Frequently Asked Questions

Health

• Accident

  Definition(s)

  A sudden, unforeseen, unexpected, or unintended event causing a physical injury which is identifiable, documented by Police or Physician, and is not a result of sickness, disease, or gradual physical or mental process. Injury arising from accident is called “accidental injury”.

   

  
  What is covered?
  We cover injuries arising from accidents (unless such accidents are attributed to an excluded condition).

   

  
  What is NOT covered?

  • Accidents resulting from an excluded condition/activity.
  • Where the accident is covered, expenses other than for medical treatment (such as loss of salary, disability compensation, and so on).

   

  
  Mode/basis of claim

  Within your eligible network

  Direct Billing.

   

  Outside your eligible network or from abroad

  Reimbursement.

• Accident-Related Dental Treatment | Diagnostic and Treatment Services for Dental and Gum Treatment in Emergency Cases

  Definition(s)

  Emergency medical treatment necessary to restore or replace sound natural teeth lost or damaged in an accident and for which medical treatment is provided within 72 hours following the accident.

   

  
  What is covered?
  Coverage is applicable in case of life-threatening emergencies due to an injury or accident.

   

  
  What is NOT covered?

  Non-accident-related or outpatient dental services (unless the benefit is subscribed for and listed in the Table of Benefits).

   

  
  Mode/basis of claim

  Within your eligible network

  Direct Billing (excluding benefits which are specifically offered on a reimbursement basis).

   

  Outside your eligible network or from abroad

  Reimbursement.

   

   

  Mandatory benefit as per Regulation

  Mandatory in case of emergencies.

• Acne | Corns | Warts

  What is covered?
  Medically necessary treatment for infected cases.

   

  
  What is NOT covered?

  Non-infected or cosmetic cases (unless specified as 'covered').

   

  
  Mode/basis of claim

  Within your eligible network

  Direct Billing.

   

  Outside your eligible network or from abroad

  Reimbursement.

• Airfare for Treatment Abroad

  What is covered?
  If listed as ‘covered’ in the Table of Benefits, it will be subject to the following: 

  • Treatment within the member’s eligible geographical area for elective treatments as per policy.
  • Inpatient treatments.
  • Cost of treatment is less than 70 percent of the applicable network customary tariff of the country of policy issuance.
  • Airfare class: Economy.
  • Reimbursement for the patient’s airfare only – no airfare coverage for companions
  • Reimbursement will be limited to AED 2,000 maximum per treatment.
  • Maximum overall cost (inclusive of airfare) should not exceed 90 percent of Sukoon’s applicable network tariff.

   

  
  What is NOT covered?

  • Air transportation costs (unless listed as ‘covered’ in the Table of Benefits).
  • Costs for companion or family members.
  • Costs exceeding the specific limits and conditions (in case airfare is covered in the policy).
  

   

   

  Mode/basis of claim 

  Reimbursement, along with proof (ticket), and inpatient claims.

   

   

  Mandatory benefit as per Regulation

  Optional.

• Allergy | Allergen Testing

  What is covered?
  Medical care, treatment, or management of allergic conditions.

   

  
  What is NOT covered?

  Allergen testing/screening or desensitisation (unless stated as ‘covered’ in the Table of Benefits).

   

  
  Mode/basis of claim

  Within your eligible network

  Direct Billing.

   

  Outside your eligible network or from abroad

  Reimbursement.

• Alternative Medicine | Alternative Therapy

  Definition(s)

  Therapeutic and diagnostic services that exist outside institutions where conventional allopathic medicine is provided. They include, but are not limited to, acupuncture, acupressure, hypnotism, rolfing, massage therapy, aromatherapy, homeopathic treatment, ayurvedic treatment, chiropody, herbal medicine, body technique, lymphatic drainage, cupping, magnetotherapy, and holistic and spa treatments. The form of treatment must be recognised and licensed by the respective authority of the country where treatment is taken.

   

   

  Explanation

  Alternative Medicine/Therapy is covered if opted for separately. 

   

  If covered, this will be paid on reimbursement basis, and will be subject to limits if the policy covers acupuncture, acupressure, homeopathic treatment, ayurvedic treatment, chiropody, podiatry, lymphatic drainage, magnetotherapy, Chinese medicine and/or chiropractic. The form of treatment must be recognised and licensed by the respective authority in the country where the policy has been issued.

   

   

  
  What is covered?
  For Basic Alternative Medicines cover

  • Services include Ayurveda, Homeopathy, and Chinese Medicine. 
  • To be performed or provided by a licensed practitioner.

   

  For Enhanced Alternative Medicines cover

  • Services include acupuncture, acupressure, chiropody, lymphatic drainage (cupping), magneto therapy, chiropractic, and osteopathy on top of Basic Alternative Medicines cover.
  • To be performed or provided by a licensed practitioner only.
  

   

   

  What is NOT covered?

  • Alternative system of medicines not listed in the covered list. 

  • Where alternative treatment is covered, the following are excluded:

  o Treatments medically not necessary.
  o Treatments by persons not licensed by the local regulatory bodies.
  o Treatments in Health Hydro/Spa.
  

   

   

  
  Mode/basis of claim 

  Reimbursement.

   

   

  Tips

  Even though podiatry and herbal medicine could be included, you must nevertheless read the Table of Benefits in length. The same, by default, is not part of the Alternative Medicine cover if offered.

   

   

  Mandatory benefit as per Regulation

  Optional.

• Ambulance Services

  Definition(s)

  A licensed vehicle designed for transportation of sick or injured people to, from, or between places of treatment.

   

   

  What is covered?

  Expenses for a local, licensed road ambulance to transport the Insured to or from the medical facility for treatment when the patient cannot use any other vehicle for such purpose.

   

   

  What is NOT covered?

  We will neither cover:

  • Cross-border road or air ambulance transportation; nor
  • Transportation from the place of treatment to the place of residence (unless recommended by the Treating Doctor and approved by the Insurer).

   

    

  Mode/basis of claim 

  Reimbursement (unless the service is provided by one of the eligible network providers).

   

   

  Tips

  Where emergency medical evacuation is eligible as per the Emergency Assistance Program prescribed in the policy, air ambulance or cross-border transportation may be used by the service provider as and when required.

• Cash Benefit - Inpatient

  Definition(s)

  A lumpsum amount payable to the Insured who receives treatment as an inpatient for an eligible medical condition, within the area of coverage, absolutely free of charge. No other benefit will be payable in respect of the period for which the cash benefit has been paid.

   

   

  Explanation

  To claim the Inpatient Cash Benefit, the Insured must submit the original discharge summary as proof of hospital admission. The Cash Benefit is payable only when treatment was availed free of charge and has not been billed to any insurance company. The extent of payment will be defined in your policy’s Table of Benefits.

   

   

  
  What is covered?
  If opted for

  • Cash indemnity benefit of AED 200 per night (for a maximum of 30 nights) for inpatient hospitalisation against free, covered treatment received and/or not being claimed from any insurance company. 
  • Original discharge summary must also be submitted.

   

   

  What is NOT covered?

  Cash Indemnity is not payable if the treatment is invoiced.
  

   

   

  
  Mode/basis of claim 

  Reimbursement.

   

   

  Tips

  The cash amount may vary. Please review the Table of Benefits before availing treatment or a medical service.

   

   

  Mandatory benefit as per Regulation

  Optional.

• Chronic Conditions

  Definition(s)

  A disease, illness, or injury with one or more of the following characteristics: 

  • It needs ongoing or long-term monitoring through consultations, examinations, check-ups, and/or tests. 
  • It needs ongoing or long-term control or relief of symptoms.
  • It may require rehabilitation or the patient to be trained to cope with it.
  • It continues indefinitely.
  • It comes back or is likely to come back.

   

  Explanation

  Are chronic conditions are covered or not? Is there any waiting period or a limit applicable to it? Please refer to your policy’s Table of Benefits to find out. 

   

  Relevant terms are applicable irrespective of whether the condition was declared or not. 

   

  We will not cover any Chronic Condition if it is listed as not covered in your table of benefits. Similarly, even if chronic conditions are covered but the specific condition is listed as an exclusion, then it will not be covered. 

   

  Pharmaceutical Benefits Management (PBM) system in pharmacies limits dispensing medication up to maximum of 60 days only.

   

   

  What is covered?

  If listed in the Table of Benefits as ‘covered’, all chronic medical conditions which are not part of the policy’s Exclusions are covered up to limits, if any, defined in the Table.

