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Policy Holder M/s. M/S. AL MAWAKEB SCHOOL – TEACHERS/EMPLOYEES

Policy Staring Date June 01, 2016

Policy Expiring Date May 31, 2017

Third Party Administrator NAS

AL ITTIHAD AL WATANI

P.O.Box : 3000, Dubai, UAE

Phone : +971 4 2823266, Fax : +971 4 2823490

Health Insurance Program

General Insurance Company for the Near East

• Preamble

• Mode and Payment Terms

• Rider Specifications

• Maternity Cover Benefit

• Alternative Medical Treatment Cover

• UAE Vaccination Schedule

• Wellness Benefit

• Group Medical Assistance Insurance Rider

• NAS Beneficiary User’s Guide

Contents

AMS TS ‐ AL BARSHA ‐ 27332 H of 30

(The Insurer) (The Policyholder)

AL ITTIHAD AL WATANI M/S. AL MAWAKEB SCHOOL – TEACHERS/EMPLOYEES

General Insurance Company for the Near East

Acceptance and use of the Access Card(s) automatically implies acceptance of all the terms, conditions,

limitations and exclusions of this Policy.

PREAMBLE

This document is intended to describe the basic purpose of the Insurance Policy and includes a

description of the General Scope of Coverage, a list of General Exclusions, details of the General Terms

and Conditions and some Definitions of the most commonly used words or phrases.

The overall purpose of this Insurance Policy is to provide cover to eligible Beneficiaries for reasonable

and customary expenses incurred through the Medically Necessary Treatment of Medical Conditions

and Bodily Injuries under the terms and conditions of this Insurance Policy as agreed with the

Policyholder.

NAS is the appointed administrator providing certain administrative services on behalf of and at the

direction of Al Ittihad Al Watani.

In consideration of the payment or agreement to pay the Premium, and on the basis of the request

and statements made by the Policyholder on the initial Application Form(s), and subject to the terms

and conditions of this Insurance Policy for Better Healthcare and any attachment forming part of it, the

Insurer agrees with the Policyholder and guarantees to provide the Benefits and Services and their

related expenses incurred by each Beneficiary as set out in this Insurance Policy.


POLICYHOLDER :

POLICY NUMBER : PAS/51/55/27332/H RIDER EFFECTIVE DATE : 01‐June‐16

EXPIRY DATE : 31‐May‐17

A) BASIS OF INSURANCE :

FOR EMPLOYEES : NON‐CONTRIBUTORY FOR DEPENDENTS : CONTRIBUTORY

B)

C)

D)

E)

ELIGIBILITY

All Employees under age 65 in service on the Policy date are eligible on that date. Subsequently hired Employee

under age 65 shall be eligible on the first day of employment.

GROUP MEDICAL ASSISTANCE RIDER

RIDER SPECIFICATIONS

ADMINISTRATION OF THE POLICY IS DONE BY NAS. PLEASE REFER TO THE NETWORK AND BENEFICIARY USER GUIDE

(AS ATTACHED) FOR ASSISTANCE.

M/s. M/S. AL MAWAKEB SCHOOL – TEACHERS/EMPLOYEES

The Basis of Insurance under this Rider shall be :

Under this provision, Contributory insurance means insurance for which the Employee contributes towards the

premium and Non‐Contributory insurance means insurance provided at no cost to the Employee.

Resident Dependants (entire family) can be enrolled at the inception date of the policy, same rates and benefits

will apply.

If not enrolled at that date, they can be added on only on next renewal.

CANCELLATION CLAUSE:

ELIGIBILITY OF DEPENDENTS Age limits for children

(See Clause 4 Of Insurance Rider)

Dependents are eligible From Date of Birth to Maximum 25th birthday

Deletion with prorate premium refund will be processed only on return of the physical insurance card back to

the insurer or a relevant liability letter from the Client for the recovery of the claims settled for members and

incurred after the deletion date.

For cancellation of the policy during the policy period, premium refund shall be calculated on a pro‐rata less one

month.

DELETION CLAUSE:

Pro‐rata refund is applicable for deletion of insured members during the policy period


G. INSURANCE COVERAGE Cat A

Resident Network (Welcare/City Hospital In‐patient only with 10% co‐pay at City for IP)

BENEFITS

Accidental Death and Disability

Sum Insured Covered up to AED 200,000

Repatriation costs for the transport of mortal remains

to the country of originCovered up to AED 10,000 per case

Insured As per the list of employees provided

Health InsuranceMaximum Annual Aggregate Limit

(Per Person Per Year)Covered up to AED 200,000/‐

Geographical Area of Cover Worldwide Excluding USA & Canada

Pre‐ Existing and/or Chronic Conditions Covered up to 100% of Sum Insured

In‐Patient & Day Care Healthcare Services

In‐Patient Accommodation Private room

Tests, diagnosis, treatments and surgeries in hospitals

for non‐emergency medical casesCovered

Healthcare services for emergency cases Covered

Transportation services for medical emergencies

inside the Emirate of Dubai by a Licensed Ambulance

service

Covered, if followed by an inpatient admission

Liability (coinsurance) of the Insured member and the

Insurance company

‐ 20% coinsurance payable by the insured with a cap of 500 AED payable per encounter

‐ An annual aggregate cap of 1000/‐ AED

‐ Above these caps, the insurer will cover 100% of treatment

Accommodation for a person accompanying an

insured child up to 16 years of ageCovered up to AED 300/‐ per night

Accommodation of an accompanying person in the

same room in cases of critical condition as per

recommendation of attending physician, subject to

prior approval

Covered up to AED 300/‐ per night

Covered up to AED 300/‐

Subject to prior approval

Voluntary Selection not allowed

All members to be covered must have UAE valid residence visa & must be permanent residents of UAE

Hospital Cash Benefit if Inpatient Treatment is

received free of charge in a Government Hospital

(Limited to maximum of 20 days)

DESCRIPTION

Group Scheme

As per policy limitations

All the employees and their dependants (if policy covers dependents) are mandatory to be included to the policy from inception

No other benefit will be payable In respect of the period for which the cash benefit has been claimed.




