Membership Handbook

health insurance
Membership handbook
Health Perfect and
Secure Series
what you need to know

Contents
Section Page No.
1. Introduction 1
2. Important note about pre-existing conditions 2
3. In case of emergency 3
4. Understanding how to get the best from your plan 4
5. Understanding our position on certain medical conditions 9
6. Administering your policy 11
7. Definitions 14
8. What we pay for 18
9. What we do not pay for (exclusions and limitations) 20
10. Making claims 26
11. Joining, renewing and transferring 28
12. What we expect from you 30
13. General 31
14. Complaints Procedure 32
15. Your customer charter 33
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membership handbook health perfect and secure series
1. Introduction 2. Important note about pre-existing conditions
Your insurance policy comprises your the cost of eligible treatment resulting Why it is important to tell us Whether or not you told us about any
membership statement and benefits from an unexpected illness or accident. about pre-existing conditions such conditions, or missed some
table, your membership card, details Pre-existing (including pre-existing relevant details, we have the right,
You must take care of your own
of your hospital network and other chronic) conditions are those that a based on our medical knowledge and
health and not only rely on healthcare
documents related to our services member already had, already knew experience, to decide that a condition
professionals to do this for you. When
including where applicable any contract about, should reasonably have known was likely to have been symptomatic or
something unfortunate does affect your
we may have with the policyholder who about or for which there were symptoms diagnosed before your policy first came
health we will do our best to help you
may be the head of the family or your before the policy started. into force.
but we must always act within the limits
employer.
of your policy. Before you were accepted for cover you Our decision in such cases is final and
This handbook, which forms part of were given the opportunity to tell us we will therefore only provide cover for
this contract, has been designed to What our service team is there to about any pre-existing (including pre- such conditions in accordance with
set out the key features and benefits of do existing chronic) conditions even if you benefit number 21.
your Healthcare Plan and to clarify our It is the role of our Customer Service only had symptoms. The terms of your membership
position on some aspects of your cover. Team to assist you, wherever possible,
Cover for such conditions and anything agreement will apply in any event.
It includes general terms, conditions, within the terms and limits of your AXA
definitions and exclusions applicable Healthcare Plan. If you need to call us related to them is taken from benefit
to all members covered by one of our you will find our number on the reverse number 21.
Healthcare Plans. of your membership card. For your It is important that you have shared
reference it is: any information about such pre-existing
Details of your personal cover are
included in your membership statement UAE: +971 (4) 429 4000 conditions so that we can accurately
and benefits table. If there is anything assess and quickly pay your claims.
Qatar: +974 (4) 412 8733
you would like to clarify further please If you have not shared this information
call our Customer Service Team on the Bahrain: +973 17 582612 with us we may have to delay a pre-
number shown on your membership approval request or claim or may not be
card. Oman: 800 72926.
able to cover that undeclared condition
Please take a few moments to refresh Please see your membership card for at all.
your memory about the AXA Healthcare details of your local office in the AGCC
Plan then relax and look forward to the where applicable.
highest standards of service from AXA Please take a note of this and keep it in
Insurance. You can rest assured that, a safe place where you can find it easily.
whatever the coming year brings, we’ll Please have your membership card with
be there to support you. you whenever you call our Customer
Service Team. The information on your
What your health insurance cover card will help them to deal with your
is designed to do enquiry as quickly as possible.
As with all insurance policies your AXA
Healthcare Plan is there to cover you for
costs arising from an unforeseen event.
For healthcare insurance this means
1 2
3. In case of emergency 4. Understanding how to get the best from your plan
Emergency treatment separate leaflet for full details. Please Before you go for treatment
We know that in a real emergency note that, for your own protection, calls
Our agreement with you requires you to
you may not have time to contact us may be recorded in case of subsequent Contacting us before receiving seek pre-authorization for the following
for pre-authorization or help with your query. Access to this service is treatment treatment and services:
case. In such circumstances we take provided by AXA Travel Insurance. We require you to contact us before
a pragmatic approach, so, we ask you Please note that entitlement to the receiving any planned admission and In-patient and daycare
to contact us beforehand if you can evacuation service does not mean some major outpatient treatment. This
and it is safe to do so. If it is not, and that the member’s treatment following allows us to help you in a number of All in-patient and daycare admissions;
you need immediate treatment please evacuation or repatriation will be ways: by managing your admission All non-emergency tests, diagnostics,
make that your priority. eligible for benefit. Any such treatment and billing, by confirming to you and treatment, surgery and other medical
will be subject to the terms and whoever is giving you treatment that services;
Do, however, ask somebody to contact conditions of the member’s plan.
us as soon as possible and make your claim will be eligible, at what cost
and for how long treatment is approved. All in-patient maternity services;
sure that, at the earliest opportunity,
whoever is providing treatment is In the unlikely event that there is any All in-patient dental services;
given your membership card and proof difference between our confirmed level
of cover and what is requested by All psychiatric treatment.
of identity so that they can contact
us straight away. In any event, under the hospital when you are discharged
you must make arrangements to pay Out-patient
these circumstances, our authorization
must be sought and given before you this before leaving hospital. If you do Non-emergency MRI, CT, PET and
are discharged from care otherwise not contact us it is possible that you Gait;
you may be required to pay the entire will have to pay for all or part of your
Scans and internal diagnostics such
cost of your treatment and submit a treatment.
as but not limited to endoscopy,
reimbursement claim to us. colonoscopy, gastroscopy, etc;
When we pre-authorize cover we
International Emergency Medical will confirm; Physiotherapy services;
Assistance (I.E.M.A.) The planned treatment is eligible
Prescriptions covering consumables
If ‘IEMA’ is included in your benefits under your policy;
for 30 days or more;
table you have access to International The planned treatment is medically
Emergency Medical Assistance. This is All out-patient dental services
necessary;
a worldwide, 24 hours-a-day, 365 days- received on direct billing basis;
a-year emergency service providing The planned treatment will take an
All psychiatric treatment.
evacuation or repatriation services. appropriate amount of time;
If you need immediate emergency in- If you do not obtain pre-authorization
The planned treatment is within
patient treatment, where local facilities as required on page 6 it may prevent
the eligible costs for the services.
are unavailable or inadequate, a phone us from settling all or part of any claim.
Please refer to Published Rates
call to the Emergency Control Centre If we are obliged to pay for any item
section;
on: +971 4 4294000 will alert the not covered by our confirmation we will
International Emergency Medical The planned treatment costs falls have to recover that amount from you.
Assistance service. Please see the within the remaining benefit limit of In any event any cost that is not directly
your plan. related to treatment will be borne by
the member.
3 4
Pre-authorization before an important that you check a practitioner ii. Pharmacy will be paid on actual as for administrative purposes. There are
admission may protect you from or provider’s recognition status with us per terms and conditions of Policy. in excess of 1,000 procedures listed,
paying the bill before undergoing treatment. of which about 250 are commonly
iii. Benefits/Services not included in
We try very hard to pre-authorize most performed on a daily basis.
Decisions about your treatment the list of Published Rates shall be
treatment within a few hours. However dealt with on a case to case basis. This document is written in medical
sometimes we need more information We do not decide whether the
treatment you receive is given on language and it is intended for use by
about the medical condition, the planned iv. The actual amount payable shall be
an in-patient, daycare or outpatient medical practitioners and us to assess
treatment or the medical practitioner. based on the itemized bill submitted
basis. This is decided by the attending the eligibility of proposed treatment and
This can take a little time and delay and the codes used per service by the
medical practitioner. We will not usually your claim. The schedule is regularly
the approval. This is particularly the Service Provider. Where itemized bill
question this unless, in the opinion of updated to include new, proven,
case when you choose or are obliged is not submitted and where service
our medical team, it would have been procedures and is retained by us.
to use a provider outside our network or provided are without defined codes
one who is not recognized by us. When more appropriate for treatment to have they would be assessed on a case to
this happens you must pre-authorize been given differently. In the unlikely case basis.
event of this happening we will ask for Second opinion
your treatment at least 5 days before v. Published rates factor shall be
an explanation of why the particular We can ask an independent medical
admission and you must confirm with based on the country where Policy
method of treatment was chosen. We practitioner to advise us about the
the provider that our written approval is issued and shall be applicable for
recognize that there may have been a medical fact relating to a claim or to
has been received before you undergo treatments taken within the AGCC.
valid reason for the choice made by examine the member concerned in
treatment. If it has not, you must
the medical practitioner. Our intention vi. Where no network exists or the connection with the claim. This is
contact us immediately.
in questioning such matters is to be treatment is not available within the needed only very rarely and we use this
