Frequently Asked Questions - Sukoon Insurance

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Health

What is a Policy Glossary?

In a nutshell, the Policy Glossary contains a list of terms, with definitions, commonly used with your Policy, though certain terms may not be part of it. These are meant to be purely educational and, therefore, may vary from the Terms and Definitions in the healthcare plan chosen for you by your employer. Also, bear in mind that some of these terms may not carry the same meaning as the one used in your policy or plan; in such a case, the definition prescribed in your policy or plan takes precedence.

To access the Policy Glossary with a list of generally used terms and definitions, please click here.
What do ‘exclusions’ in my policy refer to?

To put it simply, these are the medical conditions and/or services which are not covered by your healthcare plan. These may vary according to the type of product. So, before buying a plan or filing a claim, please refer to your policy’s Table of Benefits.

Please click here to learn more about exclusions relevant to your plan.
I want to find out which providers are part of a given insurance network. How should I proceed?

You may view the details of our network providers through our website, sukoon.com, or the mySukoon mobile app.

You can also download the list of Non-Contracted Physicians and Deactivated Facilities for Reimbursement.

Please note that we review and update the lists on a regular basis which are, therefore, subject to change. Kindly refer to the latest list before seeking healthcare services.
Will I have to pay other charges to the medical provider even if the treatment was approved for direct billing? Can I get these charges reimbursed?

Yes, there are other charges that you may be liable to pay to a provider which are not reimbursable.

These charges include, but are not limited to, the following:

• Registration or admission charges.

• Co-insurance, co-pay, or deductible.

• Attendant or Visitor Pass charges.

• Special nursing charges not authorised by the attending doctor.

• Service charges not forming part of the room rent.

• Charges for TV usage, electricity consumed, laundry services, etc.

• Charges for use of telephone or fax services.

• Food and beverages, toiletries, etc.

• Purchase of medicines not related to the treatment.

• Stationery, photocopy services, CD, or certifying charges.

• Taxes and charges for uncovered services.

• Charges for consultation with a physiotherapist.

• Services rendered by a dietician.
I want to check the Table of Benefits for my coverage. How may I?

Simply navigate to the ‘Dashboard’ tab in the mySukoon mobile app and click on your profile under ‘Health Cardholders’ to download your Table of Benefits.
Why are certain services not considered as ‘medically indicated’ despite being requested by the treating physician?

A ‘medically indicated service’ is a healthcare service which is needed to diagnose or treat an illness, injury, condition, disease, and/or its symptoms. It meets generally accepted standards of medicine and credible scientific evidence published in peer-reviewed medical literature generally recognised by the applicable healthcare regulator.

Coverage of preventive services or screening tests is governed by terms and conditions of the health plan chosen for you by your employer as a wellness benefit (if opted for).
I incurred expenses on a medical treatment. How should I file a claim for reimbursement?

You may conveniently submit your claims online through the mySukoon portal or mobile app. How does it work? Simply download the claim form by clicking here, fill out the details, and upload it together with the supporting documents as mentioned in the form.

To ensure a seamless processing of your claims and receive timely updates, kindly provide your email address when submitting the claim form. This will allow us to send all necessary information related to your claim directly to you.

For claims above AED 5,000, you will need to submit the original documents at the address mentioned below or to any of Sukoon’s branches:

Medical Claims Department
Sukoon Insurance building | Omar Bin Al Khattab Street, next to Al Ghurair Mall, Deira, Dubai, UAE
Location Map: Click here
P.O. Box 5209 | Dubai | United Arab Emirates
Tel: +971 4 230 2700
I need to file for reimbursement. Where can I find the claim form?

You can find the reimbursement claim form in the Downloads section of our website. Please click here to get a copy now!
How can I submit a reimbursement claim online?

Please visit medical.sukoon.com or the mySukoon mobile app and follow the instructions below:

• Log in using your credentials. If you have not made an account before, click on ‘Register’, enter your email address, mobile number, date of birth, card number, and voila – you’re all set!

