COMPANY NAME : Royal & Sun Alliance Insurance (Middle …...1.Examination, diagnostic and treatment services of clinics and health centers by general practitioners, and specialists

NAME OF PRODUCT: REF No.:

PRODUCT TYPE : DATE :

IHP Custom - Nil Excess- Opt 01 IHPCUSTOM01

Enhanced

First: Total upper limit coverage Treatment outside network is reimbursed upto 100%

13/12/2012

No. Details Coverage

1. The annual upper limit for Healthcare services : Abu Dhabi

2. The annual upper limit for Healthcare services : Other Emirates

3. The annual upper limit for Healthcare services : International

38640000 AED

38640000 AED

38640000 AED

Second: Geographic coverage Treatment outside network is reimbursed upto 100%


1. Health Insurance Services offered inside the Emirate of Abu Dhabi.

2. Health Insurance Services offered in other Emirates.

Inpatient/Emergency/Outpatient

Inpatient/Emergency/OutPatient

3. International.

Home Country Inpatient/Emergency/OutPatient

Worldwide with exclusions of USA (Except Emergency)

EGYPT Inpatient / Emergency / OutPatient

LEBANON Inpatient / Emergency / OutPatient

JORDAN Inpatient / Emergency / OutPatient

PALESTINE Inpatient / Emergency / OutPatient

YEMEN Inpatient / Emergency / OutPatient

IRAQ Inpatient / Emergency / OutPatient

LIBYA Inpatient / Emergency / OutPatient

TUNISIA Inpatient / Emergency / OutPatient

ALGERIA Inpatient / Emergency / OutPatient

MOROCCO Inpatient / Emergency / OutPatient

DJIBOUTI Inpatient / Emergency / OutPatient

MAURITANIA Inpatient / Emergency / OutPatient

U.A.E Inpatient / Emergency / OutPatient

BAHRAIN Inpatient / Emergency / OutPatient

OMAN Inpatient / Emergency / OutPatient

QATAR Inpatient / Emergency / OutPatient

SAUDI ARABIA Inpatient / Emergency / OutPatient

KUWAIT Inpatient / Emergency / OutPatient

INDIA Inpatient / Emergency / OutPatient

Royal & Sun Alliance Insurance (Middle East)COMPANY NAME :

