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MetLife - IEBP (Individual Essential Benefit Plan)

Aggregate Limit : AED 150,000 per member per policy

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Co Participation : Co-Pay 20% Max upto AED 500

Network Type : EBP Network

Territory of Coverage : UAE Only

Class : Semi-Private (2 Beds)

Benefit Highlights

Please refer to the product notes (Table of Benefits) for detailed information

Referral Procedure:

•In respect of Essential Benefit Plan members, 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.

Approval Requirements:

• Non urgent medical cases (Elective) – Prior approval is compulsory
• Emergency medical service - Approval required from the insurance company within 24 hours of admission to the authorized network hospital

Liability (coinsurance) of the Insured member and the Insurance company:

• 20% coinsurance payable by the insured with a cap of AED 500 payable per encounter
• Annual aggregate cap of AED 1,000
• Above these caps the insurer will cover 100% of treatment.

Hospitalization Class:

Semi Private Room / Shared Room *In-patient services will be received in rooms of two or more beds

Hospital Accommodation and related Service:

Covered

Intensive care unit and coronary artery disease treatment:

Covered

Consultant’s, Surgeon’s and Anesthetist’s Fees:

Covered

Various therapies including physiotherapy, chemotherapy, radiation therapy etc.:

Covered

Use of hospital medical equipment (e.g. heart and lung support systems etc.):

Covered

Ground transportation services in the UAE provided by an authorized party for medical emergencies (Ground Ambulance Services):

Covered

The cost of accommodating a person accompanying an insured child up to the age of 16 years:

Covered maximum up to AED 100 per night

The cost of accommodation of a person accompanying 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:

Covered maximum up to AED 100 per night

Repatriation costs for the transport of mortal remains to the country of origin:

Covered up to AED 5,000

Co Participation : Co-Pay 20% Max upto AED 500

Network Type : EBP Network

Territory of Coverage : UAE Only

Class : Semi-Private (2 Beds)

Benefit Highlights

- Please refer to the product notes(Table of Benefits) for detailed information

Referral Procedure:

Examination, diagnostic and treatment services by authorized general practitioners, specialists and consultants:

20% coinsurance payable by the insured per visit No coinsurance if a follow-up visit made within seven days

Laboratory Tests & Radiology Diagnostic services:

20% coinsurance payable by the insured per visit In cases of non-medical emergencies, prior approval is required for MRI, CT scans and endoscopies

Pharmaceuticals:

30% coinsurance payable by the insured in respect of each and every prescription Cost of drugs and medicines are covered up to an annual limit of AED 1,500(including coinsurance). *Restricted to formulary products where available

Preventive services, vaccines and immunizations - For New Born and Children:

• Essential vaccinations and inoculations for newborns and children as stipulated in DHA’s policies and its updates (Currently the same as federal MOH) • Claims covered on reimbursement basis as per coverage specified in ‘Claims Settlement Terms’ of this TOB

Preventive services, vaccines and immunizations - For Adults:

• Diabetes: – Normal Risk: Every 3 years from age 30 – High risk individuals annually from age 18
• Preventive services as mandated by DHA periodically

Physiotherapy (Require Pre-authorization):

20% coinsurance payable by the insured per session Covered up to 6 sessions per member per year

Co Participation : Co-Pay 20% Max upto AED 500

Network Type : EBP Network

Territory of Coverage : UAE Only

Class : Semi-Private (2 Beds)

Benefit Highlights

- Please refer to the product notes(Table of Benefits) for detailed information

Maternity Services:

*Where any condition develops which becomes an emergency, the medically necessary expenses will be covered up to the annual aggregate limit

Out-patient ante-natal services:

Requires prior approval from the insurance company • 10% coinsurance payable by the insured 8 visits to PHC
• Visits to include reviews, checks and tests in accordance with DHA Antenatal Care Protocols
• All care provided by Primary
• HealthCare obstetrician for low risk or specialist obstetrician for high risk referrals
Initial investigations to include:
• FBC and Platelets
• Blood group, Rhesus status and antibodies
• VDRL
• MSU & urinalysis
• Rubella serology
• HIV
• FBS, Random blood sugar OR HbA1C
In addition to the above, the below tests are covered for high risk pregnancies only • GTT, if high risk
• Hepatitis C
Ultrasonography: 3 ante natal ultrasound scans

In-patient maternity services:

Requires prior approval from the insurance company or within 24 hours of emergency treatment
10% coinsurance payable by the insured AED 7,000 for normal delivery OR AED 10,000 for medically necessary C-section, complications and for medically necessary termination

New born cover:

Cover for 30 days from birth. BCG, Hepatitis B and following neo-natal screening tests are covered: (Phenylketonuria (PKU), Congenital Hypothyroidism, sickle cell screening, congenital adrenal hyperplasia)

Co Participation : Co-Pay 20% Max upto AED 500

Network Type : EBP Network

Territory of Coverage : UAE Only

Class : Semi-Private (2 Beds)

Benefit Highlights

- Please refer to the product notes(Table of Benefits) for detailed information

Plan:

Essential Benefits Plan (EBP)

Annual Benefit Limit (Including any coinsurance and/or deductible):

AED 150,000

Geographical Scope of Coverage for Basic Healthcare Services -Elective:

UAE + Home Country Only *
* Home country coverage is applicable only if Home country located within any of the below mentioned list of countries
* Only In Patient will be covered in Home countries (Out Patient treatment NOT covered)
• South East Asia (SEA): India, Bangladesh, Philippines, Pakistan, Burma, Thailand, Vietnam, Malaysia, Sri Lanka, Indonesia, Nepal, Bhutan.

Network Applicable:

Essential Benefits Plan (EBP) Network. Applicable as per MedNet's latest EBP Network - Please refer for further details

Pre-existing & Chronic conditions:

• Covered subject to waiting period of 6 months of first insurance membership with the contracted insurer, included thereafter
• Where a pre-existing or chronic condition develops into an emergency within the 6 month exclusion period this must be covered up to the annual aggregate limit

Day Care Treatment:

Covered

Out Patient Surgery:

Covered

New Born baby coverage:

• First 30 days of New Born from DOB is covered under Mother’s Annual Benefit Limit up to a maximum of AED 150,000 • BCG, Hepatitis B and neo-natal screening tests are covered for the first 30 days from DOB

Diagnostic and treatment services for dental and gum treatments:

Covered only in cases of medical emergencies subject to 20% copayment

Hearing and vision aids, and vision correction by surgeries and laser:

Covered only in cases of medical emergencies subject to 20% copayment