."/01'*23&,%/34"* !"#$"%&'()*+,(-"* !"#$%&'(%)**+%$'%,)'!% AXA Agent With more than 102 million customers around the globe, AXA is one of the world’s largest insurance providers. We offer a wide range of insurance products to meet your personal and business needs. Car insurance Health insurance Home insurance Travel Insurance M P 6 1 0 2 3 1 1 1 1 R P 1 1 7 1 1 N E 3 1 L C R A S 800 116 0020 www.axa-cooperative.com AXA Cooperative Insurance Company A company registered with the Ministry of Commerce and Industry of the Kingdom of Saudi Arabia under Commercial Registration No.1010271203 and holding Insurance license No. TMN/25/20101 issued by the Saudi Arabian Monetary Agency Table of Contents Section Page Description No. 1. Welcome to AXA Cooperative 1 Insurance Company Your Membership Card 2. How to contact AXA 2 3. The purpose of your coverage 3 4. Entitlement 4 Eligibility Period of Cover Effective Date Expiry Date 5. Your coverage 5 What we pay for Table of enefits Limitations and Exclusions . est use of your benefits and 8 how to claim Where to receive treatment? Designated network for In-patient and day-care treatment Outside your designated network Direct billing versus reimbursement Reimbursement claim 7. Prior approval 10 Why do we require a prior approval? Prior Approval for Treatment on a Reimbursement Basis Prior Approval for Treatment on a Direct Billing Basis What if we do not seek prior approval when required? How long does it take to obtain a prior approval? Emergency Treatment Requiring Hospitalization 8. To Summarize 12 . efinition of terms 13 10. Providers 18 11. TOB 56 12. Reimbursement Claim Form 58 membership guide 1.Welcome to AXA Cooperative Insurance Company Please read this guide and the This Membership Guide was created to accompanying Table of enefits before provide you with an overview of your you or one of your dependents needs company’s healthcare insurance plan medical treatment. Then relax, with AXA. Please use it along with your acknowledge you have access to the personal Table of enefits and best available healthcare service Membership Card to understand through AXA Cooperative Insurance various benefits available to you. Company. Your Membership Card Your company selected AXA Cooperative Membership Cards for you and your Insurance Company to manage your eligible insured dependents are healthcare benefits. is one of the important documents; please ensure world’s most trusted healthcare that the information on these cards is benefits companies, providing superior accurately in line with your personal details. coverage in more than 200 countries worldwide. Kindly note, prior to admission or We have incorporated the Arabic word receiving treatment you must identify yourself and your eligibility for “Seha” into the name of our healthcare treatment by showing your medical I.D. plans as a reection of our card together with a recognized official commitment to helping you stay form of identification such as ational healthy. To that end, we will do ID or Iqama) to any network provider as everything possible to give you access evidence that you are an insured to the best available care to support you member of an AXA insurance policy. and your family. As a member of an “AXA Seha” plan, you have the opportunity to benefit from our healthcare experience and our commitment to excellence. Healthcare Membership Card Policy Number Name: Number of your policy, used as Policy No.: re f erence by AXA and medical Network providers. Membership No.: NW: Medical provider network as DOB: ID No. agreed with your company. Membership Number Emp ID: ID No. Membership number is unique and Saudi/iqama number as provided medicalproviders use this number to Policy holder: by your company. Benefits: verify your benefits with AXA. Valid Date Benefits Valid From: To: Start and end of your policy The benefit applied with services, Area of Cover: coverage. roomlevel shows on the medical card Area of Cover Hospital Clinic/Polyclinic Lower NW Geographical areas of coverage in accordancewith the agreement during Policy issued by AXA Cooperative Insurance Company (ACIC) the contract withmember company’s Deductible The amount you have to p ay directly to the medical provider whenever you have a treatment 1 2. How to contact AXA If you have any questions about your an ress healthcare coverage, please contact Healthcare Department your Human Resources Department AXA Cooperative Insurance Company first and for further clarification, please P.O. Box 21044 contact us. Our team is available to iyadh discuss your treatment options and ingdom of audi rabia answer the questions you may have about your coverage via the phone/fax este numbers and office hours shown For further