Table of Benefits for Dubai and Others Emirates

Group Name THALLIUM CONSULTING

Effective Date 27/May/22

Quote Release Date 0/Jan/00

Category A

Insurance Plan Plan5

Territorial Scope of Coverage Worldwide

Aggregate Annual Limit AED 250,000

Medical Network NEXTCARE RN3 (Out-patient is restricted to Clinics Only)

Room type Semi-Private

Consultation Limit Covered

Parent Accommodation for child under 18 years of age AED 150 / day

Accommodation of an accompanying person in the same room as per recommendation of

AED 150 / day
attending physician, subject to prior approval.

Home Nursing post Hospitalization Covered up to Maximum AED 7,500 per person per annum

Emergency road ambulance services to and from hospital by registered ambulance services
Covered
provider

Deductible per Consultation (will not be applicable for follow-up within 7 days for same treatment
20% max 50
and with same doctor)

Covered up to AAL
Prescribed Drugs & Medicines
Subject to 0% Co-pay

Diagnostics ( X-ray, MRI, CT-Scan, Ultra Sound& Endoscopy diagonistic services ) Covered up to AAL subject to 10% Co-pay

Covered up to the Annual limit subject to the following:

No waiting period applies if evidence of continuity of coverage (COC)

in UAE is provided; otherwise, the limit will be restricted to AED
150,000/- PPPA.

Pre-existing and/or ongoing chronic conditions should be declared as

Pre-existing & Chronic Conditions
per the medical application form (MAF) for all members above 60
years old and for all the groups below 20 members and is subject to
medical underwriting. Undeclared medical conditions will not be
covered during the policy period.

Any form of Cancer shall fall within the definition of Chronic

conditions.

Claims Settlement In-Patient:

1. UAE within the Network- Direct Billing 100% after applicable co-pay

2. Area of coverage as per Territorial Scope / Outside the Network / With or without prior approval of the 80% of actual costs or 80% of the UCR as per UAE network tariffs for
ceding company - Reimbursement basis only same or similar treatment whichever is less

Claims Settlement Out-Patient:

1. UAE within the Network - Direct Billing 100% after applicable co-pay
80% of actual costs or 80% of the UCR as per UAE network tariffs for
2. Area of coverage as per Territorial Scope / Outside the Network - Reimbursement basis only
same or similar treatment whichever is less

Reimbursement in Emergency Cases:

(emergency treatment must be notified within 24 hours if treatment was received within UAE)

Eligible Treatment 100% of incurred costs

UAE 100% of incurred costs
Inside Territorial Scope 100% of incurred costs
Outside Territorial Scope
 Category A

Insurance Plan Plan5

AED 150 per night

Cash Indemnity for In-Patient Treatment post hospitlization up to max of 15 days, subject to
Applicable to all inpatient hospitalizations that are not submitted to
providing discharge summary or proof of hospitalization
the Insurance Company

Essential vaccinations and inoculations for newborns and children as stipulated in the DHA’s Inside Network: 100% Actual Cost
policies and its updates (currently the same as Federal MOH) Outside Network : UCR Basis

Physiotherapy ( Subject to pre-approval) 10 sessions per member per annum

Frequency restricted to:

Preventive services, vaccines and immunizations Diabetes: Every 3 years from age 30
High risk individuals annually from age 18

Diagnostic and treatment services for dental and gum treatments ( Emergency cases Only)
Dental emergency is any injury to your teeth or gums that can put you at a risk of permanent damage, such as Chipped or Covered
broken teeth, Knocked-out tooth ,Soft-tissue injuries and etc

Hearing and vision aids, and vision correction by surgeries and laser ( Emergency cases Only)
Hearing Emergencies include Object/insect in the ear , ruptued eardrum , sudden hearing loss and etc Covered
Vision Emergencies include bleeding or discharge from or around the eye, double vision and Loss of vision, total or partial, one
eye or both etc.

Kidney Dialysis Treatment

Covered up to Maximum AED 20,000 per person per annum
Coverage for hemodialysis or peritoneal dialysis

Healthcare services for work illnesses and injuries as per Federal Law No.8 of 1980 concerning
Covered up to Maximum AED 10,000 per person per annum
the Regulation of Work Relations, as amended, and applicable laws in this respect

Adult Pneumococcal Conjugate Vaccine Covered as per DHA Adult Pneumococcal Vaccination guidelines

Cancer Treatment
Covered as per the Terms,Conditions and Exclusions of the program
Screening, Healthcare Services, Investigations and Treatments only for members enrolled under Patient
defined by DHA.
Support Program only

Hepatitis B & C Virus Screening and Treatment

Covered as per the Terms,Conditions and Exclusions of the program
Screening, Healthcare Services, Investigations and Treatments only for members enrolled under Patient
defined by DHA.
Support Program only

Influenza Vaccine Covered once per Annum

In-Patient, Out-Patient, and Emergency cover up to a maximum of

AED 10,000/- per person per annum.

