Table of Benefits

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Table of Benefits
Healthcare Insurance
DHAP7-OPCHA
All amounts are in AED

Coverage Details
Total Annual Limit Coverage & Pre-existing
Annual upper limit for healthcare services 250,000 per insured member per year
Pre-existing & chronic conditions Covered*3
Healthcare Services Geographical Scope

In Dubai Covered
In Abu Dhabi Covered
Other Emirates Covered
Arab Countries and South East Asia Home Country only, for Inpatient treatment
International Home Country only, for Inpatient treatment
Medical Network
Applicable Network Classic Network
Inpatient Healthcare Services (at designated network hospitals – prior approval is required)
Shared room
Patient Accommodation
20% co-insurance with maximum ceiling*1
Tests, diagnosis, treatments and surgeries Covered
in hospitals for non- urgent medical cases 20% co-insurance with maximum ceiling*1
Covered
Emergency treatments
20% co-insurance with maximum ceiling*1
Transportation services for medical Covered
emergencies by an authorized party 20% co-insurance with maximum ceiling*1
Accommodation for a person accompanying Covered up to AED 100 per night
an insured child up to 16 years of age. 20% co-insurance with maximum ceiling*1
Accommodation for an accompanying
person in the same room in case of critical Covered up to AED 100 per night
conditions and as per recommendation of 20% co-insurance with maximum ceiling*1
attending physician.
Oman Insurance Company(P.S.C.), Paid up Capital AED 461,872,125, C.R. No. 41952, Insurance Authority No. 9 dated 24/12/1984,
VAT Registration No 100258594900003,
Head Office: P.O.Box 5209, Dubai, United Arab Emirates. Tel: +971 4 233 7777, Fax: +971 4 233 7775, www.tameen.ae
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Normal Delivery: AED 7,000 per policy year

Medically necessary C-Section, abortion and other maternity
complications: AED 10,000 per policy year
In patient maternity services
10% coinsurance applicable on all services. Maternity complications,
if leading to emergency, will need to be covered up to the annual
indemnity. Waiting period on pre-existing condition does not apply to
maternity.
Coverage Details
Outpatient Healthcare Services (at designated network provider – prior approval is required except GP
consultation)
Services provided by General Practitioners,

Specialists and Consultants Examination,
diagnostic and treatment services of clinics
and health centers by general practitioners, GP consultation & Specialist consultation on referral from GP
and specialist and/or consultant by a general 20% co-insurance
practitioner. Follow ups are exempted from
fees if made within a week from the date of
first examination.
Covered
Laboratory tests
20% co-insurance
X-ray diagnostic services including MRI, CT Covered
scans and endoscopies 20% co-insurance
Physiotherapy treatment. Subject to referral
8 sessions covered every year
from a specialist and prior approval from
20% coinsurance
OIC
Covered with a limit of AED 2,500 per year including co-insurance.
Cost of medicine – pharmacy Co-insurance: 30%
Coverage as per DHA approved formulary.
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Antenatal Care
8 visits to primary healthcare facility. All consultations by PHC
Obstetrician for low risk or Specialist Obstetrician for high risk, on
referral. Initial investigations includes the below.
Examination, diagnostic and treatment for
· FBC and Platelets
pregnancy and gynecology services in
· Blood group, rhesus status and antibodies
authorized health centers and clinics by
· VDRL
general practitioners and specialists,
· MSU & urinalysis
provided that the insured member is referred
· Rubella serology
to a specialist and/or consultant by a general
· HIV
practitioner. Follow ups are exempted from
· FBS, random s or A1c
fees if made within a week from the date of
· Hep C, where recommended
first examination.
· GTT where recommended
· 3 antenatal ultrasound scan
Visits to includes reviews, checks and tests in accordance with DHA
Antenatal Care Protocols
10% coinsurance for all services.
Other Benefits
Diagnostic and treatment services for Covered only for life threatening medical emergency cases only*2
dental and gum treatments. 20% coinsurance
Hearing and vision aids, and vision Covered only for life threatening medical emergency cases only*2
correction by surgeries, and laser. 20% coinsurance
Covered for 30 days from birth. Coverage includes BCG, Hepatitis B
and neo- natal screening tests (Phenylketonuria (PKU), Congenital
New born cover Hypothyroidism, sickle cell screening, congenital adrenal
hyperplasia).
The cover is provided under the mother’s policy.
• Essential vaccinations and inoculations for newborns and
children is covered as stipulated in the DHA’s policies and its
updates in the assigned facilities (currently the same as Federal
MOH), through selected providers.
• Preventive services as stipulated by DHA to include initially
diabetes screening
Preventive services, vaccines and Frequency restricted to:
immunizations Diabetes: - Every 3 years from age 30
- High risk individuals annually from age 18
• 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
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Reimbursement of return airfare for the insured member to travel to

