Table of Benefits

Norther Emirates visa holding members for Sharjah, Ajman, Umm Al Quwain, Ras Al Khaimah and
Fujairah)
BENEFITS / COVERAGE PLAN (A)
Aggregate annual limit :
The annual upper limit for Inpatient – AED 50,000
Healthcare Services Out-patient –AED 10,000
Per insured member per year
Scope of Coverage :
Territorial Scope of Coverage Sharjah, Ajman, Umm Al Quwain, Ras Al Khaimah and Fujairah
Claims Settlement Basis
Within Network (Inside UAE) 100% on Direct billing is available within the Network subject to
applicable coinsurance.
Outside Network, within UAE Not covered except for Emergencies & Life-threatening cases
(In-patient): only
Outside Network, within UAE Not covered
(Out-patient):
Outside UAE Not covered
Network :
Medical Providers Network APN- AAFIYA (Out-Patient services can be availed at clinics
(Subject to ongoing changes) only)
 Geographic scope of coverage is Northern Emirates.
 Fees related to the services will be based on the actual
costs of the applicable UAE Network tariff, meaning that
the treatment will be covered in this geographical area
based on the agreed tariffs of the applicable UAE
Network.

In patient Covered only below Hospitals

 APN NETWORK:
NAME OF THE PROVIDER EMIRATE
1 AL SHARQ HOSPITAL Fujairah
2 AJMAN SPECIALITY GENERAL HOSPITAL Ajman
3 THUMBAY HOSPITAL AJMAN Ajman
THUMBAY HOSPITAL L.L.C FUJAIRAH
Fujairah
4 BRANCH
5 AMINA HOSPITAL LLC Ajman
6 BURJEEL SPECIALITY HOSPITAL LLC Sharjah
7 CENTRAL HOSPITAL Sharjah

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Pre-existing and Chronic Covered subject to a waiting period of 12 months.
Conditions :
Sublimit on Pre-existing AED 5,000 per person per year for Inpatient and AED 1,500 for
conditions (after the end of the Outpatient.
waiting period)
INPATIENT BENEFITS
Inpatient Healthcare Services Sublimit: AED 50,000/- per person per year.
(Prior Approval is required from with 20% coinsurance payable by the insured with a gap of AED
the insurance company or TPA) 500 per encounter and an annual aggregate limit cap of AED
1000.
Above these caps the insurer will cover 100% of treatment.
In-patient Healthcare Services - Shared Room (Ward) covered with 20% coinsurance payable by
Room Type the insured with a gap of AED 500 per encounter and an annual
aggregate limit cap of AED 1000.
Above these caps the insurer will cover 100% of treatment.
Tests, diagnosis, treatments and covered with 20% coinsurance payable by the insured with a gap
surgeries in hospitals for non- of AED 500 per encounter and an annual aggregate limit cap of
emergency medical cases AED 1000.
Above these caps the insurer will cover 100% of
Ground transportation services in Covered
the UAE provided by an
authorized party for medical
emergencies
Physiotherapy treatment services Not Covered
Accommodation for a person Covered up to AED 100 per night
accompanying an insured child up
to 16 years of age.
Accommodation of an Covered up to AED 100 per night
accompanying person in the same
room in cases of critical
conditions and as per
recommendation of attending
physician
OUTPATIENT BENEFITS
Outpatient Healthcare Services Sublimit : AED 10,000/-
(Basic healthcare services: Out-patient treatment at authorized network clinics)
Referral procedure:
•The insured must consult a general practitioner or other similar competent body before obtaining
advice or treatment from a specialist.
•The GP must make his referral together with reasons via the regulatory eReferrals system for the claim
to be considered by the Insurer.
•No costs incurred for advice, consultations or treatments provided by specialists or consultants without
the insured first consulting a General Practitioner or equivalent or another competent UAE authority
will be payable by the insurer.
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Examination, diagnostic and 25% co-insurance payable by the insured per visit. Max Up to
treatment services by authorized AED 100.
general practitioners, and No Coinsurance if a follow-up visit was made within seven days
specialist and consultants for the same illness.

Radiology diagnostic services Covered with 25% coinsurance.

carried out in the authorized
facility assigned to treat the
insured person. (In cases of non-
medical emergencies, Prior
approval is required for MRI, CT
scans and endoscopies).
Laboratory test services carried Covered with 25% coinsurance.
out in the authorized facility
assigned to treat the insured
person
Physiotherapy treatment services Covered up to maximum of 6 sessions per year with 25% co-
(Prior approval of the insurance insurance.
company is required)
Pharmaceutical limit and 30% co-insurance for each and every prescription.
copayment Coverage upon prescription as per approved formulary subject to
30% coinsurance, prior approval, and up to AED 1,000 per person
per year
Other Benefits :
Diagnostic and treatment Covered only if related to a medical emergency, subject to 20%
services for dental and gum copayment
treatments
Hearing and vision aids, and Covered only if related to a medical emergency, subject to 20%
vision correction by surgeries, copayment
and laser
New born cover Not covered under the mother's policy.
New born babies will be enrolled from the date of reporting, or
from the 31st day of birth, whichever occurs later
Vaccinations Not Covered
Preventive services, routine Not covered
check-ups and Immunizations

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List of Exclusions

A. Excluded healthcare services

1. Healthcare Services which are not medically necessary

2. All expenses relating to dental treatment, dental prostheses, and orthodontic treatments.

3. Home nursing; private nursing care; care for the sake of travelling.

4. Custodial care including

a) Non-medical treatment services;
b) Health-related services which do not seek to improve or which do not result in a change in the
medical condition of the patient.

