Member Guide. Basic (Abu Dhabi Plan) DAMAN (32626)

Transcription

1 Member Guide Basic (Abu Dhabi Plan) 1

2 Daman Headquarters Millennium Tower, Hamdan St. Abu Dhabi, UAE Telephone: Fax: P.O. Box Central Branch Airport Road, Abu Dhabi Telephone: Fax: P.O. Box Corporate Sales Center Al Bateen, Tower C4 Bainuna Street, Abu Dhabi Telephone: Fax: P.O. Box Mussafah Individual Basic Branch Global Ascent Business Center Al Musaffah 4, Abu Dhabi Behind Mercedes-Benz Plot No. 12 behind SEHA Telephone: Fax: P.O. Box Corporate Sales Musaffah Global Ascent Business Centre Al Musaffah 4, Abu Dhabi Behind Mercedes-Benz Plot No. 12 behind SEHA Telephone: Fax: P.O. Box Mussafah Group and Enhanced Branch Global Ascent Business Center Al Musaffah 4, Abu Dhabi Behind Mercedes-Benz Main Entrance 1st Floor Next to SEHA Telephone: Fax: P.O. Box Abu Dhabi Service Points Infinity Services-Muroor Street Zones Corp. Mussafah Abu Dhabi Immigration (Visit Visa Only) Abu Dhabi Municipality Abu Dhabi Chamber of Commerce Marina Mall (Infinity Services) Masdar City Al-Shahama Municipality Al Ain Branch G1-G2, Al Wadi Trading Centre, Al Ain roundabout Awwal, Street, Al Ain P.O Box 69988, Al Ain Tel: / / Al Ain Service Points Infinity Services Al Wagan Municipality Mazyad Municipality Al Hayer Municipality Sweihan Municipality Al Qoaa Municipality Al Ain Immigration (Visit Visa Only) Al Khaznah Municipality Al Maqam Municipality JLT Office Fortune Tower, Ground Floor Level Jumeirah Lakes Towers, Dubai Telephone: Fax: P.O. Box Western Region Branch Madinat Zayed, Saeed Bin Humaid Complex Block A, 1st Floor Plot No. 287 Next to Qatar Al Nada School Al Senaaya Street Telephone: Fax: Western Region Service Points Madinat Zayed, Tamm Center Ghayathi, Tamm Center Silaa, Tamm Center Delma, Tamm Center Al Marfa a, Tamm Center Liwa, Tamm Center Sharjah Service Point Sharjah Immigration (Visit Visa Only) Ras Al Khaima Service Points Ras Al Khaimah Immigration (Visit Visa Only) 2

3 Table of Contents Daman: Your Health Insurance Specialist....4 Our Specialized Services...5 What Is Covered?...6 How To Obtain Your Plan Benefits?...7 What Is Not Covered?...8 Important To Know...10 Your Rights and Responsibilities...12 Definitions...13 Contact Us

4 Daman: Your Health Insurance Specialists Daman is the first specialized health insurer in the United Arab Emirates. Our strategic partnership with Munich Re, one of the largest and most reputable reinsurer in the world, has helped us develop a renowned stretch of competencies in the region, backed by the strong and reliable support of Abu Dhabi Government. Our products are a result of industry knowledge, market research, and a deep understanding of our customer s health insurance needs. Basic Plan is an optimal health insurance plan, covering benefits like hospital stays, treatments, and medicines within the Emirate of Abu Dhabi; as well as coverage for emergency services in UAE. This plan offers you health insurance cover of AED 250,000 per person annually. You can use your Daman card to get direct billing facility at health service providers across our plan s Network which includes hospitals, clinics, pharmacies and diagnostic centres. 4

5 Our Specialized Services We offer you a distinctive set of world class services as listed below: Network of more than 600 health service providers in the Emirate of Abu Dhabi 24/7 in-house Customer Service Centre staffed with bilingual representatives 24/7 access to medical authorizations (pre-approvals required to receive specific medical treatments) Automated systems for effective management of your pharmacy benefits Efficient claims processing Easy access to information on your network directory (including hospitals, pharmacies, clinics, doctors etc.) through our online portal Wide geographical representation of branches and service points across the United Arab Emirates offering you convenience and choice Easy and safe access to our online portal to submit and track your claims, search for health services providers, and ask questions through your My Daman account Access to Daman Customer Club, an online Daman member community, offering health and wellness tips, and exclusive offers from our trusted partners in the United Arab Emirates. Free Tele-coaching programs, through our Health Support services, for members with specific chronic diseases, offering advice and support on treatment facilities, procedures and medications (for more details log onto our web portal or call the Health Support toll free line ) 5

