Health Insurance Products General Guidelines
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- Luke Brice Parker
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1 Submission guidelines: Health Insurance Products General Guidelines Proposed products must be completed as per HAAD Insurance Product Template. Each product must have a product name and a unique reference number. The proposed products should be submitted by in soft copy (word document). Hard copies of the products can only be submitted after receiving confirmation of acceptance from HAAD, in the following manner; Printed on letterhead Has company stamp Has current date Contains separate attachment for the premium Maximum of 25 products per week can be submitted in one batch for validation. A subsequent batch can be submitted after validation of the previous batch. Minimum enhancements guidelines: A minimum of 2 significant enhancements must be made above the basic product that should be from different categories (e.g. upper limit coverage, geographical area, inpatient services and outpatient services). For outpatient Services, one of the following two options may be selected: Option (1): Remove deductible amount and/or percentage on all of the elements of the outpatient healthcare services and you may keep the Medicine cover AED 1,500/Year as minimum. Option (2): Increase the Medicine cover to be AED 3,000/Year as minimum with co-payment of 15% as maximum. No upper age limit for insurance coverage. The amount of deductible should not exceed (Maximum AED 50) for outpatient services other than medicines. Exclusions listed below (coloured in blue) may be used to enhance the product. 0
2 NAME OF PRODUCT: REF No. PRODUCT TYPE: Enhanced DATE: First: Total upper limit coverage 1. The annual upper limit for Healthcare Services AED 300,000 Second: Geographic Coverage 1. Health Insurance Services offered inside the Emirate of Abu Dhabi. 2. Health Insurance Services offered in other Emirates 3. Middle East Inpatient / Emergency / Outpatient Inpatient / Emergency / Outpatient 4. International Third: Inpatient Healthcare Services at Authorised Hospitals 1. In-patient Healthcare Services, subject to prior approval. Private Room 2. Tests, diagnosis, treatments and surgeries in hospitals for non-urgent medical cases, subject to prior approval. 100% 3. Healthcare services for emergency cases 100% Transportation services for medical emergencies inside the Emirate of Abu Dhabi by an authorised party. Accommodation for a person accompanying an insured child up to 10 years of age. Accommodation of an accompanying person in the same room in cases of critical conditions and as per recommendation of attending physician, subject to prior approval. 100% AED 200 / day AED 200 / day 7. In-patient maternity services, subject to insurance prior approval. No Co-payment 1
3 Fourth: Outpatient Healthcare Services 1. Examination, diagnostic and treatment services of clinics and health centers by general practitioners, and specialists provided that the Insured Person is referred to a specialist and/or consultant by a general practitioner. Follow ups are exempted from fees if made within a week from the date of first examination. 100% with co-payment of AED 20 for GP AED 10 for Specialist 2. Laboratory tests services 3. X-ray diagnostic services. In cases of non-medical emergencies, the insurance company s prior approval is required for MRI, CT scans and endoscopies. 4. Physiotherapy treatment services, subject to insurance company prior approval. 100% with co-payment of AED % with co-payment of AED % Cost of medicine, subject to insurance company s prior approval for prescriptions which exceed AED 500. Examination, diagnostic and treatment services for pregnancy and gynaecology services in authorised health centers and clinics by general practitioners and specialists, provided that the Insured Person is referred to a specialist and/or consultant by a general practitioner. Follow ups are exempted from fees if made within a week from the date of first examination. 70% with co-payment of 30% Maximum AED 1,500 / Year 100% with co-payment of AED 20 for GP AED 10 for Specialist Fifth: Other Benefits 1. Diagnostic and treatment services for dental and gum treatments. 2. Hearing and vision aids, and vision correction by surgeries, and laser. Medical Emergency cases Medical Emergency cases Exclusions: The standard defined exclusions in schedule 2 and 3 of the Abu Dhabi Health Insurance law shall apply, unless explicitly listed above as other covered benefits. 2