   

   

  What is NOT covered?

  • All excluded benefits and services.
  • Chronic conditions, declared or undeclared, excluded as per your policy.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing (except for benefits exclusively offered on reimbursement basis).

   

  Outside your eligible network or from abroad

  Reimbursement.

   

   

  Mandatory Benefit as per Regulation

  Mandatory.

• Circumcision

  What is covered?

  • Medically necessary circumcision advised by a physician as part of treatment. 
  • Circumcision for new Muslims covered by Abu Dhabi policies as mandated by the Department of Health, Abu Dhabi (HAAD).
  

   

   

  What is NOT covered?

  We do not cover expenses for circumcision carried out for non-medically necessary purposes or religious reasons (unless specified under the Schedule of Benefits).

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing (with prior approval).

   

  Outside your eligible network or from abroad

  Reimbursement.

   

   

  Mandatory Benefit as per Regulation

  As per HAAD, circumcision for new Muslims is to be covered.

• Coinsurance

  Definition(s)

  Cost-sharing arrangement under a health insurance policy through which the Insured bears only a specified percentage of the admissible costs.
  

   

   

  Explanation

  Coinsurance is stated as a percentage of the medical expenses incurred. If any coinsurance is applicable to your policy, then the fact will be stated in its Table of Benefits. It is also printed on your card to allow the provider offering direct billing services to collect only the applicable amount(s) from the Insured. 

   

  For reimbursement, the amount is deducted from your claim. 

   

  Also, all benefits’ limits/sublimits are inclusive of coinsurance/deductible if the same applies, unless explicitly stated otherwise in your policy.
  

   

• Coinsurance (Out-of-Pocket Ceiling)

  Explanation

  The maximum coinsurance amount an Insured is liable to pay per claim or year.

   

  Upon reaching the ceiling, the member will not be required to pay coinsurance for services on which an ‘out-of-pocket ceiling’ is applicable.

• Coinsurance on Reimbursement Claims

  Definition(s)

  Coinsurance applicable on claims from providers not listed in the eligible network, and reimbursement claims from network providers.
  

   

   

  Explanation

  This is an additional coinsurance applied on all reimbursement claims (unless specified otherwise in the policy). 
  
  As a standard, we apply a 20 percent coinsurance on all reimbursement claims. This will be applied after calculating the eligible amount, less policy deductible or coinsurance. 

   

   

  Tips

  Benefits covered only on reimbursement basis are not subject to network or out-of-network coinsurance. Only the deductible and/or coinsurance, if any, set against that specific benefit shall apply.

• Companion Accommodation

  Definition(s)

  Accommodation of a person accompanying the Insured (availing inpatient treatment or services) in the same room in cases of medical necessity as per recommendation of the treating doctor.

   

  What is covered?

  Accommodation of a person accompanying the hospitalised patient in the same room in cases of medical necessity as per recommendation of the treating doctor. This applies to:

  • Accommodation for parents of a patient insured by us below the age of 18.
  • Accommodation for the companion of an insured member who is critically ill.

   

   

  What is NOT covered?

  • Accommodation in a room separate from the patient’s (such as a hotel room).
  • Costs incurred on food, telephone services, and any other services availed by the companion. 
  • Accommodation expenses for an individual accompanying the patient without the recommendation of the treating doctor and at the request of the patient or said companion.
  

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing (except for benefits exclusively offered on reimbursement basis).

   

  Outside your eligible network or from abroad

  Reimbursement.

• Congenital Abnormality | Birth Defect

  Definition(s)

  A congenital anomaly (also known as a birth defect) is an abnormality that affects the baby during the period of development in utero (during the period of pregnancy before birth). This includes for example by order of incidence abnormalities affecting the limbs (arms and legs) like missing or extra fingers or toes, deficiencies in limb length, and abnormalities in positioning, such as club foot. Heart abnormalities including 'holes in the heart' where blood can pass from one side of the heart to the other. Defects affecting the spinal cord, such as spina bifida. Defects affecting the face (such as cleft lip and palate), problems with the development of the intestines and stomach, and problems affecting the sexual organs. Major chromosomal problems, such as Down's syndrome.

   

   

  What is covered?

  Abu Dhabi policies

  Congenital medical conditions covered, excluding elective treatments for new born.

   

  Dubai policies

  Cosmetic operations which are related to congenital anomaly when the primary purpose is to improve physiological functioning of the involved part of the body are covered.

   

   

  What is NOT covered?

  Abu Dhabi policies

  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.

   

  Dubai, Northern Emirates, and overseas policies
  Birth defects, congenital diseases and deformities.
  

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing (except for benefits exclusively offered on reimbursement basis).

   

  Outside your eligible network or from abroad

  Reimbursement.

   

   

  Mandatory Benefit as per Regulation

  Department of Health, Abu Dhabi (HAAD)

  Congenital medical conditions covered, excluding elective treatments for newborn. 

   

  Dubai Health Authority (DHA)

  Cosmetic operations which are related to congenital anomaly when the primary purpose is to improve physiological functioning of the involved part of the body are covered.

• Cosmetic Healthcare Services

  Definition(s)

  Any elective healthcare service or any portion thereof performed to improve physical appearance and/or treat a mental condition through change in bodily form.

   

   

  What is covered?

  Cosmetic treatments, procedures as required as part of a treatment for covered sickness or injury.

   

   

  What is NOT covered?

  • Treatments and/or procedures which are not incidental to a sickness and/or injury. 
  • Treatments for any uncovered conditions.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing.

   

  Outside your eligible network or from abroad

  Reimbursement.

• Day Care Services

  Definition(s)

  Healthcare services provided to patients who are admitted to a hospital or day-patient because they need a period of medically supervised recovery but do not need to occupy beds overnight.

   

   

  Explanation

  Outpatient deductible/coinsurance shall be applied for all short stays for observations. For all other cases including the Day Care, the inpatient coinsurance/deductible shall apply.

   

   

  What is covered?

  All covered treatments in a day-care setup.

   

   

  What is NOT covered?

  All excluded medical conditions and services.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing (except for benefits exclusively offered on reimbursement basis).

   

  Outside your eligible network or from abroad

  Reimbursement.

• Deductible | Co-pay

  Definition(s)

  A fixed amount of money stated in table of benefits or the health insurance card which insured member is required to pay to providers in direct billing when receiving health services under table of benefits before insurance company start paying. Deductible amount is deducted from total payable claims in case of reimbursement.

   

   

  Explanation

  If any deductible/copay is applicable on your policy, this would be specified in your table of benefits. This is also printed on your card, so the provider offering direct billing services can collect appropriate amounts from the member. In case of a reimbursement the amount is deducted from your claim on top of the out of network deductible unless explicitly mentioned otherwise in the policy.

   

   

  Tips

  Please notify us immediately if a provider charges you more or less than the deductible/copay specified on your card. However please note that the provider may charge you for the services that you are not eligible for.

• Dental Cover: Dental - Enhanced (including Major Dental Services)

  What is covered?

  Dental Enhanced, if opted in your policy, covers Routine Dental and, in addition:

  • General dental inspection (check-up).
  • Prosthesis - crown, bridges, posts, dentures, pins. 
  • Orthodontic treatment.
  • Dental x-rays (including Panoramic).

  Subject to limits or coinsurance.

   

  What is NOT covered?

  • Maintenance of appearance, cosmetic treatment and surgery are not covered, as well as toothpastes, mouthwash, mouth sprays, and so on, which in the sole discretion of the Company is either not ‘Medically Necessary’ or is cosmetic in nature.
  • Treatment by an oral hygienist, unless specifically stated in the Table of Benefits.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing.

   

  Outside your eligible network or from abroad

  Reimbursement.

   

   

  Mandatory Benefit as per Regulation 

  Optional.

• Dental Cover: Routine Dental

  What is covered?

  Dental, if opted for, covers: 

  • Lesions of oral cavity.
  • Endoperio surgery.
  • Scaling.
  • Filling.
  • Curettage and gum problems.
  • Root canal and pulp treatment.
  • Extraction (removal – simple and surgical).
  • Dental x-rays (excluding Panoramic).
  • Dental Consultation, except for general dental check-up.

  Subject to limits or coinsurance.

   

  What is NOT covered?

  • General dental inspection (check-up), maintenance of appearance, crown, bridges, posts and cores, dentures, pins, prosthesis, orthodontic treatment, and cosmetic treatment and surgery are not covered, as well as toothpastes, mouthwash, mouth sprays, and so on, which in the sole discretion of the Company is either not ‘Medically Necessary’ or is cosmetic in nature.
  • Treatment by an oral hygienist, unless specifically stated in the Table of Benefits.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing.

