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A
Amendments: Amendments are effective only when signed by the Company. Amendments are subject to all conditions, limitations and exclusions of the Policy except for any attached description of additional/deletion or alteration in the provision of the policy contract.
Authorization Request for Hospitalization Form: A form that must be completed by the attending Physician of the Covered Person and approved by the Company prior to hospitalization.
Accident: A sudden, unexpected, violent external event, causing a severe physical bodily Injury, which is usually visually identifiable and is documented by a competent authority such as a law enforcement officer or Physician.
Accident related Constructive Surgey: The Coverage under this policy would be restricted only for the cases resulting from Accidents incurred during the validity of the policy and may be extended to the insured whose continuity of Coverage is proven and accepted by the Company before hand.
Accident related Dental Treatment: The Coverage under this policy would be restricted (1) to sound natural teeth and (2) only for the cases resulting from Accidents incurred during the validity of the policy treatment taken within 72 hours of accidental impact and restricted to pain manage.
Active at Work: An employee who is (1) employed on a full-time basis by the Policyholder and is currently being paid a full-time salary, or (2) is on formal paid or unpaid leave from the Policyholder.
B
Benefit: The extent or degree of service Covered Persons are entitled to receive based on their contract with the Company.
Benefit Plan: The combination of all Benefits that Covered Persons are entitled to receive based on their contract with the Company.
C
Chronic Disease: A disease with one or more of the following characteristics: lasting 3 months or more, leaves residual disability, caused by non-revisable pathological alteration, requires special training of the patient for rehabilitation, or may require a long period of supervision.
Claim Form: (All) A form which must be completed by the attending Physician in order for the Covered Person to obtain Coverage for treatment. (Premier) A form which must be completed by the attending Physician in order for the Covered Person to obtain Coverage for Outpatient Benefits.
Clerical Error: Usually minor, inadvertent negligence in computing a figure, or recording or copying a fact or statement. Also called clerical mistake.
Co-Insurance: In Health Insurance, it is a percentage of each claim paid by the policyholder after the deductible has been paid.
Co-Insurance: The percentage of Eligible Expenses in addition to the Premium, which Covered Persons are required to pay for certain Health Services provided under the Policy. Covered Persons are responsible for the payment of any Co-insurance directly to the Provider of the Health Service at the time of service or when billed by the Provider.
Company - National Health Insurance Company - Daman: Entity assumes the coverage of risks subject to this contract.
Confinement and Confined: An uninterrupted overnight stay following formal admission to a Hospital.
Congenital Anomoly: An anatomical or physiological defect disease or malformation … etc which may be either hereditary/familial/genetic or due to an influence occurring during gestation up to birth, and may or may not be obvious at birth.
Consumable Medical Supplies: Are non-durable medical supplies that: (1) are usually disposable in nature; (2) cannot withstand repeated use by more than one individual;(3) are primarily and customarily used to serve a medical purpose; (4) generally are not useful to a person in the absence of illness or injury; (5) May be ordered and/or prescribed by a physician.
Country: United Arab Emirates
Coverage Category: Classifications of employees within an employer group, who are eligible for different levels of Benefits. These Coverage Categories, if any,are listed in Exhibit 1 to the Corporate Policy.
Coverage or Covered: The entitlement by a Covered Person to Health Services provided under the Policy, subject to the terms, conditions, limitations and exclusions of the Policy. Health Services must be provided (1) when the Policy is in effect; and (2) prior to the date that any of the individual termination conditions of Section 3.1 occur; and (3) only when the recipient is a Covered Person and meets all eligibility requirements specified in the Policy.
Covered Person: Either the Primary Insured or an Enrolled Dependent, but applies only while Coverage of such person under the Policy is in effect.
Covered Services: Benefits that are covered under the terms & conditions of the policy.
D
Daman card: The identification card the Company issues for every member covered under this health insurance scheme.
Day Treatment: Medical treatment which must be provided in the Hospital, but which does not require a Confinement.
Deductable: The defined monetary amount, in addition to the Premium, which Covered Persons are required to pay for certain Health Services provided under the Policy. Covered Persons are responsible for the payment of any Deductible directly to the Provider of the Health Service at the time of service or when billed by the Provider.
