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Dutco Balfour Beatty : Category - B

GROUP MEDICAL INSURANCE Policy No. GC/2012/0243


Gulfcare -Renewal Benefits with Enhancements (PY-2012- 2013)
Summary of Benefits

Category B

Product Name

Gulfcare International

Overall Maximum Benefit Limit per Person per Annum

US$ 250,000

Region of Cover (Elective Treatment)

Worldwide excluding USA

Inpatient Benefits

Hospital accommodation and meals

Covered

Surgical fees, including anesthesia & theatre charges

Covered

Physician, surgeon, & anesthetist fees

Covered

Nursing care

Covered

Prescription drugs & materials

Covered

Intensive and high dependency care

Covered

Prosthesis inserted into the body during an operation

Covered

Diagnostic Tests (such as pathology, X-rays, high tech scans)

Covered

Prescribed Physiotherapy

Covered

10

Organ transplantation (excluding donor's expenses)

Covered

11

Psychiatric treatment

Covered up to 30 days per Person per Annum

12

Accommodation Costs for one parent staying with a child

Covered for child under 18 yrs (one parent only)

13

Radiotherapy / chemotherapy (oncology)

Covered

14

Inpatient Emergency Dental Treatment

Covered

Out-patient Benefits

Overall Maximum Benefit

Deductible/Excess or Co-payment payable by the Insured Person.

Covered within the annul limit


10% Co-payment on out-patient treatment,
Nil for in-patient treatment

Inside UAE

3.1

100% direct billing inside network;


90% reimbursement (of incurred costs) outside network
for Outpatient Treatment; 100% reimbursement (of
incurred costs) outside network for Inpatient Treatment
100% reimbursement (of Reasonable & Customary UAE
Network Rates) for Visiting Surgeons and Physicians
100% reimbursment (of incurred costs) at Government
Hospitals

Application of Co-insurance

3.2

Outside UAE
(Within Region of Cover)

3.3

Reimbursement of incurred costs:


90% reimbursment for Outpatient and
100% reimbursment for Inpatient, subject to Reasonable
& Customary charges in country of treatment

Medical practitioner fees

Covered

Specialists fees

Covered

Prescription drugs

Covered

Dutco Balfour Beatty : Category - B


GROUP MEDICAL INSURANCE Policy No. GC/2012/0243
Gulfcare -Renewal Benefits with Enhancements (PY-2012- 2013)
Summary of Benefits

Category B

Product Name

Gulfcare International

Diagnostic tests and procedures, such as X-rays, CT scans, MRI


scans and physiological tests

Covered

Radiotherapy / chemotherapy (oncology)

Covered

Accidental Damage to Natural Teeth following an accident

Covered up to US$ 2,500 per Person per Annum

11

Complimentary / Alternative medicine Ayurvedic, Chiropractic,


Osteopathy, Acupuncture, Chinese Herbal Medicines, Homeopathy
and Podiatry practiced by a qualified and licensed therapist

Covered up to 12 sessions per Person per Annum


(including Medicines) subject to a maximum of
US$ 1,500 per Person per Annum

12

Prescribed Physiotherapy (subject to Insurer's review after 12


sessions per Medical Condition)

Covered up to 12 sessions per Person per Annum


elsehwere

13

Psychiatric treatment consultations

Covered up to 12 sessions per Person per Annum

Additional Benefits

Direct Billing

Available inside network

Network(s) inside UAE

NAS General Network

Networks Outside UAE but within AGCC

NAS General Network

Day-care treatment

Covered

Out-patient surgery

Covered

Nursing at Home and/or Rehabilitation (immediately after or instead


of hospitalization)

Covered up to 30 days per person per annum

Local ambulance

Covered

Emergency treatment outside area of cover (Non-Elective)

Covered up to 120 days per Person per Annum

Medical Evacuation

Covered

9.1

Reasonable travel costs incurred in connection with Evacuation of an


Covered
Insured Person

9.2

Emergency Transport necessarily incurred in connection with


Benefits under this Policy within the country where the treatment
takes place

Covered

9.3

Accommodation Costs (other than at a Hospital) incurred in


connection with Evacuation

Covered up to US$250 per day up to a total of US$5,000


per Insured Person per annum

9.4

Repatriation of mortal remains

Covered up to US$ 10,000

10

In-patient cash benefit (where treatment is free of charge)

Covered up to US$ 250 per night and a maximum of 30


nights per Person per Annum

11

Pre-existing conditions

Covered

12

Routine Maintenance of Chronic Conditions


(including renal dialysis)