   

  Outside your eligible network or from abroad

  Reimbursement (on top of dental coinsurance, if any).

   

  Note

  If coinsurance for dental is defined as "Nil", network consultation charges do not apply.

   

   

  Mandatory Benefit as per Regulation 

  Optional.

• Deviated Nasal Septum

  Definition(s)

  A condition in which the nasal septum - the bone and cartilage that divide the nasal cavity of the nose in half - is significantly off center, or crooked, making breathing difficult.

   

   

  What is covered?

  Nasal septum deviation and nasal concha resection, if listed as covered under the Table of Benefits.

   

   

  What is NOT covered?

  Nasal septum deviation and nasal concha resection are not covered in our policies, unless specifically covered.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing.

   

  Outside your eligible network or from abroad

  Reimbursement.

• Donor/Organ Donor's Expenses

  Definition(s)

  A person alive or deceased from whose body one or more organs have been extracted with the intention to transplant them (totally or partially) in the body of another person (the Recipient) via an Organ Transplant.

   

   

  What is covered?

  Organ Transplant benefit will cover the incurred charges on transplantation surgery for the beneficiary being the recipient of the transplant of an organ. 

  
  The covered amount includes doctor’s fees, hospital accommodation and other beneficiary’s related medical expenses during hospital stay.

  
  The organ transplants covered are as follows: 

  • Heart.
  • Heart/lung.
  • Lung.
  • Kidney.
  • Kidney/pancreas.
  • Liver.
  • Allogeneic bone marrow.
  • Autologous bone marrow.

   

   

  What is NOT covered?

  Cover will exclude costs related to search for donor, cost of acquisition of organ, and costs incurred for removal of organ from donor.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing.

   

  Outside your eligible network or from abroad

  Reimbursement.

• Durable Medical Equipment

  Definition(s)

  Medical equipment used externally from the human body which: 

  • Can withstand repeated use; 
  • Is not designed to be disposable; 
  • Is used to serve a medical purpose; and 
  • Is used outside of the hospital.

   

   

  Explanation

  Examples for Durable Medical Equipment include Blood Pressure Monitors, Glucometers, Nebulizers, and Ventilators.

   

   

  What is covered?

  We do not cover durable medical equipment, unless specifically listed in the Table of Benefits as ‘covered’.

• Emergency Treatment

  Definition(s)

  Emergency as defined by Law as “a situation which calls for immediate medical intervention by a health services provider for the rescuing of a person’s life/organ or the elimination of the danger threatening that person's life/organ”.

   

  Explanation

  It will be the treating doctor/provider who will categorize your case as emergency or not. In case of emergencies, you are allowed to visit the nearest medical provider even if it is not one of your eligible network providers.

   

   

  What is covered?

  All non-excluded emergency treatments and services. 
  
  If an out-of-network provider is accessed, we cover the reimbursement up to a minimum of 100% of the applicable network tariff. We do not charge additional coinsurance for non-network access in case of emergencies.
  

   

   

   

  What is NOT covered?

  Treatments and services that are excluded as per your policy's terms and conditions.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing.

   

  Outside your eligible network or from abroad

  Reimbursement.

   

   

  Tips

  Contact us well before discharge from a non-network hospital after an emergency treatment. We may be able assist with direct billing facility or may negotiate better charges, where possible.

   

   

  Mandatory Benefit as per Regulation 

  Mandatory.

• Formulary Drug List

  Definition(s)

  A list of generic medicines.

   

  Explanation

  Your policy may be subject to list of generic formularies. In such cases, the pharmacist may dispense the generic drug, irrespective of the prescribed brand.

   

   

  What is covered?

  Where applicable, generic medicines shall be covered for all the covered treatments. 

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing.

   

  Outside your eligible network or from abroad

  Reimbursement.

   

   

  Tips

  With generic medicine prescription, the pharmacist will dispense cost effective medicines. This not only helps reduce your medicine coinsurance (where applicable) but also, at the same time, keeps your medicines sub-limits in check.

• General Health Checkup, Screening or Wellness

  Definition(s)

  Examinations, tests, consultations, or other medical services that are conducted for preventative or screening reasons and which are not related to any symptom or disease. 

   

   

  What is covered?

  If 'DHA Minimum Preventive Services' is opted for
  
  Coverage includes Diabetes screening (FBS) once a year for members aged 30 years and above.

   

  If 'Routine Basic Health Checkup' is opted for

  Coverage, once a year for members 30 years old and above, includes:

  • Blood examination (CBC, Blood Sugar, Lipid profile, HIV, Hepatitis B).
  • Electrocardiogram – ECG.
  • Fundoscopy.
  • Chest x-ray.
  • Urine routine.
  • Stool OP/OB. 
  • Consultation with General Practitioner/Internal Medicine Specialist. 

   

  If 'Enhanced Health Checkup' is opted for

  The following are covered:

  • Services listed under Basic Health Check.
  • Breast Cancer for females 30 years and above: clinical exam, mammogram, pelvic sonogram if medically indicated and CA 15.3 if medically indicated.
  • Prostate Cancer for males 30 years and above: clinical exam, PSA, Rectal sonogram.
  • Colon Cancer for Adults 30 years and above: FIT (Faecal Immunochemical Test) every 2 years. 
  • Colonoscopy every 10 years or according to findings.

   

   

  What is NOT covered?

  • Tests and screening not listed under the Basic Checkup and Screening plans.
  • In case of Enhanced Check and Screening Plans, any expenses exceeding the limit specified in your policy.

   

   

  Mode/basis of claim 

  DHA Minimum Preventive Services

  Direct Billing (subject to approval).

   

  All other benefits 

  Reimbursement (unless mentioned otherwise in the policy and/or the Table of Benefits).

   

   

  Tips

  The services may be subject to approval and restricted to specific list of providers.

   

   

  Mandatory Benefit as per Regulation 

  Optional (except for DHA Minimum Preventive Services).

• Geographical Scope of Coverage

  Definition(s)

  Area of coverage where an insured member is allowed to avail medical treatment under the terms of the Policy.

   

   

  Explanation

  Please refer to your Table of Benefits for the geographical scope of coverage applicable to you.

   

   

  What is covered?

  Expenses for 'Medically Necessary' and covered treatment and services within the geographical area and limits specified in your Table of Benefits.

   

   

   

  What is NOT covered?

  • All treatments outside the geographical territory specified in your Table of Benefits.
  • Treatments for members living permanently outside the country of policy issuance.

   

   

  Mode/basis of claim 

  Within eligible network

  Direct Billing.

   

  Outside eligible network or from abroad

  Reimbursement.

   

   

  Tips

  It is advisable to check with us prior to any major elective treatments abroad. In some cases, our team may be able to assist you with direct billing facility in some locations, and can guide you through the eligibility and processes if direct billing cannot be arranged. Similarly, where possible they can guide you to quality providers with cost effective services.

   

   

  Mandatory Benefit as per Regulation 

  Department of Health, Abu Dhabi (HAAD) - Mandatory

  Emirate of Abu Dhabi: For Elective and Emergency.

  Other UAE Emirates: For Emergency only.

   

  Dubai Health Authority (DHA) - Mandatory

  Emirate of Dubai: For Elective and Emergency.

  Other UAE Emirates: For Emergency only.

   

• Geographical Scope of Coverage: Basic Territory

  Definition(s)

  The covered geographical territory in which both elective and emergency treatments are allowed.

   

   

  What is covered?

  Elective and emergency treatments for members in countries listed in the basic territory.

   

   

  What is NOT covered?

  Treatments for members living permanently outside the country of policy issuance.

• Geographical Scope of Coverage: Extension Territory

  Definition(s)

  Geographical territory in which coverage is allowed for emergency only while an insured member is travelling.

   

   

  What is covered?

  Treatments for medical emergencies arising while a member is travelling, up to a maximum travel period of 60 days per trip.

   

   

  What is NOT covered?

  • Elective treatments in the extension territory.
  • All treatments post 60 days during one trip.

• Geographical Scope of Coverage: Home Country

  Definition(s)

  The country of origin or nationality of the insured member.

   

   

  Explanation

  In case of dual citizenship, we consider the nationality as reported to us during enrolment.

   

   

  What is covered?