6 What is covered? Main Cover-Your Benefit Summary Covered at Network Providers Notes Inpatient benefits Hospital Charges Inpatient Treatments Medical appliances, diagnostic tests Specialist s or Consultant s Fee Outpatient Benefits Doctor s consultation Including room, meals, nursing, drugs and dressings. Surgeries, day procedures, radiotherapy, chemotherapy, etc. Used as part of inpatient procedures. Including General Physician consultation and Specialist consultation on referral basis. Prescribed medicines Covered as per your Drug Formulary. Diagnostic tests Physiotherapy sessions Maternity Benefits Inpatient Maternity Doctor s Consultation, Prescribed medicines Additional Benefits Any emergency treatments or services within UAE Including X-rays, blood tests, ultrasounds, CT Scans and MRI. Including childbirth, complications of pregnancy or delivery, newborn accommodation and care. Including Ambulance Services, Dental or Vision Correction treatments in case of medical emergency. Emergency treatments or services will also be covered outside Daman s Network within UAE. 6

7 How to obtain your plan benefits? Within Daman s Network: Use your Daman card You will have direct billing access at our Network Providers for health services covered under your policy. Just remember to carry your Daman Card when going to the network provider and comply with the administrative procedures there. Some health services may have deductibles or co-insurance charges that you will have to pay for. Such charges will be mentioned on your Daman Card and have to be paid either before or after the service is received. Outside Daman s Network: Get your bills reimbursed (incase of Emergency only) If you go to a Health Services provider that is not part of Daman s Provider Network, you will have to pay directly for the services provided. Only in case it is a medical emergency, and if such services are covered in your plan, you will be eligible to reimburse the cost of the health service from Daman. For reimbursement, you have to submit a claim form, along with the documents like original itemized bills, medical or investigational reports, etc. The claim form and details of our reimbursement requirements are available on our website. These documents must be submitted to Daman within 30 days from the date of service received. You can apply for reimbursement through our website or by visiting any of our branches or service points. Coverage for Emergencies We are committed to provide you the best coverage for health care services, especially when it matters the most. In case of a medical emergency within the United Arab emirates, you will be eligible to get coverage for your medical bills, whether you were treated at a Network or Non-network Provider. Prior approval is not required in case of emergency or services. However, you must notify us within 24 hours of the services received so that we can help you with the claims process. You can reach us on the Customer Service toll free number mentioned on your Daman card in case you need further information. 7

8 What is not covered? Your policy does not cover you for: Health Services, including treatments and supplies, not medically necessary Health Services including pharmaceuticals not prescribed by a physician Health Services received outside the plan Network, except in case of an Emergency Dental and gum treatment, Vision and Hearing Correction treatments and Aids, except in case of medical emergency Assistance in activities of daily living which do not change the medical condition of the member (for example-custodial care, private duty nursing, etc.) Vitamins Personal comfort and convenience items or service (fro example-beauty services) Cosmetic procedures, surgeries which are not incidental to any injury, sickness or congenital deformities Treatment or obesity and weight management programs Experimental, investigational or Unproven services, treatments, drug and supplies or devices Outpatient medical supplies including prosthetic devices and durable medical equipment (for example- bandages, syringes, wheel chair) Any services for hair fall (for example- alopecia) All cases resulting from alcoholism, use of drugs and hallucinatory substances Smoking cessation programs Health Services related to sex transformation operations, fertility or infertility Hazardous activities or professional sports (for example- bungee jumping) Treatment as a result of war, riots, military operation, etc. where a member participates in such acts Treatment as a result of nuclear risk, natural peril or any terrorist or criminal activities Mental health diseases or disorders unless it is transient mental disorder Preventive care including any associated test and investigation (for example- vaccinations) Alternative treatments (for example- herbal or Chinese treatments) Any Health Services and associated for HIV, AIDS, sexually transmitted diseases and all related medical conditions. Birth defects or Congenital Anomalies for newborn unless representing a life threat All cases related to Maternity in respect of unmarried females 8

