DHA Basic Plan - Group

Company Name: Dubai Insurance

Confirmation Date: Trading Activity:

DUBAICARE DUBAI INSURANCE CO. (P.S.C)

GROUP MEDICA L INSURANCE

DHA BASIC PLAN – GROUP
Annual upper aggregate claims limit
(Excluding any coinsurance and/or deductibles) AED 150,000

Emirates of Dubai and Northern Emirates,

Geographic scope of coverage Emergency extension to UAE.

DubaiCare N5 Network
Network
(OP restricted to Clinics)

Covered up to Annual Limit however Treatment for chronic and pre-existing

Pre-existing conditions conditions excluded for first 6 months of first scheme membership. Included
thereafter

In-Patient Benefits
Basic healthcare services: In-patient treatment at authorized network hospitals
Referral procedure: No costs incurred for advice, consultations or treatments provided by specialists or consultants without the insured
first consulting a General Practitioner (or equivalent as designated by DHA) who is licensed by DHA or another competent UAE authority
will be payable by the insurer. The GP must make his referral together with reasons via the DHA e-Referrals system for the claim to be
considered by the Insurer.
Tests, diagnosis, treatments and surgeries in hospitals for
non-urgent medical cases
(Subject to prior approval from Insurer)

Hospital Class (Semi-Private Room)

Covered with 20% coinsurance payable by the insured with a cap of 500 AED
Emergency treatment payable per encounter and an annual aggregate cap of 1000 AED. Above
these caps the insurer will cover 100% of treatment.
Approval required from the insurance company within 24
hours of admission to the authorized hospital

Healthcare services for emergency cases

Ground transportation services in the UAE provided by an
authorized party for medical emergencies
DUBAICARE DUBAI INSURANCE CO. (P.S.C)

Companion accommodation
This includes:
 The cost of accommodating a person accompanying an
insured child up to the age of 16 years
 The cost of accommodation of a person accompanying Maximum 100 AED per night
an in-patient in the same room in cases of medical
necessity at the recommendation of the treating doctor
and after the prior approval of the insurance company
providing coverage

Outpatient Benefits
Basic healthcare services: out-patient in authorized out-patient clinics.
Referral procedure: No costs incurred for advice, consultations or treatments provided by specialists or consultants without the insured
first consulting a General Practitioner (or equivalent as designated by DHA) who is licensed by DHA or another competent UAE authority
will be payable by the insurer. The GP must make his referral together with reasons via the DHA e-Referrals system for the claim to be
considered by the Insurer.

Examination, diagnostic and treatment services by 20% co-insurance payable by the insured per visit.
authorized general practitioners, specialists and No Co insurance if a follow-up visit made within seven days for the same
consultants illness.
Laboratory test services carried out in the authorized
Covered with 20% coinsurance
facility assigned to treat the insured person
Radiology diagnostic services carried out in the
authorized facility assigned to treat the insured person.
Covered with 20% coinsurance
(In cases of non-medical emergencies, Prior approval is
required for MRI, CT scans and endoscopies)

Physiotherapy treatment services Covered up to maximum of 6 sessions per year with 20% co-insurance
(Prior approval of the insurance company is required)

Drugs and other medicines

Covered up to AED 1,500 with 30% coinsurance
(Restricted to a list of formulary products to be published
by DHA)
DUBAICARE DUBAI INSURANCE CO. (P.S.C)

Maternity Benefits
10% co-insurance applied at the time of payment
8 visits to PHC; All care provided by PHC obstetrician for low risk or specialist
obstetrician for high-risk referrals
All care provided by PHC obstetrician for low risk or specialist obstetrician
Out-patient pre-natal services for high-risk referrals. Services include:

Pre-approval is required for this benefit  FBC and Platelets

 Blood group, Rhesus status and antibodies
Note: Where any condition develops which becomes life  VDRL
threating to either the mother or the new born, the  MSU & urinalysis
medically necessary expenses will be covered up to the  Rubella serology
annual aggregate limit.  HIV
 Hep C offered to high-risk patients
 GTT if high risk
 FBS, random s or A1c for all due to high prevalence of diabetes in UAE
3 ante-natal ultrasound scans Visits to include reviews, checks and
tests in accordance with DHA pre-natal care protocols