4 Schedule 2 Excluded Healthcare Services This Schedule sets out the non basic (excluded) healthcare services: 1. Healthcare Services, which are not medically necessary 2. All expenses relating to dental treatment, dental prostheses, and orthodontic treatments. (Dh 1,500 minimum coverage and co-payment Dh 50 maximum) 3. Domiciliary care; private nursing care; care for the sake of travelling. 4. Custodial care includes (1) Non-medical treatment services; or (2) 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. Healthcare Services and associated expenses for replacement of an existing breast implant. Cosmetic operations which improve physical appearance and 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. Breast reconstruction following a mastectomy for cancer is covered. 8. Surgical and non-surgical treatment for obesity (including morbid obesity), and any other weight control programs, services, or supplies. 9. Medically non-approved experimental, research, investigational healthcare services, treatments, devices and pharmacological regimens. 10. Healthcare Services that are not performed by Authorised Healthcare Service Providers, apart from Healthcare Services rendered in a Medical Emergency. 11. Healthcare services, treatments & associated expenses for alopecia, baldness, hair falling, dandruff or wigs. 3
5 12. Supplies, Treatment and services for smoking cessation programs and the treatment of nicotine addiction. 13. Non-medically necessary Amniocentesis 14. Treatment, services and surgeries for sex transformation, sterility and sterilization 15. Treatment and services for contraception 16. Treatment and services related to fertility / sterility (treatment including varicocele / polycystic ovary / ovarian cyst / hormonal disturbances / sexual dysfunction). 17. Prosthetic devices and consumed medical equipments, unless approved by the insurance company 18. 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 19. Growth hormone therapy. 20. Costs associated with hearing tests, vision corrections, prosthetic devices or hearing and vision aids. 21. Mental Health diseases, in-patient and out-patient treatments, unless the condition is a transient mental disorder or an acute reaction to stress. 22. Patient treatment supplies (including elastic stockings, ace bandages, gauze, syringes, diabetic test strips, and like products; non-prescription drugs and treatments, excluding such supplies required as a result of Healthcare Services rendered during a Medical Emergency). 23. Preventive services, including vaccinations, immunizations, allergy testing and desensitization; any physical, psychiatric or psychological examinations or testing during these examinations. 24. Services rendered by any medical provider relevant of a patient for example the Insured person and the Insured member s family, including spouse, brother, sister, parent or child. 4
6 25. Enteral feedings (via a tube) and other nutritional and electrolyte supplements, unless medically necessary during treatment. 26. Healthcare services for adjustment of spinal subluxation, diagnosis and treatment by manipulation of the skeletal structure, by any means, except treatment of fractures and dislocations of the extremities. 27. Healthcare services and treatments) by acupuncture; acupressure, hypnotism, rolfing, massage therapy, aromatherapy, homeopathic treatments, and all forms of treatment by alternative medicine. 28. All Healthcare services & Treatments for in-vitro fertilization (IVF), embryo transport; ovum and male sperms transport 29. Elective diagnostic services and medical treatment for correction of vision 30. Nasal septum deviation and nasal concha resection. 31. All chronic conditions requiring hemodialysis or peritoneal dialysis, and related test/treatment or procedure. 32. Treatments and services related to viral hepatitis and associated complications, except for treatment and services related to Hepatitis A. 33. Birth defects, Congenital diseases for newborn &/or Deformities unless lifethreatening. 34. Healthcare services for Senile dementia and Alzheimer s disease 35. Air or Terrestrial Medical evacuation except for Emergency cases or unauthorised transportation services. 36. Circumcision healthcare services. 37. 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. 38. Any inpatient treatment, tests and other procedures, which can be carried out on outpatient basis without jeopardizing the Insured Person s health 39. Any test or treatment, for purpose other than medical such as tests related for employment, travel, licensing or insurance purposes. 5
7 40. 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, convenience items / options, exercise equipment and sanitary supplies. 41. More than one consultation or follow up with a medical specialist in a single day unless referred by a physician. 42. Health services and associated expenses for organ and tissue transplants, irrespective of whether the Insured Person is a donor or recipient. 43. Services and educational program for handicaps. 6
8 Schedule No. 3 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. Healthcare services for patients suffering from AIDS and its complications. 7. Healthcare services for work illnesses and injuries as per Federal Law No. 8 of 1980 concerning the Regulation of Work Relations, as amended, and applicable laws in this respect. 8. All cases resulting from the use of alcohol, drugs and hallucinatory substances. 9. Any test 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 locally recognised epidemics. 13. Venereal sexually transmitted diseases. A list with respect thereto will be set out by the Health Authority Abu Dhabi. 7
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