9 Any test which is not related to a specific symptom/disease. This includes examinations required for employment, travel, immigration, licensing or insurance and related reports More than one physician consultation in a day or during free follow up period unless medically necessary and referred by the initial treating doctor Lesions resulting from attempted suicides or self infliction All substances which are not considered as medicines and all equipment not primarily intended to improve a medical condition or injury (for example-food supplements, air purifying systems) Growth hormone therapy unless medically necessary Enteral feeding and other nutritional and electrolyte supplement, unless medically necessary Services related to musculoskeletal treatments except for treatment of fracture and dislocation of extremities Nasal septum deviation, nasal concha resection Chronic conditions requiring hemodialysis or peritoneal dialysis including related investigations Viral hepatitis and related complications except hepatitis A Air ambulance transportation and terrestrial transportation in non-emergency cases or by nonlicensed ambulance services Circumcision and any related complications, except for newly converted Muslims Any pharmaceutical products, which is not considered as specific treatment for a particular disease or not prescribed by an approved Physician All cases where appropriate pre-authorization or notification was not carried out as per policy terms and conditions Officially recognized epidemics or pandemics Complications directly arising from services not covered Education programs or learning disabilities treatments Any treatment or services rendered by a family member or any person with the same legal residence Any inpatient treatment, tests and other procedures, which can be carried out on Outpatient basis without jeopardizing the insured s health Organ and tissue transplants Note: This is only an extract from the General Exclusions list that applies to your plan. Please refer to the Policy Wording for the complete list and details of exclusions, definitions, terms and conditions. 9

10 Important To Know Pharmacy Benefit Management Pharmacy Benefit Management (PBM) is an internet-based interface between Daman and your pharmacy within Daman s Network in Abu Dhabi. It is designed to mange your pharmaceutical benefits better. PBM will help us enhance our service quality by following established frameworks and best practices related to drug prescription and dispensing. We will be able to review every drug prescribed for consistency with your diagnosis, age, gender and previous medical history. We can avoid any potential health hazard by rejecting clinically inappropriate drugs or where we suspect negative drug-to-drug interaction. PBM will further help us with automated checks for cases like a particular drug is not covered in your policy (Drug Formulary) or you have already consumed your pharmacy benefit limit or the drug is not medically necessary or you requested for a prescription refill too soon. However, you may get a refill approved on an exceptional basis. You may contact our Customer Service Centre (by calling the toll free number mentioned on you Daman card) if you require further information or wish to file for an appeal in case for exceptional circumstances. Pre-Authorization Your policy may contain specific services that require prior-approvals or pre-authorizations. This is necessary to ensure that your Health Services Provider has appropriate information on services covered under your policy. You would need pre-authorization before availing any of the following health services: Inpatient and day treatment services Outpatient Physiotherapy MRI, CT Scans and Endoscopies Prescription Drugs above AED 500 or medication to be consumed for more than 60 days Your Network Provider, along with Daman, will carry out the pre-authorization process (where necessary) and notify you once the approval is granted. If the authorization is not granted, you have the right to ask for an explanation by calling our Customer Service Centre at the toll free number mentioned on your Daman Card. Coverage for Specific Conditions Your policy covers this listed conditions after a waiting period for 6 months, from the effective date as mentioned on your Daman Card. The waiting period applies to inpatient treatment only for the following medical conditions: 10

11 Diabetes mellitus, Arterial diseases, COPD (Chronic Obstructive Pulmonary Disease), all cancer cases, Neurosurgery, Cerebro Vascular Diseases all delivery cases (Maternity). The waiting period is not applicable if you were continuously covered without any break for atleast 6 months under a health insurance plan approved by Health Authority Abu Dhabi (HAAD). Member Cost Sharing For health services covered within Daman s Network, there maybe some services where a deductible or co-insurance is payable. In such cases, you will have to pay the specified amount as mentioned on your Daman Card directly to the Provider. The deductible and co-insurance amounts for applicable services are listed in your Schedule of Benefits. Network Directory Before going for a treatment or service, we recommend that you refer to your Network Directory and confirm if the provider is listed in Daman s Network. Our Network Directories are continuously updated as we establish new agreements with health service providers within the territories specified in your plan. Going to a Network Provider would ensure that you can enjoy the direct billing facility and avail cashless benefits for Health Services covered in your policy. You can check the Provider details on our website or call our Customer Service Centre on the toll free number mentioned on your Daman Card for any assistance. Drug Formulary If your policy covers outpatient prescription drugs, these drugs will be subjected to a Drug Formulary. A Drug Formulary details the pharmaceuticals covered under your policy as decided by Health Authority-Abu Dhabi (HAAD). Your Drug Formulary covers both brand-name and generic drugs. Generic drugs have the same active ingredients as brand-name drugs and are equally safe and effective. In case the prescribed drug is not covered in your Drug Formulary, you will have to pay the drug bill directly to the Provider. You can refer to our website to check if the medicines prescribed for you are covered in the Drug Formulary of your policy. Complaints and Appeals Daman is committed to address members coverage issues, complaints and problems. For any general inquires related to your policy benefits, or specific complaints concerning your pharmacy benefits such as adjudication of your claims (declining the pre-authorization request for a drug), dispensing oversight or provider related issues (access, quality and safety), you can call our Customer Service toll free number mentioned on your Daman Card. You can also contact us through our website. For cases where a drug cannot be found with your Network Provider or does not exist in your Drug Formulary, you have the option to request exceptional consideration for coverage. If your request is declined, you may further approach us through our appeal process. Daman will discuss the merits of your case internally and externally and will communicate the decision to you within 30 calendar days from the date of appeal. Details of appeals process and the Appeals/Exception Request Form are available on our website. 11