HAAD Approval Number: 12318 Page 1 of 28

PAKISTAN Inpatient / Emergency / OutPatient

BANGLADESH Inpatient / Emergency / OutPatient

SRI LANKA Inpatient / Emergency / OutPatient

PHILIPPINES Inpatient / Emergency / OutPatient

KOREA SOUTH Inpatient / Emergency / OutPatient

JAPAN Inpatient / Emergency / OutPatient

THAILAND Inpatient / Emergency / OutPatient

SINGAPORE Inpatient / Emergency / OutPatient

MALAYSIA Inpatient / Emergency / OutPatient

AFGHANISTAN Inpatient / Emergency / OutPatient

INDONESIA Inpatient / Emergency / OutPatient

CYPRUS Inpatient / Emergency / OutPatient

CHINA Inpatient / Emergency / OutPatient

TAIWAN Inpatient / Emergency / OutPatient

NEPAL Inpatient / Emergency / OutPatient

HONG KONG Inpatient / Emergency / OutPatient

MALDIVES Inpatient / Emergency / OutPatient

LAOS Inpatient / Emergency / OutPatient

CAMBODIA Inpatient / Emergency / OutPatient

MONGOLIA Inpatient / Emergency / OutPatient

VIETNAM Inpatient / Emergency / OutPatient

BRUNEI Inpatient / Emergency / OutPatient

BHUTAN Inpatient / Emergency / OutPatient

AZERBAIJAN Inpatient / Emergency / OutPatient

TAJIKISTAN Inpatient / Emergency / OutPatient

KAZAKHSTAN Inpatient / Emergency / OutPatient

TURKMENISTAN Inpatient / Emergency / OutPatient

UZBEKISTAN Inpatient / Emergency / OutPatient

GEORGIA Inpatient / Emergency / OutPatient

KYRGYZSTAN Inpatient / Emergency / OutPatient

ARMENIA Inpatient / Emergency / OutPatient

NAMIBIA Inpatient / Emergency / OutPatient

TANZANIA Inpatient / Emergency / OutPatient

KENYA Inpatient / Emergency / OutPatient

ETHIOPIA Inpatient / Emergency / OutPatient

SOUTH AFRICA Inpatient / Emergency / OutPatient

SENEGAL Inpatient / Emergency / OutPatient


UGANDA Inpatient / Emergency / OutPatient

GHANA Inpatient / Emergency / OutPatient

MADAGASCAR Inpatient / Emergency / OutPatient

COTE DLVOIRE Inpatient / Emergency / OutPatient

MAURITIUS Inpatient / Emergency / OutPatient

GUINEA Inpatient / Emergency / OutPatient

ZIMBABWE Inpatient / Emergency / OutPatient

GAMBIA Inpatient / Emergency / OutPatient

NIGERIA Inpatient / Emergency / OutPatient

LIBERIA Inpatient / Emergency / OutPatient

COMOROS Inpatient / Emergency / OutPatient

CAMEROON Inpatient / Emergency / OutPatient

TOGO Inpatient / Emergency / OutPatient

SIERRA LEONE Inpatient / Emergency / OutPatient

CHAD Inpatient / Emergency / OutPatient

NIGER Inpatient / Emergency / OutPatient

ANGOLA Inpatient / Emergency / OutPatient

MOZAMBIQUE Inpatient / Emergency / OutPatient

ZAMBIA Inpatient / Emergency / OutPatient

MALI Inpatient / Emergency / OutPatient

GABON Inpatient / Emergency / OutPatient

BENIN Inpatient / Emergency / OutPatient

BOTSWANA Inpatient / Emergency / OutPatient

BURUNDI Inpatient / Emergency / OutPatient

GREENLAND Inpatient / Emergency / OutPatient

CENTRAL AFRICAN REPUBLIC Inpatient / Emergency / OutPatient

CONGO Inpatient / Emergency / OutPatient

BURKINA FASO Inpatient / Emergency / OutPatient

MALAWI Inpatient / Emergency / OutPatient

RWANDA Inpatient / Emergency / OutPatient

LESOTHO Inpatient / Emergency / OutPatient

SWAZILAND Inpatient / Emergency / OutPatient

ANDORRA Inpatient / Emergency / OutPatient

UNITED KINGDOM Inpatient / Emergency / OutPatient

FRANCE Inpatient / Emergency / OutPatient

GERMANY Inpatient / Emergency / OutPatient

ITALY Inpatient / Emergency / OutPatient


NETHERLANDS Inpatient / Emergency / OutPatient

BELGIUM Inpatient / Emergency / OutPatient

IRELAND Inpatient / Emergency / OutPatient

SWEDEN Inpatient / Emergency / OutPatient

NORWAY Inpatient / Emergency / OutPatient

DENMARK Inpatient / Emergency / OutPatient

FINLAND Inpatient / Emergency / OutPatient

AUSTRIA Inpatient / Emergency / OutPatient

SWITZERLAND Inpatient / Emergency / OutPatient

LUXEMBOURG Inpatient / Emergency / OutPatient

PORTUGAL Inpatient / Emergency / OutPatient

SPAIN Inpatient / Emergency / OutPatient

GREECE Inpatient / Emergency / OutPatient

TURKEY Inpatient / Emergency / OutPatient

MALTA Inpatient / Emergency / OutPatient

SERBIA Inpatient / Emergency / OutPatient

POLAND Inpatient / Emergency / OutPatient

ROMANIA Inpatient / Emergency / OutPatient

CZECH REPUBLIC Inpatient / Emergency / OutPatient

HUNGARY Inpatient / Emergency / OutPatient

ICELAND Inpatient / Emergency / OutPatient

LIECHTENSTEIN Inpatient / Emergency / OutPatient

ALBANIA Inpatient / Emergency / OutPatient

CROATIA Inpatient / Emergency / OutPatient

SLOVENIA Inpatient / Emergency / OutPatient

BOSNIA Inpatient / Emergency / OutPatient

RUSSIA Inpatient / Emergency / OutPatient

Belarus Inpatient / Emergency / OutPatient

UKRAINE Inpatient / Emergency / OutPatient

LITHUANIA Inpatient / Emergency / OutPatient

ESTONIA Inpatient / Emergency / OutPatient

LATVIA Inpatient / Emergency / OutPatient

MOLDOVA Inpatient / Emergency / OutPatient

SLOVAKIA Inpatient / Emergency / OutPatient

BULGARIA Inpatient / Emergency / OutPatient

U.S.A Emergency

CANADA Inpatient / Emergency / OutPatient


HONDURAS Inpatient / Emergency / OutPatient

BRAZIL Inpatient / Emergency / OutPatient

MEXICO Inpatient / Emergency / OutPatient

ARGENTINA Inpatient / Emergency / OutPatient

COLOMBIA Inpatient / Emergency / OutPatient

SALVADOR Inpatient / Emergency / OutPatient