Covered AED 300/‐ up to max 13 weeks

Out Patient Services

Covered subject to 20% of co‐insurance with maximum Deductible of AED 50/‐

Laboratory tests services Covered with 15% co‐insurance

X‐ray, MRI, CT Scan, Ultra Sound and Endoscopy

diagnostic servicesCovered with 15% co‐insurance

Covered with 15% co‐insurance

PhysiotherapySubject to pre‐authorization

Covered maximum up to 15 sessions per ailment

Other Benefits

Maternity Covered as per attached Maternity Cover Benefits

New Born Cover

(if the delivery is in UAE)Covered for 30days from birth.

Coverage of a pregnant female is extended by the

insurer to provide the same benefits for a new born

child of that female for a period up to 30 days from

its date of birth. This cover is provided regardless of

whether or not the new born is eventually enrolled

as a dependent member under the insurer's policy

Dental Not covered

Covered

Optical Not covered

Recipient Organ transplantation service, excluding any

charges related to DonorCovered upto the limit of AED 200,000/‐

There must be a clear treatment plan, agreed by us in advance with the treating medical practitioner, with clear end point and expected outcome.

Subject to prior approval for prescriptions which exceed AED 700/‐

Pharmaceuticals

Limited to following

• One Return Air Ticket to Beneficiary only

Nursing at Home

(immediately after or instead of hospitalization)

Physician Consultation

Travel Expenses

(treatment of accidental injuries to sound natural teeth through violent external means within 7 days of the accident)Emergency Dental treatment due to accident

Deductibles for follow‐up visits with the same doctor for the same medical condition not applicable within network within 7 days from the date of first visit.

Travel expenses for the insured to Home country for a medically indicated inpatient preapproved treatment when the cost difference does have a

serious impact/ (Cost in Home Country <50% of UAE R and C network rates)

BCG, Hepatitis B and neo‐natal screening tests (Phenylketonuria (PKU), Congenital Hypothyroidism, sickle cell screening, congenital adrenal

hyperplasia)




Out Patient Cover up to AED 1,500/‐

In Patient Cover up to AED 8,500/‐

Alternative Medicines Covered up to AED 1600/‐

Covered

Wellness benefits Covered with a limit of AED 2,000/‐ per person per annum with 10% co‐insurance as per attached schedule

Work related injuries Covered

Preventive services Diabetic Screening is covered for members over 18 years of age

*Prior Approval is required for Free Access facility

Diagnostic and treatment services for dental and

gum treatmentCovered, subject to 20% coinsurance

Hearing and Vision aids, and vision correction by

surgeries and laserCovered, subject to 20% coinsurance

Claims Settlement Terms

Network

Within UAE : 100% of actual covered cost*

Outside UAE within territory of coverage : Approval for free access will be maximum up to 100% of UAE applicable NW rates*

Reimbursement (Non Network)

Within UAE: 100% covered with applicable deductible & co‐insurance*

Outside UAE within territory of coverage : 100% of actual covered cost subject to maximum of 80% of UAE Applicable Network rates *

UAE Government hospitals: 100% of actual covered cost subject to maximum of 80% of UAE Applicable Network rates *

* Minimum Deductable / co‐insurance will be applied

Psychiatric treatment

• Case preapproved and referred by AIAW

• Cost of the treatment in home country should be less than 50% of the applicable network rate

Excluded healthcare services except in cases of medical emergencies

Vaccination as per MOH schedule

Covered on reimbursement basis and claims are settled at 100% of actual covered cost subject to maximum of 100% of Applicable Network rates

Fasting Blood Sugar and HBA1C tests are covered once a policy year for eligible members


Cat A : AED 7,000/‐

Cat A : AED 10,000/‐

Normal delivery

Cat A : 8 visits

Cat A : 3 scans

Compulsory to enroll all members under the scheme and not selectively.

Medically necessary Caesarean Section, complications and for

medically necessary termination are covered up to a sub limit of :

MATERNITY COVER (IN & OUT PATIENT)

Cover Limit & Benefits

Normal Delivery expenses are covered up to a sub limit of:

(Inpatient Maternity Treatments are subject to Prior Approval)

Inpatient & Outpatient

coverage includes:

(All limits include co‐insurance)

Pre & Post natal

treatments

Any Medical Emergency expenses related to Maternity will be covered

up to a sublimit of AED 150,000

Medically necessary

Caesarean Section

Out Patient eligible Maternity expenses are covered up to Annual limit

10% copayment applicable on all Maternity treatments including out‐

patient Maternity consultation (no Deductible applies)

Maximum Out‐patient visits to Network providers as follows:

The following screening tests are covered as per DHA Antenatal care

protocol:

Medically necessary legal

terminations

Maternity related

Complications

FBC and Platelets

Blood group, Rhesus status and antibodies

VDRL

MSU & urinalysis

Rubella serology

HIV

Hepatitis C offered to high risk patients, where recommended

GTT, if high risk, where recommended

FBS, Random blood sugar OR HbA1C

Ultrasonography:

Any other tests as per DHA antenatal care protocols


Cover to include the following alternative medical treatments:

Acupuncture

Herbal Treatment

Chiropractic treatment

Osteopathy

Chiropody

Ayurvedic treatment

Homeopathy

Deductible : 20% of claimed amount with a minimum of Dhs 100 per claim.

