Description of Benefits Extent of Cover

International
Level of Cover
Health Plan Company Experience

Plan Gold Gold 2

Annual Maximum Limit - Maximum Benefit

SAR 7,500,000 / USD 2,000,000
Limit Per Member Per Insurance Period

In-patient and Day-case coverage

Length of in-patient and day-case stays: the pre-authorisation will specify an approved length of stay
for in-patient and day-case treatment. This is the number of days in hospital that will be covered. If the
treatment will take longer than this approved length of stay, then you or your consultant must contact
Bupa for an extension to the pre-authorisation.

No pre-authorisation is required inside the KSA except for services with sub-limits (such as dental,
optical, maternity services etc.)

In-patient and day-case treatment, as follows:

Surgical operations, including pre- and post- Covered

operative care
Nursing care, medicines and medical
supplies
Paid in full up to annual maximum limit
Theatre charges; Intensive Care (ICU); and
Emergency Room (ER)
Pathology, X-rays, diagnostic tests

Hospital Accommodation Inside the KSA:

Standard Suite

Outside the KSA:

Standard single room with private bathroom

Costs of accommodation for one companion

during a hospital stay when medically necessary
as assessed by the attending physician, or by a Paid in full up to annual maximum limit
parent accompanying a child up to age 18 years

Out-patient coverage

This is treatment which does not normally require a patient to occupy a hospital bed.

CR No.: 4030178881
Paid up capital: SAR 1,200,000,000

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Out-patient diagnosis and treatment, as follows:

Out-patient surgical operations

Pathology, X-rays and other diagnostic tests
e.g. EEG, EMG, NCV, ECG, to investigate
the cause of symptoms
Consultation fees for General
Practitioners/Specialists/Consultants/Physici
ans, including follow-up visits and referral
for the same illness
Prescribed medicines and other medical Paid in full up to annual maximum limit
necessities, such as dressings (excluding

which are covered under their own benefit);

Accident-related dental treatment received
from a dental practitioner
Note: See Annex 3 section 17 Third
Party Liability, in the event that you need
treatment after an accident caused by
someone else.

Pre-authorisation approval As per standard protocol

Out-patient co-insurance/co-payment Inside the KSA:

(Deductible)
Nil

Outside the KSA:

Nil

Further coverage

These are the additional benefits provided by your membership of the Company plan. These benefits
may be in-patient, day-case or out-patient treatments.

Inside the KSA:

Provider Network level NW7

Outside the KSA:

Bupa Network

Advanced imaging e.g. MRI, CT and PET scans Paid in full up to annual maximum limit

Basic or standard artificial limbs, appliances and

prosthetic implants.

See later for the list of Appliances and Devices

Paid in full up to annual maximum limit
(No. 15)

Excludes prosthetic hearing aids see separate

CR No.: 4030178881
Paid up capital: SAR 1,200,000,000

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benefit

Cancer treatment e.g. tests, scans, Paid in full up to annual maximum limit
consultations, and medicines

Congenital illness

This covers treatment for a congenital condition,

weakness or deformity that is life threatening,
and where you require treatment in accordance Paid in full up to annual maximum limit
with a medical report issued by the health facility
approved by the Council in the KSA, or by any
authorised party/facility elsewhere in the world

Dental treatment, including:

routine treatment (such as fillings, We pay up to SAR 5,625 / USD 1,500 each
extractions, root canal treatment, insurance period
pulpotomy),
preventive treatment (such as X-rays, gum Out-patient co-payment applies
treatment),
medication (such as antibiotics)

Optical Spectacles

This includes the cost of frames and prescribed

spectacle lenses (basic prescription lenses
without additional features, such as UV
protection and/or anti-reflection)
Paid in full up to SR 5,000 / USD 1,333
Optical treatment, including:
Out-patient co-payment applies
One routine eye test each insurance period.
Costs of contact lenses (basic prescription
lenses without additional features such as, UV
protection or anti-reflection)

Dialysis as part of renal failure treatment Paid in full up to annual maximum limit

Emergency treatment received at a healthcare Inside the KSA:

provider that is not in the Bupa Network.
100% of costs covered up to annual maximum limit
Emergency means a serious medical condition (settlement of costs by reimbursement after
or symptoms resulting from a disease, illness or treatment)
injury which arises suddenly and, in the
judgment of a reasonable person, requires Outside the KSA:
immediate treatment, generally within 48 hours
100% of costs covered up to annual maximum limit.
of onset, and which would otherwise put your
You must notify Bupa Arabia/Bupa Global within 48

