SCHEDULE OF BENEFITS

Schedule 1
Administration services to be provided under following scope of benefits

First: Total upper limit coverage Treatment outside network is reimbursed upto 0%

No. Details Coverage

1. The annual upper limit for Healthcare services : Abu Dhabi 500000 AED

2. The annual upper limit for Healthcare services : Other Emirates Only Emergencies upto 500000 AED

3. The annual upper limit for Healthcare services : International (Home Country Only) Only Emergencies upto 500000 AED

Second: Geographic coverage Treatment outside network is reimbursed upto 0%

No. Details Coverage

1. Health Insurance Services offered inside the Emirate of Abu Dhabi. Inpatient/Emergency/Outpatient

2. Health Insurance Services offered in other Emirates. Emergency Only

3. International. Emergency in Home country only

Third: Inpatient healthcare Services at Authorized hospitals Treatment outside network is reimbursed upto 0%

No. Details Coverage

1. In-patient Healthcare Services, subject to prior approval. Private (1 Bed)

Additional Details:
Accommodation Type – Single Private Room
Within UAE (Network Within Emirate of Abu Dhabi): 100% Covered
Within UAE (Network Outside Emirate of Abu Dhabi): 0% Covered except for Emergencies
Within Home Country (Network): 0% Covered except for Emergencies
Emergency is covered 100% across UAE and Home Country. Treatment not available within network is covered 100% within UAE and
Home Country.
2. Tests, diagnosis, treatments and surgeries in hospitals for non-urgent medical cases, subject to 100%
prior aproval

3. Healthcare services for emergency cases 100%

4. Transportation services for medical emergencies inside the Emirate of Abu Dhabi by an authorised 100%
party.
Additional Details:
Within UAE and Home Country: 100% Covered at Network and Non Network.

5. Accommodation for a person accompanying an insured child up to 10years of age AED 300 /day
Additional Details:
Within UAE (Network Within Emirate of Abu Dhabi): 100% Covered
Within UAE (Network Outside Emirate of Abu Dhabi): 0% Covered
Within Home Country (Network): 0% Covered
Emergency is covered 100% across UAE and Home Country. Treatment not available within network is covered 100% within UAE and
Home Country.
6. Accommodation of an accompanying person in the same room in cases of critical conditions and as AED 300 /day
per recommendation of attending physician, subject to prior approval.
Additional Details:
Within UAE (Network Within Emirate of Abu Dhabi): 100% Covered
Within UAE (Network Outside Emirate of Abu Dhabi): 0% Covered
Within Home Country (Network): 0% Covered
Emergency is covered 100% across UAE and Home Country. Treatment not available within network is covered 100% within UAE and
Home Country.
7. In-patient maternity services Co-payment 500 AED
Additional Details:
Maximum annual limit per person (Inpatient Maternity):
Within UAE (Network Within Emirate of Abu Dhabi): 100% Covered
Within UAE (Network Outside Emirate of Abu Dhabi): 0% Covered
Within Home Country (Network): 0% Covered
Copayment of AED 500 per delivery is applicable within UAE and Home Country.
Emergency is covered 100% across UAE and Home Country. Treatment not available within network is covered 100% within UAE and
Home Country.
 8. Healthcare services for work illnesses and injuries as per Federal Law No. 8 of 1980 concerning the 100%
Regulation of Work Relations, as amended, and applicable laws in this respect.
Additional Details:
Within UAE (Network Within Emirate of Abu Dhabi): 100% Covered
Within UAE (Network Outside Emirate of Abu Dhabi): 0% Covered
Within Home Country (Network): 0% Covered
Emergency is covered 100% across UAE and Home Country. Treatment not available within network is covered 100% within UAE and
Home Country.

Fourth: Outpatient healthcare Services Treatment outside network is reimbursed upto 0%

No. Details Coverage

1. Out Patient Physician Consultation with GP or Specialist. 100% with deductible of AED
Follow ups are exempted from fees if made within a week from the date of first examination. 50

Additional Details:
Within UAE (Network Within Emirate of Abu Dhabi): 100% Covered - with deductible of AED 50.
Within UAE (Network Outside Emirate of Abu Dhabi): 0% Covered for elective treatments
Within Home Country (Network): 0% Covered for elective treatments
Emergency is covered 100% across UAE and Home Country. Treatment not available within network is covered 100% within UAE and
Home Country.

