Table Of Benefits -V2022

Plan Type INPATIENT and OUTPATIENT

Territorial Limit for Elective treatment UAE , AC , ISC and Philippines.
Territorial Limit for Emergency treatment while on Holidays or on official Worldwide excluding USA and Canada- covered on reimbursement basis subject to
duty (Maximum 60 days during single journey) maximum of Claim Reimbursement tariff.
Annual Maximum Limit per person AED 150,000
Hospital cost band NLGIC CHROME ( OP RESTRICTED TO CLINICS)
Waiting period of 6 months is applicable from the first scheme enrollment. Waiting
Pre-existing/Chronic conditions Limit for Inpatient and Outpatient period does not apply for members who were previously insured, subject to the proof
of previous medical insurance cover.
In Patient Benefits within applicable network (subject to prior approval)
Hospital Accommodation and Services Sharing room at network hospital but limited to AED 300 outside the network

ICU Covered in full subject to prior approval

Consultant's, Physician's, Surgeon's and Anesthetist's Fees Covered in full subject to prior approval

Diagnostics (X-ray, MRI, CT scan, Ultra sound, etc.) Covered in full subject to prior approval

Laboratory Covered in full subject to prior approval

Medications Covered in full subject to prior approval

Covered if insured is recipient however the expenses incurred in procurement of organ
Organ transplantation and related expenses excluding donor's expenses
is excluded
Nursing at Home, for recovery and in lieu of a hospital stay up to a
AED 2500 per person subject to prior approval See note 2
maximum of 14 days per admission or procedure
Hospital Cash Benefit if Inpatient Treatment is received free of charge in a
Maximum AED 100 per day subject to 60Days PPPY
Government Hospital in UAE only
Parental accommodation for child less than 16 years of age Maximum AED 100 per day

The cost of accommodation of a person accompanying an in-patient in the

same room in cases of medical necessity at the recommendation of the
Maximum AED 100 per day
treating doctor and after the prior approval of the insurance company
providing coverage
Covers the reasonable expenses in transporting the insured member to the nearest
Ground ambulance services in UAE
medical facility in the event of medical emergency
Covered over and above medical expenses payable under workmen's compensation
Work related injury
policy on reimbursement basis only

- Treatment is taken more economically in these countries

Transportation expenses for Inpatient treatment abroad
- obtaining prior approval from the insurance company/TPA

Out Patient Benefits within applicable network

Diagnostics (X-ray, MRI, CT scan, Ultra sound, etc.) Covered in full See note 1
*Subject to pre approval if the cost exceeds AED 300 (excluding Consultation)
Laboratory
Covered with a limit of AED 7,500 per year including co-insurance if applicable.
Medications Formulary Drug Dispense applicable.
*Subject to pre approval if the cost of medicine per prescription exceeds AED 500

Physiotherapy Charges Maximum of 08 sessions per year Subject to pre approval

Accidental damage to natural teeth Covered in full See note 1

Ayurveda and Homeopathy Not Covered
Diabetes screening: Every 3 years from age 30
Preventive services
High risk individuals annually from age 18
Essential vaccinations and inoculations for newborns and children as stipulated by
Vaccines and immunizations
Federal MOH
Deductible per each and every claim (1 free follow up within 7 days
relating to same illness and same provider) ,Consultant's, Physician's, 20% copay subject to a maximum of AED 15 per claim
Surgeon's and Anesthetist's Fees
Conditions covered for medical emergencies
Diagnostic and treatment services for dental and gum treatments
Covered in full
Hearing and vision aids, and vision correction by surgeries and laser

Where any maternity condition develops life threatening(either to the

Covered up to AED 150,000 PPPY
mother or to the new born)medically necessary expenses will be covered

Additional Benefits
Passive war risk Covered See note 1
Repatriation Benefit on Death By Any Cause (For members up to the age of
AED 7,000 based on actuals
65 years)

Adult Pneumococcal Conjugate Vaccine Covered as per DHA Adult Pneumococcal Conjugate Vaccine guidelines

Hepatitis C Virus screening and treatment Covered as per guidelines laid out by DHA in the Hepatitis C support program

Cancer screening and treatment Covered as per guidelines laid out by DHA in the Cancer support program

Second Medical opinion - is a rider aiming at assisting the insured member

with a second medical opinion in order to determine or reconfirm the
Covered See note 1
diagnosis and decide on the appropriate treatment protocols for a medical
condition
Dental Benefit

Dental Sickness:
- (Consultations, Extractions, Amalgam Fillings, Composite Fillings, Glass
Not Covered
Ionomer, Dental X-Rays, Root Canal Treatment and Gum Treatment)
- Coinsurance for dental treatments (after the other applicable deductible)

Optical Benefit

Optical:
- (Consultations, Medications, Vision tests) Not Covered
- Coinsurance for optical treatments (after the other applicable deductible)

