Fay Medical Insurance Policy

Company Address and Contact Details:

Gulf Insurance and Reinsurance - Kuwait

Kuwait City, Sharq Area Al-Shuhada’ Street Kipco Tower
Tel: (+965) 1802080
Email: customer.serv@gig.com.kw Version 1.0.1
 FAY Policy Wording

Content Page
Preamble 01
1. General Terms and Conditions
Article 1: Insurance Policy........................................................................................................................................ 01
Article 2: Policy Validity, Commencement, Renewal and Termination................................................. 01
Article 3: Applications............................................................................................................................................... 01
Article 4: Eligibility...................................................................................................................................................... 02
Article 5: Applicable Scope of Coverage............................................................................................................ 02
Article 6: General Limitations................................................................................................................................ 02
Coordination Payment Clause.............................................................................................................................. 02
Territorial Scope........................................................................................................................................................ 02
Financial limitation.................................................................................................................................................... 02
Article 7: Premiums.................................................................................................................................................... 02
Article 8: Administration......................................................................................................................................... 03
Article 9. Underwriting styles and choices....................................................................................................... 03
9.1 Fully underwritten (or full medical underwriting) (FMU)................................................................... 03
9.2 Continuation of medical underwriting exclusions (CME).................................................................. 03
9.3 Medical History Disregard (MHD)................................................................................................................ 03
Addition of family members 9............................................................................................................................... 03
Article 10: Additions of Employees & Legal Dependents............................................................................ 04
Article11: Deletions of members........................................................................................................................... 05
Article 12: Policy Amendments.............................................................................................................................. 05
Article 13: Policyholder’s / Member’s Statements.......................................................................................... 05
Article 14: Claims Notification............................................................................................................................... 06
Article 15: Cancellation............................................................................................................................................. 06
Article 16: Anti Money Laundering....................................................................................................................... 06
Article 17: Subrogation............................................................................................................................................. 06
Article 18: Currency.................................................................................................................................................... 06
Article19: Change of Law......................................................................................................................................... 06
Article 20: Duties........................................................................................................................................................ 06
Article 21: Sanction Limitation and Exclusion Clause................................................................................... 06
Article 22: Arbitration............................................................................................................................................... 06
Article 23: Personal Information........................................................................................................................... 07
Article 24: Recoveries............................................................................................................................................... 07
Article 25: The Medical Card.................................................................................................................................. 07
2. Insurance Benefits 07
A. In-Hospital Treatment......................................................................................................................................... 08
B. Out-patient Treatment........................................................................................................................................ 08
C. Dental Benefit......................................................................................................................................................... 09
D. Maternity / Delivery (Childbirth) Benefit..................................................................................................... 10
E. Optical Benefit........................................................................................................................................................ 10
F. Congenital & Hereditary Conditions manifested and treated during first 90 days from
birth (Applicable for in-patient treatment only)........................................................................................... 10
G. International Emergency Medical Assistance............................................................................................ 11
H. Other Benefits........................................................................................................................................................ 11
3. Standard General Exclusions 11
A .Waiting Periods...................................................................................................................................................... 11
B. Lifetime Exclusions............................................................................................................................................... 12
4. Definitions 16
5. Policy Schedule Clarifications 21
Your policy is underwritten by your insurance company Gulf Insurance and Reinsurance Company
– GIRI and reinsured by (AXA PPP healthcare Limited). Some aspects of the administration of
your policy is undertaken by AXA Global Healthcare (UK) Limited or AXA Global Healthcare
(Singapore) Pte. Limited, jointly AXA Global Healthcare. AXA Global Healthcare process your
information mainly for managing your policy and claims, including investigating fraud. We also
have a legal obligation to do things such as report suspected crime to law enforcement agencies.
We also do some processing because it helps us run our business, such as research, finding out
more about you, statistical analysis for example to help us decide on premiums.
The AXA Global Healthcare privacy policy can be found at:
https://www.axaglobalhealthcare.com/globalassets/shared/documents/agh-
privacy-policy.pdf
Preamble
In consideration of the payment of the premium and in reliance upon the statements made by the Policyholder (the Employer)
and the Eligible Employees and their Legal Dependents, as together they form the contract between the Policyholder (the
Employer) and the Insurance Company. Subject to the terms and conditions of this Insurance Policy and any attachment
forming part of the Policy Schedule we issue to the Policyholder (the Employer), the Insurance Company (Gulf Insurance and
Reinsurance Company - GIRI) agrees with the Policyholder and guarantees to provide the benefits and healthcare services or their
related expenses incurred by the Insured (employee and/or his eligible Legal Dependents) as set forth in the Applicable Scope of
Coverage. This document also explains what is not covered. Certain words used within this document have a special meaning and
this is highlighted under Section 4: Definitions.