Covered up to US$ 25,000 per Person per Annum

Dutco Balfour Beatty : Category - B


GROUP MEDICAL INSURANCE Policy No. GC/2012/0243
Gulfcare -Renewal Benefits with Enhancements (PY-2012- 2013)
Summary of Benefits

Category B

Product Name

Gulfcare International

13

Complications of Pregnancy and/or Childbirth

Covered but treatment following Medically assisted conception


or reproduction will only be covered up to
US$ 25,000 per child OR for the first 3 months following
birth, whichever shall first occur

14

Birth Defects and Congenital Conditions (excluding Genetic


Disorders)

Covered up to US$ 25,000 per Person per Lifetime

15

Work-related injuries

Covered

16

Human Immunodeficiency Virus (HIV) and/or any HIV related illness


Covered up to US$ 25,000 per Person per Lifetime
including but not limited to Acquired Immune Deficiency Syndrome

17

Prescribed Medical Aids, such as hearing aids, speaking aids,


crutches and wheelchairs, orthopedic supports/braces, artificial limbs Covered up to US$ 2,500 per Person per Annum
and stoma supplies.

18

19

Prescribed Vitamins

Covered if medically indicated for the treatment of


conditions directly arising from clinically significant
Vitamin Deficiency Syndrome and Chronic Conditions
leading to neuropathies. Subject to a maximum of
US$ 500 per Person per Annum

Prescribed Hormone Replacement Therapy

Covered if clinically indicated for the treatment of


conditions arising from surgically induced menopause on
patients 45 years old and below. Subject to a maximum of
US$ 1,000 per Person per Annum

BENEFIT EXTENSIONS
D

Maternity Benefit Extension

Not Selected

Routine Maternity
(Inpatient and Out-patient, Pre- & Post-natal care)

Not Covered

Newborn Care (Includes circumcision and customary examinations to


assess the integrity and basic function of the child's organs and
skeletal structures. These essential examinations are carried out
immediately after birth. Any medically necessary follow up
investigationsand treatment are only covered under the newoborn's
own cover.

Not Covered

Routine Dental Benefit Extension

Direct Billing

Overall Maximum Benefit for Routine Dental

Covered up to US$ 250 per Person per Annum

Dental Treatment (examinations, tooth cleaning, normal compound


fillings, extractions, X-rays and surgery received in a dental surgery

Covered: 20% co-payment is payable by the Insured Person

Periodontic Treatment (procedures required to diagnose or treat diseases


Covered: 20% co-payment is payable by the Insured Person
of the periodontium)

Dutco Balfour Beatty : Category - B


GROUP MEDICAL INSURANCE Policy No. GC/2012/0243
Gulfcare -Renewal Benefits with Enhancements (PY-2012- 2013)
Summary of Benefits

Category B

Product Name

Gulfcare International

Orthodontic Treatment and Dental Prosthesis (procedures required to


diagnose or treat malocclusion and irregularities of the teeth)

Covered: 50% co-payment is payable by the Insured Person

Wellness Benefit Extension

Not Selected

Overall Maximum Benefit for Wellness Benefit

Not Covered

Pap smears, mammograms, prostate screening, gynaelogical


examinations, routine physical examinations, x-rays, laboratory tests, Not Covered
vaccinations, inoculations

Child Vaccinations under the age of 18 months

Not Covered

Optical Benefit Extension

Not Selected

Overall Maximum Benefit for Optical Benefit

Not Covered

Exclusions

Palliative Treatment of a Chronic Condition except as specified in 1.1


and 1.2 below

Excluded

1.1

Benefits detailed in the Benefits Table will be payable for the


treatment of a Chronic Condition, not otherwise excluded by the
Policy

Covered up to US$ 25,000 (Benefit C.12)

1.2

The Policy will cover the actual Treatment of acute phases of


Chronic Conditions

Covered

Over the counter drugs / products that can be sold without a doctors
Excluded
prescription

Vitamins and dietary supplements

Excluded unless medically indicated for the treatment of


conditions directly arising from clinically significant Vitamin
Deficiency Syndrome, Chronic Conditions leading to
neuropathies or if prescribed with antibiotics. Subject to a
maximum of US$ 500 per Person per annum (Benefit
C.18)

Treatment directly arising from or required in connection with male


and female birth control, any form of assisted reproduction, or
infertility, except the reasonable costs of investigations into the
causes of infertility to the point of diagnosis

