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Benefits & Limit of Coverage Under Policy No

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Benefits & Limit of Coverage Under Policy No مستوى التغطية Level of Cover CLASSIC نطاق التغطية المملكة العربية السعودية Geographical Area KSA الحد اﻷقصى لتغطية كل فرد 500,000 لاير Overall annual cover per member SR. 500,000 التنويم الداخلي In-patient Appropriate medical treatment, surgical & العﻻج الطبي المناسب، الجراحة و اﻹجراءات الطبية، اللوازم غرفة مشتركة medical procedures, medical supplies & Share Room الطبية والخدمات, تكلفة التمريض والدكتور وغرفة العناية services, nursing & doctor’s fees, emergency المركزة (room, Intensive Care Unit (ICU نسبة التحمل في التنويم الداخلي – المشاركة في الدفع ﻻ يوجد Coinsurance/Deductible - Inpatient Nil حد اﻹقامة واﻹعاشة خارج الشبكة لكل يوم 600 لاير Room & Board limit outside APN per day SR. 600 Room & Board charges for Companion (shared حد اﻹقامة واﻹعاشة اليومي للمرافق )غرفة مشتركة( 150 لاير SR. 150 Room) العﻻج بالعيادات الخارجية Out-patient treatment الحد اﻷدنى Minimum Limit اﻹقتطاع / التحمل داخل شبكة الحد اﻷدنى Deductible within minimum limit APN 20% بحد أقصى 75 لاير Max SR. 75 20% الحد اﻷعلى Maximum Limit اﻹقتطاع / التحمل للمستشفيات خارج شبكة الحد اﻷدنى Deductible for hospital not within minimum 20% بحد أقصى 75 لاير Max SR. 75 20% limit APN الحد اﻷوسط Medium Limit اﻹقتطاع / التحمل لباقي مقدمي الخدمة خارج شبكة الحد Deductible for other service providers not 20% بحد أقصى 75 لاير Max SR. 75 20% اﻷدنى within minimum limit APN Consultations should be done according to usual treatment procedure as إستشارة الطبيب مغطاة وتتم المعاينة للمستفيد بحسب تسلسل إجراءات تقديم الخدمة إﻻ في حالة follows here under unless the needed service is not available in the عدم توفر الخدمة في مركز تقديم الخدمة medical provider الحد اﻷقصى لتكاليف الطبيب داخل الشبكة Maximum Doctor Fees Inside APN As per CCHI As per CCHI الحد اﻷقصى لتكاليف الطبيب خارج الشبكة Maximum Doctor Fees outside APN As per CCHI As per CCHI الطبيب العام 50 لاير General Practitioner SR. 50 أخصائي )طبيب نائب أول( 200 لاير First Specialist SR. 200 أخصائي )طبيب نائب ثاني( 100 لاير Second Specialist SR. 100 اﻹستشاري 300 لاير Consultant SR. 300 التخصصات ذات الندرة 500 لاير Rare Specialists SR. 500 حد الموافقة المسبقة 500 لاير Pre-Authorization Limit SR. 500 نفقات الحمل والوﻻدة 15,000 لاير Maternity Expenses SR. 15,000 New born babies are covered under the تكاليف تغطية المواليد الجدد على وثيقة اﻷم وبحد أقصى 30 mother's policy up to 30 days of delivery until يوم من تاريخ الوﻻدة حتى يتم اضافتهم على الوثيقة بأثر رجعي مغطى Covered added in the policy retroactively from the date من تاريخ الوﻻدة of birth مضاعفات الحمل والوﻻدة مغطى Maternity Complications Covered الختان للمواليد الجدد اﻷوﻻد 500 لاير Circumcision for male newborn babies SR. 500 تخريم اﻷذن للمواليد الجدد البنات 300 لاير Ear piercing for female newborn babies SR. 300 Premature Babies & life threatening اﻷطفال الخدج والتشوهات الخلقية المهددة للحياة مغطاة لﻷطفال Congenital Deformities for new Born Babies مغطى Covered الجدد إذا كانت منفعة الحمل والوﻻدة مغطاة لﻷم are covered only whenever Maternity is covered for the mother Vaccinations (As per Ministry of Health plan النطعيمات طبقا لجدول وزارة الصحة ولغاية 6 سنوات مغطى Covered up to 6 years of age) تكاليف البرنامج الوطني للفحص المبكر لحديثي الوﻻدة للحد National program of early neonatal screening to 100,000 لاير SR. 100,000 من اﻹعاقة