1. General Terms and Conditions

Article 1: Insurance Policy
The application forms of the Policyholder and any Insured, the
Preamble, the Definitions, the General Terms and Conditions,
the Applicable Scope of Coverage with its Limitations and
Exclusions, the Policy Schedule, the Insured’s Guide as well
as any Attachment(s) and Endorsement(s) to any of the
aforementioned, shall constitute the entire contract between
the parties hereto (herein referred to as the Insurance Policy).
Any amendments or additions to the Insurance Policy shall be
void, unless it has been made in writing and is signed and sealed
by the Insurer. No Insurance intermediary has the authority to
amend this Policy or waive any of its provisions.
Article 2: Policy Validity,
Commencement, Renewal and
Termination
2.1 The policy shall start from the Effective date and subject to
payment by the Policyholder of the appropriate premium or
part premium as specified by the Insurer.
2.2 Unless otherwise agreed in writing by the Insurer, this policy
is for a Year and is renewable on the agreed date subject to
the Policyholder paying the renewal premium. The Insurer
will, prior to the renewal date either (i) issue renewal terms
and related documentation to the Policyholder, including any
proposed alteration to the cover and/or premium, or (ii) notify
the Policyholder that it does not wish to renew the policy.
If the Policyholder confirms before the renewal date that it
wishes to renew the policy for a further year, the Policyholder
and the Insurer shall enter into a new agreement incorporating
the renewal terms including the updated Insured Guide and
membership handbook.
Receipt of the renewal premium by the Insurer will be
considered as an acceptance of the renewal terms by the
Policyholder without any obligation on the Insurer to receive
the renewal acceptance from the employee/insured members.
2.3 Both parties reserve the right to refuse to renew this Policy
agreement at the renewal date.
2.4 We reserve the right to terminate the Policy at the renewal
date, if fewer than three (3) employees are insured as Insured
members under this Policy.
2.5 The Insurer reserves the right to terminate the Policy,
immediately on giving the Policyholder written notice, if
2.5.1 any part of the premium which remains unpaid for more
than 45 days after it has become due and payable; or
2.5.2 the Policyholder (the Employer) has deliberately misled
the Insurer in any way in relation to this policy or the cover to
a degree which is reasonably likely to cause material loss or
breach of its obligations arising under this; or
2.5.3 the Policyholder (the Employer) goes into liquidation
or becomes bankrupt, or if an administrator or receiver or an
administrative receiver is appointed in respect of all or any part
of the business of the Policyholder (the Employer);
2.6 Upon termination of this Policy, howsoever arising:
2.6.1 any outstanding premium then unpaid will fall due for
immediate payment; and
2.6.2 the Insurer and the reinsurer and their partners shall be
entitled to retain data relating to the cover in accordance
with all applicable law, rule, regulation or professional record
keeping procedure or with any requirement from any
competent judicial, governmental, supervisory or regulatory
body or with any existing reasonable written internal policy or
procedure relating to the back-up storage of electronic data.
2.7 Any termination of this Policy shall be without prejudice to
any accrued rights and obligations of both the Policyholder
(the Employer), the Insurer and the parties to this agreement.
Article 3: Applications
Both the initial Insurance application and any subsequent
applications by persons proposed for Insurance must be
submitted using the special forms provided by the Insurer. The
Insurer reserves the right to reject any initial or subsequent
application without any obligation to justify the decision or
to accept it under any terms that are deemed appropriate.
In case a deposit or payment on account is made before the
acceptance of the application, such advance payments do not
constitute consent to the submitted application. The Insurer
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 reserves the right to reject the application. In such a case, the
Insurer must refund the advanced amount to the Applicant for
Insurance. If there are any changes to the information provided
in the Insurance application form after the Policyholder (the
Employer) or the Eligible Employee and Legal Dependents (if
relevant) signs it and before we accept the application, please
let us know straight away.
Article 4: Eligibility
4.1 The Policyholder hereby warrants that all Eligible Employees
as at the Effective Date will be included and that other
employees who become eligible for inclusion subsequently will
be included from the first day on which they become eligible.
4.2. Legal Dependents who are eligible for inclusion will be
included from the same date as the Eligible Employee or
the date on which the person concerned first satisfied the
definition of Legal Dependent. If any Legal dependent is not
included within 30 days of the date of first eligibility, they may
join subsequently but will then be subjected to the full medical
underwriting irrespective of any agreement which may exist
between the Insurer and the Policyholder (the employer) to
allow enrolment without such underwriting.
4.3. Legal Dependent shall cease to be included on the same
date as that on which the relevant Eligible Employee ceases to
be included.
4.4. The Policyholder (the employer) can withdraw Eligible
Employees who, for whatever reason, cease to be eligible by
giving written notice. They will be withdrawn either:
4.4.1 from the end of the day on which they leave the
Policyholder’s employment providing the insurance company
is notified beforehand; or
4.4.2 from the end of the month in which the Insurer receives
written notice of their withdrawal.
The Policyholder (the employer) shall immediately advise both
the Insurer and the Employee in writing when any employee
is no longer to be included. If the Policyholder (the employer)
fails to advise the Insurer for any reason, the Policyholder (the
employer) will remain responsible for the payment of the
premium in respect of the Eligible Employee and their Legal
Dependents (if relevant) until the end of the month in which
such notice is given.
4.5. The Policyholder and the Employee’s/Insured member’s
obligations:
a)The Policyholder and the employee/Insured member are
responsible for ensuring that all data and information given to
the Insurer is sufficiently true, accurate and complete.
b)The Policyholder and the employee/Insured member shall
inform the Insurer in writing of any change in the address or
contact details or other personal details.
c)The Policyholder and the employee/Insured member must
inform the Insurer of any change in the country where the
employee/Insured member or Legal Dependents normally live.
d)The Policyholder and the employee/Insured member shall
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remain responsible for his obligations under this Insurance
Policy, even if the Policyholder and the employee/Insured
member may have delegated all or any part of those obligations
to an intermediary or agent who shall be deemed to be the
agent of the Policyholder and the employee/Insured member.
e)The Policyholder and the employee/Insured member
indemnifies the Insurer from and against all costs, losses and
expenses incurred by the Insurer resulting from the failure of
the Policyholder and the employee/Insured member - for any
reason to discharge his obligations under this Insurance Policy.
Article 5: Applicable Scope of
Coverage
The Applicable Scope of Coverage per Insured is set forth
in the corresponding Policy Schedule. The Policy Schedule
frames the coverage provided in respect of that Insured while
specifying the basis of indemnity, the class, limits, Co-payment,
Deductible(s) Excess, Insurer’s participation(s), any specific
Exclusion(s) and any special terms applicable at each level of
service or benefit, depending on the nature of the healthcare
services, the provider and the Territory of Occurrence.
Article 6: General Limitations
Coordination Payment Clause:
Except for what is mentioned in the conditions of this policy,
the Insurer shall only reimburse its proportional and net of any
deductibles share of the costs of treatment for those injuries
or illnesses that can be reimbursed by any law or legislation or
other health system.
Territorial Scope:
Coverage applies to the healthcare services and their related
expenses incurred in the territories specified in the Policy
Schedule and to the extent stated therein.
Financial limitation:
As specified in the Policy Schedule under limit per case/for
the policy period and as per the Territorial Coverage. Financial
limitations shall be defined under the aggregate limit per policy
for all territories.
Article 7: Premiums
The Premiums due by the Policyholder (the employer) to the
Insurer as defined in the Policy Schedule are payable in advance
by the Policyholder according to frequency of payment agreed
upon between the Policyholder and the Insurer and as specified
in the Policy Schedule. The coverage provided by the Insurer
under this Insurance Policy shall not commence until the first
installment is fully paid.
In the event the Insurance Premium is not paid on the due date,
the Insurer will notify the Policyholder of the amount payable
within 45 days also informing the Policyholder (the employer)
that otherwise this Insurance Policy will be canceled, and
the Policyholder will be liable for the amount due until the
Cancellation Date.
The Premiums paid by the Policyholder (the employer) to
an intermediary or agent on behalf of the Policyholder (the
employer) shall be received and held by such intermediary
or agent and not on behalf of the Insurer. Until such monies
are paid to the Insurer by the intermediary or agent on the
Policyholder’s behalf, the Policyholder remains liable and
responsible to the Insurer for such payment. The Policyholder
is responsible for the payment of the premium for all Eligible
Employees and Legal Dependents included under this Policy
Agreement.
The Policyholder shall obtain the agreement of the Insurer in
writing if, during the policy year, it wishes to make any changes
in the number of Eligible Employees to be included which may
affect membership by more than five per cent of the total
numbers which were included at the beginning of the policy
year. If such change is agreed, the Insurer/reinsurer shall have
the right, if appropriate, to reconsider the basis of calculation
of the premium and to require the immediate payment of any
further premium thereby made necessary.
Article 8: Administration
As the purpose of the Policy agreement is to provide cover for
Eligible Employees and Legal Dependents, the Policyholder
(the employer) undertakes:
8.1 that it will advise all Eligible Employees as soon as practicable
if for any reason the Policy agreement is terminated or should
not be renewed or this policy agreement should be terminated
in accordance with the provisions of Article 2 so that such
Eligible Employees are made aware that all cover has ceased
and that the benefits will not be payable for treatment costs
incurred after the termination date for Eligible Employees or
Legal Dependents.
8.2 The Policyholder hereby agrees to indemnify the Insurer
or reinsurer from and against all costs, losses and expenses
incurred by the Insurer or reinsurer in respect of claims made
by Eligible Employees or Legal Dependents, where such
costs, losses and expenses arise because of any failure by the
Policyholder to discharge its obligations under this policy
agreement.
8.3 The Policyholder shall designate an authorized person
(the ‘Group Secretary’) to administer this policy agreement
in accordance with its terms issued from time to time and
shall notify the Insurer in writing of any change in the person
designated.
8.4 The Policyholder shall not deliberately mislead the Insurer
or reinsurer in any way in relation to the membership, claims
or benefits incurred by or paid to the Eligible Employees or
Legal Dependents in respect of the cover, to a degree which
is reasonably likely to cause the Insurer material loss, and shall
remain responsible for ensuring its obligations under the
policy agreement are fully discharged notwithstanding that all
or any part of the Policyholder’s obligation are delegated to
an intermediary who shall be deemed to be the agent of the
Policyholder.
8.5 The Policyholder shall advise the Insurer immediately
if it goes into liquidation (except in respect of take-over or
amalgamation) or becomes bankrupt or an administrative
receiver is appointed in respect of all or any part of the business
of the Policyholder.
Article 9. Underwriting styles and
choices
The different medical underwriting styles and choices may be
available to your company, depending on the size of the group
and current healthcare plans.
9.1 Fully underwritten (or full medical underwriting) (FMU)
Available for international groups from 3 to 50 employees.
This requires each applicant to declare their medical history