• Go to the ‘Claim’ tab and select ‘Submit Claim’.

• Select the card number.

• Update and review your banking information.

• Select the date you availed medical services on.

• Enter the claimed amount (in AED).

• Upload the claim form and all supporting documents as requested.

• Accept the declaration at the end of the form and submit your application.
Which documents do I need to submit to get my claim processed?

Copies of the following documents need to be submitted:

• Completed, stamped, and signed Reimbursement Claim Form.
• A valid prescription issued by the treating physician for medication.
• All invoices (clearly showing the cost per service) and receipts (showing that cash payments for the treatment were made by you/credit card - customer copy generated by POS machine).
• For inpatient admissions, the Discharge Summary and Medical Report.
• All investigation results.
• If physiotherapy is prescribed, a Referral Letter from a specialist clearly indicating the goal of treatment and number of sessions.
• For accident-related claims and/or injuries, the Police Report or First Information Report (FIR).
• Refraction test results for optical-related claims.

Please ensure that the language used in these documents is either Arabic or English. If any other language is used, you will have to get that document translated before submitting it. Note that all claims must be submitted within 120 days after receiving treatment.
I’ve already received treatment. How long can I take to submit the claim?

All claims must be filed within 120 days after receiving treatment (for outpatient services) or discharge date (for inpatient admission) – whichever is applicable.
I have been admitted more than once for treatment. Can I submit a single claim for all visits?

Unfortunately, you cannot. You must fill and submit a separate claim for each individual visit or admission.
My doctor provided me consultation at my home. Can I file a claim for expenses incurred on his/her visit?

Your health plan covers only services provided at a hospital, the physician's office, or a registered health facility. Services provided at home are not covered; that is, unless your policy states otherwise.
In which currency will the claim be settled?

In UAE Dirhams, using the exchange rate as on the date of treatment.
Can I file a claim for translation cost?

Unfortunately, the cost for translation is not payable.
I’ve submitted my claim. What’s next?

Now, if all requirements were met and supporting documents submitted, we’ll process your claim and reimburse the amount within 10 calendar days following receipt of the claim.

This timeline applies to claims for which 'bank transfer' is the mode of payment.
How will I receive the claimed amount back?

For a quick and seamless settlement of your claim, we urge you to update your IBAN on the mySukoon portal or mobile app. The privilege of updating banking information, however, rests with the Principal Member only; dependents won’t be able to do so. It is essential to note that, on certain occasions, the company may opt for reimbursement to be directly made to them. In such cases, the reimbursement will be processed and disbursed accordingly to the designated company.
Any news on my claim? How can I track its progress?

As promised, we’ll keep you in the loop at every step of the way. We will send you email and SMS notifications to apprise you during the various stages of claim processing. Please ensure that your contact information is clearly mentioned on the claim form. You may also track its status on the mySukoon portal or mobile app by visiting the ‘Claims’ section.
I am unconvinced by the final settlement. How should I proceed?

Don’t worry! You have full right to represent your case, and because you matter to us, we won’t shy away from giving it another look, should the need arise. Simply reach out to us via email at weserve@sukoon.com, and we’ll take it forward.
I’ve been asked by Sukoon to provide missing information and/or additional documents. How should I proceed?

Once the requested items are ready to be submitted, please log into the mySukoon portal or mobile app, click on ‘Update Claim’, add the missing items, and then resubmit the claim. We’ll handle the rest.
What is ‘proof of payment’? Is it necessary every time I submit a claim?

In summary, ‘proof of payment’ is a guarantee that a member actually paid for the services they made a claim for. It could be the receipt of a credit card transaction or a hospital receipt with a ‘paid’ stamp on it. And yes, it is necessary.
Can I submit a claim for medical treatment or services planned in the future?

No, there is no upfront coverage or payment for treatment(s) or service(s) planned for later. Only treatments and services performed within the policy period will be reimbursed.
How can I file a claim for medical expenses incurred on my newborn baby?

