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SOHARJI

IjroL_s_JI9oIj iI idiiVgJI NATIONAL LIFE & GENERAL ONIC HOLNG GROUP

1JqI &o.o

A LU MI NI U M A)

r

Arranged by

MARSH c

MARSH MERCER KROLL GUY CARPENTER OLIVER WYMAN


Medical Insurance Member’s Guide Table of Contents

Page No

Preface

2

Type of Plans

2

Members Eligibility, Claims Process, Pre-authorization, Definitions

2-3

Network List : Annexure 1

7

General FAQ5 :Annexure 2

12

Plan A and related FAQ Annexure 3A

15

Plan B and related FAQ Annexure 3B

18

Plan C and related FAQ Annexure 3C

21


Preface Sohar Aluminium has customised and designed a comprehensive medical insurance cover with the assistance of Marsh (Insurance Consultant). The insurance is placed with National Life and General Insurance

The

Scheme provides insurance cover for the following benefits, subject to the terms, limits conditions and exclusions of Sohar Aluminium’s medical insurance policy. The benefits broadly are: • • • • • • • •

Inpatient Treatment Hospital Accommodation and Services, Consultation, Medications, Investigations, Surgical procedures Outpatient Treatment Consultation, Medications, Investigations Day care Treatment. Room Charges, Intensive Care Unit Charges Physician and Surgical Fees. Ambulance and Evacuation services expenses Maternity cover Optical cover Dental cover (for Plan A Members only) —

It would be relevant to point out that this year SA has included various improvements in coverage following discussions with Marsh and National Life. The improvements were effected following the internal feedback. Some of the improvements are: -

-

-

-

-

-

-

Wetness cover as detailed in the booklet Optical cover upto OMR 250 for Plan A, B and C Congenital Anomalies and Birth defects (over and above base cover of USD 25,000 for Plan A,B and C) upto USD 100,000 for entire scheme with 20% coinsurance —for PLAN ‘A’ & B Variable and Transitional lenses 20% coinsurance FOR PLAN A & B Cover for Dentures, Bridges and Crowns with 20% coinsurance —PLAN A Cover for Circumcision of New Baby less than 2 years with 20% coinsurance PLAN A, B, C Parents Cover on voluntary basis —

(more details in the following pages of this booklet)

Types of Plans Each employee has an option to choose from one of the three Plans as follows: Plan A Plan B Plan C More details of these Plans are available in the Annexure

Members Enrolment

Eligibility

Primary Insured: All full-time permanent employees who are legally employed subject to the attainment of minimum age of eighteen (18) but not more than sixty five (65) years ,


Eligible Dependents are also covered under the Medical Benefits with the same terms and conditions. Eligible dependents include:

-

Spouses up to 65 years Unmarried dependent children between the ages of 0 days and 19 years residing permanently with the insured person in Oman.

The term dependent shall mean legal wife or husband of an employee or the person living with an Employee in a recognized husband and wife relationship, who is registered as such in the records of the Insured and Employee’s unmarried children, step children and children legally adopted, who are within the age limits. Please note that brothers, sisters, parents, cousins, nieces, nephews and other relatives are not eligible for inclusion under the policy. Eligibility and final decisions of the Scheme shall be guided by Sohar Aluminium’s Human Resource Policy.

Claims Process I Procedure Direct billing (Cash Less Facility) Procedure Direct billing or Cash Less Facility is a facility offered to the insured members of Sohar Aluminium where by the provider network hospitals will provide the treatments and claim the bills directly from National Life. In other words the employee need not pay and seek reimbursement. List of Network hospitalsl clinics in Oman and UAE is attached as per Annexure I Procedure for Treatment in Network Hospital V V V

V

Present your medical insurance identity card at the reception of the Network Hospital The Network Hospital will fill-in the relevant sections of the claim form Please sign on the claim form after making sure that the details entered are correct. Plan A and Plan B members to pay the deductible applicable at the counter and take treatment. Plan C members need to pay 10% Coinsurance in MPH for OP treatment only A copy of claim form needs to be carried by you for procurement of the medicines.

-

-

-

Present your medical identity card to the hospital reception

Sign the claim form supplied by hospital Visit your physician and take treatment

•ta

-

Sign medical prescription


Reimbursement Procedure In case you have visited a doctor outside the provider network, you have to make payment for the treatment and submit the following to National Life within 90 days from the date of treatment. V Original claim form duly signed by the employee (Sample Claim form attached in drive ‘K’ of Sohar Aluminium. Link K:\10-Forms\HR V Prescription V Original detailed and dated receipt V Pre-authorisation form, if applicable V Detailed medical and diagnostic reports (for In-patient Treatment)

A representative from

National Life will be visiting Sohar Aluminium on Monday every week.

Personnel Timing Mobile No. Email Id Office in SA

: : : : :

Mr. Satya Teja From 11:00am to 03:OOpm 98174942 satya(nlicoulf.com Medical Centre

AtABIS

: From 03.30 pm to 03:45 pm (if requested)

All the above documentation should be submitted to NLG’s representative who will in-turn will arrange for transfer of the amount due directly to the employee’s bank account, as per the Table of Benefits / Term Sheet as attached in Annexure II and Policy Contract applicable to your membership and specific insurance Plan, within 21 days from receipt of all necessary claim documentation. Important: Please note that well documented claims, received within the reporting period, will assist faster, efficient claim settlement process.

Pre-authorization of Treatments This is the validation process where NLG determines if your treatment costs are covered and to what limits, as per the Table of Benefits and Policy Contract applicable to your membership and specific insurance Plan. Preauthorisation is to be obtained for the following conditions: • All Inpatient Treatments (Hospital) • Major investigations like MRI Scans, CT Scans, and Physiotherapy etc. • Elective treatments outside Oman Who will obtain Pre-authorization? 1- When using Designated Providers The Designated Provider will seek Pre-authorizatiori on your behalf. -

2- When using Non-designated Providers authorization from NLG.