  If home country coverage is applicable in your policy, you will be covered in your home country even if the Basic Territory or Extension Territory does not include your home country. Such coverage may be restricted to Emergency only. To learn more, please refer to the Table of Benefits.

   

   

  What is NOT covered?

  Where home country coverage is not selected, and your country of origin is not listed in the geographical scope.

• Geographical Scope of Coverage: Arab Countries

  Definition(s)

  Where Geographical Area states "Arab Countries", this would mean: 

  • Algeria.
  • Bahrain.
  • Egypt.
  • Iraq.
  • Jordan.
  • Kuwait.
  • Lebanon.  
  • Libya. 
  • Morocco.
  • Oman.
  • Palestine.
  • Qatar.
  • Saudi Arabia. 
  • Sudan. 
  • Syria.
  • Tunisia.
  • United Arab Emirates (UAE).
  • Yemen.

• Geographical Scope of Coverage: South-East Asia (SEA)

  Definition(s)

  List of countries covered by us under SEA are: 

  • Afghanistan.
  • Bangladesh.
  • Bhutan.
  • Burma.
  • India.
  • Indonesia.
  • Iran.
  • Malaysia.
  • Nepal.
  • Pakistan.
  • Sri Lanka.
  • Thailand 
  • The Philippines.
  • Vietnam.

• Global Emergency Assistance Services (Assist America)

  Explanation

  The assistance service is provided through Assist America. Please refer to the Assist America Brochure attached to your policy for details of coverage This is not a reimbursable benefit. Where service is required Assist America to be contacted, who will arrange required services free of cost. Eligible medical expenses shall be covered under your medical insurance policy.

   

   

  What is covered?

  • Emergency medical evacuation and repatriation.
  • Repatriation of Mortal Remains.
  • Medical Consultation, Evaluation and Referral.
  • Hospital Admission Assistance.
  • Medical Monitoring.
  • Care of Minor Children.
  • Prescription Assistance.
  • Emergency Message Transmission.
  • Compassionate Visit.
  • Lost luggage or Document Assistance.
  • Pre-Trip Information.
  • Interpreter and Legal Referrals Assistance.
  • Claims Assistance.

   

   

  Mode/basis of claim  

  No claim reimbursement applicable for services under Assist America benefit. The member or their authorised representative must notify the required services to Assist America who will arrange necessary services free of cost. 

   

   

  Tips

  Please refer to the contact details provided on your Medical Insurance Card or Brochure for Assist America.

• Hazardous Sports or Activities | Professional Sports

  Definition(s)

  Hazardous activities include, but are 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.

   

   

  What is covered?

  Non-hazardous recreational sports activities by amateurs.

   

   

  What is NOT covered?

  Hazardous sports and activities, as well as any professional sports activities.

• Hearing and Vision Aids | Vision Correction via Surgery | Laser in Emergency Cases

  What is covered?

  Coverage applicable only as part of emergency inpatient treatments for injury or accident.

   

  What is NOT covered?

  • Hearing aids under routine treatments. 
  • Routine vision services (unless benefit is subscribed for and listed in the Table of Benefits).

   

   

  Mode/basis of claim 

  Within eligible network

  Direct Billing (excluding benefits specifically offered on reimbursement basis).

   

  Outside eligible network or from abroad

  Reimbursement.

   

   

  Mandatory Benefit as per Regulation 

  Mandatory in case of emergencies.

• Hepatitis

  What is covered?

  Treatment for Hepatitis A.

   

   

  What is NOT covered?

  Treatment for Hepatitis B and C or Alcoholic Fatty Liver, unless your policy’s Table of Benefits explicitly covers treatment for such conditions.

   

   

  Mode/basis of claim 

  Within eligible network

  Direct Billing.

   

  Outside eligible network or from abroad

  Reimbursement.

   

   

  Mandatory Benefit as per Regulation 

  Mandatory cover for Hepatitis A.

• Hospitalisation | Inpatient and Related Health Services or Treatments

  Definition(s)

  Medical treatment that is provided in a hospital or other facility and requires at least one overnight stay or more than 8 hours continuous care delivery inside a hospital, and where the patient is registered as an admission. 

   

   

  What is covered?

  Consultation, accommodation costs, treatment costs including Surgical Fees, Anaesthesia, Operation Theatre Charges, Prescribed Drugs and Materials, Intensive Care Unit, Diagnostic Tests, and Prescribed Physiotherapy in relation to medical condition which is the cause of admission and related to the admitted medical necessity and covered conditions.

   

   

  What is NOT covered?

  • Expenses if the medical conditions/ treatment part of the list of exclusions under your policy.
  • Disposables (such as diapers or tissues), other personal hygiene consumables, and non-medical services (such as Registration charges, taxes, food & beverages, hotel accommodation costs, phone bills, taxi charges, and so on). 

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing (except for benefits exclusively offered on reimbursement basis).

   

  Outside your eligible network or from abroad

  Reimbursement.

   

   

  Tips

  All Inpatient treatments require pre-authorisation, which will be arranged by the medical provider if you are choosing one of our listed providers eligible under your network. In case of elective surgeries in the interest of providing quality and cost-effective services to our insured members, we my advice a second opinion, if found necessary. If you wish to seek a second opinion before proceeding with the surgery, we do allow this. Please call our pre-authorisation team who can advise you appropriately.

   

   

  Mandatory Benefit as per Regulation

  Mandatory.

• Immunomodulator and Immunotherapy

  Definition(s)

  A line of treatment that works on suppressing or stimulating the immune system.

   

   

  Explanation

  Drugs used when the doctors need to modify or regulate one or more immune functions.

   

   

  What is covered?

  Covered for Abu Dhabi – HAAD compliant policies if the medical condition is covered by the policy.

   

   

  What is NOT covered?

  Neither covered for Dubai (DHA-compliant) nor Northern Emirates policies, unless your policy’s Table of Benefits explicitly covers this line of treatment.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing (except for benefits exclusively offered on reimbursement basis).

   

  Outside your eligible network or from abroad

  Reimbursement.

   

   

  Tips

  All high-cost medicines or drugs are subject to prior approval. Examples of medical conditions that could be treated with an immunomodulator include autoimmune diseases, multiple sclerosis, and psoriasis.

• Infertility

  Definition(s)

  The inability to bear children, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth through the reproductive age or following either a previous pregnancy or a previous ability to carry a pregnancy to a live birth. 

   

   

  What is covered?

  If subscribed under your policy, coverage of infertility covers treatment for infertility, subject to applicable limits and coinsurance.

   

   

  What is NOT covered?

  Infertility is an exclusion, unless subscribed to under your policy.

   

   

  Mode/basis of claim  

  Reimbursement.

   

   

  Mandatory Benefit as per Regulation

  Optional.

• Inpatient - Accommodation or Room and Board

  Explanation

  Please refer to the Room Type eligible under your policy. 

   

  VIP room or suite

  A luxurious, self-contained, single room.

   

  Private Room

  A self-contained, standard single room for occupation by one patient.

   

  Semi-Private

  A room shared by two patients.

   

  Ward

  A room shared by more than two patients.

   

   

   

  What is covered?

  The type of accommodation allowed as per the specific policy’s benefits.

   

   

  What is NOT covered?

  • If a higher room type than the one eligible for is utilised, then difference in cost is not covered.
  • Hotel accommodation.
  • Food for patients, companions, and guests.
  • Items, Services availed by guests and companions.
  • Items and services used for personal convenience of the patient, unless as part of treatment.
  • Telephone or Internet services.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing (except for benefits exclusively offered on reimbursement basis).

   

  Outside your eligible network or from abroad

  Reimbursement.

• Kidney Dialysis Treatment (Haemodialysis or Peritoneal Dialysis)

  What is covered?

  Dialysis, if listed as covered under your Table of Benefits.

   

   

  What is NOT covered?

  Dialysis, if excluded from coverage.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing.

   

  Outside your eligible network or from abroad

  Reimbursement.

• Limit

  Definition(s)

  Annual Aggregate Limit

  The maximum amount, in monetary terms, of benefits allowed for all Eligible Expense, inclusive of all sublimit, Coinsurance and/or Deductibles for Treatment taken during the Policy validity. 

   

  Sublimit

  A monetary limit defined for a specified type of benefit as stated in the Table of Benefits.

   

  Maximum Number of Sessions

  The maximum number of times a patient can utilise a particular type of service (for instance, the number of physiotherapy sessions or antenatal care visits).