information, please visit our below. website at: aaeratem Toll free number: 800 116 0020 available 24/7 Land line number: +966 11 413 6900 Fax: +966 11 477 3097 fie urs unday to Thursday from 8:00 AM to 5:00 PM Always by your side áe~≤ŸGáe~ÿG ∫ƒM äɶMÓª∏d 920001177 /≈∏Y ∫É°üJE’G AÉLôdG ﻭﺻﻴﻞ w For Remarks about the service CCHI Call Center Toll - Free Prided call / 920001177 contact number For Customer Service Please call below Numbers á«dÉàdG ΩÉbQC’G »∏Y ∫É°üJ’G AÉLôdG AÓª©dG áe~ÿ »∏Y ∫É°üJ’G AÉLôdG áµ∏ªŸG πNGO øe ∫É°üJÓd Within Saudi Arabia Please Call 800 11 60020 AXA Customer Service Outside Saudi Arabia Please Call +966 11 4136900 »∏Y ∫É°üJ’G AÉLôdG áµ∏ªŸG êQÉN øe ∫É°üJÓd Toll Free contact number This Card is the property of AXA Cooperative Insurance Company and is void if membership is terminated www.axa-cooperative.com AXA Cooperative Insurance Website 2 membership guide 3. The purpose of your coverage “When my daughter broke her arm at school last winter, AXA network gave us access to a medical center close to my home and I was able to sleep at night without worrying about hospital costs.” What your health insurance cover is designed to do As with all insurance policies your “Seha” healthcare plan is there to cover you for costs arising from an unforeseen event. For healthcare insurance this means the cost of eligible treatment resulting from an unexpected illness or accident. You must take care of your own health and do not only rely on healthcare professionals to do this for you. When something unfortunate does affect your health we will do our best to help you but we must always act within the limits of your policy. At the same time, it is important that all members realize that it is in everyone’s best interest to use the group healthcare plan sensibly and responsibly to keep future premiums affordable. The level of premium your company pays for group coverage is determined by the amount of claims paid under the plan. When the plan is used irresponsibly, premiums can go up unnecessarily, taking funds away from other Company/Employee initiatives. 3 4. Entitlement Eligibility are eligible and we have not received a All on-the-job employees shall be written request for your enrolment from eligible from the date of commence- your company within 30 days, we ment of the Policy. Employees who reserve the right to request from you to later join the service of the policyholder fill and complete a ealth eclaration shall be eligible from the date of joining Form and charge you an additional the service or arrival to the Kingdom of premium. Saudi Arabia. pouses Expiry Date hildren inimum from date of Your coverage will cease at the earliest birth of the following dates ons aimum years of age. piry date of the ealth lan (Insurance coverage under the policy ancellation date of the shall include the employee’s ealth lan unemployed daughters who are ate when you cease to be eligible unmarried, widowed or divorced who for inclusion in the health plan in the are dependents of the employee) event you stop being eligible during The period of cover your company must Period of Cover send us a written request for deletion The health plan is normally valid for immediately and your membership aperiod of year unless agreed must be return cards to the company, otherwise by us in writing. Effective and including the ones of your dependents epirydates of your plan are shown on if applicable. yourmembership card and on your table ofbenefits. Please note that we will not accept a deletion date which is more than thirty Effective Date days from the date we receive the Your coverage can start if you are written request for deletion. f we find eligible and if we have received from out that you are no longer eligible and your company a written request for that your company has failed to notify enrollment in no later than ten us about your deletion, we will suspend days.Your coverage can start from the your coverage. Please note that the following date day you stop being eligible, your ffective date of the ealth lan dependents automatically will cease to ate when you first became eligible be eligible. Your company must notify us in writing about your enrolment. In the event you 4 membership guide 5. Your Coverage WHAT WE PAY FOR (RECOVERABLE f. Cases of contagious diseases EXPENSES/BENEFITS) requiring isolation in hospitals For purposes of the policy, recoverable as specified by the inistry of Health. expenses shall mean the actual costs incurred for services, supplies and g. Cases of Alzheimer within the equipment, not excluded in Section limits specified in the policy 4.3, prescribed by a licensed physician schedule. for an illness occurring to the beneficiary, provided such epenses h.