Claims Settlement : Only on a reimbursement basis on submission of all original documents

(claim form & receipts)

Annual Limit per person

Cat A : Covered up to 1,600 per person/year

ALTERNATIVE MEDICAL TREATMENT COVER


Period Vaccination

BCG

Hepatitis‐B

Pentavent (Diphtheria, Pertusis, Tetanus, H.influenza‐B, Hep‐B) 1

Oral Polio 1

Pneumoloccal Conjugate Vaccine 1


Oral Polio 2

Pneumoloccal conjugate vaccine 2


Oral Polio 3

Pneumoloccal Conjugate Vaccine 3

MMR (Measles, Mumps, Rubella) 1

Varicella

Tetravent (Diphtheria, Pertusis, Tetanus, H.influenzae‐B)

Oral Polio 4

Pneumococcal Conjugate Vaccine 4

DPT (Diphtheria, Pertusis, Tetanus)

Oral Polio

MMR (Measles, Mumps, Rubella)

Varicella

UAE VACCINATION SCHEDULE

5 – 6 years

Birth

End of month 2

End of month 4

End of month 6

End of month 18

End of month 12


MALES

‐ Medical Examination

‐ PSA

‐ Rectal Ultrasound

‐ DXA Bone Density Axial

Members age 40 & above

‐ DXA Bone Density Axial

Wellness Benefits

Members age 40 & above

Eligibility :

FEMALES

‐ Medical Examination

‐ Mammogram ‐ Bilateral

‐ Pelvic Scan

‐ Pap smear (LBC)


1 An Employee who is insured under the terms and provisions of this Rider;

and

2 If Dependents of such Employees are eligible under the terms of this rider,

to an Insured Dependent.

Elective Out / In‐patient treatment within the geographical scope of coverage

– benefit payable is limited to a maximum of the equivalent cost of such

treatment in the UAE (Rates in AL ZAHRA / WELCARE HOSPITALS are deemed

an appropriate benchmark) outside providers

THE INSURANCE COMPANY hereby agrees that the following provisions, as modified or defined under the attached

Group Medical Assistance Insurance Rider Specifications, hereinafter referred to as “RIDER SPECIFICATIONS”, shall

form part of the Policy.

CLAUSE 1 – BENEFITS

GROUP MEDICAL ASSISTANCE INSURANCE RIDER

CLAUSE 3 – DEFINITIONS

shall be deemed to refer to a charge for medical care which shall be considered

reasonable and customary to the extent that it does not exceed the general

level of charges being made by others of similar standing in the locality where

the charge is incurred, when furnishing like or comparable treatment services

or supplies to individuals of the same sex and of comparable age and income,

for a similar disease or injury.

REASONABLE AND CUSTOMARY:

INSURED:

The Insurance Company shall reimburse the necessary, reasonable and customary medical expenses incurred by

Insured's for the kinds of care described herein during the continuance of the Rider, subject to the Provisions set forth

in the Rider. However the Benefits provided on the Rider Effective Date are only those for which amounts of Benefit

are shown in (c) Insurance Coverage‐ Rider Specifications.

CLAUSE 2 – INSURANCE COVERAGE

The Insurance Coverage applicable to each Employee insured in accordance with the provisions of Clause 9 of the

Policy General Provisions, shall be as set forth in ( c ) Insurance Coverage‐ Rider Specifications.

PHYSICIAN: means only a Doctor or Surgeon who is a doctor of medicine or equivalent,

legally licensed to practice medicine and qualified to render the treatment

provided.



‐‐ Suturing a wound

‐‐ Treatment of a fracture

‐‐ Reduction of a dislocation

‐‐ Radiotherapy (excluding radioactive isotope therapy) if used in lieu of a

cutting operation for the removal of a tumor

‐‐ Electrocauterisation

‐‐ Diagnostic and Therapeutic Endoscopic procedures

means only an Institution licensed as a Hospital (if licensing is required) and

operated for the care and treatment of sick persons, which Institution provides

24 hours nursing care and has facilities for both diagnosis and except in the

case of a hospital primarily concerned with treatment of chronic diseases, for

major surgery. The term Hospital shall not be construed to include rest home,

nursing home, convalescent home, place for custodial care, home for the aged,

or a place used primarily for the confinement or treatment of drug addicts or

alcoholics.

means that a person is registered as a bed patient in a hospital (as defined

above) and incurs a daily room and board charge.

If a disability is due to causes that are the same or related to the cause of a

prior disability (including complications arising therefrom) the disability shall be

considered a continuation of the prior disability and not a new disability.

However, for cases requiring hospital confinement, after 90 days following

the latest discharge from the hospital, subsequent hospital confinement arising

from the same cause shall be considered a new disability; for cases not

requiring hospital confinement, a new disability shall be established after a

period of 1 WEEK has elapsed following the day upon which the latest

reimbursed expense was incurred, provided the treatment has been continued

with the same Doctor, unless expenses are not reimbursed because of the

exhaustion of the maximum benefit.

shall be deemed to mean a sickness or accidental bodily injury necessitating

medical treatment by a licensed physician. All bodily injuries sustained in any

one accident shall be considered one disability. All bodily disorders existing

simultaneously which are due to the same or related causes shall be

considered one disability.