home country for elective inpatient treatments, subject to following
conditions:
Return Airfare 1) Economy class, limited to a maximum of AED 2,000/- per
treatment
Maximum overall cost inclusive of the airfare does not exceed 90%
of OIC applicable UAE network tariff
Compensation in respect of :
Personal Accident Benefit*
A) Death due to accident : AED 50,000
Subject to terms and conditions as follows
B) Permanent total disability due to accident : AED 50,000
Inside UAE – Outside Network (Coinsurance applies over and above Network Deductions)
Emergency in UAE
Coinsurance (with or without PAR) 0% Coinsurance
Basis of Claims Settlement 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) Not Covered
Basis of Claims Settlement Not Applicable
Abroad (within agreed territory) – Coinsurance applies over and above network deductibles
Emergency Abroad
Coinsurance 10% Coinsurance
Basis of Claims Settlement OIC Network Tariff
Elective Abroad
Coinsurance 10% Coinsurance
Basis of Claims Settlement OIC Network Tariff
*1 Co-insurance of 20% for all inpatient services subject to a ceiling of AED 500 per claim and AED 1000 in
aggregation (maximum per year).
*2 These benefits are covered only in case of life threatening medical emergencies.
*3 Waiting period of 6 months is applicable from the first scheme enrollment. Waiting period does not apply for
members who were previously insured, subject to the proof of previous medical insurance cover.
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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, step-children 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
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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:
• Blood examination (CBC, blood sugar, lipid profile, HIV, Hepatitis B)
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• Electrocardiogram ECG
• Fundoscopy
• Chest X-Ray
• Urine routine
• Stool OP/OB Consultation with General Practitioner/Internal Medicine Specialist
• Mammogram, PSA as screening for Cancer breast / prostate
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)
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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.
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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
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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.
Maternity
The Maternity Benefit is applicable to expenses incurred for room, board and general nursing care, special
hospital services and ordinary nursing care of the baby while the mother is confined in the hospital, and for
charges made by the physician, or registered midwife. Maternity benefits also include antenatal and postnatal
medical expenses, including consultations, laboratory, radiology, medications, and any other covered medical
expense related to the pregnancy or delivery, subject to the benefit limit mentioned in the table of benefits.
Where any condition develops which becomes life threatening, the medically necessary expenses will be
covered up to the annual aggregate limit. Maternity shall include childbirth, miscarriage or legal abortion,
including any and all complications arising therefrom.
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.
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Newborn
Where the Policy covers maternity benefits for a pregnant female, the coverage is extended to provide
medical benefits for a new born child of that female for a period of 30 days from date of birth or until
enrolment of the child as a dependent of the Insured Member. The new born benefit is considered within the
indemnity limit of the mother.
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. Unless specified otherwise in the table of
benefits, the preventive services stipulated by DHA to include diabetes screening every 3 years from age 30
years and for high risk individuals annual from age 18 years.
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
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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 tooth
pastes, 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:
The benefit provides for the fees charged for eye examination carried out by a qualified and registered
ophthalmologist.
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:
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:
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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 child birth
Treatment
Any Surgery, medical, pharmaceutical or other approach used to cure or rectify a 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
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Unless specified otherwise, the Vaccines & Immunizations or Child Vaccination as referred in the Table of
Benefit covers the Essential vaccinations and inoculations for newborns and children as stipulated in the
DHA’s policies and its updates (currently the same as Federal MOH).
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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://www.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.
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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,
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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
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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.
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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.
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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
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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. 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.
Article 8 - Termination
1. Termination of the Policy
1.1. This insurance Policy may be terminated at any time at the request of the Policyholder, in which
case the Company shall be entitled to retain the Pro-rata 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
5 Months: 60% of annual premium Over 9 Months: 100% of annual premium
1.2. 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.
1.3. 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
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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:
3.2.1. If the Employee’s insurance as an Employee under this Policy terminates,