We must be advised of any proposed able to fairly and accurately assess network providers (for treatment in right only where there is uncertainty as
treatment before treatment begins. If any claim. countries where published rates are to the nature or extent of the medical
you do not allow us to manage your not available), AXA Insurance will base condition and/or our liability under the
case, wherever treatment is received, Published Rates. the calculation on the average cost of policy.
you may be exposed to additional costs. All benefits and services submitted the treatment in that area or country;
for reimbursement of claims shall be or the network in the principle country
What we mean by ‘recognized by evaluated based on the Published of residence. If you need treatment abroad
us’ Rates. AXA will pay the actual cost If you need treatment abroad, you will
Around the world there are many highly incurred or the Published Rate against vii.
Special arrangements if any
need to call AXA Insurance on +971
trained and skilled practitioners and the service whichever is less and the would reflect in the Table of Benefits
(4) 429 4000 or one of the numbers
organizations but there are also those level of reimbursement shall be decided issued by AXA.
shown on your membership card.
who, while being able to demonstrate based on the Network offered.
professional qualification, do not Schedule of procedures If your medical practitioner recommends
The following conditions would apply- In this handbook we refer to a schedule hospitalization or a major out-patient
meet acceptable standards of care,
experience and/or integrity. We do not i. Co-insurance/Deductible as of procedures which is a document that procedure then call one of the below
‘recognize’ those who do not meet our applicable under the plan would lists the proven surgical procedures telephone numbers to confirm that you
standards in this regard. Therefore if be deducted wherever applicable for which we pay benefit and classifies are entitled to the benefit.
you choose to use an ‘unrecognized’ from the eligible amount prior to them by complexity. Each of the
practitioner or provider we will not reimbursement procedures is also given a code number
be able to settle your claim. It is very
5 6
How to claim
Claim forms You can visit our website at www.axa-gulf.com to obtain a printable
claim form if you need one. You must provide a completed claim
form, signed by the medical practitioner and the member, for any visit
whether this is to a practitioner, hospital, clinic, pharmacy, diagnostic
centre or any other facility where medical services may be received.
Any bills, together with your completed AXA medical ID Card, together with a Claim forms
claim form, should be sent to: recognized official form of identification, When you register at a direct-billing network and identify yourself as
inside our a member you should be given a claim form. If not, please ask for
such as a passport, to any provider to directbilling one. It is your responsibility to ensure that this is fully completed and
AXA Insurance, P.O. Box 32505, Dubai,
show that you are an insured member network signed by you and the attending medical practitioner. The direct-billing
UAE.
of an AXA insurance healthcare policy. network hospital will send the completed claim form to us.
UAE: + 971 (4) 429 4000 If you do not ensure that the provider Outside the AGCC you will need to print a claim form from our website
recognizes your entitlement to our before receiving treatment and take it with you for the Medical
or your local AXA office in discounted services you may have to Practioner to complete and sign.
Qatar: +974 (4) 412 8733 pay any difference between the invoice Claim forms If you are not being treated in a hospital listed in the direct billing
value and our negotiated price. outside our network covered by your plan a different process applies.
Bahrain: +973 175 82612 direct-billing You must take a claim form with you (available from our website)
Oman: 800 72926. Any questions? network and make sure it is filled in and signed by yourself and the medical
Although we have tried to include practitioner treating you and sent back to us as quickly as possible,
The address of your local office can be as much useful information in this giving us all the information we request (Only original receipted
found on page 35. invoices can be accepted with your claim). A fully completed claim
handbook as possible if you have form will ensure your claim will be processed promptly. An incomplete
any questions about your cover then or unsigned claim form may delay settlement of your claim and in
While you are having please direct these, either to your HR some cases may lead to the claim form being returned to you for
Department for company schemes or completion. It may be necessary for us to obtain a medical report from
treatment the attending medical practitioner. If the medical practitioner does
AXA Insurance for individual and family
policies. not respond quickly to such a request your claim may be delayed.
Identifying yourself as an AXA We do not pay for medical reports. For treatment requiring our pre-
member Details of how to contact us are shown authorisation such approval must be received from us, in writing,
We have negotiated advantageous on the introductory page. prior to treatment commencing. A copy of that authorisation must be
terms with hospitals and practitioners included in your subsequent claim.
Please note that, for reimbursement claims, we will only consider
around the world. claims made within 90 days of treatment being received. You can visit
This is to your advantage as your our website: www.axa-gulf.com/uae/en/group-healthcare to obtain
benefits are eroded more slowly a printable pre-authorisation form if you need one.
because treatment costs are usually Where to Any bills, together with your completed claim form, should be sent to:
lower than average. To make sure send your AXA Insurance, P.O. Box 32505, Dubai, UAE.
you are benefiting from this, prior claims Tel: + 971 (4) 429 4000
to receiving treatment anywhere, or your local AXA office in
Qatar (QFC branch): 800 2921
you must identify yourself and your
Bahrain: +973 175 82612
eligibility for discounts by showing your Oman: 800 72926.
The address of your local office can be found on page 34.
Payment Regardless of your area of residence you must pay your premiums in
in local United Arab Emirati Dirhams, Bahraini Dinars, Omani Rials or Qatari
currency Riyals.
Claims reimbursement will be paid in the same currency unless we
have previously agreed otherwise in writing.
Benefits paid in a local currency will be converted using the closing
midpoint exchange rate published in the Financial Times Guide to
World Currencies current when we assess the claim.
7 8
5. Understanding our position on certain medical conditions
Our position on chronic benefit number 21 shown in the benefit is because such tests are carried out
conditions first arising after table applicable to your plan. for purposes of establishing whether a
you have been accepted for medical condition might develop and
Where oncology treatment and related
not for the identification of treatment
membership eligible expenses apply to a medical
of a medical condition. It follows that
We provide cover for such conditions condition arising after the date of
benefit cannot be paid for genetic
up to the limit shown for the benefit acceptance of a member by us for
testing or associated counseling
number 21 in the Benefit Table cover under any plan, such costs will
carried out for such purposes.
applicable to your plan. This benefit is be payable out of the overall limits of
only available for treatment of chronic the plan under which the member is Our position on psychiatric illness
conditions for which first symptoms covered at the time of first diagnosis Your policy covers treatment of
became apparent after the member of the condition. The maintenance psychiatric illness up to the level
was accepted by us for cover on a phase of any treatment will fall under shown in the benefits table for your
particular plan. and be taken from benefit number plan. The member being treated or any
22. Upgrades of plans will not be member of his/her immediate family
If there were any symptoms prior to
accepted for cancer care under any must contact us to obtain our written
inception of your policy these must
circumstances. approval of the treatment planned and
have been declared to us, in good faith,
in accordance with the previous section. In any event benefits for oncology and the proposed cost before treatment
Provided such a declaration was made related treatment will only be payable begins.
and accepted by us treatment of the for 3 years in a member’s lifetime. Please note that the member will be
condition will be covered under the required to pay 30% of any benefit we
‘Pre-existing conditions’ benefit shown Our position on kidney dialysis
pay.
for your plan. We will consider kidney dialysis
treatment, received for any reason, as
Please note that the limit shown for treatment of a chronic condition and
this benefit under your plan applies therefore subject to the limits of those
for each member each year and is an benefits covering treatment of chronic
aggregate one. Thus the level shown conditions either pre-existing or arising
is for all such conditions collectively. after policy inception whichever is
Only recognized, proven and necessary applicable.
treatment, prescribed by a medical
practitioner, will be eligible for benefit. Our position on genetic testing
We do not pay for genetic tests even
Our position on cancer care as part of health screening, nor for any
Oncology treatment and related counselling made necessary following
eligible expenses, where applicable to genetic tests, when those tests are
a medical condition or symptoms that undertaken to establish whether or
existed prior to the member first being not the member may be genetically
accepted by us for cover, will be subject disposed to the development of a
to the terms and limits applying to medical condition in the future. This
9 10
6. Administering your policy
What happens when you want to effective from that point, provided the to provide you with that plan in that make a transfer. You will need to give
move to another plan mother’s cover is in force at the time country. your approval for AXA Insurance to
You can ask us to upgrade or of delivery. release your policy history. Transfer
b) You provide us with a fully completed
downgrade your cover at any policy administration can be complicated
If the mother is not covered by us at and signed application form (both
anniversary. Please tell us at least so, by giving us as much notice as
the time of delivery a newborn baby variants are obtainable from the AXA
30 days in advance so that we can possible, you will help to ensure your
may only be added to the father’s PPP healthcare website or your current
be sure that any change takes effect new cover starts when it is needed.
policy and be eligible for benefit insurer) to reach us within one month
from the renewal date. We will do our after final discharge of the child into of the termination of your local plan Where AXA PPP healthcare is unable to
