‫ﺟﺪﻭﻝ ﺍﻟﻤﻨﺎﻓﻊ ﻭﺍﻟﻤﻤﻴﺰﺍﺕ – ﺍﻟﺸﺒﻜﺔ ﺍﻟﻄﺒﻴﺔ‬

‫ﺍﺳﻢ ﺍﻟﺠﻬﺔ‬
‫‪Insured Name‬‬ ‫ﺍﻟﻣﺅﺳﺳﺔ ﺍﻟﺩﻭﻟﻳﺔ ﻟﻸﻋﻣﺎﻝ ﻭﺍﻻﺳﺗﺷﺎﺭﺍﺕ ﺍﻟﻔﻧﻳﺔ ‪Int'l Business& Technical Consultant Inc. -‬‬
‫ﺍﻟﻤﺆﻣﻨﺔ‬
‫‪Policy No.‬‬ ‫‪TGM149-2023‬‬ ‫ﺭﻗﻢ ﺍﻟﻮﺛﻴﻘﺔ‬
‫‪Policy Period‬‬ ‫ﻣﻦ ‪ 2023/02/01‬ﺇﻟﻰ ‪2024/01/31‬‬ ‫ﻓﺘﺮﺓ ﺍﻟﻮﺛﻴﻘﺔ‬
‫‪Benefits :‬‬ ‫ﺍﻟﻤﻨﺎﻓﻊ ﻭﺍﻟﺘﻐﻄﻴﺎﺕ‪:‬‬
‫ﺍﻟﻤﻮﺍﻓﻘﺔ ﺍﻟﻤﺴﺒﻘﺔ ﻣﻄﻠﻮﺑﺔ‬
‫ﻣﺸﻤﻮﻝ‪:‬ﻳﺠﺐ ﻋﻠﻰ ﻣﻘﺪﻡ ﺍﻟﺨﺪﻣﺔ ﺍﻟﻄﺒﻴﺔ ﺃﺧﺬ ﻣﻮﺍﻓﻘﺔ ﻣﺴﺒﻘﺔ ﻟﺠﻤﻴﻊ ﺍﻟﺤﺎﻻﺕ ﻣﻦ‬ ‫ﺍﻟﻌﻼﺝ ﺩﺍﺧﻞ ﺍﻟﻤﺴﺘﺸﻔﻰ‬
‫‪In-Patient & Daycare Treatment‬‬
‫ﺍﻟﺸﺮﻛﺔ ﺍﻟﻤﺘﺤﺪﺓ ﻟﻠﺘﺄﻣﻴﻦ ﻣﺎﻋﺪﺍ ﺍﻟﺤﺎﻻﺕ ﺍﻟﻄﺎﺭﺋﺔ ﻳﺠﺐ ﺇﺷﻌﺎﺭ ﺍﻟﺸﺮﻛﺔ ﺑﻬﺎ ﺧﻼﻝ‬ ‫ﻭﻋﻼﺝ ﺍﻟﺤﺎﻻﺕ ﺍﻟﻴﻮﻣﻴﺔ‬
‫‪ 48‬ﺳﺎﻋﺔ‬
‫‪Hospital accommodation‬‬ ‫ﻏﺮﻓﺔ ﺧﺎﺻﺔ‬ ‫ﻧﻮﻋﻴﺔ ﺍﻹﻗﺎﻣﺔ‬
‫ﻣﺸﻤﻮﻝ‪ :‬ﻭﺍﻟﻤﻨﻔﻌﺔ ﺗﺸﻤﻞ‪ :‬ﺍﻻﺳﺘﺸﺎﺭﺍﺕ‪ ،‬ﺍﻹﺟﺮﺍءﺍﺕ ﺍﻟﺘﺸﺨﻴﺼﻴﺔ‪ ،‬ﺍﻷﺩﻭﻳﺔ‪ ،‬ﺍﻟﻤﻌﺎﻟﺠﺔ‬