Dependant: (All) The eligible Primary Insured’s legal spouse(s) and dependent(s) as per SEHA Group companies internal policies as long as it does not contradict with the Law. The principal place of residence of the legal spouse or unmarried Dependent child must be with the Primary Insured unless the Company approves other arrangements. Furthermore, the definition of “Dependent” must be in accordance with the Mandatory Health Insurance Law for Expatriates and respective Bylaws, as set forward by the Health Authority of Abu Dhabi (HAAD) and approved by the Executive Council of the Emirate of Abu Dhabi. (Abu Dhabi) The eligible Primary Insured’s legal spouse(s) and dependent(s) as pe SEHA Group companies internal policies as long as it does not contradict with the Law. The principal place of residence of the legal spouse or unmarried Dependent child must be with the Primary Insured unless the Company approves other arrangements. Furthermore, the definition of “Dependent” must be in accordance with the Mandatory Health Insurance Law for Expatriates and respective Bylaws, as set forward by the Health Authority of Abu Dhabi (HAAD) and approved by the Executive Council of the Emirate of Abu Dhabi. The Primary Insured will be required to reimburse the Company for any Health Services provided to their Dependants at a time when the Dependants did not satisfy these conditions.
Designated Facility: A Hospital, named by the Company as a Designated Facility, which has entered into an agreement with or on behalf of the Company to render Covered Medically Necessary and Medically Appropriate Health Services for treatment of specified diseases or conditions.
Donor: A person alive or deceased from whose body one or more organs have been extracted with the intention to transplant them (totally or partially) in the body of another person (the Recipient) via an Organ Transplant.
Durable Medical Equipment: Medical equipment used externally from the human body which: (1) can withstand repeated use; (2) is not designed to be disposable; (3) is used to serve a medical purpose; (4) is generally not useful to a person in the absence of a Sickness or Injury; and (5) is used outside of the Hospital.
E
Effective Date: The date that Coverage becomes effective, which may be either the Enrollment Date of a Covered Person, or the date on which Coverage renews.
Eligible Expenses: Reasonable and Customary Charges for Covered Health Services, incurred while the Policy is in effect.
Eligible Person: (1) an employee of the Policyholder who is Active at Work or (2) other person who meets the eligibility requirements specified in both the application and the Policy. Furthermore, the definition of “Eligible Person” must be in accordance with the Mandatory Health Insurance Law for Expatriates and respective Bylaws, as set forward by the Health Authority, Abu Dhabi (HAAD), and approved by the Executive Council of the Emirate of Abu Dhabi.
Emergency: The acute onset of a medical or surgical condition manifested by acute symptoms of sufficient severity, including pain, that the absence of immediate treatment at Health Facility could reasonable be expected to result in placing the patient’s health or bodily functions in serious jeopardy or dysfunction of any body organ or part.
Emergency Health Services: The health care services and supplies necessary for the treatment of an Emergency.
Emirate: Emirate of Abu Dhabi.
Enrolled Dependant: Dependent of principle enrolled in the policy.
Enrolled Dependent: A Dependent who is enrolled for Coverage under the Policy.
Enrollement Date: The original Effective Date of Coverage for a Covered Person.
Experimental, Investigational or Unproven Services: Medical, surgical, diagnostic, or other health care services, technologies, supplies, treatments, procedures, drug therapies or devices that, at the time the Company makes a determination regarding Coverage in a particular case, is determined to be: (A) Subject to formal review and approval by local medical authorities for the proposed use; or (B) The subject of an ongoing clinical trial; (C) Not demonstrated through prevailing pre-reviewed medical literature to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed.The Company, in its judgment, may deem an Experimental, Investigational or Unproven Service to be a Covered Health Service for treating a life threatening Sickness or condition if it is determined by the Company that the Experimental, Investigational or Unproven Service at the time of the determination: (A) Is safe with promising efficacy; and (B) Is provided in a clinically controlled research setting.
Expiry Date: The day (at 00:00 midnight local time), month and year from which the Policy expires.
F
Full -Time: An employee who is on a permanent pay roll of the Employer and having full time employee status.
G
General Exclusions: The health Benefits and services excluded from Coverage that are listed in Section 11 of this Policy and apply to all Covered Persons.
H
Health Services: The health care services and supplies Covered under the Policy, except to the extent that such health care services and supplies are limited or excluded.
Hospitalization: Hospital confinement requiring an overnight stay.
Hospitalization Class: The class of Hospital room and services, indicated in the Schedule of Benefit, to which the Covered Person is entitled according to Daman Plan.
I
Injury: Bodily damage other than Sickness including all related conditions and recurrent symptoms.
Inpatient: Hospital confinement requiring an overnight stay.
International: Outside of the country.