Excluded but Covered up to the point of diagnosis

Birth Defects or congenital conditions (unless otherwise specified in


the Benefits Schedule) or Genetic Disorders

Covered up to US$ 25,000 Per Person Per Lifetime (Benefit


C.14)

Stays in a health hydro, nature cure clinic nursing home or similar


establishment or a Hospital where the Hospital has effectively
become the Insured person's home, even if the stay is medically
prescribed

Excluded

Treatment for alcoholism, alcohol abuse, solvent abuse or any


addictive conditions of any kind and Treatment of any illness, injury
or sickness arising from any such abuse or addiction

Excluded

Dutco Balfour Beatty : Category - B


GROUP MEDICAL INSURANCE Policy No. GC/2012/0243
Gulfcare -Renewal Benefits with Enhancements (PY-2012- 2013)
Summary of Benefits

Category B

Product Name

Gulfcare International

Treatment of psychiatric, psycho-geriatric or mental illness or


conditions of any kind and any related conditions

Excluded except as stated in the Benefits Schedule


(Benefits A.11 & B.12)

Routine sight tests and the provision of visual aids

Excluded unless the Optical Benefit Extension is s elected


(Benefit G)

10

Routine hearing tests and the provision of hearing aids

Covered as a Medical Aid (Benefit C.17)

11

Treatment directly or indirectly arising from or required as a result of


self inflicted injury

Excluded

12

Treatment or diagnostic procedures for injuries arising from


engagement of professional sports

Excluded

13

Investigations into or treatment of sleep disorders, including


insomnia

Excluded

14

Treatment of and Investigations into obesity

Excluded

15

Sexual dysfunction and impotence

Excluded

16

Home visits unless they are necessary following the sudden onset of
an acute illness, which renders the insured person incapable of
Excluded
visiting their medical practitioner

17

Expenses for the acquisition of an organ including, but not limited to,
Excluded
donor search, transport and administration costs

18

Venereal disease or any other sexually transmitted diseases

19

Treatment directly or indirectly arising from or required as a


consequence of:

Excluded

19.1

Active participation in war, riots, civil disturbances, terrorism, acts


against any foreign hostility whether or not war has been declared

Active War and Active Terrorism are Excluded but Passive


War and Passive Terrorism (non-participant / innocent
bystander) are covered

19.2

Chemical contamination, radioactivity or any nuclear material


whatsoever, including the combustion of nuclear fuel

Excluded

20

Cosmetic Treatment whether or not for psychological purposes

Excluded

21

Any Treatment or surgical procedure carried out for the purpose of


removing undiseased body tissue

Excluded

22

Treatment attributably directly or indirectly to infection by Human


Immunodeficiency Virus (HIV) and/or any HIV related illness
including but not limited to Acquired Immune Deficiency Syndrome
(AIDS).

Excluded but Covered up to US$ 25,000 per Person per


Lifetime Benefit C.16)

23

Alternative Treatment and Medicines

Excluded except as stated in the Benefits Schedule (Benefit


B.10)

24

Rehabilitation where such rehabilitation takes place other than as an


Excluded except as stated in the Benefits Schedule (Benefit
in-patient immediately following Treatment covered by this Policy,
C.6)
and only then for a maximum period of 30 days per medical condition

25

Treatment including drug therapy which, is experimental or unproven Excluded

Dutco Balfour Beatty : Category - B


GROUP MEDICAL INSURANCE Policy No. GC/2012/0243
Gulfcare -Renewal Benefits with Enhancements (PY-2012- 2013)
Summary of Benefits
Product Name

Category B

Gulfcare International

Exclusions 26 to 30 apply but may be amended subject to any Benefit Extensions selected
26

Treatment directly or indirectly arising from or required in connection Covered under the Maternity Benefit Extension if selected
with Routine Pregnancy and Childbirth
(Benefit D)

27

Inoculations, vaccinations and other preventative medicines

Covered under the Wellness Benefit Extension if selected


(Benefit F)

28

Routine physical examinations by a medical practitioner

Covered under the Wellness Benefit Extension if selected


(Benefit F)

29

Routine Dental Treatment, Periodontitics, bridgework, dentures and


orthodontics

Covered under the Dental Benefit Extension if selected


(Benefit E)

30

Appliances and equipment other than a prosthesis inserted into the


body during the course of a surgical procedure

Covered up to US$ 2,500 per Person per Annum (Benefit


C.17)

EON/ This is a summary of cover and the policy wording should be read to understand the complete scope of benefits

Key

Enhanced Benefits at Renewal


Amendments done at renewal