If the mother’s policy or plan offers coverage for maternity, medical expenses incurred on treatment of newborns will be covered by us. Here is how it works:

• All newborn-related treatments under the mother’s policy are covered up to the annual indemnity limit in either of the following cases – whichever arrives earlier:

o For 30 days after the birth. This applies if the baby was born in the UAE, unless the Terms of Benefit (ToB) state otherwise.
o Till the enrolment of the baby for the insurance policy.

• If a baby was born outside the UAE while the mother is covered by us, they will be covered for up to 30 days following birth. The indemnity limit will be the same as prescribed by the Terms and Conditions of the mother’s policy. Continuity of the cover is subject to the plan a policyholder chooses – that is, if the plan allows for it.

• If the outpatient benefit is not provided in your home country, your coverage will be limited to inpatient services only; otherwise, you’re covered for both.

• Coverage will follow benefits and prescriptions under the mother’s policy.

• Here is how we will cover for you:

o For inpatient admissions and services rendered by an eligible network provider, you will be eligible for direct billing services.
o For outpatient or other services that are rendered abroad or from someone who is not our network provider, your claims will be processed on a reimbursement basis.

• If the delivery is not covered under the mother’s policy, then expenses incurred on the newborn will not be covered.
What is ‘co-pay’? Is it the same as ‘co-insurance’?

The ‘co-pay’ refers to the share of a medical bill you’ll cover, with the remaining handled by us. It could be a percentage of the bill or a fixed amount you’re liable to pay for each bill you incur. It’s already part of all the limits prescribed by your policy. And yes, co-pay and co-insurance are the same thing.
What is a ‘Reasonable and Customary Charge’?

To put it simply, it is the cost of a medical service we have agreed to with our network providers in a particular geographical area. More so, it is the maximum they will charge us for a particular service. This serves as the basis for settlement of your claim.

We understand that non-network prices could be quite high, thereby adversely impacting the policy’s renewal premium. So, when you avail a service from someone outside your plan’s network, we use the Reasonable and Customary charge to process your claims and not the actual out-of-pocket expenses you incur (unless your policy states otherwise).
What is ‘Non-Network Coinsurance’? When is it applicable?

When you avail medical services from a provider outside your defined network, you will be charged a certain percentage of the approved claim amount. The amount is pre-agreed and based on provisions of your health plan.
It says in the policy that all benefits' limits are inclusive of co-pay or co-insurance. What does it mean?

Unless stated otherwise, it means that the benefit limit is shared between Sukoon and the member.

For instance, if your benefit limit is AED 1,000 inclusive of 20% co-insurance, then, by agreement, you’ll pay AED 200 (20% of AED 1,000) while the remaining, AED 800, is covered by us.
When are claims denied?

A claim is only denied when services are not covered under your health plan. Don’t worry; you deserve clarity, so we’ll try our best to explain the reasons of denial to you via the claim settlement summary. You can also reach out to us via email at weserve@sukoon.com or by calling us at our toll-free helpline, 800 SUKOON (785666).
I paid VAT to the provider. Can I claim the amount?

Unfortunately, we will not be able to reimburse the VAT amount.
Will I be reimbursed airfare expenses if I availed treatment in my home country?

If your healthcare plan covers airfare ticket for inpatient treatment, then we will reimburse the amount (subject to criteria as specified in your policy); otherwise, we won't.
Can I reimburse the co-pay, co-insurance, or deductible I paid to the provider?

No, these costs are not subject to reimbursement.
The amount I was reimbursed is less than what I made a claim for. Why is that?

The amount you receive will have factored in the following, depending on your policy’s terms and conditions as agreed to with your employer:

• Co-pay, co-insurance percentage deducted from the total claimed amount.

• Deductibles (if applicable). If the cost of services you claimed exceeds the average cost of services determined by your provider network, the excess amount will be deducted from the total bill.

• Whether the claim was within the remaining benefit limit amounts.

• VAT amount (which is not payable).