2. Laboratory tests and Diagnostic services. (In cases of non-medical emergencies, the insurance 100% with deductible of AED 30 (the
deductible is for all tests precribed
Additional Details: within one physician consultation and
Within UAE (Network Within Emirate of Abu Dhabi): 100% Covered - with deductible of AED 30.
Within UAE (Network Outside Emirate of Abu Dhabi): 0% Covered for elective treatments
Within Home Country (Network): 0% Covered for elective treatments
Emergency is covered 100% across UAE and Home Country. Treatment not available within network is covered 100% within UAE and Home
4. Physiotherapy treatment services, subject to insurance company prior approval. 100%
Additional Details:
Within UAE (Network Within Emirate of Abu Dhabi): 100% Covered.
Within UAE (Network Outside Emirate of Abu Dhabi): 0% Covered.
Within Home Country (Network): 0% Covered.
Emergency is covered 100% across UAE and Home Country. Treatment not available within network is covered 100% within UAE and Home
Country.
5. Pharmaceuticals 70% with co-payment of 30%.

Additional Details:
Within UAE (Network): 70% Covered
Within Home Country (Network): 0% Covered
(Long term medications to be dispensed up to 90 days without pre- authorization. The medicine can be dispensed for upto 1 year as per
single doctor's prescription but the maximum drug refill shall still be for 90 days)

6. Examination, diagnostic and treatment services for pregnancy and gynaecology services in 100% with deductible of AED 30
authorised hospitals, health centers and clinics. Follow ups are exempted from fees if made within a
week from the date of first examination.

Healthcare services for work illnesses and injuries as per Federal Law No. 8 of 1980 concerning the
7. Regulation of Work Relations, as amended, and applicable laws in this respect.

Additional Details:
Within UAE (Network Within Emirate of Abu Dhabi): 100% Covered - with deductible of AED 50.
Within UAE (Network Outside Emirate of Abu Dhabi): 0% Covered.
Within Home Country (Network): 0% Covered.
Emergency is covered 100% across UAE and Home Country. Treatment not available within network is covered 100% within UAE and Home
Fifth: Other Benefits

Lim it (AED) Co- Deductible

SL# Detail Coverage % Pay(%) (AED) Additional
Details

1 Diagnostic and treatment Emergency/Life 100

services for dental and gum Threatening
treatments

2 Hearing and vision aids, and Emergency/Life 100

vision correction by surgeries, Threatening
and laser

3 Pre-existing conditions Inpatient/Emergency/OutP 100 Upto annual limit 0 0 Fully covered

atient/Life Threatening

4 Dental /OutPatient 80 2000 20 0 Covered 80%

(Network Within
Emirate of Abu
Dhabi).
Covered 0% in DNE
and Home Country

Following services
are covered: a) X-
Rays; b)
Extractions; c)
Amalgam /
Composite Fillings;
d) Root Canal
Treatments; e)
Consultations; f)
Prescribed Drugs for
the above
mentioned services
(covered as part of

5 Repatriation of Mortal Remains Emergency 100 10000 0 0 Covered 100% at

to the Country of Origin Network and Non
Network (Within
UAE and Home
Countries).

6 Second Opinion Facility. Inpatient/OutPatient 100 upto annual limit 0 0

7 Annual Screening for Breast /OutPatient 100 upto annual limit 0 0 Only Within Abu
Cancer ( applicable for females Dhabi: 100%
>35) at designated providers covered.
Within Home
Country and DNE:
Not Covered.
For females above
35 years, including
a) Clinical Exam
b) Mammogram
c) Pelvic Sonogram
and
d) CA 15.3
 8 Annual Screening for Prostate /OutPatient 100 Upto annual limit 0 0 Within Abu Dhabi:
Cancer ( applicable for 100% covered.
males>45) at designated Within Home
providers Country and DNE:
Not covered.
For males above 45
years, including
a) Clinical exam
b) PSA
c) Rectal sonogram

9 Coverage Outside UAE is Inpatient/OutPatient 0 0 0 0

limited to 90 days per treatment
2) A single holiday-or business
trip may not exceed 90 days.
Exception: For Maternity
benefit, coverage is extended
up to 180 days..

10 Network ( allowing direct billing Inpatient/OutPatient 100 Upto annual limit 0 0 Network Within
at designated Providers) UAE: compliance
to list provided in
anexxure H,
Sheet H1.
In & Out-patient on
direct billing.

Network details to
be provided for
International
Emergency
coverage

(Home Country is
defined as the
country that has
issued member’s
passport on which
UAE Residence
Visa is stamped).