-

You or your your Non-Designated Provider must seek pre

How? (1) (2)

Call the Emergency Assistance no. at the back of the Member Identity Card Inform the NLG representative as mentioned above

Important: An emergency condition does not require any pre authorization, How ever such conditions are to be reported to NLG within 48 hours.


important definitions

Annual maximum limits

Chronic condition

Co insurance

Deductible

Emergency

Pre-existing condition Reasonable and customary charges

Total amounts that may be claimed in any one (1) Policy period by an Insured member. These limits are shown in the Term Sheet

An illness that persists or would persist over a long period of time, which is not curable and requires regular Maintenance treatment.

An insurance participation percentage borne by the Insured Member towards the cost of Eligible Medical Expenses after he/she has met his/her applioable Deductible amount. The Co-insurance is specified in the Term Sheet and is expressed as a percentage of Eligible Medical Expenses after deduction of applicable Deductible amount. A specific amount of Eligible Medical Expenses that must be incurred and paid for by the Insured member before benefits are payable under this Policy. This amount is payable by the Insured member per each Outpatient Consultation per visit per sickness, except for a follow-up outpatient visit within ten (10) days for the same illness and at the same Physician or Consultant. If the Eligible Medical Expenses are less than the Deductible amount, then the Insured member will be liable to pay all the expenses incurred. The deductible is mentioned in the ‘Variations to Common Term Sheet’ and your Membership Card. Please note there is no Deductible for Plan C except for 10% Coinsurance in MPH for OP An injury or illness which happens suddenly and whose acute symptoms are of such severity that the absence of Treatment within twenty four (24) hours is medically expected to result in a serious threat to the life, health, bodily function and/or organ of the patient. Any bodily injury or illness or its related condition that medically exists prior to the enrolment date of the Insured member, whether it is known or not known to him, and necessitates the Insured member to receive care and Treatment. The amount NLG recognize for payment for a particular medical procedure. It is based on what is considered “reasonable” for that procedure in accordance with the market price, in the country where the Treatment was provided

About National Life and General Insurance (NLG)

N LG is a private Life and General Insurance Company that offers a comprehensive range of Life, Health and General insurance products in Oman. Being the largest Life Insurer in Oman, NLG is one of the best in the region with strong financials, unparalleled operating performance, offering attractive brands, diversified growing business profile and superior service standards. It has built an excellent track record of customer service with over 200,000 individuals to its credit.

5


About Marsh Marsh Inc is the world’s leading risk and insurance services firm with offices located in more than 100 countries. Marsh Inc. is an operating unit of Marsh & McLennan Companies Inc. (MMC), a global professional services firm with more than 55,000 employees and annual revenues in the region of US$ 12 Billion. Marsh is acting as the Insurance Brokers of Sohar Aluminium.


Annexure I: Designated Network Providers (Network)

—

Oman and UAE

(For Plan C only Oman Network) MUSCAT First Medical Centre (Well care Diagnostics)