• Certain exclusions for each policy which are mostly related to undeclared, pre-existing medical conditions, allergy testing, dietary supplements, alternative medicines, dental prostheses and orthodontic treatments, contraception, treatments, and services arising due to hazardous activities, preventive services, and vaccinations outside the scope mandated by insurance authorities.

Please refer to the benefit highlights (available on the mySukoon mobile app) and, if possible, keep the Table of Benefits provided by your employer handy. It’s really helpful!
Can I file claims for alternative medicine services?

If your health plan chosen for you by your employer offers Alternative Medicine services, then you will be able to make a claim for services incurred, subject to the list of services covered, benefit limit, and coinsurance as applicable. Then, you will be covered on a reimbursement basis.

When applying for reimbursement for availing alternative medicine services, here are a few things you need to know:

• The benefit can be claimed for only conditions covered by the policy.

• The treatment must be deemed medically necessary, which is the case when it is necessitated by an illness.

• A debit card is the preferred payment method for an alternative benefit claim.

• Ayurvedic services for post-delivery status and newborn are not medically indicated.

• If the limit was reached by a member of your family, coverage cannot be extended under another member’s limit.

• Make sure you keep a check on the list of Deactivated Facilities for Reimbursement, updated regularly and made available on our website and mySukoon mobile app, before availing the service.
Why were provider charges adjusted in the claim?

If a member does not opt for direct billing facility and pays cash upfront to a network provider, the claim will be settled as per the tariff agreed to with said provider.
I’m getting myself tested for influenza soon. Will it be covered?

Yes, but only for high-risk groups and if deemed as ‘medically indicated’ (as defined by applicable guidelines, rules and regulations). People who usually qualify under the bracket include:

• Children younger than age 5.
• Adults who are 65 years of age and above.
• Pregnant women and women up to two weeks postpartum.
I’m getting my Vitamin D levels tested. Will my plan cover it?

The healthcare plan chosen for you by your company covers tests that are medically indicated.

Simply put, screening for Vitamin D levels is only considered medically necessary when a claimant is dealing with:

• Malabsorption (including cystic fibrosis and coeliac disease).

• Significant hepatic and renal disease.

• A child with clinical rickets.

• Osteoporosis, osteomalacia, and osteopenia.

• Use of drugs such as Rifampicin, anticonvulsants, antiretroviral therapy, high dose glucocorticoids, and cholestyramine.
I am a pregnant woman who wants to avail Down syndrome or Genetic Screening (NT scan, PAPP-A, Non-Invasive Prenatal Testing) services. Will my plan cover it?

Your health plan covers medically indicated services to ensure provision of appropriate medical care towards your health and that of your unborn baby. The plan also follows requirement mandated by the applicable healthcare regulator.

Therefore, Nuchal Translucency scan, Pregnancy-Associated Plasma Protein-A, and Non-Invasive Prenatal Testing are not considered part of the mandated antenatal tests and are, therefore, not covered by a Sukoon-issued policy.
What constitutes an ‘emergency’?

An ‘emergency’ is defined as the sudden onset of an illness, injury or medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) requiring immediate and unscheduled medical care. If left untreated, it may result in placing the person’s life and/or health in serious jeopardy, serious impairment to bodily functions, serious dysfunction of a bodily organ or part, serious disfigurement, or - in the case of a pregnant woman - serious jeopardy to the health of the foetus.
I have a complaint. What should I do?

We are here for you through thick and thin! So, if you were unable to address your concerns effectively, we’ll help you out. Simply raise a complaint by sending us an email at compaints@sukoon.com or reaching out to us via the Contact Us section of our website.
Can I use eCards for UAE residence visa stamping?

Definitely. You can use eCards for visa stamping.
Can I use my Emirates ID if I travel outside UAE?

No, you cannot use your Emirates ID outside the UAE since international direct billing is managed by our network partner MSH International. They will require eCards to validate your eligibility.
Can I visit a healthcare facility outside my network? If I can, how do I pay?