reduce disability عﻻج اﻷسنان 2,000 لاير Dental treatment SR. 2,000 النظارة الطبية :Cost of spectacles 400 لاير SR. 400 الحد اﻷعلى الفرعي ﻹطار النظارة 400 لاير Spectacles sub limit for frame SR. 400 التشوهات الخلقية المهددة للحياة مغطى Life threatening congenital Deformities Covered Page 8 of 15 تكاليف حاﻻت التلف في صمامات القلب المكتسبة 150,000 لاير Acquired heart valves deficiency SR. 150,000 اﻷمراض السابقة و المزمنة مغطى Pre-Existing and Chronic Covered تكاليف إجراء عملية التبرع باﻷعضاء للمتبرع 50,000 لاير Organ transplantation expenses for the Donor SR. 50,000 العﻻج الطبيعي والتأهيل مغطى Physiotherapy and Rehabilitation Covered غسيل الكلى 100,000 لاير Renal dialysis SR. 100,000 Acute psychological cases expenses including 4 الحاﻻت النفسية الحادة وتشمل 5,000 لاير للحاﻻت النفسية 15,000 لاير sessions and medications up to SR. 5,000 for SR. 15,000 الغير حادة لـ 4 جلسات مع اﻷدوية خﻻل مدة الوثيقة non-acute cases during the policy period عمليات جراحة معالجة السمنة المفرطة عن طريق عملية تكميم Gastric sleeve surgeries if the body mass index 20,000 لاير SR. 20,000 المعدة فقط Sleeve في حال تجاوز كتلة الجسم exceeds 45 BMI 45 تكاليف حاﻻت التوحد 50,000 لاير Autism Cases SR. 50,000 تكاليف حاﻻت الزهايمر 15,000 لاير Alzheimer Cases SR. 15,000 تكاليف حاﻻت اﻹعاقة 100,000 لاير Cost of disability cases SR. 100,000 تكاليف السماعات الطبية 6,000 لاير Cost of Hearing Aids SR. 6,000 سيارة اﻹسعاف مغطى Ambulance Covered إعادة الجثمان إلى المواطن اﻷم 10,000 لاير Repatriation of mortal remains to home country SR. 10,000 Respiratory Syncytial Virus (RSV) vaccination برنامج التحصينات لفيروس اﻹلتهاب التنفسي المخلوي )RSV( مغطى program as per the vaccination schedule issued Covered وفق جدول التحصينات للفيروس والصادر من وزارة الصحى by the Ministry of Health برنامج الفحص المبكر لﻹعاقة السمعية وبرنامج تشوهات القلب Early screening programs for hearing disability مغطى Covered الخلقية الحرجة لجميع المواليد and critical congenital heart defects Milk for newborn babies until the age of 24 حليب اﻷطفال للرضع المحتاجين إليه طبيا حتى عمر 24 شهر مغطى Covered months if medically required تكاليف معالجة الصدفية مغطى Psoriasis treatment expenses Covered 80% حسب أسعار المراكز الطبية المعتمدة في الشبكة داخل المملكة أو أيهما أقل. لن يتم تطبيق مبدأ التعويض النقدي على مطالبات عﻻج اﻷسنان والنظر. في حاﻻت التنويم يشترط الموافقة المسبقة من اتحاد الخليج. باﻹضافة يجب تسليم جميع المستندات خﻻل 30 يوم من تاريخ تلقي العﻻج. تغطية مصاريف العﻻج للحاﻻت غير الطارئة في العيادات Cash reimbursement for Non-Emergency Cases الغير معتمدة داخل المملكة العربية السعودية in (K.S.A) incurred outside APN 80% subject to network rating in KSA or which is less. However, prior approval should be obtained from Gulf Union for inpatient cases only and no cash reimbursement for Dental and Optical claims .In addition to that all cash claims documents shall be submitted to us within 30 days from date of treatment غير مغطى تغطية مصاريف العﻻج للحاﻻت غير الطارئة في العيادات Cash reimbursement for Non-Emergency Cases الغير معتمدة خارج المملكة العربية السعودية out of (K.S.A) incurred outside APN Not Covered 100% حسب أسعار المراكز الطبية المعتمدة في الشبكة داخل المملكة أو أيهما أقل. في حاﻻت التنويم يشترط إخطار اتحاد الخليج خﻻل 24 ساعة من تلقي العﻻج. يجب تسليم جميع المستندات خﻻل 30 يوم من تاريخ تلقي العﻻج. تغطية مصاريف العﻻج للحاﻻت الطارئة في العيادات الغير Cash reimbursement for Emergency Cases in 100% subject to network rating in KSA or معتمدة داخل