2/5/2018 Administration Panel

Table of Benefits for: DR. SAMIR MOHAMMED ALI ABBAS CO. LTD
TPA: Total Care Saudi Third Party Administrators ‫ﺷﺮﻛﺔ ادارة اﻟﻤﻄﺎﻟﺒﺎت اﻟﺘﺄﻣﯿﻨﯿﺔ‬
Insurer Name: United Cooperative Assurance Company ‫اﺳﻢ ﺷﺮﻛﺔ اﻟﺘﺄﻣﯿﻦ‬
Provider Name: ANDALUSIAH HAI AL JAMEA HOSPITAL - JEDDAH ‫اﺳﻢ ﻣﻘﺪم اﻟﺨﺪﻣﺔ‬
Policy Number: 01/51/000105/2014 ‫رﻗﻢ اﻟﻮﺛﯿﻘﺔ‬
Policy Ref: 10862 ‫ﻣﺮﺟﻊ اﻟﻮﺛﯿﻘﺔ‬
Inception date: 26/01/2018 ‫ﺗﺎرﯾﺦ اﺑﺘﺪاء اﻟﺘﺄﻣﯿﻦ‬
Expiry date: 25/01/2019 ‫ﺗﺎرﯾﺦ اﻹﻧﺘﮭﺎء‬

Schedule of Benefits
Cover Limits
Class of Cover
ROOM A B VIP
ACCOMODATION PRIVATE ROOM SHARED ROOM REGULAR SUITE
‫اﻟﺤﺪ اﻷﻗﺼﻰ ﻟﻠﻐﺮﻓﺔ ﻗﻲ ﺷﺒﻜﺔ‬ ‫ﻏﺮﻓﺔ ﻣﻔﺮدة‬ ‫ﻏﺮﻓﺔ ﻣﺸﺘﺮﻛﺔ‬ ‫ﺟﻨﺎح ﻋﺎدي‬
‫اﻟﻤﺴﺘﺸﻔﯿﺎت اﻟﻤﻌﺘﻤﺪة‬
NEED PRE-APPROVAL SR 750 SR 750 SR 1000
750 ‫﷼ ﺳﻌﻮدي‬ 750 ‫﷼ ﺳﻌﻮدي‬ 1000 ‫﷼‬
ABOVE
‫ ﻣﻄﻠﻮب اﻟﻤﻮاﻓﻘﺔ ﻓﻮق ﺣﺪود‬20% UP TO MAX 20% UP TO MAX 20% UP TO MAX
DEDUCTIBLE 100 SR 100 SR 100 SR
PORTABILITY -1 20 % ‫ ﷼‬100 ‫ ﺣﺪ أﻋﻠﻰ‬20 % ‫ ﷼‬100 ‫ ﺣﺪ أﻋﻠﻰ‬20 % ‫ ﷼‬100 ‫ﺣﺪ أﻋﻠﻰ‬
‫اﻹﻗﺘﻄﺎع \ اﻟﺘﺤﻤﻞ‬