Here's how it works. Non-network access is always subject to the terms and conditions of your policy. You will have to pay the whole cost of the treatment and then apply for reimbursement. Your claim shall be settled as per the terms and conditions of your policy, after applying any non-network deductibles.

In the case of elective hospitalisation, you need to make sure that you inform us before you get admitted.

If the procedures or investigations during any outpatient visit in a non-network hospitalisation might exceed AED 500, you will need to get the necessary prior approval from us.

In case of emergencies, please call our helpline 800 SUKOON (785666) as soon as possible for all required details.
How can I avail medical care in the UAE without medical cards?

You should be fine even if you don't have your physical medical card with you. Healthcare providers across the UAE have access to our online platform where they can validate your insurance details using your Emirates ID or your eCard that's available on the mySukoon portal and mySukoon mobile app (available on Google PlayStore and Apple App Store). For your ease, we advise you to download and save the eCards to your mobile phones.

International direct billing is managed by our network partner MSH International. They too can validate your eligibility with your eCard.
How can I update my Emirates ID number on mySukoon portal?

It's a simple process. To update your Emirate ID, please log in to the mySukoon portal and go to the ‘Update KYC’ tab under Policy Servicing.
How do I register on mySukoon App?

Don't worry, it's a quick and easy process. To register on mySukoon App, please click here. You will need to enter your email address, UAE registered mobile number, date of birth, Emirates ID or medical insurance card number to register.

Your medical insurance card number was shared as part of the onboarding email sent to you from noreply@sukoon.com. If you are unable to find it, kindly contact your HR or insurance coordinator. Alternatively, you can call us on our toll-free number 800 4746 and get your card number after verifying your identity. Kindly keep your passport copy ready before making the call, as the executive may request for these details to validate your identity.
How will the medical provider check my eligibility?

Healthcare providers have access to our exclusive online platform, where they can validate your insurance details using your Emirates ID or eCard. Your eCard details are available on the mySukoon portal and mySukoon mobile app. For your ease, we advise you to download and save the eCards on your mobile phone.
I am currently holding a physical card and my card is expiring after 1st Aug 2020. Is it still valid?

Don't worry, you can use your physical card until its expiry date if you wish. In case you forget to carry the card at any time, you can use your Emirates ID or show your eCard to avail our direct billing services. Just note that for your Emirates ID to work, it should be registered with us. To register, you can log into mySukoon and update your details.
I do not hold an Emirates ID and don’t know my insurance card number. How can I register on mySukoon and generate the eCard?

Don't worry. We've got you covered. Your medical insurance card number was shared as part of the onboarding email sent to you from noreply@sukoon.com. If you are unable to find it, kindly contact your HR or insurance coordinator. Alternatively, you can call us on our toll-free number 800 SUKOON (785666) and get your card number after verifying your identity. Kindly keep your passport copy handy before making the call, as the executive may request for these details to validate your identity.
I have a new-born baby and the Emirates ID is under processing. Can I avail the medical services?

Yes, of course you can, as long your new-born is enrolled in the policy. Once enrolled, the primary insured (the father or the mother), can generate the eCard for the baby through his or her mySukoon account.
Is the validity of my medical Insurance linked to my Emirates ID?

No, they are not linked. You will need to renew each one separately.
On my card, it says, "20% co-insurance on all outpatient services". What does it mean?

The coinsurance or co-pay is the percentage or amount you will need to pay the hospital or healthcare provider for all services that are covered under your policy. In your case, you will need to pay 20% of the total bill from your side.
On my card, it says, "Deductible: AED 40 on consultation". Do I have to pay anything for investigations/medicines?

No, you don't. As it says, the deductible/co-pay is applicable only for consultation. Hence you need to pay the mentioned amount only for that service. You don't need to pay anything from your side for any of the other covered services.
What is mySukoon mobile app?

mySukoon is a mobile app exclusively available to all our customers. The app is available on the Apple App Store and the Android Play Store as ‘mySukoon’.

