Schedule INDM202200111963 0.HomeLite

Insurance Policy
Individual Healthcare Insurance
Thank you for choosing Oman Insurance Company to manage your healthcare benefits. We assure you of a
healthy partnership through the policy year.
This document will give a detailed description of your plan, benefits, exclusions and terms and conditions.
We have also included a user guide to onboard you on the processes you and your employees need to know
when availing medical services. After carefully reading the document, please return one signed copy to us
for our records. In case of any clarification, please contact us at weserve@omaninsurance.ae.
Medical Expenses Insurance Policy No. INDM202200111963
Whereas the ‘Policyholder, by a proposal and declaration together with any statement, report or other
document, which shall be the basis of this insurance contract and shall be deemed to be incorporated herein
and forming an integral part of this insurance contract, has applied to Oman Insurance Company P.S.C. and
has paid or agreed to pay the premium as consideration for such insurance to Oman Insurance Company
(P.S.C.) (Hereinafter called the “Company” or “OIC”) Now this Policy witnesseeth that in respect to the
agreed insurance conditions occurring during the Period of Insurance within the Territorial Limits stated in
the Policy Schedule and subject to the Schedule, Table of Benefits, Exclusions, Terms and conditions,
Eligibility Definitions, Medical Insurance Clauses, General Provisions and Beneficiary User’s Guide
contained herein, endorsed or attached hereto or otherwise expressed hereon (hereinafter collectively
referred to as the “Terms” of this Policy) – the Company shall pay the agreed Benefits to Policyholder or the
Insured Member , as the case may be, up to but not exceeding the amounts specified in the Schedule
against the Medical Expenses incurred by the Policyholder for the treatment of his himself / herself and their
Insured Dependents in the manner described hereafter.
IN WITNESS whereof this Policy had been signed on behalf of the “Company” and the “Policy Holder” in
Dubai this 30th June 2022
For OMAN INSURANCE COMPANY ( P.S.C)
AUTHORIZED SIGNATORY
For ZEESHAN HASAN
AUTHORIZED SIGNATORY
Registered in accordance with the UAE Federal Law Number 6 of 2007 (Registration No. 9). Regulated by the
UAE Insurance Authority
Policy Schedule
Healthcare Insurance
Policyholder Details
Policyholder ZEESHAN HASAN
Address Dubai, U.A.E.
Telephone 0585142952
Fax
Policy Details
Policy Number INDM202200111963
Intermediary NA
Issue Date 30/06/2022
Period of 30/06/2022 to 29/06/2023
Insurance or until exhaustion of the Indemnity Limit, whichever occurs first.
Territory Limits United Arab Emirates
Currency United Arab Emirates Dirham
Policy Sections
The Policy Holder, holding a UAE Residence permit
01. Insured Members (Iqama) in the UAE, as per initial proposal provided by the
Policy Holder at inception.
Employed, Investor & Partner and their dependents with
02. Selection Criteria
Dubai employment visa
Lower Upper
03. Age Limit Criteria
Adult 0 Years 80 Years
a. The Benefits offered under this policy do not comply
04. Special Conditions with the Health Authority of Abu Dhabi regulation for
compulsory insurance.
b. Non-disclosure or misrepresentation of any facts may
lead to refusal of any claim or the cancellation of the
policy.
c. Extension to the geographical territory (if Provided), is
covered only for medically necessitated emergency
conditions while insured member is travelling vacation
/ business trip) is subject to maximum aggregate
period of 90 days in a policy year.
d. The Scheme being offered does not apply to the UAE
Nationals enrolled under Thiqa Scheme.
e. Waiting period of 6 months applicable is from the first
scheme enrollment. Waiting period does not apply for
members who were previously insured, subject to
proof of previous medical insurance cover.
f. All benefits are Inclusive of its Coinsurance (where
coinsurance is applicable).
Mode: ANNUAL
05. Premium Payment
Due Date(s): 30/06/2022
Table of Benefits
Plan code: HomeLite-1
The Table of benefits is to be read along with the list of exclusions applicable and OIC’s Glossary.
All amounts are in AED

General Covers
Indemnity Limit 250,000
Basic Territory for Elective & Emergency treatment UAE, Arab Countries & South East Asia
Emergency extension cover is limited to Worldwide
excluding USA & Canada for 90 days per year and only
Extended Territory for Emergency treatment only applies in case of accident / emergency during business
trips or holidays abroad (Elective treatment is not
covered)
Pre-existing conditions (Subject to Exclusions List)
Covered up to 150,000 per person per year
If the waiting period is applicable, cover will be provided to
(without waiting period)
pre-existing conditions that develop into an emergency
within the 6 month exclusion period.
Non-Pre-existing Chronic Conditions (Subject to Exclusions
Covered up to Indemnity Limit
List)
Elective Treatment
Inside UAE / Inside Network – (Direct Billing) Covered
Inside UAE / Outside Network – (Reimbursement) Covered
Outside UAE - (within Covered Territory – Reimbursement) Covered
Emergency Treatment
Medical Providers Network
Subject to ongoing changes.
Advance Network
Available online at OIC Network: www.omaninsurance.ae
Inpatient Benefits – with PAR
Room Accommodation Private
Diagnostic Investigations (Lab, Scan and X-ray) and other
prescribed medically necessary diagnostic procedures e.g. Covered
endoscopy & histopathology.
Accommodation Costs for one parent staying with a child up
500 Per day
to the age of 18 years.
Accommodation Costs for one accompanying family
member in case of critical medical conditions. *1 100 Per day
Subject to treating doctor recommendation
Daycare treatment including out-patient minor surgeries > 6
Covered
hours stay.
Internal Prosthetic devices implanted during covered
Covered
surgeries. *1
Outpatient Benefits
Consultation
(Follow up on same medical condition and at the same provider is free within 7 days from first consultation date)
General Practitioner – GP Covered
Specialist or Consultant – SP Covered
Pharmacy
Prescribed Pharmaceuticals (Pre-approval is required for
Covered
long term medication above 30 days)
ONLY Formulary products(Generic Medication) No
Vitamins prescribed as replacement therapy for known
vitamin deficiency conditions up to prescribed Covered
pharmaceutical limit only.
Diagnostic Investigations & Procedures (Lab, Scan, X-ray,
Covered
endoscopy, etc.)
Outpatient procedures Covered
Physiotherapy *1 prescribed by respective specialist doctor
Covered up to 10 sessions
and administered by a qualified physiotherapist.
Other Benefits
Local Emergency Transportation by Road Ambulance Covered
Birth Defects, Genetic Disorders & Congenital Conditions*1 Not Covered
DHA minimum preventive services*1 Covered
Diabetes screening Covered
Hepatitis C virus screening and treatment Covered
Basmah Initiative Covered
Adult Pneumococcal Conjugate Vaccine Covered
Hepatitis B Virus Screening and treatment: To be
Covered
followed as per the guidelines (TBA)
Basic Vaccination: Vaccines for Children (0-6) as per MOH
Covered
mandatory schedule*1
Medical Expenses related to Work Related Accidents,
Not Covered
Injuries and Illness*1
Injuries related to Road Traffic Accidents*1 Covered
Immunotherapy & Immunomodulators Covered if medically necessary
Hepatitis A Covered
Hormone replacement therapy. (Excluding growth hormone
Covered
and excluded medical conditions)
Ophthalmology: Medical conditions related to it
(Illness/Injury) of the eye excluding vision, sight test & Covered
refraction error.
Recreational non-hazardous sports activities (professional
and hazardous sports activities even if recreational are not Covered
covered)
In emergency cases:
i. Diagnostic and treatment services for dental
and gum treatments. Covered
ii. Hearing and vision aids, and vision correction
by surgeries and laser.
Circumcision for new Muslims subject to the following:
i. The member is insured with OIC.
ii. The member declared Islam in the Emirate of Not Covered
Abu Dhabi in line with all the legal formalities in
this aspect along with a letter from Judicial
Department in the Emirate.
Air fare for outside UAE treatment (Limited to Geographical
Covered
area specified) (On Reimbursement)
Maternity (Limits & Coverage)