3.2.2. If the Insured’s Dependents cease to be eligible as a Dependent, If this Policy terminates.
3.2.3. 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
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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
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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
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cases:
3.1. New born - 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 a 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.
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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.
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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 Transaction
The Policyholder and the Insured Member agrees to adhere to and comply with all such 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 centres, 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 the 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 by the Policyholder:
The Policyholder on behalf of itself and with full authority of the Insured Member hereby agrees and
authorizes:
1. 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;
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2. 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;
3. The Company, at any time and at its absolute discretion, to use and/or disclose the particulars and
information provided by the Policyholder and/or the Insured Member in the Policy or the application or
any information relating to the Policyholder’s liabilities towards the Company;
4. 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.
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
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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
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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.
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SECTION 5
EXCLUSIONS
EXCLUDED (NON-BASIC) HEALTHCARE SERVICES
1. Healthcare Services which are not medically necessary

2. All expenses relating to dental treatment, dental prostheses, and orthodontic treatments.
3. Care for the sake of travelling.
4. Custodial care including:
(1) Non-medical treatment services;
(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 that 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. All cosmetic healthcare services and services associated with replacement of an existing
breast implant. Cosmetic operations which are related to an Injury, sickness or congenital
anomaly when the primary purpose is to improve physiological functioning of the involved part
of the body and breast reconstruction following a mastectomy for cancer are covered.
8. Surgical and non-surgical treatment for obesity (including morbid obesity), and any other
weight control programs, services, or supplies.
9. Medical services utilized for the sake of research, medically non-approved experiments and
investigations and pharmacological weight reduction regimens.
10. Healthcare Services that are not performed by Authorized Healthcare Service Providers.
11. Healthcare services and associated expenses for the treatment of alopecia, baldness, hair
falling, dandruff or wigs.
12. Health services and supplies for smoking cessation programs and the treatment of nicotine
addiction.
13. Treatment and services for contraception
14. Treatment and services for sex transformation, sterilization or intended to correct a state of
sterility or infertility or sexual dysfunction. Sterilization is allowed only if medically indicated
and if allowed under the Law.
15. External prosthetic devices and medical equipment.
16. 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
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and any professional sports activities.

17. Growth hormone therapy unless medically necessary.
18. Costs associated with hearing tests, prosthetic devices or hearing and vision aids.
19. Mental Health diseases, both out-patient and in-patient treatments, unless it is an emergency
condition.
20. Patient treatment supplies (including for example: elastic stockings, ace bandages, gauze,
syringes, diabetic test strips, and like products; non-prescription drugs and treatments,)
excluding supplies required as a result of Healthcare Services rendered during a Medical
Emergency.
21. Allergy testing and desensitization (except testing for allergy towards medications and supplies
used in treatment); any physical, psychiatric or psychological examinations or investigations
during these examinations.
22. Services rendered by any medical provider who is a relative of the patient for example the
Insured person himself or first degree relatives.
23. Enteral feedings (via a tube) and other nutritional and electrolyte supplements, unless
medically necessary during in-patient treatment.
24. Healthcare services for adjustment of spinal subluxation.
25. Healthcare services and treatments by acupuncture; acupressure, hypnotism, massage
therapy, aromatherapy, ozone therapy, homeopathic treatments, and all forms of treatment by
alternative medicine.
26. All healthcare services & treatments for in-vitro fertilization (IVF), embryo transfer; ovum and
sperms transfer.
27. Elective diagnostic services and medical treatment for correction of vision
28. Nasal septum deviation and nasal concha resection.
29. All chronic conditions requiring hemodialysis or peritoneal dialysis, and related investigations,
treatments or procedures.
30. Healthcare services, investigations and treatments related to viral hepatitis and associated
complications, except for the treatment and services related to Hepatitis A and C.
31. Any services related to Birth defects, congenital diseases and deformities unless if left
untreated will develop into an emergency.
32. Healthcare services for senile dementia and Alzheimer’s disease.
33. Air or terrestrial medical evacuation and unauthorized transportation services.
34. 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 where possible.
35. Any inpatient treatment, investigations or other procedures, which can be carried out on
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outpatient basis without jeopardizing the Insured Person’s health.