Al khuwair

24477666, 24477602

Muscat Private Hospital

Azaiba

24583780

KIMS Oman hospital

Darsait

24760119

Al Raffah hospital

Ghubra

24618959

Al llayat Polyclinic

Quruni

24565941

Star Care hospital

Seeb

24558828

Babylon Medical Centre

AlAmreet

24878911

Al flail Clinic

Al Ilail

24537583

Al Ghadeer clinic

Al Kabourah

26802470

Al Amal Medical & llealth Care

Al Khoud

24543070

BadrAl-Sama Polyclinic

Al Kboud

24546099

Al Kawakeb Medical Complex

Al Khoud

24543289

Al Amal Medical & Ilcaith Care

Al khuwair

24485822, 24487905

l,ama Polyclinic

Al khuwair

24478817,18

Badr Al-Samaa Polyclinic

Al khuwair

24488322

Al Rehana Dental Care

Al khuwair

24486646

Al Lamki Poly Clinic

Al khuwair

24489543, 24489563

Barakath Al Noor

Al khuwair

99474995

Al Oman Medical Centre

Al khuwair

24478536

Sri Sri Ayurveda Clinic

Al khuwair

24424991, 24480874

Sagar Poly Clinic

Al khuwair

24393655

health For All

Al khuwair

24486005

Al Namaa Medical Centre

Al khuwair

92970375

I latat Polyclinic

Azaiba

24499269, 24493270

Emmar International & holistic Med. Centre

Azaiba

24490583, 558, 540

Al Maha Polyclinic

Azaiba

24491803

Luxury Medical Centre

Azaiba

95855377

Bowshcr General Clinic

Bowshcr

24482831

Atlas Star Medical Centre

Bowshcr

24502560, 24504000

Lama Polyclinic

CBD

24799077

Al Najd Medical Clinic

Ghala

24594565

Green Corner Clinic

Ghala

24596840

Nanaa Medical Centre

Ghala

24593377

Ruwi Clinic

Ghala

24592741

Al Ansab Polyclinic

Ghubra

24495686

Al Moheet Poly Clinic

Ghubra

24499190

Bar Al Iluda hlomeo Care Clinic

Ghubra

24494665

7


24495700

Middle East Poly Clinic

Ghubra

Al Maqooq Clinic/A M Medical Centre

Ghubra

24491988

Sun Dental Centre

Ghubra

95961234

Al Adnan Poly Clinic

llamriya

24834940

Al Ruwaisiah Clinic

Hamriya

24833003, 24833064

Al Redha Clinic

Masira

25504045

Lama Polyclinic

Mawelah

24540807

Al Farooq Polyclinic

Mawelab

99754628

Al Bhashayer Specialised Medical Centre

Mina Al Fahal

24488666, 24488667

Muscat Medical Center/ Muscat Polyclinic

Muttrah

24713320

NaherAl Kauther Medical Clinic

Quriyat

24846670

Al Massarat Clinic & Laboratory

Qurum

24571033

Al Zahara Medical Complex

Qurum

24571094/24571093

Al Abraj Dental Clinic

Qurum

99418792 24780606

Specialised Modern Medical Clinic

Rex Road

Atlas hospital

Ruwi

Abdul MalikAlAmin Clinic

Ruwi

Al Essa Dental Clinic

Ruwi

24797406

Al FajrAl Jadeed Clinic

Ruwi

24832115

Al Shifa Clinic

Ruwi

24701818

Bombay Diagnostic Centre

Ruwi

24795252, 24798383

El Shola Polyclinic

Ruwi

24706540

International Medical Speciality Centre

Wattayah

24567745

lbn lIazm Clinic

Ruwi

24832721

International Medical Centre

Ruwi

24794501

Kottakal Arya Vaidaya Salai

Ruwi

24701555

Marwan Al Balushi Flomeopathic Clinic

Ruwi

24785821

Maxcare Ilospital

Ruwi

24788444

Rose Medical Centre

Ruwi

24837693

Star Medical Center

Ruwi

24789366

Al Amal Medical & Health Care

Ruwi

24811519, 28411514

Badr Al-Samaa Polyclinic

Ruwi

24799760, 24799761

Apollo Medical Centre

Ruwi

24787766

Gift Of Nature Ayurvedic Clinic LLC

Ruwi

99656459

24837123

Safa Medicare

Azaiba

24617116

Al Rimah Medical Centre

Ruwi

24700515

Coimbatore Ayurvedic Centre LLC

Seeb

24422246/24421010

Scientific Polyclinic

Seeb

24605060

Al Amri Clinic

Seeb

9201S894

Al Hilal Specialised Polyclinic

Seeb

24540216

Al Manasir Medical Centre

Seeb

99753610

Feeri Clinic

Seeb

24453050

Azhar Polyclinic

Seeb

24539095


24423894

Bin Said Polyclinic

Seeb

Ilatat Polyclinic

Wadi Adai

24563641

Magrabi Eye & Ear Care Centre

Wadi Adai

24568870 24877152

lJm-Salama Polyclinic

Wadi 1-latat

Al Sawaqam Clinic & Pharmacy

Wadi kabhir

24814359

Mazoon Clinic

Wadi Kabhir

24819500, 24811515

Alawi Clinic

Wadi Kabir

24813903

International Medical Speciality Centre

Wattaya

24567746

Badr Al-Samaa Polyclinic

Barka

26884915

Star Medical Centre

Barka

24538540

Al Farooq Polyclinic

Barka

26884408, 26884553

Bidaya

26708600

Buraimi

25655088, 25655388

Ibri

25688075, 25689929

BARKA

I3IDAYA Al Kiyumi Med Complex & Pharmacy I3URAIMI Yas Medical centre (formerly Iranian Medical Centre) IBRI Oman Polyclinic IBRA Al Lamma Poly clinic

Ibra

25570165

lbn Al Ilaitham Clinic

Ibra

25571899

Liwa

24762283

LIWA

Al Raffaha Medical Centre MUKHAIZNA

Peaceland Clinic

Mukhaizna

n


MUSANNA Musana

26870808

Basmat Nizwa Medical Complex

Nizwa

25432103

Nizwa Medical Centre

Nizwa

25412323

l3adr Al-Samaa Polyclinic

Nizwa

25447775

Rusayl

24446151

Rustaq

26876935

Saham

95840311

Badr Al-Samaa Polyclinic

Salalah

23290122

Life Line hospital

Salalah

23212340

Al Zahir Medical Complex

Salalah

23291040

City homeopathy Clinic

Salalah

23289712

Al Andhar Clinic

Salalah

23298547

Abu Al Dahab Clinic

Salalah

23291303

Al Mlshaal Clinic

Salalah

99496604

Al Murazaa & Al lnzl Clinic

Salalah

23292540

Al Raazi Poly Clinic

Salalah

23294400

Naif Medical Centre

Salalah

23299466

Dhofar International Medical centre

Salalah

23288101

Omani Medical Centre

Salalah

23288109

Al hlakeem Medical Centre

Salalah

23201100

Al Thuraya Medical Clinic NIZWA

RUSAYL Rusayl Ilealth Centre RUSHTAQ Al Mulshli Clinic SAHAM Teeba Specialised Medical Centre SAIAI.AH

SOHAR Lama Polyclinic

Sohar

26751128

Al hlayat Polyclinic

Sohar

26845104

Al Raffah Medical Centre

Sohar

26704300

Said Al Shaer Clinic

Sohar

26751394

Al Wafi Medical Clinic & Diagnostic Centre

Sohar

26843465, 26846448

The Blue Medical Centre

Sohar

97181980

hlatat Poly Clinic

Sohar

26853075


DarAllnaya

Sohar

26753666

Ibrahim Mohammed Ahamed Al balushi Clinic

Sohar

99335310

Pure Medical Clinic

Sohar

2684 7519

Badar Al Samaa

Sohar

26846660

Al Raffah hospital

Sohar

26704512

Life Line Hospital

Sohar

26753084/26753099

Sur Private Hospital

Sur

25542880, 2554 3441

Al Noor Medical Complex

Sur

25545393

Al Rawdah l’olyclinic

Sur

25546454

Badr Al-Samaa Polyclinic

Sur

25546112

Awan Diagnostic Centre

Azaiba

24527123

Al Afaq Diagnsotic Centre

Azaiba

24501182

Allied Diagnostics

Bowsher

24583868

SUR

JMAGNOSTLC CENTRE

PHARMACY All Branches

24602737

All Branches

24822162

hlatat Pharmacy

All Branches

24565622

lbn Sina Pharmacy

All Branches

24822162

Mazoon Pharmacy

All Branches

24819500, 24811515

Muscat Pharmacy

All Branches

24786198

Scientific Pharmacy

All Branches

24605060

Sohar Pharmacy

All Branches

26841825

Khimji Pharmacy

All Branches

24817131

Al Farsi Pharmacy

All Branches

24694255

Al Farabi Pharmacy

All Branches

Al Riyami Pharmacy

All Branches

Al liashar l’harmacy

/ Capital Pharmacy

Baism Pharmacy

(For Plan A,B & C Members have to bear 10% of the medical expenses in Muscat Private Hospital Oman) —

P.O.Box

TeI.no.