   

   

  Explanation

  Your eligible limits are defined in the table of benefits. The limits are per insured person per year, unless specifically stated otherwise. All Limits/Sublimit are inclusive of applicable coinsurance or deductibles.

   

   

  What is covered?

  Expenses for ‘Medically Necessary’ and covered treatment and services within limits specified in your Table of Benefits.

   

   

  What is NOT covered?

  • All excluded benefits and services.
  • Expenses in excess of applicable policy limits and sublimit.

   

   

  Tips

  It is advisable to check with us your approximate available limit prior to any major treatments. Our team can guide you to choose quality providers at reasonable cost. Treatments availed exceeding your eligible limits will ultimately be recovered from you through your employer.

   

   

  Mandatory Benefit as per Regulation

  Department of Health, Abu Dhabi (HAAD) - Mandatory

  Annual limit: AED 250,000

   

  Dubai Health Authority (DHA) - Mandatory

  Annual limit: AED 150,000

• Maternity Benefit | Maternity Service

  Definition(s)

  Maternity Benefit is applicable to expenses incurred for room, board (as per policy) and general nursing care, special hospital services and ordinary nursing care of the baby while the mother is confined in the hospital, and for charges made by the physician, or registered midwife. They also include antenatal and postnatal medical expenses, including consultations, laboratory, radiology, medications, and any other covered medical expense related to the pregnancy or delivery, subject to the benefit limit mentioned in the Table of Benefits. 

   

  Where any condition develops which becomes life threatening, the medically necessary expenses will be covered up to the annual aggregate limit. Maternity shall include childbirth, miscarriage, or legal abortion, including any and all complications arising therefrom.

   

   

  Explanation

  Where a sublimit is indicated for a combined maternity benefit, the limit specified shall be inclusive of all expenses, including for outpatient services and procedures, treatment, medication, and delivery (that is, antenatal, post-natal and delivery). 
  
  Where a different sublimit is indicated for delivery only, such as normal delivery, caesarean delivery, legal abortion, and so on, the Limit specified shall be specific to delivery services and procedures only (that is, antenatal and post-natal services are not part of that limit). 
  
  If no deductible or coinsurance specified for maternity, the deductibles and/or coinsurance applicable for basic inpatient or outpatient cover shall also apply to maternity benefits. 
  
  Please refer to your policy’s Table of Benefits to learn more about your specific coverage.
  

   

   

   

  What is covered?

  Where maternity is covered, the coverage includes: 

  • Antenatal or post-natal consultations.
  • Medically necessary tests or investigations.
  • Screening as mandated by applicable regulations.
  • Childbirth (normal delivery, non-elective caesarian delivery).
  • Miscarriage.
  • Medically necessary termination of pregnancy.
  • Complications and emergencies during antenatal or childbirth. 

   

  Post-natal services are limited to 45 days from the delivery date, following which it is considered as a regular gynaecology visit.

   

   

  What is NOT covered?

  • Services medically not necessary.
  • Antenatal trisomy screening, chromosomal anomalies, downs screen, and the like.
  • Non-medically necessary amniocentesis.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing (except benefits exclusively offered on reimbursement basis).

   

  Outside your eligible network or from abroad

  Reimbursement.

   

   

  Tips

  Department of Health - Abu Dhabi (HAAD) and Dubai Health Authority (DHA) antenatal care and delivery protocols are to be followed.

   

   

  Mandatory Benefit as per Regulation 

  Mandatory.

• Maxillofacial Surgeries or Treatments

  Definition(s)

  Any medically necessary operative procedure or portion of a procedure performed to treat diseases, injuries and defects in the head, neck, face, jaws, and the hard and soft tissues of the oral (mouth) and Maxillofacial (jaws and face).

   

   

   

  What is covered?

  All non-related dental or cosmetic treatment, such as TMJ disorders, neoplasm of the salivary glands, and so on.

   

   

  What is NOT covered?

  Claims related to Dental, and treatments provided by a dentist even if the claim is not dental in nature.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing.

   

  Outside your eligible network or from abroad

  Reimbursement (subject to applicable deductibles and policy's reimbursement conditions).

• Medical Expenses in relation to Work-Related Accidents, Injuries and Illness

  Definition(s)

  Any of the occupational diseases listed in the schedule attached to the Federal Law No. 8 of 1980 (as amended) or any other accident sustained by a worker during the performance or as a result of their work. Any accident sustained by the worker on their way to or back from their work shall be deemed an employment injury provided that the trip to or from the place of work is made directly, without delay, default, or diversion from the normal route.

   

   

  What is covered?

  If listed in the Table of Benefits, we cover medical expenses for treatment of injuries from accidents occurred in the course of work. Coverage also includes treatment for work-related ailments. 

   

   

  What is NOT covered?

  Not covered if not specifically listed in the Table of Benefits.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing.

   

  Outside your eligible network or from abroad

  Reimbursement. 

   

   

  Mandatory Benefit as per Regulation 

  Mandatory as per Department of Health - Abu Dhabi (HAAD).

• Mental Illness (Psychiatry or Psychological Treatments)

  Definition(s)

  Collectively, all diagnosable mental disorders or health conditions that are characterised by alterations in thinking, mood, behaviour, or a combination thereof, associated with distress and/or impaired functioning.

   

   

  Explanation

  Unless offered as an additional benefit, we neither cover Psychiatry nor psychological treatments. If your policy covers Psychiatry, this will be on reimbursement basis (with sublimit applicable).

   

   

  What is covered?

  Where Psychiatry is covered in the Table of Benefits, we cover all mental health disorders (subject to applicable limits).

   

   

  What is NOT covered?

  • Mental health disorders are excluded if they are not listed as ‘covered’ in the Table of Benefits.
  • Psychological consultations and or management are excluded (unless stated otherwise in the Table of Benefits).

   

   

  Mode/basis of claim  

  Reimbursement. 

   

   

  Mandatory Benefit as per Regulation 

  Dubai Health Authority (DHA)

  Mental health diseases are to be covered in emergencies. 

   

  Department of Health - Abu Dhabi (HAAD)

  Transient Mental Disorders are to be covered.

• Network of Medical Providers

  Definition(s)

  A group of Medical Providers contracted by the Insurer or TPA for the purpose of providing Insured Members with access to their services on a direct billing basis in conformity with the terms of this Policy. Listings of Network Providers are subject to change without notice.

   

   

  Explanation

  We do have different levels network, and each category under a policy is assigned a specific network of providers based on the plans selected. The network type eligible is mentioned in your Table of Benefits. The provider network is subject to ongoing changes.

   

  Please click here to check if a particular provider exists in your eligible network. 
  

   

   

   

  What is covered?

  Expenses for ‘Medically Necessary’ and covered treatment and services within the limits specified in your Table of Benefits.

   

   

  What is NOT covered?

  • Excluded benefits and services.
  • Direct billing facility for benefits that are offered on reimbursement.
  • Direct billing facility if the network provider is not part of the specific class of network that you are eligible for.
  • Direct billing facility if you do not present your card to the network provider.

   

   

  Mode/basis of claim  

  Direct Billing within your eligible network (except for benefits which are exclusively offered on reimbursement basis). 

   

   

  Tips

  We encourage our members to use one of our network providers eligible under your plan. We have specially negotiated contractual agreements with these providers which provide for discounted prices, as well as better support to our insured members. This will help us manage your insurance plan better.

• Network Tariff | Reasonable and Customary Charges

  Definition(s)

  Charges considered by the Insurer or its medical advisors as being so for medical care provided by healthcare facilities or physicians outside of the applicable provider network to the extent that they do not exceed the general level of charges being made by other facilities or physicians of similar standing in the locality where the charges are incurred when giving like or comparable treatment, services or supplies to individuals of the same sex and of comparable age for a similar disease or injury. 

   

  The charges will be limited to the level of charges that would have been incurred by the Insurer should the Insured Member have received treatment at any of the applicable provider network facilities.

   

   

  Explanation

  Where reimbursement is allowed in a policy, our minimum reimbursement will as per HAAD's base tariff as published. 

   

  The calculation of reimbursement is applied as per the following sequence:

  Eligible amount =

  Minimum amount as per published tariff

  (Less) Coinsurance or Deductible

  (Less) Coinsurance applicable for reimbursement claims 

   

  If the reimbursement is at actual incurred cost, this will be explicitly stated in the Table of Benefits.

   

   

  Tips

  Reimbursement claims from the eligible network provider may be settled as per the agreed tariff of the provider, applicable policy deductible, and non-network access coinsurance.