DISABILITY:

SURGICAL OPERATION:

HOSPITAL CONFINEMENT:

HOSPITAL:



‐‐ Injection treatment of Haemorrhoids and varicose veins

1 Such a list shall be provided by the Insurance Company, but may be

amended from time to time by the insurance co. Such a change will be

evidenced in writing;

2 A Statement in (c) Insurance Coverage ‐ Rider Specifications or an

Endorsement to the Policy may negate or reduce the benefits payable in

the case of treatment furnished by a non‐participating Hospital or

physician.

means a Hospital or Physician approved by both the Policyholder and the

Insurance Company to provide treatment for which a Benefit may be payable

under this Rider. Where a restricted list of participating hospitals and

physicians is in use:

The exclusions which are applicable under this Insurance Policy to all Benefits

and as shown in CLAUSE 6 of this Rider.

EMERGENCY

(For Applicable Plans):

MEDICALLY NECESSARY:

UNNECESSARY TREATMENT:

SUBSTANDARD TERMS:

PARTICIPATING HOSPITAL /

PARTICIPATING PHYSICIAN:

GENERAL EXCLUSIONS:

“A sudden sickness or Injury whose acute symptoms (Including but not limited

to severe pain) are of such severity that the absence of immediate treatment

at a Hospital Emergency facility is medically expected to constitute a serious

threat to the life, health, a bodily function and/or organ of the patient”.

A Service or Treatment which, in the medical opinion is appropriate and

consistent with diagnosis and which in accordance with generally accepted

Medical Standards could not have been omitted without adversely affecting

the Beneficiary’s condition or the quality of medical care rendered.

Service or treatment which is not medically necessary.

Special terms under which a Beneficiary is covered under this Insurance Policy

(i.e., Special limits as per the Policy underwriting).



A.

1.

2.

3.

4.

B.

1.

PRE‐EXISTING CONDITION:

CHRONIC CONDITIONS:

DEPENDENTS ELIGIBILITY:

An incurable disease requiring a regular, lifetime Treatment.

EMPLOYEE Eligibility:

The term EMPLOYEE shall mean any active at work person, working on a full time and permanent basis for

the policy holder and being remunerated accordingly. If for any reason the employee is away ill at the

policy commencement date, then his/her insurance would not become effective until he/she resumes

active employment.

CLAUSE 4 – EMPLOYEE & DEPENDENT ELIGIBILITY:

Any illness, sickness, disease or other physical, medical, mental or other

condition, disorder or ailment where, in the opinion of a medical practitioner

appointed by the Insurer, signs or symptoms of the condition existed at any

time in the period prior to the Insured Member becoming insured under the

Policy. The test applied relies upon signs or symptoms of the condition being

present and not on an eventual diagnosis. It is not necessary for the Insured

Member or his doctor to know what their condition is or was at the time of

taking out the policy. In forming an opinion, the Insurer appointed medical

practitioner who makes the decision must take into account information

provided by the Insured Member's treating doctor.

The legal wife or husband of an Employee, ( but not including those legally separated) or the person living

with an Employee in a recognised Husband and Wife relationship, which is registered as such in the records

of the Policy Holder, and

The policyholder has declared in writing at the date of the initial application that ALL EMPLOYEES are

enrolled on a compulsory basis. In virtue of the policy holder declaration, this insurance policy was

underwritten and issued by the Insurer.

In accordance with the policyholder declaration on the initial application, it is agreed and understood that

all employees, without exception, are to be included under this insurance policy.

Notwithstanding the above, the policyholder has the right to assign medical benefits only to a certain

category of staff as per the internal grading system subject always to the prior declaration of the policy

holder and the prior approval of the Insurer.

The term “DEPENDENT” shall be deemed to refer only to:



2.

C.

1

•

•

2

•

Any Employee who has Dependents shall be eligible for Dependents insurance on the date the Employee

becomes insured under this rider, or on the day the employee first acquires such Dependents, whichever is later.

When the Provision (a) Basis of Insurance – Rider Specifications stipulates that Insurance is non‐

contributory, the dependents shall become insured as follows:

If the employee has one or more Dependents on the effective date of his insurance as an Employee

under this Rider, the insurance for such Dependents shall become effective on that date.

If the Employee acquires one or more Dependents after the effective date of his insurance as an

Employee under this Rider, such Dependents shall become insured automatically.

When the provision (a) Basis of Insurance – Rider Specifications stipulates that insurance is contributory,

the insurance for the Dependents of an Employee who makes written request to the Policy Holder for such

Dependent’s insurance on a form approved by the Insurance Company and who agrees to make the

required contribution shall become effective as follows:

An Employee’s unmarried children, step‐children and children legally adopted who are within the age limits

set forth in (d) Eligibility of Dependents – Rider Specifications, living in the Employee’s household and

having the same permanent residence as the Employee or absent there from only to attend School. Such

children must be dependent upon the Employee for support and registered as Dependents of the Employee

in the records of the Policyholder.

In the event that the age‐limit set forth in (d) Eligibility of Dependents‐Rider Specifications is beyond nineteen

year, such children over nineteen shall only be eligible if they have the same permanent residence as the

Employee and if they are full‐time students at an accredited college or university.