on the application form and occasionally, we might request
a medical report. Pre-existing medical conditions are then
excluded where necessary. Any new member to join the group
at later date must also be fully medically underwritten.
9.2 Continuation of medical underwriting exclusions (CME)
This option is for groups transferring from a fully medically
underwritten international policy with another insurer and this
is not available to groups of less than three employees.
If your members join the plan based on “CME” this means that
we may transfer any medical underwriting terms for medical
conditions they had before joining that previous insurer to the
new plan, however, this relates only to the specific underwriting
terms. The Plan will be subject to the general terms including
the exclusions and benefit limitations. “CME” only applies at
the point of switching to Insurance Company (Gulf Insurance
and Reinsurance Company - GIRI) and subsequent new joiners
to the group will be underwritten. If the group had selected
medical history disregarded underwriting with their current
insurance provider and wishes to continue this basis with
the Insurance Company (Gulf Insurance and Reinsurance
Company - GIRI), they should consider our medical history
disregarded option.
9.3 Medical History Disregard (MHD)
Available for international groups from 11 employees and
above. This option, which is the most expensive, allows
members of groups and their family members, when agreed,
to be enrolled without any exclusions relating to their previous
medical history. However, it is the Policyholder’s responsibility
to disclose any material fact that would influence our
underwriting decision to accept the risk as well as the terms
and conditions of the policy. The Plan will be subject to our
general terms including the exclusions and limitations of this
policy, Medical history disregarded terms are extended to any
subsequent joiners to the group.
Addition of family members
Family members on a Medical History Disregarded (MHD)
group plan will only be eligible for MHD under the following
circumstances:
• If they join at the same time as the Eligible Employee (lead
member)
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 • If they join within 30 days of the date the employee (lead
member) joins
• For newly married spouses if added within 60 days of them
qualifying as a family member as outlined in the policy glossary
together with the completed Addition of family members
application form and a copy of the marriage certificate.
• For New-born children must be added from their date of birth
and the completed Addition of family members application
form within 30 days of their birth date (and not be adopted
or conceived through assisted conception) and a copy of the
birth certificate.
If a family member is added at any other time, they must declare
their full medical history and will be fully medically underwritten.
For children who are adopted or were born because of any
method of assisted reproduction treatment or surrogacy
are always subject to medical underwriting, we reserve the
right to apply restrictions to the cover we will offer, and we will
notify the member of those terms. This would mean that the
child will not be covered for treatment carried out for medical
conditions which existed prior to joining, such as treatment in a
Special Care Baby Unit.
Please note:
This is our default position and alternate arrangements may
apply where this has been separately agreed by us.
Article 10: Additions of Employees
& Legal Dependents
10.1 If the Eligible Employees want to join or add Legal
Dependents, the Policyholder must send to us the completed
forms with information we require within thirty (30) days
from the member’s Eligibility Date. Depending on the policy
agreement, there may be restrictions on when members can
be added.
The Insured must be:
• Your Employee aged between eighteen (18) and to seventy-
five (75) years, and Actively at Work on his/her Eligibility Date. If
an Employee is not Actively at Work on his/her Eligibility Date,
he/she will become eligible for coverage as soon as he/she is
Actively at Work.
• If the Plan includes cover for your Eligible Employee’s spouse,
the employee must apply cover on behalf of the spouse,
provided they are under 75 year of age on their date of entry. The
spouse must be able to perform all the Activities of Daily Living
and within the allowable age on their date of entry. If the spouse
included under your Plan are no longer eligible for cover under
the group Plan/policy, we will have to transfer the cover for
the spouse on to their own individual Plan/policy provided the
spouse continue to meet the eligibility requirements outlined
in the Plan/policy. To enable us to do this, we will require the
member to complete a new application form and return to us
within thirty (30) days of the date of termination of cover.
• If the Plan includes cover for your Eligible Employee’s Legal
Dependent child(ren), the employee must apply cover on
4
behalf of eligible dependent child(ren), who is unmarried and
unemployed under 18 years old or to age twenty-five (25) years
old in case of a child is a full-time student in an institution of
higher learning. The age limit of your employee’s child(ren)
will be extended to age up to thirty (30) years, provided they
remain unmarried, financially dependent on the employee for
support or maintenance and do not have any independent
sources of income nor is employed. For child(ren) who is a full-
time student in an institution of higher learning, we reserve the
right to request proof of a child being in full-time education.
If one of your employee’s children has married or has reached
the age of thirty (30) years old, they will no longer be able to
be included on the plan from the renewal date following their
marriage/birthday. However, they may apply to be insured on
their own individual plan/policy. To enable us to continue their
cover as before we will require a new application form, which
must be completed and returned to us within 30 days of your
Renewal Date along with the appropriate Premium due, which
will be subject to our individual terms and Premium rates. If we
do not receive your employee’s child’s application form and
Premium within 30 days of your renewal date, their cover will
automatically cease from midnight on the day before your
Renewal Date.
10.2 If the plan includes cover for employees’ newborn babies
without underwriting, provided we are notified of their full
name, date of birth as required by the Insurer within 30 days of
their date of birth and the Eligible Employee has been insured
with us for a continuous period of 365 consecutive days or
more at the newborn babies’ date of birth. The child’s cover
will be restricted to the cover provided by the employee’s plan
type.
If we are not informed about the birth of the newborn babies
within 30 days of their birth, and Policyholder does not pay
the additional Premium, the employee will have to make a
new application for the child to be added to the plan, and this
application will be subject to full medical underwriting.
Newborn children who have been born due to assisted
reproduction treatment, or before 37 weeks of gestation, or
are adopted or because of surrogacy are always subject to full
medical underwriting.
The inclusion of new Eligible Employees and the Legal
Dependents must be formally acknowledged and accepted
in writing, signed and sealed by Us. The Premiums for any
additions of Insureds shall be due by the Policyholder to the
Insurer. For mid-term inclusion, premium shall be calculated on
a pro-rata daily basis starting from the newly added Insured’s
Enrolment Date up to the Policy’s Expiration Date.
The cover under this Policy is limited to the Eligible Employee
and his/her Legal Dependents whose Principal Country of
Residence is Kuwait only.
Article11: Deletions of members
The Policyholder may formally request in writing the deletion
of an Insured covered under this Insurance Policy from the
Insurer without any delay; in this case the Insured’s status
is not any more in conformity with the definitions of Legal
Dependents.
The Insurer shall have the right to terminate the Policy
anytime if the Insured left the Kuwaiti territory for a period of
180 consecutive days during the contractual period unless
agreed by the Insurer. In this case, the Insured maybe entitled
to a Premium refund computed on pro-rata basis applied by
the Insurer based on the period the Insured has been covered
since the effective date of the Policy. There is no Premium
refund related to the plan under which the Insured would have
benefited from a covered claim.
The Policyholder can formally request the deletion of an
Insured covered under this Insurance Policy prior to or at the
Expiration Date, upon:
• The death of the Insured; or
• Insured’s termination of employment with the Policyholder;
or
• Insured exceeding the maximum renewable age limits as set
out in the Policy, unless otherwise stated.
The Legal Dependents’ coverage shall automatically be
terminated when an employee’s name is deleted from the
policy.
Any Insured is automatically deleted at the Cancellation Date
of this Insurance Policy according to the terms of Article 15, the
Termination Date coinciding with the Policy Cancellation Date.
Any deletion within the Insurance Policy shall be void unless
it has been formally acknowledged and accepted in writing,
signed and sealed by the Insurer.
The Premium refund related to the deletion which shall be
due by the Insurer to the Policyholder shall be processed
on a pro-rata basis starting from the Termination Date up
to the respective Expiration Date. However, the insured will
not benefit from any Premium refund in case of usage of the
medical card and/or submission of claim either by (direct
billing) or (reimbursement).
We will continue to charge the group Premiums for Employees
and the Legal Dependents until we are informed in writing that
have left your company’s employment and should no longer be
covered. Please therefore let us know about members leaving
the plan within 30 days to avoid your company incurring the
cost of premiums for them.
Members of this policy who leave this plan may apply to us
for an individual policy. In all such cases the member will be
required to complete a new application form and make a full
medical history declaration in respect of each person to be
insured either thirty (30) days prior to, or thirty (30) days after
leaving the group. We reserve the right to apply any exclusion
clauses and/or special terms we may deem necessary to any
existing and/or pre-existing medical conditions at the date of
application even if such conditions were previously covered
under this policy.
Article 12: Policy Amendments
12.1 Any amendment on this Insurance Policy requested by the
Policyholder during the validity of this Insurance Policy or on
the Renewal Date must be formally requested in writing from
the Insurer.
The Insurer reserves the right to decline, accept on special or
standard terms, amendments required by the Policyholder.
Any amendment to this Insurance Policy shall be void unless
it has been formally acknowledged and accepted in writing,
signed and sealed by the Insurer. The Insurer shall credit or debit
the Policyholder with the Premium related to the accepted
and implemented amendments, which shall be calculated on
a pro-rata basis starting from the date of the amendment’s
implementation up to the Expiration Date.
The Insurer may change all or any part of the policy including
the benefits table or these terms, as per the policy conditions.
The changes shall take effect from the renewal date, unless
the Insurer is obliged by law to apply the changes immediately
or has agreed otherwise with the Policyholder in writing.
The Insurer shall send details on any of those changes in the
renewal notice (or separately in case the change must apply
sooner as per the laws and regulations). The terms of the policy
cannot be changed by any verbal communication between the
Policyholder/Employee/Insured member and the Insurer. Any
changes in the policy must be confirmed in writing.
12.2 Our policy on changing your level of cover or moving to
another plan
We reserve the right to refuse any request to upgrade or
amend cover. If we do accept a request for an upgrade of plan,
we may restrict cover for conditions existing at the time of
the upgrade to the level of benefits enjoyed under the original
policy. In any event, final acceptance of any amendment by us
and particularly the application of upgraded benefits will only
be made at the next renewal following such a request. Neither
amendments nor upgrades can be made during the policy
year. Any condition known about or that should reasonably be
known about at the time of an amendment or upgrade must be
advised to us before the policy amendment takes effect.
Article 13: Policyholder’s / Member’s
Statements
This Insurance Policy, including its related additions, deletions
and amendments, has been and shall be issued by the Insurer
based on the statements made by the Policyholder on the
initial application form and on the subsequent written formal