• Newborn Cover

  Definition(s)

  Coverage for medical expenses for treatment of newborns of females who are covered for maternity under the medical insurance policy.

   

   

  What is covered?

  All Newborn treatments covered under the mother's indemnity limit, within 30 days of birth if baby is born inside UAE (unless the Table of Benefits states otherwise), or until enrolment of the baby under the insurance policy – whichever comes first.

   

   

  What is NOT covered?

  • All treatments after 30 days of birth.
  • Costs incurred post 30 days from birth, in case of continuous hospitalisation for more than 30 days.
  • However, if the newborn is enrolled, these will be covered under the baby's own medical insurance policy.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing (except benefits exclusively offered on reimbursement basis).

   

  Outside your eligible network or from abroad

  Reimbursement.

   

   

  Tips

  This cover is mandatory for Dubai Health Authority (DHA) compliant policies.

   

   

  Mandatory Benefit as per Regulation 

  Mandatory.

• Nursing at Home

  Definition(s)

  The services of a qualified and registered nurse, recognised by the Insurance Company, when considered medically necessary for the provision of continuous care, at the member’s home, immediately following eligible inpatient treatment covered under the plan.

   

   

  What is covered?

  If subscribed separately, charges for nursing at home immediately after an inpatient treatment, subject to applicable limits and coinsurance.

   

   

  What is NOT covered?

  • Home nursing is not covered if this is not subscribed under your policy.
  • Home nursing for excluded medical conditions.
  • Home nursing obtained for non-medical and personal assistance services, including, but not limited to, home nursing following a delivery.

   

   

  Mode/basis of claim 

  Reimbursement.

   

   

  Mandatory Benefit as per Regulation 

  Optional.

• Optical or Vision Care

  Explanation

  Optical or Vision Care benefit refers specifically to eyesight-related problems and their treatments. General medical conditions related to the eye are covered under your basic medical benefit, such as injury to the eye, foreign body, glaucoma, cataract, and so on.

   

   

  What is covered?

  If opted for Routine Optical

  The benefit provides for the following:

  • Fees charged for only refraction test carried out by a qualified and registered Ophthalmologist. 
  • A coinsurance or deductible will apply as mentioned in Table of Benefits to all eligible charges incurred. This amount will be payable by the member. 

   

  If opted for Enhanced Optical

  We cover:

  • Fees charged for refraction test carried out by a qualified and registered Ophthalmologist.
  • Cost of spectacle frames (once a year). 
  • Cost of corrective lenses (including Contact Lenses) prescribed by the Ophthalmologist (excluding tinted or reactive lenses and sunglasses, whether prescribed or not). 

   

   A coinsurance or deductible will apply as mentioned in TOB to all eligible charges incurred. This amount will be payable by the member.

   

   

  Mode/basis of claim 

  Consultation

  Direct Billing (within eligible network).

   

  Lenses or frames (if covered)

  Reimbursement.

   

   

  Mandatory Benefit as per Regulation 

  Optional.

• Outpatient Services

  Definition(s)

  Medical care or treatment which does not require an overnight stay or requires less than 8 hours' continuous care in a hospital or medical facility. It may include Physician consultation, prescribed drugs, diagnostic tests and treatments, and procedures which do not medically necessitate admission to a hospital before, during and/or after the procedure.

   

   

  What is covered?

  • Physician consultation, prescribed drugs, diagnostic tests.
  • Lab and radiology, treatments, physiotherapy, and procedures which do not medically necessitate hospital confinement before, during and/or after the procedure.

   

   

  What is NOT covered?

  All expenses pertaining to excluded medical conditions and services.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing (except for benefits which are exclusively offered on reimbursement basis).

   

  Outside your eligible network or from abroad

  Reimbursement.

   

   

  Tips

  Prior approval protocols apply for certain outpatient services such as MRI, CT scan, PET Scan, Tread Mill Test, Echocardiography, Endoscopic examinations, and multiple session services such as Cryocautery, Electrocautery, Sclerotherapy, Laser therapy, and Physiotherapies. Some policies may have a limit per visit above which pre-approval may be required. For treatments within the network, providers arrange necessary approvals.

   

   

  Mandatory Benefit as per Regulation 

  Mandatory cover.

• Outpatient Treatment: Consultation

  What is covered?

  Outpatient consultation with General Practitioners, Specialists or Consultants for covered medical conditions. Visiting consultants are allowed; however, if the consultant is not listed within your eligible network, the charges payable will be as per the reasonable and customary tariff.

   

   

  What is NOT covered? 

  • Consultation for excluded medical conditions.
  • More than one consultation related to the same medical condition within the same day.
  • Specialist consultations where it is subject to a referral from a General Practitioner (as specified in the Table of Benefits).
  • Reimbursement of claims for follow-up visits. 

   

   

  Mode/basis of claim 

  Consultation

  Direct Billing (within eligible network).

   

  Lenses or frames (if covered)

  Reimbursement.

   

   

  Tips

  Follow-up visits within 7 days at the same provider for the same primary diagnosis is expected to be free of cost; therefore, deductible or coinsurance applicable on consultation should not be charged for follow-up visit. Please contact us immediately when a provider asks you to pay for the follow-up visits.

• Outpatient Treatment: Diagnostic Investigations (Laboratory services, Radiology services, and other investigations)

  Explanation

  Investigations include laboratory tests and radiology services (such as X-rays, MRI, CT scan, and tests like ECG and ECHO).

   

   

  What is covered?

  Medically necessary diagnostic investigations for covered medical treatments.

   

   

  What is NOT covered? 

  • Investigations as part of preventive screening or general check-up without a medical indication.
  • Investigations for experimental purposes.

   

   

  Mode/basis of claim 

  Within eligible network

  Direct Billing (except for benefits which are exclusively offered on reimbursement basis).

   

  Outside eligible network or from abroad

  Reimbursement.

   

   

  Tips

  Pre-approval is required for MRI, CT scan, and endoscopic examinations. Network providers obtain approvals directly from us.

• Outpatient Treatment: General Practitioner

  Definition(s)

  Including family and primary care doctors who diagnose, treat, and prevent illness, disease, injury, and other physical and mental impairments and maintain general health in human through application of the principles and procedures of modern medicine. They plan, supervise, and evaluate the implementation of care and treatment plans by other health care providers. They do not limit their practice to certain disease categories or methods of treatment and may assume responsibility for the provision of continuing and comprehensive medical care to individuals, families, and communities.

   

   

  What is covered?

  Consultation and treatment by general practitioners (as long as the treatment or medical condition does not fall under the policy’s exclusions).

   

   

  What is NOT covered? 

  • Consultation and treatments for all excluded conditions. 
  • Where gatekeeper arrangement is in place (please refer your policy), visit to other network providers without a referral from the gatekeeper.

   

   

  Mode/basis of claim 

  Within eligible network

  Direct Billing (except for benefits which are exclusively offered on reimbursement basis).

   

  Outside eligible network or from abroad

  Reimbursement.

   

   

  Tips

  Your employer may have arranged with us to provide visiting doctor facility in your location (gatekeeper doctor), and you may need a referral from this doctor before visiting any other network provider. Please check your policy for details. We advise our members wherever possible to opt clinics for your outpatient needs instead of hospitals. This will help us maintain your policy cost effectively.

• Outpatient Treatment: Physiotherapy

  What is covered?

  Medically necessary physiotherapy sessions prescribed by respective specialist doctor and administered by a qualified physiotherapist.

   

   

  What is NOT covered?

  • Physiotherapy session conducted without the specialist doctor prescription.
  • Sessions that are in excess of medical necessity.
  • Sessions in excess of the limit approved or applicable to your policy.

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing (except for benefits which are exclusively offered on reimbursement basis).

   

  Outside your eligible network or from abroad

  Reimbursement.

   

   

  Tips

  Pre-approvals required for Outpatient physiotherapy. Network providers obtain approvals directly from us.

• Outpatient Treatment: Prescribed Medicines, Pharmaceuticals or Drugs

  Definition(s)

  Pharmaceuticals which can only be obtained through a prescription provided by a licensed physician, and which are approved by UAE's Ministry of Health.

   

   

  Explanation

  Please refer to your policy table of benefits to check your eligibility. Some policies or categories, especially involving Network type Essential, may be restricted to prescription or dispensation of generic drug only.

   

   

  What is covered?

  Prescribed medication for covered treatments. Vitamins are covered for vitamin deficiency, antenatal and chronic conditions where indicated.