Maternity Benefit
1. Normal Delivery expenses are covered up to a sublimit of AED 7,000 / -
2. Medically necessary Caesarean section and complication expenses are
covered up to a sublimit of AED 10,000 /-
3. Any condition develops which becomes an emergency, the medically necessary
expenses will be covered up to the AED 150,000/-
Inpatient & Outpatient coverage
4. 10% copayment applicable on all Maternity treatments, including out-patient
includes:
Maternity consultation (no Deductible applies)
5. The following screening tests are covered as per DHA antenatal care protocol:
1. Pre & post natal treatments
• FBC and Platelets
2. Normal delivery
• Blood group, Rhesus status and antibodies
3. Medically necessary Caesarean section
• VDRL
4. Maternity related complications
• MSU & urinalysis
5. Medically necessary legal terminations
• Rubella serology
• HIV
Inpatient Maternity Treatments are subject to prior approval
• Hep C offered to high risk patients
• GTT if high risk
• FBS , random sugar or HbA1c
• Visits shall include reviews, checks and tests in accordance with DHA Antenatal Care
Protocols
• 3 ante-natal ultrasound scans
 Cover for 30 days from birth.
New born cover BCG, Hepatitis B and neo-natal screening tests (Phenylketonuria (PKU), Congenital
Hypothyroidism, sickle cell screening, congenital adrenal hyperplasia)

Claims Settlement for Elective & Emergency Medical Treatment

Inside network - Covered, even for outside UAE as per network.

Elective Treatments (Inside UAE and Outside UAE, as per the geographical
coverage) Outside network - Covered (Reimbursement subject to maximum of the Published
Tariff. Pharmacy encounters submitted as reimbursement will be paid with 15% Co-
Insurance )
Inside network - Covered, even for outside UAE as per network.

Emergency Treatments (Inside UAE and Outside UAE, as per the

geographical coverage) Outside network: Covered (Reimbursement subject to maximum of the Published
Tariff. Pharmacy encounters submitted as reimbursement will be paid with 15% Co-
Insurance )

Other Conditions
Pre-authorization requirements As per annexure

Exclusions As attached (Standard Exclusion of DHA Applicable)

Claims submission period (Reimbursement) Within 60 days of availing the treatment

Declaration of major condition is mandatory for inception and mid term enrollments including ongoing Maternity
Major Medical Conditions

CONDITIONS TO DECLARE Yes/No

1. Cancer / Tumor

2. Cardio Vascular Conditions/ organ failure or end stage organ disease

diagnosed / organ transplant performed

3. Brain & Spine / Knee ( Any major ongoing cases/conditions)

4. Ongoing Pregnancy / Maternity and related

5. Gynae complications

Notes
1. Coverage is subject to annual maximum limit and sub limits per person. Maximum age at entry shall be 60 years of age.

2. For non-emergency inpatient treatments, at the discretion of the insurer and subject to pre-authorization.
3. Treatment for emergency conditions shall not require pre-authorization, but such cases are to be notified to the company within 48 hours of the emergency
treatment.
4. Terms and conditions are as per policy wording.

5. This benefit schedule is not applicable for members (visa holders) based in the emirate of Abu Dhabi.
6. National Life & General Insurance Company or its TPA reserves the right to include/exclude/upgrade banding/degrade banding of any clinic at anytime from the
designated provider network list.

7. Direct billing shall be provided only at the listed hospital network and the reimbursement at non designated clinics and hospitals will be based on
Reimbursement published Tariff for Elective & Emergency Treatment. Pharmacy encounters submitted as reimbursement will be paid with 15% Co-Insurance

8. The above terms are not applicable for employees holding Dubai Visa having a gross monthly salary of less than AED 4000. Should this assumption be incorrect,
we reserve the right to withdraw this quotation or cancel the policy (if issued) since inception.
9. The Benefits and Network applicable to the policy, which are negotiated and confirmed before communication of the policy shall not be modified/altered under
any circumstances during the policy period
10. Group Health Declaration to be sumitted to the Insurance Company for review. Final terms shall be released by Insurance Copmany upon review of Group
Health Declaration
 Addition Clause
The insured may add Primary insured and/or their Dependents to the Policy subject to:
• Compliance to regulatory requirements, if any and their timelines.
• Submission of completed addition request form/template, issued by Insurer or other mode acceptable to the insurer.
• Submission of other documents (eg. Health declaration, Passport copy, Visa copy etc.,), wherever applicable, as informed/requested by the Insurer.
• The addition shall be effected from the date of the receipt of the request for addition.
• The premium payable for additions shall be on prorated basis.

Deletion Clause
The insured may at any time, upon completing and sending the insurer the relevant request form, to delete Primary insured and their Dependents from the Policy
subject to:

• Submission of completed deletion request form, issued by Insurer or other mode acceptable to the insurer
• Return of Membership cards and other materials facilitating Treatment prior to the deletion date

The deletion shall be effected from the date of the receipt of the request for deletion. In the event of not returning the membership cards or loss of membership card,
the insured shall make good of the loss/liability incurred by insurer in respect of any claim occurring after the deletion date or due to loss of membership card.

• The Premium refund relating to any approved deletion shall be calculated in accordance with the following Conditions:

a) No refund will be payable for deleted Insured members who have registered any Claim under the policy.
b) Insured members, who did not report any Claim prior to their deletion date, will be refunded proportionately for the period remaining from the deletion date
until the Expiry date of the less 20% of the annual premium

The amount of refund will be reduced proportionately if the return of Membership cards and other materials Facilitating Treatment is delayed. In addition, insured
will be the sole and fully liable party towards the Provider and/or Insurer in respect of any expenses incurred by the deleted Insured member from his deletion date,
until the Membership card and other materials facilitating Treatment are returned.
• Covered benefits arising from Accident or Illness occurring during the Policy period for your Insured member Shall cease immediately upon his deletion from the
Policy.