International Hospitalization: A Confinement in a Hospital located outside of the Country.
L
Limit: The maximum amount paid by the Company under the terms of this Policy.
Limitation of Action: If a dispute between Daman and the Parties (includes Policyholders and / or Covered persons on behalf of Policyholder) dealing in business with it arises out of or is related to any Agreement, the concerned Party and Daman shall meet and negotiate in good.
M
Maternity Benefit - Inpatient: (Premier) Includes charges for a vaginal delivery, a Medically Necessary cesarean section, any complications of pregnancy or delivery and legal abortion. New born accommodation, new born care and birth defects coverage is given up to the maximum as described in Exhibit 1, Schedule of Benefits. (All) Includes charges for a vaginal delivery, a Medically Necessary cesarean section, any complications of pregnancy or delivery and legal abortion.
Maternity Benefit - Outpatient: (All) Includes charges for all outpatient pre-natal and post-natal physician visits, including investigations & treatment. (Regional) Includes charges for all outpatient pre-natal and post-natal Physician visits, including investigations & treatment. (Coverage for Maternity Benefit-Outpatient is only provided if the services are assured in Exhibit 1).
Maternity Services: Services related to maternity benefit. It include outpatient and inpatient maternity services.
Medically Appropriate: Based on the prevailing standards of medical practice relative to a specific condition.
Medically Necessary: Health care services and supplies which are determined by the Company to be Medically Appropriate, and (A) Necessary to meet the basic health needs of the Covered Person; and (B) Rendered in the most Medically Appropriate manner and type of setting appropriate for the delivery of the Health Service, taking into account both cost and quality of care; and (C) Consistent in type, frequency and duration of treatment with scientifically based guidelines of medical, research, or health care Coverage organizations or governmental agencies that are accepted by the Company; and (D) Consistent with the diagnosis of the condition; and Required for reasons other than the convenience of the Covered Person or his or her Physician; and (F) Demonstrated through prevailing pre-reviewed medical literature to be either: ( 1) Safe and effective for treating or diagnosing the condition or Sickness for which their use is proposed or, (2) Safe with promising efficacy (a) for treating a life threatening Sickness or condition, (b) in a clinically controlled research setting. The fact that a Physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular Injury, Sickness or Mental Illness does not mean that it is a Medically Necessary Covered Health Service as defined in this Policy. The definition of Medically Necessary used in this Policy relates only to Coverage and differs from the way in which a Physician engaged in the practice of medicine may define Medically Necessary.
Mental Illness: A mental or bodily condition marked primarily by sufficient disorganization of personality, mind and emotions to seriously impair the normal psychological, social, or work performance of the individual.
N
Network: (All) (Services are 100% covered on direct billing) when used to describe a Provider of Health Services, means that the Provider has a participation agreement in effect with the Company, to provide Health Services to Covered Persons. The Company may change the participation status of providers from time to time. (Abu Dhabi) When used to describe a Provider of Health Services, means that the Provider has a participation agreement in effect with the Company, to provide Health Services to Covered Persons. The Company may change the participation status of Providers from time to time.
Network Benefits: Benefits available for Covered Health Services when provided by a Network Provider. Health Services provided by a non-Network Provider are considered Network Benefits when such Health Services are approved in advance by the Company or are Emergency Health Services are approved in advance by the Company or are Emergency Health Services.
Non-Emergency Hospitlaization: Any Confinement which is not as a direct result of Emergency Health Services.
Non-Network Benefits: (UAE/Regional) Coverage available for Health Services obtained from non-Network Providers. Coverage for Non-Network Benefits is only provided if the services are assured in Exhibit 1. Health services provided by a non-Network Provider are considered Network Benefits when such Health Services are approved in advance by the Company or are Emergency Health Benefits. (Abu Dhabi) Coverage available for Health Services obtained from non-Network Providers. Coverage for Non-Network Benefits is only provided if the services are assured in Exhibit 1. Health services provided by a non-Network Provider are considered Network Benefits when such Health Services are approved in advance by the Company or are Emergency Health Benefits. (Premier) Coverage available for Health Services obtained from non-Network Providers. Health services provided by a non-Network Provider are considered Network Benefits when such Health Services are approved in advance by the Company or are Emergency Health Benefits.
O
Out of Hospital Benefits: Benefits offered under this cover are services as Physician consultation, incl. Accident related Dental Treatment, Prescribed medicines, Physiotherapy & Diagnostic testing including preoperative investigations which are conducted on an Out-of-Hospital basis without jeopardizing the insured’s health or which do not require Hospitalization/Day treatment or necessitate specialized medical attention and care in a Hospital before, during or after the delivery of the service.