المملكة العربية السعودية K.S.A.) which is less. should be inform Gulf Union for) inpatient cases within 24 hours from treatment. In addition to that all cash claims documents shall be submitted to us within 30 days from date of treatment Page 9 of 15 100% حسب أسعار المراكز الطبية المعتمدة في الشبكة داخل المملكة أو أيهما أقل. في حاﻻت التنويم يشترط إخطار اتحاد الخليج خﻻل 24 ساعة من تلقي العﻻج. يجب تسليم جميع المستندات خﻻل 60 يوم من تاريخ تلقي العﻻج. تغطية مصاريف العﻻج للحاﻻت الطارئة في العيادات الغير Cash reimbursement for Emergency Cases out 100% subject to network rating in KSA or معتمدة خارج المملكة العربية السعودية of (K.S.A.) which is less. should be inform Gulf Union for inpatient cases within 24 hours from treatment. In addition to that all cash claims documents shall be submitted to us within 60 days from date of treatment شبكة المرافق Network of Providers CLASSIC Page 10 of 15 Network - 200000189 to 200000195 (ABDUL AZIZ M AL MADHI AND PARTNER CO) Gulf Union Cooperative Insurance Company Health Insurance Policy – Health Care Provider Network ( Kingdom of Saudi Arabia) Gold Silver Classic Deductible Type of Provider (Preferred (Preferred (Preferred Tel No اسم مقدم الخدمة` Region City Provider Name Provider Provider Provider Type Network) Network) Network) Medical Complex Gold Silver Classic Minimum 138200150 مجمع اﻷحمدي الط يب - بالدمام Eastern Dammam Al Ahmadi Medical Complex Medical Center Gold Silver Classic Minimum 138427461 مجمع الذكري الط يب - بالدمام Eastern Dammam Al Thukair Medical Center Dispensary Gold Silver -- Medium 138122161 مجمع المانع الط يب بالمنطقة الصناعية الثانية . بالدمام Eastern Dammam Al Mana Medical Dispensary -Dammam Dispensary Gold Silver -- Medium 138182584 مجمع عيادات الراي الط يب- بالدمام Eastern Dammam Al Rai Medcial Dispensary - Dammam Dispensary Gold Silver -- Medium 138420909 مستوصف الفارا يب - الدمام Eastern Dammam Al Faraby Dispensary - Dammam Clinic Gold Silver -- Medium 138420909 مستوصف الفارا يب بالصناعية اﻷوىل Eastern Dammam Al Faraby Medical Center- Industrial City Medical Services Gold Silver -- Medium 138097777 مجمع الكحال الط يب بالدمام Eastern Dammam Kahhal Company For Medical Services Hospital Gold -- -- Maximum 138262111 مستش ىف المانع العام بالدمام Eastern Dammam Al Mana Hospital - Dammam Hospital Gold -- -- Maximum 138200000 مستش ىف المواساة بالدمام Eastern Dammam Al Mouwasat Hospital - Dammam Medical Complex Gold Silver -- Medium 138346555 مجمع لروضة الط يب بالدمام Eastern Dammam Arrawdha Medical Complex Dispensary Gold Silver Classic Minimum 138326000 مستوصف بدر الربيع الط يب بالدمام Eastern Dammam Badr Al Rabie Dispensary - Dammam Medical Center Gold Silver -- Medium 920005510 مجمع المركز الكندي الط يب العام -بالدمام Eastern Dammam Canadian Medical Center Clinic Gold -- -- Medium 138276195 عيادات أمراض القلب واﻷوعية الدموية بالدمام Eastern Dammam Cardio Vascular Centre - Dammam Dispensary Gold Silver Classic Minimum 138056888 مجمع الدمام الط يب الخاص رقم 1 بالدمام Eastern Dammam Dammam Private Medical Complex 1 Medical Complex Gold Silver Classic Minimum 138204221 مستوصف الدمام الط يب رقم 2 بالدمام Eastern Dammam Dammam Private Medical Complex 2- Industrial Medical Complex Gold Silver -- Medium 138434090 مجمع عيادات الدمام اﻻه يل بالدمام Eastern Dammam Dammam National Medical Complex Clinic Gold Silver Classic Minimum 138253331 مجمع دار الحكمة الط يب .
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