Page 22 - Ipsos

IPSOS STAT FZ LLC

Attached to and forming part of the Policy No: - TBA

(Policy Period: - September 28th, 2016 To December 31st, 2017)

BENEFIT SCHEDULE – CLASSIC PLAN – CATEGORY A – Non Abu Dhabi
The following Benefits Schedule should be read together with the whole of the Policy wording, particularly
the Definitions and it shall override the Policy Wordings wherever deemed necessary

TYPE OF SERVICE & BENEFIT COST, CHARGES AND FEES
PAYABLE

Maximum Annual Aggregate Benefit Level
1 i) In-Patient Limit AED. 350,000/- per member

Room & Board Class Private Room

Unlimited visits.
ii) Out-Patient Limit

i) Geographical Territory i) UAE, Arab Countries, South East Asia,
Elective / Non Emergency / Emergency Indian Sub-continent

2 ii) Restricted to Emergency Treatment whilst traveling ii) World-wide Excluding USA & Canada
outside of country of normal residence either on vacation and claim will be reimbursed at 100% of the
or business up to a maximum stay of 60 days per trip. equivalent of the applicable Network

charges.

i) Consultations including initial consultations FULL REFUND
and examinations in respect of a medical
condition.

ii) Out-Patient Medicines and Drugs combined FULL REFUND
which require a prescription including any state
3 Health Service charges for such Medicines and
Drugs.
(Except those being listed on the Third Party
Administrator list of exclusions) FULL REFUND
iii) Prescribed Out-Patient Diagnostic Tests

iv) Prescribed Out-Patient physiotherapy Full refund but limited to 15 sessions per
treatment illness.

Contribution per person:
Covered with 15% copayment per
i) Deductible applicable on Physician consultation up to a maximum of Deductible
4 consultation AED 50/-

ii) Co-Insurance applicable on Not applicable for follow up within 7 days
Pharmaceuticals, Diagnostic tests and 15% Co. Insurance
Physiotherapy