. Such children shall
be dependent upon the Employee for support and registered as dependents of the Employee in the
records of the Policyholder.

If any person defined as Dependent is also eligible as an Employee under this Policy, such person shall then
not be eligible as a Dependent hereunder. When both husband and wife living in the same household are
insured as Employees, the children shall be eligible only as Dependents of the husband Employee.

Insured Dependants

If stated in the Schedule, Dependents of Insured Employees are eligible for insurance under this insurance
Policy. Written declaration by the Policyholder is required for insurance of the Insured Employee’s
Dependents under this Policy. It is compulsory to include all eligible Dependents of the Insured Employees as
per selection criteria defined in the Policy Schedule.

Insured Member

This term shall be deemed to refer to any Insured Employee and/or the Insured Dependent under this Policy.

Other Definitions

Accident

A sudden, violent, unforeseen event which leads to a person’s state of injury and/or ill-health and/or
discomfort and/or pain and hence in need of immediate medical attention.

Alternative Medicine (to be applicable only if mentioned in the Table of Benefits)

Medically Necessary treatment by alternative system of medicines like herbal, homeopathy, chiropractic,
acupuncture, Ayurvedic, etc. Chinese and Ayurvedic massages are subject to prior written approval from the
Company. All such treatments have to be carried out by a legally registered Physician.

Applicable Network

The type of Network assigned to the respective category of the Policyholder as specified in the Policy
Schedule.

Arab Countries

If referred in the Policy Table of Benefits, shall mean the following countries: United Arab Emirates, Algeria,
Bahrain, Egypt, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Sudan,
Syria, Tunisia and Yemen.

Basic Routine Health Check-up (to be applicable only if mentioned as covered under the Table of Benefits)
shall include and refer to unless specified otherwise:

The coverage includes (once a year for members 30 years and above):

• Blood examination (CBC, Blood Sugar, Lipid profile, HIV, Hepatitis B),
• Electrocardiogram ECG,
• Fundoscopy,
• Chest X ray,
• Urine routine, Stool OP/OB
• Consultation with General Practitioner/Internal Medicine Specialist).

Cash Indemnity Benefit (to be applicable only if mentioned in the Table of Benefits).

In case of a free Inpatient treatment availed by the insured member, and no claims being lodged for the
admission an amount as specified in the table of benefit shall be paid to the insured member, upon
submitting a proof of hospital stay and that the treatment was free of cost.

Chronic Condition

A disease, Illness or Injury (including a mental condition) which has at least one of the following
characteristics:

• Has no known cure or recurs. Has only symptomatic/palliative cure whereby the state of disease
never cured.
• Leads to permanent Disability.
• Is caused by changes to Insured Member’s body, which cannot be reversed.
• Requires the Insured Member to be specially trained or rehabilitated.
• Needs prolonged supervision, monitoring or treatment.

Claim Adjudication

The process of placing a claim through a series of administrative, contract and medical edits to determine
coverage or non-coverage of a claim as well as the determination of financial settlement parameters.

Claim Submission

A written demand made to the Company by or on behalf of the Insured Members for the payment of medical
expenses under this insurance Policy. A claim is submitted on a claim form, which is accompanied by
supporting billing documentation and medical reports proving that chargeable Medically Necessary services
were or will be rendered to the Insured Member and the medical reasons for conduction of such services.

Under the direct-billing mode (the “Direct-billing”), the Applicable Network’s Provider submits the claim on
behalf of the Insured Member for services rendered by the Provider in accordance with the medical service
agreement with the Company and the Company pays to the Provider Eligible Medical Expenses minus any
Deductibles, Coinsurance or other non-covered medical expenses.

Under the reimbursement mode (the “Reimbursement”) (if applicable), the Insured Member submits claim
directly to the Company who then pays the Policyholder / Insured member (as per arrangement) Eligible

Medical Expense minus any deductible, coinsurance, limits or other non- covered medical expenses.

Coinsurance (Excess)

The portion of Eligible Medical Expenses, usually a fixed percentage of all services (Inpatient or Outpatient)
received by the Insured Member and which, the Insured Member is obliged to pay.

Congenital Anomaly

A condition (abnormality, deformity, disease, Illness or Injury) existing at or from birth, whether diagnosed or
not, which is a significant deviation from the common form or normal and for the purposes of this Insurance
Policy will include both visible and hidden structural body deviations as well as chromosomal abnormalities.

Customary Charge

In the Company’s sole opinion, a charge or expense for medical care which according to the Company’s
experience with their Network Providers does not exceed the general level of charges being made by other
Providers of similar standing in the locality where the charge is incurred, when furnishing like or comparable
medical Treatment, services or supplies.

Day-care

Surgery, medical Treatment and/or diagnostic tests which are performed at Hospital and need a short stay
(6-12 hours) and require specialized medical attention and care in a Hospital, before, during and/or after a
Surgery, Treatment and/or test; but do not Medically Necessitate stay longer than 12 hours in a Hospital.

Deductible (Excess)

The amount deducted from a medical expense claim which is specified in monetary units (i.e. 25 or 50 or 75
Dirhams) and which is applied on any Service (example - Doctor’s consultation fee) or all Services rendered
as specified in the Policy Schedule. This Deductible amount must be paid by the Insured Member and is
deducted from the total claim. The Company’s payment portion is calculated on the remaining balance.

Disability

Shall be deemed to refer to illness or accidental bodily injury necessitating medical Treatment by a Physician.

• All bodily injuries sustained in any one accident shall be considered one Disability.
• All bodily disorders existing simultaneously, which are due to the same or related causes, shall be
considered one Disability.
• If a Disability is due to causes that are the same or related to the cause of a prior Disability (including
complications arising there from), the Disability shall be considered a continuation of the prior
Disability and not a separate Disability.
• However, for cases requiring hospital confinement after 90 days following the latest discharge from
the Hospital, subsequent Hospital confinement arising from the same cause shall be considered a
new Disability. For cases not requiring Hospital confinement, a new Disability is established after a

period of 90 days has elapsed following the day upon which the last reimbursed expense was
incurred, unless new expenses are not recoverable because of the exhaustion of the maximum
out-patient benefits.

Eligible Medical Expense

The medical expenses, which are determined by Claims Adjudication as covered by the contract before the
deduction of Deductible or Coinsurance (Excess).

Emergency

An acute, unbearable health condition sustained as a result of sudden non-excluded sickness or injury raising
a legitimate professional concern that there may be significant medical problem necessitating treatment
(medical or surgical) to be performed exclusively within the Territory of occurrence which cannot be delayed,
and which required immediate confinement to a facility followed by Hospitalization or not.

Healthcare Services

Health care (or healthcare) is the diagnosis, Treatment, and prevention of Disease, Illness, Injury, physical
and mental impairments of the Insured Member based on terms, conditions and exclusions of this Policy.

Hospital Confinement or Hospitalization

Refers to when the Insured Member’s Medically Necessary Healthcare Service or Treatment is registered
and provided as bed patient in a Hospital and incurs an overnight daily room and board charge.

Hospital

Shall be deemed to refer only to an institution licensed as a Hospital and operated for the care and treatment
of sick and injured persons, which institution provides 24-hour nursing care and has facilities for diagnosis
and, except in the case of a hospital primarily concerned with treatment of chronic diseases, for major
surgery. The term “Hospital” shall not be construed to include a hotel, rest home, nursing home,
convalescent home, place for custodial care, home for the aged, or a place used primarily for the
confinement or treatment of drug addicts or alcoholics.

Illness

A disease, impairment, interruption, cessation or disorder of bodily function(s), system(s) or organ(s).

Injury

Physical damages other than Illness, including all related conditions and recurrent symptoms, which are
usually caused by an Accident.