   

   

  What is NOT covered? 

  • Prescribed medication for excluded treatments.
  • Drugs purchased over the counter (OTC) without a doctor's prescription. 
  • Prescribed medication not related to the diagnosis. 
  • Supplements and/or vitamins which are not related to vitamin deficiency.

   

   

  Mode/basis of claim 

  Within eligible network

  Direct Billing (except for benefits which are exclusively offered on reimbursement basis).

   

  Outside eligible network or from abroad

  Reimbursement.

   

   

  Tips

  Pharmacy approvals inside Sukoon Network are managed by PBM (Pharmaceuticals Benefit Management) in line with local authorities’ requirements. Approvals for outpatient medications are handled through the PBM. 

   

  Please consider the following to avoid over prescription and or wastage of prescribed drugs: 

  • If you feel the quantity of drugs being prescribed is more than you may need, please clarify from your doctor or pharmacist.
  • You may find repeated prescription of drugs if more than one member of your family visiting the doctor for the same condition. If possible, please share the drugs in such cases.
  • In case you already have some of the medicines at home, please tell your doctor or pharmacy.
  • Some brands of drugs have less expensive alternatives, with the same composition and results. You may opt for such alternatives where possible.

• Outpatient Treatment: Specialist Consultation

  Definition(s)

  A practitioner who can diagnose, treat, and prevent illness, disease, injury, and other physical and mental impairments using specialised testing, diagnostic, medical, surgical, physical and psychiatric techniques, through application of the principles and procedures of modern medicine. They plan, supervise, and evaluate the implementation of care and treatment plans by other healthcare providers. They specialise in certain disease categories, types of patient or methods of treatment, and may conduct medical education and research activities in their chosen area(s) of specialisation.

   

   

  What is covered?

  Consultation and treatment by specialist as long as the treatment or medical condition does not fall under the policy’s exclusions.

   

   

  What is NOT covered? 

  • Consultation and treatments for all excluded conditions.
  • Where gatekeeper arrangement in place (please refer your policy), visit to other network providers without a referral from the gatekeeper.
  • Where first visit is restricted to a General Practitioner, direct visit to specialists.

   

   

  Mode/basis of claim 

  Within eligible network

  Direct Billing (except for benefits which are exclusively offered on reimbursement basis).

   

  Outside eligible network or from abroad

  Reimbursement.

   

   

  Tips

  Your employer may have arranged with us to provide visiting doctor facility in your location (gatekeeper doctor), and you may need a referral from this doctor before visiting any other network provider, or your policy may need a referral from a GP before accessing specialist. Please check your policy for more details.

   

  We advise our members, wherever possible, to opt for a General Practitioner (unless your condition demands consultation by specialist). 

   

  For Essential and DHA Plus Networks

  Access to a specialist or consultant will be allowed upon referral from a General Practitioner (GP), unless the policy’s Table of Benefits explicitly mentions otherwise.

• Outpatient Treatment: Surgery

  Explanation

  Minor surgeries or treatments undertaken at outpatient clinics where the stay is less than 6 hours.

   

   

  What is covered? 

  All medically necessary outpatient surgeries as part of an eligible treatment are covered in our policy.

   

   

  What is NOT covered?

  Treatments and services which are excluded as per your policy's terms and conditions.

   

   

  Mode/basis of claim 

  Consultation

  Direct Billing (within eligible network).

   

  Lenses or frames (if covered)

  Reimbursement.

• Passive War Risk

  What is covered?

  If opted for, Passive War and Terrorism benefit extends to cover accidental injuries suffered by the insured member as an innocent bystander only, and excludes if the person insured is training or serving in any capacity as a member of the Armed Forces or whilst engaging in any War, invasion, acts of foreign enemies, hostilities or warlike operations (whether declared or not), civil war, rebellion, revolution, insurrection, military or usurped power, martial law, or an act of terrorism.
  

   

   

   

  What is NOT covered?

  Passive War cover is excluded if an insured is traveling to a country (unless otherwise to their home country) after war has been declared in that country, or after it has been recognised as a war zone by the United Nations, or where there are warlike operations.

   

   

  Mode/basis of claim

  Reimbursement.

• Patient Treatment Supplies

  What is covered? 

  If opted for, we cover needles, syringes, or lancets for diabetes (subject to coverage of pre-existing or chronic conditions in the policy).

   

   

  What is NOT covered?

  We exclude items such as, but not limited to:
  • Test strips.
  • Alcohol swabs.
  • Glucometers.
  • Stockings for varicose veins.

• Polycystic Ovary | Ovarian Cyst

  Definition(s)

  Polycystic ovarian syndrome (or polycystic ovary syndrome – PCOS) is a complex condition in which a woman’s ovaries are generally bigger than average. ‘Polycystic’ means the ovaries have many cysts or follicles that rarely grow to maturity or produce eggs capable of being fertilised.

   

  Explanation

  Women who have PCOS may experience: 

  • Irregular menstrual cycles – menstruation may be less or more frequent due to less frequent ovulation (production of an egg).
  • Amenorrhea (no periods) – some women with PCOS do not menstruate, in some cases for many years.
  • Excess hair growth and acne – possibly due to increased free testosterone.
  • Scalp hair loss.
  • Reduced fertility – (difficulty in becoming pregnant) related to less frequent or absent ovulation.
  • Mood changes – including anxiety and depression.
  • Obesity.

   

   

  What is covered?

  Medically necessary conditions not related to infertility, hirsutism, mood changes or obesity. Patient's personal and social history will be required to determine eligibility of cover.

   

   

  What is NOT covered?

  Treatment to correct a state of sterility, infertility, or sexual dysfunction (unless the policy’s Table of Benefits explicitly covers infertility treatment).

   

   

  Mode/basis of claim

  Within eligible network

  Direct Billing (except for benefits which are exclusively offered on reimbursement basis).

   

  Outside eligible network or from abroad
  

  Reimbursement.

   

   

  Tips

  Direct billing claims will be rejected back to the provider and will be reviewed upon resubmission.

• Preauthorisation

  Definition(s)

  It is a process whereby the Insurer and/or its appointed TPA reviews and gives its decision on treatment proposed by the treating Physician for which an approval is required. The Insurer or its TPA will either approve, reject, or require further information.

   

  Explanation

  Following services require prior approvals:

  • All medical and surgical admissions and day case procedures.
  • Outpatient diagnostic tests, including MRI, CT scan, Tread Mill Stress test, Echocardiography, or Endoscopic examinations.
  • Multiple-session services, such as Cryocautery, Electrocautery, Sclerotherapy, Laser therapy, or Physiotherapies.
  • Other Outpatient tests, or if a procedure (not including consultation) in one visit exceeds net cost of AED 1,000 - except for our Essential & DHA plus Network - for which this limit is set at AED 150 

  o Note: For Abu Dhabi-based policies, the approval limit shall not apply; instead, specific approval requirements as defined in the Table of Benefits applies.
  
  

  For certain products, approval is required for all services. Please refer to your policy and Table of Benefits for applicable approval requirements.

   

   

  Tips

  Required that pre-approvals are obtained by the medical provider if you are visiting one within our network.

• Pre-existing Condition

  Definition(s)

  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 a diagnosis. It is not necessary for the Insured Member or his doctor to know what their condition is or was. 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.

   

   

  Explanation

  Pre-existing conditions, whether covered or not, or if any waiting period or limit is applicable, will be clearly mentioned in your Table of Benefits. Relevant terms are applicable irrespective of the condition were declared or not. 

   

  We will not cover any Pre-existing condition if it is listed as not covered in your Table of Benefits. Similarly, even if pre-existing is covered, but a particular condition is listed under exclusions, it will not be covered.

   

   

   

  What is covered?

  If listed in the Table of Benefits as covered, all pre-existing medical conditions which are not part of the policy exclusions are covered up to limits, if any, defined in the Table of Benefits.

   

   

  What is NOT covered?

  • All excluded benefits and services.
  • Pre-existing conditions, declared or undeclared, if excluded in your policy. 

   

   

  Mode/basis of claim 

  Within your eligible network

  Direct Billing (except for benefits exclusively offered on reimbursement basis).

   

  Outside your eligible network or from abroad

  Reimbursement.

   

   

  Tips

  Please let your physician know if you are aware of your pre-existing medical conditions. This will help you obtain appropriate treatment for your medical conditions.

   

   

  Mandatory Benefit as per Regulation

  Mandatory.

