Category 3 - TOB 2

Table of Benefits
Healthcare Insurance
The Table of benefits is to be read along with the list of exclusions applicable and Sukoon’s Glossary.
All amounts are in AED

General
Cat 3
Eligibility Criteria Employee + Dependents
Regulatory DHA
Indemnity Limit 250,000/-
Basic Territory for Elective & Emergency treatment Worldwide
Extended Territory for Emergency treatment only Worldwide
Home Country Covered if within basic territory
Pre-existing conditions (Subject to Exclusions List)

If the waiting period is applicable, cover will be provided to pre- Covered
existing conditions that develop into an emergency within the 6
month exclusion period.
Chronic Conditions (Subject to Exclusions List) Covered
Elective Treatment
Inside UAE / Inside Network – (Direct Billing) Covered
Inside UAE / Outside Network – (Reimbursement) Covered
Outside UAE (Within covered Territory) Reimbursement
Emergency Treatment
Inside UAE / Inside Network – (Direct Billing) Covered
Inside UAE / Outside Network – (Reimbursement) Covered
Outside UAE (Within covered Territory) Reimbursement
Medical Providers Network

Signature Network + Medcare Women & Children Hospital (Only
Maternity – IP/OP)
Subject to ongoing changes.
Available online at www.omaninsurance.ae
Inpatient Benefits – with PAR
This is a computer-generated document and does not require signatures or the company stamp.
SUKOON.COM | +971 4 233 7777 | P.O. Box 5209 | Dubai, United Arab Emirates
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Classification: :‫ 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
Sukoon-Business
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
Cat 3
Room Accommodation Private room
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 to
Covered
the age of 18 years.
Accommodation Costs for one accompanying family member in
case of critical medical conditions. *1 Covered
Subject to treating doctor recommendation
Daycare treatment including out-patient minor surgeries > 6
Covered
hours stay.
Internal Prosthetic devices implanted during covered surgeries.
Covered
*1
Outpatient Benefits
Cat 3
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 Covered
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 and
Covered
administered by a qualified physiotherapist.
Other Benefits
Cat 3
Local Emergency Transportation by Road Ambulance Covered
Birth Defects, Genetic Disorders & Congenital Conditions *1 50,000 pppy
1
DHA minimum preventive services *
i. Diabetes screening Covered
ii. Hepatitis C Virus Screening and treatment Covered
iii. Basmah Initiative Covered
iv. Adult Pneumococcal Conjugate Vaccine (as per DHA
Covered
guidelines) reference PD07/2018
v. Hepatitis B Virus Screening and treatment (To be
followed as per the guidelines laid out in the Covered
Hepatitis B program)
vi. Influenza Vaccine (once in a year) Covered
Basic Vaccination: Vaccines for Children (0-6) as per MOH
Covered
mandatory schedule*1
Medical Expenses related to Work Related Accidents, Injuries,
Covered
and Illness*1
1
Injuries related to Road Traffic Accidents* Covered
Hepatitis A Covered
Immunotherapy & Immunomodulators Covered only if medically necessary
Hormone replacement therapy. (Excluding growth hormone and
Covered
excluded medical conditions)
Ophthalmology: Medical conditions related to it (Illness/Injury) of
Covered
the eye excluding vision, sight test & refraction error.
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Classification:٩٠٠٠٠٣ :‫ 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
Sukoon-Business
Recreational non-hazardous sports activities (professional and
hazardous sports activities even if recreational are not covered).
Covered
For Dubai policies, Hazardous activities if not related to
professional sports are 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 Abu Dhabi Not Covered
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 area
Covered
specified) (Reimbursement)
Maternity & New-Born
Cat 3
A. Maternity (Limits & Coverage)
Visits to include reviews, checks & tests in accordance with
DHA Antenatal Care
Inside UAE – Inside Network Covered
Ante Natal Consultation Covered
Ante Natal Investigations Covered