requests.
Any proven false statement(s) made by the Policyholder, the
Insured Member and/ or material information relating to the
proposed Insured’s state of health, professional activities and
place of residence, shall result in the Insurer’s right to do one or
more of the following:
5
 • cancel this Insurance Policy and end all cover immediately;
• refuse to pay any claims;
• recover from the Insured any loss caused by the break;
• refuse to renew the policy or membership;
• impose different terms to the cover.
The Policyholder must immediately inform the Insurer of any
alteration that may occur during the validity of this Insurance
Policy or at Renewal Date regarding the profession, activities
and place of residence of the Insured covered under this
Insurance Policy. The Insurer reserves the right to reconsider
the Policy terms, conditions and Premiums accordingly.
Article 14: Claims Notification
All In-Hospital treatment must be pre-approved before
admission by the insurer.
In case of Emergency In-Hospital claim occurring at a Network
or at a Non-Network provider, the Insured is obliged to notify
the Insurer at least 24 hours before Discharge Date. Such
notification can be in writing and/or verbally.
In some other cases, the Insurer may also ask the Insured to
complete additional forms. The Insurer will need the Insured
to complete these forms as soon as possible, but no later than
3 (three) months after the Insured’s Treatment starts (unless
there is a good reason why this is not possible).
Article 15: Cancellation
The Policyholder has the right to formally request the
cancellation of this Insurance Policy from the Insurer and any
Premium refund related to a cancellation and being due by the
Insurer to the Policyholder shall be calculated on a pro-rata
basis starting from the Cancellation Date up to the Expiration
Date. However, as per Article 11 the Insured will not benefit
from any Premium refund in case of usage of the Insurance
Policy and/or submission of claim either by direct billing or
reimbursement.
The Insurer has the right to cancel this Insurance Policy in case
of non-payment of Premium according to the terms of Article
7 or in case of proven false statements and/or of material
information according to the terms of Article 13 or when
attainment of maximum age limit allowed in this policy and/
or for any other reason and the insured will not be entitled in
this case for any refund for the remainder part of the insurance
period.
Article 16: Anti Money Laundering
The insurer has the right to revoke any Insurance contract
if the company could not accomplish the requirements of
identification and activity verification for the Insurer and/or
for the insured and notify the anti-money laundering unit-
which is formed according to the current effective anti-money
laundering law.
6
Article 17: Subrogation
Once the Insurance claim has been paid in accordance with
the current terms, the Insured subrogates his/her right to the
Insurer to pursue any third party responsible for an injury. The
Policyholder and the Insured transfer to the Insurer every
relevant, substantial and legal right. Both, the Policyholder and
the Insured shall provide the Insurer every possible assistance
in the case the Insurer exercises the above right of subrogation.
Should the Policyholder and the Insured breach this obligation,
they shall be responsible for any losses incurred by the Insurer.
Article 18: Currency
Any money payable to or by the insurer shall be in Kuwaiti Dinar.
Article19: Change of Law
This Insurance Policy is intended to conform to the law of
the country in which the insurer’s home office is located. If
a conflict arises between this Insurance Policy and such law
becomes effective after the Policy Effective Date, the Insurer
may, at its own option, renegotiate the terms of this Policy from
the date such law becomes effective.
Article 20: Duties
Any levies on the Insurance Policy applied by legislations, tax or
stamp duty shall be borne exclusively by the Policyholder.
Article 21: Sanction Limitation and
Exclusion Clause
No (re)insurer shall be deemed to provide cover and no
(re)insurer shall be liable to pay any claim or provide any
benefit hereunder to the extent that the provision of such
cover, payment of such claim or provision of such benefit
would expose that (re)insurer to any sanction, prohibition
or restriction under United Nations resolutions or the trade
or economic sanctions, laws or regulations of the European
Union, United Kingdom or United States of America.
The (re)insurer shall immediately end cover and stop paying
claims on the policy if the Policyholder or his Legal Dependents
are directly or indirectly subject to economic sanctions,
including sanctions against the Insured’s country of residence.
The (re)insurer will do this even if the Insured has permission
from a relevant authority to continue cover or Premium
payments under a policy. In this case, the (re)insurer can cancel
the policy or remove a Legal Dependent immediately without
notice but will then tell the Policyholder if they do this.
If the Policyholder knows that he or a Legal Dependent are on a
sanctions list or subject to similar restrictions, the Policyholder
must let the re(insurer) know within 7 days of finding this out
Article 22: Arbitration
All differences arising out of this Insurance Policy shall be
referred to the decision of an Arbitrator to be appointed in
writing by the parties in difference or if they cannot agree upon
a single Arbitrator to the decision of three Arbitrators, one to
be appointed in writing by each of the parties, and the third will
be appointed by the Arbitrators, and the Kuwaiti arbitration law
shall be applicable to the arbitration.
Article 23: Personal Information
Please make sure that all the Insured are aware of the
information in this section.
Protecting your information:
Your Insurer Gulf Insurance and Reinsurance Company – GIRI
and AXA involved in your Policy will deal with all personal
information you supply in the strictest confidence.
The summary of the respective AXA Privacy Policies can be
found at:
https://www.axaglobalhealthcare.com/globalassets/shared/
documents/agh-privacy-policy.pdf
We collect personal data and, in some cases, special category
data including health related information about the members
who are covered by your policy from you, those Legal
Dependents, your healthcare providers, your insurance broker
if you have one and third-party suppliers of information, such
as credit reference agencies.
We process your information for the performance of a
contract between you and us and do so mainly for managing
your membership and claims, including investigating fraud.
We also have a legal obligation to do things such as report
suspected crime to law enforcement agencies. We may also
do some processing because it helps us run our business, such
as research, finding out more about you, statistical analysis, for
example to help us decide on Premiums and marketing.
We may disclose your information to other people or
organizations located in Kuwait, Singapore, UK, to do some
of our work for us and assist with managing your insurance,
or where we have your consent for marketing purposes. For
example, we will do this to:
• manage your claims, e.g. to deal with doctors;
• manage your policy with your insurance broker;
• help us prevent and detect crime and medical malpractice by
talking to other insurers and relevant agencies; and
• allow AXA companies to contact you if you have agreed.
We want to reassure you that we never sell personal members
information to third parties. We will only use your information
in ways we can by law, which includes only collecting as much
information as we need. We will get your consent to process
information such as your medical information when it’s
necessary to do so.
Where our using your information relies on your consent you
can withdraw your consent, but if you do we may not be able to
process your claims or manage your policy properly.
We will inform you if a data breach occurs and that your personal
and medical information are disclosed to unauthorized
parties. The notification will be provided within 72 hours of the
confirmation of the incident.
In some cases, you have the right to ask us to stop processing
your information or tell us that you don’t want to receive certain
information from us, such as marketing communications.
You can also ask us for a copy of information we hold about you
and ask us to correct information that is wrong.
Article 24: Recoveries
The Insurer reserves the right to recover any paid amounts in
the following cases:
a) Expenses related to a Treatment, illness or injury that is not
covered by the policy;
b)If the employee/Insured Member and/or dependents
reached the policy limits for a benefit;
c)If the Insurer has paid a claim that is (partially or in full)
fraudulent.
The Insurer will pay the provider after the Employee /Insured
member and/or dependents have had their Treatment. If it
turns out that the Treatment is not covered, the Policyholder
will be responsible for paying the Insurer for the cost of the
Treatment incurred.
Article 25: The Medical Card
a)The Insurer shall issue a medical card to the Employee/
Insured member and each dependent subject to the receipt of
the premium.
b)In case of medical cards loss and/or damage, the Insurer
shall issue replacement cards. In the case of lost cards,
the Policyholder is responsible for informing the Insurer
immediately. If the lost cards are found, it is the Policyholder’s
obligation to return these cards to the Insurer as soon as
possible.
2. Insurance Benefits
The respective description of cover stated in the following
Sections shall apply in conformity with Article 5 of the General
Terms and Conditions of this Insurance Policy and as specified
in the Policy Schedule, comprising of all reasonable and
necessary medical costs incurred in the event of any non-
excluded Health Conditions unless otherwise agreed by the
Insurer.
A. In-Hospital Treatment
A1. In-patient (In-Hospital) and Day-Care Treatment
• For in-patient/in-hospital overnight stay, we pay for room
and board in a basic standard single room. If multiple levels of a
7
 single occupancy accommodation exist within a given Hospital,
it shall mean the lowest cost level.
• For Day-Care Treatment, we do not pay accommodation for
in-patient accommodation.
• Intensive care unit, coronary care unit.
• Surgeon and Anesthesiologist fees.
•Hospital services (e.g. Surgery Procedures, Operating
Theatre, Anesthesia, Pharmacy, Laboratory, Radiology).
•Use of Hospital medical equipment (e.g. heart and lung
support systems).
•Intra-venous infusions, injections, prescribed drugs and
dressings.
•Diagnostic and Laboratory tests, Pathology, X-rays,
electrocardiograms, scans, Computerized tomography,
magnetic resonance imaging and other such proven medical
imaging techniques (Only related to the original cause of
covered In-patient or Day-Care Treatment).
•Various therapies including Physiotherapy, Speech Therapy,
Chemotherapy, Radiation therapy, if it is needed as part of the
Treatment in hospital.
•Doctor Hospital visits (only related to the original cause of
covered In-patient and Day-Care Treatment).
•Nursing care or special nursing care, if medically necessary
and approved by us.
•Recipient transplantation service of kidneys, heart, liver, lung
or bone marrow.
•Surgical Implants (medical devices surgically implanted
into the body as part of the treatment, excluding any dental
implants).
•Reconstructive Surgery (For the initial reconstructive surgery
when it is medically necessary and carried out to restore
function after an accident or a surgery and done at a medically
appropriate stage after the accident or surgery).
•Parent Accommodation fees for one parent staying with
an Insured(s) below 17 years of age who is receiving eligible
Treatment, and the child is a Legal Dependent covered by the
policy.
•Psychiatric treatment as an in-patient, including room,
board and treatment costs for medically necessary In-patient
Treatment or Day-Care Treatment when the treating doctor is
a licensed psychiatrist.
•In-hospital rehabilitation when it is part of treatment following
an acute brain injury such as stroke and carried out by a specialist
in rehabilitation and in a recognized rehabilitation hospital or
unit which we have confirmed in writing that it is recognized by
us. Such treatment could not be carried out on a Day-Care or
out-patient basis or in another appropriate setting. The costs
have been agreed by us before the rehabilitation begins.
A2. In-Hospital Cash benefit
This benefit covers a fixed amount for each complete day
(twenty-four hours) of uninterrupted in-patient Treatment for
8
a covered Health Condition (excluding delivery (childbirth))
incurred within the area of cover (Territorial Coverage) and
provided no cost for that Treatment is claimed under this Plan
or no bills submitted for reimbursement of related treatment
expenses. This benefit is also payable in case of any free or
charged treatment received in any Kuwaiti Government
Hospitals where no bills submitted for reimbursement of