5. Services which do not require continuous administration by specialized medical personnel.

6. Personal comfort and convenience items (television, barber or beauty service, guest service and
similar incidental services and supplies).

7. All cosmetic healthcare services and services associated with replacement of an existing breast
implant. Cosmetic operations which are related to an Injury, sickness or congenital anomaly when the
primary purpose is to improve physiological functioning of the involved part of the body and breast
reconstruction following a mastectomy for cancer are covered.

8. Surgical and non-surgical treatment for obesity (including morbid obesity), and any other weight
control programs, services, or supplies.

9. Medical services utilized for the sake of research, medically non-approved experiments and
investigations and pharmacological weight reduction regimens.

10. Healthcare Services that are not performed by Authorized Healthcare Service Providers.

11. Healthcare services and associated expenses for the treatment of alopecia, baldness, hair falling,
dandruff or wigs.

12. Health services and supplies for smoking cessation programs and the treatment of nicotine
addiction.

13. Any investigations, tests or procedures carried out with the intention of ruling out any foetal
anomaly.

14. Treatment and services for contraception

15. Treatment and services for sex transformation, sterilization or intended to correct a state of
sterility or infertility or sexual dysfunction. Sterilization is allowed only if medically indicated and if
allowed under the Law.

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16. External prosthetic devices and medical equipment.

17. Treatments and services arising as a result of hazardous activities, including but not limited to,
any form of aerial flight, any kind of power-vehicle race, water sports, horse riding activities,
mountaineering activities, violent sports such as judo, boxing, and wrestling, bungee jumping and any
professional sports activities.

18. Growth hormone therapy.

19. Costs associated with hearing tests, vision corrections, prosthetic devices or hearing and vision
aids.

20. Mental Health diseases, both out-patient and in-patient treatments, unless it is an emergency
condition.

21. Patient treatment supplies (including for example: elastic stockings, ace bandages, gauze,
syringes, diabetic test strips, and like products; non-prescription drugs and treatments,) excluding
supplies required as a result of Healthcare Services rendered during a Medical Emergency.

22. Allergy testing and desensitization (except testing for allergy towards medications and supplies
used in treatment); any physical, psychiatric or psychological examinations or investigations during
these examinations.

23. Services rendered by any medical provider who is a relative of the patient for example the
Insured person himself or first degree relatives.

24. Enteral feedings (via a tube) and other nutritional and electrolyte supplements, unless medically
necessary during in-patient treatment.

25. Healthcare services for adjustment of spinal subluxation.

26. Healthcare services and treatments by acupuncture; acupressure, hypnotism, massage therapy,
aromatherapy, ozone therapy, homeopathic treatments, and all forms of treatment by alternative
medicine.

27. All healthcare services & treatments for in-vitro fertilization (IVF), embryo transfer; ovum and
sperms transfer.

28. Elective diagnostic services and medical treatment for correction of vision

29. Nasal septum deviation and nasal concha resection.

30. All chronic conditions requiring hemodialysis or peritoneal dialysis, and related investigations,
treatments or procedures.

31. Healthcare services, investigations and treatments related to viral hepatitis and associated
complications, except for the treatment and services related to Hepatitis A.

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32. Birth defects, congenital diseases and deformities.

33. Healthcare services for senile dementia and Alzheimer’s disease.

34. Air or terrestrial medical evacuation and unauthorized transportation services.

35. Inpatient treatment received without prior approval from the insurance company including cases
of medical emergency which were not notified within 24 hours from the date of admission.

36. Any inpatient treatment, investigations or other procedures, which can be carried out on
outpatient basis without jeopardizing the Insured Person’s health.

37. Any investigations or health services conducted for non-medical purposes such as investigations
related to employment, travel, licensing or insurance purposes.

38. All supplies which are not considered as medical treatments including but not limited to:
mouthwash, toothpaste, lozenges, antiseptics, milk formulas, food supplements, skin care products,
shampoos and multivitamins (unless prescribed as replacement therapy for known vitamin deficiency
conditions); and all equipment not primarily intended to improve a medical condition or injury,
including but not limited to: air conditioners or air purifying systems, arch supports, exercise
equipment and sanitary supplies.

39. More than one consultation or follow up with a medical specialist in a single day unless referred
by the treating physician.

40. Health services and associated expenses for organ and tissue transplants, irrespective of whether
the Insured Person is a donor or a recipient. This exclusion also applies to follow-up treatments and
complications.

41. Any expenses related to immunomodulators and immunotherapy.

42. Any expenses related to the treatment of sleep related disorders.

43. Services and educational programs for handicaps.

44. Maternity.

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B. Healthcare services outside the scope of health insurance

1. Injuries or illnesses suffered by the Insured Person as a result of military operations of whatever
type.

2. Injuries or illnesses suffered by the Insured Person as a result of wars or acts of terror of
whatever type.

3. Healthcare services for injuries and accidents arising from nuclear or chemical contamination.

4. Injuries resulting from natural disasters, including but not limited to: earthquakes, tornados and
any other type of natural disaster.

5. Injuries resulting from criminal acts or resisting authority by the Insured Person.

6. Injuries resulting from a road traffic accident.

7. Healthcare services for work related illnesses and injuries.

8. All cases resulting from the use of alcoholic drinks, controlled substances and drugs and
hallucinating substances.

9. Any investigation or treatment not prescribed by a doctor.

10. Injuries resulting from attempted suicide or self-inflicted injuries.

11. Diagnosis and treatment services for complications of exempted illnesses.

12. All healthcare services for internationally and/or locally recognized epidemics.

13. Healthcare services for patients suffering from (and related to the diagnosis and treatment of)
HIV – AIDS and its complications and all types of hepatitis except virus A hepatitis.

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