Within UAE
(Network Outside
Emirate of Abu
Dhabi): 0% Covered
for elective
treatment
Within Home
Country (Network):
11 Colorectal Cancer Screening at /OutPatient 100 Upto annual limit 0 0 Within UAE
designated Providers (Network Within
(applicable for males and Emirate of Abu
females above 50 years) Dhabi): 100%
covered.
Within Home
Country and DNE:
Not covered.
Colorectal Cancer
Screening at
designated
Providers
(applicable for
males and females>
50 years); includes:
a) FIT (Fecal
Immunochemical
 12 Circumcision /OutPatient 100 Upto annual limit 0 0 Circumcision for
Male only.
Within UAE
(Network Within
Emirate of Abu
Dhabi): 100%
Covered.
Within Home
Country and DNE:
Not covered.

13 Medical Teleconsultation /OutPatient 100 Upto Annual 0 0 Please provide name of

partner
14 Emergency is covered 100%. Inpatient/Emergency/OutP 100 Upto annual limit 0 0
Treatment not available within atient/Life Threatening
network is covered 100% within
UAE and Home Country.

15 Vaccinations as per HAAD and /OutPatient 100 Upto annual limit 0 0 Covered within
MOH list. Emirate of Abu
Dhabi SEHA
Providers only.

16 Health services and associated Inpatient 100 Upto annual limit 0 0 Health services and
expenses for organ and tissue associated
transplants expenses for organ
and tissue
transplants, for
Insured Person as a
recipient only.

Any additional benefits listed above shall not cancel, limit, or contradict any mandatory benefit defined as a minimum coverage by
the Abu Dhabi health insurance law, and shall be interpreted within the context of law and to the benefit of the insured.The presence
of such limitations shall be applicable only to treatments covered outside the mandatory geographical area of coverage.
 Schedule 2
Excluded healthcare Services

1. Healthcare Services, which are not medically necessary Not Covered

2. All expenses relating to dental prostheses, and orthodontic treatments. Not Covered

3. Domiciliary care; private nursing care; care for the sake of travelling. Not Covered

4. Custodial care includes (1) Non medical treatment services; or (2) Health related services which do not Not Covered
seek to improve or which do not result in a change in the medical condition of the patient.

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

6. Personal comfort and convenience items (television, barber or beauty service, guest service and similar Not Covered
incidental services and supplies).

7. Healthcare Services and associated expenses for replacement of an existing breast implant. Cosmetic Not Covered
operations which improve physical appearance and which are related to an Injury, sickness or congenital anomaly
when the primary purpose is to improve physiological functioning of the involved part of the body. Breast
reconstruction following a mastectomy for cancer is covered.
8. Surgical and non-surgical treatment for obesity (including morbid obesity), and any other weight control Not Covered
programs, services, or supplies.

9. Medically non-approved experimental, research, investigational healthcare services, treatments, devices and Not Covered
pharmacological regimens.

10. Healthcare Services that are not performed by Authorised Healthcare Service Providers, apart from Healthcare Not Covered
Services rendered in a Medical Emergency.

11. Healthcare services, treatments & associated expenses for alopecia, baldness, hair falling, dandruff or wigs. Not Covered

12. Supplies, Treatment and services for smoking cessation programs and the treatment of nicotine addiction. Not Covered

13. Non-medically necessary Amniocentesis. Not Covered

14. Treatment, services and surgeries for sex transformation, sterility and sterilization Not Covered

15. Treatment and services for contraception Not Covered

16. Treatment and services related to fertility / sterility (treatment including varicocele / polycystic ovary / ovarian Not Covered
cyst / hormonal disturbances / sexual dysfunction).

17. Prosthetic devices and consumed medical equipments, unless approved by the insurance company with an Not Covered
exception for Diabetes test strips and monitor.
18. Treatments and services arising as a result of hazardous activities, including but not limited to, any form of Not Covered
aerial flight, any kind of professional power-vehicle race, water sports, horse riding activities, mountaineering
activities, violent sports such as judo, boxing, and wrestling, bungee jumping and any professional sports activities

19. Growth hormone therapy unless medically necessary as part of treatment Not Covered

20. Costs associated with hearing tests, vision corrections, prosthetic devices or hearing and vision aids. Not Covered

21. Mental Health diseases, in-patient and out-patient treatments, unless the condition is a transient mental Not Covered
disorder or an acute reaction to stress.