If any person defined as a Dependent is also eligible to participate as an Employee under this Rider, such person

shall not be eligible as a Dependent hereunder. When both husband and wife living in the same household are

insured as Employees, the children shall be eligible only as Dependents of the Husband.

DEPENDENTS – DATE INSURED:

If the Employee has one or more Dependents on the effective date of his insurance as an Employee

under this Rider, the insurance for such Dependents shall become effective on that date.



•

•

D.

E.

a)

b)

c)

d)

If request to participate is made by the Employee after the end of the 31 day period immediately

following the first day he is both eligible and actively at work on full time, or is made after previous

termination of insurance because of failure to make a required contribution, evidence of good health

of each Dependent the Employee then has, satisfactory to the Insurance Company, must be furnished

by him before such dependents may become insured. If such evidence is submitted for any individual

dependent, such dependent shall be insured as of the date communicated by the Insurance Company.

DELETION DATE:

The deletion date of any approved deletion should be one day following the death of the Employee or Legal

Dependant or one day following the date of termination of the Employee. The Policy Holder shall be the sole

and fully liable party towards the expenses incurred by the deleted Beneficiaries as from the Deletion Date. To

this effect, the Policyholder should make sure that the Access card has been withdrawn from the deleted

Beneficiaries. The premium refund related to any approved deletion shall be calculated on a pro‐rata basis for

the period remaining after the deletion date. No refund is due as long as the Beneficiary’s Access Card is not

returned to the Insurer.

DEPENDENTS – TERMINATION OF INDIVIDUAL INSURANCE:

If the Employee acquired one or more Dependents after the effective date of his insurance as an

Employee under this Rider, such Dependents shall become insured on the date he makes written

request and payment of any required increase in contribution due to a resulting change in the

enrollment category. If, however, such written request is made more than 31 days after the Employee

acquired such Dependents, evidence of the good health of such Dependents must be furnished. If

such evidence is submitted, the Dependents shall be insured as of the date communicated by the

Insurance Company.

Dependent’s Insurance under this rider shall automatically terminate

If the Employee’s insurance as an Employee under this Rider terminates

If the Insured Dependent ceases to be eligible as a Dependent

If this Rider terminates

If the Employee fails to make, when due, any required contribution.



1

2

3

4

(a)

(b)

5

6

7

8

9

10

11

CLAUSE 5 – EXTENSION OF BENEFITS

Notwithstanding the provisions of Clause 11 of the Policy – General Provisions and Clause 4 of this Rider, provided

this Rider is still in effect at the time such Hospital Expenses are incurred, benefits hereunder will continue to be

payable with respect to any disability resulting in a Hospital confinement which is in progress on the date of

termination of individual insurance for the duration of that confinement. In no event, however, will such benefits be

payable for expenses incurred beyond the end of the month following termination of individual insurance would

normally occur.

Custodial care including:

Surgical and non‐surgical treatment for obesity (including morbid obesity), and any other weight control

programs, services, or supplies.

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.

Personal comfort and convenience items (television, barber or beauty service, guest service and similar

incidental services and supplies).

Home nursing; private nursing care; care for the sake of travelling.

All expenses relating to dental treatment, dental prostheses, and orthodontic treatments.

Healthcare Services which are not medically necessary

CLAUSE 6 – GENERAL EXCLUSIONS (Unless specifically agreed otherwise)

Healthcare services and associated expenses for the treatment of alopecia, baldness, hair falling, dandruff or

wigs.

Healthcare Services that are not performed by Authorized Healthcare Service Providers.

Medical services utilized for the sake of research, medically non‐approved experiments and investigations and

pharmacological weight reduction regimens.

Services which do not require continuous administration by specialized medical personnel.

Health‐related services which do not seek to improve or which do not result in a change in the medical

condition of the patient.

Non‐medical treatment services;



12

13

14

15

16

17

18

19

20

21

22

23

24

25

Treatment and services for contraception

Any investigations, tests or procedures carried out with the intention of ruling out any foetal anomaly.

Services rendered by any medical provider who is a relative of the patient for example the Insured person

himself or first degree relatives.

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.

Treatments and services arising as a result of hazardous 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 professional sports activities.

External prosthetic devices and medical equipment.

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.

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.

Mental Health diseases, both out‐patient and in‐patient treatments, unless it is an emergency condition.

Costs associated with hearing tests, vision corrections, prosthetic devices or hearing and vision aids.

Growth hormone therapy.

Healthcare services for adjustment of spinal subluxation.

Enteral feedings (via a tube) and other nutritional and electrolyte supplements, unless medically necessary

during in‐patient treatment.

Health services and supplies for smoking cessation programs and the treatment of nicotine addiction.



26

27

28

29

30

31

32

33

34

35

36

37

38

39

Any services related to birth defects, congenital diseases and deformities.

Healthcare services, investigations and treatments related to viral hepatitis and associated complications, except

for the treatment and services related to Hepatitis A.

Healthcare services and treatments by acupuncture; acupressure, hypnotism, massage therapy, aromatherapy,

ozone therapy, homeopathic treatments, and all forms of treatment by alternative medicine.

All chronic conditions requiring hemodialysis or peritoneal dialysis, and related investigations, treatments or

procedures.

Nasal septum deviation and nasal concha resection.

Elective diagnostic services and medical treatment for correction of vision

All healthcare services & treatments for in‐vitro fertilization (IVF), embryo transfer; ovum and sperms transfer.

Inpatient treatment received without prior approval from the insurance company including cases of medical

emergency which were not notified within 24 hours from the date of admission.

Air or terrestrial medical evacuation and unauthorized transportation services.