CR No.: 4030178881
Paid up capital: SAR 1,200,000,000

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health at risk. hours of hospitalisation

Emergency medical treatment (unplanned) in

the USA
Choice of:
See later for details -
applying to the Table of Benefit We pay up to SAR USA Full Covered
187,500 / USD 50,000
up to a maximum of 30
days each insurance
period

Healthline services Included

Local road ambulance for emergency cases

only. This covers transportation from hospital to
hospital based on your medical needs and by Paid in full up to annual maximum limit
the hospital ambulance

Local air ambulance for emergency cases only Paid in full up to the annual maximum limit

Maternity Services see below

This includes:

normal pregnancy (antenatal) care Paid in full up to SR 100,000 / USD 26,666

normal delivery (postnatal) care
rouine nursing care for newborn baby (from
day one)

Maternity complications, including:

miscarriage Covered
caesarean section (CSD)
haemorrhages Paid in full up to annual maximum limit
ectopic pregnancy
medically necessary termination (legal
abortion)

Neonatal / Newborn cover

Inside the KSA:

CR No.: 4030178881
Paid up capital: SAR 1,200,000,000

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 We pay for routine care for the baby for up to 28

benefit. From day 29 following birth, the baby must

be enrolled under the plan before you can claim for
any benefits under their own policy.

Outside the KSA:

We pay for routine care for the baby (during first 90

days of life)

For any non-routine care (excluding for premature

babies see below), NEWBORN CARE benefit
applies: we pay up to SAR 560,000 / USD 150,000.
This is paid instead of any other benefit for all
treatment required by a newborn child during the
first 90 days following birth. Children must be
enrolled under the plan before you can claim for
this benefit.

Treatment of premature babies, including: Inside the KSA:

incubation and Paid in full up to annual maximum limit from birth

all related care outside of normal nursing while the mother is still confined after delivery
care
while the mother is still confined after delivery Outside the KSA:

NEWBORN CARE benefit applies see above

Mental Health Conditions

Acute psychiatric treatment

This covers diagnosis and treatment of the We pay up to SAR 15,000 / USD 4,000 each
condition for in-patient, day-case and out-patient insurance period
treatment

Mental Health Conditions

Non-acute psychiatric treatment.

This covers consultants, psychologists and / or We pay up to 30 visits each insurance period

for both in-patient, day-case and out-patient

treatment

Non-emergency (elective) treatment received at Inside the KSA:

a healthcare provider that is not in the Bupa
Network Based on 100% of customary prices of Network
hospitals in Network level NW7

Outside the KSA:

CR No.: 4030178881
Paid up capital: SAR 1,200,000,000

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 Reasonable and customary costs, meaning the
costs charged should not be more than would
normally be charged and are representative of
charges for the same treatment in the same area

Physiotherapy when medically necessary.

This covers physiotherapy sessions for you to Paid in full up to annual maximum limit
fully regain the function as approved by your
doctor/physician Out-patient co-payment applies

Pre-existing and chronic conditions Covered

Preventive tests - Full health screening,

including cholesterol, blood pressure, diabetes,
anaemia, lung function, cardiac risk assessment
and hearing tests

Preventive tests Wellness, meaning only the

Paid in full up to annual maximum limit
following four tests:
Out-patient co-payment applies
mammogram
cervical smear test
prostate cancer screening or
colon cancer screening

Rehabilitation (physiotherapy)

This covers the cost of your physiotherapy Paid in full up to annual maximum limit
sessions with a target to achieve the most
achievable function

Repatriation of mortal remains to your home

country in the case of your death while you
away from home

This means we pay for reasonable costs for the We pay up to SAR 10,000 / USD 2,666 each
transportation only of your body or cremated insurance period
mortal remains to your home country, or to the
country you specified as your country of
residence, subject to airline requirements and
restrictions. Claims will be paid on
reimbursement only (pay and claim)

Hearing aids when requested by a licensed

physician.
We pay up to SAR 6,000 / USD 1,700 each
For example, cochlear implant (prosthetic insurance period

CR No.: 4030178881
Paid up capital: SAR 1,200,000,000

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implant)

- We pay up to SAR 150,000 / USD 562,500 each

congenital) heart valves insurance period

This includes any drug treatment required for We pay up to SAR 15,000 / USD 4,100 each
the condition. insurance period

Autism treatment
We pay up to SAR 50,000 / USD 13,333 each
This includes any drug treatment required for insurance period
the condition.