related treatment expense. The minimum in-patient stay must
exceed one (1) complete day of stay.
A3. Pre/Post Hospitalization Treatment
•Pre-Hospitalization Treatment (up to 60 days before
in-patient admission), this is for consultation, prescribed
investigations and essential medications by a Physician,
received as an out-patient within sixty (60) days prior to an
in-patient (in-hospital), where such hospitalization is eligible
for cover under the Insured’s plan and where the need for
such hospitalization has arisen as a direct result of the medical
examination and investigation findings drawn from that
consultation.
•Post-Hospitalization Treatment (within 90 days after
discharge), this is for medically necessary follow-up
consultations, Diagnostic Tests and/or treatment required on
an out-patient basis following In-patient (in-hospital) or Day-
Care Treatment covered by the Insured’s plan and received
within the ninety (90) day period following the date the Insured
was discharged from hospital.
B. Out-patient Treatment
B1. Consultations & Doctor Fees
This Policy covers visits to a General Practitioner (GP) or
Specialist to diagnose or treat a covered Health Condition. If
a covered Health Condition requiring immediate treatment
arises outside of usual business hours, we will cover reasonable
charges from the doctor for a home visit. The Insurer retains
the right to determine if a condition was sufficiently urgent to
justify a home visit, when the home visit was not recommended
or organized by our contracted Assistance Company.
B2. Prescribed Medicines, Drugs & Dressings
This Policy covers Medicines, Drugs & Dressings prescribed
by your Medical Practitioner, where medically necessary for
the condition being treated. For medicines and drugs, these
shall be recognized as medicines defined under Conventional
Treatment and must also be duly registered by the relevant
government regulatory board within the country where
treatment is provided. Please note, for medicines, drugs &
dressings prescribed for any period after your policy has
terminated will not be covered.
B3. Diagnostic Tests
Usual and necessary tests, where prescribed by a treating
doctor to assist with a diagnosis, are covered for:
•Pathology (e.g. blood and urine tests)
•Radiology (e.g. X-rays)
•Advanced Diagnostics (e.g. MRI, CT, PET, Gait scans)
•Other diagnostic tests such as a laboratory, ECG /EKG
•Endoscopies including Cystoscopy, Arthroscopy,
Gastroscopy, Colonoscopy, Laryngoscopy, Bronchoscopy
conducted for diagnostic purposes or on specialist referral
B4. Wellness & Preventive Benefits
B4.1 Annual Health Check-Up
The Policy covers the listed preventive health checks and tests
for an Insured adult (age 18 years and above) once per policy
period:
•routine adult physical examinations and health risk
assessment, height, weight,
•blood test for liver, lipids, cholesterol, diabetes, glucose
tolerance,
•kidney profile, urinalysis,
•blood pressure,
•lung function,
•ECG and cardiac assessment,
•Pap smear, mammogram for breast cancer screening (for
adult Insured females),
•Prostate cancer screening (for adult Insured males).
B4.2 Vaccination
The cost of vaccinations and immunizations and the
administration of the vaccines by a Medical Practitioner or
nurse for a Newborn and child Dependents up to 6 (six) years
of age, recommended by the Ministry of Health of the country
in which they are residing. Influenza virus vaccine is covered
once a year for an Insured if over 50 (fifty) years of age.
B5. Complementary medicines or therapies
Complementary medicine or therapies Benefit of your Plan are
covered, when provided by a chiropractor and acupuncturists,
if they are fully trained, legally qualified, recognized, and
permitted to practice by the relevant authorities in the
country in which the treatment takes place. We do not cover
any complementary therapies or therapists other than those
mentioned above.
B6. Physiotherapy
Physiotherapy Benefit of your Plan is covered for rehabilitation
through physiotherapy sessions, when referred by a Medical
Practitioner (a copy of the referral must be attached to your
claim). Pre-Authorization is required for any treatment that will
exceed 5 sessions for a single Health Condition.
B7. Speech Therapy
Speech therapy Benefit of your Plan is covered, when it is for
short-term and part of the treatment for a covered sickness
(such as a stroke), provided during or immediately following
treatment for that condition, and has been prescribed by the
Insured’s Specialist.
B8. Out-patient surgical procedures
Minor surgical procedures and treatment performed as an
out-patient.
B9. Emergency treatment due to an accident
Medical treatment as an out-patient at a Hospital or Clinic
following an accident which the Insured obtained medical
attention within 24 (twenty-four) hours of the accident.
Eligible Expenses incurred thereafter for follow up treatment
will be reimbursed up to 30 (thirty) days from the date of the
Accident.
B10. Cancer treatment for radiotherapy and chemotherapy
Treatment costs when cancer is diagnosed after the Insured
joining the Policy and for treatments delivered within the
Period of Insurance on an Out-patient basis:
•Fees directly related to ongoing Cancer Treatment, including
tests, scans, consultations and drugs.
•Radiation therapy and Chemotherapy.
•Treatments after acute stage treatment (meaning after
surgery, radiation therapy or chemotherapy).
(Any Pre-existing Condition limitations apply to this benefit).
B11. Psychiatric & Psychological Care
Treatment of psychiatric or psychological conditions is
covered up to the limits of your Plan, when the treating doctor
is a licensed psychiatrist or psychologist and you have been
referred by your attending Medical Practitioner. Subject to
a combined aggregate lifetime limit as stated in the Policy
Schedule for In-patient, Day-Care and out-patient treatments.
C. Dental Benefit
C1. Basic, Complex Dental and Major Restorations
•Dental Consultations
•X-Ray
•Extractions
•Amalgam/Composite
•Glass lonomer filling
•Root Canal Treatment
•Local Anesthesia
•Prescribed drugs
•Scaling and Polishing
•Crown
•Bridge
•Dental Implants
•Surgical removal of impacted/un-erupted teeth and buried
teeth which are diseased or causing symptoms;
•Surgical removal of complicated buried roots which are
diseased or causing symptoms.
C2. Oral and maxillofacial Surgery
Procedures performed by an oral and maxillofacial surgeon:
•Enucleation (removal) of cysts of the jaw;
•Treatment of cancers (for lesion or lump in the mouth).
9
 (Any Pre-existing Condition limitations apply to this benefit).
D. Maternity / Delivery (Childbirth) Benefit
Please note, a single combined limit as detailed in your
benefits table applies to the Insured’s benefits for Pre/Post
Natal Complications, Pre-Natal, Delivery (Childbirth), Post-
Natal treatment expenses and New Born Care. Your chosen
Deductible (if any) will apply to any Maternity related expenses
incurred on an Inpatient basis including any applicable Waiting
Period.
D1. Pre/Post Natal Complications
Cover is provided for Maternity related conditions, not
including the delivery (childbirth) itself (whether medically
assisted or not), where the related complications are Medically
Necessary and life threatening to the mother, after the Insured
mother has been continuously insured under the Policy for 12
months. This includes the following conditions:
a)Antiphospholipid syndrome,
b)Cervical incompetence,
c)Ectopic pregnancy,
d)Gestational diabetes (if the Insured has exclusions because
of her past medical history which relates to diabetes, the
Insured will not be covered for any treatment for diabetes
during pregnancy),
e)Hydatidiform mole – molar pregnancy,
f)Hyperemesis gravidarum,
g)Obstetric cholestasis,
h)Pre-eclampsia / Eclampsia,
i)Rhesus (RH) factor,
j)Miscarriage requiring immediate surgical treatment,
k)Post-partum hemorrhage,
l)Retained placental membrane.
Under post-natal complications, we will only pay for treatment
received within ninety (90) days following the Delivery
(childbirth) of the baby.
Complications of Maternity related to a pregnancy resulting
from assisted conception or from fertility treatment are not
eligible for cover.
D2. Maternity Benefits of your Plan are provided except to child
Dependents.
Multiple pregnancies within a policy year are entitled to the
single policy year's Maternity benefit amount.
D2.1. Pre-Natal Checkups and Treatments
As prescribed by your treating doctor. Prescribed, recognized
supplements for pregnancy are covered.
D2.2. Delivery (Childbirth)
•Hospitalization costs (room type to be the room type
provided by your In-patient Benefits).
•Obstetrician.
10
•Normal delivery (childbirth), medically necessary assisted
delivery or medically necessary caesarean.
•Medical care required by the mother and child immediately
following delivery.
•Elective caesarean will be reimbursed only up to the cost of
a normal delivery, the usual cost of which will be determined
solely by the Insurer.
•Medically necessary termination of pregnancy as per
applicable Kuwaiti laws and rules.
D2.3. Post-Natal Out-patient Treatments
•As prescribed by your treating doctor for up to 6 (six) weeks
after Delivery (childbirth).
•Eligible Out-patient treatments for the mother after that time
may be claimed under her Out-patient Benefits if the Plan she is
enrolled into provides them. Your Newborn will be entitled to
further benefits only if enrolled as a Dependent within 30 days
of birth and then in accordance with the benefits of the Plan.
D3. Newborn Care
The Policy will pay for In-patient treatments of a Newborn
when the delivery (childbirth) of the Newborn was eligible for
benefits under the Insured mother’s Policy, for up to 7 days after
birth, the limit and Waiting Period stated in the Policy Schedule.
A pregnancy overlapping two policy years is entitled to a single
policy year’s Newborn Care benefit limit. Multiple pregnancies
within a policy year are entitled to the single policy year’s
Newborn Care benefit limit.
Newborn Care benefits are not available to Newborn children
born as a result of assisted conception treatment or from any
fertility treatment. Application for the newborn enrolment
into a Policy may only be made within 30 (thirty) days after birth,
and the application will be subject to full medical underwriting.
In-patient treatment of Congenital or hereditary conditions
are not covered under this Newborn Care benefit.
E. Optical Benefit
Optical Benefits are provided where included in your Plan,
covers one (1) examination by an ophthalmologist or
optometrist each policy year and corrective eye glasses and
associated spectacle frames or corrective contact lenses
prescribed for correcting a vision problem (such as myopia or
short sightedness).
F. Congenital & Hereditary Conditions manifested and
treated during first 90 days from birth (Applicable for
in-patient treatment only)
For a newborn insured as a Legal Dependent from birth (from
a covered maternity claim), the Medically Necessary In-patient
treatment of Congenital or hereditary conditions manifested
and treated during the first 90 days after a child’s birth are
eligible for cover up to this benefit Plan limit stated in the Policy
Schedule. This benefit is paid from the insured baby’s plan.
Congenital and hereditary conditions treatment received
after 90 days following the child’s birth or any Congenital or
hereditary conditions impacting the child or an Insured later
in life and was not evident or treated during the first 90 days of
birth, are excluded.
For the purpose of this Policy, we define Congenital
Conditions, as birth defects, congenital disorders, anomalies,
or malformations, as structural or functional anomalies (e.g.
metabolic disorders) that occur during intrauterine life or at
birth and can be identified prenatally at birth or hereditary
conditions because they have been passed down through the
generation of your family.
Congenital and hereditary conditions declared to the Insurer at
time of application are considered as Pre-Existing Conditions.
G. International Emergency Medical Assistance
This coverage shall apply as specified in the Policy Schedule as
follows:
•Evacuation where the medical facilities are not adequate
according to our appointed doctor or
•Repatriation for returning to the domicile/principal country
of residence following evacuation,
•Evacuation will be to the nearest medical facility where
treatment is adequate,
•Cost of one accompanying person while the insured is being
evacuated,
•Bringing the body or ashes back to a port or airport in the
domicile/principal country of residence or home country if the
Insured dies abroad as a result of an eligible Health Condition.
H. Other Benefits
H1. Ambulance
The Policy covers registered local road ambulance services to
transport the Insured, to and between hospitals and another
medical facility.
H2. Maintenance of Chronic Conditions
Conditions which exist or arises after the Enrollment Date or
reinstatement date or plan upgrade (whichever is the later).
If the Insured did have a Chronic Condition before joining the
Plan and declared it to us in the application, the terms of cover
for that condition will be noted in the Policy Schedule.