Healthcare services for senile dementia and Alzheimer’s disease.

More than one consultation or follow up with a medical specialist in a single day unless referred by the treating

physician.

All supplies which are not considered as medical treatments including but not limited to: mouthwash,

toothpaste, lozenges, antiseptics, milk formulas, 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.

Any investigations or health services conducted for non‐medical purposes such as investigations related to

employment, travel, licensing or insurance purposes.

Any inpatient treatment, investigations or other procedures, which can be carried out on outpatient basis

without jeopardizing the Insured Person’s health.



40

41

42

43

1

2

3

4

5

6

7

8

9

10

11

12

13

Any expenses related to immunomodulators and immunotherapy.

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.

Healthcare services outside the scope of health insurance

Injuries resulting from a road traffic accident.

Injuries resulting from criminal acts or resisting authority by the Insured Person.

Services and educational programs for handicaps.

Any expenses related to the treatment of sleep related disorders.

Injuries resulting from natural disasters, including but not limited to: earthquakes, tornados and any other type

of natural disaster.

Healthcare services for injuries and accidents arising from nuclear or chemical contamination.

Injuries or illnesses suffered by the Insured Person as a result of wars or acts of terror of whatever type.

Injuries or illnesses suffered by the Insured Person as a result of military operations of whatever type.

Injuries resulting from attempted suicide or self‐inflicted injuries.

Any investigation or treatment not prescribed by a doctor.

All cases resulting from the use of alcoholic drinks, controlled substances and drugs and hallucinating substances.

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.

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 hepatitis.

All healthcare services for internationally and/or locally recognized epidemics.

Diagnosis and treatment services for complications of exempted illnesses.



a)

b)

The Plan covering the Insured as an Employee will determine the Benefits before a plan which covers such person as a

Dependent.

The foregoing does not apply to any benefits which any Insured receives or is entitled to receive from any Individually‐

owned Insurance Policy.

If 1 or 2 do not establish an order or priority, the plan which has covered the Insured for the longer period of

time determines its benefits first.

CLAUSE 7 ‐ DUPLICATION OF BENEFITS

The Benefits of this Rider will not duplicate the benefits of any other group plan or statutory plan for which any

Insured may be eligible. When any Insured is also covered by any such duplicate benefits; the benefits under this Rider

will be reduced to an amount which, when added to such duplicate benefits; will equal 100% of the benefits provided

by this Rider.

If only this Rider provides for non‐duplication of Benefits, benefits will be paid first by all other duplicate plans. Where

benefits are payable by more than one plan having a non‐duplication‐of‐benefits provision, benefits will be payable as

follows:

The plan covering the Insured as a Dependent of a Male Employee determines its benefits before a plan covering

him as a dependent of a female Employee.



1

2

a)

b)

c)

1.

2.

CLAUSE 8 – HOSPITAL CONFINEMENT BENEFITS:

An accidental bodily injury or

DAILY BENEFITS

If, as a result of a disability, an Insured incurs expenses in connection with his Hospital Confinement, the Insurance

Company will pay the benefits described in A and B below.

HOSPITAL SERVICES BENEFITS

The expense incurred by the Insured for reasonable and customary charges made by the Hospital for

Services or supplies furnished to the Insured for his use during his hospital confinement, including charges

for blood and blood plasma.

Anaesthetics and the administration by a Hospital Employee;

The expense incurred by the Insured for reasonable and customary charges made by the Hospital for room,

Board and general nursing care furnished during his hospital confinement, but not to exceed the daily maximum

for each day of confinement. And the maximum amount during any one disability, both as set forth in ( c )

Insurance Coverage‐ Rider specifications.

The local use of an Ambulance;

But not to exceed, during any one disability the hospital services maximum set forth in ( c ) Insurance Coverage‐

Rider Specifications.

No benefits will be payable under hospital services benefits for charges made for guests/companion overnight

except for children aged <12 years, Telephone & Cafetaria , for room and board, private nurses, technicians

and doctors not regularly employed by the Hospital.

CLAUSE 9 – HOSPITAL OUT‐PATIENT BENEFITS

If as a result of

A sickness for which a surgery benefit is payable under Clause11

An insured incurs expenses for services and supplies provided by the Out‐patient department of a hospital, the

Insurance Company will pay the reasonable and customary charges for such services, not to exceed the maximum

during any one disability as set forth in ( c ) Insurance Coverage‐Rider Specifications

CLAUSE 10 – SURGERY BENEFITS



1)

2)

3)

4)

5)

1)

•

•

2)

Hospital charges including general nursing care and nursery care for the baby, while the mother is confined

in the hospital.

Charges made by a physician or a registered midwife for delivery, pre‐ and post natal care.

This benefit is payable once for any one pregnancy, including any and all the complications in connection with

any one pregnancy.

Payment for all surgical operations performed during any one disability shall not exceed the surgical

disability maximum as set forth in ( c ) Insurance Coverage‐ Rider Specifications.

CLAUSE 11 – MATERNITY BENEFITS

If, as a result of pregnancy, an Insured incurs hospital and medical expenses for resulting childbirth, miscarriage or

legal abortion, the Insurance Company shall make reimbursement for such expenses up to the maximum amount set

forth in ( c ) Insurance Coverage – Rider Specifications, subject to the following provisions.

When an incidental procedure is performed through the same incision, or in the same natural body orifice,

or in the same operative field, the payment will be that value for the major procedure only, except where

otherwise specified.