10% co-insurance applied at the time of payment

In-patient maternity services  Maximum AED 7,000 for normal delivery.
 Maximum AED 10,000 for medically necessary C-section, complications
(Requires prior approval from the insurance company or and medically necessary termination
within 24 hours of emergency treatment)
(All limits include coinsurance)
Covered for 30 days from birth including BCG, Hepatitis B and neo-natal
screening test (Phenylketonuria, Congenital hypothyroidism, sickle cell
New born cover screening, congenital adrenal hyperplasia)

Other Benefits
 Essential vaccinations and inoculations for newborns and children as
stipulated in the DHA’s policies and its updates (currently the same as
Federal MOH)
 Preventive services as stipulated by DHA to include initially diabetes
Preventive services, vaccines and immunizations screening. Frequency Restricted to:
o Diabetes:
 Every 3 years from age 30
 High risk individual annually from age 18
 Adult Pneumococcal Conjugate Vaccine
 Cancer Screening and treatment
o Screening, Healthcare services, investigations and
treatments only for members who are enrolled
under Patient Support Program.
 Hepatitis B Virus Screening and treatment Covered as per terms, conditions and exclusions of the program defined by
 HCV Hepatitis C Virus Infection DHA
Screening, Healthcare services, investigations and
treatments related to viral Hepatitis and associated
complications related to Hepatitis C shall only for be for
members who are enrolled under Patient Support
Program.
DUBAICARE DUBAI INSURANCE CO. (P.S.C)

Diagnostic and treatment services for dental and gum

treatments Subject to 20% coinsurance

Hearing and vision aids, and vision correction by surgeries Excluded healthcare services except in cases of medical emergencies
and laser

Claims Settlement Basis

Inside U.A.E
Within Network: 100% on direct billing subject to applicable coinsurance.
Outside Network, within UAE (In-patient): Not covered except for Emergencies & Life-threatening cases only
Outside Network, within UAE (Out-patient): Not covered

Outside UAE, within Area of Cover (In-Patient only for Elective & Emergency Treatment): 100% of actual costs subject to a maximum of 80% of
applicable UAE Network tariff on reimbursement basis, prior approval required from the insurance company within 24 hours of admission to the
authorized hospital
Outside UAE, within Area of Cover (Out-Patient Treatment): Not Covered
DUBAICARE DUBAI INSURANCE CO. (P.S.C)

Premium

Premium No. Of
Region Age Band Total
(Per Person Per Year) Lives
Dubai - NLSB 00 - 65 715 0.00
Dubai - LSB 00 - 65 525 0.00
Northern Emirates 00 - 65 525 0.00
Basmah & HCV Charges 37 0 0.00
Total 0.00
VAT - 5% 0.00

GRAND TOTAL 0.00

VAT Clause
The quote provided above is inclusive of Value Added Tax ('VAT') which may be applicable on the policy.

**The company reserves the right to vary the premium rates, if there is a change in the total number of insured members above
or below 15% during the policy year.

Product Guidelines
1 Minimum number of employees per group shall be 5, and maximum up to 500 lives.
Eligible dependents can be added on compulsory basis. Children will be accepted up till age of 18 years. Subject to
2 undertaking letter that all dependents are covered and no additions or deletions during the policy year except for new
entry or new born or for all employees to be covered.
3 These plans are not applicable for persons holding Abu Dhabi visa;
4 All overage members above age 65 need to be referred to the underwriter with the Health Declaration form.
5 No Anti selection is allowed. All employees need to be covered as per MOL
Following Groups are not Eligible for these Plan Rates: (Need to approach Insurer for Quotation)
 Association Groups
 Transportation Companies
 Insurance Companies. TPA’s & Insurance Brokers
 Schools & Universities
6  Healthcare Providers
 Clubs
 Government entities
 Religious groups
 Legal firms
 Airlines
7 Group Declaration form is mandatory
8 All Plans are eligible for LSB and HSB members up to Salary AED 16,000 only
DUBAICARE DUBAI INSURANCE CO. (P.S.C)