12 Your Right and Responsibilities As a Daman member you have the Right to: 1. Receive information about Daman s health insurance plans and services including but not limited to health insurance plan benefits, exclusions, policy terms and conditions, Pharmacy Benefit Management (PBM) services, details of network providers (including hospital, pharmacy, dental clinic etc), online services, list of medications covered under your health insurance plan (Drug List) and your Rights and Responsibilities. 2. Be treated with respect and dignity and have the right to privacy. 3. Preserve the confidentiality of your treatment records to the extent protected by Federal and Emirate laws in the UAE. You are also entitled to receive an explanation regarding exceptions to confidentiality. 4. Voice complaints or to appeal to Daman on benefits offered, claim settlement, services offered, PBM services or any other grievance. 5. Be provided, upon request, with information about your plan s benefits including limitations and exclusions applicable and details related to your health plan Drug List. 6. Receive services in English and Arabic when contacting Daman Customer service. 7. Make suggestions and give comments on ways Daman can improve its services. 8. Exercise your rights in accordance with the Health Insurance Law of the Emirate of Abu Dhabi. As a Daman member, your Responsibilities are: 1. To read your insurance policies for the details of benefits, exclusions, other terms and conditions applicable under your health insurance plan. If you do not understand the information, you should contact Daman Customer Service for explanations on the covered benefits, limitations and authorization procedures. 2. To present your Daman Card (health insurance card) when accessing covered health services from our Network Providers. 3. To know how to access covered health services and pharmacy benefit you are entitled to as part of your health insurance plan benefits. 4. To pay any applicable co-insurance and deductible at the time of availing a health service. 5. To demonstrate mutual respect and courtesy towards providers (including hospitals, pharmacies, dental clinics etc.) and Daman personnel. 12

13 Definitions Daman Card - the identification card issued by Daman for every member (Eligible Person). Co-insurance - the percentage of eligible expenses that you need to pay for specified medical services availed under your policy. Deductible - the defined fixed amount that you need to pay for the specified medical services received under your policy. Eligible Expenses - Reasonable and Customary Charges for Covered Health Services, incurred while the Policy is in effect. Emergency - A sudden development of a medical or surgical condition where lack of immediate medical treatment at a health service provider might result in a life threatening situation or seriously affect member s bodily functions. Drug Formulary - A list of medications or drugs covered under your policy Health Services - the health care services and supplies covered under the Policy, unless such health care services and supplies are not limited or not excluded in the policy. Inpatient Benefit - Hospitalization or Day Treatment or observation or treatment in an Emergency room or facility which cannot be carried out on an outpatient basis. Network - Used to describe a Health Services Provider, which holds an agreement in effect with Daman to provide Health Services to members. Non-Network Benefits - Coverage available for Health Services obtained from the non-network Providers. Coverage for the Non-Network Benefits is only provided if the services are assured in Schedule of Benefits. 13

14 Outpatient Benefit - are those services which do not require Hospitalization or Day treatment or necessitate specialized medical attention and care in a Hospital before, during or after the delivery of the service. Pre-authorization - a prior approval or official permission, granted by Daman to the Network Provider, before initiating certain medical procedures. Pre-Existing Condition - any known or unknown injury, sickness, disease or other medical, mental or nervous condition, disorder or ailment that with reasonable medical certainty that existed at the time of applying for this policy. Provider - a Physician, Hospital, group practice, pharmacy or any facility, individual or group of individuals that provides a health care service. Refill-too-soon - Replenishment or dispensing of a prescribed medicine before the previous dispense of the same pharmaceutical is consumed. Appeal - A request contesting a denial availed or are intended to be availed. or reduction of coverage for services which have been 14

15 PM/E/0007/E002/010315/V1R0/P Contact Us For any product related queries or general inquiries, kindly contact us on: Toll Free: DAMAN (32626) Website: Fax: P.O. Box , Abu Dhabi, UAE Disclaimer This document is for information purposes only and does not form part of the policy. The complete list of benefits, definitions, exclusions, policy terms and conditions are set out in the Letter of Acceptance, Schedule of Benefits, and the Policy Wordings. While every effort is made to ensure the accuracy of the content as of the print date, Daman cannot be held accountable for any typographical errors, errors of fact or any other error or inconsistency found in this document 15