The payable charges shall include the normal pre‐operative consultation, investigation and preparation of

the Insured, the operative procedure, the total post‐operative care rendered by the Surgeon while the

Insured is in Hospital, and convalescent care following discharge from the hospital.

Payment shall not exceed the maximum set forth in item ( c ) Insurance Coverage – Surgery Benefits nor

exceed the amount actually charged to the Insured.

If, as a result of a disability, an Insured incurs expenses for a surgical operation, the Insurance Company, will subject to

the provisions of this Rider, reimburse the reasonable and customary amounts paid, subject to the following

provisions.

When multiple or bilateral surgical procedures, which add significant time or complexity to patient care, are

performed at the same operative session the payment will be the amount payable for the major procedure

plus 50% of the value for the secondary procedure and 25% of the value for the third procedure except if

the combined procedure is otherwise specified that value shall be payable.

This Benefit is in lieu of all other Benefits under this rider and is applicable to expenses for



3)

4)

5)

a)

b)

1

a)

b)

c)

2

Reimbursement will be made on account of pregnancies which had their inception after the effective date of

insurance coverage, for the dependent wife or married female employee under this Rider.

If, as a result of a disability, an Insured incurs expenses for professional attendance and treatment by a physician for

causes other than pregnancy, the Insurance Company shall make reimbursement for such expense up to the

maximum amount per visit and per disability set forth in ( c ) Insurance Coverage – Rider Specifications, subject to the

following provisions:

DEFINITIONS:

Home visits ‐‐ professional attendance and treatment at the home of the Insured

Specialist Consultations ‐‐ professional attendance and consultations by a qualified specialist, ordered in

advance by the attending physician.

LIMITATIONS:

Office visits ‐‐ professional attendance and treatment in the Physician’s office or clinic

CLAUSE 12 – MEDICAL BENEFITS – HOSPITAL CONFINED

In the event of termination of employment of insured female Employees, coverage under this Clause for

Maternity expenses will nevertheless be provided without further premium payment for pregnancies which had

their inception prior to such termination, provided this Rider is still in effect at the time such expenses are

incurred. For insured dependent wives, no maternity benefits are payable after coverage terminates.

Maternity benefits are available for dependent wives and for married female employees who are insured under

this rider.

No benefit is payable for services of a Surgeon or Anaesthetist for which benefits are payable under Clause 11 –

surgery and anaesthesia benefits: nor for visits by any Physician on or after the day that a surgical operation is

performed.

Payment shall not be made for more than one visit on any one day and shall not exceed the amount actually

charged.

CLAUSE 13 – MEDICAL BENEFITS – OTHERS

If, as a result of a disability, an Insured incurs expenses for professional attendance and treatment by a physician while

confined in hospital, for causes other than pregnancy, the Insurance Company shall make reimbursement for such

expenses up to the maximum amount per visit and per disability set forth in ( c ) Insurance Coverage – Rider

Specifications, subject to the following provisions:



a)

b)

c)

d)

1

2

a)

b)

c)

For the settlement of eligible expenses for non‐excluded cases, the Beneficiary should submit to the Insurer the

following documents within 90 days from the date these expenses were incurred by the Beneficiary:

Appropriate completed AL ITTIHAD AL WATANI Claim forms (by the Consulting Physician or Surgeon).

Original Itemized receipts and Invoices.

The Treating Doctor’s Prescription of the Medicines.

CLAUSE 15 – CLAIMS SETTLEMENT

Payment shall not be made for more than five specialist consultations during one disability.

The maximum per disability set forth in (c) Insurance Coverage – Rider Specifications applies to the sum

of all payments for office and home visits and specialist consultations.

CLAUSE 14 ‐‐ DIAGNOSTIC X‐RAY AND LAB BENEFITS

If, as a result of a disability, an Insured incurs expenses for diagnostic x‐ray examinations or microscopic or other

laboratory tests or analyses for causes other than pregnancy, the Insurance Company shall make reimbursement for

such expenses in excess of the deductible and up to the maximum set forth in (c) Insurance Coverage – Rider

Specifications, provided such examinations are related to the symptom and/or disease, are made or ordered by the

consulting physician, And are Medically necessary for the diagnosis of the disease. The deductible and maximum

apply to each disability.

CLAIMS OUTSIDE U.A.E :

Reimbursement of eligible expenses for treatment of non‐excluded cases outside U.A.E. shall be effected upon

submission of the required claims documents at the rate prevailing in the U.A.E. network (reasonable and

customary charges).

CLAIMS ARE REIMBURSED WITHIN 30 DAYS FROM DATE OF RECEIPT OF COMPLETE DOCUMENTS.

REQUIRED CLAIMS DOCUMENTATION

Benefits under this clause are limited to the types of visits defined.

Payment shall not be made for more than one visit, of any type, on one day (if related to the same

disability) and shall not exceed the amount actually charged (unless documented that the Patient has

been referred by the consulting physician to a Specialist for expert opinion and treatment ).



d)

e)

f)

3

4

1

2 Treatment availed by any beneficiary for an excluded or uncovered conditions

Copies of Laboratory, Radiology and Imaging Request forms.

Original Official results of Diagnostic tests.

Your claim will not be considered if not submitted within the above period.

For Inpatient claims – detailed discharge summary report / medical report / operative notes if it is a surgical

procedure and itemized invoice breakdown for the in hospital bill required, with relevant prescriptions and results of

all investigations done.

CLAUSE 16 – PHYSIOTHERAPY

The policyholder and/ or the insured member shall be liable to reimburse the Company all claims amounts paid by the

latter to any of its Providers in respect of the following:

Treatment availed by any beneficiary in excess of the limits of benefits provided in the policy

PRIOR APPROVAL

Required as in cases mentioned in Clause 6.

DISPOSAL OF CLAIM RECORDS

All original documents regarding settled claims shall be destroyed by Al Ittihad Al Watani at its sole discretion

within one year form the date of settlement without the need to notify the beneficiary, and the beneficiary shall

not have any right thereto.

This coverage shall apply as specified in the event of non‐excluded cases requiring reeducation through Physiotherapy

as prescribed by the Attending Orthopedic Specialist (Maximum of 10 sessions per disability – 30 minutes per

session) subject to prior approval being obtained.

CLAUSE 17 – AUTOMATIC RECOVERY CLAUSE


CLAIM PROCEDURES

Access Card:

Always present your personalized Access Card while seeking Treatment at any NAS Network provider to

acknowledge your affiliation with NAS and Al Ittihad Al Watani Insurance Company.

Treatment within Network:

When seeking treatment within NAS applicable Network of Providers, please make sure that you / your family

members:

Present both Identification and Beneficiary Access cards, this way the healthcare provider will recognize your

affiliation with NAS and deliver the required service.

Pre‐approval is granted whenever applicable. For any medical expense over AED 700/‐, prior approval is

needed from NAS.

Sign the necessary forms provided by the healthcare provider. Your signature is essential to validate the

utilized services.

To call NAS should there be a delay in receiving the service. Our numbers are printed on the back of your

Beneficiary Access Card, and our Claims Center is always there around the clock to assist you

Are aware of the healthcare benefits provided to you. For example, class of coverage, aggregate amount,

what is not covered by the scheme, etc.

Contact details of NCCS Center, also printed on the reverse side of the Access Card,

are +971 2 6940700, toll‐free 800 2311 and email [email protected].

NAS ‐ Beneficiary User’s Guide

Al Ittihad Al Watani Insurance Company has appointed NAS Administration Services (NAS) to administer healthcare

claims on its behalf. In doing so, all the matters related to healthcare claims & network providers are handled by

NAS.

NAS CLAIMS & CUSTOMER SUPPORT CENTER (NCCS CENTER)

A 24‐hours hot line can be called at any time to seek assistance and/or guidance. Their 24/7 NCCS Center staff is

ready to answer all your queries, give indications concerning nearest Network Providers, assist you in claims,

procedures and grant pre‐approvals applicable to your cover.

With your prior notification, NCCS Center can:

Secure appointments with Doctors (within the Network).

Arrange for prescribed medicines before you reach Network pharmacy.

Direct you to the nearest Network Provider.



A.

B.

C.

Sign the necessary forms provided by the Network Provider. Your signature is essential to validate the utilized

services.

We recommend utilizing NAS Network at all time to avoid unnecessary payments and paper work. However,

should you seek Treatment outside the Network, make sure to obtain required Pre‐Authorizations from NCCS

Center prior to the commencement of Treatment.

Reimbursement Claims:

In the event of Treatment outside Network, kindly provide us with the following:

Network Providers are instructed to commence Treatment immediately in case of Emergency. If any approval

is needed in this regard, provider will arrange with NAS. However, you or any of your companions may call

NCCS Center for assistance.

Treatment, diagnostic test, or prescribed medicine exceeding AED 700/‐

Day‐care treatments, Surgical procedures

In some instances, the procedures that Network Providers have to apply may not be compatible with your

healthcare scheme benefits; therefore, we encourage you to contact NCCS Center for guidance and

assistance in case of any delay or foreseen problem.

Treatment outside Network:

Pre‐approval is required in case of, or for:

Diagnostic procedures such as MRI, CT‐Scan, Treadmill Stress Test, EEG, endoscopic procedures

Prescribed medicines for 30 days (one month) or more such as, more than one standard unit of a given

medication, medication for chronic diseases, vitamins, etc.

In‐Hospital admission

Absence of NAS form

Physiotherapy / Chiropractic

In all situations, for inquiry and/or assistance NAS Customer Support Center is available at all times at your disposal.

Moreover, in emergency cases, our participating network providers are instructed to commence treatment

immediately. If any approval is needed in this regard, provider will arrange with NAS. However, you or any of your

companions may call NAS Customer Support Center for assistance.



1

2

3

4

5

Original Lab Test Reports

Original Radiology Reports

In case of loss of Access Card, promptly report it to Al Ittihad Al Watani Insurance Company.

Reimbursement claims shall be quickly processed and returned to Al Ittihad Al Watani Insurance Company.

Original Drug Prescriptions

Any other documents relevant to the treatment

Prescriptions

Forward all the above to Al Ittihad Al Watani Insurance Company. Please ensure forwarding all documents to avoid

delays.

Miscellaneous:

If the total cost of outpatient procedures or tests ordered during one visit exceeds AED 700.

If the total cost of single prescription exceeds AED 700

If the medicines are prescribed for a more than 30 days (one month) duration

For all elective surgeries and physiotherapy

All emergency admissions / procedures / surgeries within UAE or outside UAE should be notified to

the company within 24 hours from the time such treatment is started.

Prior approval should be obtained from the company for the following:

All original invoices that you have settled

Original Medical Report

Filled and signed Reimbursement Claim Form (obtained from Al Ittihad Al Watani Insurance) to be

submitted within 90 days. Make sure to include your contact details to be able to contact you if

necessary.


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