The app allows you to submit and track your reimbursement claims, find the network providers closest to you, generate the eCard for yourself and your dependents. The login details for the app are the same as those for the mySukoon portal.
Who all have access to mySukoon to generate the eCard?

Brokers, the policyholder and the insured members have access to mySukoon to generate the eCard. If you are a broker or policyholder, then kindly contact your Relationship Manager for your mySukoon access, if you don’t have an account already. Insured members can register themselves instantly using their email address, UAE registered mobile number, date of birth, Emirates ID or healthcare insurance card number.
Who can I contact in case of any further queries?

Please email us on service@sukoon.com or call our toll-free number at 800 SUKOON (785666). Our agents will be available to assist you from 8 am till 8 pm from Monday to Friday and from 8 am till 5 pm on Saturdays.
Will my insurance coverage be affected because of the expiry of my Emirates ID?

No, of course not. Even if your Emirates ID is no longer valid, you can use your eCard, that's available on the mySukoon portal or the mySukoon mobile app, for eligibility verification with the network provider.

Commercial Health Motor

CRS Entities CRS Individuals Value Added Tax (VAT) UAE Value Added Tax (VAT) Oman

CRS Entities

A Disclaimer

The information on this website is based on Sukoon’s interpretation of the CRS regulations and we make no claims about its accuracy, completeness, or up-to-date character, and that applies to any site linked to this website as well. The information contained on this website does not constitute any form of legal advice or tax advice.

Nothing on this website should be viewed as tax advice nor as a substitute for the advice of a competent attorney. The information on this site is not intended to be used for the purpose of avoiding compliance with the CRS regulations.
Can the POA or authorized signatory provide the CRS self-certification on behalf of the entity/controlling person? And will he/she be reported under the CRS?

The authorized signatory can provide the certification on behalf of the entity/controlling person as the CRS self-certification form is required for the account holder only. The authorized signatory will be reported if he/she maintains a separate account with Sukoon and if he/she is a tax resident in one or more of the participating jurisdictions.
For existing customers, what are the consequences of not providing the required information?

We will be unable to establish your tax residency as per the CRS regulations. We shall use the information held on our records to determine whether you may be tax resident outside the UAE and report them accordingly to the UAE Ministry of Finance. We encourage you to complete and return the form, so as to ensure that reporting decisions are based on accurate information.
How is CRS different from FATCA?

FATCA requires information to be reported about US persons, including US citizens and residents, whereas, CRS requires financial institutions to report the policy/account and 'tax residency' information of all reportable persons (a tax residency concept, regardless of citizenship).
How often do we need to provide information under the CRS?

Information needs to be provided once at the time of policy/account opening. The customer is required to provide an updated form, in case of change in customer circumstances, which may indicate a change in tax residency status.
Is Sukoon the only financial institution asking for this data?

All financial institutions regulated in the UAE, including banks, custodians, insurers and asset managers are required to be compliant with the CRS.
Is the CRS form mandatory for all customers like US nationals and nationals of countries not participating in the CRS?

The tax residency status of all customers should be identified and all accounts should be classified. Although customers may be residents in the US, they may also be tax residents in other jurisdictions.
What are the tax residency points a policy/account holder needs to consider?

• Determine and monitor the tax residency status of the individual or entity based on management and control and / or incorporation
• Tax residency of an individual or entity is not fixed
• Multiple tax residencies are possible in the same year
• Different tax residencies in subsequent years
What happens if I am a tax resident in more than one country?

Customers may be tax resident in more than one jurisdiction depending on their circumstances. You should list all jurisdictions in which you are treated as tax resident and provide the tax identification number for each one. Please contact a professional tax advisor or check the OECD website for more information on how to determine your tax residency, as Sukoon cannot provide any tax advice.
What if a customer does not have a Tax Identification Number (TIN)?

There is a possibility that certain countries do not issue Tax Identification Numbers. In such a case, a customer is required to provide details as to why it has no TIN in the self-certification.