‫‪Out-Patient treatment‬‬
‫‪..‬‬ ‫ﺍﻟﻌﻼﺝ ﻓﻲ ﺍﻟﻌﻴﺎﺩﺍﺕ‬
‫ﺗﻜﺎﻟﻴﻒ ﺍﻟﻌﻼﺝ ﺍﻟﻄﺒﻴﻌﻲ ﺍﻟﻤﻮﺻﻰ ﺑﻪ ﻣﻦ ﺍﻟﻄﺒﻴﺐ ﺍﻟﻤﻌﺎﻟﺞ‪ ،‬ﺗﻜﺎﻟﻴﻒ ﺇﺟﺮﺍءﺍﺕ‬ ‫ﺍﻟﺨﺎﺭﺟﻴﺔ‬
‫ﺍﻟﺘﺸﺨﻴﺺ ﻟﻠﺮﻧﻴﻦ ﺍﻟﻤﻐﻨﺎﻁﻴﺴﻲ‬
‫‪Long Term Medications (more‬‬ ‫ﺍﻟﻌﻼﺟﺎﺕ ﻁﻮﻳﻠﺔ ﺍﻷﻣﺪ ‪-‬‬
‫ﺍﻟﻤﻮﺍﻓﻘﺔ ﺍﻟﻤﺴﺒﻘﺔ ﻣﻄﻠﻮﺑﺔ‬
‫)‪than one month‬‬ ‫ﺃﻛﺜﺮ ﻣﻦ ﺷﻬﺮ ﻭﺍﺣﺪ‬
‫‪Physiotherapy Sessions‬‬ ‫ﺍﻟﻤﻮﺍﻓﻘﺔ ﺍﻟﻤﺴﺒﻘﺔ ﻣﻄﻠﻮﺑﺔ‬ ‫ﺟﻠﺴﺎﺕ ﺍﻟﻌﻼﺝ ﺍﻟﻄﺒﻴﻌﻲ‬
‫ﺍﻟﻤﻮﺍﻓﻘﺔ ﺍﻟﻤﺴﺒﻘﺔ ﻣﻄﻠﻮﺑﺔ‬
‫‪Ambulance‬‬ ‫ﻣﺸﻤﻮﻝ‪:‬ﻓﻲ ﺣﺎﻟﺔ ﺍﻟﻀﺮﻭﺭﺓ ﺍﻟﻄﺒﻴﺔ ﻣﻦ ‪ /‬ﺇﻟﻰ ﺍﻟﻤﺴﺘﺸﻔﻰ ﺿﻤﻦ ﺍﻟﻌﻼﺝ ﺍﻟﺪﺍﺧﻠﻲ‬ ‫ﺳﻴﺎﺭﺓ ﺍﻹﺳﻌﺎﻑ‬
‫ﻭﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﻴﻮﻣﻴﺔ‪.‬‬
‫ﺍﻟﻤﻮﺍﻓﻘﺔ ﺍﻟﻤﺴﺒﻘﺔ ﻣﻄﻠﻮﺑﺔ‬
‫ﻣﺸﻤﻮﻝ ‪:‬ﻓﻲ ﺣﺎﻝ ﻅﻬﻮﺭ ﺍﻟﺮﻣﺰ ‪ M‬ﻋﻠﻰ ﺍﻟﺒﻄﺎﻗﺔ‪ .‬ﻭﺗﺸﻤﻞ ﻫﺬﻩ ﺍﻟﻤﻨﻔﻌﺔ ‪:‬ﺍﻟﻌﻨﺎﻳﺔ ﻗﺒﻞ‬
‫ﻭﺑﻌﺪ ﺍﻟﻮﻻﺩﺓ ‪،‬ﺍﻟﺘﻮﻟﻴﺪ ‪ ،‬ﺍﻟﻌﻤﻠﻴﺎﺕ ﺍﻟﻘﻴﺼﺮﻳﺔ ‪،‬ﺧﺪﻣﺎﺕ ﺍﻟﻤﺴﺘﺸﻔﻰ ‪،‬ﺃﺗﻌﺎﺏ ﺍﻟﻄﺒﻴﺐ‬
