Allianz Health

8/8/2019 Allianz Health

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Group Health Takaful ContractSehhati


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1. preamble 2

2. definitions 22.1. contract definitions 22.2. coverage definitions 22.3. operational definitions 32.4. medical definitions 4

3. scope of healthcare benefits 44. entire contract 5

5. eligibility 6

6. contract validity 6

7. contributions 6

8. addition of participants 7

9. deletion of participants 7

10. claim provisions 710.1. claim settlement 710.2. claim limitations 810.3. pre-authorization 810.4. arbitration 810.5. medical examination 8

10.6. recovery 810.7. coordination of benefits 810.8. subrogation 8

11. currency 8

12. renewal of contract 9

13. termination 9

14. general exclusions 9

15. jurisdiction and limitation of action 11

16. other conditions 11

CONTENTS


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1. Preamble

1.1. This Health Takaful Contract is made between the Group, forand in behalf of the individual Participants, and ALLIANZTAKAFUL B.S.C. (Closed), hereinafter referred to as theCompany.

1.2. The Company has been incorporated in the Kingdom of Bahrain and is authorized by the Central Bank of Bahrain toconduct takaful business. To ensure compliance with therules and principles of the Shariah, the Company hasappointed a Shari-ah Supervisory Board for the vetting of allthe Companys operations. The Board is comprised of renowned independent Shari-ah scholars.

1.3. By entering into this Contract, the Group appoints theCompany as a Wakeel for the management of the insuranceoperations in exchange for the Wakalah fees (a percentageof the Contribution), and as a Mudarib for the purpose of investing their funds in a Shariah compliant manner for apre-agreed share on investment income.

2. definitions

2.1. contract definitions

Actively-at-Work - The work situation of an employee reportingregularly on a full-time basis to his workplace, performing theusual and normal duties of his occupation in conformity with theemployment conditions, and being remunerated accordingly,excluding employees who are disabled, granted a leave of absence,temporarily laid-off, or placed on part-time employment.

Allianz Takaful

Cash Indemnity - A lump sum payable to a Participant inconnection with covered Healthcare Benefits, which may bepayable on: (a) a healthcare service basis (i.e. type of Treatment);

(b) a specific assessment basis (i.e. type of diagnosis); or, (c) aper day basis

Claim - A written demand made to the Company by or on behalf of a Participant for the payment of Healthcare Benefits under thisContract

Co-Insurance, Co-Participation or Co-Payment - The pre-definedpercentage of incurred healthcare expenses or amount of Claimwhich the Participant is obliged to pay at the time the healthcareservice is rendered

Contract Schedules - The schedules which specify the specificconditions of this Contract and the data on the Group and theindividual Participants. The data includes: Effective, Enrollment,and Expiry Dates; Plan of Coverage, scope and amount of Healthcare Benefits, Room Accommodation; amount and modeof Contributions; amount of charges, if any; Limits, Co-Insurance,and Deductibles; and additional Exclusions, if any.

Contribution - The amount payable by the Group as a contributionfor the Participants who shall be covered under this Contract

Contribution Due Date - The date upon which any Contributionfalls due

Deductible - The amount which the Participant must pay eachtime for healthcare services and is deducted from the Claimpayable by the Company


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Effective Date - The date this Contract commences

Expiry Date - The date this Contract is scheduled to terminate

Group - The corporation or legal entity entering into thisContract which shall be the sole owner of this Contract

Limit - A Contract provision that sets a cap on types of eligiblehealthcare expenses. Limits may be a: (a) monetary amount perParticipants lifetime; (b) quantity amount per Participantslifetime; (c) monetary amount per year; (d) quantity amountper year; (e) monetary amount per Claim; (f) quantity amountper Claim; or (g) geographical scope of coverage.

Participants - Any person eligible and enrolled under this Contract

Pre-Authorization - Prior written approval obtained from theCompany or its appointed Third Party Administrator prior to certainTreatments and/or other healthcare services as specified in thisContract

Usual, Customary and Reasonable Charges (UCR) - A charge orexpense for necessary healthcare which, in the sole opinion of the Company and based on its or its appointed Third Party Administrators experience, does not exceed the general level of charges being made by other Providers of similar standing in the

Kingdom of Bahrain, when providing like or comparableTreatments or healthcare services

Utilization - The actual amount of healthcare services coveredby the Company plus allowance for Incurred But Not yet Reported(IBNR) Claims

Waiting Period - The period of time under this Contract whereina Healthcare Benefit is not yet available to an eligible Participant

2.2. coverage definitions Accident - An unforeseen, unexpected and unintended eventinvolving an external force or impact to the body