Fax no.

Belhoul Speciality Ilospital & Pharmacy

5627

2733333

2737674

Canadian Specialist Ilospital & Pharmacy Deira

1S881

7072222

7072800

Canadian Specialiat Ilospital & Pharmacy- Oud metha

15881

3364444

3377776

Al Musalla Medical Centre

26238

3966123

3966493

Providers

S.No.

DUBAI Hospitals/Clinics

11


Al Noor Poly Clinic-Deira

26160

2233324

2278704

Al Noor Polyclinic Satwa

26160

3498100

3498007

Dr. Ismail Medical Centre (Al Qouz)

504333

3381550

3383119

Dr. lsmail Medical Centre (Al Qusais)

504333

2646529

2646528

6628

3376808

3349019

Harley International Clinic

34801

3986677

3989012

Karama Medical Centre Br. Karama

52001

Dr. lsmail Medical Centre (Karama)

3366889

3365903

Karama Medical Centre Br. Al Qouz

3413645

3413636

Karama Medical Centre Br. DIP

8858538

8858539 3932009

Jansons Star Polyclicnic

5868

3933280

NMC family Clinic

7832

3956660

3955661

New Apollo Polyclinic

52380

3379040

33469800

Al Riyadh Medical Clinic

34238

2615550

2613816

Pharmacies 6.AlAnberPharmacy

51659

3973396

3973033

1.)Sana Pharmacy

30753

3377028

3353866

2.)Bader Pharmacy

103566

3348129

3346837

Al Woqaya Pharmacy

27227

3348348

3360631

3414626

3414625

1201

2724279

2729809

Mumtaz Pharmacy

34238

2614318

2614318

Lulu Group of Pharmacies 1. Lulu centT pharmacy

Better Life Pharmacy Faith Pharmacy

78872

2988771

2988616

2.Amaan Pharmacy LLC

77456

2647264

2644614

3. Lulu Barsha Pharmacy

77150

3418828

3418838

4.Lulu Karama Pharmacy

88468

3369970

3369971

46598

5599379

S533411

3805

5583351

5385559

5630693

5630893

5615545

5614478

Abu Shagara Pharmacy

5536414

5536414

Hamad Pharmacy

5388299

5388299

New Hamad pharmacy

5673388

5672292

Majid pharmacy

5683422

5689170

5599379

5533411

5623850

5628955

SI-IARJAH Clinics Liberty Medical Centre Riaz Medical Centre Union Medical Centre Al Amanah Medical Centre

29504

Pharmacies

Saif Pharmacy

46598

Sharjahpharmcay AJMAN Al Gharafa Medical Centre

1840

7448322

7443730

Al Shrooq Clinic

3454

7455688

7446678

Advance Medical Centre

3272

7441248

7441288

Pharmacies


Al bustan pharmacy

7447969

7447959

Al musalla pharmacy

7421271

7446678

Emirates pharmacy

7474900

7474877

RAS AL KAI MAll Ras AL Kaimah Ilospital & Pharmacy

2074334

Al Zahrawi Hospital

2288544

Al Zahrawi Pharmacy

2288544 UMM AL QWAIN

Al Khaleej Medical Centre

1062

7651212

7651331

Dr. Easow Medical Clinic

1145

7654647

7652653

1360

2232850

2232860

FUJAIRAH National Med Centre & pharmacy

13


Annexure 2: Frequently Asked Questions (Common for all Options) What are the different options available? Each employee can chose one of the three options (1) Plan A (2) Plan B or (3) Plan C. The entire family can chose only one option. For instance you cannot have a Plan A for you and Plan B Plan for your spouse. The members get an option to switch over from one option to other only at the time of policy anniversary (which is annual). 2.

What are the differences between the different options? Broadly, the difference is in the Basic Territory, Dental Coverage, Network and Deductible. -

-

-

Plan A and Plan B has a wider Base territory when compared to Plan C, which is a Oman only cover. The outpatient deductible per claim in Plan A, Plan B and Plan C is RO 5, RD 2 and Nil respectively. Network for Plan A and Plan B is as per Annexure A (Oman + UAE), whereas for Plan C, the applicable network is Oman only. Further the use of Muscat Private for Plan A, Plan B and Plan C carries a co-insurance/co-payment to the extent of 10% of the treatment costs for OP only There is no Dental Cover for Plan B and Plan C

3.

What happens if I exceed my Benefit Limit(s)?

4.

Your Plan only covers you to the maximum financial limits indicated in the Term Sheet. You will not be reimbursed for any costs which exceed your Annual Maximum Limit, or the benefit sub limits. Where you incur costs at one of NLG’s Designated Providers and the cost of treatment is in excess of the remaining balance of your benefit limits, you will be responsible for payment of the excess cost amount to either NLG or the treating Designated Provider. What shall I do if I lose my Membership Card? NLG will provide you with a membership card which identifies you as a member of the NLG Medical Insurance Scheme. Your membership card must be produced as proof of membership when seeking medical treatment from our Designated Medical Providers. A list of these providers is obtainable from your employer. Should you lose your membership card, in form your employer immediately who will request NLG to issue a replacement card. Upon receipt of your employer’s request, NLG will issue a replacement card, which you should receive within two weeks from the date that the replacement card was requested.