3. Standard General Exclusions

A.Waiting Periods
All In-patient Treatment (In-Hospital) and Day-Care (including medical treatment, surgeries, services, investigational tests,
medicines, consumables, accessories and implants/ prostheses and others) for the following Health Conditions are subject to
below applicable Waiting Period starting from the Insured’s first joining / Enrollment Date under the Plan provided that these
Health Conditions are NOT present before the Insured’s enrollment in this Policy and/or NOT related to any Pre-existing
condition unless otherwise specified as Covered in the Policy Schedule. As such any In-patient treatment (or Hospitalization) and
Day-care treatment for below Health Conditions will not be covered during the below mentioned Waiting Periods.

Health Condition (provided that it is not Pre-existing) Waiting Period

1 Hernia repair. 6 months
2 Hemorrhoids, Anal Fissures and Fistula. 6 months
3 Tonsillectomy, Adenoidectomy, Turbinate Hypertrophy, Nasal septal deviation and Nasal Sinusitis. 12 months
4 Uterine Fibroids, Hysterectomy, Endometriosis. 12 months
Varicose veins, Hydroceles, Varicoceles (Varicocele related to infertility will be excluded for
5 12 months
lifetime).
Any treatment related to Spine and Knee joint disorders and surgeries. Except for car
6 12 months
accidents and accidents details of which have been recorded by the competent authorities.
In-patient Maternity, pregnancy, Delivery (childbirth), Treatment including any
7 12 months
complications of pregnancy and Delivery (childbirth).

Out-Patient Treatment that are subject to Waiting Period, unless otherwise specified as covered in the Policy
Schedule:

Health Condition (provided that it is not Pre-existing) Waiting Period

Maternity, pregnancy, Delivery (childbirth) including any complications of pregnancy and Delivery
1 12 months
(childbirth)
11
 2 Health Checks. 12 months
3 Acupuncture & Chiropractor. 12 months
4 Vaccination. 3 months
All Out-patient drugs and dressings for Chronic Conditions which occur and diagnosed after
5 the Insured’s enrollment under this Policy (example, including but not limited to Diabetes, 12 months
Hypertension, Cardiovascular diseases, Cholesterol, Epilepsy, Parkinson’s Disease, etc.).