VENEZUELA Inpatient / Emergency / OutPatient

JAMAICA Inpatient / Emergency / OutPatient

BOLIVIA Inpatient / Emergency / OutPatient

PERU Inpatient / Emergency / OutPatient

ECUADOR Inpatient / Emergency / OutPatient

BAHAMAS Inpatient / Emergency / OutPatient

GUYANA Inpatient / Emergency / OutPatient

CHILE Inpatient / Emergency / OutPatient

URUGUAY Inpatient / Emergency / OutPatient

NICARAGUA Inpatient / Emergency / OutPatient

PANAMA Inpatient / Emergency / OutPatient

BARBADOS Inpatient / Emergency / OutPatient

COSTA RICA Inpatient / Emergency / OutPatient

PUERTO RICO Inpatient / Emergency / OutPatient

DOMINICAN REPUBLIC Inpatient / Emergency / OutPatient

HAITI Inpatient / Emergency / OutPatient

GRENADA Inpatient / Emergency / OutPatient

GUATEMALA Inpatient / Emergency / OutPatient

MARTINIQUE Inpatient / Emergency / OutPatient

PARAGUAY Inpatient / Emergency / OutPatient

FRENCH GUYANA Inpatient / Emergency / OutPatient

SURINAM Inpatient / Emergency / OutPatient

BERMUDA Inpatient / Emergency / OutPatient

BELIZE Inpatient / Emergency / OutPatient

AUSTRALIA Inpatient / Emergency / OutPatient

NEW ZEALAND Inpatient / Emergency / OutPatient

FIJI ISLANDS Inpatient / Emergency / OutPatient

NEW CALEDONIA Inpatient / Emergency / OutPatient

ERITREA Inpatient / Emergency / OutPatient

KOSOVO Inpatient / Emergency / OutPatient

MACEDONIA Inpatient / Emergency / OutPatient


TRINIDAD Inpatient / Emergency / OutPatient

KASAKISTAN Inpatient / Emergency / OutPatient

SEYCHELLES Inpatient / Emergency / OutPatient

BELARUS Inpatient / Emergency / OutPatient

PAPUA NEW GUINEA Inpatient / Emergency / OutPatient

ANTIGUA & BARBUDA Inpatient / Emergency / OutPatient

COTE D'IVOIRE Inpatient / Emergency / OutPatient

Third: Inpatient healthcare Services at Authorized hospitals Treatment outside network is reimbursed upto 100%


In-patient Healthcare Services, subject to prior approval. Private (1 Bed)1.2. Tests, diagnosis, treatments and surgeries in hospitals for non-urgent medical cases,

subject to prior aproval

100%

Healthcare services for emergency cases3. 100%

4. Transportation services for medical emergencies inside the Emirate of Abu Dhabi by an

authorised party.

100%

5. Accommodation for a person accompanying an insured child up to 18years of age Full Coverage

Full CoverageAccommodation of an accompanying person in the same room in cases of critical

conditions and as per recommendation of attending physician, subject to prior approval.

6.

7. In-patient maternity services No Co-payment

8. Healthcare services for work illnesses and injuries as per Federal Law No. 8 of 1980

concerning the Regulation of Work Relations, as amended, and applicable laws in this

respect.

100%

Additional Details:

The above services are covered only in the emirate of Abu Dhabi up to AED 250,000 without co-pay.

The inpatient coverage of high cost medical conditions as defined by the Health Authority

(to be attached with the table of benefits), is subject to a 6 month waiting period unless

there is continuity of health insurance coverage or specifically waived in this table of

benefits.

9. Waiting period not waived

Fourth: Outpatient healthcare Services


Treatment outside network is reimbursed upto 100%

1. Examination, diagnostic and treatment services of clinics and health centers by general

practitioners, and specialists provided that the Insured Person is referred to a specialist

and/or consultant by a general practitioner. Follow ups are exempted from fees if made

within a week from the date of first examination.

100% with no co-payment

2. Laboratory tests services 100% with no co-payment

3. X-ray diagnostic services. In cases of non-medical emergencies, the insurance company ’s

prior approval is required for MRI, CT scans and endoscopies.


Physiotherapy treatment services, subject to insurance company prior approval. 4. 100%


5. Cost of medicine, subject to insurance company’s prior approval for prescriptions which

exceed AED 1840.

100%with co-payment of 0%

Subject to maximum AED

38640000/ Year

6. Examination, diagnostic and treatment services for pregnancy and gynaecology services in

authorised health centers and clinics by general practitioners and specialists, provided that

the Insured Person is referred to a specialist and/or consultant by a general practitioner.

Follow ups are exempted from fees if made within a week from the date of first

examination.


7.Healthcare services for work illnesses and injuries as per Federal Law No. 8 of 1980

concerning the Regulation of Work Relations, as amended, and applicable laws in this

respect.


Fifth: Other Benefits

SL# Detail %

Limit

(AED)

Co-Pay

(%)

Deductible

(AED)Coverage Additional Details

Diagnostic and treatment

services for dental and gum

treatments

100Emergency/Life

Threatening

1

Hearing and vision aids, and

vision correction by surgeries,

and laser

100Emergency/Life

Threatening

2

Hospital Cash Benefit 100 For treatment of an

eligible medical

condition. Subject to

maximum of 20

nights & no costs

are incurred for

accomodation and /

or treatment. This

is not applicable to

accident and

Emergency

addmissions.

Limit AED 645 per

night.

Inpatient 3 0 0 920


Evacuation & Additional Travel

Expense

Evacuation of a member in the

event of an emergency, where

treatment is not readily available

at the place of the incident, to

the nearest appropriate medical

facility as determined by us, by

the most appropriate method of

transportation as determined by

us, for the purpose of admission

to hospital as an inpatient or day

patient.

Evacuation is subject to written

agreement from us, prior to

travel and certified instructions

to us from the attending medical

practitioner or specialist

including confirmation that the

required treatment is

unavailable at the place of

incident.

This benefit excludes all

maternity and childbirth costs

except where these are covered

under the benefit for

Complications of Pregnancy,

and any air-sea rescue or

mountain rescue costs that are

not incurred at recognised ski

resorts or similar winter sports

resorts. Cover is provided for:

100Emergency 4 0 038640000

v) Non-hospital

accommodation for the

member and escort for

immediate pre- and

post-hospital admission

periods provided that the

member is under the care of

a specialist.

AED 920 per

person per day and

AED 36,800 per

person, per

Evacuation

Emergency 100 36,800 0 0 4.1

i) Evacuation costs

including the costs of one

other person to travel with

the member as an escort, if

medically necessary.

Emergency 100 38,640,000 0 0 4.2

iii) For an accompanying

person to travel to and from

the hospital to visit the

member following admission

as an inpatient.

Emergency 100 38,640,000 0 0 4.3


ii) Travel to and from

medical appointments when

treatment is being received

as a day patient.

Emergency 100 38,640,000 0 0 4.4

iv) Economy class airline

tickets to return the member

and the escort to the country

of residence or to the

country where evacuation

occurred.

Emergency 100 38,640,000 0 0 4.5

Mortal Remains 100 i)Transportation of a

body or ashes to

Country of

Nationality or

Residence, or

ii)Burial or

cremation costs at

the place of death

Emergency 5 0 0 55200

Inpatient Care

Reconstructive Surgery and

Rehabilitation

Charges incurred for the

treatment of a medical

condition, including stabilisation

of an acute chronic condition,

when treatment is received as

an inpatient or day patient

including:

100Inpatient/OutPatient 6 0 038640000

iii) Charges for nursing by

a qualified nurse and theatre

fees.

Inpatient 100 38,640,000 0 0 6.1

ii) Admittance to the

intensive care unit.

Inpatient 100 38,640,000 0 0 6.2

iv) Medical practitioner fees

including consultations,

specialist fees and

anaesthetist fees.

Inpatient 100 38,640,000 0 0 6.3

v) Diagnostic and surgical

procedures including

pathology and x-rays.

Inpatient 100 38,640,000 0 0 6.4

i) Accommodation and

associated charges.

Accommodation is

subject to any

selected inpatient

bed limit

Inpatient 100 38,640,000 0 0 6.5


viii) Rehabilitation (including

outpatient treatment) in a

recognised rehabilitation

unit of a hospital

subsequent to inpatient

treatment lasting 3 days or

more, which takes place

within 14 days of discharge.

Treatment must be

recommended and under

the direct control of a

specialist. Treatment

includes the use of special

treatment rooms, physical

and/or speech therapy fees,

and other services usually

given by a rehabilitation unit.

(For treatment recieved

outside Abu Dhabi).

Up to 120 days per

medical condition

Inpatient/OutPatient 100 38,640,000 0 0 6.6

vii) Drugs, dressings,

medicines and appliances

prescribed by a medical

practitioner or specialist,

including Traditional

Chinese Medicine.


vi) Reconstructive surgery

(including outpatient

treatment) to restore natural

function or appearance

required as a result of an

accident or illness occurring

during the period of cover

and where treatment takes

place within 12 months of

the insured event occurring.


Organ transplant 100 The Organ

Transplants cover

for Heart,

Heart/lung, Lung,

Kidney,

Kidney/pancreas,

Liver, Allogenic

bone marrow, and

Autologous bone

marrow.

Inpatient/Emergency/Life

Threatening

7 0 038640000


Out Patient Surgery 100 This benefit extends

to cover the cost of

Endoscopy

investigations

carried out under an

Out-Patient basis,

including

Gastroscopy,

Bronchoscopy,

Colonoscopy,

Colposcopy, but

excludes

Laparoscopy and

Arthroscopy which

are covered under

the In-Patient Care

Benefit.

Emergency/OutPatient/Life

Threatening

8 0 038640000

New Born Cover (In patient

Treatment of an Acute Medical

Condition and any associated

costs which presents symptoms

at birth or which manifests itself

within 30 days of birth.)

100 Maximum of 90

days hospital stay.

Inpatient 9 0 0 367800

New Born Accommodation 100 Hospital

accommodation

costs relating to a

New Born baby (up

to 16 weeks old) to

accompany it

mother (being an

insured person)

whilst she is

receiving treatment

as an in patient in a

hospital

Inpatient 10 0 038640000

Oncology 100 All medically

necessary

treatment received

for, or related to, the

diagnosis of cancer

when received as

an inpatient, day

patient or outpatient

including palliative

treatment.

Inpatient/OutPatient/Life

Threatening

11 0 038640000


Prosthetic devices and

consumed medical equipments

approved by the insurance

company

100 Up to AED 36,800

per period of cover

Inpatient/OutPatient 12 0 0 36800

Home Nursing 100 Immediately

following hospital

discharge on the

recommendation of

a Specialist and

must be provided by

Qualified Nurse.

All treatments under

this benefit must be

pre-authorized by

Us.

Up to 28 weeks per

condition.

Inpatient/Emergency/Life

Threatening

13 0 038640000

AIDS - Medical Expenses which

arise from or are in any way

related to Human

Immunodeficiency Virus (HIV)

and/or HIV related illness,

including Acquired Immune

Deficiency Syndrome (AIDS) or

AIDS related Complex (ARC)

and/or any mutant derivative or

variation thereof.

100 Expenses are

limited to pre and

post diagnosis

consultations,

routine check-ups

for this condition,

Drugs and

Dressings (except

experimental or

those unproven),

Hospital

accommodation and

nursing fees

Inpatient/Life Threatening 14 0 038640000

Out-Patient Psychiatric

Treatment

Including Specialist

consultations. All Benefits are

conditional upon

pre-authorization from Us and

all Treatment must be

administered under the direct

control of a registered

psychiatrist.

100 For Treatment

within Abu Dhabi -

Conditions related

to transient mental

disorder or an acute

reaction to stress is

covered 100% up to

AED 250,000 strictly

under the Abu

Dhabi Health

regulations.

Inpatient/Emergency 15 0 0 18400


In Patient Psychiatric Treatment

In a registered psychiatric unit of

a Hospital. All benefits are

conditional upon

pre-authorisation and all

treatment being administered

under the direct control of a

registered psychiatrist

100 Up to 30 days

treatment per period

of cover if availed

outside the Emirate

of Abu Dhabi.

However, if availed

within the Emirate

of Abu Dhabi

-Conditions related

to transient mental

disorder or an acute

reaction to stress is

covered 100%

without the above

cap of 30 days..

Inpatient/Emergency 16 0 038640000

Complications of Pregnancy

Treatment of a medical

condition arising during the

antenatal stages of pregnancy,

a medical condition arising

during childbirth and one that

requires a recognised obstetric

procedure, and post natal

checkups required as a result of

the complication of pregnancy

for up to six weeks.

100Inpatient 17 0 038640000

Chronic Conditions

Routine checkups, drugs and

dressings prescribed for

management of the condition,

hospital accommodation

nursing, renal dialysis, surgery

and palliative treatment of

chronic conditions (excluding

cancer). Costs for the treatment

of cancer are covered under the

oncology benefit.

100Inpatient/Emergency/OutP

atient

18 0 038640000

CT PET and MRI Scans 100 Scans received as

an In-Patient,

Day-Patient, or

Out-Patient.

This must be

pre-authorised by

insurance company.

Inpatient/OutPatient 19 0 038640000


Parental Accommodation 100 Hospital

accommodation

costs for a standard

Private Room in

respect of a parent

or legal guardian

staying with a

Member who is

under 18 years of

age and is admitted

to Hospital as an

In-Patient.

Inpatient 20 0 038640000

Transportation services for

medical emergencies by an

authorised party

100 Emergency

transportation costs

to and from Hospital

to receive

Treatment as an

In-Patient or

Day-Patient, by the

most appropriate

transport method

when considered

Medically

Necessary by a

Medical Practitioner

or Specialist.

This benefit does

not include the cost

of car hire.

Inpatient/Emergency/OutP

atient/Life Threatening

21 0 038640000


Accident & Emergency

Treatment outside area of cover

100 Benefit is payable

for medical

expenses which

arise as a result of

an Emergency,

which require the

Member to seek

Treatment in the

Accident and

Emergency unit of a

Hospital whilst

temporarily

travelling inside the

USA and where the

Medical Condition

did not exist prior to

travel and the

member was

Treatment,

symptom and

Advice free.

This benefit extends

to include

Out-Patient

Treatment arising

as a result of an

Accident or

Emergency, whilst

you are temporarily

travelling in the USA

and where the

Medical Condition

did not exist prior to

travel and you were

Treatment,

symptom and

Advice free. For

Out-Patients

treatment a Benefit

Excess applies.

In the event of

Accident and

Emergency

Treatment being

required inside the

USA, the Member

should contact Us

or Our 24-hour

Emergency

Emergency/OutPatient/Life

Threatening

22 0 038640000


Assistance Medical

Helpline either

before or as soon

as possible after

admission to the

Accident and

Emergency unit of

the Hospital.

Complications of

pregnancy and/or

childbirth are not

covered under this

benefit.

AED 1,839

per medical

condition

and is subject to an

excess of AED 295

Congenital Anomalies -

Including Pre-existing

Congenital Anomalies Outside

the Emirate of Abu Dhabi

100 Treatment of

congenital

anomalies. This

benefit excludes

any hereditary

medical conditions.


Congenital Anomalies -

Including Pre-existing

Congenital Anomalies

Treatment of congenital

anomalies

within the Emirate of Abu Dhabi

100 Where Insured

Persons are

receiving Treatment

in Abu Dhabi this

benefit is extended

to include

Congenital

Anomalies which

are life threatening,

including hereditary

Congenital

anomalies. .

Inpatient/OutPatient/Life

Threatening

24 0 0 368000

Vaccinations and Inoculations 100 This Benefit

includes that are

Medically

Necessary for travel



Hospice Care

Treatment provided by a

hospice for the care of a

Member upon diagnosis of a

terminal Illness. Such Treatment

will cover:

i) Palliative Treatment and other

Acute and Chronic symptom

management.

ii) Medical social services under

the direction of a Medical

Practitioner or Specialist.

iii) Physiological and dietary

counselling.

iv) Consultation or case

management services by a

Medical Practitioner or

Specialist.

v) Part-time or intermittent

Qualified Nurse services for up

to eight hours in any one day for

Out-Patient care.

100 Covered in full up to

30 days per lifetime

Inpatient/Emergency 26 0 038640000


Routine Pregnancy 100 Costs associated

with normal

pregnancy and

childbirth, including

normal deliveries as

a result of infertility

treatment (assisted

conception),

voluntary caesarean

section costs and

medically necessary

caesarean costs

due to any previous

non-emergency

caesarean sections

undertaken. This

benefit covers the

cost of pre- and

post-natal checkups

for up to six weeks,

prescribed pre natal

vitamins and

delivery costs,

including qualified

midwives. All costs

relating to

complications of

pregnancy or

childbirth following

infertility treatment

(assisted

conception) will be

limited to this

benefit.

This benefit extends

to include neo natal

care, new born

packages (including

elective

circumcision) and

costs incurred for

the care of the baby

or babies for the

first 24 hours

following birth when

the baby is

accompanying its

mother (being a

member) whilst she



is receiving

treatment as an

inpatient in a

hospital. The policy

excess does not

apply.

Other HAAD Mandated Benefits 100 All other HAAD

mandated benefits

that are not

specifically stated in

this benefit

schedule

Inpatient/Emergency/OutP

atient/Life Threatening

28 0 0 250000

Emergency Services in UAE 100 All cases of

Emergency and Life

Threatening

services in UAE are

covered up to AED

250,000 or to a

higher amount as

specifically stated in

this Benefit

schedule

Emergency 29 0 0 250000

Alternative Treatment

Treatment administered by

registered chiropractors,

osteopaths, homeopaths,

podiatrists and acupuncturists

when given under the direct

control of and following referral

by a medical practitioner or

specialist.

100 Up to 20 sessions in

aggregate per

medical condition



Extended Evacuation 100 This benefit covers

the evacuation

costs of a member

in the event

emergency

treatment is not

readily available at

the place of

incident, to the

nearest appropriate

medical facility,

country of

residence, country

of nationality or

country of the

member’s choice

for the purpose of

admission to

hospital as an

inpatient or day

patient, including

the cost of one

other person to

travel with the

member as an

escort if medically

necessary.

Evacuation is

subject to written

agreement from us

prior to travel and

certified instructions

to us from the

attending medical

practitioner or

specialist including

confirmation that

the required

treatment is

unavailable in the

place of incident.

The member’s

country of choice is

limited to

appropriate medical

facilities being in

place and where it

is medically suitable

at our discretion.

Emergency 31 0 038640000


This option is not

rative where travel

is undertaken

against the advice

of our medical

advisors or where

the nominated

country does not

have the

appropriate facility

to treat the medical

condition. Our

medical advisors

will decide the most

appropriate method

of transportation for

the evacuation.

This benefit

excludes any

air-sea rescue or

mountain rescue

costs that are not

incurred at

recognised ski

resorts or similar

winter sports

resorts, all maternity

and childbirth costs

except where these

are covered under

the benefit for

complications of

pregnancy, and

elective treatment in

the USA unless this

benefit has been

purchased and

appears on the

member’s benefit

schedule.

Traditional Chinese or Ayurvedic

Medicine

Treatment administered by a

recognised medical practitioner.

The policy excess does not

apply.

100 AED 110 per

session to a

maximum of 20

sessions.

/OutPatient 32 0 0 2200


Wellness

This benefit covers the cost of:

• Bilateral mammogram/breast

examination and routine

gynaecological tests including

PAP tests

• Testicular/prostate

examination/PSA/DRE tests

• Routine medical checkups

and associated tests. Such

routine checkups/tests include:

blood and cholesterol checks,

height/weight body mass index,

resting blood pressure, urine

analysis, cardiac examination,

exercise electrocardiogram

(ECG), other vital organ function

tests, and chest x-ray.

• Well-baby checks following

the first 24 hours after birth as

recommended by a medical

practitioner or specialist. This

includes physical examinations,

measurements, sensory

screening, neuropsychiatric

evaluation, development

screening, as well as hereditary

and metabolic screening,

immunisations, urine analysis,

tuberculin tests and hematocrit,

haemoglobin and other blood

tests, including tests to screen

for sickle hemoglobinopathy.

The policy excess does not

apply.

100 Up to 6,256 per

insured person per

period of cover

/OutPatient 33 0 0 6256

Compassionate Emergency

Travel

Reasonable travel and

accommodation expenses in

respect of one member,

together with any minors (under

the age of 16) necessarily

having to travel to and the return

journey from the normal country

of nationality or country of

residence of a near relative who

has unexpectedly been placed

on the critical list following an

accident or who has died.

100Emergency 34 0 0 11040


Out of Country Transportation

The costs of moving an insured

person in the event of medically

necessary non-emergency

treatment not being readily

available at the place of the

incident,

to the nearest centre of medical

excellence, within the area of

cover, for the purpose of

admission to hospital as an

inpatient or day patient

(excluding all

maternity or childbirth costs,

except for complications of

pregnancy) and/or for the

purpose of seeking any

medically necessary inpatient,

day patient or

outpatient treatment. Cover

under this benefit is subject to

written agreement from us prior

to travel and certified

instructions from the attending

medical

practitioner or specialist,

including confirmation that the

required treatment is

unavailable at the place of

incident. Cover is provided for:

100Emergency 35 0 038640000

Economy class airline

ticket to return the member

and any escort to the

country of residence or to

the country where

evacuation occurred

Emergency 100 38,640,000 0 0 35.1

For an accompanying

person to travel to and from

the hospital to visit the

member following admission

as an inpatient

Emergency 100 38,640,000 0 0 35.2

Travel to and from medical

appointments when

treatment is being received

as a day patient

Emergency 100 38,640,000 0 0 35.3


Evacuation costs (restricted

to economy class flight

tickets only) including the

costs of one other person to

travel with the member as

an escort, if medically

necessary

Emergency 100 38,640,000 0 0 35.4

Non-hospital

accommodation for the

member and escort for

immediate pre- and

post-hospital admission

periods provided that the

member is under the care of

a specialist.

Up to 920 per

person per day and

AED 36,800 per

person, per

evacuation

Emergency 100 36,800 0 0 35.5


Infertility Treatment

Ovulation induction induced via

certain oral or injectable

infertility medication, artificial

insemination and advanced

reproductive technology (ART)

procedures and in vitro

fertilisation (IVF) with embryo

transfer.

This benefit requires

preauthorisation prior to any

treatment taking place and

approval of medication and

procedures to be undertaken.

The following exclusions apply:

• Couples in which one of the

partners has undergone a

sterilisation procedure with or

without a surgical reversal

• Females with FSH levels 19

mlU/ml or greater on day 3 of

their menstrual cycle, or who

manifest a positive clomid

challenge

• Charges for: the purchase and

storage of donor sperm, the

care of the donor required for

donor egg retrievals or transfers,

cryopreservation or storage of

cryo-preserved embryos

• ART for women without male

partners who have not had at

least 12 cycles of donor

insemination prior to enrolling in

the infertility programme for

ART (6 cycles if the member is

age 35 or older)

• Charges associated with a

gestational carrier programme

(surrogate parenting) for either

the member or the gestational

carrier

100 Up to AED 92, 000

per member per

lifetime


Any additional benefits listed above shall not cancel, limit, or contradict any mandatory benefit defined as a minimum

coverage by the Abu Dhabi health insurance law, and shall be interpreted within the context of law and to the benefit of

the insured.The presence of such limitations shall be applicable only to treatments covered outside the mandatory

geographical area of coverage.


Schedule 2

Excluded healthcare Services

1. Healthcare Services, which are not medically necessary Not Covered

2. All expenses relating to dental treatment, dental prostheses, and orthodontic treatments. Not Covered

3. Domiciliary care; private nursing care; care for the sake of travelling. Not Covered

4. Custodial care includes (1) Non medical treatment services; or (2) Health related services

which do not seek to improve or which do not result in a change in the medical condition of the

patient.

Not Covered

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

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

similar incidental services and supplies).

Not Covered

7. Healthcare Services and associated expenses for replacement of an existing breast implant.

Cosmetic operations which improve physical appearance and 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. Breast reconstruction following a mastectomy for cancer is covered.

Not Covered

8. Surgical and non-surgical treatment for obesity (including morbid obesity), and any other weight

control programs, services, or supplies.

Not Covered

9. Medically non-approved experimental, research, investigational healthcare services, treatments,

devices and pharmacological regimens.

Not Covered

10. Healthcare Services that are not performed by Authorised Healthcare Service Providers, apart

from Healthcare Services rendered in a Medical Emergency.

Not Covered

11. Healthcare services, treatments & associated expenses for alopecia, baldness, hair falling,

dandruff or wigs.

Not Covered

12. Supplies, Treatment and services for smoking cessation programs and the treatment of nicotine

addiction.

Not Covered

13. Non-medically necessary Amniocentesis. Not Covered

14. Treatment, services and surgeries for sex transformation, sterility and sterilization Not Covered

15. Treatment and services for contraception Not Covered

16. Treatment and services related to fertility / sterility (treatment including varicocele / polycystic

ovary / ovarian cyst / hormonal disturbances / sexual dysfunction).

Not Covered

17. Prosthetic devices and consumed medical equipments, unless approved by the insurance

company

Not Covered

18. 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

Not Covered

19. Growth hormone therapy Not Covered


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

aids.

Not Covered

21. Mental Health diseases, in-patient and out-patient treatments, unless the condition is a transient

mental disorder or an acute reaction to stress.

Not Covered

22. Patient treatment supplies (including elastic stockings, ace bandages, gauze, syringes, diabetic

test strips, and like products; non-prescription drugs and treatments, excluding such supplies

required as a result of Healthcare Services rendered during a Medical Emergency).

Not Covered

23. Preventive services, including vaccinations, immunizations, allergy testing and desensitization;

any physical, psychiatric or psychological examinations or testing during these examinations.

Not Covered

24. Services rendered by any medical provider relevant of a patient for example the Insured person

and the Insured member.s family, including spouse, brother, sister, parent or child.

Not Covered

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

necessary during treatment.

Not Covered

26. Healthcare services for adjustment of spinal subluxation, diagnosis and treatment by

manipulation of the skeletal structure, by any means, except treatment of fractures and dislocations

of the extremities.

Not Covered

27. Healthcare services and treatments) by acupuncture; acupressure, hypnotism, rolfing, massage

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

Not Covered

28. All Healthcare services & Treatments for in-vitro fertilization (IVF), embryo transport; ovum and

male sperms transport

Not Covered

29. Elective diagnostic services and medical treatment for correction of vision. Not Covered

30. Nasal septum deviation and nasal concha resection. Not Covered

31. All chronic conditions requiring hemodialysis or peritoneal dialysis, and related test/treatment or

procedure.

Not Covered

32. Treatments and services related to viral hepatitis and associated complications, except for

treatment and services related to Hepatitis A.

Not Covered

33. Birth defects, Congenital diseases for newborn &/or Deformities unless life-threatening. Not Covered

34. Healthcare services for Senile dementia and Alzheimer.s disease. Not Covered

35. Air or Terrestrial Medical evacuation except for Emergency cases or unauthorised transportation

services.

Not Covered

36. Circumcision healthcare services. Not Covered

37. 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.

Not Covered

38. Any inpatient treatment, tests and other procedures, which can be carried out on outpatient basis

without jeopardizing the Insured Person.s health.

Not Covered

39. Any test or treatment, for purpose other than medical such as tests related for employment,

travel, licensing or insurance purposes.

Not Covered


40. 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,

convenience items / options, exercise equipment and sanitary supplies.

Not Covered

41. More than one consultation or follow up with a medical specialist in a single day unless referred

by a physician.

Not Covered

42. Health services and associated expenses for organ and tissue transplants, irrespective of

whether the Insured Person is a donor or recipient.

Not Covered

43. Services and educational program for handicaps. Not Covered

Healthcare Services outside the Scope of Health Insurance

Schedule No.3

Not Covered1. Injuries or illnesses suffered by the Insured Person as a result of military operations of whatever

type.

Not Covered2. Injuries or illnesses suffered by the Insured Person as a result of wars or acts of terror of whatever

type.

Not Covered3. Healthcare services for injuries and accidents arising from nuclear or chemical contamination.

Not Covered4. Injuries resulting from natural disasters (including but not limited to) earthquakes, tornados and any

other type of natural disaster.

Not Covered5. Injuries resulting from criminal acts or resisting authority by the Insured Person.

Not Covered6. Healthcare services for patients suffering from AIDS and its complications.

Covered7. Healthcare services for work illnesses and injuries as per Federal Law No. 8 of 1980 concerning the

Regulation of Work Relations, as amended, and applicable laws in this respect.

Not Covered8. All cases resulting from the use of alcohol, drugs and hallucinatory substances.

Not Covered9. Any test or treatment not prescribed by a doctor.

Not Covered10. Injuries resulting from attempted suicide or self-inflicted injuries.

Not Covered11. Diagnosis and treatment services for complications of exempted illnesses.

Not Covered12. All healthcare services for internationally and locally recognised epidemics.

Not Covered13. Venereal sexually transmitted diseases. A list with respect thereto will be set out by the General

Authority of Health Services.


Documents

COMPANY NAME : Royal & Sun Alliance Insurance (Middle …...1.Examination, diagnostic and treatment services of clinics and health centers by general practitioners, and specialists