Abroad

Any country other than the United Arab Emirates (U.A.E.).

Access Card

A personalised card issued in the name of each Beneficiary, facilitating his/her access to the Healthcare services covered under this Insurance Policy and provided by the Network.

Accident

Any sudden and unforeseen event, occurring to a victim beyond his/her control and resulting in a Bodily Injury, the cause of which, is violent and external to the victim’s own body.

Active at Work

The work situation of any Employee reporting regularly and on a permanent and full time basis to his work place and performing the usual and normal duties of his occupation in conformity with the employment conditions.

Application Form

Written statement of facts, requested by the Insurer and duly completed and signed by the Policyholder, on the basis of which the Insurer will carry out an Underwriting in full accordance with the general provisions of this Insurance Policy. Two types of Application Forms are in use:

Initial Application Form: The first Application filled by the Policyholder/and or by his/her Legal Dependent(s) (as defined hereafter).

Subsequent Application Form:Any form that the Policyholder completes, requesting the introduction of modifications to the Insurance Policy in force, and/or addition/deletion of Beneficiary (ies) in full conformity with the general provisions of this Insurance Policy.

Beneficiary

The Enrolled Employee or his Legal Dependent listed in the Application for this Insurance Policy, or included thereafter, formally accepted by the Insurer and listed in the Schedule or in any subsequent Endorsement thereon, are considered under this Insurance Policy as eligible and referred to as Beneficiary hereinafter.

Beneficiary User’s Guide

The booklet or pamphlet provided by the Insurer to the Policyholder, which explains how to benefit from this Insurance Policy coverage.

Benefit

The smallest block of a Plan which is linked to a Family of Benefits and described by the Scope of Coverage.

Benefit Description

Describes the scope of cover and modalities of claims payment and is part of the contract.

Bodily Injury

An identifiable physical injury caused by an Accident, which occurred during the period of insurance.

Cancellation Date

The day (at 12:00 noon local time) month and year on which this Insurance Policy has been cancelled as a result of the Policyholder's written notice and/or as a result of the non-fulfillment of the Policyholder's obligations as set forth in the general terms herein.

Category

The sub-group of Beneficiaries within the group covered under this Insurance Policy and for which the Policyholder has selected a Plan providing particular considerations as specified in the Schedules.

Chronic Disorder

An incurable disease requiring a regular, lifetime Treatment.

Claim

Information submitted by a Provider or by a Beneficiary to establish that medical services were provided to the Beneficiary, within the frame of the Benefits selected, and upon which processing for payment to the Provider or Beneficiary is made. The term generally refers to the liability of the Insurer for Healthcare services received by one of the Beneficiaries.

Co-participation

The participation of the Beneficiary, Policyholder and/or a Co-Payer in accordance with pre-defined percentages in the payment of Eligible Expenses covered under this Insurance Policy. The Insurer shall be liable for the balance of the Eligible Expenses.

Co-Payer

An entity or a person participating jointly with the Insurer in the payment of an Eligible Expense, in accordance with a defined percentage as specified under the Partnership Schedule and/or the Scope of Coverage Schedule.

Day-Hospitalization

Sometimes called Day-Care. Same day surgery, medical treatment or diagnostic tests including but not restricted to oncology (chemotherapy) and cardiology related to any Non-Excluded cases, not requiring an overnight stay at a Hospital but, nevertheless, necessitating specialised medical attention and care in a Hospital, before, during and after the Treatment.

Declared Condition

Any pre-existing Condition that was declared by the Policyholder in an Application Form.

Deductible Excess per Beneficiary

The accumulated amount of money relating to Eligible Expenses, and as specified in the Applicable Scope of Coverage Schedule to be borne by the Policyholder on behalf of a specific Beneficiary in addition to Specific Deductible Excess and/or the Policyholder Co-Participation if and when applicable during the period of this Insurance Policy.

Deletion Date

The day (at 12:00 noon local time), month and year on which the Beneficiary's coverage is terminated as the result of his/her deletion at the request of the Policyholder, and/or in case his/her status as Employee or Legal Dependant no longer holds, or upon the cancellation of this Insurance Policy.

Disease

Medical condition/sickness/illness involving fever, pain, and/or malfunction of a bodily organ or function.

Denial Form

The form issued by the Medical Call Center (MCC) for the attention of the Insurer, the Policyholder and the Network Provider denying eligibility of the Beneficiary and therefore denying Free Access on a direct billing basis according to the applicable Scope of Coverage.

Effective Date

The day (at 12.00 noon local time), month and year from which this Insurance Policy commenced.

Eligible Claim

Eligible Expenses net of Specific Deductible Excess, Co-Participation, Priority Payer share and Aggregate Deductible Excess, within the limits of liability of the Insurer as defined in the Schedules.

Eligible Expenses

All healthcare expenses incurred by a Beneficiary, relating to Non-Excluded Cases before allowing for any Specific Deductible Excess, Aggregate Deductible Excess, Co-Participation Priority Payer share and limits, within the limits of liability of the Insurer as defined in the Schedules.

Emergency

A sudden Sickness or Injury whose acute symptoms (including but not limited to severe pain) are of such severity that the absence of immediate treatment at a Hospital Emergency facility is medically expected to constitute a serious threat to the life, health, a bodily function and/or organ of the patient.

Employee

Any Active At Work person, working on a full time and permanent basis for the Policyholder and being remunerated accordingly. If any reason the employee is away ill at the policy commencement date, his/her insurance would not become effective until he/she resumes active employment.

Endorsement

Contractual document issued by the Insurer subsequent to this Insurance Policy, introducing alterations to this Insurance Policy in full conformity with its provisions.

Enrolled Employee

Any Employee covered under this Insurance Policy as the result of the Policyholder Application and the acceptance of the Insurer in conformity with the contractual procedure.

Enrolment Date

The day (at 12:00-noon local time) month and year, from when the first Insurance Policy became effective for a particular Beneficiary.

Expiry Date

The day (at 12:00 noon local time), month and year on which this Insurance Policy expires.

Family of Benefits

A group of Benefits of one nature in term of utilisation and Treatment (e.g. Family of In-Hospital Benefits, Family of Out-of-Hospital Benefits)

First Effective Date

The day (at 12.00 noon local time), month and year from which the first Insurance Policy became effective for this Policyholder.

Free Access

The Insurer undertaking of direct settlement to the Network Providers of an Eligible Claim incurred by a Beneficiary.

General Exclusion

The Exclusions, which are applicable under this Insurance Policy to all Benefits and shown in the General Exclusions List.

Geographical Scope of Cover

Geographical Scope of Cover is as follows:


Arab Countries (AC): KSA, Oman, Kuwait, Bahrain, Yemen, Lebanon, Jordan, Iraq, Syria, Qatar, Egypt, Libya, Algeria, Morocco, Sudan, Somalia, Tunisia, Djibouti, Palestine, Mauritania.


South East Asia (SEA): India, Bangladesh, Philippines, Pakistan, Burma, Thailand, Vietnam, Malaysia, Sri Lanka, Indonesia, Nepal, Bhutan.


Non-Arab Countries: Iran, Afghanistan

Hazardous Activity

Any physical activity exposing the Beneficiary to a serious Injury in case an unexpected accident occurs during the course of this physical activity, as described in the General Exclusions list.

Hospital

Any medical institution, public or private, which is legally licensed to provide medical treatment to sick and/or injured persons. The facility must consist of organised premises, possess the necessary technical and scientific equipment for diagnosis and surgical operations, and provide healthcare services 24 hours a day by a staff comprising at least one resident Physician and qualified nurses. The term "Hospital" excludes Outpatient clinics, sanatoria, physiotherapy centers, health clubs, retirement homes, nursing homes, and similar institutions, including those specializing in substance abuse (drugs, alcohol).

Hospital Confinement

An uninterrupted stay for a defined period of time in a Hospital at least overnight.

Hospitalisation

Any Hospital Confinement, for a minimum of one night, of Medically Necessary Treatment/ observation, of any Non-Excluded Disease or Bodily Injury necessitating specialised medical attention and care in a Hospital before, during and after the Treatment/observation, and which cannot be performed on an Out-of-Hospital basis.

Hospitalisation Class

The class of Hospital accommodation services which the Policyholder has selected on behalf of the Beneficiary to be applied for his/her Hospital Confinement and which are identified in the Policy Schedule.

Illness

See Disease.

In-Hospital Treatment

A Hospitalisation or Day-Hospitalisation-or Treatment and/or observation in an Emergency Room in a Hospital.

In-Patient

A patient who occupies a bed overnight, or been formally admitted as a Day-Hospitalisation patient in a Hospital.

Insurance Policy

The particular arrangement of Plans/Programs as described by this Insurance Policy, the Schedules, Scope of Coverage and Endorsements which constitute the full agreement.

Insurance Policy for Better Healthcare

The contract, or the Insurance Policy, (as defined in Article 1 of the General Terms and Conditions) whereby the Insurer, subject to the terms, provisions, limitations, exclusions and other conditions provided herein, guarantees the payment of the Benefits set forth in the Schedules.

Insurer

The Insurance Company duly registered & Licensed to operate in the country of issuance of this Insurance Policy for Better Healthcare.

Legal Dependants

The unmarried children who are under 18 year old, or below 25 if still a full-time university student, and the Spouse(s) of the Enrolled Employee.

Maternity

Hospital Confinement for Normal or Caesarean-Delivery, Medically Necessary abortion or miscarriage and/or any complications arising wherefrom, ante- and postnatal Treatment as Medically Necessary.

Medically Necessary

A service or Treatment, which, in the medical opinion of the MCC, is appropriate and consistent with diagnosis, and which, in accordance with generally accepted medical standards, could not have been omitted without adversely affecting the Beneficiary's condition or the quality of medical care rendered.

MedNet

MedNet is a managed care organisation and appointed to act in the name and on behalf of the Insurer in administering this Insurance Policy in part. Among other management services, MedNet interfaces with the Beneficiary through a MedNet Call Center (referred to hereinafter as MCC).

MedNet Call Center

Professional service Center operating 24 hours, all year round, staffed with a team of Medical and Claims administrative specialists working for MedNet to support and monitor the proper application of the Insurance Policy. The MCC provides Beneficiaries and Providers with medical and procedural guidance and information through telephone inquiries; advises claims and membership eligibility; carries out pre-approval reviews; provides appropriate authorizations; takes decision in the name and on behalf of the Insurer as to whether or not grant Free Access to the specific healthcare service under consideration and evaluates submitted claims in order to approve payment.

Network

Providers forming the MedNet Network(s) through a special and formal contractual arrangement whereby they agree to avail the Beneficiary, usually on his Access Card presentation, with Free Access on a direct billing basis to their healthcare services in conformity with the terms of this Insurance Policy and as set forth in the Policy Schedule and in the Beneficiary User's Guide.

Non Excluded Cases

Any specific Illness or Treatment that is covered, and not listed under the General Exclusions.

Non-Network Provider

Any Providers that are not part of the Network.

Out-of-Hospital

Physician's consultation, prescribed drugs, diagnostic tests and Treatment not requiring Hospitalisation nor necessitating specialised medical attention and care in a Hospital before, during and after the procedure.

Out of pocket limit

Out of pocket limit is the maximum aggregate amount of eligible expense the beneficiary should bear during the policy year out of co-insurance options. This is not applicable to Maternity in hospital claims.

Partnership Schedule

In which additional information is specified (Priority Payer details if any, Co-Payer percentages, etc).

Pharmaceutical Exclusions List

List of medications and/or products not covered for purpose of treatments and/or use of the insured member, even if prescribed by the treating doctor.

Physician

Any doctor of medicine (MD) duly licensed and qualified to render the Treatment provided under the law of jurisdiction in which such Treatment is provided.

Plan

The combination of Benefits offered by the Insurer and selected by the Policyholder on the Application Form.

Policyholder

Initially the applicant for this Insurance Policy for Better Healthcare acting in the name and on behalf of, his Employees and their Legal Dependants whose Application has been formally accepted by the Insurer. By virtue of acceptance, this Insurance Policy has been issued and the applicant becomes the Policyholder.

Policy Schedule

In which all Beneficiary and the Insurer information are specified, together with the specific conditions of this Insurance Policy (the Contractual Parties' Data, the Effective Date, the Expiry Date, the Beneficiaries Date, the Enrolment Dates, the Category, the Specific Exclusions and related waiting periods if any, the Lifetime Limits when applicable, the Hospitalisation Class, the Selected Plans, the Premium, the Frequency of Payment and any reference(s) to other schedule(s).

Pre-existing Condition

Any health condition known/unknown to the Beneficiary and/or to the Policyholder which exhibited symptoms or was a consequence of injury or illness for which Medical, Surgical, and/or Pharmaceutical treatment, Medical diagnosis or advice was provided prior to the Beneficiary’s Enrolment Date.

Premium

The periodic payment required for providing coverage and to keep the Insurance Policy in force.

Priority Payer

An entity identified under the Partnership Schedule as being the first party fully liable towards the Eligible Expenses of a specific Beneficiary up to a certain limit, which is specified under the Partnership Schedules. The Insurer shall be liable to pay any amount of any Eligible Expenses exceeding this limit.

Program

The combination of Plans offered by the Insurer and selected by the Policyholder on the Application Form.

Proof of Insurability

The process of completing an Application form and submitting it to the Insurer for Underwriting.

Providers

A generic term for Physicians, Hospitals, Clinics, Medical Centres, Pharmacies, Laboratories, Physiotherapy Centres, and other Paramedical Institutions or Persons who are licensed to offer healthcare services.

Renewal

New coverage under a new Insurance Policy following a previous term and the acceptance of a Premium for a new Insurance Policy insurance period.

Renewal Date

The day (at 12:00 noon local time) month and year on which a Renewal takes place and which coincides with the Expiry date.

Schedule

Technical addenda forming an integral part of this Insurance Policy. There are three Schedules, which further define the details of this Insurance Policy - the Policy Schedule, the Scope of Coverage Schedule and the Partnership Schedule.

Scope of Coverage Schedule

In which the Plan/Program selected by the Policyholder on behalf of the Beneficiaries is specified showing for each Family of Benefits: Coverage, Limits, Deductible Excess, Co-Participation, etc.

Second Opinion

Second opinion is an opinion obtained from an additional health care professional of to the same clinical standing and specialty. 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.

Sickness

See Disease.

SOAP

Subjective Objective Assessment Plan. A claim form that may be issued in the name of the Beneficiary (Personalised SOAP), which must be completed by the attending Physician. The completion and submission of the SOAP is a mandatory pre-requisite to any Out-Of-Hospital Treatment.

Specific Deductible Excess

The amount of money stated in the Applicable Scope of Coverage Schedule to be borne by the Policyholder in respect of the particular service under consideration.

Specific Exclusions

The Exclusions resulting from Underwriting to be applied specifically to a certain Beneficiary.

Substandard Terms

Special terms under which a Beneficiary is covered under this Insurance Policy (i.e. Additional Premium and/or Specific Exclusion and/or special limits and/or Waiting Period) as a result of an Underwriting.

Surgery

Any invasive procedure, including laser use, whose aim is to diagnose/cure disease or damage and/or rectify a defect or malformation. In this connection, invasive diagnostic procedures such as endoscopy, cauterisation (with the exception of rhino gastric, urethral, peripheral venous and/or arterial), angiography as well as destruction of kidney or gallstones will be considered as Surgery.

Territory

The country (or group of countries) as selected by the Policyholder to allow Beneficiaries to access In-Hospital Benefits at the rates prevailing there in.

Territory of Occurrence

The country where the Beneficiary's health conditions have required healthcare services and where the related expenses were incurred.

Treatment

A generic term to include all healthcare services provided under this Insurance Policy, including In-Hospital Treatment and Out-of-Hospital Treatment and embracing all In-Patient services, Out-Patient Consultations, Diagnostic Tests and Procedures, prescription of medicines, minor surgery and procedures, physiotherapy, dental care, etc.

Undeclared Pre-Existing Condition

The non-disclosure or error by the Beneficiary and/or from the Policyholder acting on behalf of the Beneficiaries, in completing any part of the Application for this Insurance Policy, of Pre-existing Conditions relating to health, (symptoms, diagnosis, conditions), or any other details (explicitly or implicitly).

Underwriting

The process of evaluation to which the Insurer submits all Application Forms prior to issuance of the Insurance Policy and any other subsequent related Endorsement in full conformity with the provisions of this Insurance Policy.

Unnecessary Treatment

A service or Treatment, which is not Medically Necessary.

Visa Form

The form issued by the MCC, for the attention of the Insurer, Policyholder and the Network Provider, confirming eligibility of the Beneficiary and guaranteeing the direct billing issued by the Network Provider to the Insurer according to the Applicable Scope of Coverage, upon which Free Access is granted.

Waiting period

The period of time starting from the first Enrolment Date of the Beneficiary during which an Exclusion is in force under a specific benefit covered under this Insurance Policy.

Waiver Date

Waiver Date
The date of termination of the Waiting Period after which an Exclusion is deleted.