Special Conditions
DENTAL BENEFIT COVER IS LIMITED TO TOOTH EXTRACTION,
FILLINGS (COMPOSITE FILLING - NON
COSMETIC), XRAYS, ROOT CANAL AND GUM ‫ ﺣﺸﻮ اﻷﺳﻨﺎن واﻟﺤﺸﻮ اﻟﻤﺮﻛﺐ اﻟﻐﯿﺮ‬،‫ﺣﺪود ﺗﻐﻄﯿﺔ ﺧﻠﻊ اﻷﺳﻨﺎن‬
‫وﻋﻼج اﻟﻠﺜﺔ ﺑﺎﻻﺿﺎﻓﺔ إﻟﻰ‬. ‫اﻟﺘﺠﻤﯿﻠﻲ واﻷﺷﻌﺔ اﻟﻌﺎدﯾﺔ وﺳﺤﺐ اﻟﻌﺼﺐ‬ ‫اﻟﺘﻐﻄﯿﺔ ﻟﻤﻨﻔﻌﺔ‬
TREATMENT, IN ADDITION TO OTHER ‫اﻟﺨﺪﻣﺎت اﻟﻀﺮورﯾﺔ ﻟﻌﻼج اﻟﺤﺎﻻت اﻟﻨﺎﺗﺠﺔ ﻋﻦ ﻋﻮاﻣﻞ ﺧﺎرﺟﯿﺔ ﻋﻨﯿﻔﺔ‬ ‫ﻋﻼج اﻷﺳﻨﺎن‬
SERVICES NECESSITATED FOR CASES CAUSED
BY VIOLENT EXTERNAL FACTORS.
MEDICAL Covered of regular lenses and Frame attached with an
EYEGLASSES invoice name, number and amount in addition to the ‫اﻟﻌﺪﺳﺎت اﻟﻌﺎدﯾﺔ وإطﺎر ﻋﺎدي ﻣﺮﻓﻖ ﺑﻔﺎﺗﻮرة ﺗﻮﺿﺢ ﻗﯿﻤﺔ اﻻطﺎر ورﻗﻤﮫ‬
BENEFIT lenses cost with a signed & stamped report from the ‫وإﺳﻤﮫ ﺑﺎﻻﺿﺎﻓﺔ اﻟﻰ ﻗﯿﻤﺔ اﻟﻌﺪﺳﺎت ﻣﻊ ﺗﻘﺮﯾﺮ ﻣﻮﻗﻊ وﻣﺨﺘﻮم ﻣﻦ طﺒﯿﺐ‬ ‫ﻣﻨﺎﻓﻊ ﺗﻐﻄﯿﺔ‬
licensed ophthalmologist. All claims received without , ‫ﻣﺮﺧﺺ وﻣﻮاﻓﻘﺔ ﻣﺴﺒﻘﺔ ﻣﻦ اﻟﻌﻨﺎﯾﺔ اﻟﺸﺎﻣﻠﺔ ﻟﺘﺴﻮﯾﺔ اﻟﻤﻄﺎﻟﺒﺎت اﻟﺘﺄﻣﯿﻨﯿﺔ‬ ‫اﻟﻨﻈﺎرات اﻟﻄﺒﯿﺔ‬
pre-authorization will be rejected. Excludes optical ‫ﻋﺪا ذﻟﻚ ﯾﺴﺘﺜﻨﻰ أي ﺗﻐﻄﯿﺔ أﺧﺮى‬
appliances, contact lenses and other related expense
VACCINATION COVERED AS PER CCHI POLICY AMENDED . (‫ﻣﻐﻄﻰ ﺣﺴﺐ وﺛﯿﻘﺔ ﻣﺠﻠﺲ أﻟﻀﻤﺎن أﻟﺼﺤﻲ أﻟﺘﻌﺎوﻧﻲ )أﻟﻤﻌﺪﻟﺔ‬ ‫اﻟﺘﻄﻌﯿﻤﺎت‬
MATERNITY COVERD FROM DAY ONE ( 1 ) UP TO THE
BENEFITS EXPIRY OF THE POLICY. MATERNITY BENEFIT
, ‫ﯾﻐﻄﻲ ﻣﺘﺎﺑﻌﺔ اﻟﺤﻤﻞ واﻟﻮﻻدة ﻣﻦ اﻟﯿﻮم اﻻول ﺣﺘﻰ اﻧﺘﮭﺎء ﻓﺘﺮة اﻟﺘﺄﻣﯿﻦ‬
PER SPOUSE ONLY. DELIVERY OUTSIDE SAUDI ‫ﺗﻐﻄﯿﺔ ﻣﺘﺎﺑﻌﺔ‬
ARABIA OR OUTSIDE THE AUTHORIZED ‫وﻓﻲ ﺣﺎﻟﺔ ﺗﻤﺖ اﻟﻮﻻدة ﺧﺎرج ﻧﻄﺎق اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ أو ﺧﺎرج‬
‫ ﻓﺴﻮف ﯾﻐﻄﻲ اﻟﺘﺄﻣﯿﻦ اﻟﺨﺪﻣﺎت‬،‫ﻧﻄﺎق ﺷﺒﻜﺔ ﻣﻘﺪﻣﻲ اﻟﺨﺪﻣﺔ اﻟﻤﻌﺘﻤﺪة‬ ‫اﻟﺤﻤﻞ واﻟﻮﻻدة‬
HEALTHCARE PROVIDER'S NETWORK WILL BE ‫اﻟﻄﺒﯿﻌﯿﺔ‬