DHA EXCLUSIONS

This Insurance Policy is intended to provide cover for expenses incurred for Medical Treatment of Medical Conditions or
Bodily Injuries which, in the opinion of both the treating physician are Medically Necessary and which are covered under
the Terms and Conditions of the Insurance Policy.
This Insurance Policy does not cover, amongst other things, expenses arising directly or indirectly from the following:
Excluded healthcare services except in cases of medical emergencies
1. Diagnostic and treatment services for dental and gum treatments
2. Hearing and vision aids, and vision correction by surgeries and laser

Excluded (non-basic) healthcare services

1. Healthcare Services which are not medically necessary
2. All expenses relating to dental treatment, dental prostheses, and orthodontic treatments.
3. Care for the sake of travelling.
4. Custodial care including
(1) Non‐medical treatment services;
(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 that 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, 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. Treatment and services for contraception
14. 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.
15. External prosthetic devices and medical equipment.
16. Treatments and services arising as a result of professional sports 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 other professional sports activities.
17. Growth hormone therapy unless medically necessary.
18. Costs associated with hearing tests, prosthetic devices or hearing and vision aids.
19. Mental Health diseases, both outpatient and in‐patient treatments, unless it is an emergency condition.
20. 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.
21. 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.
22. Services rendered by any medical provider who is a relative of the patient for example the Insured person himself or
first‐degree relatives.
23. Enteral feedings (via a tube) and other nutritional and electrolyte supplements, unless medically necessary during in‐
patient treatment.
24. Healthcare services for adjustment of spinal subluxation.
DUBAICARE DUBAI INSURANCE CO. (P.S.C)

25. Healthcare services and treatments by acupuncture; acupressure, hypnotism, massage therapy, aromatherapy, ozone
therapy, homeopathic treatments, and all forms of treatment by alternative medicine.
26. All healthcare services & treatments for in‐vitro fertilization (IVF), embryo transfer; ovum and sperms transfer.
27. Elective diagnostic services and medical treatment for correction of vision
28. Nasal septum deviation and nasal concha resection.
29. All chronic conditions requiring haemodialysis or peritoneal dialysis, and related investigations, treatments or
procedures.
30. Healthcare services, investigations and treatments related to viral hepatitis and associated complications, except for
the treatment and services related to Hepatitis A and C.
31. Any services related to birth defects, congenital diseases and deformities unless if left untreated will develop into an
emergency.
32. Healthcare services for senile dementia and Alzheimer’s disease.
33. Air or terrestrial medical evacuation and unauthorized transportation services.
34. Inpatient treatment received without prior approval from the insurance company including cases of medical
emergency that were not notified within 24 hours from the date of admission where possible.
35. Any inpatient treatment, investigations or other procedures, which can be carried out on outpatient basis without
jeopardizing the Insured Person’s health.
36. Any investigations or health services conducted for non‐medical purposes such as investigations related to
employment, travel, licensing or insurance purposes.
37. All supplies which are not considered as medical treatments including but not limited to: mouthwash, toothpaste,
lozenges, antiseptics, , 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.
38. More than one consultation or follow up with a medical specialist in a single day unless referred by the treating
physician.
39. 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 unless if left untreated
will develop into an emergency.
40. Any expenses related to immunomodulators and immunotherapy unless medically necessary.
41. Any expenses related to the treatment of sleep related disorders.
42. Services and educational programs for people of determination, this also includes disability types such as but not
limited to mental, intellectual, developmental, physical and/or psychological disabilities.

Healthcare services outside scope of 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 as per Federal Law No. 8 of 1980 concerning the Regulation
of Work Relations, its amendments, and applicable laws in this respect.
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 and C hepatitis.
DUBAICARE DUBAI INSURANCE CO. (P.S.C)