Inside UAE – Inside Network Covered
Ante/Post-Natal Consultation Covered
Ante/Post-Natal Investigations Covered
Maternity complications
(Life threatening maternity complications are covered 10,000
up to indemnity limit)
Normal Delivery*1 10,000
Medically necessary C-Section*1 10,000
Legal Abortion/Miscarriage*1 10,000
Inside UAE – Outside Network & Abroad. Limit specified is
Not Covered
an aggregate for all services (Subject to policy deductibles)
* For Dubai Policies: Visits to include reviews, checks & tests in accordance with DHA Antenatal Care
Newborn Cover (Covered services are as per MOHAP guidelines and protocols)
A New born delivered in UAE is covered up to 30 days as
part of the mother’s insurance and shall share the same
indemnity limit. Continuity of cover is subject to scheme Covered
opted for allows dependents, addition notification within 30
days and the newborn added to the policy.
If the scheme allows dependents addition, then
i. HAAD: A New born will be enrolled to the scheme
from date of birth subject to the notification within 30
days from that date.
ii. DHA: A New born will be enrolled to the scheme from Covered
date of birth subject to the notification within 7 days
from that date.
iii. When a baby is born outside UAE, he/she will be
enrolled to the scheme only following their entry to the
UAE, with a valid entry permit and entry stamp.
Co-Insurance/Deductible
Inside UAE – Inside Network *2
Inpatient Services & Daycare cases/surgeries
Coinsurance NIL
Maximum copay amount per encounter Not Applicable
Annual aggregate maximum copay amount Not Applicable
Outpatient
Consultation Deductible/Coinsurance 10%
Outpatient procedures 10%
Physiotherapy 10%
Diagnostic Services
i. Laboratory 10%
ii. Radiology 10%
Prescribed Pharmaceuticals
i. Co-Insurance 10%
ii. Maximum out of pocket limit Not Applicable

Maternity
Inpatient Maternity NIL
Delivery NIL
Outpatient Ante/Post Natal Consultation
10%
Deductible/Coinsurance
Outpatient Ante/Post Natal Investigations Coinsurance 10%
Outpatient Ante/Post Natal Procedures Coinsurance 10%
Outpatient Ante/Post-Natal Prescribed Pharmaceuticals (including Ante-Natal Vitamins)
i. Co-Insurance 10%
ii. Maximum out of pocket limit Not Applicable
Additional Benefits (If opted)
Dental Co-Insurance Not Applicable
Optical Co-Insurance Not Applicable
Alternative Medicine Co-Insurance Not Applicable
Inside UAE – Outside Network (Co-Insurance applies over and above Network Deductions)
Emergency in UAE. (In Emergency cases as defined by PD 02-2017, healthcare services outside the scope of health
insurance must be covered until stabilization at minimum)
Coinsurance (with or without PAR) 0%
Basis of Claims Settlement Reimbursed at Actual value
Elective in UAE. If treatment / service is not available within the network then cover is 100% at actual subject to PAR*1
Basis of Claims Settlement OIC Network Tariff
Abroad (within agreed territory) (Co-Insurance applies over and above Network Deductions)
Emergency Abroad
Coinsurance 0%
Elective Abroad
Coinsurance 0%
Basmah Initiative – The Patient Support Program (PSP)
The Dubai Health Authority (DHA) announced the launch of Basmah initiative for Dubai Residents only, making
Dubai the first government entity in the world to provide a complete spectrum of care from screening to treatment for
three types of cancer under the enhanced as well as the basic mandatory benefit plans in Dubai.
The 3 inlcuded cancer types are Breast, Colorectal and Cervical cancer. Screening is strictly as per MOHAP
guidelines and protocols.
Prior to this scheme, cancer coverage was limited to the annual limit or the pre-exisitng limits defined in the policies.
Now, that is no longer the case. Patients detected with breast, colorectal or cervical cancer will have the choice to be
part of the PSP program, where they will receive coverage from screening until treatment in Dubai’s centers of
excellence (COE) without a limit.
Optional Benefits
Patient treatment supplies (Reimbursement) Not Covered
Organ transplant (excluding donor’s expenses) *1 Covered up to 10,000 per person per year
Kidney Dialysis Treatment (Hemodialysis / Peritoneal
Not Covered
Dialysis) *1
Hepatitis B and its complications*1 Not Covered
Home Nursing following inpatient treatment. Must be
registered / licensed nurse and with doctor’s Covered up to 15,000 per person per year
recommendation (Reimbursement)
Enhanced Vaccination (All census) – MOH approved
vaccines. Benefit does not include vaccination against
Not Covered
internationally or locally recognized epidemics.
(Reimbursement)
Psychiatric treatment other than mandated by HAAD for Covered up to 5,000 per person per year with 30%
Abu Dhabi schemes (Reimbursement) Coinsurance
Allergy testing (Reimbursement) Not Covered
External Prosthetic devices and medical equipment
Not Covered
(Reimbursement)
Infertility treatment. (Reimbursement) Not Covered
Deviated Nasal Septum (if medically indicated) *1 Not Covered
Cash indemnity benefit (Reimbursement) 500 per day
Passive War Risk (Reimbursement) Not Covered
Assist America Package. All services must be arranged and provided through Assist America.
No claims for reimbursement will be accepted.
Emergency Medical Evacuation Activated at 120 Kilometers
Medical Repatriation Activated at 120 Kilometers
Repatriation of Mortal Remains Activated at 0 Kilometers
Second Medical Opinion Covered
Wellness Benefit (Reimbursement at actual within specified limits and coinsurance)
Wellness Health Check-Up Not Covered
Alternative Medicine (Reimbursement at actual within specified limits)
Basic Alternative Medicine – Services To be performed only
Not covered
by a licensed practitioner
Enhanced Alternative Medicine – Services To be performed
Not covered
only by a licensed practitioner
Dental Benefit
Routine Dental cover*1 Not Covered
Enhanced Dental cover*1 Not Covered
Optical Benefit (Reimbursement at actual within specified limits and coinsurance)
Basic Optical cover *1 Not Covered
Enhanced Optical cover *1 Not Covered
TruDoc Telehealth
- Free consultation Covered
- No booking of appointments is required
Compensation in respect of :
Personal Accident Benefit* Subject to terms and conditions A) Death due to accident : AED 100,000
as followsersonal Acident B) Permanent total disability due to accident : AED
100,000
* 1 PAR = Prior Authorization request (please refer to claim administrative & prior approval procedures)
* 2 Treatment taken inside the network if submitted on reimbursement basis will be settled at the agreed tariff of the medical provider and
subject to policy deductibles/coinsurance. Policy must support reimbursment for the claim to be considered
Table of Benefits
Plan code: HomeLite-2
The Table of benefits is to be read along with the list of exclusions applicable and OIC’s Glossary.
All amounts are in AED

General Covers
Indemnity Limit 250,000
Basic Territory for Elective & Emergency treatment UAE, Arab Countries & South East Asia
Emergency extension cover is limited to Worldwide
excluding USA & Canada for 90 days per year and only
Extended Territory for Emergency treatment only applies in case of accident / emergency during business
trips or holidays abroad (Elective treatment is not
covered)
Pre-existing conditions (Subject to Exclusions List)
Covered up to 150,000 per person per year
If the waiting period is applicable, cover will be provided to
(with waiting period)
pre-existing conditions that develop into an emergency
within the 6 month exclusion period.
Non-Pre-existing Chronic Conditions (Subject to Exclusions
Covered up to Indemnity Limit
List)
Elective Treatment
Emergency Treatment
Medical Providers Network
Subject to ongoing changes.
Advance Network
Available online at OIC Network: www.omaninsurance.ae
Inpatient Benefits – with PAR
Room Accommodation Private
Diagnostic Investigations (Lab, Scan and X-ray) and other
prescribed medically necessary diagnostic procedures e.g. Covered
endoscopy & histopathology.
Accommodation Costs for one parent staying with a child up
500 Per day
to the age of 18 years.
Accommodation Costs for one accompanying family
member in case of critical medical conditions. *1 100 Per day
Subject to treating doctor recommendation
Daycare treatment including out-patient minor surgeries > 6
Covered
hours stay.
Internal Prosthetic devices implanted during covered
Covered
surgeries. *1
Outpatient Benefits
Consultation
(Follow up on same medical condition and at the same provider is free within 7 days from first consultation date)
General Practitioner – GP Covered
Specialist or Consultant – SP Covered
Pharmacy
Prescribed Pharmaceuticals (Pre-approval is required for
Covered
long term medication above 30 days)
ONLY Formulary products(Generic Medication) No
Vitamins prescribed as replacement therapy for known
vitamin deficiency conditions up to prescribed Covered
pharmaceutical limit only.
Diagnostic Investigations & Procedures (Lab, Scan, X-ray,
Covered
endoscopy, etc.)
Outpatient procedures Covered
Physiotherapy *1 prescribed by respective specialist doctor
Covered up to 10 sessions
and administered by a qualified physiotherapist.
Other Benefits
Local Emergency Transportation by Road Ambulance Covered
Birth Defects, Genetic Disorders & Congenital Conditions*1 Not Covered
DHA minimum preventive services*1 Covered
Diabetes screening Covered
Hepatitis C virus screening and treatment Covered
Basmah Initiative Covered
Adult Pneumococcal Conjugate Vaccine Covered
Hepatitis B Virus Screening and treatment: To be
Covered
followed as per the guidelines (TBA)
Basic Vaccination: Vaccines for Children (0-6) as per MOH
Covered
mandatory schedule*1
Medical Expenses related to Work Related Accidents,
Not Covered
Injuries and Illness*1
Injuries related to Road Traffic Accidents*1 Covered
Immunotherapy & Immunomodulators Covered if medically necessary
Hepatitis A Covered
Hormone replacement therapy. (Excluding growth hormone
Covered
and excluded medical conditions)
Ophthalmology: Medical conditions related to it
(Illness/Injury) of the eye excluding vision, sight test & Covered
refraction error.
Recreational non-hazardous sports activities (professional
and hazardous sports activities even if recreational are not Covered
covered)
In emergency cases:
iii. Diagnostic and treatment services for dental
and gum treatments. Covered
iv. Hearing and vision aids, and vision correction
by surgeries and laser.
Circumcision for new Muslims subject to the following:
iii. The member is insured with OIC.
iv. The member declared Islam in the Emirate of Not Covered
Abu Dhabi in line with all the legal formalities in
this aspect along with a letter from Judicial
Department in the Emirate.
Air fare for outside UAE treatment (Limited to Geographical

Covered
area specified) (On Reimbursement)
Maternity (Limits & Coverage)
Inside UAE – Inside Network Covered
Ante/Post-Natal Consultation Covered
Ante/Post-Natal Investigations Covered
Maternity complications
(Life threatening maternity complications are covered 10,000
up to indemnity limit)
Normal Delivery*1 10,000
Medically necessary C-Section*1 10,000
Legal Abortion/Miscarriage*1 10,000
Inside UAE – Outside Network & Abroad. Limit specified is
Not Covered
an aggregate for all services (Subject to policy deductibles)
* For Dubai Policies: Visits to include reviews, checks & tests in accordance with DHA Antenatal Care
Newborn Cover (Covered services are as per MOHAP guidelines and protocols)
A New born delivered in UAE is covered up to 30 days as
part of the mother’s insurance and shall share the same
indemnity limit. Continuity of cover is subject to scheme Covered
opted for allows dependents, addition notification within 30
days and the newborn added to the policy.
If the scheme allows dependents addition, then
iv. HAAD: A New born will be enrolled to the scheme
from date of birth subject to the notification within 30
days from that date.
v. DHA: A New born will be enrolled to the scheme from Covered
date of birth subject to the notification within 7 days
from that date.
vi. When a baby is born outside UAE, he/she will be
enrolled to the scheme only following their entry to the
UAE, with a valid entry permit and entry stamp.
Inside UAE – Inside Network *2
Inpatient Services & Daycare cases/surgeries
Coinsurance NIL
Maximum copay amount per encounter Not Applicable
Annual aggregate maximum copay amount Not Applicable
Outpatient
Consultation Deductible/Coinsurance 10%
Outpatient procedures 10%
Physiotherapy 10%
Diagnostic Services
iii. Laboratory 10%
iv. Radiology 10%
Prescribed Pharmaceuticals
iii. Co-Insurance 10%
iv. Maximum out of pocket limit Not Applicable
Maternity
Inpatient Maternity NIL
Delivery NIL
Outpatient Ante/Post Natal Consultation
10%
Deductible/Coinsurance
Outpatient Ante/Post Natal Investigations Coinsurance 10%
Outpatient Ante/Post Natal Procedures Coinsurance 10%
Outpatient Ante/Post-Natal Prescribed Pharmaceuticals (including Ante-Natal Vitamins)
iii. Co-Insurance 10%
iv. Maximum out of pocket limit Not Applicable
Additional Benefits (If opted)
Dental Co-Insurance Not Applicable
Optical Co-Insurance Not Applicable
Alternative Medicine Co-Insurance Not Applicable
Inside UAE – Outside Network (Co-Insurance applies over and above Network Deductions)
Emergency in UAE. (In Emergency cases as defined by PD 02-2017, healthcare services outside the scope of health
insurance must be covered until stabilization at minimum)
Basis of Claims Settlement Reimbursed at Actual value
Elective in UAE. If treatment / service is not available within the network then cover is 100% at actual subject to PAR*1
Abroad (within agreed territory) (Co-Insurance applies over and above Network Deductions)
Emergency Abroad
Coinsurance 0%
Elective Abroad
Coinsurance 0%
Basmah Initiative – The Patient Support Program (PSP)
The Dubai Health Authority (DHA) announced the launch of Basmah initiative for Dubai Residents only, making
Dubai the first government entity in the world to provide a complete spectrum of care from screening to treatment for
three types of cancer under the enhanced as well as the basic mandatory benefit plans in Dubai.
The 3 inlcuded cancer types are Breast, Colorectal and Cervical cancer. Screening is strictly as per MOHAP
guidelines and protocols.
Prior to this scheme, cancer coverage was limited to the annual limit or the pre-exisitng limits defined in the policies.
Now, that is no longer the case. Patients detected with breast, colorectal or cervical cancer will have the choice to be
part of the PSP program, where they will receive coverage from screening until treatment in Dubai’s centers of
excellence (COE) without a limit.
Optional Benefits
Patient treatment supplies (Reimbursement) Not Covered
Organ transplant (excluding donor’s expenses) *1 Covered up to 10,000 per person per year
Kidney Dialysis Treatment (Hemodialysis / Peritoneal
Not Covered
Dialysis) *1
Hepatitis B and its complications*1 Not Covered
Home Nursing following inpatient treatment. Must be
registered / licensed nurse and with doctor’s Covered up to 15,000 per person per year
recommendation (Reimbursement)
Enhanced Vaccination (All census) – MOH approved
Not Covered
vaccines. Benefit does not include vaccination against
internationally or locally recognized epidemics.
(Reimbursement)
Psychiatric treatment other than mandated by HAAD for Covered up to 5,000 per person per year with 30%
Abu Dhabi schemes (Reimbursement) Coinsurance
Allergy testing (Reimbursement) Not Covered
External Prosthetic devices and medical equipment
Not Covered
(Reimbursement)
Infertility treatment. (Reimbursement) Not Covered
Deviated Nasal Septum (if medically indicated) *1 Not Covered
Cash indemnity benefit (Reimbursement) 500 per day
Passive War Risk (Reimbursement) Not Covered
Assist America Package. All services must be arranged and provided through Assist America.
No claims for reimbursement will be accepted.
Emergency Medical Evacuation Activated at 120 Kilometers
Medical Repatriation Activated at 120 Kilometers
Repatriation of Mortal Remains Activated at 0 Kilometers
Second Medical Opinion Covered
Wellness Benefit (Reimbursement at actual within specified limits and coinsurance)
Wellness Health Check-Up Not Covered
Alternative Medicine (Reimbursement at actual within specified limits)
Basic Alternative Medicine – Services To be performed only
Not covered
by a licensed practitioner
Enhanced Alternative Medicine – Services To be performed
Not covered
only by a licensed practitioner
Dental Benefit
Routine Dental cover*1 Not Covered
Enhanced Dental cover*1 Not Covered
Optical Benefit (Reimbursement at actual within specified limits and coinsurance)
Basic Optical cover *1 Not Covered
Enhanced Optical cover *1 Not Covered
TruDoc Telehealth
- Free consultation Covered
- No booking of appointments is required
Compensation in respect of :
Personal Accident Benefit* Subject to terms and conditions A) Death due to accident : AED 100,000
as followsersonal Acident B) Permanent total disability due to accident : AED
100,000
* 1 PAR = Prior Authorization request (please refer to claim administrative & prior approval procedures)
* 2 Treatment taken inside the network if submitted on reimbursement basis will be settled at the agreed tariff of the medical provider and
subject to policy deductibles/coinsurance. Policy must support reimbursment for the claim to be considered.
Individual Healthcare Insurance
Essential Benefit Plan Terms & Conditions
Thank you for choosing Oman Insurance Company for your Healthcare Insurance. You are now insured with
the largest insurance company in the United Arab Emirates. You can be confident that we will be there
whenever you need us.
Please take some time to read this booklet, the accompanying table of benefits and the Policy Schedule.
These documents provide details of what the policy does and does not cover.
If you would like to change your level of cover or have any queries, please contact your Relationship
Manager.
Thank you!
‫ رقم التسجيل‬١٩٨٤/١٢/٢٤ ‫ لدى المصرف المركزي لدولة االمارات العربية المتحدة بتاريخ‬٩ ‫ رقم القيد‬،٤١٩٥٢ .‫ ت‬.‫ رقم س‬،‫ درهم إماراتي‬٤٦١,٨٧٢,١٢٥ ‫ع) رأس المال المدفوع‬.‫م‬.‫شركة عُمان للتأمين (ش‬
١٠٠٢٥٨٥٩٤٩٠٠٠٠٣ ‫الضريبي‬
www.omaninsurance.ae ،+٩٧١ ٤ ٢٣٣ ٧٧٧٥ :‫ فاكس‬،+٩٧١ ٤ ٢٣٣ ٧٧٧٧ :‫ هاتف‬.‫ اإلمارات العربية المتحدة‬،‫ دبي‬،٥٢٠٩ ‫ب‬.‫ ص‬:‫المركز الرئيسي‬
Oman Insurance Company (P.S.C.), Paid up Capital 461,872,125, C.R. No. 41952, Licensed by the Central Bank of the UAE, No. 9 dated 24/12/1984 TRN
100258594900003
Head Office: P.O. Box 5209, Dubai, United Arab Emirates, Tel.: +971 4 233 7777, Fax: +971 4 233 7775, www.omaninsurance.ae
INDM2022000XXXXX
DD/MM/YYYY to DD/MM/YYYY
Page No. 16
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.
Accident Related Dental Treatment

Emergency medical treatment necessary to restore or replace sound natural teeth lost or damaged in an
accident and for which medical treatment is provided within 72 hours following the accident.
Alternative Medicine
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.
Note: This benefit, if offered, is covered on reimbursement basis only.
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, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi
Arabia, Sudan, Syria, Tunisia, Iraq and Yemen.
Basic Routine Health Check-up shall include and refer to unless specified otherwise:
1. Blood examination (CBC, blood sugar, lipid profile, HIV, Hepatitis B)
2. Electrocardiogram ECG
3. Fundoscopy
4. Chest X-Ray
5. Urine routine
6. Stool OP/OB Consultation with General Practitioner/Internal Medicine Specialist
7. Mammogram, PSA as screening for Cancer breast / prostate
Note: This benefit, if offered, is covered on reimbursement basis only.
Cash Indemnity Benefit

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:
1. Has no known cure or recurs. Has only symptomatic/palliative cure whereby the state of disease never
cured.
2. Leads to permanent Disability.
١٠٠٢٥٨٥٩٤٩٠٠٠٠٣ ‫الضريبي‬
100258594900003
INDM2022000XXXXX
Page No. 17
3. Is caused by changes to Insured Member’s body, which cannot be reversed.
4. Requires the Insured Member to be specially trained or rehabilitated.
5. Needs prolonged supervision, monitoring or treatment.
Claim Adjudication
The process of placing a claim through a series of administrative, contract and medical edits to determine
coverage or non-coverage of a claim as well as the determination of financial settlement parameters.
Claim Submission
A written demand made to the Company by or on behalf of the Insured Members for the payment of medical
expenses under this insurance Policy. A claim is submitted on a claim form, which is accompanied by
supporting billing documentation and medical reports proving that chargeable Medically Necessary services
were or will be rendered to the Insured Member and the medical reasons for conduction of such services.  
Under the direct-billing mode (the “Direct-billing”), the Applicable Network’s Provider submits the claim on
behalf of the Insured Member for services rendered by the Provider in accordance with the medical service
agreement with the Company and the Company pays to the Provider Eligible Medical Expenses minus any
Deductibles, Coinsurance or other non-covered medical expenses.
Under the reimbursement mode (the “Reimbursement”) (if applicable), the Insured Member submits claim
directly to the Company who then pays the Policyholder / Insured member (as per arrangement) Eligible
Medical Expense minus any deductible, coinsurance, limits or other non- covered medical expenses.
Coinsurance (Excess)
The portion of Eligible Medical Expenses, usually a fixed percentage of all services (Inpatient or Outpatient)
received by the Insured Member and which, the Insured Member is obliged to pay.
Note: All benefits are inclusive of its coinsurance (if coinsurance is applied).
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.
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1. All bodily injuries sustained in any one accident shall be considered one Disability.
2. All bodily disorders existing simultaneously, which are due to the same or related causes, shall be
considered one Disability.
3. 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.
4. However, for cases requiring hospital confinement after 90 days following the latest discharge from the
Hospital, subsequent Hospital confinement arising from the same cause shall be considered a new
Disability. For cases not requiring Hospital confinement, a new Disability is established after a period of
90 days has elapsed following the day upon which the last reimbursed expense was incurred, unless
new expenses are not recoverable because of the exhaustion of the maximum out-patient benefits.
Eligible Dependent
This term shall be deemed to refer only to:
1. The legal wife or husband (not including those legally separated) or the person living with Principal
Insured in a recognized husband and wife relationship.
2. Any unmarried children, stepchildren and children legally adopted, who are:
a. Within the age of cover as specified under item 3 of the Policy Schedule and living in the Principal
Insured’s household in United Arab Emirates resident. Or absent therefrom only to attend an
academic institution as a student.
b. 18 years and over but under 25 years of age, having the same permanent residence as the Principal
Insured, and who are full-time students at an accredited college or university. Such children shall be
dependent upon the Principal Insured for support and registered as dependents of the Principal
Insured in the records of the Policy Holder.
Commencement of coverage on Eligible Dependents automatically follows that stipulated for Principal
Insured.
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
As defined by the Law is “A situation which calls for immediate medical intervention by a health services
provider for the rescuing of a person’s life/organ or the elimination of the danger threatening that person's
life/organ”.
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
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.
Hospital Confinement or Hospitalization
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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.
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.
Insured Dependent
Dependents of principal insured are eligible for insurance under this policy.
1. Written declaration by the Policy Holder for insurance of the dependents under this Policy shall
compulsory include all eligible Dependents as per selection criteria defined in “The Schedule” and
holding a valid UAE residence, together with an agreement to declare promptly all changes in the status
of such Dependents,
2. The insurance for the dependents shall become effective as follows:
a. If the policyholder has one or more dependents on the effective date of his insurance under this
policy, the insurance for such dependents shall become effective on that date.
b. If the policyholder acquires one or more dependents after the effective date of his insurance under
the policy, such dependents shall become insured on the date of the declaration of such additional
Eligible Dependents. The additional premium due shall be calculated as from the declaration date of
such Eligible Dependent.
Insured Member
This term shall be deemed to refer to any Principal Insured / Insured Dependent under this Policy.
Life Threatening
Diseases or conditions where the likelihood of death or permanent Disability of one or more of body organs
or extremities is high unless the course of the disease or condition is interrupted with immediate medical
care.
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.
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 enrolment of the Insured
Member under this medical Policy. The Medical Insurance Card shall always remain the property of the
Company.
Medically Necessary
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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:
1. Required for the Treatment or management of an Illness or Injury;
2. Appropriate to diagnose or treat the Insured Member’s Illness or Injury; Consistent with standards of
good medical practice;
3. Are not primarily for the personal comfort or conveniences of the Insured Member or the Provider;
4. Are not an associated with the scholastic education or vocational training of the Insured Member, the
Policyholder or primarily for education or experimental purposes;
5. In case of Inpatient care, cannot be provided safely on an Outpatient basis;
6. 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.
New Born
Where the Policy covers maternity benefits for a pregnant female, the coverage is extended to provide
medical benefits for a newborn 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 newborn 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 or immunization for disease prevention and health maintenance. Refer to Table of
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Benefits for covered services
Pre-existing Conditions
Bodily injuries or medical conditions relating to accidents or illnesses which occurred and/or were declared
and/or have been diagnosed and/or have already incepted treatment relating to same prior to the
commencement of this initial commencement date of the Policy.
Prior Approval
Shall refer to the process used to review proposed medical treatment plan prior to and / or during Hospital
Confinement or Outpatient Treatment of an Insured Member to assure that the Insured Member’s Medically
Necessary specific medical needs are met in the most cost-effective setting suitable for Medically Necessary
treatment of the Injury or Illness and are within the reasonable and Customary Charges and which shall need
to be specifically approved in writing by the Company before undergoing any such Treatment or
Hospitalization.
Provider
A generic term for Physicians, Hospitals, clinics, medical centres, pharmacies, laboratories, physiotherapy
centres, dentists and other paramedical institutions or persons who are licensed to offer medical services.
Routine Dental Benefits Cover shall be deemed to refer to the following:
1. Lesions of oral cavity
2. Endoperio Surgery
3. Scaling
4. Filling
5. Curettage & gum problems
6. Root canal and pulp treatment
7. Extraction (removal - simple & Surgical)
However, general dental inspection (check-up), maintenance of appearance, crown, bridges, posts,
dentures, pins, prosthesis, orthodontic Treatment and cosmetic Treatment & Surgery are not covered as well
as toothpastes, mouth wash, mouth sprays etc. which in the sole discretion of the Company is either not
Medically Necessary or is cosmetic in nature.
Routine Optical 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 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 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: Brunei, Cambodia, Burma
(Myanmar), Afghanistan, Timor-Leste, Laos, India (Indian Subcontinent: Bhutan, Bangladesh, Maldives,
Nepal, Pakistan and Sri Lanka), Indonesia, Iran, Malaysia, Philippines, Singapore, Thailand and Vietnam.
Surgery or Surgical Operation

Shall be deemed to refer to the following:
1. A cutting operation
2. Suturing a wound
3. Treatment of a fracture
4. Reduction of a dislocation
5. Radiotherapy (excluding radioactive isotope therapy) if used in lieu of a cutting operation for the removal
of tumour.
6. Electrocatherisation
7. Diagnostic and therapeutic endoscopic procedures
8. Injection treatment hemorrhoids and varicose veins
9. Organ transplant
10. Angiography
11. Normal childbirth
Table of Benefits
Shall mean the table of benefits in the Policy Schedule detailing the eligible benefits and its Limits.
Treatment
Any Surgery, medical, pharmaceutical or other approach used to cure or rectify an Insured Member’s Illness
or injury which is deemed as being Medically Necessary and which must be legally permitted in the country
where the Treatment was prescribed and covered under this insurance Policy contract.  
Vaccines & Immunizations

Unless specified otherwise, the Vaccines & Immunizations or Child Vaccination as referred in the Table of
Benefit covers the Essential vaccinations and inoculations for new borns and children as stipulated in the
DHA’s policies and its updates (currently the same as Federal MOH).
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General Conditions
1. Network of Providers are subject to on-going changes at sole discretion of the Company. Updated list
of Providers available at
https://www.omaninsurance.ae/downloads?product=Health&productcategory=Business
2. Company reserves the right for referring for a second opinion from another doctor, if needed for
elective surgeries and outpatient investigations/procedures.
3. Insured Members must present their Medical Insurance Card / Emirates ID every time they request
Healthcare Services from the Applicable Network’s Provider.
4. The Premium payable by the Policyholder to the Company shall be calculated at the rate agreed.
5. The initial premium shall be calculated on the number of to be Insured Members reported by the
Policyholder at Policy inception.
6. 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 immediate from
invoicing, unless mutually agreed otherwise.
7. The Policyholder shall report all addition / deletions of Members / 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.
8. The Company shall process the eligible requests and issue premium adjustment documents Medical
Insurance Cards where necessary.
9. 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.
10. Coinsurance if any applicable on reimbursement claims, shall be calculated over and above the
network coinsurance/deductible, unless specified otherwise.
11. Servicing of this scheme shall be subject to Oman insurance Operational as well as Claims
management standard Service Levels.
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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.
1. 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.
2. 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:
a. Use of operating room, treatment rooms and equipment.
b. Dressings, ordinary splint and plaster casts but excluding special braces, appliances and equipment.
c. 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.
d. When furnished as a regular service customarily provided by the Hospital in which the Insured
Member is confined, and when performed by an employee of the Hospital. Laboratory examinations,
electrocardiograms, basal metabolism tests, oxygen and anesthetic and administration thereof, X-
Ray examination, administration of blood and blood plasma, intravenous injections and solutions.
e. 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.
3. 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:
a. 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
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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.
b. 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.
c. 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.
4. Doctor’s Visits
If an Insured Member incurs expenses for care and treatment by a Physician and:  i. Such care and
treatment are 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.
5. 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

1. Doctor’s Visits If as result of a Disability, an Insured Member incurs expenses for professional
attendance and treatment by a Physician, the Company shall reimburse such expenses up to the
maximum amount per visit and per Disability and in excess of deductible (if any) as set forth in the Table
of Benefits under Out-Patient Benefit, subject to the following provision:
a. Office visits-professional attendance and treatment in the physician’s office or clinic.
b. Specialist consultations - professional attendance and consultation by a qualified specialist.
2. 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.
3. 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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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

In the event of a dispute arises between the Company and the Policyholder or Insured Member out of or
related to this Policy, the concerned party and the Company shall meet and negotiate in good faith to attempt
to resolve the dispute. If this could not be resolved mutually between the involved parties, then the dispute
shall be referred to relevant insurance regulators for an amicable settlement, and any other dispute
resolution procedures shall be of no force and effect unless and until the complaints procedure set out by the
regulators have been exhausted. In such instance, the dispute shall be referred to and determined by the
UAE Courts, which shall have exclusive jurisdiction.
Article 3 - Premiums
1. The premiums under this Policy are payable in advance or at the intervals indicated on the Policy
Schedule.
2. All premiums are due for respective payment upon their due dates at the head-office or to an agent or
cashier of the Company. Furthermore, no payment in respect of any premium shall be deemed to be
effected to the Company unless a printed form of receipt complete with a signature by a duly authorised
Company’s Official or duly appointed Agent is issued to the Policyholder against such payment as
effected.
3. The premium payable by the Policyholder to the Company shall be calculated at the agreed rate.
4. The initial Premium shall be calculated on the actual number of Insured Members as indicated at
inception of this Policy.
5. Adjustments - Additional premium shall be due by the Policyholder upon the addition of new Insured
Members. This shall be calculated on a pro-rata basis from the date of joining of such Insured Member
till the date of renewal.
6. Similarly, a return premium by the Company shall be allowed to the Policyholder and calculated on a
pro-rate basis from the date of cancellation of such removed Insured Members till the date of renewal
of the Policy.
7. Either additional or return premium shall be settled either way within 30 days of declaration and
submission of all required documents to the Company as required to the satisfaction of the Company.
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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 Member exceed that stated in the application, this Policy shall not be void
but there shall be an equitable adjustment. If the misstatement of age does not alter in any way the
outcome of a claim submitted, then the benefits shall remain unchanged; but if the change in age effects
such, then these shall be corrected accordingly, and a premium adjustment shall take such corrections
into account with effect from inception.
2. With respect to the calculation of age for the calculation of the premium to the policy, in the case where
only the year of birth of the Insured Member is indicated the day of birth shall be considered as the 1st of
January of the year indicated as that of birth.
Article 7 - Renewal of Policy

This Policy shall continue for the period of insurance as stated in the schedule and shall be renewable
annually on mutual agreement by the Policyholder and the Company on each subsequent Policy Anniversary
on rates and terms to be agreed.
Article 8 - Termination
1. Termination of the Policy
a. 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.
b. If this policy is terminated by Company or at any time at the request of the Policyholder, then the
Company shall be liable to repay as per Article 3, clause no. 6 for the unexpired term from the
effective date of cancellation.
c. If this Policy is terminated by Company, then the Company shall be liable to repay as per Article 3,
clause no. 6 for the unexpired term from the effective date of cancellation.
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d. All coverage shall terminate upon termination date indicated on the Notice of Cancellation
2. Termination of Individual Insurance of a Principal Member

A Principal Member’s insurance under this Policy shall automatically terminate:
a. If this Policy terminates,
b. If premium payments for his/her insurance are unpaid
3. Termination of Individual Insurance of Dependents

A Dependent’s insurance under this Policy shall automatically terminate:
a. If the Insured’s Dependents cease to be eligible as a Dependent
b. If this Policy terminates.
c. 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

a. 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.
b. 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.
c. For treatment in medical facilities not specified in Insured Member’s Applicable Network, or for
treatments obtained from Applicable Network without presenting valid medical insurance card,
Insured Members shall pay cash for medical treatment/services and medications and submit
invoices together with a completed claim form to the Company, as applicable and defined in the
Table of Benefits, through their offices, not later than ninety (90) days from the date of availing the
Medically Necessary Healthcare Services or Treatment. The Company shall reimburse the
Policyholder provided that all supplementary documents/receipts are in order, subject to the terms,
conditions, limitations and exclusions of this Policy. Company reserves the right to repudiate claims
on failure to comply with proper prior approvals and protocols.
d. 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.
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e. 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.
f. 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
g. 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.
h. 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.
i. 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
a. 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.
b. Outpatient (consultation) treatment by visiting Physician’s specialists from both inside and outside
UAE is covered (provided it remains within the consultation Limit as specified in this Policy). The
Company’s standard prior approval protocols are applicable, and the claims shall be payable at
Company’s UAE- applicable Network charges only.
c. 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.
d. Company may require additional information relating to a treatment recommended by the Provider
and may assign an independent Physician to give a second opinion.
e. 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.
f. 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.
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g. 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.
2. The Policyholder shall advise the Company on any new Dependent eligible for the insurance hereunder,
on any individual insurance termination This shall be on the prescribed “Turnover Form”
3. The company may cover substandard risks at extra premium. Additions/Deletions of Dependents during
the term of Period of Insurance is restricted to the following cases:
a. Newborn - as specified under Eligibility Section of Policy Schedule.
b. Dependents - from the date of marriage (for newlywed spouse) or Entry into UAE on residence
whichever is later.
c. Change of Status - From effective date of such change.
d. Deletion - from 30 days from visa cancellation date or exit date from UAE or visa transfer date
whichever is the earliest
e. Age Limit - As specified under eligibility Section of Policy’s Schedule.
4. Any addition/deletion of Eligible Dependents should be reported to the Company within maximum of 15
calendar days. Requests for back-dated additions/deletions shall not be honored or recognized by the
Company.
5. The Company shall not process any Insured Member deletion requests without the Policyholder
returning the original issued Medical Insurance Card. In case it is specifically agreed mutually to delete
an Insured Member without the original issued Medical Insurance Card being returned, the Policyholder
shall be fully liable in relation with any expenses incurred by such terminated/excluded members as from
the termination date unless the original Medical Insurance Card of the terminated member has been
returned to the Company. The Company may debit the Policyholder for any such amounts, as and when
settled to the Providers. The Policyholder and the Insured Members clearly acknowledge that the
Medical Insurance Cards shall all times be considered proprietary and property of the Company.
6. 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.
7. 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.
8. 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.
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Article 12 - Misrepresentation, Errors and Omissions

1. The Company shall not be liable under the Policy in the event of any misrepresentation or non-
disclosure by the Policyholder or the Insured Member of any material information at any time during the
currency of the Policy.
2. Furthermore, it is to be noted that the issue of this Policy document is affected under the Company’s part
and obligation towards the governance of utmost good faith. Hence it is to be understood that due care
and diligence have been employed in the issue of such Policy contract.
3. Thus, it shall be the onus and responsibility of the Policyholder and/or the Insured Member to ensure
that all facts, circumstances, terms and limitations enlisted under this Policy contract are as per the
agreements intended to be entered into between all Parties to such Policy.
4. Failure to indicate any errors and omissions from the part of the Policyholder following the issue of this
Policy shall not bind the Company towards any liability arising there from.
Article 13 - Forfeiture
If the Policyholder or the Insured Member shall lodge any claim or connive in the making of any
claim, knowing the claim to be false or fraudulent, the Policy shall become void for that particular
Insured Member and all claims pertaining to that Insured Member will stand forfeited.
Article 14 - Written Communication

Any notice and/or other communication to the Company relevant to the insurance cover as afforded by this
Policy or towards the maintenance of same or claims submitted must be submitted in writing or in printed
form and addressed/delivered to the Company at the indicated correspondence channels of same.
Article 15 - Representation
The Policyholder agrees to nominate a coordinator to act on behalf of the Policyholder and the Insured
Members enlisted under this Policy to administer the Policy on behalf of the Policyholder in accordance to
the terms of this Agreement. All communications and correspondence between the parties related to the
Policy shall be maintained through this channel of representation.
Article 16 - Sanction Limitation and Exclusion Clause

The Company shall not provide cover and the Company shall not be liable to pay any claim or
provide any benefit hereunder to the extent that the provision of such cover, payment of such claim
or provision of such benefit would expose the Company to any sanction, prohibition or restriction
under United Nations resolutions or the trade or economic sanctions, laws or regulations of the
European Union, United Kingdom, United States of America, United Arab Emirates and / or all other
jurisdictions where the Company transacts its business.
Article 17 - Anti-Money Laundering & Combating Terrorist Financing

The Company is in compliance with Anti-Money Laundering & Combating Terrorist Financing laws (UAE
Federal Law No. 4, 2002 - Criminalization of Money Laundering, UAE Federal Law No. 1, 2004 - Combating
Terrorism Offences, Insurance Authority Resolution No. 16 of 2013 - Anti-Money Laundering and Combating
Terrorism Financing).
Article 18 - Language
All Insurance Policies are issued in both Arabic and English, In case of dispute over the interpretation of the
Insurance Policy, the Arabic text shall prevail.
Article 19 - Assignment
This Policy and the rights and obligations of the Policyholder or the Insured Member shall not be assignable
to any other party without the prior consent of the Company.
Article 20 - Promotion
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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 Proposer/Policyholder/all of the Insured Members agrees to adhere to and comply with all such
electronic transaction terms and conditions as the Company may prescribe from time to time and hereby
agrees and confirms that all transactions effected by or through facilities for conducting remote transactions
including the internet, world wide web, electronic data interchange, call centers, tele-service operations
(whether voice, video, data or combination thereof) or by means of electronic, computer, automated
machines network or through other means of telecommunication, established by or on behalf of the
Company, for and in respect of this Policy or its terms, or the Company’s other products and services, shall
constitute legally binding and valid transactions when done in adherence to and in compliance with the
Company’s terms and conditions for such facilities, as may be prescribed from time to time.
Article 24 - Authorization
Authorization by the Policyholder:
The Policyholder on behalf of itself and with full authority of the Insured Member hereby agrees and
authorizes:
• The Company to use any of the approved verification agencies to make references/inquiries from
any source of information, about the Policyholder, any Insured Member, beneficiary, person or entity
nominated or insured herein;
• All financial institutions, bank, debt collection agencies, credit bureaus or any other person or entity
to disclose and provide to the Company with any information requested about or related to the
Policyholder and/or the Insured Member as in its possession;
• The Company, at any time and at its absolute discretion, to use and/or disclose any financial
information available with the Company (including any breach of obligations or defaults (including in
premium payment or repayment)) to any other organization, entity, financial institutions, banks, debt
collection agencies or credit bureaus.
The Proposer/Policyholder/all of the Insured Members hereby confirm that their personal data has been
collected and is being provided to Oman Insurance Company in compliance with relevant regulations. By
providing any such personal data/information, the Proposer/Policyholder & the underlying Insured Members
hereby give their unambiguous consent to:
a. the Company to collect, store, process, share and transfer your personal data (including but not limited
to your personal sensitive information) to third parties including but not limited to reinsurers, surveyors,
loss adjustors, loss assessors , IT service providers, claim administrators, medical providers, emergency
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support/assistance providers, professional advisors, consultants, auditors, additional administrative

and/or support service providers, and other entities or persons , whether within or outside the UAE , as
may be required in relation to underwriting/ issuing/administering / processing/ reinsuring your policy/
claims or as may be required by the Company including but not limited to for further product
development/statistical analysis etc., or as may be required under law/regulatory requirements.
b. the Company and its associate partners to contact the Proposer/Policyholder/any of the Insured Member
anytime (including electronically through email, SMS or telephone) for seeking any additional information
and/or for providing any additional information whether related to the Policy and/or Company’s other
products or promotions.
Article 25 - General
1. The Insured Member/Policyholder shall furnish the Company with any information the Company may
require (including details of the state of health) in respect of the Insured Member for the benefits
hereunder. Prior to acceptance, the Company may, at its sole discretion, require any Insured Member to
undergo a medical examination by a legally qualified medical practitioner in the manner the Company
deems required or fit.
2. No Benefits shall be paid in respect of an Insured Member who attains the Maximum Coverage Age
specified in the schedule of this policy (at which time that Insured Member shall cease to be covered).
3. The Policyholder agrees to provide clear, detailed and accurate information about this Policy, its
exclusions and terms and conditions to each of the Insured Member upon their enrolment under this
Policy.
4. The Insured Members must take reasonable care to prevent loss, damage, accident, bodily injury or
illness.
5. All words appearing in the gender of one sex shall be taken to include both sexes. If the context
requires, the singular shall imply the plural and vice versa.
6. In the event that the Company incurs any cost and/or expense not insured under this Policy on the
Insured Person’s or the Policyholder’s behalf, the Policyholder shall reimburse such costs and expenses
to the Company.
7. This Policy shall continue to benefit the Insured Member effective the Policy inception, subject to the
terms and conditions herein, unless the Insured Member specifically expresses his intention not to be
covered under this Policy.
8. No person or third party or agent is authorized to alter or amend this Policy, to accept premiums in
arrears or to extend the due date of any premium, to waive any notice or proof of claim required by this
Policy, or to extend the date before which any such notice or proof must be submitted. No change in this
Policy shall be valid unless approved by the Company and evidenced by endorsement hereon or by
amendment hereto, signed by the Policyholder and by an authorized representative of the insurance
Company.
9. Any notice, direction or instruction given under this Policy shall be in writing and delivered by hand, post,
or facsimile to:
a. In case of the Policyholder, at the last-known address as recorded with the Company.
b. 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
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Article 26 – Taxes
(A) Premium Payments:

For avoidance of doubt, all premium amounts mentioned herein are exclusive of Value added tax (VAT).
VAT and any other taxes currently applicable or which will be applicable in connection with this insurance
policy shall solely be borne by the Insured/Policyholder.
The Insured/Policyholder hereby agrees to pay to the Insurer the applicable VAT/any other taxes paid by the
Insurer, on the Insured/Policyholder’s behalf, within 15 working days of receiving the invoice failing which the
Insured/Policyholder shall be considered to be in material breach of the Policy’s terms and conditions and,
the Insurer shall be within its right to invoke legal remedies available to the Insurer including to terminate the
policy and/or offsetting such VAT or other tax amounts from any other amount which the
Insured/Policyholder owes to the Insurer without the need to obtain any further consent from the
insured/policyholder and/or any court judgment/order. The Insured hereby unconditionally accepts to the
same.
In the event that VAT/any other tax treatment as assessed by relevant tax authorities is different from that
assigned by the Insurer on our tax invoice/invoice to you and/or the invoice generated/computed by the
Insurer is incorrect/, the Insured/ Policyholder hereby agrees to pay immediately and on demand the
differential balance of any VAT/tax to the Insurer.
(B) Claim settlements - where OIC agree to pay the policyholder

When Oman Insurance Company ("OIC" or "we") pays a claim, your VAT registration status will determine
the amount we pay you.
When you are:
1. Not registered for VAT, the amount we pay, will be the sum insured/limit of indemnity or any other limits of
insurance cover, including VAT;
2. Registered for VAT, the amount we will pay will be the sum insured/limit of indemnity or any other limits of
insurance cover and where you are liable to pay an amount of VAT in respect of an acquisition relevant to
your claim, we will pay the VAT amount. However we will reduce the VAT amount we pay for by the amount
of any input tax credits to which you are or would be entitled to if you had made the relevant acquisition. In
such instances the input tax credit would be claimable by you upon filing of your VAT return.
All policyholders making a claim with OIC must declare their VAT registration status.
Any VAT liability arising from your incorrect declaration is and will be payable by you (the policyholder).
Where the settlement amount of your claim is less than the sum insured/limit of indemnity or any other limits
of insurance cover, we will only pay an amount of VAT (less any entitlement to an input tax credit) applicable
to the settlement amount.
PREMIUM PAYMENT CONDITION
Notwithstanding any provision to the contrary within this quotation/any binding confirmation, in
respect of non-payment of premium the following clause will apply. The Insured undertakes that
premium will be paid in full to Insurers within the notified payment terms (or, in respect of
installment premiums, when due). If the premium due under the policy (if issued) has not been so
paid to Insurer within the notified payment terms (and, in respect of installment premiums, by the
date they are due) Insurers shall have the right to cancel the policy (if issued) by notifying the
Insured and/or the broker (if applicable) in writing. In the event of cancellation, premium will be due
to Insurers for the period that Insurers were on risk but the full policy premium shall be payable to
Insurers in the event of a loss or occurrence prior to the date of termination which gives rise to a
valid claim under the policy (if issued). It is agreed that Insurers shall give not less than 30 days prior
notice of cancellation to the Insured via the broker or intermediary (if applicable). If premium due is
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paid in full to Insurers before the notice period expires, notice of cancellation shall automatically be
revoked. If not, the policy shall automatically terminate at the end of the notice period. If any
provision of this clause is found by any court or administrative body of competent jurisdiction to be
invalid or unenforceable, such invalidity or unenforceability will not affect the other provisions of
this clause which will remain in full force and effect.
INCONTESTABILITY
This medical policy shall be incontestable after a period of one (1) calendar year from the policy
inception date for any reason other than misrepresentation, fraud, non-payment of premium or as
otherwise permitted under respective laws and regulations.
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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,
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 professional sports activities, including but not
limited to, any form of aerial flight, any kind of power-vehicle race, water sports, horse riding
activities, mountaineering activities, violent sports such as judo, boxing, and wrestling, bungee
jumping and any other professional sports activities.
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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 outpatient 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 haemodialysis 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.
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34. Inpatient treatment received without prior approval from the insurance company including cases
of medical emergency that 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
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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User Guide
Direct Billing
When you go to one of the eligible hospitals listed in our preferred Healthcare Provider (HCP) Network, you
will pay only the deductible and/or co-payment. The hospital bills us directly for the remaining charges.
1. Go to our website www.omaninsurance.ae or click here to review the list of approved providers who
belong to Vital network.
2. Present a valid healthcare insurance card. Remember to carry a valid proof of identity like you your
Emirates ID, as most of the providers ask for it.
3. Receive required medical assistance as per treatment recommended and as covered by Policy
conditions and limitations.
4. Sign a claim form that is completed by the HCP from whom treatment was received.
5. Settle any deductibles and/or co-insurance shares as indicated at the back of the healthcare insurance
card.
6. Once you are served, the healthcare provider shall send us all documents.
Reimbursement Claims
When you go outside your eligible Network or undertake a treatment covered on reimbursement basis, you
will pay for the treatment directly and send us the claim for reimbursement. You should send us all the
documents related to the treatment and the prescriptions. We will then reimburse you according to the
provisions of your plan.
We have listed some points that you should remember, whenever you go for a treatment outside the
network, to avoid delay or rejection of your claim reimbursements.
1. Carry a newly downloaded claim form, whenever you visit a hospital outside your eligible network or
travel abroad.
2. The reimbursement claim form can be downloaded from our website www.omaninsurance.ae by visiting
the quick links section under individual and business tabs. For direct access to the form, click here.
3. One claim form is valid for one person only per visit. Family members need to submit separate forms.
4. Download a new form for a new claim as every form has a unique number. Please do not use
photocopies of an already downloaded form.
5. Please read the ‘How to Complete the Form’ section in the claim form to fill the form correctly.
6. Give us your contact details while filling up the claim form, so we can keep you informed on the progress
of your claim by SMS or by e-mail.
7. Include your IBAN number and we will send the reimbursement straight to your account. You will receive
your payment faster and will not need to waste time collecting and depositing the cheque.
8. Ensure that you provide all the information and documents as per the checklist provided on the last page
of the claim form. This will reduce the chances of delay in your claim processing or complete rejection.
Ask your treating doctor to sign and stamp the claim form.
9. Claim settlement/reimbursement will be done as per directives shown on the Table of Benefits.
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10. In case of emergency treatments, the Company must be notified within 24 hours of admission or not
later than discharge from the Hospital.
How to submit your claim
If your claim is below AED 5,000, you can submit it online via our portal OICare. To create your account on
the portal or submit your claim in case you are already registered, click here. Alternatively, you can send it to
our Head Office.
Healthcare Claims Department

Oman Insurance Company
Rigga Claim Office:
Oman Insurance Building, Omar Bin l Khattab St, Al Ghurair Mall, Deira
PO 5209, Dubai, UAE Tel: +971 4 230 2700
All documents should be submitted within ninety (90) days of the claim. Claims submitted after ninety (90)
days of treatment shall not be accepted or honored. Any requirements requested by the company, such as
supporting documents or missing information should be provided within thirty (30) days from the date of
request, failing which the company reserves the right to repudiate the claim.
800 4746 - UAE Toll Free

If you have any enquiries, 8am till 8pm Sunday to Thursday, 8am till 4pm on Saturday
contact us on: Fax: +971 (0) 4 238 4769
weserve@omaninsurance.ae
Obtaining Pre-Approval
Healthcare providers shall be responsible for obtaining necessary approval from the insurance company if
you are accessing one of the Applicable Network Providers. For life threatening medical emergency
treatments out of network, the representatives of the member should be obtaining the approval within 24
hours or prior to discharge.
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
4. Following multiple sessions services: Cryocautery, Electrocautery, Sclerotherapy, Laser therapy,
Physiotherapies
Who to Contact for Prior Approval?
For pre-authorization disputes 800 6626, UAE Toll Free, 24-hour center
Abroad Calls: +971 50 4543778
Email medpar@omaninsurance.ae
Fax 04 2684623 / 04 2384721
For service coverage inquiry 800 4746 - UAE Toll Free

8am till 8pm Sunday to Thursday, 8am till 4pm on Saturday
Email service@omaninsurance.ae
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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.
Complaints
Tell us what you think of Oman Insurance Company, we are always happy to hear your comments or
complaints:
Phone 800 4746 – UAE Toll Free

8am till 8pm Sunday to Thursday, 8am till 4pm on Saturday
Email complaints@omaninsurance.ae.
Web Visit our website www.omaninsurance.ae

Click here for direct access.
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Personal Accident Insurance (PA)

Benefits Overview & Sum insured
Cover As per Oman Insurance Company Standard Personal Accident Insurance policy
wording, general conditions, exclusions, and clauses to cover the benefits for the
sum insured mentioned herein.
Insured Persons Nationals and expatriate residents of United Arab Emirates enrolled under OIC
individual Medical Insurance
Eligibility members enrolled for individual medical insurance
Age Limit In line Medical Insurance Policy
Benefits As per the attached Schedule of Benefits
Scope of Coverage Worldwide coverage excluding sanction countries and war zones
Governing Law & Competent courts of United Arab Emirates (other than DIFC Courts and ADGM
Jurisdiction Courts)
Benefits Sum Insured AED

Death Due to accident -Single Indemnity AED 100,000
Permanent Total Disability (Accident)- Single Indemnity AED 100,000
Schedule of Benefits and definition

Benefits Description
In the event of death (accident) of an Insured Person, the Principal Sum in
Death (Due to accident)
respect of that person shall be paid.
In the event of permanent total disablement caused by an accident
incapacitating an Insured Person unable to follow at-least 4 out of 6
Activities of Daily Living, a lump sum amount equivalent to Principal Sum
shall be paid, subject to deferment Period – 12 months.
Activities of Daily Living are defined as below:
• Washing: the ability to wash in the bath or shower (including
getting into or out of the bath or shower) or wash satisfactorily by
other means
• Dressing: the ability to put on, take off, secure and unfasten all
garments and, as appropriate, any braces, artificial limbs or other
surgical appliances
• Feeding: the ability to feed oneself once food has been prepared
Permanent Total Disability and made available
(Accident) • Toileting: the ability to use the lavatory or otherwise manage
bowel and bladder function to maintain a satisfactory level of
personal hygiene
• Mobility: the ability to move indoors from room to room on level
surfaces
• Transferring: the ability to move from a bed to an upright chair or
wheelchair and vice versa
Cover for the member automatically terminates upon payment of PTD

Claim.
Disabilities for which the relevant specialists cannot give a clear prognosis
are not covered.
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Exclusions from Death & Disability Benefits

For all covered benefits
No sum assured shall be payable if death results directly or indirect consequence of:
1. War, invasion, act of foreign enemy, hostilities, or warlike operations (whether war be declared or not),
civil war, military rising, insurrection, rebellion, revolution, military or usurped power, martial law,
mutiny or riot or civil commotion assuming the proportions of or amounting to a popular rising, Insured
engaging in any illegal act, breach of Law or criminal act, Insured engaging in or taking part in any
naval, military or air force operation.
2. Passive War & Terrorism
3. Acts of terrorism (other than innocent bystander when passive war extension has been insured)
4. Atomic, Biological, and Chemical contamination
5. nuclear fission, nuclear fusion, or radioactive contamination.
6. Mental illness and nervous disorders.
7. Intentionally self-inflicted injury, suicide, or attempted suicide (whether sane or insane)
8. Aviation, gliding or any form of aerial flight other than as a fare paying passenger of a recognized
airline or charter service
9. Drug or alcohol abuse
10. The exercise of dangerous sports including but not limited to:- polo, boxing, climbing/mountaineering
requiring ropes or guide or free climbing, gliding, ballooning, racing of any kind other than on foot
(including but not limited to horse or motor racing), participation in speed or endurance tests or record
breaking feats, any underwater activity involving breathing apparatus, such as deep sea diving,
skydiving or parachuting, bungee jumping, show jumping, steeple chasing, evening or flat racing with
horse, potholing, sailing outside territorial waters.
11. Participation in any sports in a professional capacity
12. Insured engaging in or taking part in any naval, military or air force operation.
13. Pre-existing conditions
14. HIV/AIDS or related infections
15. Ingestion of poison or drugs, or inhalation of fumes, voluntarily, except in the case of an Accident
admitted by any occupational health and safety board.
DEFINITIONS
Accident means a sudden, unforeseen, and unexpected event caused by external, violent, and visible
means (but does not include any illness or disease) which results in physical bodily injury (but does not
include mental, nervous, or emotional disorders, depression, or anxiety).
Accidental Death means a sudden, unforeseen, and unexpected event caused by external, violent, and
visible means which occurs at an identifiable time and place, resulting in death.
Permanent means lasting twelve calendar months and at the expiry of that period being beyond reasonable
hope of improvement and certified to that effect by a competent and qualified Physician appointed by OIC.
Permanent Total Disability means an accidental disability in which an Insured Person unable to follow at-
least 4 out of 6 Activities of Daily Living
Activities of Daily Living are defined as below:

• Washing: the ability to wash in the bath or shower (including getting into or out of the bath or
shower) or wash satisfactorily by other means
• Dressing: the ability to put on, take off, secure and unfasten all garments and, as appropriate, any
braces, artificial limbs or other surgical appliances
• Feeding: the ability to feed oneself once food has been prepared and made available
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• Toileting: the ability to use the lavatory or otherwise manage bowel and bladder function to maintain
a satisfactory level of personal hygiene
• Mobility: the ability to move indoors from room to room on level surfaces
• Transferring: the ability to move from a bed to an upright chair or wheelchair and vice versa
Policy means this document, endorsements and Policy Schedule attached or issued with it.
Policy Effective Date means the date at which the Policy incepts as defined in the Policy Schedule.
Policy Expiry Date means the date after which the Policy is no longer valid as defined in the Policy
Schedule.
Policy Period means the time from the Policy Effective Date to the Policy Expiry Date as defined in the
Policy Schedule.
Policy Schedule means the document which gives details such as, but not limited to, Policyholder name,
Insurance Plan selected, Premiums, benefit limits, enclosed covers, extensions, exclusions, and conditions.
Principal Sum Insured (for Accidental Death) means the Sum Insured to be paid by the Company to the
Beneficiary in the event of the Insured Person’s Accidental Death.
Sum Insured means the maximum amount afforded to each benefit according to the Table of Benefits.
Claims Notification It is a condition precedent to Our liability hereunder that written notice of claim must be
given to Us immediately after the occurrence or commencement of any loss that may be covered by the
Policy and in any event within thirty (30) days thereafter.
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Insurance Policy

Individual Healthcare Insurance

For OMAN INSURANCE COMPANY ( P.S.C)

For ZEESHAN HASAN

All amounts are in AED

Maternity (Limits & Coverage)

ii. Maximum out of pocket limit Not Applicable

All amounts are in AED

Air fare for outside UAE treatment (Limited to Geographical

Accident Related Dental Treatment

Note: This benefit, if offered, is covered on reimbursement basis only.

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

6. Stool OP/OB Consultation with General Practitioner/Internal Medicine Specialist

7. Mammogram, PSA as screening for Cancer breast / prostate

Note: This benefit, if offered, is covered on reimbursement basis only.

Cash Indemnity Benefit

2. Leads to permanent Disability.

3. Is caused by changes to Insured Member’s body, which cannot be reversed.

4. Requires the Insured Member to be specially trained or rehabilitated.

5. Needs prolonged supervision, monitoring or treatment.

Eligible Medical Expense

Hospital Confinement or Hospitalization

2. The insurance for the dependents shall become effective as follows:

Medical Insurance Card

Hospitalizations, confinements, surgeries, procedures, treatments, services, supplies, medications,

1. Required for the Treatment or management of an Illness or Injury;

5. In case of Inpatient care, cannot be provided safely on an Outpatient basis;

Policy Period or Period of Insurance

Preventive Medical Services

Benefits for covered services

Routine Dental Benefits Cover shall be deemed to refer to the following:

1. Lesions of oral cavity

5. Curettage & gum problems

6. Root canal and pulp treatment

7. Extraction (removal - simple & Surgical)

Routine Optical shall be deemed to refer to the following:

Routine Optical with Lenses shall be deemed to refer to the following:

Schedule or Policy Schedule

South East Asia

Surgery or Surgical Operation

7. Diagnostic and therapeutic endoscopic procedures

8. Injection treatment hemorrhoids and varicose veins

11. Normal childbirth

Vaccines & Immunizations

6. Premium adjustments additions/deletions of members and other approved transactions shall be

Clause 2 - Inpatient Benefits

1. Daily Room/Board and Nursing

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

Clause 3 - Outpatient Benefits

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

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

Article 2 - Governing Law and Jurisdiction

Article 4 - Grace Period and Reinstatement

Article 6 - Misstatement of Age

Article 7 - Renewal of Policy

2. Termination of Individual Insurance of a Principal Member

a. If this Policy terminates,

b. If premium payments for his/her insurance are unpaid

3. Termination of Individual Insurance of Dependents

a. If the Insured’s Dependents cease to be eligible as a Dependent

b. If this Policy terminates.

Article 9 - Reporting and Settlement of Claims