best to accommodate your request parental care. Please note that we are or of leaving the country, whichever is provide continuous cover we will, with
but we reserve the right to decline not obliged to accept any additional earlier. Please ask AXA Insurance for your permission, provide all possible
any request to amend your cover. In member. If we do accept an additional evidence of recent membership if you details of your claims history with us to
the event that we do accept a request member during the policy year we may do not already have it in the form of your any company to which you are applying
for an upgrade we may restrict cover add an administration fee to the pro current or most recent membership to help both you and they to make an
for conditions existing at the time of rata premium charged. statement. informed decision about your transfer
the upgrade to the level of benefits request. It will be the company to
enjoyed under the original policy. In The additional member’s policy c) You have been a member of your
which you are applying that will agree
the case of a downgrade in cover new anniversary will be the same as that of current AXA Insurance plan for a
with you, if cover can be provided, at
policy terms will apply immediately the original policy however any waiting minimum of one year and have paid
what level that will be.
upon renewal. In any event, final period applicable to a benefit under your premiums for that period.
acceptance of any amendment by us the policy will start from the date the What happens if you wish to
d) You accept the price offered by AXA
will only be made at the next renewal additional member joins.
PPP healthcare in the UK for the plan cancel your policy
following such a request. Amendments you have chosen. You may cancel your policy at any time
cannot be made during the policy Transferring to a policy that is not
by giving us no less than 30 days
year under any circumstances. Any provided by AXA Insurance This will be above the normally
notice in writing.
condition known about or that should If you are planning to change your published rate for that plan and
reasonably be known about at the time principal country of residence (where reflects the increased risks posed by Bearing in mind that this is an annual
of any amendment must be advised you live for most of the year) you must such transfers. contract we will not refund premiums
to us, in good faith, before the policy tell us. You may transfer to an AXA PPP if any claim, however small, has been
Please note that we reserve the
amendment takes effect. healthcare UK Plan (in the UK only) or made in the current policy year. In
right to deny cover if we believe
International Health Plan, available at the event that we do agree to make
that the transfer is being requested
What to do if you wish to add the time of transfer, with no additional
just to obtain enhanced benefits
a refund (and this will be at our
other members to your policy medical underwriting exclusions. This sole discretion), we will only refund
for a condition about which you are
If you want to add someone else to can be done when you leave your premiums on a pro-rata basis from the
or reasonably should be aware. You
an existing policy we will send you the principal country of residence and end of the Gregorian calendar month in
must, in good faith, declare any such
forms to complete and you must give cancel your residence permit provided which cancellation takes effect.
conditions on your application form at
all the information we request. that:
the time of requesting a transfer. Note: We will make an administrative
You can ask to add family members to a) Such a plan is available and AXA charge of no less than 20% of the
In the first instance please contact the
your policy at any time. Any newborn PPP healthcare may legally provide it annual premium for any cancellation to
AXA PPP International Sales Centre
infant may be added to the mother’s in the country to which you are going. which we agree. Please also note that
on +44 (0)1892 512345, if you are
policy within 30 days of the moment You will need to meet any residence or no claim of any kind will be considered
thinking about or actually wanting to
of birth, with the child’s cover being other criteria required for us to be able
11 12
7. Definitions
after notification by you and acceptance In any insurance document you will Some words and phrases have special Benefits table
by us of any cancellation. find detailed definitions, terms and meanings. These meanings are set out The table applicable to your plan
exclusions which form part of the below. When we use these terms they showing the maximum benefits we will
For group policies where the number
contract between us. Please read them are in bold print. pay for each member.
of employees (absolute minimum six)
carefully and ask us if there is anything
determines eligibility for a discounted
you do not understand. Area/area of cover Chronic
group premium we reserve the right to
one of the following: A medical condition or episode of ill
apply a minimum premium requirement
health which persists for a long period
reflecting that number of employees, in Area 1: Worldwide
or indefinitely.
the event of deletion of one or more
Area 2: Worldwide excluding the USA.
employees. Company
Area 3: Arabian Gulf Cooperation Your employer and/or sponsor.
What this membership agreement Council (A.G.C.C.) member countries
means being Saudi Arabia, Kuwait, Bahrain, Company agreement
This document sets out the terms of Qatar, UAE and Oman plus Iran, An agreement we have with the company
your membership agreement with us Lebanon, Jordan, Syria, Egypt, India, which allows you to be registered as
and must be read in conjunction with Pakistan, Sri Lanka, Bangladesh, the policyholder. That agreement sets
any supplementary documentation we Korea, the Philippines, Indonesia, out who can be covered, when cover
provide to you from time to time (e.g. Nepal & Bhutan. begins, how it is renewed, and how the
your membership statement including premiums are paid.
Area 4: Your principal country of
your Benefit Table, any Group Summary
residence being one of the Arabian
Benefits Table, your membership card Currency
Gulf Cooperation Council member
and International Emergency Medical The currency, United Arab Emirate
countries being Bahrain, Qatar, UAE
Assistance terms). We have tried Dirhams, Bahraini Dinars, Omani
and Oman.
to keep this as simple as possible Rials or Qatari Riyals in which claims
however, if there is anything you do Area 5: Your principal country of reimbursed to the member will be paid
not understand or would like to clarify, residence being one of the Arabian and in which premiums must be paid.
please contact us. Decisions regarding Gulf Cooperation Council member
your benefits and/or changes to the countries being Bahrain, Qatar, UAE Enrolment/time of enrolment
terms of your membership agreement and Oman plus your home country With effect from 23:59 hours on the
cannot be made verbally but must be being any one of India, Pakistan, Sri date that a member is accepted by
confirmed by us in writing. We may Lanka, Bangladesh, The Philippines, us and premium for the member’s
record calls for your protection in Nepal & Bhutan. plan has been received and accepted
the event of subsequent query or for by us. Any anniversary at which we
training purposes. Area of residence have accepted the member under the
Normally the United Arab Emirates, conditions applicable at that time.
Oman, Qatar or Bahrain or your principal
country of residence as defined in Family member
(Principal country of residence, page Your partner and your unmarried
16). children (or those of your partner) living
13 14
with you when you take out the policy Medical condition Plan as your address and place of residence
or when it is renewed. By partner we Any disease, illness or injury, including Any plan in the AXA Insurance (Gulf) in our records.
mean your husband or wife with whom psychiatric illness. B.S.C.(c) plan range.
you live permanently. Children cannot Schedule of procedures
stay on your policy after the renewal Medical practitioner Policy A document we maintain which lists the
date following their 21st birthday. A person who, being recognised by us, The insurance contract between you surgical procedures we pay benefits for
has the primary degrees in the practice and us. Its full terms are set out in and classifies them according to their
Group of medicine and surgery following the current versions of the following complexity.
When the person paying the premium attendance at a recognised medical documents as sent to you from time
for the policy is not the member school and who is licensed to practice to time: Surgical procedure
benefiting from cover under the plan medicine by the relevant licensing An operation or other invasive surgical
and is not a family member. Normally any application form we ask you to intervention listed in the schedule of
authority where the treatment is given.
this will be the member’s employer or fill in. procedures.
By “recognised medical school” we
sponsor. mean “a medical school which is these terms and the benefits table
listed in the current World Directory setting out the cover under your plan. Treatment
Hospital of Medical Schools published by the A surgical procedure or medical
Any establishment which is licensed your membership statement and our procedure carried out by a medical
World Health Organisation”.
as a medical or surgical hospital clinic, letter of acceptance. practitioner. This includes:
specialist centre or provider in the Member/policyholder the hospital beds directory or list of diagnostic procedures – consultations
country where it operates and which is You and any family member included in hospitals which you may use if such and investigations needed to establish
recognised by us. your policy. a list is attached to this document a diagnosis.
as part of a group contract. When
Hospital beds directory/directory Notice of Cancellation at such a list is attached to a group in-patient treatment – treatment at
of hospitals/ direct billing Anniversary Date contract it will take precedence over a hospital where the member has to
network list Unless we and/or you have agreed the hospital beds directory. stay in a hospital bed for one or more
A document we publish in which before the end of the year to renew nights.
the policy, cover will cease on the Changes to these terms must be
those hospitals with which we have daycare treatment – treatment at a
anniversary date. This will happen confirmed in writing and we will
direct settlement facilities are shown. hospital, daycare unit or out-patient
whether or not written notice of write to you to confirm any changes,
Policyholders should use a hospital clinic where the member is admitted
cancellation has been given by us to undertakings or promises that we
listed in the hospital beds directory to a hospital bed but does not stay
you. make.
except in the case of emergency where overnight.
this may not be possible.
Nurse Prescription out-patient treatment – treatment
Out-patient drugs and dressings as at an out-patient clinic, a medical