5.

Why should I seek treatment from the Designated Providers? Designated Providers participating in NLG’s Network are committed to quality care. NLG constantly assesses new hospitals and medical facilities for inclusion in the Network. Where any providers meet NLG’s quality criteria, they will be added to the Network and you will be regularly updated with the network lists. NLG is endeavouring to manage your insurance program, professionally and efficiently NLG is having better control with the Designated Providers, which will eventually be favourable to Sohar Aluminium.

6.

Where can I obtain further advice and support? This guide offers most of the information that you will need to enjoy your membership. However,


should you require further information about your entitlement to benefits, or the medical facilities available to you, please feel free to contact us on the hot line 00968- 99441859 or 00968- 24730999 NLG’s friendly and helpful staff shail assist you. Further, support can also be obtained from National Life representative who will be visiting Sohar Aluminium on Monday ever,’ week. Personnel Timing Mobile No. Email id Office in SA AtABIS

7.

: : : : :

Mr. Satya Teja From 11:00am to 03:OOpm 98174942 satva (d.).nlicgulf.com Medical Centre : From 03.30 pm to 03:45 pm (if requested)

Are my parents covered under the new insurance plan? Yes, on a voluntary basis. The coverage for parents to be as foiows: Basic cover without any Optional covers. Other conditions: No pre-existing or chronic cover Cover in Band B and in Oman only No Wellness cover Parents above 65 years of age should provide a health declaration, on review of which they shail be considered for inclusion -

-

-

8.

Are pre-conditions covered?

9.

Yes, for all existing employees and dependents. Pre-existing conditions are excluded for Parents What is the Optical cover under the policy?

Vision tests to diagnose the following errors of refraction: a. Hyperopia b. Myopia c. Astigmatism d. Anisometropia e. Presbyopia Ptosis

Plain lenses only for the correction of the above mentioned errors of refraction Treatment for any sickness related to eye or in respect of the following conditions including advanced treatment techniques like Laser for correction of internal disorders of eye are covered for the full policy limit whether this option is chosen or not (Reimbursement basis only) a. Cataract

b. Diabetic Retinopathy c. Retinal detachment d. Glaucoma e. All ophthalmic conditions other those mentioned in the below exclusions Exclusions withlwithout this option: The following Treatments and services are excluded: 1) Spectacle frames 2) Contact lenses 3) Photo chromatic lenses Is


4) Surgeries for corrections of errors of refraction 5) Strabismus Maximum limit per member RO.250 per year for this Optical cover only (not applicable for the Optical sickness cover) 10.

What is the Maternity Cover under the policy? Maternity/Obstertrical benefits under the policy includes any medical expenses incurred in relation to Pregnancy and Deilve,y including legal abortion and associated or required procedures as a result of maternity or deliveiy. The limit per member per year is RO 2,500

11.

Can I obtain Medicines from Pharmacies for a long period say 2 or 3 months? Yes. Medicines may now be obtained for upto 3 months from the Inhouse Pharmacy itself. For longer term medication, the members have can purchase medicines from outside pharmacies (not from pharmacies attached to clinics) where Cash Less Facility is available. These are : Muscat Pharmacy, Sohar Pharmacy, Ibn Sma Pharmacy or Mazoon Pharmacy. The member can avail the ‘cash-less’facility by providing the third copy of the Claim Form they receive from the Network Cilnic to either of the above mentioned Pharmacies.

Annexure 3A: Term Sheet Period of Insurance:

Plan ‘A’

From 15 September 2011 to 14 September 2012

The Territorial Limits under this medical option is: Sultanate of Oman, GCC, Indian Sub-continent, Philippines, Thailand and Home Country extended to worldwide excluding USA and Canada whilst on Business and Holiday. In respect of Treatments outside Oman depending on the territory where the treatment is taken a small element of Co-insurance (percentage to be borne by the member) is applicable. The following reimbursement percentage depending upon the area where the treatment is done. Inside Oman • 100% inside Network Hospital (10% Coinsurance in MPH OP Only) • 100% reimbursement shall be provided for treatment taken outside the network Outside Oman • 100% reimbursement for Indian sub-continent, Philippines, Thailand, UAE and Home Country Elsewhere: 90% reasonable and customary country of treatment. All options provide emergency worldwide treatment excluding USA or Canada whilst on business or holiday. -

Territorial Limits

Important: USA and Canada trips: Emergency medical expenses incurred during official trips are covered under SA’s travel policy. To get Emergency Medical cover for Personal trips (to any country), details of trip need to be notified to Marsh in advance (contact Saiith.Kumarcimarsh.com with a copy to Pankaj Bafna of Sohar Aluminium).


Out Patient Claim RD 5 per visit I sickness. 10% Coinsurance in MPH for OP Only Nil for follow up visits within 16 days for the same ailment OR if treatment is taken in in-house clinic or in-house pharmacy or lab tests In Patient Claim NIL

Deductible

Sum Insured per member per year

US$ 40,000

Daily Room & Board Limit

Inside Network HosjtaIs 100% for average private room inside the network hospitals in Oman Elsewhere Reasonable & Customary inside & outside Oman

Intensive Care Unit Benefit

Double the daily room and board limit up to a maximum of 30 days per ailment. After 30 days the benefits revert to normal room & board limit.

