GET HEALTH COVERAGE FOR YOUR EMPLOYEES

• Pre-existing medical conditions are illnesses or injuries that exist before you take out a health insurance policy, they include chronic diseases, such as hypertension, respiratory diseases, and diabetes as well as any diseases that you may be receiving treatment for, such as cancer. Mental health conditions such as depression and anxiety may also fall under pre-existing conditions
• Large corporates do not require any declarations. However, most of the SME plans require declarations. Also, a declaration would be required for aged members in the group.
• For the policies with declarations, premiums will vary based on the conditions declared.

Kindly note, the coverage of the medical insurance is subject to the table of benefits under the policy, where the coverage is well defined with the limits and sub-limits.

Some of the coverages under the medical insurance are as below, which again depends on the benefits the group chooses.

• Maternity cover - Maternity coverage includes the prenatal, postnatal and delivery expenses as per the agreed policy terms.
• Emergency cover - The Emergency Medical Benefit covers treatment for an unexpected illness or injury or any life-threatening conditions which offer extensive coverage and acts as a financial pillow in case of medical emergencies.
• Vaccination cover for the kids – It covers the cost of immunizations and preventive care services as per the health plan.
• Diagnostic test & treatments – The medical policies will cover the medically indicated tests, diagnoses, treatments, and surgeries in hospitals for non-urgent medical cases.
• Outpatient services – Any services as an outpatient, such as consultation, lab/radiology tests, pharmaceutical/medicine, etc., will be covered.
• Inpatient services – Any treatment which required more than 12 hours of admission is referred as inpatient services and the same will be covered as per the terms agreed.
• Day case – Any day case admission for any small procedures will also be covered under the medical insurance.

All medical insurance plans have a standard set of exclusions and any services mentioned under the same will not be covered.

Some of the excluded services are as below.

• Any treatment which is not medically indicated will not be covered.
• Treatments related to cosmetics will not be covered.
• Treatments related to obesity will not be covered.
• Any hazardous sports activity, suicide, etc., will not be covered.
• External prosthetic devices and medical equipment.
• Patient treatment supplies (including for example: elastic stockings, ace bandages, gauze, syringes, diabetic test strips, and similar products; non-prescription drugs and treatments,) excluding supplies required as a result of Healthcare Services rendered during a Medical Emergency.

• Pre-existing conditions
• Age Factor - Overage members
• Marital Status (E.g., Married Females)
• Gender
• Loss Ratio
• Type of coverage (Network/Benefits, etc.)

• The deductible is applied based on the policy terms and conditions.
• For groups, you have the options to choose from such as 20% with a CAP.
• The amount is being borne by the member/insured and paid from their own pocket when going for the outpatient check-ups and/or diagnostic, whenever applied as per the terms and conditions of the policy.

Yes, the PEC conditions are covered as per the policy terms and conditions and also based of the declaration, if required for the group policy.

• These days, most of the policies are cardless policies, that can be activated on the Emirates ID and medical insurance policy is linked through the member’s Emirates ID.
• Emirates iD is a mandatory requirement for all medical providers.
• Members can use insurer’s or TPA Mobile Application.
• Members can use E-Cards.

• The coverage is subject to the updating of the marital status as ‘Married’ in the insurance system with a valid marriage certificate.
• For Abu Dhabi & Dubai Visa holders, it is a mandatory cover (DOH & DHA). So yes, it is covered.
• For the Northern Emirates, some plans may not have maternity cover.
• Any undeclared maternity cases will not be covered, for the group policies with declaration.
• For Daman AUH Basic, if the member was added as single and is newly married (after policy inception), maternity benefit can be requested to Daman during midterm amendment to add/update in the policy of the member. However, if the marriage date mentioned in the certificate is prior to the policy inception date, maternity correction can only be done during the renewal period and must be informed accordingly.

• Optical & dental is an additional benefit covered if chosen by the group (additional premium applies), and wil be covered as per the agreed terms.
• Dental and Optical covers always have certain services with a specific limit.

• There are no restrictions on the number of claims during the policy period, however, the maximum coverage will depend on the annual limit and sub-limits.
• At the same time, certain services will have limited sessions like physiotherapy, alternative benefit, etc., which will be as per the agreed benefits.

• The coverage outside the network is subject to the availability of the reimbursement benefit under the group policies.
• In case of any life-threatening emergencies, the member can access a non-network provider with a case notification to the insurer within 24 hours from the time of the incident
• There will not be any reimbursement for elective treatment for the basic policies, without reimbursement benefits.

• Yes, we can categorize the employees in different categories based on the designations or salary bands.

Yes, this can be done based on the proof provided of the association.

Yes, the policies can be customized as per the company requirements. However, the pre- underwritten plans modifications will be limited.

In order to obtain group health insurance in UAE, the business/ company must be registered and approved legally by the regulations and guidelines of UAE (with a valid trade license). An organization also needs to have a minimum number of employees for a Group Health Insurance policy.

The minimum number of employees required to get a group of medical insurance varies from insurance provider to provider.

Medical Claim Reimbursement Checklist:

• Duly filled out claim form of the concerned insurance company / TPA, signed and stamped by the treating doctor with beneficiary signature
• All official itemized invoices with the service details
• Payment proof such as official receipts, paid stamp, card payment slips, etc.
• Prescription from the treating doctor for all the medications availed and for optical items.
• All the diagnostic reports including but not limited to Laboratory and Radiology reports
• Referral letter from specialist consultant and progress reports (after every 5 sessions) for claims related to physiotherapy treatment/ chiropractic treatment
• Discharge summary with the operative notes (for surgical treatment) for all the inpatient, daycare, emergency admissions
• Medical Report with injury details (when, where and how) for claims related to any kind of injuries
• Medical Insurance card copy
• Bank Details (if applicable)
• Copy of passport showing exit and entry stamp for the treatments done outside the UAE
• A police report in case of an accident (if covered under the medical policy)

Important Notes:

• The insurance company has the right to request further documents not mentioned above such as detailed medical report, etiology, medical justification, etc. if required to further process the claim
• Pre-approval / intimation is required for In-Patient and Daycare treatments outside network and outside UAE including high cost (invasive) Out-patient procedures
• All Emergency cases must be notified within 24 hours from the admission date per DHA exclusion # 21
• Claim documents must be in English or Arabic language only
• All the documents must be submitted with the cut off period per policy terms and conditions