Lapse A qualified nurse who is registered to
practice as such where the treatment prescribed by a medical practitioner for practitioner’s consulting rooms or in
The termination of cover.
is given and is recognised by us. the treatment of a medical condition a hospital where the member is not
Lifetime covered by the member’s policy. admitted to a bed.
The period in which the member is Physiotherapist
alive. This does not refer to the life of A person who is qualified and licensed Principal country of residence United Kingdom
to practice as a physiotherapist where The country where you live or intend Great Britain and Northern Ireland,
the policy.
the treatment is given and who is to live for most of the year being 185 including the Channel Islands and the
recognised by us. days or more and which will be shown Isle of Man.
15 16
8. What we pay for
Visit 1. This policy insures the members d. for treatment by a suitably
Each separate occasion that the against the cost of necessary qualified physiotherapist,
member meets with a medical treatment carried out by a medical chiropractor, osteopath,
practitioner and receives a consultation practitioner. However, we will pay homeopath, acupuncturist
and/or treatment for a medical only: recognised by us or for the
condition. services of a nurse if the plan
a. for charges actually incurred
covers it and then only as
for items listed in your benefits
We/us/our allowed by the benefits table;
table subject to the limits
AXA Insurance (Gulf) B.S.C(c).
shown there. Note: if you incur e. provided the costs are not for
Year costs in excess of the limits you something excluded by the
Twelve Gregorian calendar months will have to pay the difference; terms of this policy;
from when your policy began or was b. for treatment of a medical f. for costs incurred during a
last renewed unless we have agreed condition which is commonly period for which the premium
something different with the company. known to respond quickly to has been paid;
treatment. When the medical
You g. treatment of conditions that
condition has been stabilized
The policyholder named on your existed prior to inception of this
we may stop making payments.
membership statement (in the case of plan/Scheme except where
We reserve the right to
large group schemes this may be each such treatment relates to a
determine when a medical
member on a list of members agreed condition that has previously
condition has become chronic
with the company or the company been excluded or subject to a
or recurrent in nature;
itself). moratorium by AXA Insurance
c. if the charges made by the or any previous insurer and
medical practitioner, laboratory such exclusion or moratorium
or other such medical has not expired; or as allowed
service, are at the level for by your plan;
customarily charged by medical
h. the initial diagnosis and
practitioners generally for the
stabilization of a chronic
services received. If necessary
condition (a medical condition
we can delay paying the claim
that does not respond quickly
until we are satisfied that the
to treatment or recurs) arising
charges are appropriate. If the
after policy inception.
charges made by the medical
practitioner, are higher than Stabilization means that, in
is customary we will only the event of such a medical
pay the amount which is, in condition entering an acute
our experience, customarily phase (flaring-up), treatment
charged and the member will to return the condition to a
have to pay the rest; stable state will be covered.
17 18
9. What we do not pay for (exclusions and limitations)
However we will not pay PLEASE ALSO NOTE THAT WE 1. WE DO NOT PAY FOR THE FOLLOWING: SCHEDULE OF PROCEDURES,
for routine, long term DO NOT PAY FOR MINERALS, UNLESS WE HAVE AGREED, IN
a. TREATMENT OF ANY MEDICAL
maintenance aimed at HERBAL REMEDIES AND OTHER WRITING, BEFOREHAND;
CONDITION (AND ITS ASSOCIATED
controlling and monitoring DIETARY SUPPLEMENTS EXCEPT
MEDICAL CONDITIONS WHETHER e. ANY TREATMENT WHICH ONLY
the condition once stabilized AS PART OF YOUR ALTERNATIVE
DIAGNOSED OR NOT) WHICH OFFERS TEMPORARY RELIEF
such as routine consultation THERAPY AND ONLY WHEN WE
THE MEMBER ALREADY HAD OF SYMPTOMS RATHER THAN
and/or medications whether RECOGNISE THESE AS LEGITIMATE
WHEN HE OR SHE JOINED AND DEALING WITH THE UNDERLYING
or not these are prescribed by TREATMENTS.
WHICH YOU SHOULD HAVE TOLD MEDICAL CONDITION;
a medical practitioner unless
2. If treatment is received in United US ABOUT BUT DID NOT TELL
allowed for by the benefits f. NORMAL PREGNANCY OR
Arab Emirates, Saudi Arabia, US AT ALL OR DID NOT TELL US
table and accepted by us in CHILDBIRTH (DELIVERY) UNLESS
Bahrain, Oman, or Qatar we EVERYTHING UNLESS WE HAD
writing; THIS IS SPECIFICALLY INCLUDED
will normally only make direct AGREED OTHERWISE IN WRITING
IN YOUR BENEFITS TABLE - BUT
i. Prescriptions, being out- settlement payments for charges THAT THERE WAS NO NEED FOR
WE WILL PAY FOR TREATMENT OF
patient drugs and dressings made by, or incurred in, a hospital YOU TO TELL US.
A MEDICAL CONDITION WHICH IS
as prescribed by a medical listed in the hospital beds THIS INCLUDES ANY MEDICAL DUE TO AND OCCURS DURING
practitioner for the treatment directory or your list of hospitals CONDITION OR SYMPTOMS THE PREGNANCY OR CHILDBIRTH
of a medical condition covered attached to this document (as WHETHER OR NOT BEING EXCEPT CAESAREAN SECTION.
by the member’s policy defined in hospital and hospital TREATED AND ANY PREVIOUS CAESAREAN SECTION AND ANY
provided that this cover is bed, page 15). If it is medically MEDICAL CONDITION WHICH COMPLICATION RELATED TO IT
included in your plan. necessary to use another hospital RECURS OR WHICH THE IS NOT COVERED UNLESS YOUR
PLEASE NOTE THAT WE DO NOT and we have specifically agreed, MEMBER SHOULD REASONABLY PLAN PROVIDES FOR ‘DELIVERY’
PAY FOR STANDARD TOILETRIES in writing, to its use before the HAVE KNOWN ABOUT EVEN IF HE AND THIS IS NOT LIMITED BY ANY
SUCH AS, BUT NOT LIMITED TO, treatment begins (and we will not OR SHE HAS NOT CONSULTED A WAITING PERIOD APPLICABLE
SHAMPOOS, SOAPS, TOOTH-PASTES, unreasonably refuse to agree) we MEDICAL PRACTITIONER; TO YOUR PLAN. IN THIS EVENT
CONTRACEPTIVES, PROPRIETARY will try to arrange direct settlement CAESAREAN SECTION AND
facilities. Please be aware that b. NON-SURGICAL TREATMENT OF
HEADACHE AND COLD CURES, ANY RELATED COMPLICATIONS
some providers refuse to entertain A MEDICAL CONDITION WHICH
VITAMINS (EVEN IF PRESCRIBED) ETC. WILL BE COVERED UNDER THE
such arrangements. DOES NOT RESPOND QUICKLY
WHICH MAY BE BOUGHT OVER THE ‘DELIVERY’ BENEFIT AND SUBJECT
TO TREATMENT OR WHICH
COUNTER, WITHOUT PRESCRIPTION, We will only pay the hospital TO THE LIMIT SHOWN THERE. WE
CONTINUES OR RECURS UNLESS
AT A LOCAL PHARMACY NOR DO accommodation charges associated WILL NOT PAY FOR TREATMENT OF
ALLOWED FOR BY THE BENEFITS
WE PAY FOR TELEPHONE CALLS OR with the treatment up to a reasonable ANY MEDICAL CONDITION THAT
TABLE AND ACCEPTED BY US IN
MEDIA SERVICES. level. i.e. the use of a single-bedded ARISES DURING PREGNANCY
WRITING;
room with its own bathroom. OR CHILDBIRTH (DELIVERY) IF
c. THE MONITORING OF A MEDICAL THE PREGNANCY WAS A RESULT
CONDITION ONCE IT HAS BEEN OF ANY FORM OF ASSISTED
STABILIZED UNLESS ALLOWED CONCEPTION INCLUDING
FOR BY THE BENEFITS TABLE AND ARTIFICIAL INSEMINATION. WE
ACCEPTED BY US IN WRITING; WILL SEND YOU A LIST OF THE
MEDICAL CONDITIONS WE PAY
d. ANY SURGICAL PROCEDURE
FOR IF YOU ASK US;
WHICH IS NOT LISTED IN THE
19 20
g. TREATMENT BEGUN, OR FOR OF FAT OR SURPLUS TISSUE v. THE COSTS OF PROVIDING BASE JUMPING, CLIFF
WHICH THE NEED HAD ARISEN, (INCLUDING LIPOMA) FROM ANY OR FITTING ANY EXTERNAL DIVING, FLYING IN AN
DURING THE FIRST 90 DAYS PART OF THE BODY WHETHER OR PROSTHESIS OR APPLIANCE; UNLICENSED AIRCRAFT OR
AFTER BIRTH FOR ANY CHILD NOT NEEDED FOR MEDICAL OR AS A LEARNER, MARTIAL
w. OUT-PATIENT DRUGS
CONCEIVED BY ARTIFICIAL MEANS PSYCHOLOGICAL REASONS; ARTS, FREE CLIMBING,
OR DRESSINGS EXCEPT
OR ANY FORM OF ASSISTED MOUNTAINEERING WITH OR
o. THE COSTS OF COLLECTING THOSE DEFINED IN 8.1 (I),
CONCEPTION INCLUDING WITHOUT ROPES, SCUBA
DONOR ORGANS FOR PRESCRIPTIONS, AND WHERE
ARTIFICIAL INSEMINATION; DIVING TO A DEPTH OF MORE
TRANSPLANT SURGERY OR YOUR POLICY PROVIDES THIS
THAN 10 METRES, TREKKING
h. TERMINATION OF PREGNANCY OR ANY ADMINISTRATION COSTS COVER;
TO A HEIGHT OF OVER
ANY CONSEQUENCES OF IT; INVOLVED EVEN IF SUCH
x. ORTHODONTICS, PERIODONTICS, 2,500 METRES, BUNGEE
TRANSPLANTS ARE ALLOWED BY
i. INVESTIGATIONS INTO AND ENDODONTICS, PREVENTATIVE JUMPING, CANYONING,
THE TERMS OF THIS PLAN;
TREATMENT OF INFERTILITY, DENTISTRY, AND GENERAL HANGLIDING, PARAGLIDING
CONTRACEPTION, ASSISTED p. TREATMENT WHICH ARISES FROM DENTAL CARE INCLUDING OR MICROLIGHTING,
REPRODUCTION, STERILIZATION OR IS DIRECTLY OR INDIRECTLY FILLINGS, NO MATTER WHO PARACHUTING, POTHOLING,
(OR ITS REVERSAL) OR ANY CAUSED BY A DELIBERATELY GIVES THE TREATMENT UNLESS SKIING OFF PISTE OR ANY
CONSEQUENCE OF ANY OF THEM SELF-INFLICTED INJURY OR AN PROVIDED FOR BY YOUR PLAN OTHER WINTER SPORTS
OR OF ANY TREATMENT FOR ATTEMPT AT SUICIDE; AND AGREED, IN WRITING, BY US; ACTIVITY CARRIED OUT OFF
THEM; PISTE.
q. TREATMENT WHICH ARISES FROM y. CLAIMS IN RESPECT OF
j. TREATMENT OF IMPOTENCE, OR IS IN ANY WAY CONNECTED TREATMENT RECEIVED OUTSIDE aa. ANY TREATMENT SPECIFICALLY
SEXUAL DYSFUNCTION OR ANY WITH ALCOHOL ABUSE OR DRUG THE AREA OF COVER OR IF THE EXCLUDED BY THE TERMS
CONSEQUENCE OF THEM; OR SUBSTANCE ABUSE OR ANY MEMBER TRAVELLED AGAINST SHOWN ON YOUR MEMBERSHIP
ADDICTION; MEDICAL ADVICE EVEN INSIDE STATEMENT OR THE SCHEDULES
k. TREATMENT OF SEXUALLY
THE AREA OF COVER; FORMING PART OF THIS
TRANSMITTED DISEASES OR ANY r. ANY TREATMENT TO CORRECT
AGREEMENT;
CONSEQUENCE OF IT; LONG OR SHORTSIGHTEDNESS; z.
i. PROFESSIONAL SPORTS – ab. ANY CHARGES WHICH ARE
l. TREATMENT WHICH ARISES s. TREATMENT DIRECTED TOWARDS
ANY TREATMENT COSTS INCURRED FOR SOCIAL OR
FROM OR IS DIRECTLY OR DEVELOPMENTAL DELAY IN
INCURRED AS A RESULT DOMESTIC REASONS OR FOR
INDIRECTLY MADE NECESSARY CHILDREN WHETHER PHYSICAL
OF ENGAGING IN OR REASONS WHICH ARE NOT
BY A SEX CHANGE; OR PSYCHOLOGICAL OR
TRAINING FOR ANY SPORT DIRECTLY CONNECTED WITH
LEARNING DIFFICULTIES;
m. TREATMENT OF ANY MEDICAL FOR WHICH YOU RECEIVE TREATMENT SUCH AS BUT
CONDITION WHICH ARISES IN t. PREVENTIVE (I.E.: PROPHYLACTIC) A SALARY OR MONETARY NOT LIMITED TO STANDARD
ANY WAY FROM HIV INFECTION; TREATMENT; REIMBURSEMENT, TOILETRIES, SHAMPOOS,
SOAPS, TOOTH-PASTES,
n. TREATMENT OF OBESITY OR ANY u. VACCINATIONS AND ROUTINE INCLUDING GRANTS OR
CONTRACEPTIVES, PROPRIETARY
MEDICAL CONDITION WHICH OR PREVENTATIVE MEDICAL SPONSORSHIP (UNLESS
HEADACHE AND COLD CURES,
ARISES FROM, OR IS RELATED EXAMINATIONS (OTHER YOU RECEIVE TRAVEL COSTS
VITAMINS (EVEN IF PRESCRIBED)
TO, OBESITY IN ANY WAY THAN HEALTH SCREENS AS ONLY).
ETC. WHICH MAY BE BOUGHT
INCLUDING BUT NOT LIMITED TO ALLOWED FOR BY YOUR PLAN),
ii. DANGEROUS SPORTS – OVER THE COUNTER, WITHOUT
THE USE OF GASTRIC BANDING INCLUDING ROUTINE FOLLOW-UP
TREATMENT OF INJURIES PRESCRIPTION, AT A LOCAL
OR STAPLING, THE REMOVAL CONSULTATIONS;
SUSTAINED FROM PHARMACY NOR DO WE PAY
21 22
FOR TELEPHONE CALLS OR CONDITIONS AND/OR AND SPECIALISING IN