Dental Treatment that are subject to waiting period, unless otherwise specified as covered in the Policy
Schedule:

Dental Waiting Period

1 Basic, Complex Dental and Major Restorations 3 months

B.Lifetime Exclusions
All tests, investigations, Treatments, items, conditions, activities and their related or consequential expenses are excluded from
this Policy and the Company shall not be liable for, unless otherwise specified as covered in the Policy Schedule:

Exclusions
Pre-existing conditions and its Associated conditions or complications that were present before enrolment unless
1
Declared and Accepted by GIG – Kuwait.
2 Any case excluded under Specific Exclusion(s) and clearly mentioned in the Policy Schedule.
Visiting Doctor Fees that exceed the fees of the resident doctors of the service provider hospitals or any medical
3
service fees or charges that are not Reasonable & Customary (R&C).
All cases requiring In-Hospital stay/treatment which has not been notified to the Medical Call Center at least 24 hours
4
before Discharge Date.
All cosmetic related medicines, products, treatments and surgery (unless mandated by a covered accidental injury
5 and is an essential part of treatment, occurring during the Policy’s contractual period) or Treatment that is connected
to a previous cosmetic Treatment or cosmetic surgery or any previous reconstructive surgery.
All substances, which are not considered as medicines and all alternative medications without proven efficacy and/or
6 considered Experimental from insurance Company aspect based on established medical practices except medically
necessary therapeutic vitamins in case of reported deficiency.
Out-patient medical supplies including but not limited to (Elastic stockings, bandages, Gauze, Syringes, Diabetic test
7
strips, and like products) unless it is a part of Emergency Room treatment.
Any treatment within the hospital, examinations or other procedures that may be performed in out-patient clinics
8
without endangering the insured’s health for any risk.
9 All kinds of preventive treatment and procedures and all general check-ups for members ages below 18.
Any treatment, tests, medications, medical procedure, and medical supply which is not related to a specific covered
10
symptom and/or disease or considered medically unnecessary and /or cases not prescribed by a treating Physician.
All cases directed for In-Hospital by a non-Physician or unrecognized medical practitioner, hospital or healthcare
11
facility.
12 Surgery for the correction of refraction error.
Infertility and all fertility related treatment and In-vitro fertilization (IVF) and all related tests and/or medications and/
13
or medical procedures and/or medical supplies.
14 Any surgery for correction of acuteness of the sense of hearing and hearing aids.
Upper and lower jawbone surgery (including that related to the temporomandibular joint) except for direct
15
treatment of acute traumatic Injury or cancer. No coverage is provided for orthodontic surgery, jaw alignment.

12
 Congenital and hereditary conditions treatment, unless otherwise specified as covered in the Policy Schedule.
16 Note for newborn child conceived by artificial means or any form of assisted conception/assisted pregnancy such
conditions are excluded (refer to exclusion no 45).
17 Circumcision (adult and child) and all related complications.
Treatment for polycystic ovary, Hormonal dysfunction and Varicoceles repair for purpose of fertility or any sexual
18
dysfunction or impotence.
19 All cases related to Viral Hepatitis and the complications except Hepatitis A.
Health Services and associated expenses for sterilization, vasectomy and for reversal of sterilizations. In addition to
20
Contraceptive supplies or services or any assisted conception or reproduction.
21 Work Related accidents, injuries and/or illnesses.
22 All treatment related to Renal Dialysis.
Aging related conditions such as Senile dementia, Alzheimer’s, Menopause and Osteoporosis or arising from any
23
physiological or natural cause.
All cases resulting from the Insured taking part actively in the regular armed forces (naval, military, air force service
or operation) and or any paramilitary force and all cases resulting from war risks, invasion, act of foreign enemy,
24
hostilities or warlike operations (whether war be declared or not), civil war, rebellion, mutiny, revolution, martial law
and any Act of Terrorism.
25 Experimental, investigational Health services and associated expenses.
26 Artificial limbs and joints, external prostheses, orthoses or appliances.
Alternative medicine or therapies including but not limited to Acupressure, hypnosis, Hypnotism, Rolfing, Massage
27 Therapy, Aromatherapy, chiropody, podiatry, osteopath, Traditional Chinese Medicine Practitioner, Ayurvedic
medicine and Homeopathic Treatments except as stated in the Policy Schedule and /or the Policy.
Excess use or abuse of alcohol or drugs, substance or solvent abuse, narcotics and, addictive conditions or disorders
28 and all services and supplies’ that are part of smoking cessation programs and use for the treatment of nicotine
addiction.
Sexually transmitted infections or diseases (STD) and conditions including and not limited to Syphilis, Gonorrhea,
29 Genital Warts, Acquired Immune Deficiency Syndrome (AIDS), AIDS related Complex (ARC) tests and any conditions
or diseases related to AIDS/HIV.
Pharmaceuticals & tests for Mental and Psychological disorders and all related cases except what is covered under
30
your Policy Schedule up to the lifetime limit. All the other exclusions still apply to this cover.
Suicide attempts, self-injury and /or injury resulting from committing of or attempts to commit an illegal action or as
31 a direct involvement in criminal activity or putting yourself in needless peril, such as going to a place of unrest as an
onlooker.
32 Earthquakes, flood, volcanic eruption, landslide and other natural hazards or disasters.
All cases resulting from biological or chemical contamination, or nuclear contamination, i.e. any exposure to ionizing
33
radiation, radioactive contamination, nuclear processes, military material or nuclear waste of any kind.
34 All services attained/incurred outside the Territorial Coverage as per your Policy Schedule.
Any kind of bariatric surgery and its related complications, regardless of why the surgery is needed. This includes
35 fitting a gastric band, creating a gastric sleeve or other similar treatment in addition to, weight loss drugs and diet,
clinic or diet programs.
Any treatment, investigations, assessment or grading to do with language or learning disorders, educational
36 problems, behavioral problems, physical development, personality disorder, psychological development and speech
delay.
Treatment at the health hydro, spa, nature cure clinic and other similar facilities even if they are registered as a
37
hospital.

13
 Gender re-assignment operations or any other surgical or medical treatment including psychotherapy or similar
38
services which arise from or are directly or indirectly associated with gender re-assignment.
Any administration costs or reports of any kind or any other charges of a non-medical nature in connection with the
39
provision and/or performance of medical supplies and/or services; telephone calls.
Treatment whilst staying in a hospital for more than ninety (90) continuous days for permanent neurological damage
40
or if the insured person is in a persistent vegetative state.
41 Treatment you require after you have already been on artificial life maintenance for more than 60 continuous days.
Claim for cryopreservation or harvesting or storage of stem cells as a preventive measure or implantation or re-
42
implantation of living cells or living tissues whether autologous or provided by a donor.
43 Treatment directly related to surrogacy whether the insured person is acting as surrogate or are the intended parent.
44 Fetal surgery meaning any treatment given or undertaken on a fetus while in the womb.
Treatment that begins, or for which the need had arisen, during the first ninety (90) days after birth for any newborn
45
child conceived by artificial means or any form of assisted conception/assisted pregnancy.
46 Where payment of the benefit under this policy would result in us contravening a law of any country.
47 Training or participating in a professional sport of any kind.
All cases related to hazardous activities such as flying in an unlicensed aircraft, any activity at a height of over 5,000
meters above sea level, base jumping, cliff diving, free falling, piloting, motorcycling, mountaineering necessitating
48 the use of ropes, Underwater activities requiring the use of artificial apparatus, parachuting, hang, gliding and motor
racing, canyoning, skiing, or any other winter sports activity carried out off piste without an instructor with the
appropriate qualifications.
49 Travelling against the advice of a doctor or Specialist.
Claim for the removal of fat or surplus tissue from any part of the body whether or not it is medically necessary or for
50
psychological reasons (including but not limited to breast reduction).
Claim as a consequence of any treatment that is not covered by or provided in accordance with the policy, including
51
increased treatment costs.
Tonics, anabolic, fat burners, Milk formula, lozenges, antiseptics, chewing gums, nutritional supplies, herbal medicine
52
(unless specified as first line of treatment), Glucosamine compounds and Hyaluronic acid products.
Costs for nutritional supplements including but not limited to special infant formula and cosmetic products even if
53
medically recommended or prescribed or acknowledged as having therapeutic effects.
Costs for standard toiletries including but not limited to, shampoos, soaps, toothpastes, mouthwash, lotions,
54 moisturizer, cleansers, shower gels, contraceptives, proprietary headache and cold cures, with or without
prescriptions.
55 Sleep related disorders including, but not limited to, snoring, insomnia, obstructive sleep apnea, or sleep study tests.
56 Costs for investigations or the treatment of thinning hair or hair loss.
Claim as a result of any complications arising out of any alternative treatment unless at the absolute instructions of
57
the treating doctor and/or specialist.
Orthodontics, periodontics, endodontics, preventative dentistry Dental products such as tooth paste, zymofluor,
58
dental floss, toothbrushes and other items or drugs used for dental care purpose.
59 Routine, general dental care including fillings, unless otherwise specified as covered in the Policy Schedule.
60 Eating disorder like Bulimia, anorexia nervosa.
Pregnancy including Delivery (childbirth), caesarean section, abortion, termination of pregnancy, miscarriage or any
related complications, any treatment, investigations or complications of pregnancy following assisted conception,
61
or via any assisted reproduction technology or fertility treatment, other than eligible services claimed under the
Maternity benefits where specifically provided on the Policy Schedule.
Health screening, Preventative medical examination including routine health checks and vaccinations unless
62
otherwise specified as covered in the Policy Schedule.

14
 Any treatment that offers temporary relief of symptoms rather than dealing, when it is reasonable to do so, with the
63
underlying Health Condition or any palliative care.
Genetic screening tests and checks when you have no symptoms or to check for genetic risks of developing a Health
64
Condition in the future; or where such tests of the results is not proven to change the course of treatment.
Organ and tissue donation including the costs of collecting donor organs for transplant surgery or any administration
65
costs involved even if such transplants are allowed by the terms of this Policy.
Private or special nursing in hospital unless the Company has agreed in writing beforehand that it is necessary and
66
appropriate.
Any charges which are incurred for social or domestic reasons or for reasons which are not directly connected with
67
Treatment.
Any claim or part of a claim in respect of which the Insured has to pay an excess (or deductible or co-insurance).
68 In this case, the Company will only pay the balance of the claims after deducting the excess (or deductible or co-
insurance) amount.
Upgrade of level of cover is not allowed except at each policy anniversary and only then when requested, in writing,
69 to do so. Acceptance by the Company of such an upgrade must be confirmed in writing by the Company before the
upgrade can become effective.
In-hospital rehabilitation more than 28 days except in cases such as in severe central nervous system damage caused
70
by external trauma.
71 Treatment that is not medically necessary or can be considered as a personal choice.
Contact lens check-ups or solutions, tinted/ reactive lenses, non-prescribed spectacles, sunglasses, non-corrective
72 contact lenses, spectacle repairs or new frames, replacement needed after accidental damage, lasik / laser eye
surgery and/or similar, whether prescribed or not.
Any upgrades to your room and food or drink choices that are not on the standard menu, or costs that would not
73
normally be charged to a person staying in a basic, standard, single room, visitors’ accommodation or meals.
In-Hospital Cash Benefit for any in-patient treatment (or hospitalization) stay for one overnight stay or lesser or
74
when it was for an Insured below 19 years old.