Limit(s)

The Policy provision that sets and mentions a ceiling (maximums) on types of Eligible Medical Expenses.
Limit(s) may be (i) monetary amount per year (ii) monetary amount per claim (iii) quantity amount per year (iv)
quantity amount per claim.

Life Threatening

Diseases or conditions where the likelihood of death or permanent Disability of one or more of body organs
or extremities is high unless the course of the disease or condition is interrupted with immediate medical
care.

Medical Insurance Card

Shall mean an identification card as issued by the Company confirming the initial enrollment of the Insured
Member under this medical Policy. The Medical Insurance Card shall always remain the property of the
Company.

Medically Necessary

Hospitalizations, confinements, Surgeries, procedures, Treatments, services, supplies, medications,

equipment and other items or expenses requested, provided or charged by a Provider which the Company, in
its own opinion determines are all of the following:

• Required for the Treatment or management of an Illness or Injury;

• Appropriate to diagnose or treat the Insured Member’s Illness or Injury; Consistent with standards of
good medical practice;
• Are not primarily for the personal comfort or conveniences of the Insured Member or the Provider;
• Are not an associated with the scholastic education or vocational training of the Insured Member, the
Policyholder or primarily for education or experimental purposes;
• In case of Inpatient care, cannot be provided safely on an Outpatient basis;
• Are given in the most cost-efficient manner and setting consistent with maintaining safe care legally
available in the country of prescription. The fact that a Provider has prescribed, recommended or
approved a Hospitalization, surgery, procedure, treatment, service, supply, medication, equipment or
other item or expense does not, in itself, makes it Medically Necessary. For avoidance of doubt, the
Company shall at its sole discretion decide and shall be the binding decision any aspect establishing
any such aspect to be Medically Necessary or not.

Network

A group of medical providers contracted by Company for the purpose of providing Insured Members medical
service. Company may have more than one type of network.

Non-network

Medical Service Providers that are not part of the Company network or although are a part of Company
Network but are not part of the applicable network available for a particular Group / Category/ Policyholder.

Outpatient

Physician consultation, prescribed drugs, diagnostic tests and treatments, procedures which do not medically
necessitate hospital confinement before, during and /or after the procedure. Day-care are considered
outpatient.

Physician

Shall be deemed to refer only to a doctor or surgeon who is a Doctor of Medicine or equivalent legally
licensed to practice medicine and qualified to render the treatment provided, under the law of jurisdiction in
which Treatment is provided.

Policy

Shall mean this document, Policy’s Schedule, any supplementary contracts or endorsements, any
amendments hereto signed by the Company and the Policyholder, the details provided by the Policyholder to
the Company, all of which shall together constitute the entire contract between the Parties.

Policy Period or Period of Insurance

Shall mean the period as mentioned in the policy Schedule.

Preventive Medical Services

Medical screening for disease prevention and health maintenance. Refer to Table of Benefits for covered
services.

Pre-existing Conditions

Bodily injuries or medical conditions relating to accidents or illnesses which occurred and/or were declared
and/or have been diagnosed and/or have already incepted treatment relating to same prior to the
commencement of this initial commencement date of the Policy.

Prior Approval

Shall refer to the process used to review proposed medical treatment plan prior to and / or during Hospital
Confinement or Outpatient Treatment of an Insured Member to assure that the Insured Member’s Medically
Necessary specific medical needs are met in the most cost-effective setting suitable for Medically Necessary
treatment of the Injury or Illness and are within the reasonable and Customary Charges and which shall need
to be specifically approved in writing by the Company before undergoing any such Treatment or
Hospitalization.

Provider

A generic term for Physicians, Hospitals, clinics, medical centres, pharmacies, laboratories, physiotherapy
centres, dentists and other paramedical institutions or persons who are licensed to offer medical services.

Routine Dental Benefits Cover (to be applicable only if mentioned as covered in the Table of Benefits) shall
be deemed to refer to the following:
• Lesions of oral cavity
• Endoperio Surgery
• Scaling
• Filling
• Curettage & gum problems
• Root canal and pulp treatment
• Extraction (removal - simple & Surgical)

However, general dental inspection (check-up), maintenance of appearance, crown, bridges, posts, dentures,
pins, prosthesis, orthodontic Treatment and cosmetic Treatment & Surgery are not covered as well as
toothpastes, mouth wash, mouth sprays etc. which in the sole discretion of the Company is either not
Medically Necessary or is cosmetic in nature.

Routine Optical (to be applicable only if mentioned as covered in the Table of Benefits) shall be deemed to
refer to the following:

Routine Optical benefit provides for the fees charged for eye examination carried out by a qualified and
registered Ophthalmologist. A coinsurance/ deductible will apply as mentioned in TOB to all eligible charges
incurred. This amount will be payable by the member.

Routine Optical with lenses (to be applicable only if mentioned as covered in the Table of Benefits) shall be
deemed to refer to the following:

The benefit provides for the fees charged for eye examination carried out by a qualified and registered
ophthalmologist, the cost of corrective lenses including contact lenses (maximum one pair a policy year)
prescribed by the ophthalmologist (excluding tinted/reactive lenses and sunglasses, whether prescribed or
not). A Coinsurance/ Deductible will apply as mentioned in Table of Benefits to all eligible charges incurred.
This amount will be payable by the Insured Member.

Routine Optical with Lenses & Frames (to be applicable only if mentioned as covered in the Table of
Benefits) shall be deemed to refer to the following:

The benefit provides for the fees charged for eye examination carried out by a qualified and registered
ophthalmologist, the cost of corrective lenses including contact lenses (maximum one pair a policy year) and
spectacle frame (one frame a policy year) prescribed by the ophthalmologist (excluding tinted/reactive lenses
and sunglasses, whether prescribed or not). A Coinsurance/ Deductible will apply as mentioned in Table of
Benefits to all eligible charges incurred. This amount will be payable by the Insured Member.

Schedule or Policy Schedule

Shall mean the integral document of this Policy which detail the respective benefits as applicable under this
Policy and their Limits.

South East Asia

If referred in the Policy Table of Benefits, shall mean the following countries: Afghanistan, Bangladesh,
Bhutan, Burma, India, Indonesia, Iran, Malaysia, Nepal, Pakistan, Philippines, Sri Lanka, Thailand and
Vietnam.

Surgery or Surgical operation

Shall be deemed to refer to the following:

• A cutting operation
• Suturing a wound
• Treatment of a fracture
• Reduction of a dislocation
• Radiotherapy (excluding radioactive isotope therapy) if used in lieu of a cutting operation for the
removal of tumour.
• Electrocatherisation
• Diagnostic and therapeutic endoscopic procedures
• Injection treatment hemorrhoids and varicose veins
• Organ transplant
• Angiography
• Normal childbirth

Treatment

Any Surgery, medical, pharmaceutical or other approach used to cure or rectify an Insured Member’s Illness
or injury which is deemed as being Medically Necessary and which must be legally permitted in the country
where the Treatment was prescribed and covered under this insurance Policy contract

Table of Benefits

Shall mean the table of benefits in the Policy Schedule detailing the eligible benefits and its Limits.

Vaccines & Immunizations

Shall be deemed to refer to the essential vaccinations and inoculation as mandated by the UAE health
regulatory authorities, unless specified otherwise.

