Page 23 - 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
5 Accommodation charges incurred as an FULL REFUND

In-Patient or as a Day-Care Patient on a
per day basis in a Private Room

6 Approved Ancillary Charges incurred as an FULL REFUND
In-Patient or Day-Care Patient

Prescribed medicines and drugs combined
7 administered whilst an In-Patient or Day- FULL REFUND
Care Patient and charged separately.
8 Surgeon’s and Anaesthetists’ Services FULL REFUND

9 Specialist Physicians’ Services for In- FULL REFUND
Patient Treatment

In-Patient Specialist Services including
10 consultations and Diagnostic Procedures FULL REFUND
as recognized by T.P.A. administration.

Radiotherapy, Chemotherapy and
11 Computerised Tomography received as an FULL REFUND
In-Patient OR Out-Patient as referred by
an approved Specialist.
Pre-approved Minor Surgical Procedures
12 undertaken by a General Practitioner at a FULL REFUND
Recognised Medical Facility, Hospital or
Private Hospital.

13 Treatment at any State Health Service/ Reimbursed up to a maximum of the applicable UAE
Government Hospitals.
Network charges / rates.
Reasonable charges necessarily incurred
14 for the use of private road ambulances in FULL REFUND
the time of an emergency.
FULL REFUND (Subject to a max of 13 Weeks of such
15 Home Nursing Care if medically necessary Nursing per Member or Dependant per Period of
Insurance)
In-Patient Parent/Companion
16 accommodation for child up to age 16 UAE Dhs. 300 per night (subject to a max of UAE
Dhs. 3,000 per Period of Insurance)
years

17 Organ Transplant Limit (as recipient) for Fully covered up to Annual Benefit Level
Heart, Liver & Kidney only