Cost of early screening for newborns National Inside the KSA:

program in the KSA for early diagnosis of
newborns to alleviate disabilities We pay up to SAR 100,000 / USD 27,000 each
insurance period

Outside the KSA:

Not covered

Disability cases:

These are cases which have been diagnosed

and concluded as long term or permanent
disabilities.

Examples of disabilities: Paid in full up to annual maximum limit

Post-Polio syndrome
Amputation
Neural tube defects and consequent
disability
Spinal cord injury and consequent disability
Traumatic Brain Injury and consequent
disability
All forms of paralysis (Quadriplegia,
Hemiplegia, Paraplegia, hemiplegia )
Muscular Dystrophy (MD)
Cerebral Palsy
Examples of services included are:
All forms of musculoskeletal assistance
such as crutches, wheel chairs, prosthesis,
other mobility aids and physiotherapy
rehabilitation.
Medications used to treat
Botox injections for CP
Surgical release of spastic CPs
Any corrective surgical procedure for
deformities leading to physical disability.

CR No.: 4030178881
Paid up capital: SAR 1,200,000,000

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Cost of circumcision (for males) We pay up to SAR 500 / USD 140 each insurance
period

Cost of ear piercing (for females) We pay up to SAR 300 / USD 80 each insurance
period

Cost of obtaining /

We pay donor expenses, for each condition

needing a transplant whether the donor is a
member or not, including: We pay up to SAR 50,000 / USD 13,333 each
insurance period
- the harvesting of the organ, whether from
live or deceased donor
- hospital/operation costs of the donor
- any donor complications (which is related to
the donation procedure)
- out-patient treatment costs of the donor
received before or after the transplant
(which is related to the transplant
procedure)
Transplant of organ or bone marrow.

This covers cornea, small bowel, kidney,

kidney/pancreas, liver, heart, lung, or heart/lung
transplant. It also covers bone marrow transplants
(either using own bone marrow or that of a compatible
donor) and peripheral stem cell transplants, with or Paid in full up to annual maximum limit
without high dose chemotherapy.

Costs associated with the donor or the donor organs

are not covered under this benefit (see above -

drugs prescribed for use as an out-patient, including

anti-

Treatment for contagious or endemic diseases Covered - Treated as any other condition or
sickness

Young child care Covered (for complete MOH list) for children up to
but not including age 6 years old
We pay the following benefits for children up to
but not including age 6 years of age under the Inside the KSA:
plan.
Paid in full up to annual maximum limit
This includes:
Outside the KSA:
- routine preventive care and checkups; Paid in full up to annual maximum limit
- vaccinations and inoculations, as per the KSA
Ministry of Health (MOH) Schedule and
regulations which is available on request.

All vaccinations are optional for children

CR No.: 4030178881
Paid up capital: SAR 1,200,000,000

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Artificial milk &milk products Covered for new babies until 24 months if its
medically indicated

Isolation
Covered for Infectious diseases

Respiratory Syncitial Virus Covered according to the newly developed

Guidelines

Newborn congenital heart anomalies screening

Covered using pulse oximetry

Covered for new babies but after using OtoAcoustic

Newborn screening hearing test Emission test (OAE)

Obesity Covered up to SAR 20,000 / USD 5,333 only for

sleeve gastrectomy if BMI > 45

Optional benefits, if purchased

USA cover Covered

See later for details - 100% of costs in

network

80% of costs out of

Not Covered network

Treatment must be pre-

authorised

Assistance cover (Evacuation and

Repatriation)
The overall annual maximum benefit limit does not
See later for details - apply.

Additional Benefits

CR No.: 4030178881
Paid up capital: SAR 1,200,000,000

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 Substance Abuse treatment 100% of eligible expenses

Allergies & Allergic Disorders. 100%

Developmental problems including learning

100% after $10
difficulties, behavioural problems related to
co-payment per visit
physical development

Medications covered under the outpatient prescription

Family Planning & Contraception benefit drug benefit. Other
services covered same as any other condition.

80% of eligible
Hearing test
expenses

Same as any other

HIV/AIDS drug therapy including ART
condition

100% after $10

Home nursing after in-patient treatment
co-payment per visit

100% of eligible
Hospice and palliative care
expenses

CR No.: 4030178881
Paid up capital: SAR 1,200,000,000

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