SECTION 2
GENERAL CONDITIONS
a. Network of Providers are subject to on-going changes at sole discretion of the Company. Updated list of
Providers available at http://medicalnetwork.tameen.ae/

b. Company reserves the right for referring for a second opinion from another doctor, if needed for elective
surgeries and outpatient investigations/procedures.

c. Company reserves the right to amend the terms and conditions of the Policy in cases of the number of
Insured Members at any point of time during the Period of Insurance drop by more than 15% reported
from the Policy inception/renewal.

d. Insured Members must present their Medical Insurance Card every time they request Healthcare
Services from the Applicable Network’s Provider. All reimbursement claims, where allowed, shall be
treated as per the Non-Network access rules, unless specified otherwise in the Policy Schedule.

e. The Premium payable by the Policyholder to the Company shall be calculated at the rate agreed.

f. The initial premium shall be calculated on the number of Eligible Employees and to be Insured Members
reported by the Policyholder at Policy inception.

g. Premium adjustments additions/deletions of members and other approved transactions shall be invoiced
as and when reported. Payment of premium for such invoices shall be within 30 days from invoicing,
unless mutually agreed otherwise.

h. The Policyholder shall report all addition / deletions of Employees / eligible Dependents in the format
prescribed by the Company, accompanied by the supporting documents as intimated from time to time.
The Company has the right to request additional information / supporting documents to comply with the
regulatory requirements.

i. The Company shall process the eligible requests and issue premium adjustment documents Medical
Insurance Cards where necessary.

j. The Policyholder is requested to report all additions/deletions of Insured Members within 15 calendar
days from the date of eligibility of such addition/deletion of such Insured Member.

k. Coinsurance if any applicable on reimbursement claims, shall be calculated over and above the network
coinsurance/deductible, unless specified otherwise.

SECTION 3
CLAUSES
These clauses issued in conjunction with the Policy to which it is attached witnesses that the Company has
granted a Medical Insurance Cover whereby:

Clause 1- Benefits

If an Insured Member, while insured under the terms of these Policy clauses, incurs Medically Necessary
expenses, the Company shall reimburse such Medically Necessary expenses, subject to the provisions and
limitations set forth hereinafter. The Medically Necessary expenses should be incurred (i.e. actual Medically
Necessary Healthcare Service rendered by medical service Provider and its costs paid by Insured Member)
within the Policy’s expiry date (unless otherwise the Policy has been renewed). If the Policy lapses, then the
costs payable are only those incurred in respect of Medically Necessary Healthcare Services rendered up to
the Policy’s expiry/lapse date.

Clause 2 - Inpatient Benefits

If, as a result of bodily Injury or sickness, an Insured Member incurs Medically Necessary expenses in
connection with his Hospital Confinement, the Company subject to the terms, conditions and exclusions of
this Policy shall pay upto the agreed Limits for the following, provided prior written authorization of Company
has been obtained before becoming an Inpatient.

a. Daily Room/Board and Nursing:

The expense incurred by the Insured Member for reasonable and Customary Charges made by the Hospital
for room, board and general nursing care furnished during his Hospital Confinement, but not to exceed the
maximum amount as set forth in the Table of Benefits.

b. Hospital Services

The Medically Necessary expense incurred by the Insured Member and directly related to the specific Illness
for the Healthcare Services rendered during his Hospital Confinement, but not to exceed during any one
Disability/disease the maximum under Inpatient and Outpatient Healthcare Services set forth in the Table of
Benefits, and which are enumerated hereinafter:

i. Use of operating room, treatment rooms and equipment.

ii. Dressings, ordinary splint and plaster casts but excluding special braces, appliances and equipment.

iii. Drugs and medicines prescribed by the attending Physician and which are commercially available for
purchase by the Hospital in which the Insured Member is confined.

iv. When furnished as a regular service customarily provided by the Hospital in which the Insured
Member is confined, and when performed by an employee of the Hospital. Laboratory examinations,
electrocardiograms, basal metabolism tests, oxygen and anesthetic and administration thereof,

X-Ray examination, administration of blood and blood plasma, intravenous injections and solutions.

v. Administration of an anesthetic by a qualified physician subject to maximum reimbursement, during

any one Disability at actual costs.

Hospital Services shall not include, and no reimbursement shall be made for expenses incurred for the
services of technicians not regularly employed or designated by the hospital, or doctors, room, board or
general nursing care, or any services furnished by the hospital other than those listed under Hospital
Services above.

c. Surgical Fees

If the Insured Member undergoes a Surgical Operation, the Company shall pay the surgical fees actually
charged for such Surgical Operation (including charges for pre-and-post-operative care by the surgeon)
subject to the following:

i. Payment of any Surgical Operation shall not exceed the amount of the Company’s tariff, which
reflects current UAE pricing structures for medical and surgical fees. If the operation of comparable
severity and gravity as determined by the Company shall be paid unless payment for such Surgical
Operation is expressly accepted in such tariff f or by the provisions of this Policy.

ii. Payment for all surgical interventions performed during any Disability shall not exceed the maximum
limit per case per Insured Member shown in the Table of Benefits.

iii. Any Surgical expense to be reimbursed must be incurred for Medically Necessary services rendered
by a surgeon legally licensed to practice, and qualified to render the Surgical Operation for which
claim is made.

d. Doctor’s Visits

If an Insured Member incurs expenses for care and treatment by a Physician and: i. Such care and treatment
is given during the Insured Member’s Hospital Confinement, and ii. Such Hospital Confinement is for causes
other than maternity. The Company shall make reimbursement for such expenses up to the maximum
amounts indicated in the Table of Benefits under Inpatient healthcare services section.

e. Emergency Outpatient

If as a result of an accidental bodily injury, or a sickness for which a Surgery benefit is payable under section
(C) above, an Insured Member incurs expenses for services and supplies provided by the Out-Patient
(emergency room) department of a Hospital, the Company shall reimburse the charges for such services, not
to exceed during any one Disability the maximum set forth as under Out-Patient benefits section.

Clause 3 - Outpatient Benefits

a. Doctor’s Visits

If as result of a Disability, an Insured Member incurs expenses for professional attendance and treatment

by a Physician, the Company shall reimburse such expenses up to the maximum amount per visit and per
Disability and in excess of deductible (if any) as set forth in the Table of Benefits under Out-Patient
Benefit, subject to the following provision:

i. Office visits-professional attendance and treatment in the physician’s office or clinic;

ii. Specialist consultations - professional attendance and consultation by a qualified specialist.

b. Diagnostic X-ray and Laboratory Benefits

If, as a result of a Disability, an Insured Member incurs expenses for diagnostic imaging examination,
x-ray examination or microscopic or other laboratory tests or analyses, the Company shall reimburse such
expenses in excess of the deductible (if any) and up to the maximum set forth in the Table of Benefits
under Out-Patient Benefits, provided such examinations are made or ordered by a physician.

c. Prescribed Drug

If, as a result of illness, injury or disability, an Insured Member incurs expenses for drugs prescribed by a
Physician during the course of treatment, while not confined as a In Patient in a Hospital, the Company
shall reimburse such expenses up to the maximum amount expressed within the Table of Benefits, in
excess of the deductible (if any) as set forth in the Table of Benefits under Out-Patient Benefits.

SECTION 4
GENERAL PROVISIONS
Article 1 - The Policy

1. The Policy, comprising the Schedule, Table of Benefits, Eligibility definitions, the Medical Insurance
Clauses, the Exclusions, the General Provisions, the proposal form and other details provided to the
Company, the User’s Guide attached hereto and the application of the Policyholder and the individual
applications, if any, of the Insured Members, shall constitute the entire contract between the Parties
hereto.

2. This Policy and the Schedule shall be read together as one contract and any word or expression to which
a specific meaning has been assigned in any part of this Policy or of the Schedule shall bear such
specific meaning wherever it may appear.