36. Any investigations or health services conducted for non-medical purposes such as
investigations related to employment, travel, licensing or insurance purposes.
37. All supplies which are not considered as medical treatments including but not limited to:
mouthwash, toothpaste, lozenges, antiseptics, 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,
exercise equipment and sanitary supplies.
38. More than one consultation or follow up with a medical specialist in a single day unless
referred by the treating physician.
39. Health services and associated expenses for organ and tissue transplants, irrespective of
whether the Insured Person is a donor or a recipient. This exclusion also applies to follow-up
treatments and complications unless if left untreated will develop into an emergency.
40. Any expenses related to immunomodulators and immunotherapy unless medically necessary.
41. Any expenses related to the treatment of sleep related disorders.
42. Services and educational programs for people of determination, this also includes disability
types such as but not limited to mental, intellectual, developmental, physical and/or
psychological disabilities.
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HEALTHCARE SERVICES OUTSIDE THE SCOPE OF HEALTH INSURANCE.

(In Emergency cases as defined by PD 02-2017, the following must be covered until stabilization at minimum)
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. Injuries resulting from a road traffic accident.
7. Healthcare services for work related illnesses and injuries as per Federal Law No. 8 of 1980
concerning the Regulation of Work Relations, its amendments, and applicable laws in this
respect.
8. All cases resulting from the use of alcoholic drinks, controlled substances and drugs and
hallucinating substances.
9. Any investigation or treatment not prescribed by a doctor.
10. Injuries resulting from attempted suicide or self-inflicted injuries.
11. Diagnosis and treatment services for complications of exempted illnesses.
12. All healthcare services for internationally and/or locally recognized epidemics.
13. Healthcare services for patients suffering from (and related to the diagnosis and treatment of)
HIV – AIDS and its complications and all types of hepatitis except virus A and C hepatitis.
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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
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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 medical and surgical admissions & day case procedures.

2. The following specific Outpatient diagnostic tests: MRI, CT scan, Tread mill stress test,
Echocardiography, Endoscopic examinations
3. Other Outpatient tests or a procedure (not including consultation) in one visit exceeds net cost of AED
1000 except for our Essential Network policies. For Essential Network Policies, this limit would be AED
500. Please refer to your Medical Insurance Card for verifying the Applicable Network you are eligible
for.
4. Following multiple sessions services: Cryocautery, Electrocautery, Sclerotherapy, Laser therapy,
Physiotherapies
How to Obtain Prior Approval from the Insurance Company
UAE Toll Free No. 800 6626 – 24 hours