Maternity complications
(Life threatening maternity complications are covered up to AED 20,000
150,000)
Normal Delivery *1 15,000
Medically necessary C-Section *1 20,000
1
Legal Abortion/Miscarriage * 20,000
Inside UAE – Outside Network & Abroad. Limit specified is an
20,000
aggregate for all services (Subject to policy deductibles)
B. New-born Cover
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 opted for allows Covered
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 from date
Covered
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
Cat 3
2
A. Inside UAE – Inside Network *
Inpatient Services & Daycare cases/surgeries
Coinsurance Nil
Maximum copay amount per encounter N/A
Annual aggregate maximum copay amount N/A
Outpatient
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Sukoon-Business
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 N/A
Maternity
Inpatient Maternity 10%
Delivery 10%
Outpatient Ante/Post Natal Consultation Deductible/Coinsurance 10%
Lab: 10%
Outpatient Ante/Post Natal Investigations Coinsurance
Rad: 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 N/A
Additional Benefits (If opted)

Dental Co-Insurance (Opted level) 20%
Optical Co-Insurance (Opted level) Nil
Alternative Medicine Co-Insurance (Opted level) Nil
B. 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% Coins

Basis of Claims Settlement Actual
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) 20% Coins

Basis of Claims Settlement Network Tariff
C. Abroad (within agreed territory) – Co-Insurance applies

over and above network deductibles
Emergency Abroad
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Sukoon-Business
Coinsurance 0% Coins
Elective Abroad
Coinsurance 20% Coins
Optional Benefits
Cat 3
Patient treatment supplies (Reimbursement) Not Covered
Organ transplant (excluding donor’s expenses) *1 Covered
Kidney Dialysis Treatment (Hemodialysis / Peritoneal Dialysis) *1 Covered
Hepatitis B & C and its complications*1 Covered
Elective Vitamins/Supplements prescribed by relevant physician Not Covered
Home Nursing following inpatient treatment. Must be registered /

licensed nurse and with doctor’s recommendation Covered
(Reimbursement)
Enhanced Vaccination (All census) – MOH approved vaccines.

Benefit does not include vaccination against internationally or Not Covered
locally recognized epidemics. (Reimbursement)
IP: 8500 pppy
Psychiatric treatment other than mandated by DHA Dubai OP: 1500 pppy (with 20% coinsurance for both IP & OP)
schemes (Reimbursement)
Allergy testing (Reimbursement) Not Covered

External Prosthetic devices and medical equipment
Covered
(Reimbursement)
Infertility treatment. (Reimbursement) Not Covered
Medically indicated deviated nasal septum *1 Covered
Cash indemnity benefit (Reimbursement) 750 per day for maximum of 20 days
Passive War Risk (Reimbursement) Not Covered
Trudoc Telehealth
- Free consultation Covered
- No booking of appointments is required
In-patient Rehabilitation Covered

Papanicolaou Test Covered
Reconstructive Surgery (if medically necessary) Covered
Oral & Maxillofacial Surgery (if medically necessary) Covered
Bone Densitometry *1 Covered
Circumcision (for new-born male within 2 years of birth) Covered
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Sukoon-Business
Sexually Transmitted Infection (STD/STI) – excluding screening
Covered
tests
Acne Treatment (if medically necessary & not related to

Covered
cosmetics)
Warts (if medically necessary & not related to cosmetics) Covered
Sleep Disorders*1 Covered
Varicose veins, Varicocele, hydrocele (if medically necessary) Covered
Hysterectomy (if medically necessary) Covered
Palliative Care *1 & *3 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 up to AED 2,500 pppy

Wellness Health Check-Up
(With 10% copayment)
Alternative Medicine (Reimbursement at actual within specified

limits and coinsurance)
Basic Alternative Medicine Refer to below
Enhanced Alternative Medicine 1,500/- pppy
Dental Benefit (Limit is exclusive of its coinsurance
Routine Dental*1 2,000/- pppy

1
Enhanced Dental* Not Covered
Optical Benefit (Reimbursement at actual within specified limits

and coinsurance)
Basic Optical AED 500/- pppy
Enhanced Optical
Not Covered
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 included cancer types are Breast, Colorectal and Cervical cancer. Screening is strictly as per MOHAP guidelines and protocols.
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Sukoon-Business
Prior to this scheme, cancer coverage was limited to the annual limit, or the pre-existing 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.
LivFit - A free wellness program for a healthier workforce