Psychiatric Treatment

Up to a maximum of RO.1 000 per member per year (for medication only)

Wellness Cover for all employees and spouses ABOVE 40 YEARS

Annual check-up including Mammogram, Papsmia, Bone Density Tests, Dental Checking and cleaning, eye sight test with a sublimit of OMR 500 per member per annum

Wellness Cover for all members above 40 years

Colonoscopy, Stress ECG (once every year) (On reimbursement basis only)

Maternityl Obstetrical Benefits

Limit per member per year

RD 2,500

Dental Treatment (Sickness)

RO.350 per member per year. Details of coverage in Question 6 below

Optical Treatment (Sickness)

RO.250 per member per year. Details of coverage in Question 9 of Annexure 2

Pre Existing & Chronic Disease

Waived for all the members

Daily Allowance

Daily Allowance of RD 35 per day if hospitalized in any Govemment Hospitals in Sultanate of Oman

Parent Accommodation

RD 35 per day for a maximum of 30 days for a parent accompanying a child less than 15 years of age

Evacuation Expenses Limit

Maximum of 20% of individual sum insured per member per disability (No Co insurance)

Additional Benefits

1. Wellness cover for all employee and spouses (annual check-up, dental checking and cleaning, eye sight test with a sublimit of DMR 500 per person per annum (20% Coinsurance for Members Below 40 years of age) 2. Additional Extra Cover for Congenital anomalies and birth defects (over and above the base cover) up to US$ 100,000 for the entire scheme (20% Coinsurance to apply for the extra US$ 100,000 alone) 3. Cover for Variable and Transitional lenses (20% Coinsurance to apply) 4. Cover for Dentures, Bridges and Crowns (20% Coinsurance to apply) 5. Circumcision for New Baby less than 2 years (20% Coinsurance)

Coverage for Parents

Details in Question 7 of Annexure 2

17


Exclusions 1. 2. 3. 4. 5. 6.

Selfinflicted injury while sane or insane; treatment of chronic alcoholism, drug addiction, desensitization and allergen tests or nervous or mental disorders; Injury or illness resulting from insurrection or war, declared or undeclared, or as a result of a riot, strike or civil commotion; Rest cures sanitaria or custodial care or periods of quarantine or isolation; Cosmetic or plastic surgery including related medicines and products unless medical treatment necessitated by an accidental injury occurring while the Insured is covered; Dental & Optical exclusion unless arising out of an accident or as per coverage brought back. More details of the coverage in Question 6 below; (Covered upto RO 750 for Herbal Medicines, Ayurvedic treatment, Homeopathy treatment (Reimbursement basis); Medication only Hirsutism, Podiatrist services, Dietician services, Anorexia, obesity, insomnia, baldness, Expenses related to uncovered Conditions including any complication arising there from Sexual disorders; Durable medical appliances (e.g.., nebuliser) unless prescribed by the Doctor; Contraceptive measures; Ovulation induction, invitro-fertilization (IVF); Vitamins, except when prescribed by the medical practitioner OR for the following conditions: Pernicious Anaemia, Scurvey, Rickets, Pellagra, Malabsorption, Poly Neuritis, Kwashiorkor (Vitamins are not on a Direct Billing basis’ and will have be submitted for reimbursement to National Life) Pre-existing conditions subject to limit as stated in the ‘Benefits of Scheme’; Injury or illness covered under Workmen’s Compensation or similar laws arising out of the Insured’s occupation; Congenital anomalies and birth defects. However this exclusion shall be waived fora total pooi of US$ 25000 for the entire scheme to meet the medical expenses for congenital conditions —

7. 8. 9. 10.

-

11. 12. 13.

SDecific Questions related to Plan A 1. Can I or my family go to any doctor in my neighbourhood in Oman? Yes. But Direct Billing only with network providers. Treatment taken outside the network providers will be on a reimbursement basis 2. If my home country is Australia, and I am in Australia on holiday and need treatment, will all my treatment costs be covered 100%? (Unplanned treatment) Yes. The unplanned treatment in home country will be covered for 100% costs subject to annual maximum limits. 3. If my home country is Australia, and I am in London on holiday and need treatment, will all my treatment costs be covered 100%? (Unplanned treatment) No. The treatment outside Indian subcontinent, Philippines, Thailand, UAE, and Home country will be reimbursed only up to 90% subject to annual maximum limits. 4. If my home country is Australia, can I choose to return to Australia and have my treatment there? Will all costs be covered 100%? (Elective treatment) Yes. The elective inpatient treatment in home country will be covered for 100% costs subject to annual maximum limits and other limits under the policy.. However the cost of transport will not be covered for planned treatments. 5. If my home country is Australia, and I choose to have treatment in London rather than Oman or UAE, what % of my costs will be covered? (Elective treatment) None. The Territory is Oman, GCC, Indian Sub-continent, Philippines, Thailand and Home Country only for Plan A and Plan B members and Oman only for Plan C members 6.

What is covered under the Dental option? The scope of cover of dental benefit includes the following: Dentist’s Consultation


Diagnostic procedures Related prescription Extractions • All fillings including amalgam, composite and glass ionomer fillings • Gum and root canal Treatments • Routine Dental Check-up once per annum • Clean-up once a year with 20% Coinsurance Scaling and Polishing once a year with 20% coinsurance The following Treatments and services are excluded: Dentures, bridges and crowns -

ii.

Cosmetic Treatments

Other related Questions on Dental •

Is fallen off crown covered? Not covered.

