| Annual Maximum Limit Per Person |
SAR 1,000,000 |
| In-patient treatment Cost: |
| Level of accommodation within the network |
Standard Suite |
| Room & Board outside the network of providers (in/out KSA) Per Day |
SR 1,500 |
| In-patient / day-case coverage Appropriate medical treatment, surgical & medical procedures, medical supplies & services, nursing & doctor’s fee, Emergency Room (ER), Intensive care unit (ICU) and theatre charges, medication |
Covered |
| Chronic & Pre-existing Conditions up to Policy Limit PPPY |
Covered |
| Deductible (Co-payment) for Hospital admission expenses |
No |
| Only one escort is covered for children up to 12 years old or when medically needed and justified by treating physician up to 150 SR per day. |
| Referral from Primary Health Care to Specialist, Consultants or Hospitals Needed except for Emergency cases; If no referral; Patient will pay the consultation difference (No reimbursement) |
| Out-patient treatment costs: |
| Co-insurance/Deductible: The Insured/Patient will pay the percentage mentioned as co-insurance against each Outpatient Claim, as follows: |
| The copayment amount for outpatient (not including the medication) SAR |
| At Minimum provider Network (MPN) |
20% Up to 75 |
| At hospitals out of the MPN |
20%Up to 300 |
| At providers other than hospitals out of the MPN |
20%Up to 100 |
| Generic medicine, over-the-counter drug (OTC drug) and innovate treatment – with no generic alternative available* |
20% Up to 30 |
| Innovative treatment – with a generic alternative * |
50% Without Cap |
| Pharmaceuticals are classified according to the regulations of the Food and Drug Authority, and medical providers must follow the regulations, procedures and controls specified by the Food and Drug Authority. |
| * The deductible amount (copayment): The percentage paid by the beneficiary (the Insured) upon receiving the prescribed drugs when visiting an outpatient doctor, including all prescriptions for the same illness and not for each drug separately. |
| Pregnancy/Delivery Benefit |
| (Normal Delivery, Ante Natal Care, Caesarean Section & legal Abortion) |
15,000 SR |
| Pregnancy complication: |
Covered |
| Premature babies’ coverage is up to policy annual limit from day one of the policy |
Covered |
| Treatment of premature babies |
Covered |
| Dental Treatment: |
| Dental consultations, medical examinations, fillings, cleaning, extraction, periodontal treatment, cleaning scaling and polishing teeth with health implications Covered without deduction |
Covered up to SR 1,200 |
| Treatment of root canals and emergencies |
Covered up to 800
Co-pay 20% Without Cap |
| Optical Coverage: |
| Cost of Spectacles for those aged 14 years and less during the policy period and same Co-insurance of out-patient coverage. |
Covered up to 400 |
| Cost of Spectacles for person over 14 years old during the policy period |
Not Covered |
| Functional vision correction interventions Costs “Interventions to improve vision that are important for vision preservation “avoiding vision loss” up to policy limit. |
Covered |
|
| Benefits for all classes: |
| Out-patient treatment costs: |
| The beneficiary (Insured) shall pay the deductible amount (i.e., copayment) upon a visit to an out-patient doctor, which includes all the consultations and requirements of the doctor as well as the laboratory tests, x-rays, any treatment supplies requested by it, in addition to the follow-up visit, and the referral for the same illness and not for each procedure separately, except for drugs for which the coverage limit was cancelled. |
| the cost of infant on & Birth and therapy of premature babies’ mother policy and for Maximum 30 days from the date of birth up to addition date on their dependent policy .to be added to the retroactively and up policy limit document |
| Milk formula for infants up to 24 months of age, when medically necessary and as per the Internationally recognized indications |
| Maximum doctor’s consultation fees: |
| – General Practitioner/ specialist (First 100 – 150 SAR Registrar Doctor). |
| – Specialist (Second Registrar Doctor)/ 200 – 300 SAR Consultant. |
| – Specializations with scarcity and the like, such as cardiology, neurosurgery, vascular surgery and subspecialties according to the 400 SAR standards of the Saudi Commission for Health Specialties. |
| (The beneficiary shall be inspected according to the sequence of procedures for providing the service, unless the service is not available at the service center) These prices are used to regulate the relationship between the service provider and the Insurance Company |
| Vaccinations for Children Up to school age only and as per MOH regulations |
Covered |
| Hearing aids costs |
Covered up to SR 6,000 |
| Dialysis Costs during the policy period |
Covered up to SR 180,000 |
| Kidney Transplant Costs during the policy period |
Covered up to SR 250,000 |
| Transportation of a Deceased to His or Her Country during the policy period |
Covered up to SR 10,000 |
| Physiotherapy Physician Charges Limits inside the network as a complementary part of comprehensive health care, if requested by the treaty physician according to the medical report and diagnosis. |
Covered |
| Organ harvesting procedures (insured donor) during the policy period |
Covered up to SR 50,000 |
| Alzheimer’s Cases during the policy period |
Covered up to SR 15,000 |
| Schedule of the National Newborn Screening Program to eliminate disabilities Up to a maximum of 100,000 Saudi riyals during the policy period |
Covered up to SR 100,000 |
| Disability cases during the policy period |
Covered up to SR 50,000 |
| Circumcision cases (male) during the policy period |
Covered up to SR 500 |
| Contraception during the policy period |
Covered up to SR 1,500 |
| Table of immunization of the Respiratory syncytial virus (RSV) approved by the Ministry of Health |
Covered |
| Schedule of the National Newborn Screening Program to eliminate disabilities during the policy period |
Covered up to SR 100,000 |
| Complications resulting from a benefit treatment covered in the policy up to policy limit |
Covered |
| operation of obesity surgery during the policy period, Insurance coverage for other procedures and surgeries in addition to sleeve gastrectomy surgery, if BMI exceeds 40 or 35 with complications. |
Covered up to SR 15,000
1,00020% Co-insurance up to SR |
| Autism Cases Covered up to |
Covered Up to SR 50,000 |
| Psychiatric treatment during the policy period. |
Covered up to SR 50,000 |
| Cost of acquired valvular heart disease during the policy period |
Covered up to SR 150,000 |
| Reimbursement Claims |
Claim in Network
(Emergency, Non-Emergency) |
% 100 Customary Charge price
* Based on definition of emergency cases of MOH |
| Claim – (KSA) Non-Network (Emergency*) |
% 100 Customary Charge price |
| Claim – (KSA) Non-Network (Non-Emergency) |
% 80 Customary Charge price Subject to prior approval |
| Claim (WW)(Emergency) during business trip |
% 100 Customary Charge price |
| Claim outside KSA (WW)(Non-Emergency) |
% 80 Customary Charge price Subject to prior approval |
| Reimbursement for Dental and Optical |
Not Applicable |