Jurisdictional guidance on TINs (or functional equivalents) may be found on the OECD website.
What information are you asking customers to provide and verify?

In line with the CRS requirements, we will ask you for your:

- Name
- Address
- Country(ies) of tax residence
- Taxpayer identification number(s) of each identified tax residency
- Place of registration/incorporation (for Entities)
- Entity Type (for Entities)
- Controlling Person Type for certain Entity Types:
- Date of Birth
- Place of Birth
- Residence Address
- Country(ies) of tax residence
- Taxpayer identification number of each identified tax residency
What information will be reported to tax authorities?

The information provided to the tax authorities will include the following details:

- Name
- Address
- Jurisdiction(s) of tax residence
- TIN(s)
- Name of the reporting financial institution
- Account number
- Account balance
- Gross amount paid to the account in a year (interest, dividends, other income)
- Gross proceeds paid or credited to the account

Additional information for individual accounts and Controlling Persons may include:
- Date of birth
- Place of birth
What is my obligation if my information changes?

You must notify Sukoon within reasonable time if there is any change in circumstances regarding your tax status, and provide an updated self-certification declaration on a dedicated form.
What is tax residency?

For entities, this is typically where the entity has an obligation to file a tax return or is liable to pay income or corporation taxes. This may be determined by where the entity is incorporated, but there are other determining factors, based on each jurisdiction's tax residency rules.

Please note that Sukoon is not authorized to provide any tax advice to customers. Therefore, we suggest you to contact a tax advisor. Additional information may also be found on the OECD website.
What is the Common Reporting Standard?

The Common Reporting Standard (CRS) is a global standard under OECD (Organization for Economic Co-operation and Development) for automatic exchange of financial account information for tax purposes. CRS is a global version of FATCA and the UAE Ministry of Finance has committed to implementing the CRS guidelines, starting 1 January, 2017. The CRS regulations require financial institutions such as Sukoon or any of its affiliates , to collect and report certain information about a policyholder's current tax residency, policy/account information and information about its Controlling Persons, as mandated by the concerned UAE authority. The concerned UAE authority may then share this information with the tax authority where you are tax resident.
What will happen if I do not provide the required information?

CRS is a mandatory requirement of our policy/account opening procedure. In case you do not want to provide the required information then we will not be able to process your policy request for dealing with Sukoon.
Where can I find further information and advice?

For further information on your tax residency, please refer to the rules governing tax residence that have been published by each local tax authority. You can also find out more at the OECD website.
Which jurisdiction's rules should apply to determine an Entity's status?

The CRS provides that an Entity's status as a Financial Institution or non-financial entity (NFE) should be resolved under the laws of the Participating Jurisdiction in which the Entity is resident.

If an Entity is resident in a jurisdiction that has not implemented the CRS, the rules of the jurisdiction in which the account is maintained determine the Entity's status as a Financial Institution or NFE, since there are no other rules available.

When determining an Entity's status as an active or passive NFE, the rules of the jurisdiction in which the account is maintained determine the Entity's status. However, a jurisdiction in which the account is maintained may permit (e.g. in its domestic implementation guidance) an Entity to determine its status as an active or passive NFE under the rules of the jurisdiction in which the Entity is resident, provided that the jurisdiction in which the Entity is resident has implemented the CRS.
Why are you asking me for my jurisdiction(s) of tax residency?

Under the CRS, tax authorities require financial institutions such as Sukoon to collect and report certain information relating to their customers' tax statuses.

If you open a new account/policy, invest in new financial products or change your circumstances in some way, we will ask you to certify a number of details about yourself. This process is called 'self-certification' and we are required to collect this information under the CRS.
Will Sukoon respect my data privacy?

Sukoon will respect your data privacy. We will only disclose your information to the relevant tax authorities if we are legally required to do so.
Will Sukoon share my data with other parties?

The CRS regulations require Sukoon, to collect and report information, as mandated by the concerned UAE authority. The concerned UAE authority may then share this information with the tax authority where you are tax resident.

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.

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