‫‪Maternity‬‬ ‫ﺍﻟﺤﻤﻞ ﻭﺍﻟﻮﻻﺩﺓ‬
‫‪،‬ﺍﻟﻤﻀﺎﻋﻔﺎﺕ ﺍﻟﻨﺎﺟﻤﺔ ﻋﻦ ﺍﻟﺤﻤﻞ‪ ،‬ﺍﻹﺟﻬﺎﺽ ﺍﻟﻘﺎﻧﻮﻧﻲ ‪،‬ﺍﻟﻔﻴﺘﺎﻣﻴﻨﺎﺕ‬
‫ﻭﺍﻟﻤﺴﺘﺤﻀﺮﺍﺕ ﺍﻟﻤﻌﺪﻧﻴﺔ‪ ،‬ﺍﻟﻌﻨﺎﻳﺔ ﺑﺎﻟﻤﻮﻟﻮﺩ ﺃﺛﻨﺎء ﺗﻮﺍﺟﺪ ﺍﻷﻡ ﻓﻲ ﺍﻟﻤﺴﺘﺸﻔﻰ‬
‫ﻟﻠﻮﻻﺩﺓ‪،‬ﻛﻤﺎ ﺗﺸﻤﻞ ﺃﻳﻀﺎ ﺍﻟﻔﺤﻮﺻﺎﺕ ﺍﻟﻤﺨﺒﺮﻳﺔ ﺍﻻﻋﺘﻴﺎﺩﻳﺔ ﻟﻠﻤﻮﺍﻟﻴﺪ ﺣﺪﻳﺜﻲ ﺍﻟﻮﻻﺩﺓ‬
‫ﺍﻟﻣﻭﺍﻓﻘﺔ ﺍﻟﻣﺳﺑﻘﺔ ﻣﻁﻠﻭﺑﺔ‬
‫ﻣﺷﻣﻭﻝ‪ :‬ﻫﺫﻩ ﺍﻟﻣﻧﻔﻌﺔ ﺍﻟﻣﻧﻔﻌﺔ ﻣﻘﺗﺻﺭﺓ ﻋﻠﻰ ﺗﻛﺎﻟﻳﻑ ﺍﺳﺗﺷﺎﺭﺓ‬
‫‪Dental‬‬ ‫ﺍﻷﺳﻨﺎﻥ‬
‫ﺍﻟﻁﺑﻳﺏ‪،‬ﺗﻛﺎﻟﻳﻑ ﺍﻟﺧﻠﻊ‪ ،‬ﺗﻛﺎﻟﻳﻑ ﺍﻟﺣﺷﻭ ﺑﺎﻟﺭﺻﺎﺹ‬
‫ﻭﻋﻼﺝ ﻗﻧﻭﺍﺕ ﺍﻟﺟﺫﻭﺭ ﻭﻋﻼﺝ ﺍﻟﻠﺛﺔ‬
‫ﺍﻟﻣﻭﺍﻓﻘﺔ ﺍﻟﻣﺳﺑﻘﺔ ﻣﻁﻠﻭﺑﺔ‬
‫ﻣﺷﻣﻭﻝ‪:‬ﻫﺫﻩ ﺍﻟﻣﻧﻔﻌﺔ ﻣﻘﺗﺻﺭﺓ ﻋﻠﻰ ﻓﺣﻭﺻﺎﺕ ﺍﻟﻧﻅﺭ ﻟﻠﻣﺷﺎﻛﻝ‬
‫ﺍﻟﺑﺻﺭﻳﺔ‪،‬ﺍﻟﻌﺩﺳﺎﺕ ﺍﻟﻁﺑﻳﺔ‪ .‬ﺇﻥ ﺍﻟﻌﺩﺳﺎﺕ ﺍﻟﻼﺻﻘﺔ ﻣﺳﺗﺛﻧﺎﺓ‪.‬‬
‫‪Optical‬‬ ‫ﺍﻟﻨﻈﺮ‬
‫ﻋﻣﻠﻳﺎﺕ ﺗﺻﺣﻳﺢ ﺍﻟﻣﺷﺎﻛﻝ ﺍﻟﺑﺻﺭﻳﺔ ﻭﻋﻼﺝ ﺃﻣﺭﺍﺽ ﺍﻟﻌﻳﻥ ﻻ‬
‫ﺗﺗﻌﻠﻖ ﺑﻬﺫﻩ ﺍﻟﻣﻧﻔﻌﺔ ﺑﻝ ﺗﻘﻊ ﺿﻣﻥ ﻧﻁﺎﻕ ﺍﻟﺗﻐﻁﻳﺔ ﺍﻷﺳﺎﺳﻳﺔ )ﺍﻟﻌﻼﺝ ﺩﺍﺧﻝ‬
‫ﺍﻟﻣﺳﺗﺷﻔﻰ ﻭﺍﻟﻌﻼﺝ ﻓﻲ ﺍﻟﻌﻳﺎﺩﺍﺕ ﺍﻟﺧﺎﺭﺟﻳﺔ(‬