SUBJECT TO THE CONDITIONS OF THE .‫واﻟﺘﻜﺎﻟﯿﻒ ﺣﺴﺐ اﻟﺒﻨﺪ اﻟﻤﺘﻌﻠﻖ ﺑﺘﻌﻮﯾﺾ اﻟﺒﺪل اﻟﻤﺬﻛﻮر ﻓﻲ ھﺬة اﻟﻮﺛﯿﻘﺔ‬
REIMBURSEMENT CLAUSE OF THIS POLICY.
PRE-APPROVAL No pre-approval below the above set minimum except
LIMITS for : INPATIENT SERVICES MATERNITY
COVERAGE CHRONIC MEDICATIONS FOR MORE ‫ ﺗﻨﻮﯾﻢ واﻟﻌﻼج‬:‫ﻻ ﻣﻮاﻓﻘﺔ ﻣﺴﺒﻘﺔ دون اﻟﺤﺪود اﻟﻤﺬﻛﻮرة أﻋﻼه ﺑﺈﺳﺘﺜﻨﺎء‬
THAN ONE MONTH HEARING AIDS & EAR ‫داﺧﻞ ﻣﺮﻛﺰ اﻟﺮﻋﺎﯾﺔ اﻟﺼﺤﯿﺔ اﻟﺤﻤﻞ وﻣﺘﺎﺑﻌﺔ اﻟﺤﻤﻞ واﻻﻣﻮﻣﺔ ادوﯾﺔ‬
PIERCING. DUPLEX SCAN OF EXTERMITIES. ‫اﻟﺤﺎﻻت اﻟﻤﺰﻣﻨﺔ ﺗﺘﻌﺪى اﻛﺜﺮ ﻣﻦ ﺷﮭﺮ اﺟﮭﺰة اﻟﺴﻤﻊ وﺛﻘﺐ اﻻذن ﺻﻮرة‬ ‫ﺣﺪود اﻟﻤﻮاﻓﻘﺔ‬
CARDIAC ECHOs. BONE DENSITOMERTY. ‫اﻟﻘﻠﺐ ﻓﺤﺺ ﺗﺮﻗﻖ اﻟﻌﻈﺎم ﻓﺤﺺ وظﺎﺋﻒ اﻟﺮﺋﺔ ﺻﻮرة اﻟﺠﻨﯿﻦ داﺧﻞ‬ ‫اﻟﻤﺴﺒﻘﺔ‬
PHYSIOTHERAPY SPIROMETRY BIOPHYSICAL ‫اﻟﺮﺣﻢ اﻟﺘﻄﻌﯿﻢ ﺣﺴﺐ وزارة اﻟﺼﺤﺔ ﻋﻼج اﻵﺳﻨﺎن اﻟﻨﻈﺎرات‬
PROFILE BASIC VACCINATIONS DENTAL
COBERAGE OPTICAL SERVICES
PHYSIOTHERAPY * PHYSIOTHERAPY IS COVERED IF MEDICALLY
(‫اﻟﻌﻼج اﻟﻄﺒﯿﻌﻲ ﻣﻐﻄﻰ ﻋﻨﺪ اﻟﻀﺮورة اﻟﻄﺒﯿﺔ )ﻣﻊ اﻟﻤﻮاﻓﻘﺔ اﻟﻤﺴﺒﻘﺔ‬ ‫اﻟﻌﻼج اﻟﻄﺒﯿﻌﻲ‬
NECESSARY(REQUIRE PRE APPROVAL)
HEARING AIDS COVERED UP TO SR 6000 PER INSURED PER ‫ﺗﻜﺎﻟﯿﻒ اﻟﺴﻤﺎﻋﺎت‬
‫ ﺧﻼل ﻣﺪة اﻟﻮﺛﯿﻘﺔ‬SR 6000 ‫ﺑﺤﺪ أﻗﺼﻰ‬
YEAR ‫اﻟﻄﺒﯿﺔ‬

https://www.tcs-ksa.net/policy_cond.aspx?policy_seq=10862&HP_CLASS_D=A%20|%20B%20|%20L%20&HP_CLASS_R=&time=449 1/2
2/5/2018 Administration Panel
This authorization letter has been automatically generated and stamped on 9:37 5/2/2018. It is an official document that the healthcare provider may use to
accept and treat the insured members of the above mentioned policy as medically indicated and further to the above set limits/benefits...

https://www.tcs-ksa.net/policy_cond.aspx?policy_seq=10862&HP_CLASS_D=A%20|%20B%20|%20L%20&HP_CLASS_R=&time=449 2/2