• Can I go annually to the dentist, get me teeth checked and fixed if necessary? Yes

Annexure 3B: Term Sheet Period of Insurance :

Plan ‘B’

From 15 September 2011 to 14 September 2012

The Territorial Limits under this medical option is: Sultanate of Oman, GCC, Indian Sub-continent, Philippines, Thailand and Home Country extended to worldwide excluding USA and Canada whilst on Business and Holiday. In respect of Treatments outside Oman depending on the territory where the treatment is taken a small element of Co-insurance (percentage to be borne by the member) is applicable. The following reimbursement percentage depending upon the area where the treatment is done. Inside Oman • 100% inside Network Hospital including MPH (10% Coinsurance in MPH OP Only) • 100% reimbursement shall be provided for treatment taken outside the network Outside Oman • 100% reimbursement for Indian sub-continent, Philippines, Thailand, UAE and Home Country Elsewhere: 90% reasonable and customary country of treatment. -

Territorial Limits

All options provide emergency worldwide treatment excluding USA or Canada whilst on business or holiday. Important: USA and Canada trips: Emergency medical expenses incurred during official trips are covered under SA’s travel policy. To get Emergency Medical cover for Personal trips (to any country), details of trip need to be notified to Marsh in advance (contact Saiith.Kumarcff.marsh.com with a copy to Pankaj Bafna of Sohar Aluminium).

19


Deductible

Out Patient Claim RD 2 per visit I sickness. 10% Coinsurance in MPH for OP Only Nil for follow up visits within 16 days for the same ailment OR if treatment is taken in in-house clinic or in-house pharmacy or lab tests In Patient Claim NIL —

Sum Insured per member per year

Daily Room & Board Limit

US$ 40,000 Inside Network Hospitals 100% for average private room inside the network hospitals in Oman Elsewhere Reasonable & Customary inside & outside Oman

Intensive Care Unit Benefit

Double the daily room and board limit up to a maximum of 30 days per ailment. After 30 days the benefits revert to normal room & board limit.

Psychiatric Treatment

Up to a maximum of RO.1,000 per member per year (for medication only)

Wellness Cover for all employees and spouses ABOVE 40 YEARS

Annual check-up including Mammogram, Papsmia, Bone Density Tests, Dental Checking and cleaning, eye sight test with a sublimit of OMR 500 per member per annum

Wellness Cover for all members above 40 years

Colonoscopy, Stress ECG (once every year)

(On reimbursement basis only)

MaternitylObstetrical Benefits

Limit per member per year

Dental Treatment (Sickness)

No cover

Optical Treatment (Sickness)

RO.250 per member per year. Details of coverage in Question 9 of Annexure 2

Pre Existing & Chronic Disease

Waived for all the members

Daily Allowance

Daily Allowance of RD 35 per day if hospitalized in any Government Hospitals in Sultanate of Oman

Parent Accommodation

RD 35 per day for a maximum of 30 days for a parent accompanying a child less than 15 years of age

Evacuation Expenses Limit

Maximum of 20% of individual sum insured per member per disability (No Co-insurance)

Additional Benefits

Coverage for Parents

—

RD 2,500

1. Wellness cover for all employee and spouses (annual check-up, dental checking and cleaning, eye sight test with a sublimit of OMR 500 per person per annum (20% Coinsurance for Members Below 40 years of age) 2. Additional Extra Cover for Congenital anomalies and birth defects (over and above the base cover) up to US$ 100,000 for the entire scheme (20% Coinsurance to apply for the extra US$ 100,000 alone) 3. Cover for Variable and Transitional lenses (20% Coinsurance to apply) 4. Circumcision for New Baby less than 2 years (20% Coinsurance) Details in Question 7 of Annexure 2


Exclusions 1. 2. 3. 4. 5. 6.

Self inflicted injury while sane or insane; treatment of chronic alcoholism, drug addiction, desensitization and allergen tests or nervous or mental disorders; Injury or illness resulting from insurrection or war, declared or undeclared, or as a result of a riot, strike or civil commotion; Rest cures sanitaria or custodial care or periods of quarantine or isolation; Cosmetic or plastic surgery including related medicines and products unless medical treatment necessitated by an accidental Injury occurring while the Insured is covered; No Dental cover unless arising out an accident; Herbal Medicines, Ayurvedic treatment, Homeopathy treatment (Covered upto RO 750 for Medication only (Reimbursement basis); Hirsutism, Podiatrist services, Dietician services, Anorexia, obesity, insomnia, baldness, Expenses related to uncovered conditions including any complication arising there from Sexual disorders; Durable medical appliances (e.g.., nebuliser) unless prescribed by the Doctor; Contraceptive measures; Ovulation induction, invitro-fertilization (IVF); Vitamins, except when prescribed by the medical practitioner OR for the following conditions: Pernicious Anaemia, Scurvey, Rickets, Pellagra, Malabsorption, Poly Neuritis, Kwashiorkor (Vitamins are not on a Direct Billing basis’ and will have be submitted for reimbursement to National Life) Pre-existing conditions subject to limit as stated in the ‘Benefits of Scheme’; Injury or illness covered under Workmen’s Compensation or similar laws arising out of the Insured’s occupation; Congenital anomalies and birth defects. However this exclusion shall be waived for a total pool of US$ 25,000 for the entire scheme to meet the medical expenses for congenital conditions —

7. 8. 9. 10.

11. 12. 13.

Specific Questions related to Plan B 1. Can I or my family go to any doctor in my neighbourhood in Oman? Yes. But Direct Billing only with network providers. Treatment taken outside the network providers will be on a reimbursement basis 2. If my home country is Australia, and I am in Australia on holiday and need treatment, will all my treatment costs be covered 100%? (Unplanned treatment) Yes. The unplanned treatment in home country wiil be covered for 100% costs subject to annual maximum limits. 3. If my home country is Australia, and I am in London on holiday and need treatment, will all my treatment costs be covered 100%? (Unplanned treatment) No. The treatment outside Indian subcontinent, Philippines, Thailand, UAE, and Home country will be reimbursed only up to 90% subject to annual maximum limits. 4. If my home country is Australia, can I choose to return to Australia and have my treatment there? Will all costs be covered 100%? (Elective treatment) Yes. The elective inpatient treatment in home country will be covered for 100% costs subject to annual maximum limits and other limits under the policy.. However the cost of transport will not be covered for planned treatments. 5. If my home country is Australia, and I choose to have treatment in London rather than Oman or UAE, what % of my costs will be covered? (Elective treatment) None. The Territory is Oman, GCC, Indian Sub-continent, Phiilppines, Thailand and Home Country only for Plan A and Plan B members and Oman only for Plan C members 6.