3. Special provisions shall be valid only when endorsed on this Policy or confirmed in writing by the
Company.

4. Utmost Good Faith - The due observance and fulfillment of the Terms and Conditions of this Policy in so
far as relating to the Policyholder’s responsibility towards the declaration of all facts material to the
insurance cover as afforded by this Policy and/or the computation of the respective premium shall
constitute conditions precedent to the liability of the Company towards awarding any payment with
respect to claims under this Policy.

Article 2 - Governing Law and Jurisdiction

This Insurance Policy shall be subject to and governed by, in its interpretation or in respect of any difference
or dispute arising out of or in connection with it, to the laws and regulations of the United Arab Emirates. The
competent Courts of the United Arab Emirates shall have the sole jurisdiction in case of any difference or
dispute arising out of or in connection with this Insurance Policy.

Article 3 - Premiums

1. The premiums under this Policy are payable in advance or at the intervals indicated on the Policy
Schedule.

2. All premiums are due for respective payment upon their due dates at the head-office or to an agent or
cashier of the Company. Furthermore, no payment in respect of any premium shall be deemed to be
effected to the Company unless a printed form of receipt complete with a signature by a duly
AUTHORISED Company’s Official or duly appointed Agent is issued to the Policyholder against such
payment as effected.

3. The premium payable by the Policyholder to the Company shall be calculated at the agreed rate.

4. The initial Premium shall be calculated on the actual number of Insured Members as indicated at
inception of this Policy.

5. Adjustments - Additional premium shall be due by the Policyholder upon the addition of new Insured
Members. This shall be calculated on a pro-rata basis from the date of joining of such Insured Member till
the date of renewal.

6. Similarly, a return premium by the Company shall be allowed to the Policyholder and calculated on a
pro-rate basis from the date of cancellation of such removed Insured Members till the date of renewal of
the Policy.

7. Either additional or return premium shall be settled either way within 30 days of declaration and
submission of all required documents to the Company as required to the satisfaction of the Company.

Article 4 - Grace Period and Reinstatement

1. A grace period of 30 days towards premium payment and/or renewal premium payment, is granted for
the payment of the required premium/renewal premium. During this grace period the Policy shall remain
in force but shall be suspended at the end of such grace period if no premium/renewal premium payment
in respect of this Policy/renewal is effected. If the Policy terminates during, or at the end of the grace
period, the Policyholder shall be liable to the Company for the payment of the premium/renewal premium
accruing for the time the Policy was in force during such grace period.

2. Immediately after the grace period, the Policy at sole discretion of the Company may either be
suspended or shall lapse. If the Policy is suspended then during such suspended time and until the
required premium/ renewal premium is received in full no claims shall be valid / accepted or entertained,
no payments will be effected, no prior approvals shall be held valid or considered and no Insured
Member turnover shall be accepted.

3. The period of time allowed for a Policy to be in a state of suspension is for 30 days. This state may either
incept immediately after the Grace Period is terminated or co-current to the Grace Period itself. A
Policyholder may be notified in writing when the Policy is being suspended by the Company. For a
suspension to be lifted, renewal premium payment must be effected at which time the Policy shall be
reinstated.

Article 5 - Currency

Unless otherwise mentioned in the Policy’s Schedule, the currency of this Policy shall be deemed to be that
of the country of the office of issue of the Policy. All payments by the Company under this Policy shall be
made in the same currency as that in which premiums were received by the Company with respect to the
insurance hereunder, unless otherwise arranged by mutual agreement between the Policyholder and the
Company and defined accordingly by endorsement.

Article 6 - Misstatement of Age

1. Should the age of an Insured Employee exceed that stated in the application, this Policy shall not be void
but there shall be an equitable adjustment. If the misstatement of age does not alter in any way the
outcome of a claim submitted, then the benefits shall remain unchanged; but if the change in age effects
such, then these shall be corrected accordingly, and a premium adjustment shall take such corrections

into account with effect from inception.

2. With respect to the calculation of age for the calculation of the premium to the policy, in the case where
only the year of birth of the Insured Member is indicated the day of birth shall be considered as the 01st
of January of the year indicated as that of birth.

Article 7 - Renewal of Policy

This Policy shall continue for the period of insurance as stated in the SCHEDULE and shall be renewable
annually on mutual agreement by the Policyholder and the Company on each subsequent Policy Anniversary
on rates and terms to be agreed.

Article 8 - Termination

1. Termination of the Policy

1.1. It is hereby provided that the Policyholder or the Company may terminate this Policy or any of its
Schedules at any time after inception by mailing to the other party written notice of such intention at
least thirty (30) days before the indicated termination date.

1.2. If this insurance Policy is terminated at any time at the request of the Policyholder, then the
Company shall be entitled to retain the premium due for the period during which this Policy has been
in force corresponding to the Short Rate Scale as follows:

Period Of Policy In Force: Period Of Policy In Force:

Premium Amount Retained by the Company Premium Amount Retained by the Company
1 Month: 20% of annual premium 6 Months: 70% of annual premium
2 Months: 30% of annual premium 7 Months: 75% of annual premium
3 Months: 40% of annual premium 8 Months: 80% of annual premium
4 Months: 50% of annual premium 9 Months: 85% of annual premium
5 Months: 60% of annual premium Over 9 Months: 100% of annual premium

1.3. If this Policy is terminated by Company, then the Company shall be liable to repay on demand a
ratable proportion for the unexpired term from the effective date of cancellation.

1.4. All coverage shall terminate upon termination date indicated on the Notice of Cancellation.

2. Termination of Individual Insurance of Employee

2.1. An Insured Member’s insurance under this Policy shall automatically terminate:
2.1.1. If his/her employment terminates as defined below,
2.1.2. If he/she ceases to be a member of the classes of Employees eligible for the insurance
under this Policy.
2.1.3. If this Policy terminates,
2.1.4. If premium payments for his/her insurance are discontinued,

2.1.5. When he/she reaches the age of sixty-five (65) unless otherwise accepted by the Company

2.2. Termination of employment shall, for all purposes of this Policy, be deemed to occur when an
Employee ceases to be actively engaged in work on a full-time basis with the Policyholder. However,
an Employee who is disabled, granted a leave of absence (whether with or without pay) temporarily
laid-off, or placed on a part-time employment basis, will nevertheless be considered as still
employed on a full- time basis until the Policyholder, acting on a basis precluding individual selection,
terminates the Employee’s insurance by notifying the Company to that effect or by discontinuing
premium payment for his insurance.

3. Termination of Individual Insurance on Dependants

3.1. A Dependent’s insurance under this Policy shall automatically terminate:

3.1.1. If the Employee’s insurance as an Employee under this Policy terminates,
3.1.1. If the Insured’s Dependents cease to be eligible as a Dependent,
3.1.2. If this Policy terminates.
3.1.3. Time Limitation - In no case whatsoever shall the Company be liable for any loss or damage
after the expiration of twelve (12) months from the happening of any event giving rise to the
loss or damage unless the claim is subject to pending action or litigation.

Article 9 - Reporting and Settlement of Claims

1. Notice and Proof of Loss: The Company, will require claim forms in the format as provided by the
Company to be duly filled in. The claim forms must be completed and returned to the Company
within ninety (90) days from the date of availing the Medically Necessary Healthcare Services or
Treatment. Any requirements requested by the Company, such as supporting documents or
missing information to be provided within 30 days from the date of request letter, failing which
the Company reserves the right to repudiate the claim.

2. Examination: The Company shall have the right and opportunity to examine the Insured Member when
and as often as it may reasonably require, prior to and during the payment of any benefit hereunder.

3. Administration / Payment of Claims:

3.1. The Company will issue a medical card preferably carrying the photographed image of each
Insured Member entitling such member to access and medical treatment, services and
medications at the hospital, clinics and medical facilities specified in Applicable Network subject to
prior approvals, terms, conditions, limitations and exclusions of this Policy.