Psychiatric and Mental Health 20% coinsurance payable by the insured per visit for Out-Patient
services.
No coinsurance is applicable if a follow-up vist is made within seven
days

Covered up to Maximum AED 10,000 per person per annum settled

Repatriation of Mortal Remains to the Country of Domicile:
on Reimbursement basis with no co-pay

This benefit gives members access through NEXtCARE mobile

application to world renowned providers to re-evaluate their earlier
diagnosis, medical history and treatment plan for non-emergency
Second Medical Opinion
cases.
Cardholder is entitled to use the Second Medical Opinion service two
times within the 12 months Policy validity period.
 Category A
Insurance Plan Plan5

In-patient maternity services:

10% coinsurance payable by the insured,
Maximum benefit AED 10,000 per delivery

Requires prior approval from the insurance company or within 24

hours of emergency treatment
10% coinsurance payable by the insured

Out-patient maternity services:

10% coinsurance payable by the insured
maximum 8 visits are allowed (as per applicable network);
Maternity Services
Initial investigations to include:
- FBC and Platelets
- Blood group, Rhesus status and antibodies
- VDRL
- MSU & urinalysis
- Rubella serology
- HIV
- Hep C offered to high risk patients
- GTT if high risk
- FBS , random s or A1c for all due to high prevalence of diabetes in
UAE
Visits to include reviews, checks and tests in accordance with DHA
Antenatal Care Protocols
3 ante-natal ultrasound scans

Dental benefit Limited to AED 1,500/- subject to 20% Co-pay

C overs the following: Consultation & X-Ray, Scaling & Polishing, Tootth Extraction, Amalgam fillings, In-Network: Direct Billing
Temporary and/or permanent composite, fillings and root canal treatment only. Out of Network: Reimbursement

Optical benefit
C overs the following: Optical examinations conducted for the purpose of obtaining eye glasses or
upgrading existing lenses, Consultation by an ophthalmologist, Sight testing, Medication (included within
the optical benefit)
Not covered
Subject to following Sub Limits :
AED 300/- per pair per single vision lenses.
AED 400/- per pair per bifocal or tri-focal vision lenses.
AED 500/- per pair of contact lenses

Limited to AED 2,500 per person per annum

Alternative Medicines
20% coinsurance payable by the insured per visit.
Covers the following: Chiropractic, Osteopathy, Homeopathy, and Ayurveda
No coinsurance is applicable if a follow-up vist is made within seven
days

Organ transplantation shall cover the organ transplantation as

recipient excluding any cost related to donor, and excluding the
Organ Transplant acquisition and organ cost
Organs covered are: heart, lung, kidney, pancreas, liver, Allogeneic &
autologous bone marrow.

Covered as per the Terms,Conditions and Exclusions defined by

New Born Cover
DHA.

This benefit gives members access through NEXtCARE mobile

application to a qualified doctor, for general medical advice and
instructions for self-care or recommendations on medications. For
Medical Advice Service “See A Doctor” (UAE)
users calling from the UAE only, the physician can issue a
prescription for the recommended medications. The service can only
be accessed during the validity period of the policy coverage.

This benefit can be covered subject to the following guidelines:

- Cost of In-Patient treatment at home country is 50% or less

Return Airfare Ticket compared to the cost of the same treatment and applicable network
for In-Patient treatment at home country charges in UAE
- Covered only for the patient (i.e. excluding accompanying persons)
- Only on reimbursement basis, and subject to pre-approval
- Covered up to a maximum of AED 3,000 for the round trip ticket

Cash benefit in case of death

- Applicable only to groups having at least 10 members

- Applicable only to members above age 1 year and below age 65 years only
- 100% of the cash benefit will be payable in the event of death of an Employee
- Only 50% of the cash benefit shall be payable in the event of death of an enrolled Spouse
- Only 25% of the cash benefit shall be payable in the event of death of an enrolled Child

Exclusions:
Life benefits will not be paid if the death was as a result of:
1) Active participation in war, riots, civil disturbances, terrorism, criminal acts, illegal acts or acts against any foreign The following cash benefit shall be payable to a member's declared
hostility, whether war has been declared or not. beneficiary in the event of death:
2) Intentionally caused diseases or self-inflicted injuries, including suicide
3) Chemical or biological contamination, radioactivity or any nuclear material contamination, including the AED 10,000
combustion of nuclear fuel.
4) Passive War Risk:
a) Being in a country, where the UAE government has recommended their citizens to leave (this criterion will apply
regardless of the insured person’s nationality) and advised against ‘all travel’ there; or
b) Travelling to or staying, for a period of more than 28 days per stay, in a country or an area where the UAE
government advise against all but essential travel;
The Passive War Risk exclusions apply regardless of whether the claim arises directly or indirectly as a
consequence of war, riots, civil disturbances, terrorism, criminal acts, illegal acts or acts against any foreign hostility,
whether war has been declared or not.
5) All military engineers during training are excluded, except for mandatory training of UAE nationals as per
government directives

Wellness Benefit Not Covered

Please note that in case benefits fall below the minimum required by DHA or the benefit which is not provided in this TOB and is required by DHA, then the cover under the policy will automatically
increase/include the benefit to the same level as requested by DHA