LivFit is a turnkey comprehensive wellness solution that will help your employees to make positive lifestyle choices Sukoon. It is a free
program that will allow your employees to take charge of their physical and mental wellbeing. Your employees will be able to enjoy the below
benefits.
Health Report Take the heath assessment to get the personal report
Checkups Discounts on general and disease specific checkups
Wellness Coach Discuss the health report with the coach, learn about lifestyle programs and get a personal fitness plan
Challenges Take part in different corporate challenges which can be tracked via the mobile app
Mobile App Track moves and follow the personal fitness plan
Gym Facilities Enjoy free trails and discounted gym packages
Group Classes Participate in free weekly fitness classes
Star Program Lose weight and get part of the cost sponsored
Tobacco Cessation Seminars to help people stop smoking
Stress Management Seminars to cope with pressure
Wellness Awareness Read articles on different health and wellness related topics
Offers and Discounts Enjoy discounts on various wellness products.
Visit www.livfit.ae to know more about the program. All terms and conditions of the program are available on the website.
* 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
* 3 In-patient, Daycare or Out-patient treatment following the diagnosis by the treating physician that the condition is terminal
wherein terminal means that medical treatment cannot further cure the condition with Restricted Life Expectancy of 12 months.
Included within the benefit we will pay for Supportive physical care, psychological care as well as hospital or hospice
accommodation, nursing care and prescription drugs. This benefit should be provided in accordance to the actively at work
clause. Benefit is limited to 30 days lifetime
This table of benefit is to be read along with list of exclusions and Sukoon Insurance Company glossary
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Sukoon-Business

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Table of Benefits

All amounts are in AED

Basic Territory for Elective & Emergency treatment Worldwide

Extended Territory for Emergency treatment only Worldwide

Home Country Covered if within basic territory

Pre-existing conditions (Subject to Exclusions List)

Chronic Conditions (Subject to Exclusions List) Covered

Inside UAE / Outside Network – (Reimbursement) Covered

Outside UAE (Within covered Territory) Reimbursement

Inside UAE / Outside Network – (Reimbursement) Covered

Outside UAE (Within covered Territory) Reimbursement

Medical Providers Network

Inpatient Benefits – with PAR

Ante Natal Investigations Covered

Inpatient Services & Daycare cases/surgeries

Maximum copay amount per encounter N/A

Annual aggregate maximum copay amount N/A

Outpatient procedures 10%

ii. Maximum out of pocket limit N/A

Outpatient Ante/Post Natal Consultation Deductible/Coinsurance 10%

Outpatient Ante/Post Natal Procedures Coinsurance 10%

Outpatient Ante/Post Natal Prescribed Pharmaceuticals

ii. Maximum out of pocket limit N/A

Additional Benefits (If opted)

Alternative Medicine Co-Insurance (Opted level) Nil

B. Inside UAE – Outside Network (Co-Insurance applies

Coinsurance (with or without PAR) 0% Coins

Elective in UAE. (If treatment / service is not available within the

Coinsurance (with or without PAR) 20% Coins

C. Abroad (within agreed territory) – Co-Insurance applies

Patient treatment supplies (Reimbursement) Not Covered

Organ transplant (excluding donor’s expenses) *1 Covered

Kidney Dialysis Treatment (Hemodialysis / Peritoneal Dialysis) *1 Covered

Hepatitis B & C and its complications*1 Covered

Elective Vitamins/Supplements prescribed by relevant physician Not Covered

Home Nursing following inpatient treatment. Must be registered /

Enhanced Vaccination (All census) – MOH approved vaccines.

Allergy testing (Reimbursement) Not Covered

Infertility treatment. (Reimbursement) Not Covered

Medically indicated deviated nasal septum *1 Covered

Passive War Risk (Reimbursement) Not Covered

In-patient Rehabilitation Covered

Reconstructive Surgery (if medically necessary) Covered

Oral & Maxillofacial Surgery (if medically necessary) Covered

Bone Densitometry *1 Covered

Circumcision (for new-born male within 2 years of birth) Covered

Acne Treatment (if medically necessary & not related to

Warts (if medically necessary & not related to cosmetics) Covered

Sleep Disorders*1 Covered

Varicose veins, Varicocele, hydrocele (if medically necessary) Covered

Hysterectomy (if medically necessary) Covered

Palliative Care *1 & *3 Covered

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

Covered up to AED 2,500 pppy

Alternative Medicine (Reimbursement at actual within specified

Basic Alternative Medicine Refer to below

Enhanced Alternative Medicine 1,500/- pppy

Dental Benefit (Limit is exclusive of its coinsurance

Routine Dental*1 2,000/- pppy

Palliative Care 1 & 3 Covered