3.2. If treatment for a specific medical condition is unavailable at any Applicable Network’s Provider in
Company assigned Network, the Insured Member can avail of treatment at any other medical
Provider’s facility, subject to prior written approval of the Company.

3.3. For treatment in medical facilities not specified in Insured Member’s Applicable Network, or for
treatments obtained from Applicable Network without presenting valid medical insurance card,
Insured Members shall pay cash for medical treatment/services and medications and submit
invoices together with a completed claim form to the Company, as applicable and defined in the
Table of Benefits, through their offices, not later than ninety (90) days from the date of availing the

Medically Necessary Healthcare Services or Treatment. The Company shall reimburse the
Policyholder provided that all supplementary documents/receipts are in order, subject to the terms,
conditions, limitations and exclusions of this Policy.

3.4. Under the direct payment system, medical claims are settled upon the submission of invoices for
Healthcare Services rendered to the Insured Members from any Medical Provider enlisted under
the Applicable Network to the Company and reimbursement is effected by the Company on behalf
of the Insured Members for claims incurred during the Policy Period.

3.5. In the case where a breach arises from the Policy exclusions, invalid treatment/s or excess of
Policy limits at the settlement of valid medical claims, a periodical shortfall statement accompanied
by a debit note for the purpose of recovery shall be submitted to the Policyholder. The Policyholder
shall at all times be responsible for such amounts including for any benefit payment exceeding the
maximum liability of the Company as stated in the Schedule.

3.6. Benefits shall be payable in the Currency indicated in the Policy Schedule. Where benefits are
payable in respect of expenditure incurred in some other currency, the rate of exchange applicable
to the payment of benefit shall be the average rate of exchange at the date of Treatment or, if
receipted accounts are submitted by the claimant, as at the average rate of exchange at the date
shown on the invoices submitted. Such conversion rate shall be sole determined and at sole
discretion of the Company.

3.7. All supplementary documents and claim form must be received within 90 days of the expenditure
being incurred in the absence of which the Company reserves the right to treat the submitted claim
as time barred. Any additional information/report that the Company may reasonably require, shall
be requested from the Policyholder/Insured member, which should be submitted within 15 calendar
days of having received such request from the Company, in the absence of which the Company
reserves the right to treat the submitted claim as time barred.

3.8. The Company may in the case of any claim require the submission of a medical report, to be
obtained at the expense of the claimant, giving such information as the Company may reasonably
require, and reserves the right at its own expense to appoint an independent medical examiner.

3.9. All Benefits recoverable hereunder except for Direct Billing Network Providers access shall be
payable to the Policyholder unless otherwise agreed in writing.

4. Prior Approvals
4.1. In case of access to a Network Provider, the Network Provider will obtain necessary prior approval
(Please refer to the user’s guide for services that require prior approval) from the Company. To
facilitate this, Insured Members should produce the Medical Insurance card to the Provider to
identify themselves as Company’s Insured Members.

4.2. For reimbursement claims, it is not mandatory to obtain pre-approval by the members. Claims
shall be adjudicated according to the policy terms and conditions.

4.3. Outpatient (consultation) treatment by visiting Physician’s specialists from both inside and outside
UAE is covered (provided it remains within the consultation Limit as specified in this Policy). The

Company’s standard prior approval protocols are applicable, and the claims shall be payable at
Company’s UAE- applicable Network charges only.

4.4. Under pharmaceuticals, pharmaceutical treatment comprises of drugs recognized by the UAE
Ministry of Health as prescription drugs and as approved by the Company as Medical Necessary
for the Healthcare Services of the Treatment being availed for. The Company reserves the right to
apply relevant drug formulary / generic drug list, as approved by the local regulatory authorities.

4.5. Company may require additional information relating to a treatment recommended by the Provider
and may assign an independent Physician to give a second opinion.

4.6. Any Insured Member covered by more than one insurance scheme/another insurance policy
(whether or not issued by the Company) may not claim more than once for the same expenditure
and the claim shall be subjected to Contribution as better defined in Article 10 below.

4.7. The Company’s nominated medical staff shall attend to the Policyholder’s/member’s written
requests for prior approvals within 24 hours. However, clarifications regarding prior approvals may
be attended to over the phone immediately. In case of emergencies, Insured Member/ Insured
Member’s representative can notify the Company over the phone within 24 hours. All approval
requirements within Applicable Network’s Providers shall be arranged by the provider supporting
facts, figures, information, reports as asked by the duty Officer.

4.8. The Company undertakes not to unreasonably withhold according approval to pre-approval
requests of the Insured Member.

Article 10 - Contribution

If any claim covered by the scope of cover of this Policy is also covered by any other contract of cover or
insurance policy also simultaneously active at the time of occurrence, then this Policy shall not be liable to
contribute more than its rate able proportion of any payment in respect of such claim. In the event the
Company (whether knowingly or unknowingly) pays or reimburses more than its rate able proportion, then the
Company shall be within its rights to request recovery or initiate any action or proceeding to recover amounts
paid more than the Company’s rate able proportion.

Article 11 - Records, Reports & Changes in Insurance Coverage

1. The Policyholder shall keep a record of each Insured Member hereunder containing, for each such
Insured Member, the essential particulars of the insurance. The Policyholder shall periodically forward to
the Company such information concerning Eligible Employees or Dependents or Insured Members as
may be reasonably considered to have a bearing on the administration of the Policy and on the
computation of the premium thereof.

2. The Policyholder shall advise the Company on any new Employee or Dependent eligible for the
insurance hereunder, on any individual insurance termination and finally on any changes in Employee
classification or salary. This shall be on the prescribed “Turnover Form” attached to this Policy.

3. The company may cover substandard risks at extra premium. Additions/Deletions of Employees,

Dependents and Insured Members during the term of Period of Insurance is restricted to the following
cases:

3.1. Newborn - as specified under Eligibility Section of Policy Schedule.

3.2. Dependents - from the date of marriage (for newlywed spouse) or Entry into UAE on residence
whichever is later.
3.3. Change of Status - From effective date of such change.
3.4. End of Service - from one day following the last working day with the Policyholder.
3.5. New Recruitment - From date of joining the Policyholder.
3.6. Age Limit - As specified under eligibility Section of Policy’s Schedule.

4. Any addition/deletion of Employees, Eligible Dependents, Insured Members should be reported to the
Company within maximum of 15 calendar days. Requests for back-dated additions/deletions shall not be
honored or recognized by the Company.

5. The Company shall not process any Insured Member deletion requests without the Policyholder returning
the original issued Medical Insurance Card. In case it is specifically agreed mutually to delete an Insured
Member without the original issued Medical Insurance Card being returned, the Policyholder shall be fully
liable in relation with any expenses incurred by such terminated/excluded members as from the
termination date unless the original Medical Insurance Card of the terminated member has been returned
to the Company. The Company may debit the Policyholder for any such amounts, as and when settled to
the Providers. The Policyholder and the Insured Members clearly acknowledge that the Medical
Insurance Cards shall all times be considered proprietary and property of the Company.

6. If an Insured Employee’s classification changes, the Policyholder shall report the same to the Company
in writing. The Company shall process the request and issue any premium adjustment documents. The
change in cover shall be effective from the date as reported by the Policyholder.

7. Records of the Policyholder having a bearing on this Policy shall be opened for inspection by the
Company at any reasonable time upon reasonable prior notice. The Policyholder is also obliged to
provide the Company any document pertaining to this Policy and its Insured Members as per the
requirements by the local regulators.