Terms & Conditions

 The proposal assumes compulsory coverage for all employees residing in UAE on valid residence and there is no
voluntary option exercised by any employee.
 This policy assumes that all UAE national members, if any, enrolled under this scheme do not hold Thiqa medical Cards.
 All employees must be on the payroll of the policy holder.
 The benefits offered in this quotation do not comply with the Health Authority Abu Dhabi regulation for compulsory
insurance and hence Abu Dhabi residence visa holders and/or members working/residing in Abu Dhabi/Al Ain and/or
any person likely to be working in Abu Dhabi/Al Ain temporarily or permanently are not eligible for this cover.
 The quote is valid for 30 days from the date of issue.
 If dependents are to be covered it has to be on compulsory basis within the group /sub group for all employees with
dependents residing in UAE on valid residence. There is no voluntary option exercised by any employee to add his/her
dependents
 Quotation is available only to United Arab Emirates Nationals and persons holding a valid residence status visa for the
United Arab Emirates and who are ordinarily resident in the United Arab Emirates.
 All known major pre- existing / Chronic cases including but not limited to Chemotherapy, radiotherapy, Heart surgery,
any major surgery, renal dialysis & osteoarthritis treatment to be mentioned to Dubai Insurance Company before
submitting the final documents to issue the policy if the policy is subject to major medical declaration and Members
having any major medical conditions (as detailed above) shall be subject to individual medical evaluation & acceptance
shall be at the discretion of the insurer with an additional premium &/or application of sub limits or declined
 This quote is valid only if all categories proposed are selected and with no substantial variation in total member census or
distribution of members in each category.
 Maximum age of entry is up to 64 years, members 65 years and above shall be subject to individual medical evaluation &
acceptance shall be at the discretion of the insurer with an additional premium &/or application of sub limits or declined
 Children are covered from Date of Birth
 Change of benefits class may only take place at renewal of the Group Scheme or upon satisfactory proof of promotion.
 Deductibles and any co-insurance amounts are to be paid by the insured person. If deductibles and/or co-insurance
amounts are paid by the employer the premium quoted will be subject to revision.
 Premiums are per person per annum and are payable annually in advance.
 If maternity cover is included all female employees and spouses must be enrolled.
 If routine dental treatment is covered all persons must be enrolled.
 Where pre-existing conditions are not covered, Medical Health Declaration form needs to be completed by all the
applicants. DIN reserves the right to ask for any medical check-up if necessary and the cost of which should be borne by
the applicant.
 This proposal is based on the information given. Any change in the number, age or sex of the persons to be insured or
the scope of coverage will result in recalculation of the premium rates.
 Additions/Deletions will be on a pro-rata premium basis.
 Treatment within the DubaiCare Network in UAE will be settled on a direct billing basis.
 The company reserves the right to vary the premium rates, if there is a change in the total number of insured members
above or below 15% during the policy year.
 No Insurer shall be deemed to provide cover and no insurer shall be liable to pay any claim or provide any benefit
hereunder to the extent that the provision of such cover, payment of such claim or provision of such benefit would be in
violation of any trade or economic sanctions, laws or regulations applicable in the insurer jurisdiction of domicile, or
which the insurer is legally obligated to comply.
 Required minimum number of employees in a category is 03.
 ALL NETWORKS: Please note that the network list is subject to change without any prior notice due to various factors.
DUBAICARE DUBAI INSURANCE CO. (P.S.C)

Cancellation of the policy

The Policy can be cancelled by either party giving 30 days notice in writing to Dubai Insurance co. (P.S.C).
In the event of cancellation by the Policyholder, Dubai Insurance co. (P.S.C) will retain premium as per the following short
term premium rates.

• 25% of the annual premium for the first month or part thereof.
• 12.5% of the annual premium for each subsequent month or part thereof

Dubai insurance co. (P.S.C) have the right to cancel the policy with immediate effect if;

• Premium is not paid as per the premium payment agreed terms or issued CDC/PDC Cheques are not honored.
• Misrepresentation of info
• None disclosure of material facts.

In the event of cancellation by the company, Dubai insurance co. (P.S.C) will refund premium for the remaining policy period
on prorate premium basis.

Errors & Omissions excepted (E & OE):

• We make every effort to make sure that the information in this document is accurate and up to date, based on the
information given to us.
• We will promptly correct any errors brought to our attention. If you find an error, please contact us.
• We cannot accept responsibility for the supply of incorrect information, copied within this document.
• We reserve the right to withdraw this quotation and its acceptance at any point and for any reason. You will be
informed immediately if such a situation arises