‫‪Pre-existing & Chronic‬‬ ‫ﺍﻷﻣﺮﺍﺽ ﺍﻟﻤﺰﻣﻨﺔ‬
‫ﻣﺸﻤﻮﻝ‬
‫‪Conditions‬‬ ‫ﻭﺍﻟﺴﺎﺑﻘﺔ ﻟﻠﺘﺄﻣﻴﻦ‬
‫‪Co-insurance/‬‬ ‫‪Inpatient & Daycare‬‬ ‫‪Nil‬‬ ‫ﺍﻟﻌﻼﺝ ﺍﻟﺪﺍﺧﻠﻲ ﻭﺍﻟﺮﻋﺎﻳﺔ ﺍﻟﻴﻮﻣﻴﺔ‬
‫‪deductible‬‬ ‫‪Outpatient‬‬ ‫‪10%‬‬ ‫ﺍﻟﻌﻴﺎﺩﺍﺕ ﺍﻟﺨﺎﺭﺟﻴﺔ‬
‫‪Dental Benefit‬‬ ‫‪10%‬‬ ‫ﺍﻷﺳﻨﺎﻥ‬
‫‪Optical Benefit‬‬ ‫‪10%‬‬ ‫ﺍﻟﻨﻈﺮ‬ ‫ﺍﻟﻤﺸﺎﺭﻛﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ‪/‬‬
‫‪Maternity‬‬ ‫‪10% OP‬‬ ‫ﺍﻟﺤﻤﻞ ﻭﺍﻟﻮﻻﺩﺓ‬ ‫ﺍﻟﻤﺒﻠﻎ ﺍﻟﺬﻱ ﻳﺘﺤﻤﻠﻪ‬
‫‪10% OP‬‬ ‫ﺍﻟﺤﺎﻻﺕ ﺍﻟﺴﺎﺑﻘﺔ ﻟﻠﺘﺄﻣﻴﻦ ﻭﺍﻷﻣﺮﺍﺽ‬ ‫ﺍﻟﻤﺮﻳﺾ‬
‫‪Pre Existing/Chronic Conditions‬‬
‫ﺍﻟﻤﺰﻣﻨﺔ‬
‫‪10% OP‬‬ ‫ﻣﻧﻔﻌﺔ ﺍﻟﺣﺎﻻﺕ ﺍﻟﻧﺎﺗﺟﺔ ﻋﻥ ﺣﻭﺍﺩﺙ‬
‫‪Medical expenses due to Accedint Related to Work‬‬
‫ﺍﻟﻌﻣﻝ – ﻟﻠﻣﻭﻅﻔﻳﻥ ﻓﻘﻁ‬

‫‪Note : For Exclusions please refer to Provider Manual Guide‬‬