OTHER MEDIA SERVICES; DEFORMITIES WHETHER OR NOT REHABILITATION; AND
iii. III. WE AGREE THE COST OF
MANIFEST AND/OR DIAGNOSED
ac. ANY CHARGES FROM HEALTH THE TREATMENT IN WRITING IT IS CARRIED OUT IN A
OR KNOWN ABOUT AT BIRTH.
HYDROS, SPAS, NATURE CURE BEFORE IT IS DONE. REHABILITATION HOSPITAL
CLINICS (OR PRACTITIONERS) OR ai. ANY CHARGES FOR TREATMENT OR UNIT WHICH IS
b. ANY DENTAL PROCEDURE
ANY SIMILAR PLACE, EVEN IF IT IS REQUIRED AS A RESULT OF ANY RECOGNISED BY US; AND
UNLESS PROVIDED FOR BY
REGISTERED AS A HOSPITAL; ILLEGAL ACTION ON THE PART
YOUR PLAN. HOWEVER, WE THE COSTS HAVE BEEN
OF THE MEMBER REQUIRING
ad. ANY CLAIM OR PART OF A CLAIM WILL PAY FOR SOME SURGICAL AGREED, IN WRITING, BY US
TREATMENT;
IN RESPECT OF WHICH YOU PROCEDURES WHICH NEED TO BEFORE THE REHABILITATION
HAVE TO PAY AN EXCESS (OR aj. ANY CHARGES FOR MEDICAL BE CARRIED OUT BY AN ORAL BEGINS.
DEDUCTIBLE OR CO-INSURANCE). REPORTS, REGISTRATION OR AND MAXILLOFACIAL SURGEON.
WE WILL NOT PAY FOR IN-PATIENT
IN THIS CASE WE WILL ONLY PAY ADMISSION FEES OF ANY KIND; WE WILL SEND YOU A LIST OF
REHABILITATION FOR MORE
THE BALANCE OF THE CLAIM THESE PROCEDURES IF YOU ASK
2. SPECIAL TERMS APPLY IN THE THAN 28 DAYS EXCEPT IN CASES
AFTER WE HAVE DEDUCTED THE US.
FOLLOWING CASES. SUCH AS IN SEVERE CENTRAL
EXCESS (OR DEDUCTIBLE OR CO-
c. SPECIAL NURSING IN HOSPITAL NERVOUS SYSTEM DAMAGE
INSURANCE) AMOUNT; WE WILL NOT PAY BENEFITS FOR:
AND/OR ANY NURSING AT HOME CAUSED BY EXTERNAL TRAUMA.
ae. IN-PATIENT OR DAYCARE a. COSMETIC (AESTHETIC) UNLESS WE HAVE AGREED IN
f. TREATMENT WHICH HAS
TREATMENT IN UNITED ARAB SURGERY OR TREATMENT, OR WRITING BEFOREHAND THAT IT IS
NOT BEEN ESTABLISHED AS
EMIRATES, SAUDI ARABIA, ANY TREATMENT WHICH RELATES NECESSARY AND APPROPRIATE.
BEING EFFECTIVE OR WHICH
BAHRAIN, OMAN, OR QATAR TO OR IS NEEDED BECAUSE
d. HORMONE REPLACEMENT IS EXPERIMENTAL. HOWEVER
UNLESS AS DEFINED IN CLAUSE OF PREVIOUS COSMETIC
THERAPY, EXCEPT WHEN IT IS WE WILL PAY IF, BEFORE
8.2 ABOVE; TREATMENT. HOWEVER WE WILL
MEDICALLY INDICATED (RATHER THE TREATMENT BEGINS, IT
PAY FOR RECONSTRUCTIVE
af. IN-PATIENT, DAYCARE OR OUT- THAN FOR THE RELIEF OF IS ESTABLISHED THAT THE
SURGERY IF:
PATIENT TREATMENT IN UNITED PHYSIOLOGICAL SYMPTOMS), TREATMENT IS RECOGNISED
STATES OF AMERICA UNLESS i. IT IS CARRIED OUT TO WHEN WE WILL PAY FOR THE AS APPROPRIATE BY AN
ALLOWED FOR IN YOUR PLAN; RESTORE FUNCTION OR CONSULTATIONS AND FOR THE AUTHORITATIVE MEDICAL BODY
APPEARANCE AFTER AN COST OF THE IMPLANTS OR AND WE HAVE AGREED IN
ag. IN-PATIENT CHARGES FOR
ACCIDENT OR FOLLOWING PATCHES (BUT NOT TABLETS). WRITING, WITH THE MEDICAL
ANY HOSPITAL WHICH ARE
SURGERY FOR A MEDICAL WE WILL ONLY PAY BENEFITS PRACTITIONER, WHAT THE FEES
UNREASONABLE OR EXCESSIVE.
CONDITION, PROVIDED FOR A MAXIMUM OF 18 MONTHS WILL BE.
WE WILL PAY ONLY FOR THE
THAT THE MEMBER HAS FROM THE DATE OF THE FIRST
REASONABLE COST OF A 3. WE WILL NOT PAY BENEFITS FOR
BEEN CONTINUOUSLY CONSULTATION.
SINGLE BEDDED ROOM WITH MORE THAN 100 DAYS IN TOTAL
COVERED UNDER A PLAN
ITS OWN BATHROOM AS THE e. IN-PATIENT REHABILITATION IN ANY MEMBER’S LIFETIME
OF OURS SINCE BEFORE
ACCOMMODATION CHARGE EXCEPT WHEN: FOR INPATIENT TREATMENT OF
THE ACCIDENT OR SURGERY
ASSOCIATED WITH THE PSYCHIATRIC ILLNESS.
HAPPENED; AND IT IS AN INTEGRAL PART OF
TREATMENT GIVEN;
TREATMENT; AND 4. WE WILL NOT PAY FOR
ii. IT IS DONE AT A MEDICALLY
ah. ANY CHARGES FOR TREATMENT ANY TREATMENT, OR FOR
APPROPRIATE STAGE AFTER IT IS CARRIED OUT BY A
RELATED TO AND/OR THE INTERNATIONAL EMERGENCY
THE ACCIDENT OR SURGERY; MEDICAL PRACTITIONER
CORRECTION OF CONGENITAL
23 24
10. Making claims
MEDICAL ASSISTANCE, IF THEY ADVISE US IF ANY CLAIM IS Please refer to page 4 for details of and by law a right to recover
ARE NEEDED AS A RESULT OF WORK RELATED. how to make a claim. the amount of those benefits
NUCLEAR CONTAMINATION, from the third party. In this
7. WE WILL NOT ALLOW MEMBERS 1. Before we can consider a claim
BIOLOGICAL CONTAMINATION case the following shall apply:
TO UPGRADE THEIR LEVEL OF you must ensure that:
OR CHEMICAL CONTAMINATION,
COVER EXCEPT AT EACH POLICY i. you must tell us as quickly
WHILST ENGAGING IN OR TAKING the member sends us a
ANNIVERSARY AND ONLY THEN as possible that the injury
PART IN WAR, ACT OF FOREIGN completed claim form as soon
WHEN REQUESTED, IN WRITING, or medical condition was
ENEMY, INVASION, CIVIL WAR, as they can and no later than
TO DO SO. ACCEPTANCE BY US caused by, or was the
RIOT, REBELLION, INSURRECTION, 90 days from the date the
OF SUCH AN UPGRADE MUST fault of, a third party. We
REVOLUTION, OVERTHROW treatment starts; and
BE CONFIRMED IN WRITING BY will then send you a form
OF A LEGALLY CONSTITUTED
US BEFORE THE UPGRADE CAN we receive original invoices for on which the member can
GOVERNMENT, EXPLOSIONS OF
BECOME EFFECTIVE. treatment costs; and give us full written details.
WAR WEAPONS OR ANY SIMILAR
EVENT TO ONE OF THOSE LISTED. 8. WE WILL NOT PAY UPGRADED the member promptly gives us ii. if you or the member is
BENEFIT LEVELS FOR all the information we request. making a claim, or has
PLEASE NOTE, FOR CLARITY:
TREATMENT OF ANY MEDICAL not made (or refuses to
THERE IS COVER FOR TREATMENT 2. The member must tell us on the
CONDITION WHICH AROSE make) a claim against
REQUIRED AS A RESULT OF claim form if they think any of
OR SHOULD REASONABLY the third party, you or
A TERRORIST ACT PROVIDING the cost can be claimed from
HAVE BEEN FORESEEN BY the member must act in
THAT TERRORIST ACT DOES NOT anyone else or under another
THE MEMBER PRIOR TO THE good faith and do all the
RESULT IN NUCLEAR, BIOLOGICAL insurance policy or source (such
UPGRADE BECOMING EFFECTIVE. things we shall require to
OR CHEMICAL CONTAMINATION. as but not limited to Workman’s
MEMBERS ARE REQUIRED TO ensure that monies are
5. WE WILL NOT PAY BENEFITS FOR DECLARE ANY SUCH MEDICAL Compensation or G.O.S.I or motor
recovered from the third
ANY TREATMENT IF WE HAVE CONDITION TO US WHEN insurance policy). If so, then:
party and are repaid to
NOT RECEIVED A PROPERLY REQUESTING THE UPGRADE. if another insurance policy is us up to the amount of
COMPLETED CLAIM FORM AND WHERE SUCH A MEDICAL involved we will only pay our the benefits we have paid
ORIGINAL INVOICES WITHIN 90 CONDITION IS, OR BECOMES, proper share; or (and any interest). You will
DAYS OF THE TREATMENT BEING APPARENT BENEFITS FOR SUCH be asked to sign a written
GIVEN. A MEDICAL CONDITION WILL if benefits are claimed for undertaking to this effect;
BE RESTRICTED TO THE LEVEL treatment to a member whose and
6. WE WILL NOT PAY BENEFITS FOR injury or medical condition
OF COVER THAT WOULD HAVE
ANY TREATMENT NEEDED AS was caused by some other iii. if you or the member do
BEEN APPLICABLE TO SUCH A
A RESULT OF WORK RELATED person (the “third party”), we not repay to us monies
MEDICAL CONDITION PRIOR TO
ACCIDENT OR INJURY WHERE will pay only those benefits recovered from the third
THE UPGRADE.
THE COST OF SUCH TREATMENT the member can claim under party up to the amount of
IS NORMALLY RECOVERABLE the policy (unless these are benefits (and any interest),
UNDER WORKMAN’S covered by another insurance we shall be entitled to
COMPENSATION, G.O.S.I OR policy, when we will only recover the same from you
SIMILAR GOVERNMENT ACT pay our proper share of the and/or the member.
PREVAILING AT THE TIME OF benefits). However, in paying
INJURY OR ACCIDENT. YOU MUST 3. We can appoint and pay for an
those benefits we obtain both
independent medical practitioner
through the terms of the policy
25 26
11. Joining, renewing and transferring
to advise us on the medical issues Any exchange costs incurred will Please refer to AXA Insurance for and make a full medical history
relating to any claim. If required be payable by the member and will details of how to change your policy. declaration in respect of each
by us the independent medical be subtracted from any payment and every person to be insured.
1. We will tell you in writing the date
practitioner will also medically made to the member in respect of The insurer reserves the right to
your policy starts and any special
examine the member making the such a claim. apply any exclusion clauses and/
terms which apply to it. We can
claim and provide us with a report. or special terms it may deem
refuse to give cover and will tell
The member must co-operate necessary to any existing and/or
you if we do.
with the independent medical pre-existing medical conditions at
practitioner otherwise we will not 2. Your policy is for one year unless the date of application even if such
pay the claim. we have agreed something conditions were previously covered
different with the company, where under the company’s group medical
4. If a member makes a claim which
this policy applies to a group scheme. Please refer to page 11 if
is in any way dishonest:
contract. At the end of that time, you wish to transfer to a policy that