Abroad Calls: +971 50 4543778
Email ID: medpar@tameen.ae
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
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(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: medclaims@tameen.ae
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.tameen.ae, alternatively you can email us on complaints@tameen.ae.
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SECTION 7
PERSONAL ACCIDENT COVER – ADDENDUM
Table Of Benefits
Compensation Payable In Respect Of Accident: Per Person
1) Death: AED 50,000
2) Total And Irrecoverable Loss Of Sight Of Both Eyes: Not Covered
3) Total And Irrecoverable Loss Of Sight Of One Eye: Not Covered
4) Total And Irrecoverable Loss Of Two Limbs: Not Covered
5) Total And Irrecoverable Loss Of One Limb: Not Covered
Total And Irrecoverable Loss Of Sight Of One Eye And Loss Of
6) Not Covered
One Limb:
7) Permanent Total Disablement By Accident: AED 50,000
8) Temporary Total Disablement By Accident: Not Covered
9) Temporary Partial Disablement By Accident: Not Covered
Compensation Payable In Respect Of Illness:
10) Total And Irrecoverable Loss Of Sight Of Both Eyes: Not Covered
11) Permanent Total Disablement By Illness: Not Covered
12) Temporary Total Disablement By Illness Of Any Kind: Not Covered
Words in bold print in this Insurance have special meaning, as defined in the DEFINITIONS of this Insurance
IMPORTANT NOTICE
PLEASE NOTE THAT SEPARATE INSURANCE IS PROVIDED UNDER THIS POLICY FOR BODILY
INJURY CAUSED BY AN ACCIDENT AND FOR ILLNESS. THIS INSURANCE ONLY RELATES TO THE
BENEFITS OF THE POLICY WHICH ARE SHOWN IN THE SCHEDULE AS BEING INCLUDED AND FOR
WHICH PREMIUM HAS BEEN PAID.
THE INSURED MUST DISCLOSE TO THE UNDERWRITERS ALL FACTS, MATTERS AND
CIRCUMSTANCES MATERIAL TO THIS INSURANCE, INCLUDING, BUT NOT LIMITED TO WHETHER
THE INSURED PERSON ENGAGES IN ANY OCCUPATION, SPORT OR PASTIME OR OTHER ACTIVITY
OF A HAZARDOUS NATURE.
We, the Underwriters, hereby agree with the Insured, to the extent and in the manner herein provided, that if
the Insured Person:
(a) sustains Bodily Injury caused by an Accident or
(b) suffers Illness;
We will pay to the Insured, or to the Insured's Executors or Administrators, according to the Schedule of
Benefits after the total claim shall be substantiated under this Insurance
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Provided Always That:
1. No weekly benefit shall become payable until the total amount thereof has been ascertained and agreed.
2. the total sum payable under this Insurance in respect of any one or more claims shall not exceed in all
the total of the larger of benefit 7 or 11 and benefit 8 or 12 multiplied by the maximum benefit period as
shown in the Schedule of Benefits less any excess as shown in the Schedule of Benefits.
3. If Item 1 of the Schedule of Benefits is not covered, then no claim shall be payable, other than for weekly
benefits, in respect of any Accident which would have given rise to a claim for death had that item been
covered.
4. If Item 1 of the Schedule of Benefits is covered and an Accident causes the death of the Insured Person
within twelve months following the date of the Accident and prior to the definite settlement of the benefit
for disablement provided for under Items 2 to 7 of the Schedule of Benefits, there shall be paid only the
benefit provided for in the case of death.
5. no benefit shall be payable under Items 10 or 11 of the Schedule of Benefits should Illness cause the
death of the Insured Person within twelve months of that Illness first manifesting itself.
DEFINITIONS
In this Insurance:
1. 'BODILY INJURY' means identifiable physical injury which
a) is caused by an Accident, and
b) Solely and independently of any other cause, except illness directly resulting from, or medical
or surgical treatment rendered necessary by such injury, occasions the death or disablement of
the Insured Person within twelve months from the date of the Accident.
2. 'ACCIDENT' means a sudden, unexpected, unusual, specific event which occurs at an identifiable time
and place during the Period of Insurance.
Accident shall also include disappearance. If the Insured Person is not found within twelve months
of disappearing, and sufficient evidence is produced satisfactory to the Underwriters that leads them
inevitably to the conclusion that the Insured Person has sustained Bodily Injury and that such injury
has caused the Insured Person’s death, the Underwriters shall forthwith pay any death benefit, where
applicable, under this Insurance, provided that the person or persons to whom such sum is paid shall
sign an undertaking to refund such sum to the Underwriters if the Insured Person is subsequently
found to be living.
3. 'ILLNESS' means sickness or disease of the Insured Person which first manifests itself during the Period
of Insurance and occasions the total disablement of the Insured Person within twelve months after
manifesting itself.
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4. 'TEMPORARY TOTAL DISABLEMENT' means disablement which entirely prevents the Insured Person
from attending to their business or occupation.
5. 'TEMPORARY PARTIAL DISABLEMENT' means disablement which prevents the Insured Person from
attending to a substantial part of their business or occupation.
6. 'PERMANENT TOTAL DISABLEMENT' means disablement which entirely prevents the Insured Person
from attending to any and every occupation and which lasts twelve months or the maximum benefit
period for Temporary Total Disablement as stated in the Schedule of Benefits whichever is the longer
and at the end of that period is beyond hope of improvement.
7. 'LOSS OF A LIMB' means permanent loss by physical separation of a hand at or above the wrist or of a
foot at or above the ankle and includes permanent total and irrecoverable loss of use of hand, arm or leg.
8. ‘LOSS OF SPEECH’ shall mean total loss of speech which lasts twelve months and at the end of that
period is beyond hope of improvement.
9. ‘LOSS OF HEARING’ shall mean total loss of hearing in one or both ears which lasts twelve months and
at the end of that period is beyond hope of improvement.
EXCLUSIONS
This Insurance does not cover claims in any way caused or contributed to by:
1.war, whether war be declared or not, hostilities or any act of war or civil war;
2.the actual or threatened malicious use of pathogenic or poisonous biological or chemical