15
 4. Definitions
Words, terms, expressions and abbreviations used in the
context of this Insurance Policy shall have the meanings set
forth here below:
Accident:
An unexpected violent and sudden event causing physical
bodily injury (injuries) to the Insured.
Act of Terrorism:
Including but not limited to the use of force or violence and/
or the threat thereof, of any person or group(s) of persons,
whether acting alone or on behalf of or in connection with any
organization(s) or government(s), committed for political,
religious, ideological, or ethnic purposes or reasons including
the intention to influence any government and/or to put the
public, or any section of the public, in fear.
Active Treatment of Cancer:
Treatment intended to shrink, stabilize, or slow the spread of
the Cancer and not given solely to relieve the symptoms.
Actively at Work:
Employee who is mentally and physically capable of working
their normal contracted numbers of hours, either at their place
of business or at the location to which business requires them
to travel. This also includes when the employee is on normal
annual leave, maternity leave, study leave, compassionate
leave, public holidays and/or other holidays, not due to illness
at the time of enrollment on his/her Eligibility Date. The insurer
reserves the right to cancel or to modify the terms of this policy
should it be found out that any employees were not actively at
work at the time they were enrolled for benefits.
Activities of Daily Living
Applicable to family member (who is eligible for cover under
this Policy) and who can perform all the following activities:
•Dressing: The ability to put on, take off, secure, and unfasten
all garments and as appropriate, any braces, artificial limbs, or
other surgical appliances;
•Feeding: The ability to feed one’s self once food has been
prepared and made available;
•Mobility: The ability to move indoors from room to room on
level surfaces;
•Toileting: The ability to use the lavatory or otherwise manage
bowel and bladder functions to maintain a satisfactory level of
personal hygiene;
•Transferring: The ability to move from a bed to an upright
chair or wheelchair and vice versa;
•Washing: The ability to wash in the bath or shower (including
getting into and out of the bath or shower) or wash satisfactorily
by other means.
Aggregate Deductible Excess per Insured:
The amount of Eligible Expenses relating to an Insured person
16
to be borne by the Policyholder over an accumulation period
as specified in the Policy Schedule before any Insurance
coverage applies during the validity of the Insurance Policy.
Whenever this Aggregate Deductible Excess is satisfied within
the accumulation period, the Insurance coverage shall apply
in respect of that Insured for any Eligible in hospital claim only
based on the geographical area specified in the Policy Schedule.
Annual Aggregate Limit:
The maximum amount shown each policy year for each
Insured and all benefits in total paid during the policy period will
account against the Annual Aggregate Limit. This amount does
not apply to the Global Emergency Services.
Associated Conditions:
A symptom, disease, injury or illness that has one or more of the
followingcharacteristics:
•Health Condition(s) caused by or related to directly or
indirectly to Pre-existing Condition; or
•Health Condition(s) in which the underlying condition
(disease, injury or illness) is generally known to be same with
the underlying disease that cause a Pre-existing Condition; or
•Risk factor(s) that is generally or directly known to be a Health
Condition that may cause or is arising from a Health Condition
that may cause Pre-existing Condition.
AXA:
AXA Global Healthcare (UK) Limited, AXA Global Healthcare
(Singapore) Pte. Limited, and AXA PPP healthcare Limited and
each of their affiliates, subsidiaries and holding companies.
Cancellation Date:
The day (at 00:01 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
nonfulfillment of the Policyholder’s obligations as set forth in
the General Terms herein.
Cancer:
A malignant tumor, tissues or cells, characterized by the
uncontrolled growth and spread of malignant cells and
invasion of tissue.
Chronic Condition:
A disease, illness or injury that has 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 requires your rehabilitation or for you to be specially trained
to cope with it
•it continues indefinitely
•it has no known cure
•it comes back or is likely to come back.
Co-payment:
The percentage of healthcare cost as stated in the Policy
Schedule to be borne by the Policyholder. In respect of the
service or benefit under consideration.
Complimentary Medicine Practitioner:
An acupuncturist, or chiropractor who is fully trained and
legally qualified and permitted to practice by the relevance
authorities in the country in which treatment is received.
Covered Person:
Insured person listed and named in the Policy.
Day-Care:
Same day services comprising all Surgical and other procedures
related to non-excluded Health Conditions, not requiring an
overnight stay at a Hospital but nevertheless necessitating
specialized medical attention and care in a Hospital.
Delivery:
Hospitalization for normal or medically necessary cesarean
delivery, medically necessary abortion or miscarriage and/or
any complications arising there from.
Diagnostic Tests:
Investigations, such as x-rays or blood tests, to find or to assist
to find the cause of the Insured’s symptoms.
Drugs and Dressings:
Prescribed medical treatment by a Physician or Specialist
including related medical consumables like bandages, gauze,
alcohol swaps, cotton wool, transparent tapes etc., utilized in
the hospital, clinic or medical facility for wound cleaning, post-
surgery dressing, or STO.
Effective Date:
The day (at 00:01 local time), month and year on which the
Insurance Policy takes effect for the first time or for each
subsequent renewal.
Eligibility Date:
Date or period stated in the Policy Schedule and/or
Endorsement on which an Insured becomes eligible for cover
under the Policy.
Eligible Claim:
Any claim falling within the Applicable Scope of Coverage as
set forth in the General Terms and Conditions of this Insurance
Policy shall qualify as an Eligible Claim under this Insurance
Policy.
Eligible Expenses:
All expenses for healthcare services delivered to the Insured
which are identifiable or covered under this Insurance Policy
after allowing for any Specific Deductible Excess defined
hereinafter, applicable at the level of such service(s) as
provided.
Emergency:
A Health Condition sustained as a result of sudden, non-
excluded sickness or bodily injury, raising a legitimate concern
that there may be a significant medical problem necessitating
treatment (Medical or Surgical) to be performed exclusively
within the Territory of Occurrence which must not be delayed
and which requires confinement to a Hospital Emergency
Room/ Facility followed by Hospitalization or not Emergency
treatment in an Emergency Room is only covered in case
treatment cannot be performed on an out-patient basis.
Eligible Employee(s)
This shall be individuals currently employed by the Policyholder
(and/or a Company Group which are subsidiaries or holding
companies of the Policyholder) and accepted by the Insurer as
members under the plan and Actively at Work.
Employer
The business or commercial establishment or organization for
whom the Employee works for and who is responsible for the
payment of Premiums under this Policy.
Endorsement
A supplementary document We issue to the Policyholder to
record and confirm changes to the Policy.
Enrollment Date:
The day (at 00:01 local time), month and year when the
Insured has been enrolled and covered for the first time
under this Insurance Policy or enrolled and covered under an
initial Insurance Policy which has been renewed without any
interruption.
Experimental:
Treatment, medicine in our reasonable opinion is not effective
and considered as experimental based on acceptable current
clinical evidence and practice including equipment used for
purposes other than those defined under their license.
Expiration Date:
The day (at 00:01 local time), month and year on which the
Insurance Policy expires.
Facility:
A Hospital or centre with which we have an agreement to
provide a specific range of medical services.
Free Access / Direct Billing:
The Insurer’s undertaking of direct settlement to the Network
of all Eligible Expenses incurred by the Insured and related
to non-excluded cases net of any applicable Policyholder’s
Co-payment and/or Deductible Excess and/or any underlying
health fund participation and within the limits of liability of the
Insurer as defined in this Insurance Policy.
Health Condition:
Any disease, illness or injury, including psychiatric illness (if
covered)
Hospital:
Any medical institution, government/public or private, which
is legally licensed and provides medical treatment to a sick and
17
 injured person. The facility must consist of organized premises,
possess the necessary technical and scientific equipment
for diagnosis and surgical operations and should provide
healthcare services by a staff of at least one resident Physician
and qualified nurses. The term “Hospital” excludes out-
patient clinics, sanatoria, Physiotherapy centers, health clubs,
retirement/nursing homes and similar institutions, including
those specialized in substance abuse (drugs, alcohol).
Hospitalization:
Any Hospital confinement for a minimum of one (1) night due
to any non-excluded Health Condition and which cannot be
performed on an Out-Patient basis.
In-Hospital Treatment:
A Hospitalization or Day-care or treatment/observation in an
Emergency Room/ Facility or in a Hospital, which cannot be
performed on an Out-Patient basis.
Insurance Policy:
The contract (as defined in Article 1 of the General 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 Policy
Schedule, its Modules and Appendices (referred to as Policy
Schedule hereinafter).
Insured Guide:
A booklet that provides information on how to benefit from
the Insurance Policy.
Insured (Member):
The eligible full-time and permanent Employees, Legal
Dependents and/or person(s) listed in the application for this
health Insurance for whom the insurance cover is applied for,
with an insurable interest with the Policyholder / the Employer,
and as shown in the Policy Schedule or membership listing or
Census. This shall also include person(s) in any subsequent
Endorsement.
Insured (Member)Listing/Census:
The census list of Insured provided by us to the Policyholder,
listing the relevant details of your Insured(member) and
your membership/census movement listing, which indicates
changes made to your Insured listing.
Insurer/The Company/Us:
The Insurance Company (Gulf Insurance and Reinsurance
Company-GIRIC) duly registered and licensed to operate in the
country of issuance of this Insurance Policy.
Legal Dependent (s) / Dependent (s)/Family Member:
The unmarried child(ren) of the Employee who are under 18
years old or below 25 if still a full-time university student. The
age limit of your employee’s child(ren) will be extended to age
thirty (30) years, provided they remain unmarried, financially
dependent on the employee for support or maintenance
and do not have any independent sources of income nor is
employed. The Spouse(s) of the Employee up to age 75 years
old at the point of application and renewable up to 80 years old.
18
The age is computed from the Effective Date of the Policy
minus the date of birth.
Medical Call Centre:
Professional service center operating 24 hours all year round
staffed with a team of medical and claims administrative
specialists working for the Company to support and monitor
the proper application of the Insurance Policy. The Medical Call
Centre provides the Insured with guidance and information
through telephone inquiries at no cost; and verifies eligibility,
carries out pre-admission reviews, and takes the decision in
the name and on behalf of the Insurer as to whether or not
to grant Free Access to the specific healthcare service under
consideration.
Medical Card:
A personalized card issued in the name of each Insured,
facilitating his/her access to the healthcare services covered
under this Insurance Policy and provided by the Medical
Network.
Medical Case:
All cases and/or reasons and/or services and/or treatments
and/or the covered diseases in the Insurance Policy and their
complications, which falling within the medical cases limitation
stated in the Policy Schedule for the same diagnosis.
Medical Necessity:
Medical Treatment/Services or supplies that is needed &
necessary to diagnose/treat a Health Condition which must
meet acceptable standards of medical practice. Considering
the quality and not the luxury of the Insured or the Physician.
Medical Network:
Member Physicians, Hospitals, Clinics, Medical Centers,
Pharmacies, Laboratories and Physiotherapy centers
forming the Company network through a special and formal
contractual arrangement whereby these providers agree to
avail the Insured with Free Access to their healthcare service
in conformity with the terms of this Insurance Policy and as set
forth in the Policy Schedule.
Non-Network:
Any Physician and Health institution, Hospital, Clinic, Medical
Center, Physiotherapy center and Pharmacy which are not part
of the Medical Network.
Out of Hospital (Out-patient) Treatment:
Benefits that may be offered under this Policy in respect of
services such as Doctor’s consultation, prescribed drugs,
Diagnostic Tests, Physiotherapy treatment, etc. and which
do not require Hospitalization or any In-Hospital treatment/
observation.
Physician/Medical Practitioner:
A person who has the primary degrees in the practice of
medicine and Surgery following attendance at a recognized
medical school and who is licensed to practise medicine by the
relevant licensing authority where the Treatment is given.
Plan:
The combination of the terms and conditions, benefits
offered by the Insurer and selected by the Policyholder on
the application form and documented in the Policy Schedule
and Policy Agreement including the membership handbook/
insured guide.
Policy Anniversary
The same date and month following a year from the Policy
Commencement Date or last policy anniversary.
Policy Commencement Date
The date on which the insurance coverage starts as set forth in
the Policy Schedule.
Policy Schedule:
The insurance certificate which contains information related
to Insured personal detail, type of cover, Territorial Coverage
and special exclusions if any and other details related to the
type of plan enrolled.
Policyholder/You/Your/Employer:
The legal entity or company who is purchasing this private
medical insurance benefit of all, or certain of, its employees from
the Insurer, and who is named in the Corporate Application
Form, as completed by the policyholder and returned to the
Insurer.
Pre-Existing Condition:
A Pre-existing Condition is any disease, illness or injury that:
•Insured/Policyholder has been diagnosed; or
•Insured /Policyholder had received medication, advice or
treatment prior to the Enrollment Date; or
•Insured/Policyholder had experienced symptoms prior to the
Enrollment Date, whether or not the condition was diagnosed;
or
•Insured/Policyholder should reasonably, in our opinion, have
known about; or
•is a consequence of injury or illness for which medical, surgical
and/or Pharmaceutical treatment or advice was provided prior
to the Insured/Policyholder’s Enrollment Date.
If the Insured did have a Pre-Existing Condition before joining
and declared it to us in the application, the terms of cover for
that condition will be noted in the Policy Schedule.
Pre-Hospitalization Form:
A form that must be completed by the attending Physician of
the Insured and submitted to the Medical Call Centre prior to
In-Hospital treatment. It is a mandatory pre-requisite to benefit
from any In-Hospital coverage.
Premium(s):
The amount(s) payable by the Policyholder to the Insurer for
the year, in return for the Insurer providing cover for the Eligible
Employees and Legal Dependents.
Principal Country of Residence:
The country where the Insured lives or intend to live for most of
the Year being one hundred eighty-five (185) days or more and
which will be shown as Insured’s address and place of residence
in our records.
Psychiatric illness / Mental illness:
Collectively all diagnosable mental disorders or Health
Conditions that are characterized by alterations in thinking,
mood, or behavior (or some combination thereof) associated
with distress and/or impaired functioning.
Reasonable and Customary Charges:
This refers to charges for medical care which shall be
considered by us or by our medical advisers to be Reasonable
and Customary to the extent that they do not exceed the
general level of charges being made by others of similar
standing in the locality where the charges are incurred when
giving like or comparable Treatment.
The fees for Covered Health Services which, as determined
by the Company, are either: (1) for Network Providers, the
contracted charge; or (2) Is the average of the cost to perform
a similar or comparable treatment of the same category within
Company’s network inside or outside Kuwait.
We may also base that calculation on a combination of global
experience, statistical information provided by local health
authoritative body and information collected from medical
specialists and surgeons practicing in the country or area
where the Treatment is received.
For the avoidance of doubt when comparing Treatment, we
will take into account the complexity of the procedure and
the standard of the medical facility where the Treatment is
received.
If the charges are higher than is customary, we will only pay the
amount which is, in our experience, customarily charged and
you will have to pay the rest. If the Insured’s Treatment requires
more than one Specialist or surgeon or anesthetist present
at the same operative (surgical) session, we shall review the
medical necessity in the management of such surgical problem
or Health Condition in terms of the different trained skills
and complexity of the services provided as an identification
to cover the total services. No additional benefits or cost is
payable for surgical assistants.
Rehabilitation:
Treatment in the form of a combination of therapies such as
physical, occupational and speech therapy aimed at restoring
full function after an acute event such as stroke.
Renewal Date:
The day (at 00:01 local time), month and year that coincides
with the Expiration date and the date this Policy Agreement
renews “Renews”, “renewal” and “renewed” shall be construed
as the entry by the Policyholder into a new Policy Agreement
with the insurer for a further year.
Specialist:
A medical practitioner registered and licensed as such in the
geographical area of his practice where treatment takes place
and who is classified by the appropriate health authorities as a
19
 person with superior and special expertise in specified fields of •been shown to be effective for your or insured Family
medicine or dentistry. Member's Covered Health Condition through substantive peer
reviewed clinical evidence in published authoritative medical
Specific Deductible Excess per Service/Benefit:
journals; or
The amount of money stated in the Policy Schedule to be
•been approved by NICE (The National Institute for Health and
borne by the Policyholder in respect of the service or benefit
Care Excellence) as a Treatment which may be used in routine
under consideration.
practice.
Surgery:
If the Treatment is a drug, the drug must be:
An operation or other invasive surgical intervention listed in
•licensed for use by the European Medicines Agency (in
the schedule of procedures and fees, and duly registered by
Europe) or the Medicines and Healthcare products Regulatory
the relevant government regulatory board within the country
Agency or the US Food and Drugs Administration (FDA), (when
where treatment is provided.
treatment is outside Europe); and
Termination Date:
•used according to that license and dosage for which it is
The day (at 00:01 local time), month and year on which the approved for.
Insured’s coverage is terminated as the result of his/her deletion
Undeclared hazardous activities:
at the request of the Policyholder and/or in case his/her status
as Legal Dependent no longer holds or upon the cancellation The non-disclosure from the Insured at the date of application,
of this Insurance policy. for this Insurance Policy, of a hazardous activity(ies) which was/
were specifically inquired about, in the application form, if any.
Territorial Coverage:
Undeclared Pre-existing conditions:
The area of Cover stated in the Policy Schedule applicable to the
Insured’s Plan which is either (1) Worldwide or (2) Worldwide The non-disclosure by the Insured at the date of application,
excluding USA and Canada. for this Insurance Policy, of Pre-existing conditions restrictively
relating to Health Conditions specifically inquired about, in the
Territory of Occurrence:
application form, if any.
The country where the Insured’s Health Condition has
Waiting Period:
required healthcare services and where the related expenses
were incurred. The period of time starting from the Enrollment Date of the
Insured during which a specific or general Health Condition
Treatment:
shall not be covered under this Insurance Policy.
A Surgical Procedure or medical procedure carried out by a
Waiver date:
Physician or Specialist that is Conventional Treatment. This
includes: The date of termination of the Waiting Period after which the
exclusion related to a specific or general Health Condition is
•Diagnostic procedures – consultations and investigation
deleted.
needed to establish a diagnosis.
Year:
•In-patient (in-hospital) Treatment - Treatment at a Hospital
where the Insured has to stay in a Hospital bed for one or more The twelve (12) months from the Insured’s Policy start date or
nights. last renewal date.
•Day-care Treatment - Treatment (excluding Out-patient
Treatment) at a Hospital or daycare unit where the Insured is
admitted to a Hospital bed but does not stay overnight.
•Out-patient Treatment - Treatment at an out-patient clinic, a
Physician/Specialist consulting rooms or in a Hospital where
the Insured is not admitted to a bed.
For avoidance of doubt, any of the above listed Treatment
is according to the Insured’s Plan and stated in the Policy
Schedule. Certain benefits may exclude an entire class of
Treatment.
We define Conventional Treatment as Treatment that:
•is established as best medical practice and is practiced widely;
and
•is clinically appropriate in terms of necessity, type, frequency,
extent, duration and the facility or location where the
Treatment is provided; and has either:

20
5. Policy Schedule Clarifications
1. Foreign currencies referred to in this Policy under Limits and Deductible Excess shall be converted into Kuwaiti Dinars at the date
of claim(s) invoicing. Eligible amounts and/or balances shall be adjusted accordingly.
2. Reimbursement of Non-Network claims will be according to the Reasonable and Customary charges in the network.
3. In case of rendering health care services at a network provider on direct billing basis, the agreed contractual rates including any
applicable Co-payment(s) and/or Deductible(s) shall be applied.
4. Special exclusions are stated in the policy schedule under each insured name if such exclusions exist.
5. There are different benefit limits applicable for each benefit in the Policy Schedule:
•Annual Aggregate Limit – the Insurer will pay up to this amount for Treatment, for each Policy membership Year.
•Visit limit – the Insurer will cover up to the number of visits or sessions or treatment for each Policy membership Year.
•Lifetime limit – the Insurer will pay up to this amount (in money or visits) for the whole period of the Insured’s membership on the
Plan/Policy.
•Money limit – the Insurer will pay up to this amount for a particular Treatment, each Policy membership Year.

21