we will not pay any benefits for provided the plan you are on is is not provided by AXA Insurance.
that claim; and still available, you or, where this
policy applies to a group contract, When the terms of your policy
if we have already paid
the company can renew it on the might change
benefits for that claim before
terms and conditions applicable We do not intend to change the terms
we discovered the dishonesty
at that time. You will be bound by of your plan during the policy year
we can recover those benefits
those terms. However, we reserve however we do have the right to cancel
from you (the member and/or
the right to refuse to accept you as or change all or any part of your policy
the company); and
a customer or to renew your policy from any renewal date.
we can take any of the actions at any policy anniversary.
We will generally make adjustments
listed in paragraph 13.2.
3. Only those people described in the only to reflect any past or foreseeable
5. Claim costs incurred in any company agreement where this changes in medical practice or
currency other than United Arab policy applies to a group contract procedures and the type and frequency
Emirates Dirhams, Bahraini can be members of this plan. All of claims made by all those of our
Dinars, Omani Riyals or Qatari cover ends when you stop working members covered under the same
Riyals will be converted using the for the company or if the company plan as you.
closing mid-point exchange rate decides to end the cover.
The purpose of such changes will be to
published in the Financial Times
4. If your cover under a company seek, as far as possible, to maintain
Guide to World Currencies current
agreement comes to an end you substantially the same level and type
when we assess the claim. If we
can apply to transfer to another of cover in place while ensuring that
agree, in writing in advance, to
plan. the plan remains affordable.
reimburse benefits to a member in
a currency other than those above 5. Members of this policy who leave a We may also change premiums if
the exchange rate used will be as company’s group medical scheme costs, taxation, regulations or benefit
above. may apply to AXA Insurance for an changes make this necessary.
individual policy. In all such cases
In the event that we are required by law
the member will be required to
to make a change during the policy year,
complete a new application form
27 28
12. What we expect from you
for example if a new tax is introduced, 1. You must make sure that whenever 4. You (the member or the company)
we will be obliged to do so before the you are required to give us must write and tell us if you change
next renewal date. We do reserve the information all the information your address. You are acting on
right to apply underwriting terms to you give is true, accurate and behalf of any member covered
your policy at any time if a medical complete. If it is not then we by your policy so we will send all
condition that should reasonably have can set the policy aside or apply correspondence about the policy
been declared comes to our attention, different terms of cover. to the company address or that of
a chronic condition manifests itself the member.
2. This policy is designed for people
within an excluded period or a medical
living in the United Arab Emirates, 5. If there is a dispute between you
condition becomes chronic in nature
Kingdom of Bahrain, Sultanate of and us we have a complaints
during a policy year.
Oman and the State of Qatar. You procedure, set out on pages 32 -
must tell us if a member changes 33, which the company or member
their principal country of residence must follow so that we can resolve
even if they are staying in the it.
same area. If you don’t tell us we
can refuse to pay benefits.
3. You (or the company, where this
policy applies to a group contract)
must pay your premium when it is
due. We will decide the amount
at the start of each year and tell
you how much it is. You can pay
it in the way you have agreed with
us. As your policy runs for a year
you must pay your premium for the
whole year no matter how it is paid.
If your premium payments are not
up to date your policy will end.
29 30
13. General 14. Complaints Procedure
1. We can change all or any part of Sultanate of Oman or the State We are committed to provide you the will be made to revert back within 10
the policy including the benefits of Qatar. If the principal country of highest level of customer service. We working days, if our final response will
table or these terms, but only residence for the policyholder or, do realize that things can sometimes be delayed beyond 15 working days or
for the reasons shown in our for a group contract, the company go wrong, and when this happens, we if more time is needed for investigation,
handbook or Agreement, and the office administering the policy is would like to hear about it. Telephone we will inform you when we will be
changes will only apply to you when in our records; in the United Arab calls may be recorded for training and able to contact you again about the
monitoring purposes. We would like to complaint.
you renew unless we are obliged Emirates then Emirati law will assure you that all matters are dealt
by law to apply any change with apply; in the Kingdom of Bahrain with seriously and in a confidential If you are dissatisfied with our final
immediate effect. We will give you then Bahraini law will apply; in the manner. response or dissatisfied with the delay
reasonable notice of the changes Sultanate of Oman then Omani in our response (beyond 15 working
and will send details of them to the law will apply; in the State of Your complaint can be made in any of days) you may refer the complaint
the following ways: to the Insurance Regulator (please
address we have for the company Qatar then Qatari law will apply;
provide them the details and AXA
or the member on our records. regardless of the location of any 1. Visit our Website www.axa-gulf. Complaint Reference Number). Their
individual member at any time. com - select Country ‘UAE’ and contact details are provided alongside.
The changes will take effect from select ‘Complaints’ under ‘AXA &
when you renew or when applied 4. We do not pay for medical reports. You’ (at the bottom of the webpage) For Abu Dhabi Healthcare Policies
by law even if, for any reason, any and register your complaint. You only:
5. The terms of your policy cannot be
member does not receive details will recieve an auto email with
changed nor claims authorization the reference number which HAAD
of them.
given by any verbal communication should be quoted in all future PO Box 5674, Abu Dhabi, United Arab
2. If any member breaks any of the between you and us. Any changes, communications. Emirates
terms of the policy or makes, or approvals, or other statements Telephone: +971 2449 3333 or Local
attempts to make, any dishonest relating to your policy must be Alternatively, should you not have an Toll Free Number: 800 555
email address or access to the internet: Fax: +971 2444 9822
claim, we can: confirmed, in writing, by us. We
Email: contact@abudhabi.ae
are not bound by any verbal 2. Send a letter to the management
refuse to make any payment; at AXA Insurance (Gulf) BSC (c), For Dubai Healthcare Policies only:
commitment not confirmed by us
and PO Box 5862, Dubai, United Arab
in writing. Website for registering Complaints:
refuse to renew your policy; or Emirates; or
6. AXA Insurance may be required http://www.isahd.ae/Home/Ipromes
impose different terms to to apply legitimate international 3. Transmit a fax to +971 44392188;
or For all other complaints:
any cover we are prepared to sanctions to this policy. In such a
4. Telephone Us on 8004845 and Insurance Authority
provide; or case AXA Insurance may be unable
request our Customer Service PO Box 113332, Abu Dhabi, United
to meet its full obligations under Arab Emirates
end your policy and all cover Staff to register Your complaint; or
the terms of this policy where to Telephone: +971 2499 0111
under it immediately.
do so would render it subject to 5. Walk into Our office and request Fax: +971 2557 2111
3. This policy is governed by the law legal action under international or Our Customer Service Staff to Email: contactus@ia.gov.ae Website
of the country in which it was domestic law. register Your complaint. for registering Complaints:
issued being the United Arab h t t p s : / / e s e r v i c e s . i a . g o v. a e /
In these situations, and on your behalf, Wirestorm/Pages/Render.aspx?page=
Emirates, Kingdom of Bahrain, the complaint will be registered by Complaints&layout=NewAnonymousCo
our Staff and a Reference Number
generated and provided to you mplaint
which please quote in all future
communications. Whilst all efforts
31 32
15. Your customer charter
Where to send your reimbursement Bahrain

Advance notification of change in claims AXA Insurance (Gulf) B.S.C. (c)
As a valued customer of AXA Insurance
Ground Floor, Building no. 177, Road
you have important rights and cover. UAE 2803, Al Seef District 428, P. O. Box
entitlements. You are entitled to expect: Essential changes to the terms of the
+971 4 429 4000 45, Manama, Kingdom of Bahrain
cover (including benefits, premiums
Courtesy. and your membership agreement) will Qatar Oman
Your requirements will always be be notified to you, in writing, in advance +974 4 412 8733 AXA Insurance (Gulf) B.S.C. (c)
dealt with promptly, considerately and of the date from which the changes P. O. Box 1276, P.C.112, Ruwi –
courteously. take effect. Bahrain Sultanate of Oman
No customer query is too trivial or too +973 17 582612
much trouble to sort out.
Professional and efficient service.
All requests for assistance and any Oman
claims you submit will be considered 800 72926
Helpful advice and guidance.
AXA Insurance staff will help you, if you impartially (without any bias or Our Branch locations:
have any doubts, to understand the preference) in accordance with the
terms of your contract and any other benefits and membership agreement UAE
factors which affect your cover. They of your plan. AXA Insurance (Gulf) B.S.C (c)
will help you to make proper use of 2nd Floor, Bldg. 7, Dubai Outsource
your cover should you need to make a For further information contact: Zone, Manama Street (off Academic
claim. AXA Insurance City Road),
P.O. Box 32505 P. O. Box 32505, Dubai, United Arab
Confidential handling of your Dubai, UAE Emirates
personal details and affairs Telephone: +971 (4) 429 4000
Fax: +971 (4) 429 4099 Qatar
wherever possible. AXA Insurance (Gulf) B.S.C. (c)
Any medical details we require will QFC Branch
always be kept confidential if possible.
AXA Insurance may be required to Corporate Office
provide information regarding claims QFC Tower 1, West Bay, Office No. 604,
you make or have made in the past 6th Floor, PO Box 15319, Doha, Qatar
or other details you have given us AXA Insurance (Gulf) B.S.C. QFC
to your sponsor or employer or a Branch
government department if they are
paying for all or part of this policy or Retail Sales Office
are entitled by law to require this of QFC Tower 1, Ground Floor, P.O. Box
us. No liability will be accepted by us 15319, Doha, Qatar
for any outcome resulting from the Incorporated in Bahrain – QFC Licence
provision of such information to any of No. 00024
the aforementioned parties.
Authorised by the Qatar Financial
Centre Regulatory Authority
33 34
35 36
AXA Agent
With more than 103 million customers around the