What is covered under the Dental option? Dental Sickness cover is totally excluded under Plan B

21


Annexure 3C: Term Sheet

Plan ‘C’

Period of Insurance: From 15 September 2011 to 14 September 2012 The Territorial Limits under this medical option is: Sultanate of Oman extended to worldwide excluding USA and Canada whilst on Business and Holiday Inside Oman • 100% inside Network Hospital (10% Co-insurance in MPH OP only) • 100% reimbursement shall be provided for treatment taken outside the network —

10% of all medical expenses incurred in Muscat Private Hospital, Oman must be paid by the insured member

Territorial Limits

All options provide emergency only worldwide treatment excluding USA or Canada whilst on business or holiday. In respect of emergency only treatments outside Oman depending on the territory where the treatment is taken an element of Co-insurance (percentage to be paid by the member) is applicable.

Important: USA and Canada trips: Emergency medical expenses incurred during official trips are covered under SA’s travel policy. To get Emergency Medical cover for Personal trips (to any country), details of trip need to be notified to Marsh in advance (contact Saiith.Kumartämarsh.com with a copy to Pankaj BAfna of Sohar Aluminium). Deductible Sum Insured per member per year Daily Room & Board Limit

NIL 10% Coinsurance in MPH

OP Only

US$ 40,000

Inside Network Hospitals 100% for average private room inside the network hospitals in Oman

Intensive Care Unit Benefit

Double the daily room and board limit up to a maximum of 30 days per ailment. After 30 days the benefits revert to normal room & board limit.

Psychiatric Treatment

Up to a maximum of RO.1 ,000 per member per year (for medication only)

Wellness Cover for all employees and spouses ABOVE 40 YEARS Wellness Cover for all members above 40 years

Annual check-up including Mammogram, Papsmia, Bone Density Tests, Dental Checking and cleaning, eye sight test with a sublimit of OMR 500 per member per annum

Colonoscopy, Stress ECG (once every year) (On reimbursement basis only)


Maternity/ Obstetrical Benefits

Limit per member per year

Dental Treatment (Sickness)

RO 2,500

No cover

Optical Treatment (Sickness)

RO.250 per member per year. Details of coverage in Question 9 of Annexure 2

Pre Existing & Chronic Disease

Waived for all the members

Daily Allowance

Daily Allowance of RO 35 per day if hospitalized in any Government Hospitals in Sultanate of Oman

Parent Accommodation

RO 35 per day for a maximum of 30 days for a parent accompanying a child less than 15 years of age

Evacuation Expenses Limit

Maximum of 20% of individual sum insured per member per disability (No Co insurance)

Additional Benefit

Circumcision for New Baby less than 2 years (20% Coinsurance)

Coverage for Parents

Details in Question 7 of Annexure 2

Exclusions 1. 2. 3. 4. 5. 6.

Self inflicted injury while sane or insane; treatment of chronic alcoholism, drug addiction, desensitization and allergen tests or nervous or mental disorders; Injury or illness resulting from insurrection or war, declared or undeclared, or as a result of a riot, strike or civil commotion; Rest cures sanitaria or custodial care or periods of quarantine or isolation; Cosmetic or plastic surgery including related medicines and products unless medical treatment necessitated by an accidental Injury occurring while the Insured is covered; No Dental cover unless arising out an accident; Herbal Medicines, Ayurvedic treatment, Homeopathy treatment (Covered upto RO 750 for Medication only (Reimbursement basis); Hirsutism, Podiatrist services, Dietician services, Anorexia, obesity, insomnia, baldness, Expenses related to uncovered conditions including any complication arising there from Sexual disorders; Durable medical appliances (e.g.., nebuliser) unless prescribed by the Doctor; Contraceptive measures; Ovulation induction, invitro-fertilization (IVF); Vitamins, except when prescribed by the medical practitioner OR for the following conditions: Pernicious Anaemia, Scurvey, Rickets, Pellagra, Malabsorption, Poly Neuritis, Kwashiorkor (Vitamins are not on a Direct Billing basis’ and will have be submitted for reimbursement to National Life) Pre-existing conditions subject to limit as stated in the Benefits of Scheme’; Injury or illness covered under Workmen’s Compensation or similar laws arising out of the Insured’s occupation; Congenital anomalies and birth defects. However this exclusion shall be waived for a total pooi of US$ 25,000 for the entire scheme to meet the medical expenses for congenital conditions —

7. 8. 9. 10.

11. 12. 13.


Specific Questions related to Plan C 1. Can I or my family go to any doctor in my neighbourhood in Oman? Yes. But Direct Billing only with network providers. Treatment taken outside the network providers will be on a reimbursement basis. Further 10% of all medical expenses incurred in Muscat Private Hospital, Oman has to be paid by the insured member 2. What is covered under the Dental option? Dental Sickness cover is totally excluded under Plan C

Important Note: This booklet is just a brief reference guide regarding the benefits available under the policy and the claims procedure for availing the benefits. For full list of Benefits, Exclusions and Definitions; please refer to the policy document. This guide does not replace or override the original policy and the contract signed between the insurance company and your organization.


I RX Management Services LIC P.O. Box 43585, Dubai, United Arab Emirates Helpline : +968994418591+96899343623 (Oman) +971 43555122 / +971 4 3516923 (LJAE) Pbone +968 24730999 Ext 834 fax +968 24730903 (Oman) +971 43516924 (UAE) web site www.pconnet.com


ABIS Staff Health Insurance