8. Clerical error or omission in keeping the records shall not invalidate this Policy but upon discovery of
such error or omission an equitable adjustment of premium shall be made.

9. Local regulatory rules being implemented from time to time shall be applied in the process of Insured
Member enrolment and documentation requirements from the Policyholder.

Article 12 - Misrepresentation, Errors and Omissions

1. The Company shall not be liable under the Policy in the event of any misrepresentation or non-disclosure
by the Policyholder or the Insured Member of any material information at any time during the currency of
the Policy.

2. Furthermore, it is to be noted that the issue of this Policy document is affected under the Company’s part
and obligation towards the governance of utmost good faith. Hence it is to be understood that due care

and diligence have been employed in the issue of such Policy contract.

3. Thus, it shall be the onus and responsibility of the Policyholder and/or the Insured Member to ensure that
all facts, circumstances, terms and limitations enlisted under this Policy contract are as per the
agreements intended to be entered into between all Parties to such Policy.

4. Failure to indicate any errors and omissions from the part of the Policyholder following the issue of this
Policy shall not bind the Company towards any liability arising there from.

Article 13 - Forfeiture

If the Policyholder or the Insured Member shall lodge any claim or connive in the making of any
claim, knowing the claim to be false or fraudulent, the Policy shall become void for that particular
Insured Member and all claims pertaining to that Insured Member will stand forfeited.

Article 14 - Written Communication

Any notice and/or other communication to the Company relevant to the insurance cover as afforded by this
Policy or towards the maintenance of same or claims submitted must be submitted in writing or in printed
form and addressed/delivered to the Company at the indicated correspondence channels of same.

Article 15 - Representation

The Policyholder agrees to nominate a coordinator to act on behalf of the Policyholder and the Insured
Members enlisted under this Policy to administer the Policy on behalf of the Policyholder in accordance to the
terms of this Agreement. All communications and correspondence between the parties related to the Policy
shall be maintained through this channel of representation.

Article 16 - Sanction Limitation and Exclusion Clause

The Company shall not provide cover and the Company shall not be liable to pay any claim or
provide any benefit hereunder to the extent that the provision of such cover, payment of such claim
or provision of such benefit would expose the Company to any sanction, prohibition or restriction
under United Nations resolutions or the trade or economic sanctions, laws or regulations of the
European Union, United Kingdom, United States of America, United Arab Emirates and / or all other
jurisdictions where the Company transacts its business.

Article 17 - Anti-Money Laundering & Combating Terrorist Financing

The Company is in compliance with Anti-Money Laundering & Combating Terrorist Financing laws (UAE
Federal Law No. 4, 2002 - Criminalization of Money Laundering, UAE Federal Law No. 1, 2004 - Combating
Terrorism Offences, Insurance Authority Resolution No. 16 of 2013 - Anti-Money Laundering and Combating
Terrorism Financing).

Article 18 - Language

All Insurance Policies are issued in both Arabic and English, In case of dispute over the interpretation of the
Insurance Policy, the Arabic text shall prevail.

Article 19 - Assignment

This Policy and the rights and obligations of the Policyholder or the Insured Member shall not be assignable
to any other party without the prior consent of the Company.

Article 20 - Promotion

1. Company will not be responsible for any promotional costs incurred by the Policyholder in connection with
this Policy.

2. Prior to the printing of any promotional material, the Policyholder will obtain the written approval of
Company for any promotional material referring directly to the Policy or to Company, such approval not to
be unreasonably withheld.

Article 21 - No Constructive Notice

Any knowledge or information of any circumstances or condition in connection with the Insured Member, in
possession of any official of the Company shall not be the notice to or be held to bind or prejudicially affect
the Company notwithstanding subsequent acceptance of the premium.

Article 22 - Material Change

The Policyholder shall immediately notify the Company by fax or in writing of any material change in the risk
and cause at his own expense such additional precaution to be taken as circumstances may require to
ensure safety thereby containing the circumstances that may give rise to a claim and the Company may
adjust the scope of the cover and/or the premium, if necessary accordingly.

Article 23 - Electronic Transactions

The Proposer/Policyholder/all of the Insured Members agrees to adhere to and comply with all such
electronic transaction terms and conditions as the Company may prescribe from time to time and hereby
agrees and confirms that all transactions effected by or through facilities for conducting remote transactions
including the internet, world wide web, electronic data interchange, call centers, tele-service operations
(whether voice, video, data or combination thereof) or by means of electronic, computer, automated
machines network or through other means of telecommunication, established by or on behalf of the
Company, for and in respect of this Policy or its terms, or the Company’s other products and services, shall
constitute legally binding and valid transactions when done in adherence to and in compliance with the
Company’s terms and conditions for such facilities, as may be prescribed from time to time.

Article 24 - Authorization

Authorization by the Policyholder:

The Policyholder on behalf of itself and with full authority of the Insured Member hereby agrees and
authorizes:

• The Company to use any of the approved verification agencies to make references/inquiries from
any source of information, about the Policyholder, any Insured Member, beneficiary, person or entity
nominated or insured herein;

• All financial institutions, bank, debt collection agencies, credit bureaus or any other person or entity to
disclose and provide to the Company with any information requested about or related to the
Policyholder and/or the Insured Member as in its possession;

• The Company, at any time and at its absolute discretion, to use and/or disclose any financial
information available with the Company (including any breach of obligations or defaults (including in
premium payment or repayment)) to any other organization, entity, financial institutions, banks, debt
collection agencies or credit bureaus.

The Proposer/Policyholder/all of the Insured Members hereby confirm that their personal data has been
collected and is being provided to Oman Insurance Company in compliance with relevant regulations. By
providing any such personal data/information, the Proposer/Policyholder & the underlying Insured Members
hereby give their unambiguous consent to:

a. the Company to collect, store, process, share and transfer your personal data (including but not limited to
your personal sensitive information) to third parties including but not limited to reinsurers, surveyors, loss
adjustors, loss assessors , IT service providers, claim administrators, medical providers, emergency
support/assistance providers, professional advisors, consultants, auditors, additional administrative
and/or support service providers, and other entities or persons , whether within or outside the UAE , as
may be required in relation to underwriting/ issuing/administering / processing/ reinsuring your policy/
claims or as may be required by the Company including but not limited to for further product
development/statistical analysis etc., or as may be required under law/regulatory requirements.

b. the Company and its associate partners to contact the Proposer/Policyholder/any of the Insured Member
anytime (including electronically through email, SMS or telephone) for seeking any additional information
and/or for providing any additional information whether related to the Policy and/or Company’s other
products or promotions.

Article 25 - General

1. The Insured Member/Policyholder shall furnish the Company with any information the Company may
require (including details of the state of health) in respect of the Insured Member for the benefits
hereunder. Prior to acceptance, the Company may, at its sole discretion, require any Insured Member to
undergo a medical examination by a legally qualified medical practitioner in the manner the Company
deems required or fit.

2. No Benefits shall be paid in respect of an Insured Member who attains the Maximum Coverage Age
specified in the schedule of this policy (at which time that Insured Member shall cease to be covered).

3. The Policyholder agrees to provide clear, detailed and accurate information about this Policy, its

exclusions and terms and conditions to each of the Insured Member upon their enrolment under this
Policy.

4. The Insured Members must take reasonable care to prevent loss, damage, accident, bodily injury or
illness.

5. All words appearing in the gender of one sex shall be taken to include both sexes. If the context requires,
the singular shall imply the plural and vice versa.

6. In the event that the Company incurs any cost and/or expense not insured under this Policy on the
Insured Person’s or the Policyholder’s behalf, the Policyholder shall reimburse such costs and expenses
to the Company.

7. This Policy shall continue to benefit the Insured Member effective the Policy inception, subject to the
terms and conditions herein, unless the Insured Member specifically expresses his intention not to be
covered under this Policy.

8. No person or third party or agent is authorized to alter or amend this Policy, to accept premiums in
arrears or to extend the due date of any premium, to waive any notice or proof of claim required by this
Policy, or to extend the date before which any such notice or proof must be submitted. No change in this
Policy shall be valid unless approved by the Company and evidenced by endorsement hereon or by
amendment hereto, signed by the Policyholder and by an authorized representative of the insurance
Company.

9. Any notice, direction or instruction given under this Policy shall be in writing and delivered by hand, post,
or facsimile to:

9.1. In case of the Policyholder, at the last-known address as recorded with the Company.
9.2. In case of the Company: Customer Services: Oman Insurance Company: PO Box 5209,
Dubai, UAE.

10. Notice and instructions will be deemed served 72 hours after posting or immediately upon receipt in the
case of hand delivery, facsimile or e-mail.

Article 26 – Taxes

(A) Premium Payments:

For avoidance of doubt, all premium amounts mentioned herein are exclusive of Value added tax (VAT). VAT
and any other taxes currently applicable or which will be applicable in connection with this insurance policy
shall solely be borne by the Insured/Policyholder.

The Insured/Policyholder hereby agrees to pay to the Insurer the applicable VAT/any other taxes paid by the
Insurer, on the Insured/Policyholder’s behalf, within 15 working days of receiving the invoice failing which the
Insured/Policyholder shall be considered to be in material breach of the Policy’s terms and conditions and,
the Insurer shall be within its right to invoke legal remedies available to the Insurer including to terminate the
policy and/or offsetting such VAT or other tax amounts from any other amount which the Insured/Policyholder

owes to the Insurer without the need to obtain any further consent from the insured/policyholder and/or any
court judgment/order. The Insured hereby unconditionally accepts to the same.

In the event that VAT/any other tax treatment as assessed by relevant tax authorities is different from that
assigned by the Insurer on our tax invoice/invoice to you and/or the invoice generated/computed by the
Insurer is incorrect/, the Insured/ Policyholder hereby agrees to pay immediately and on demand the
differential balance of any VAT/tax to the Insurer.

(B) Claim settlements - where OIC agree to pay the policyholder

When Oman Insurance Company ("OIC" or "we") pays a claim, your VAT registration status will determine
the amount we pay you.

When you are:

1. Not registered for VAT, the amount we pay, will be the sum insured/limit of indemnity or any other limits of
insurance cover, including VAT;

2. Registered for VAT, the amount we will pay will be the sum insured/limit of indemnity or any other limits of
insurance cover and where you are liable to pay an amount of VAT in respect of an acquisition relevant to
your claim, we will pay the VAT amount. However we will reduce the VAT amount we pay for by the amount
of any input tax credits to which you are or would be entitled to if you had made the relevant acquisition. In
such instances the input tax credit would be claimable by you upon filing of your VAT return.

All policyholders making a claim with OIC must declare their VAT registration status.

Any VAT liability arising from your incorrect declaration is and will be payable by you (the policyholder).

Where the settlement amount of your claim is less than the sum insured/limit of indemnity or any other limits
of insurance cover, we will only pay an amount of VAT (less any entitlement to an input tax credit) applicable
to the settlement amount.

PREMIUM PAYMENT CONDITION

Notwithstanding any provision to the contrary within this quotation/any binding confirmation, in
respect of non-payment of premium the following clause will apply. The Insured undertakes that
premium will be paid in full to Insurers within the notified payment terms (or, in respect of installment
premiums, when due). If the premium due under the policy (if issued) has not been so paid to Insurer
within the notified payment terms (and, in respect of installment premiums, by the date they are due)
Insurers shall have the right to cancel the policy (if issued) by notifying the Insured and/or the broker
(if applicable) in writing. In the event of cancellation, premium will be due to Insurers for the period
that Insurers were on risk but the full policy premium shall be payable to Insurers in the event of a
loss or occurrence prior to the date of termination which gives rise to a valid claim under the policy
(if issued). It is agreed that Insurers shall give not less than 30 days prior notice of cancellation to the
Insured via the broker or intermediary (if applicable). If premium due is paid in full to Insurers before
the notice period expires, notice of cancellation shall automatically be revoked. If not, the policy
shall automatically terminate at the end of the notice period. If any provision of this clause is found
by any court or administrative body of competent jurisdiction to be invalid or unenforceable, such

invalidity or unenforceability will not affect the other provisions of this clause which will remain in
full force and effect.

INCONTESTABILITY

This medical policy shall be incontestable after a period of one (1) calendar year from the policy
inception date for any reason other than misrepresentation, fraud, non-payment of premium or as
otherwise permitted under respective laws and regulations.

SECTION 5
EXCLUSIONS
EXCLUDED (NON-BASIC) HEALTHCARE SERVICES

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; care for the sake of travelling.

4. Custodial care includes

(1) Non-medical treatment services; or

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

5. Services which do not require continuous administration by specialized medical personnel.

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

7. Healthcare Services and associated expenses for replacement of an existing breast implant.
Cosmetic operations which improve physical appearance, and 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. 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 Authorised 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. Supplies, Treatment and services for smoking cessation programs and the treatment of nicotine
addiction.

13. Non-medically necessary Amniocentesis

14. Treatment, services and surgeries for sex transformation, sterility and sterilization.

15. Treatment and services for contraception.

16. Treatment and services related to fertility/sterility (treatment including varicocele / polycystic
ovary / ovarian cyst / hormonal disturbances / sexual dysfunction).

17. Prosthetic devices and consumed medical equipments, unless approved by the insurance
company.

18. 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.

19. Growth hormone therapy

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

21. Mental Health diseases, in-patient and out-patient treatments, unless the condition is a transient
mental disorder or an acute reaction to stress.

22. Patient treatment supplies (including elastic stockings, ace bandages, gauze, syringes, diabetic
test strips, and like products; non-prescription drugs and treatments, excluding such supplies
required as a result of healthcare services rendered during a medical emergency).

23. Preventive services, including vaccinations, immunizations, allergy testing and desensitization;
any physical, psychiatric or psychological examinations or testing during these examinations.

24. Services rendered by any medical provider relevant of a patient for example the Insured person
and the Insured member’s family, including spouse, brother, sister, parent or child.

25. Enteral feedings (via a tube) and other nutritional and electrolyte supplements, unless medically
necessary during treatment.

26. Healthcare services for 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.

27. Healthcare services and treatments by acupuncture; acupressure, hypnotism, rolfing, massage
therapy, aromatherapy, homeopathic treatments, and all forms of treatment by alternative
medicine.

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

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

30. Nasal septum deviation and nasal concha resection.

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

32. Treatments and services related to viral hepatitis and associated complications, except for
treatment and services related to Hepatitis A.

33. Birth defects, Congenital diseases for newborn &/or Deformities unless life-threatening.

34. Healthcare services for Senile dementia and Alzheimer’s disease.

35. Air or Terrestrial Medical evacuation except for Emergency cases or unauthorized transportation
services.

36. Circumcision healthcare services.

37. Inpatient treatment received without prior approval from the insurance company including cases
of medical emergency which were not notified within 24 hours from the date of admission.

38. Any inpatient treatment, tests and other procedures, which can be carried out on outpatient basis
without jeopardizing the insured person’s health.

39. Any test or treatment, for purpose other than medical such as tests related for employment,
travel, licensing or insurance purposes.

40. 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.

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

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

43. Services and educational program for handicaps.

HEALTHCARE SERVICES OUTSIDE THE SCOPE OF HEALTH INSURANCE

1. Injuries or illnesses suffered by the Insured Person as a result of military operations of whatever
type.

2. Injuries or illnesses suffered by the Insured Person as a result of wars or acts of terror of
whatever type

3. Healthcare services for injuries and accidents arising from nuclear or chemical contamination.

4. Injuries resulting from natural disasters (including but not limited to) earthquakes, tornados and
any other type of natural disaster.

5. Injuries resulting from criminal acts or resisting authority by the Insured Person.

6. Healthcare services for patients suffering from AIDS and its complications.

7. All cases resulting from the use of alcohol, drugs and hallucinatory substances.

8. Any test or treatment not prescribed by a doctor.

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

10. Diagnosis and treatment services for complications of exempted illnesses.

11. All healthcare services for internationally and locally recognised epidemics.

12. Venereal sexually transmitted diseases. A list with respect thereto will be set out by the General
Authority of Health Services.

SECTION 6
USER GUIDE

The Policyholder and the Insured Members must ensure to adhere to procedures in order to avail himself/
herself of the best service that this valuable Policy offers.

Below are some procedures applicable to the various possibilities that the Insured Member might find
himself/ herself in when seeking medical assistance:

Direct Billing Facility - What you should know.

1. Insured Member in need of medical assistance.

2. Seeks the services of an OIC-Approved Network Health Care Provider (HCP).

3. Presents a valid Medical Insurance Card to HCP.

4. Receives required medical assistance as per treatment recommended and as covered by Policy
conditions and limitations.

5. Signs a claim form that is completed by the HCP from whom Treatment was received

6. Settles any Deductibles and/or Co-insurance shares as indicated at the back of the Medical Insurance
Card.

7. Once the Insured Member is served the Network Provider shall send all documents to the Company.

Reimbursement Facility (where it is allowed in the Policy) – What you should know.

1. Insured Member in need of medical assistance.

2. Seeks the services of a Healthcare Services Provider (‘HCP’) who is not listed under Company’s Network
of Providers or the treatment is sought abroad (if Policy covers) or in the case where a valid Medical
Insurance Card is not produced and therefore the HCP cannot verify eligibility of Insured Member (if
reimbursement is covered in the Policy).

3. Receives required medical assistance as per Treatment recommended.

4. In case of emergency treatments, the Company must be notified within 24 hours of admission or not later
than discharge from the Hospital.

5. Insured Member settles bills in respect of treatment received directly with HCP.

6. Insured Member is to obtain a medical report from treating Physician together with a completed claim
form (a Reimbursement claim form is available on the Company’s website or from the Policyholder’) that

is signed and stamped by the treating Physician. All relevant bills must be presented to the Company in
original for reimbursement.

7. Claim settlement/reimbursement shall be as per directives shown on the Table of Benefits

Obtaining Pre-Approval

Health Care providers shall be responsible for obtaining necessary approval from the insurance company if
you are accessing one of the Applicable Network Providers.

Services that Require Preauthorization from the Company

1. All non-emergency medical and surgical admissions & day case procedures.

2. Below specific OP diagnostic tests:

• MRI
• CT Scan
• Endoscopic examinations
• Physiotherapies

3. In case one of above services is not available at primary provider location and would be done in
another location, the preauthorization request must be initiated by first location, then OIC will direct the
approval to the 2nd provider location.

4. Pre-authorization is valid up to 30 days from date of issue or up to expiry date of the card as printed
whichever is earlier.

How to Obtain Prior Approval from the Insurance Company

UAE Toll Free No. 800 6626 – 24 hours

Abroad Calls: +971 50 4543778
Email ID: [email protected]
Fax: 04 2684623/ 04 2384721

Pre-Approvals are given verbally over the phone on the mobile number mentioned above as well as in written
form via telefax or e-mail as indicated to OIC.

Important: Medical Approval Center – UAE 800 6626 Abroad +97150 4543778 are dedicated lines for
Emergency Pre- Approvals and therefore should not be utilized otherwise such as a means to
follow-up claims.

Submitting a Claim & Follow-up

When a medical treatment is received on a reimbursement facility, the Insured Member must:

1. All claims documents to be submitted with claim form through Policyholder’s HR department or directly
as per instructions on the claim form.

2. All documents must be presented in original and in either English or Arabic languages only.
Documentation in other languages must be officially translated prior to their submitting to OIC’s claims
department. Also, to note that the claim form needs be completed in block letters and all relevant
literature must be legible.

3. It is important to complete the claim form in full including your Mobile No., Email ID and IBAN Number
to help us pay your claim in shortest time.

4. All documents are to be submitted within thirty (30) days of the claim. Claims submitted after ninety
(90) days of treatment shall not be accepted or honored.

Inquiries About Your Reimbursement Claims May Please Be Addressed to:

Toll Free No. 800 4746 - 08:00 till 19:00

Email ID: [email protected]
Fax: 04 2384769

General Inquiries May Please Be Addressed To:

Toll Free No. 800 4746 - 08:00 till 19:00

Complaints

Tell us what you think of Oman Insurance Company, we are always happy to hear your comments.

If you have any feedback or complaints, please contact us through our call centre on 800 4746 from inside
the UAE, or on +971 50 4543778 from outside the UAE (8 AM to 8 PM - Saturday to Thursday), or by visiting
our website www.omaninsurance.ae, alternatively you can email us on [email protected].

The website mentions details process on complaints: https://www.omaninsurance.ae/Complaints-Policy

Group Life Assurance Rider

This Rider is a part of the Policy to which it is attached and takes effect on the effective date shown above.

Lives Assured Covered: All members of the Policy

Scope of Coverage: 24 hours worldwide
Principal Sum: AED 100,000 per member
Benefits Covered: Death any cause
Age Limit: 65 years

Death (Due to any cause)

In the event of Death (natural or accidental) of the Life Assured, the Company agrees to pay the Principal
Sum of that Life Assured under this Rider.

Limitations

The benefit under this Rider shall be paid only for Losses:

(a) Occurring after the effective date of this Rider.

(b) Occurring prior to the 65th birthday of the Life Assured.

(c) Occurring prior to any default in the payment of a premium under said Policy or within the grace
period allowed in said Policy for such payment.

Exclusions

• Active War, warlike operations (whether war is declared or not, conventional, biological, chemical or
nuclear), invasion, acts of foreign enemies, hostilities, acts of terrorism, terrorist sabotage, rebellion,
mutiny, civil commotion, civil war, revolution, insurrection, military or usurped power, martial law,
embargo, or any act committed by any person or persons for the purpose of overthrowing a government
by violent force or to influence political decision making. Active terrorism (suspected or proven) shall be
understood to include the consequences of hostage taking, drive-by shooting, planting of bombs, and any
other form of physical violence.

• In the event of loss, damage, cost or expense directly or indirectly caused by, contributed to by, resulting
from or arising out of or in connection with biological, chemical, or nuclear explosion, pollution,
contamination and/or fire following thereon.

• Injuries contracted or sustained while violating or attempting to violate the law, or committing an assault,
or resisting arrest.

Passive War Risk Extension

Passive War and/or Passive terrorism as an innocent bystander is covered for death benefit, however;
Passive war is excluded in Iraq, Afghanistan& Syria and any other country where war or war like operation
takes place. It is also excluded for any member who travels to any country where war has been declared or
war like operations takes place and remains there for more than 28 days following the outbreak.

Notice of Claim

Written notice of a claim under this Rider must be given to the Company within thirty (30) days after the date
of death of the Life Assured. Failure to furnish notice of claim to the Company within the above time limit shall
not invalidate the claim if it shall be shown not to have been reasonably possible to give such notice within
the time limit and that notice was given as soon as was reasonably possible.

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