Out-of-Pocket Limit: (UAE Plus) The maximum amount of Coinsurance each Covered Person pays per prescription for Prescription Drugs. Once a Covered Person reaches the Out-of-Pocket Limit, Eligible Expenses are Covered at 100% for the rest of that prescription for Prescribed Drugs. (Regional Plus) The maximum amount of Coinsurance each Covered Person pays per prescription for Prescription Drugs. Once a Covered Person reaches the Out-of-Pocket Limit, Eligible Expenses are Covered at 100% for the rest of that prescription for Prescription Drugs, unless otherwise specified.
P
Physician: Any practitioner of medicine who is duly licensed and qualified under the laws of the country in which treatment is received.
Policy: The Corporate policy, the application of the Policyholder, any individual Primary Insured applications, Amendments and Riders which constitute the agreement regarding the Benefits, exclusions and other conditions between the Company and the Policyholder.
Policy Charge: Any charges in addition to the Policy Premium that are payable by the Policyholder.
Policy Holder: The employer or other defined or otherwise legally constituted group to whom the Policy is issued.
Policy Period: The period of time (typically one year) from the Effective Date of Coverage, to the termination of coverage prior to renewal.
Pre-Existing Condition: Any known/unknown injury, illness, sickness, disease or other physical, medical, mental or nervous condition, disorder or ailment that with reasonable medical certainty existed at the time of application, whether or not previously manifested or symptomatic, diagnosed, treated or disclosed prior to the effective date, including any subsequent, chronic or recurring complications or consequences related thereto or arising there from.
Premium: The periodic fee required for each Primary Insured and each Enrolled Dependant in accordance with the terms of the Policy.
Prescription Drugs: Pharmaceuticals which can only be obtained through a prescription written by a licensed physician.
Primary Insured: An Eligible Person who is properly enrolled for Coverage under the Policy. The Primary Insured is the person (who is not a Dependant) on whose behalf the Policy is issued to the Policyholder.
Profit Sharing: (UAE Plus) The sharing of profits, as between the Company and the Policy Holder in such a way that the Policy Holder receives, in addition to the Benefits specified in this Policy.
Prosthetic Devices: An artificial device, either external or implanted, that substitutes for or supplements a missing or defective part of the body, e.g. artificial limbs and pacemakers.
Provider: Physician, Hospital, group practice, pharmacy or any facility, individual or group of individuals that provides a health care service.
R
Recipient: A Covered Person who received or is receiving an Organ Transplant Covered under this Policy.
Reconstructive Surgery: Surgery, which is incidental to an Injury, Sickness or Congenital Anomaly when the primary purpose is to improve physiological functioning of the involved part of the body.
Renewal: New coverage under a new Policy following a previous term and the acceptance of a Premium for a new Policy Period.
Renewal Date: (Regional Plus/Premier) The day (at 00:00 midnight local time) month and year on which a Renewal takes place and which coincides with the Expiry Date.
Repatriation: Case an Insured member has passed away the Mortal Remains will be repatriated to country of origin.
Riders: Any attached description of Health Services Covered under the Policy. Health Services provided by a Rider may be subject to payment of additional Premiums. Riders are effective only when signed by the Company and are subject to all conditions, limitations and exclusions of the Policy.
S
Sickness: (UAE/Regional Plus/Premier) Physical illness or disease. The term "Sickness" as used in this Policy does not include Mental Illness or substance abuse, except those mentioned in Section 11. (Abu Dhabi) Physical illness or disease. The term "Sickness" as used in this Policy does not include Mental Illness or substance abuse, except those mentioned in Section 10. (UAE Plus) Physical illness or disease. The term "Sickness" as used in this Policy does not include substance abuse.
Specific Exclusions: Non-Covered services or Benefits which are specific to the Covered Person being insured.
T
Territory of Occurrence: The country where the claimed expenses are incurred.
Transplant Center: A Hospital with a specialized unit that performs Organ Transplants.
U
Undeclared Pre-existing Condition: Any Pre- Existing Condition known to the Covered Person or Policyholder, which is not declared on the medical questionnaire or Policy application in case a medical underwriting has been applied.
V
Visiting Doctors: A medical doctor (typically from abroad) who works temporarily for a hospital in the country or who uses temporary the operating theatre and/or the health facilities of a hospital in the country, paid on reimbursement basis.