22. Patient treatment supplies (including elastic stockings, ace bandages, gauze, syringes, and like products; Not Covered
non-prescription drugs and treatments, excluding such supplies required as a result of Healthcare Services
rendered during a Medical Emergency).

23. Preventive services, including vaccinations, immunizations, prophylactic allergy testing and desensitization; Not Covered
any physical, psychiatric or psychological examinations or testing during these examinations.

24. Services rendered by any medical provider reletive of a patient for example the Insured person and the Insured Not Covered
member's family, including spouse, brother, sister, parent or child.

25. Enteral feedings (via a tube) and other nutritional and electrolyte supplements, unless medically necessary Not Covered
during treatment.

26. Healthcare services for adjustment of spinal subluxation, diagnosis and treatment by manipulation of the Not Covered
skeletal structure, by any means, except treatment of fractures and dislocations of the extremities.

27. Healthcare services and treatments: by acupuncture; acupressure, hypnotism, rolfing, massage therapy, Not Covered
aromatherapy, homeopathic treatments, and all forms of treatment by alternative medicine.

28. All Healthcare services & Treatments for in-vitro fertilization (IVF), embryo transport; ovum and male sperms Not Covered
transport
29. Elective diagnostic services and medical treatment for correction of vision. Not Covered

30. Nasal septum deviation and nasal concha resection unless non-cosmetic medically necessary or post Not Covered

31. All chronic conditions requiring hemodialysis or peritoneal dialysis, and related test/treatment or procedure. Not Covered

32. Treatments and services related to viral hepatitis and associated complications, except for treatment and Not Covered
services related to Hepatitis A.

33. Birth defects, Congenital diseases for newborn &/or Deformities unless life-threatening. Not Covered

34. Healthcare services for Senile dementia and Alzheimer.s disease. Not Covered

35. Air or Terrestrial Medical evacuation except for Emergency cases or unauthorised transportation services. Not Covered

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

38. Any inpatient treatment, tests and other procedures, which can be carried out on outpatient basis without Not Covered
jeopardizing the Insured Person.s health.

39. Any test or treatment, for purpose other than medical such as tests related for employment, travel, licensing or Not Covered
insurance purposes.

40. All supplies which are not considered as medical treatments including but not limited to: mouthwash, Not Covered
toothpaste, lozenges, antiseptics, milk formulas, food supplements, skin care products, shampoos and
multivitamins (unless prescribed as replacement therapy for known vitamin deficiency conditions) and all
equipment not primarily intended to improve a medical condition or injury, including but not limited to air
conditioners or air purifying systems, arch supports, convenience items / options, exercise equipment and
sanitary supplies.

41. More than one consultation or follow up with a medical specialist in a single day unless referred by a Not Covered
physician.

42. Elective non accident related surgery for correction of refrection errors and/or improvement of visions Not Covered
(Quantitative or Qualitative) such as but not restricted to Radial Keratotomy, Photokeratectomy or Laser Surgery
43. Services and educational program for handicaps. Not Covered
 Schedule 3
Healthcare Services outside the Scope of Health Insurance

1. Injuries or illnesses suffered by the Insured Person as a result of military operations of whatever type. Not Covered

2. Injuries or illnesses suffered by the Insured Person as a result of wars or acts of terror of whatever type. Not Covered

3. Healthcare services for injuries and accidents arising from nuclear or chemical contamination. Not Covered

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

5. Injuries resulting from criminal acts or resisting authority by the Insured Person. Not Covered

6. Healthcare services for patients suffering from AIDS and its complications. Not Covered

8. All cases resulting from the use of alcohol, drugs and hallucinatory substances. Not Covered

9. Any test or treatment not prescribed by a doctor. Not Covered

10. Injuries resulting from attempted suicide or self-inflicted injuries. Not Covered

11. Diagnosis and treatment services for complications of exempted illnesses. Not Covered

12. All healthcare services for internationally and locally recognised epidemics. Not Covered

13. Venereal sexually transmitted diseases. A list with respect thereto will be set out by the General Authority of Not Covered
Health Services.
14. All cases related to maternity for unmarried females Not Covered

S.No. Topic Details

1 Profit Share Formula Profit refund = 100% x (88% of gross premium - Total Claims*)
2 Frequency of Premium
Quarterly
Payment

* Total Claims = Paid claims + outstanding Claims + Claims Incurred but not reported

Pharmaceutical Benefit:

Prescribed medication to be dispensed at pharmacies as per Department of Health Circular Number

US/27/18 dated 23/07/2018