globe, AXA is one of the world’s largest insurance
providers. We offer a wide range of insurance
products to meet your personal and business
needs.
car insurance
health insurance
home insurance
travel insurance
yacht insurance
relocation insurance
golf insurance
GULPL13EN15511PR9AUG262013PM
motorcycle insurance
personal accident insurance
UAE: 800 29 26
Bahrain: 800 010 60
Oman: 800 70 292
Qatar: 800 29 21
www.axa-gulf.com
AXA Insurance (Gulf) B.S.C. (c)

Bahrain:CommercialRegistrationNo.22373.InsurancelicenseNo.LII/008issuedbytheCentralBankofBahrain.
Qatar:IncorporatedinBahrain.QFCLicenseNo.00024.AuthorizedbytheQatarFinancialCenterRegulatoryAuthority.
Oman:CommercialRegistrationNo.1112244.InsuranceregistrationNo.6issuedbytheCapitalMarketsAuthority.
UAE: Registered in the Insurance Companies Register - Certificate No. (69) dated 22/01/2002. Subject to the
provisionsofFederalLawNo.(6)of2007concerningtheestablishmentofInsuranceAuthorityandOrganizationofits

Membership Handbook

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Membership Handbook

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health insurance

what you need to know

Section Page No.

>> AXA Home Comfort

1. Introduction 2. Important note about pre-existing conditions

5. Understanding our position on certain medical conditions

6. Administering your policy

8. What we pay for

9. What we do not pay for (exclusions and limitations)

FOR TELEPHONE CALLS OR CONDITIONS AND/OR AND SPECIALISING IN

10. Making claims

11. Joining, renewing and transferring

12. What we expect from you

13. General 14. Complaints Procedure

15. Your customer charter

Where to send your reimbursement Bahrain

With more than 103 million customers around the

AXA Insurance (Gulf) B.S.C. (c)

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