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TABLE OF BENEFITS

PRODUCT NAME: EIC/SME/DOH/PLAN 5/BLUE PEARL/SR

CATEGORY
Network SUPER RESTRICTED
Sum Insured AED 250,000/-

United Arab Emirates, Extended to Indian Sub-Continent & South East

Asia for both emegency and non-emergency treatment; however
Geographical Cover
Worldwide on emergency basis only. All treatments are based on
usual customary charges of UAE designated network
Direct billing 100% subject to applicable Copay/ Deductible
Elective: 80% of applicable Network Customary Rates
Reimbursement (Within UAE)
Emergency: 100% Covered
Reimbursement (Outside UAE) 80% of applicable Network Customary Rates
Pre-existing & Chronic Conditions Covered
Regulatory Compliance DOH
Inpatient Treatment
Inpatient and Daycare Treatment
(including Pre & Post In Hospital treatment Covered up to Annual Limit
covered)
Accommodation Type SEMI-PRIVATE
Hospital Accommodation & Services Covered
Consultant’s, Surgeon’s & Anesthetist’s Fees
Covered
and other fee etc.

Ground Ambulance Services

(Medical emergency only, subject to General Covered
Exclusion)

Parent Accommodation
accompanying an Insured Child under 18 years UP TO 150 AED PER NIGHT
of age

Companion Accommodation in cases of

medical necessity at the recommendation of UP TO 150 AED PER NIGHT
the treating doctor

Home Nursing
(following an in-patient hospitalization & NOT COVERED
subject to prior approval for max 14 days)
Emergency Treatment Covered

In Hospital Cash Benefit per day max 20 days

150 AED
(in case of free inpatient treatment)
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Repatriation of Mortal remains to country of

UP TO 7,500 AED FOR ALL COSTS
origin
Outpatient Treatment

Physician Consultation Deductible / Copay

30 AED
(not applicable for follow up within 7 days)

Diagnostics (X-Ray, MRI, CT-Scan, Ultra Sound,

etc.),
NIL
Laboratory (MRI, CT and Endoscopies with pre-
authorization only)
Pharmaceutical copay / out of pocket 25% CO-INSURANCE
Pharmaceutical Limit 3000

Physiotherapy (with pre-authorization only) Covered

Maternity Benefit

Covered up to annual aggregate limit for both in-patient & out-

patient maternity treatments per married female employee &
spouse.
Maternity Services
Outside Abu Dhabi
Covered up to AED 10000 per married female employee & spouse for
all anti-natale and delivery cases including normal, cesarean /
complication & legal abortions.

Maternity Deductible In patient deductible of AED 500 per delivery. Out Patient Deductible
(not applicable for follow up within 7 days) applies for maternity as non-maternity claims

Additional Benefits

Diagnostic and treatment services for dental

Covered - Medical Emergency Cases Only
and gum treatments (Emergency cases)

Hearing & Vision Aids, and vision correction by

Covered - Medical Emergency Cases Only
surgeries, and laser (Emergency Cases)

Child Vaccinations Max upto 6 year old child as per MOH

Healthcare services for work related injuries & illness are covered as
Work related injuries per Federal Law No. (8) of 1980 regarding work relations, its
amendments & the applicable laws & resolutions in this regard.

Medical Check-Up Not Covered

Exclusions As per DOH

SPECIAL RULES AND CONDITIONS:

• All the above coverage are available within UAE when the treatment is taken within our
network except in emergency cases.
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• Treatments received from Government Hospitals (Excluding Sheikh Khalifa Medical Center
and Tawam Hospital) are covered on reimbursement basis subject to a co-payment of 20% for
each and every claim.
• Emergency and Treatment not available within network is covered in full within UAE.
• A non-emergency treatment received from Al Zahra group of hospitals/clinics and American
Hospitals will not be covered.
• Treatment received from Al Zahra Hospital/ Pharmacy - Sharjah will not be covered.

NOTES:
• Premium Payment is annual and in advance.
• Additions/ deletions shall be on pro-rata basis.
• It is hereby declared and agreed that if Value Added Tax (VAT) is applicable on the insurance
premium and other charges payable/paid in relation to this insurance policy retrospectively
from inception or prospectively from the date of implementation of VAT, the Insurer reserves
its right to collect the same from the Insured in line with the impending VAT laws and
regulations as implemented in the UAE."
• Indian Sub Continent (ISC) - India, Pakistan, Sri-Lanka, Bangladesh & Philippines.
• South East Asia (SEA) - Brunei, Cambodia, East Timor, Indonesia, Laos, Malaysia, Myanmar,
Philippines, Singapore, Thailand.
• Chronic Cases / Cancer cases to be declared at the time of quotation.
• Maximum Age Limit is 65 years.
• Members age above 65 are excluded from the quote and requires individual underwriting.
Please fill out the attached application form in order to quote for them.
• Our underwriting decision would be revised if it comes to our notice through any other source
that the information provided at the same time of isuing the initial quote was inadequate or
different. The most recent quote/ terms will supersede the previous issued quotation.

• Emirates Insurance can review the quoted premium rates when the actual number of insureds
become significantly different from the initial number of insureds.
• DOH compliant quote is applicable for Abu Dhabi based members.

The person applying for this insurance agrees, by acceptance of this quotation:
• that the statements and particulars in the slip and/or proposal form, and/or any supplementary
information referred to above are fair representations and that this quotation is issued in
reliance upon the truth of such representations; and
• that in the event of the slip and/ or proposal form, and/ or the supplementary information
referred to above, containing misrepresentations which would materially affect the acceptance
of risk hereunder by the company the policy issued based on this quotation shall be void in its
entirety and of no effect whatsoever.
• Please note that deliberate failure to disclose all material facts that might influence us in
offering insurance or the terms at which we would offer insurance will invalidate our quotation
and the cover. If the person applying for this insurance is unsure whether any information
should be disclosed please bring this to our attention.
• The insured must provide notice in writing if, during the policy period, there is any alteration in
any material fact in relation to any of the information originally provided. Material facts are
those that an insurer would regard as likely to influence the acceptance and assessment of your
insurance risk.
• Please note this is only a quotation and not an acceptance of risk and the policy would be
subject to standard policy terms and conditions.
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• This quotation is valid for 30 days as from quotation's date, subject to no material change in
data eg. sum insured, persons covered, occupation changes and in particular with reference to
any claims experience provided.
• In case of acceptance of the above terms, you are kindly required to duly sign and stamp the
given quote and the related policy wordings, in original.
• We trust you will find the quotation of interest, however, should you have any query or wish to
discuss any aspect of this quotation please do not hesitate to call us.
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Statement of Acceptance:
I/We have reviewed your proposal and hereby confirm our acceptance of the terms, conditions and
exclusions stated therein and which we understand shall form part of the policy document. I/We are
made aware that the policy wording attaching to the above proposal will also be subject to standard
conditions, warranties, exclusions and/ exceptions as more specifically mentioned therein and I/We are
in full consent of the same.

I/We have reviewed your proposal and hereby declare that no insured member has any on-going or
planned treatment in respect of cancer, heart or any other major medical conditions to the knowledge of
employer/beneficiary and I/We are in full consent of the same.

By accepting the above, I/we agree that in case of any non-disclosure of any of the above mentioned
conditions, the Insurer has the right to suspend the cover and/or can reprice the Policy as they may
deem fit.

Name :
Designation :
Signature :
Date :