materials;
3.nuclear reaction, nuclear radiation or radioactive contamination;
4.the Insured Person engaging in or taking part in armed forces service or operations;
5.the Insured Person engaging in flying of any kind other than as a passenger;
6.the Insured Person’s suicide or attempted suicide or intentional self-injury or the Insured Person
being in a state of insanity;
7.venereal disease or Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC)
or Human Immuno-deficiency Virus (HIV) howsoever these have been acquired or may be named;
8.the Insured Person’s deliberate exposure to exceptional danger (except in an attempt to save
human life);
9.the Insured Person 's own criminal act;
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10. the Insured Person being under the influence of alcohol or drugs;
11. pregnancy or childbirth;
12. Neuroses, psychoneuroses, psychopathies or psychoses, anxiety, stress, fatigue or mental or

emotional diseases or disorders of any type.
CONDITIONS
1. If the Insured Person shall regularly engage in any occupation, sport, pastime or other activity in which
materially greater risk may be incurred than previously disclosed in connection with this Insurance without
first notifying the Underwriters and obtaining their written agreement to the inclusion under this Insurance,
(subject to the payment of any additional premium as the Underwriters may reasonably require as the
consideration for such agreement), then no claim shall be payable in respect of any Accident or Illness
arising from such activity.
2. Unless otherwise declared and agreed by the Underwriters no benefit will be payable for any condition for
which the Insured Person has sought advice, diagnosis, treatment or counseling or of which the Insured
Person was or should reasonably have been aware at inception of this Insurance or for which the Insured
Person has been treated at any time prior to inception.
3. Notice must be given to the Underwriters as soon as reasonably practicable of any Accident or Illness
which causes or may cause a claim within the meaning of this Insurance, and the Insured Person must
as early as possible seek the attention of a duly qualified medical practitioner. Notice must be given to
the Underwriters as soon as reasonably practicable in the event of the death of the Insured Person
resulting or alleged to result from an Accident.
All medical records, notes and correspondence referring to the subject of a claim or a related
Pre-existing condition shall be made available on request to any medical adviser appointed by or on
behalf of the Underwriters and such medical adviser shall, for the purpose of reviewing the claim, be
allowed so often as may be deemed necessary to make an examination of the Insured Person.
4. Any fraud, concealment, or deliberate mis-statement either in the proposal on which this Insurance is
based or in relation to any other matter affecting this Insurance or in connection with the making of any
claim hereunder shall render this Insurance null and void and all claims hereunder shall be forfeited.
5. The law and jurisdiction applicable to this insurance contract are as stated in the Schedule.

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OIGM201900063511

All amounts are in AED

Healthcare Services Geographical Scope

Applicable Network Classic Network

Normal Delivery: AED 7,000 per policy year

Services provided by General Practitioners,

Reimbursement of return airfare for the insured member to travel to

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

• Blood examination (CBC, blood sugar, lipid profile, HIV, Hepatitis B)

Eligible Medical Expense

Hospital Confinement or Hospitalization

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

Medical Insurance Card

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

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

Policy Period or Period of Insurance

Shall mean the period as mentioned in the policy Schedule.

Preventive Medical Services

• Lesions of oral cavity

Schedule or Policy Schedule

South East Asia

Surgery or Surgical operation

Shall be deemed to refer to the following:

Vaccines & Immunizations

Clause 2 - Inpatient Benefits

a. Daily Room/Board and Nursing:

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

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

Clause 3 - Outpatient Benefits

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

Article 2 - Governing Law and Jurisdiction

Article 4 - Grace Period and Reinstatement

Article 6 - Misstatement of Age

into account with effect from inception.

Article 7 - Renewal of Policy

1. Termination of the Policy

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

2. Termination of Individual Insurance of Employee

2.1.1. If his/her employment terminates as defined below,

3. Termination of Individual Insurance on Dependants

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

3.2.1. If the Employee’s insurance as an Employee under this Policy terminates,

Article 9 - Reporting and Settlement of Claims

3. Administration / Payment of Claims:

payable at Company’s UAE- applicable Network charges only.

Article 11 - Records, Reports & Changes in Insurance Coverage

3.1. New born - as specified under Eligibility Section of Policy Schedule.

Article 12 - Misrepresentation, Errors and Omissions

Article 14 - Written Communication

Article 16 - Sanction Limitation and Exclusion Clause

Article 17 - Anti-Money Laundering & Combating Terrorist Financing

Article 21 - No Constructive Notice

Article 22 - Material Change

Article 23 - Electronic Transaction

Article 24 - Authorization by the Policyholder:

(A) Premium Payments :

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

When you are: