TOB - Sukoon

HEALTHCARE INSURANCE
TABLE OF BENEFITS
Plan code: SME-OIC-DXB-S8
The Table of benefits is to be read along with the list of exclusions applicable and Oman Insurance
Company P.S.C. ("Sukoon") Glossary.
All amounts are in AED
General Cover
Indemnity Limit 500,000
UAE, Arab Countries, South East Asia & Indian
Basic Territory for Elective & Emergency treatment
sub-continent
Emergency extension cover is limited to Worldwide
excluding USA & Canada for 90 days per year and
Extended Territory for Emergency treatment only 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
Non Pre-existing Chronic Conditions (Subject to
Covered up to Indemnity Limit
Exclusions List)
Elective Treatment
Inside UAE / Inside Network – (Direct Billing) Covered
Inside UAE / Outside Network – (Reimbursement) Covered
Outside UAE / Inside Network – (Direct Billing) Covered
Emergency Treatment
Inside UAE / Inside Network – (Direct Billing) Covered
Inside UAE / Outside Network – (Reimbursement) Covered
Outside UAE / Inside Network – (Direct Billing) Covered
Medical Providers Network

Subject to ongoing changes. Available online at
Signature Network
www.sukoon.com
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
100 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
1 Covered
surgeries.*
SUKOON.COM | +971 4 233 7777 | P.O. Box 5209 | Dubai, United Arab Emirates
١٠٠٢٥٨٥٩٤٩٠٠٠٠٣ :‫ ﺭﻗﻢ ﺍﻟﺘﺴﺠﻴﻞ ﺍﻟﻀﺮﻳﺒﻲ‬٢٤/١٢/١٩٨٤ ‫ ﻟﺪﻯ ﺍﻟﻤﺼﺮﻑ ﺍﻟﻤﺮﻛﺰﻱ ﻟﺪﻭﻟﺔ ﺍﻹﻣﺎﺭﺍﺕ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﻤﺘﺤﺪﺓ ﺑﺘﺎﺭﻳﺦ‬٩ ‫ ﺭﻗﻢ ﺍﻟﻘﻴﺪ‬،٤١٩٥٢ .‫ ﺕ‬.‫ ﺭﻗﻢ ﺱ‬،‫ ﺩﺭﻫﻢ ﺇﻣﺎﺭﺍﺗﻲ‬٤٦١٫٨٧٢٫١٢٥ ‫ﺭﺃﺱ ﺍﻟﻤﺎﻝ ﺍﻟﻤﺪﻓﻮﻉ‬، ("‫ )"ﺳﻜﻮﻥ‬.‫ ﻉ‬.‫ ﻡ‬.‫ﺷﺮﻛﺔ ﻋُﻤﺎﻥ ﻟﻠﺘﺄﻣﻴﻦ ﺵ‬
Oman Insurance Company P.S.C. (“Sukoon”), 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
Classification: OIC-Business
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
Covered
for 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
1
Physiotherapy * prescribed by respective specialist doctor Covered
and administered by a qualified physiotherapist.
Other Benefits
Local Emergency Transportation by Road Ambulance Covered
1
Birth Defects, Genetic Disorders & Congenital Conditions* Not Covered
1
DHA minimum preventive services*
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
1 Covered
mandatory schedule*
Medical Expenses related to Work Related Accidents,
1 Covered up to 5,000 per person per year
Injuries and Illness*
1
Injuries related to Road Traffic Accidents* Not 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:
Diagnostic and treatment services for dental and gum
treatments.
Hearing and vision aids, and vision correction by surgeries Covered
and laser.
Circumcision for new Muslims subject to the following:
The member is insured with Sukoon
The member declared Islam in the Emirate of Abu Dhabi in Not Covered
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)
١٠٠٢٥٨٥٩٤٩٠٠٠٠٣:‫ ﺭﻗﻢ ﺍﻟﺘﺴﺠﻴﻞ ﺍﻟﻀﺮﻳﺒﻲ‬٢٤/١٢/١٩٨٤ ‫ ﻟﺪﻯ ﺍﻟﻤﺼﺮﻑ ﺍﻟﻤﺮﻛﺰﻱ ﻟﺪﻭﻟﺔ ﺍﻹﻣﺎﺭﺍﺕ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﻤﺘﺤﺪﺓ ﺑﺘﺎﺭﻳﺦ‬٩ ‫ ﺭﻗﻢ ﺍﻟﻘﻴﺪ‬،٤١٩٥٢ .‫ ﺕ‬.‫ ﺭﻗﻢ ﺱ‬،‫ ﺩﺭﻫﻢ ﺇﻣﺎﺭﺍﺗﻲ‬٤٦١٫٨٧٢٫١٢٥ ‫ﺭﺃﺱ ﺍﻟﻤﺎﻝ ﺍﻟﻤﺪﻓﻮﻉ‬، ("‫ )"ﺳﻜﻮﻥ‬.‫ ﻉ‬.‫ ﻡ‬.‫ﺷﺮﻛﺔ ﻋُﻤﺎﻥ ﻟﻠﺘﺄﻣﻴﻦ ﺵ‬
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 up to Covered up to the Indemnity Limit
indemnity limit)
Normal Delivery*1 15,000
Medically necessary C-Section*1 15,000
Legal Abortion/Miscarriage*1 15,000
Inside UAE – Outside Network & Abroad. Limit specified is
10,000
an aggregate for all services (Subject to policy deductibles)
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. DOH: A New born will be enrolled to the scheme
from date of birth subject to the notification within
30 days from that date.
ii. DHA: A New born will be enrolled to the scheme
Covered
from 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 20% up to 50/-
Physiotherapy NIL
Diagnostic Services
Laboratory NIL
Radiology NIL
Prescribed Pharmaceuticals
Co-Insurance 20%
Maximum out of pocket limit Not Applicable
Maternity
Delivery Maternity 10%
Outpatient Ante Natal Consultation
10% up to 50/-
Deductible/Coinsurance
Outpatient Ante Natal Investigations Coinsurance 10%
Outpatient Ante/Post-Natal Prescribed Pharmaceuticals (including Ante-Natal Vitamins)
Co-Insurance 10%
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 Nil
Co-Insurance/Deductible
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
Coinsurance (with or without PAR) 30%
Abroad (within agreed territory) (Co-Insurance applies over and above Network
Deductions)
Emergency Abroad
Coinsurance 30%
Elective Abroad
Coinsurance 30%
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 Not Covered
Kidney Dialysis Treatment (Hemodialysis / Peritoneal Dialysis)*1 Not Covered
Hepatitis B and its complications*1 Refer to above DHA benefits
Home Nursing following inpatient treatment. Must be registered
Covered up to 6,000 per person per year,
/ licensed nurse and with doctor’s recommendation
subject to 300 per day
(Reimbursement)
Enhanced Vaccination (All census) – MOH approved vaccines.
Benefit does not include vaccination against internationally or Not Covered
locally recognized epidemics. (Reimbursement)
Psychiatric treatment other than mandated by DOH for Abu
Not Covered
Dhabi schemes (Reimbursement)
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) Not Covered
Passive War Risk (Reimbursement) 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)
Covered tests - Blood examination (CBC,
Blood Sugar, Lipid profile,
HIV, Hepatitis B), Electrocardiogram ECG,
Fundoscopy, Chest X-ray,
Basic Routine Health Check-Up
Urine routine, Stool OP/OB Consultation
with General
Practitioner/Internal Medicine Specialist.
Alternative Medicine (Reimbursement at actual within specified limits)

Enhanced Alternative Medicine – Services To be performed only Covered up to 3,000 per person
by a licensed practitioner per year
Dental Benefit
Routine Dental cover*1 Not Covered
Optical Benefit (Reimbursement at actual within specified limits and coinsurance)
Routine Optical cover*1 Not Covered
Life Insurance Cover – Death due to any cause 50,000
*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
reimbursement for the claim to be considered.
EXCLUSIONS LIST FOR DHA
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.
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.
١٠٠٢٥٨٥٩٤٩٠٠٠٠٣ :‫ ﺭﻗﻢ ﺍﻟﺘﺴﺠﻴﻞ ﺍﻟﻀﺮﻳﺒﻲ‬٢٤/١٢/١٩٨٤ ‫ ﻟﺪﻯ ﺍﻟﻤﺼﺮﻑ ﺍﻟﻤﺮﻛﺰﻱ ﻟﺪﻭﻟﺔ ﺍﻹﻣﺎﺭﺍﺕ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﻤﺘﺤﺪﺓ ﺑﺘﺎﺭﻳﺦ‬٩ ‫ ﺭﻗﻢ ﺍﻟﻘﻴﺪ‬،٤١٩٥٢ .‫ ﺕ‬.‫ ﺭﻗﻢ ﺱ‬،‫ ﺩﺭﻫﻢ ﺇﻣﺎﺭﺍﺗﻲ‬٤٦١٫٨٧٢٫١٢٥ ‫ﺭﺃﺱ ﺍﻟﻤﺎﻝ ﺍﻟﻤﺪﻓﻮﻉ‬، ("‫ )"ﺳﻜﻮﻥ‬.‫ ﻉ‬.‫ ﻡ‬.‫ﺷﺮﻛﺔ ﻋُﻤﺎﻥ ﻟﻠﺘﺄﻣﻴﻦ ﺵ‬
32. Healthcare services for senile dementia and Alzheimer’s disease.
33. Air or terrestrial medical evacuation and unauthorized transportation services.
34. Inpatient treatment received without prior approval from the insurance company including cases of medical
emergency 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.
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.
GROUP HEALTHCARE INSURANCE
PROPOSAL FORM
Please complete this form using black or blue ink. Write in BLOCK LETTERS and tick the relevant items. If your application is
incomplete it might cause a delay. Kindly ensure that you submit a fully filled form together with the signed illustration. The
proposed life assured and policy owner are required to disclose all information requested. Please retain a copy of this
proposal form and other correspondences with us for your future reference.
1. Client Details
1. Company Name
2. Nature of Business
3. No. of Employees
4. Address Building:
Street:
PO Box: City: Country:
Telephone:
5. Contact for Policy Name: Designation:

Administration
Email: Telephone:
2. Eligibility Criteria
Low Salary
Senior Managers Managers Junior/Clerical Band Workers
1. Employee
2. Dependents
3. Claim Reimbursement
What is your preferred choice of payment for medical reimbursement claims? Policyholder Members
1
4. Existing or Previous Medical Insurance Details
Were you insured with Oman Insurance Company P.S.C. (“Sukoon”) in the last 48 months? Yes No
If yes, kindly provide policy numbers
5. Subsidiaries/Subgroups Details
Number of Subsidiaries / Subgroups (in case of no subsidiaries, please fill 0)

Kindly fill the subgroup declaration form and provide trade license of all entities
Do you need financial invoices as per subsidiaries?

(applicable for group tailor-made policies) Yes No
We the undersigned hereby request Sukoon to add below listed entities, which are our branches / subsidiaries / sister
companies / any other business relationship to be filled by Master policyholder (if applicable), as subgroups under the group
healthcare insurance policy issued to us. We hereby confirm that we are fully authorized by the below listed entities to negotiate
terms of the group insurance policy and enter into a contract as master policyholder on their behalf.
S.NO Subgroup Name Address* VAT TRN Number*
** Address and TRN are mandatory for policies where invoices are to be issued per subsidiary. Please attach separate sheet
in case of more subsidiaries.
2
6. Declaration
We the undersigned hereby request Oman Insurance Company (hereinafter referred to as ‘Sukoon’) to issue a Group
Medical Insurance Policy on the lives of all our employees and their eligible dependents and / or on the lives of of eligible insured
persons where eligibility is defined in the quotation as detailed above and in accordance to the terms, exceptions, limitations
and exclusions of the applied medical product/policy and as indicated under quotation number issued on
with Policy commencement date This declaration is completed in respect of
proposed employees joining the Group on or after .
We acknowledge that no liability from the part of Sukoon shall be accepted against medical conditions existent or
originating prior to the inception date of this cover or upon the acceptance of any member under same, unless otherwise
indicated on the Table of Benefits in the quotation bearing the number mentioned above. Furthermore we understand and
accept that failure on our part to notify Sukoon of any such existing medical conditions will be considered
misrepresenation and will prejudice the acceptance of such claims by Sukoon.
We undertake to have already provided all information that Sukoon may reasonably require to underwrite the Policy.
We also undertake that in the case of termination of cover, Sukoon shall retain a portion of the premium corresponding to the
Short Rate Scale as indicated on the insurance policy. We hereby declare that the statements and details provided are true and
accurate and warrant that this Proposal Form and other written statements submitted by us for the purposes of this insurance
shall form the basis of the insurance contract and that non-disclosure or misrepresentation of any fact may lead to the refusal
of any claim or the cancellation of any issued policy.We, on our and each employees/dependent’s/ Insured person’s behalf,
also authorize Sukoon (i) to contact us/employees/dependents/Insured person anytime and through any medium (phone,
email, sms, mail etc.) for purpose of this proposal form/insurance policy (if issued) and/or for keeping me informed about other
products and/or promotion activities (ii) to collect/ process/ store/ transfer/ disclose personal information whether within or
outside the UAE as may be required in relation to underwriting/ issuing/administering/ processing/ reinsuring insurance policy/
claims or as may be required by Sukoon.
We hereby agree to enroll a Dubai visa holder in a DHA compliant and Abu Dhabi /Al Ain visa holder in Department of Health,
Abu Dhabi compliant health insurance policy only. We agree to notify Sukoon as and when any of our insured members change
their residence visa from Dubai to Abu Dhabi / Al Ain or Vice versa to be enrolled under a compliant policy. Finally, we hereby
declare that the statements and details provided are true and accurate and warrant that this Proposal Form and other written
statements submitted by us for the purposes of this insurance shall form the basis of the insurance contract.
I agree to be enrolled for the below additional services: applicable as per the agreed Table of benefits;
Yes No Service Service Provider
Tele consultation services
Assistance & Repatriation
Employee Wellness
Employee Mental Wellness
Any other
By confirming the above enrolment, I/We on our and each employee/dependent/insured member’s behalf fully authorize (i)
Sukoon to share the insured member(s) personal and contact details with the service providers to enable them to enroll,
contact, and provide services and (ii) the service provider(s) to collect/process/ store/ transfer personal information whether
within or outside the UAE as may be required in relation to these services. This authorization will remain valid until I do not
renew the above service(s).
Date (dd/mm/yy) Place of Signing
Signature & Seal (Name & title of authorised official)
3
Documentation Checklist
Group Healthcare Insurance
Administrative Requirements (all Emirates)

Complete form as requested, sign and stamp.
Confirm ‘quotation number’ and ‘policy commencement date’.
Group Application Form Confirm Reimbursement Claim Settlement Method

OIC’ system is configured to settle reimbursement claims under the
‘principal member name’. You need to declare if claims are to be
reimbursed under Company name.
Provide a valid copy of your company Trade License.
When more than one company is involved, a declaration letter from
Valid Trade / Commercial
Master Policy Holder is required listing all the subsidiaries along with
License Copy
copies of their respective trade licenses.
Renewed Trade License copies are required at the time of renewal.
Credit Questionnaire Complete the Form if you need to apply for credit terms.
Employees List (all Emirates)

Use the ‘Census’ document to provide the employees list details
respecting the Excel sheet requirements and formats. Please fill all
Census List
the fields highlighted as mandatory to comply with legal requirements
and OIC standards.
Provide photos for each member respecting the following:
One passport size picture per member
Picture should be in JPEG format
File name should be unique and as per the following format:
“Employee Number-First name”
Photographs Save all pictures in one folder called “Pictures”
Name of each picture must match the ‘Photo File Name’
column in the Census List
Note: If the above is not strictly respected, the process to issue
medical card will take longer.
Extra Requirements for Groups Below 9 Employees and/or below 50 members and/or members
above 65 years
Passport & Visa Copy Provide Passport copy and valid Visa page copy for each member.
Individual Enrollment
Completed, signed and stamped by each proposed members.
Form
Extra Requirements for Abu Dhabi. For DHA Essential Basic Plan only Workers List required.
Workers List As per the Ministry of Labor records.
Insurance Continuity
From the previous insurers. Please specify the certificate expiry date.
Certificate
 :‫ رﻗﻢ اﻟﺘﺴﺠﯿﻞ اﻟﻀﺮﯾﺒﻲ‬‫ ﻟﺪى اﻟﻤﺼﺮف اﻟﻤﺮﻛﺰي ﻟﺪوﻟﺔ اﻹﻣﺎرات اﻟﻌﺮﺑﯿﺔ اﻟﻤﺘﺤﺪة ﺑﺘﺎرﯾﺦ‬‫ رﻗﻢ اﻟﻘﯿﺪ‬،.‫ ت‬.‫ رﻗﻢ س‬،‫ درھﻢ إﻣﺎراﺗﻲ‬٫٫‫رأس اﻟﻤﺎل اﻟﻤﺪﻓﻮع‬، ("‫)"ﺳﻜﻮن‬.‫ ع‬.‫ م‬.‫ﺷﺮﻛﺔ ﻋﻤﺎن ﻟﻠﺘﺄﻣﯿﻦ ش‬
A CORPORATE WELLNESS
PROGRAM FOR A
HEALTHIER WORKFORCE
Your partner for health

LivFit is a turnkey comprehensive wellness solution that HR Managers can use to help employees make positive
lifestyle choices. Exclusively designed for healthcare policyholders at Oman Insurance Company P.S.C. ("Sukoon"),
LivFit empowers individuals to take charge of their physical and mental well-being.
What is LivFit? Key benefits for you

It is a free corporate wellness program that comes It can be hard for an organization to dedicate time and
automatically with our healthcare insurance plans. money to develop an internal wellness program. LivFit
With LivFit, your employees will get to choose from a will help you overcome this challenge. It gives you all
variety of programs to help them with their health and the benefits and none of the hassles.
fitness goals, including weight management, exercise,
• Free for all. It is automatically included in your
stress management and tobacco cessation.
healthcare insurance plan.
To start the wellness journey, employees will take the • Ready to use. You only need to communicate it to
online health survey, receive personalized report and your employees, we will do the rest.
discuss their goals with our wellness coach. They can • Comprehensive solution. It includes all aspects to
then track their fitness plan via our mobile app, like our empower employees take charge of their wellness.
facebook page, enjoy free group classes, participate • Easy to access. All the elements of the program are
in self-improvement workshops, and get discounts on centralized on www.livfit.ae
wellness products.
It’s time to Take Charge.

Are you ready?
www.livfit.ae
Like us on /MyLivfitSpace
Follow us on /MyLivfitSpace
LivFit at a glance
KNOW YOUR HEALTH GET INSPIRED
Health Report Checkups Wellness Coach Social Engagement

Take the health Prevent illnesses with Discuss your wellness Follow us, get inspired &
assessment survey to get discounted screenings. journey path. share your success.
your personal report.
TAKE CHARGE
Wellness Awareness Challenges
Visit livfit.ae for articles Push yourself,
and tips on health & compete with peers &
wellness. have fun.
LivFit App Gym Facilities

Download ‘LivFit Take advantage of free
Wellness’ app to track trials & discounted
your fitness plan. gym packages.
OFFERS &
DISCOUNTS Partner Offers
Enjoy discounts on
various wellness
Group Classes Star Program products.
Participate in free Lose weight and
weekly fitness classes. get part of the cost
sponsored.
ACTIVATE WELLNESS
Visit www.livfit.ae
Download the ‘Livfit Wellness’ App
Like us on /MyLivfitSpace
Tobacco Cessation Stress Management Follow us on /MyLivfitSpace
Stop smoking… Attend seminars to cope Participate in Lifestyle Programs
before it’s too late. with pressure & balance Email us info@livfit.ae
your life. Call 04 230 2737
GROUP LIFE ASSURANCE RIDER (FOR MEDICAL SME
PRODUCT IN UAE)
Policy Number: OIG- Effective Date: DD/MM/YYYY
This Rider is a part of the Policy to which it is attached and takes effect on the effective date shown above.
Lives Assured Covered : All members of the Policy

Scope of Coverage : 24 hours worldwide
Principal Sum : AED 50,000 per member
Benefits Covered : Death any cause
Age Limit : 65 years
Death (Due to any cause)

In the event of Death (natural or accidental) of the Life Assured, the Company agrees to pay the Principal Sum
of that Life Assured under this Rider.
Limitations
The benefit under this Rider shall be paid only for Losses:
a) Occurring after the effective date of this Rider.
b) Occurring prior to the 65th birthday of the Life Assured.
c) Occurring prior to any default in the payment of a premium under said Policy or within the grace
period allowed in said Policy for such payment.
Exclusions
- Active War, warlike operations (whether war is declared or not, conventional, biological, chemical or
nuclear), invasion, acts of foreign enemies, hostilities, acts of terrorism, terrorist sabotage, rebellion,
mutiny, civil commotion, civil war, revolution, insurrection, military or usurped power, martial law,
embargo, or any act committed by any person or persons for the purpose of overthrowing a
government by violent force or to influence political decision making. Active terrorism (suspected or
proven) shall be understood to include the consequences of hostage taking, drive-by shooting,
planting of bombs, and any other form of physical violence.
- In the event of loss, damage, cost or expense directly or indirectly caused by, contributed to by,
resulting from or arising out of or in connection with biological, chemical, or nuclear explosion,
pollution, contamination and/or fire following thereon.
- Injuries contracted or sustained while violating or attempting to violate the law, or committing an
assault, or resisting arrest.
‫ﺭﻗﻢ ﺍﻟﺘﺴﺠﻴﻞ‬٢٤/١٢/١٩٨٤ ‫ ﻟﺪﻯ ﺍﻟﻤﺼﺮﻑ ﺍﻟﻤﺮﻛﺰﻱ ﻟﺪﻭﻟﺔ ﺍﻹﻣﺎﺭﺍﺕ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﻤﺘﺤﺪﺓ ﺑﺘﺎﺭﻳﺦ‬٩ ‫ﺭﻗﻢ ﺍﻟﻘﻴﺪ‬،٤١٩٥٢ .‫ ﺕ‬.‫ﺭﻗﻢ ﺱ‬،‫ﺗﻲ‬
‫ﺩﺭﻫﻢ ﺇﻣﺎﺭﺍ‬٤٦١٫٨٧٢٫١٢٥ ‫ﺭﺃﺱ ﺍﻟﻤﺎﻝ ﺍﻟﻤﺪﻓﻮﻉ‬، ("‫ )"ﺳﻜﻮﻥ‬.‫ ﻉ‬.‫ ﻡ‬.‫ﻋﻤﺎﻥ ﻟﻠﺘﺄﻣﻴﻦ ﺵ‬
ُ ‫ﺷﺮﻛﺔ‬
١٠٠٢٥٨٥٩٤٩٠٠٠٠٣ :‫ﺍﻟﻀﺮﻳﺒﻲ‬
Passive War Risk Extension
Passive War and/or Passive terrorism as an innocent bystander is covered for death benefit, however; Passive
war is excluded in Iraq, Afghanistan& Syria and any other country where war or war like operation takes
place. It is also excluded for any member who travels to any country where war has been declared or war like
operations takes place and remains there for more than 28 days following the outbreak.
Notice of Claim
Written notice of a claim under this Rider must be given to the Company within thirty (30) days after the date of
death of the Life Assured. Failure to furnish notice of claim to the Company within the above time limit shall
not invalidate the claim if it shall be shown not to have been reasonably possible to give such notice within
the time limit and that notice was given as soon as was reasonably possible.
‫ﺭﻗﻢ ﺍﻟﺘﺴﺠﻴﻞ‬٢٤/١٢/١٩٨٤ ‫ ﻟﺪﻯ ﺍﻟﻤﺼﺮﻑ ﺍﻟﻤﺮﻛﺰﻱ ﻟﺪﻭﻟﺔ ﺍﻹﻣﺎﺭﺍﺕ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﻤﺘﺤﺪﺓ ﺑﺘﺎﺭﻳﺦ‬٩ ‫ﺭﻗﻢ ﺍﻟﻘﻴﺪ‬،٤١٩٥٢ .‫ ﺕ‬.‫ﺭﻗﻢ ﺱ‬،‫ﺗﻲ‬
‫ﺩﺭﻫﻢ ﺇﻣﺎﺭﺍ‬٤٦١٫٨٧٢٫١٢٥ ‫ﺭﺃﺱ ﺍﻟﻤﺎﻝ ﺍﻟﻤﺪﻓﻮﻉ‬، ("‫ )"ﺳﻜﻮﻥ‬.‫ ﻉ‬.‫ ﻡ‬.‫ﻋﻤﺎﻥ ﻟﻠﺘﺄﻣﻴﻦ ﺵ‬
ُ ‫ﺷﺮﻛﺔ‬
١٠٠٢٥٨٥٩٤٩٠٠٠٠٣ :‫ﺍﻟﻀﺮﻳﺒﻲ‬
YOUR EMIRATES ID IS NOW YOUR
MEDICAL INSURANCE CARD!
To simplify experience of accessing medical care, Sukoon does not

print medical cards any more. You can present your Emirates ID or
eCard at our healthcare provider locations.
To access your eCard, please log on to medical.sukoon.com

or download mySukoon app on your smartphone.

TOB - Sukoon

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HEALTHCARE INSURANCE

Plan code: SME-OIC-DXB-S8

Medical Providers Network

Inpatient Benefits – with PAR

Basmah Initiative – The Patient Support Program (PSP)

Alternative Medicine (Reimbursement at actual within specified limits)

Excluded (non-basic) healthcare services

Healthcare services outside the scope of health insurance (In

PO Box: City: Country:

5. Contact for Policy Name: Designation:

Number of Subsidiaries / Subgroups (in case of no subsidiaries, please fill 0)

Do you need financial invoices as per subsidiaries?

S.NO Subgroup Name Address* VAT TRN Number*

Tele consultation services

Assistance & Repatriation

Employee Mental Wellness

Date (dd/mm/yy) Place of Signing

Signature & Seal (Name & title of authorised official)

Administrative Requirements (all Emirates)

Group Application Form Confirm Reimbursement Claim Settlement Method

Employees List (all Emirates)

Your partner for health

What is LivFit? Key benefits for you

It’s time to Take Charge.

KNOW YOUR HEALTH GET INSPIRED

Health Report Checkups Wellness Coach Social Engagement

LivFit App Gym Facilities

Lives Assured Covered : All members of the Policy

Death (Due to any cause)

a) Occurring after the effective date of this Rider.

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

To simplify experience of accessing medical care, Sukoon does not

To access your eCard, please log on to medical.sukoon.com

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