• Preventive Medical Services

  Definition(s)

  Medical screening or immunisation for disease prevention and health maintenance. Also refer to General Health Checkup or Screening and Vaccination. Refer to the Table of Benefits for covered services.

   

   

  Explanation

  Preventive medical services include General Health Check-up, Screening and Vaccination. This is an optional benefit (except for mandatory services). If covered, the list of services covered will be listed in your Table of Benefits.

   

   

   

  What is covered?

  Where listed in the Table of Benefits, preventive services as mandated by the regulators to be part of the mandatory insurance coverage.

   

   

  What is NOT covered?

  Preventive services which are not mandated by the regulators to be part of the mandatory insurance coverage (unless it is opted for and included separately in your policy).

   

   

  Mode/basis of claim  

  Optional preventive services (such as General Health Checkup, Screening, Vaccinations) are covered on reimbursement basis.

   

   

  Tips

  The services may be subject to approval and restricted to specific list of providers.

   

   

  Mandatory Benefit as per Regulation

  Dubai Health Authority (DHA)

  Diabetes screening after every 3 years from age 30; for high-risk individuals, annually from age 18.

• Preventive Medical Services: Vaccination

  Definition(s)

  Medical screening or immunisation for disease prevention and health maintenance. Please refer to General Health Checkup or Screening and Vaccination as well. Also, consult your policy's Table of Benefits for covered services.

   

   

  What is covered?

  For Basic Vaccination cover

  0-6 years cover as listed in your Table of Benefits – child vaccination services which are mandated by regulators as part of medical insurance cover. 

   

  For Enhanced Vaccination cover 

  In addition to the above, we also cover optional child vaccinations and travel vaccines (for adult or child), subject to applicable limits. Rabies vaccine following animal bites and/or Tetanus shots following accident- or work-related injuries are also covered.
  

   

   

   

  What is NOT covered?

  No preventive vaccinations are covered, if not listed in your Table of Benefits. 

   

   

  Mode/basis of claim  

  Reimbursement.

   

  For DHA Basic Vaccination cover

  It may be covered on Direct Billing basis.
  

   

   

   

  Tips

  The services may be subject to approval and restricted to specific list of providers. Basic Vaccinations for DHA compliant policies (MOH schedule 0-6) can be claimed on Direct Billing basis in-line with the minimum benefits set by DHA. However, this needs to reflect on the cards. Since it is not, providers are urged to call for approval. If they don’t and the member pays in cash, then:

  • If the benefit is availed inside network: To be reimbursed at actual less applicable network deductibles.
  • If the benefit is availed outside network: If the policy allows for reimbursement, then to be reimbursed according to the policy’s terms and conditions.

   

   

  Mandatory Benefit as per Regulation

  Dubai Health Authority (DHA)

  Essential vaccinations and inoculations for newborns and children as stipulated in DHA’s policies and their updates (currently the same as Federal Ministry of Health – MOH).

• Prosthesis

  Definition(s)

  An artificial device, either external or implanted, which substitutes for or supplements a missing or defective part of the body (for example, artificial limbs and pacemakers).

   

   

  What is covered? 

  Internal Prosthetic devices implanted during a covered surgery.

   

   

  What is NOT covered?

  Artificial organs or limbs, devices such as external pacemaker, cochlear implants, or any such device that replace or act as an external body part. We also do not cover physical aids, such as Crutches, Wheelchair, Walking Sticks, Special Shoes, Splints, Knee Braces, and Supports.

   

   

  Mode/basis of claim  

  Within eligible network

  Direct Billing.

   

  Outside eligible network or from abroad

  Reimbursement.

• Reconstructive Surgeries

  Definition(s)

  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 mastectomy for cancer are covered.

   

   

  What is covered?

  • Covered following accidents and burns. 
  • Breast reconstruction following mastectomy for cancer.

   

   

  What is NOT covered?

  • All healthcare services associated with replacement of an existing breast implant. 
  • All other cosmetic treatments, surgeries, or consultations.

   

   

  Mode/basis of claim  

  Within eligible network

  Direct Billing (except for benefits which are exclusively offered on reimbursement basis).

   

  Outside eligible network or from abroad

  Reimbursement.

• Rehabilitation

  Definition(s)

  Healthcare services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings. Inpatient rehabilitation may be covered provided that: 

  • It is an integral part of treatment.
  • It is carried out by a medical practitioner specialising in rehabilitation.
  • It is carried out in a recognized rehabilitation hospital or unit which is recognised by the insurer. 
  • Costs have been agreed to, in writing, by the insurer before rehabilitation begins.

   

   

  What is covered?

  Only Rehabilitation following Inpatient treatments from non-excluded medical conditions may be covered (for instance, rehabilitation following a stroke).

   

   

  What is NOT covered?

  Autism and developmental delay-related rehabilitation.

   

   

  Mode/basis of claim  

  Within eligible network

  Direct Billing.

   

  Outside eligible network or from abroad

  Reimbursement (subject to applicable deductibles and the policy's conditions for Reimbursement).

   

   

  Mandatory Benefit as per Regulation

  This is an undisclosed benefit, as communication from both Dubai Health Authority (DHA) and Department of Health - Abu Dhabi (HAAD) is not clear about it. It is not an exclusion and is not clearly defined as a minimum required benefit (HAAD BASIC plan and DHA EBP).

• Road Traffic Accidents

  What is covered?

  Injuries arising from Road Traffic Accidents are covered in our Abu Dhabi-based policies as per Circular No. 37/2010.

   

   

  What is NOT covered?

  Medical expenses for Road Traffic Accidents for Dubai- and Northern Emirates-based policies (unless specified as ‘covered’).

   

   

  Mode/basis of claim  

  Within eligible network

  Direct Billing (where covered).

   

  Outside eligible network or from abroad

  Reimbursement (where covered).

   

   

  Mandatory Benefit as per Regulation

  Mandated by Department of Health - Abu Dhabi (HAAD) for members not covered by a Third-Party Liability (TPL) policy.

• Second Opinion

  Definition(s)

  Second opinion is an opinion obtained from an additional health care professional of the same clinical standing as the initial treating physician. This opinion maybe either prior to or after the performance of a medical treatment or surgical procedure, whereby it will then confirm the diagnosis, medical necessity and/or appropriateness of the treatment given.

   

   

  What is covered?

  We cover consultation availed to obtain a second opinion for elective surgeries or major treatments.

   

   

  What is NOT covered?

   Multiple consultation within the same day (unless referred by the treating physician).

   

   

  Mode/basis of claim  

  Within eligible network

  Direct Billing.

   

  Outside eligible network or from abroad

  Reimbursement.

   

   

  Tips

  Where elective surgeries are recommended, members are encouraged to contact us, so we can guide you to a second opinion doctor, if necessary.

• Varicocele

  Definition(s)

  A 'varicocele' is a varicose vein of the testicle and scrotum that may cause pain and lead to testicular atrophy (shrinkage of the testicles). The raised temperature that results from the pooled blood in these blocked veins can decrease sperm count and motility of sperm and increase the number of deformed sperm. It is considered as the leading cause of male infertility.

   

   

  What is covered?

  Treatment for this condition if NOT related to infertility. For this, the patient's personal and social history will be required to determine eligibility of cover.

   

   

  What is NOT covered?

  Treatment to correct a state of sterility, infertility or sexual dysfunction (unless the policy’s Table of Benefits explicitly covers infertility treatment).

   

   

  Mode/basis of claim  

  Within eligible network

  Direct Billing.

   

  Outside eligible network or from abroad

  Reimbursement (subject to applicable deductibles and the policy's conditions for Reimbursement).

   

   

  Tips

  Direct billing claims will be rejected back to the provider and will be reviewed upon resubmission.

• Work-Related Illnesses and Injuries

  Definition(s)

  Healthcare services related to 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.

   

   

  What is covered?

  Medical expenses under Department of Health – Abu Dhabi (HAAD) policies. For other policies, please refer to the Table of Benefits.

   

   

  What is NOT covered?

  • Wage or salary compensation.
  • Any other non-medical expenses or compensation.

   

   

  Mode/basis of claim  

  Direct Billing

  For Abu Dhabi providers.

   

  Network Reimbursement

  For policies not regulated by HAAD, out-of-network providers, and overseas (subject to applicable deductibles and the policy's conditions for reimbursement).

   

   

  Tips

  Hazardous activities and/or professional sports, if part of a job, are: 

  • Covered for all HAAD-regulated policies.
  • To be covered for other policies if work-related injuries cover is opted for.