Cause - A term that broadly describes the reason a Participantseeks healthcare, that is, description of the disease and accidentfor an Illness and Accident, respectively

Congenital Disease - All diseases, anomalies, hereditary conditionsincluding neurological disorders, chromosomal and/or genetic,defects and deficiencies whether present at birth in either in anevident manner or in a potential manner triggered at a later stage

Cosmetic - To improve physical appearance and/or treat a mentalcondition through change in bodily form

Day-Care - Treatments and/or other healthcare services in aHospital or a recognized Day-Care facility where the Participantis admitted to a hospital bed but does not stay overnight

Elective - Planned Treatment which is medically necessary butnot an Emergency

Emergency - The sudden, unexpected onset of a non-excludedIllness or Injury, raising a legitimate professional concern thatthere may be a significant medical problem necessitating aTreatment which cannot be delayed and requires immediateconfinement to a Hospital


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Hazardous Activity - Any activity which exposes the Participantto serious Injury or Illness including but not limited to shooting,motor sports, water sports (e.g. diving, jet-skiing, power boats,

water ski), horse riding activities (e.g. hunting, jumping, polo),climbing activities (e.g. mountaineering and rock-climbing),winter sports (e.g. bob-sleighing, snowboarding, ice-hockey,snow-skiing, ski-jumping), ballooning, bungee jumping, skydiving, parachuting, paragliding, and martial arts of all kinds

Healthcare Benefit - The Out-Patient benefits, HospitalizationBenefits, and other medical benefits as provided for in this Contract

Healthcare Service - Individual medical services, tests,examinations, consultations, or other items which may be chargedduring the care of a Participant by a Provider

Home Nursing - Skilled nursing services given by a registerednurse at home immediately after an In-Patient Treatment anddeemed to be medically necessary by a Physician

Hospitalization - Confinement in a Hospital for a minimum of one overnight stay for medically necessary Treatment, or othercare related to an Illness or Injury which cannot be performed onan Out-Patient basis. The Hospitalization services are subject tothe rules and regulations of the Hospital, including its rules andregulations governing admission

Illness - A disease, impairment, interruption, cessation or disorderof bodily function/s, system/s, or organ/s.

Injury - Physical damage other than Illness, including all relatedconditions and recurrent symptoms which are usually caused byan Accident.

In-Patient - Treatments and/or other healthcare services whichare delivered to a Participant in a Hospital and medicallynecessitate the Participants Hospitalization as a registered bed

patient for at least twenty-four (24) hours. Day-Care admissionsshall be considered as In-Patient.

Out-Patient - Treatments and/or other healthcare treatmentswhich do not medically necessitate the ParticipantsHospitalization

Plan of Coverage - Any of the insurance schemes provided by theCompany covering a set of covered healthcare services, subjectto a set of Limits, Co-Insurance, Deductibles, and other conditions

Pre-Existing Condition - Any known Illness or related conditionfor which, before the Effective Date of the coverage of theParticipant, he: (a) has been diagnosed; (b) received Treatment;(c) sought medical advice for, including check-ups; (d) neededTreatment, including drugs and injections; or, (e) had undiagnosedsymptoms, whether recognized or not

Room Accommodation - The class of room and board servicewhich the Group has selected on behalf of its Participants to beapplied for In-Patient Treatment or Hospitalizations, and which isidentified in the Contract Schedules according to the followingcodes:

a. Class VIP - Suite (private room with sitting, sleepingaccommodations for one companion)

b. Class A - Private room (basic level one bedroom)

c. Class B - Semi-Private room with 2 beds


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2.3. operational definitions

Access Card - A personalized card issued in the name of eachParticipant, facilitating Free Access to the covered healthcareservices provided by the Designated Network Providers underthis Contract

Claim Form - A form issued by the Companys appointed ThirdParty Administrator that contains: (a) the medical details of theClaim as documented by the Participants Physician; (b) listingof chargeable healthcare services which were or shall be rendered,as requested and documented by the Participants Physician; (c)the claims adjudication decision; (d) the availability of Free Accessfor the Participant; (e) the coverage or non-coverage of the

Participant for chargeable healthcare services; and, (f) thedirections for financial settlement

Designated Network Providers - A group of healthcare serviceproviders contracted by the Companys appointed Third Party Administrator for the purpose of providing Participants with Free Access to their services in conformity with the terms of thisContract. Listings of Designated Network Providers are subjectto change without advanced notice and may be obtained fromthe Company or its appointed Third Party Administrator.

Free Access or Direct Billing - The Designated Network Providersdirect billing of eligible healthcare expenses to the Company andsubmission of payment to the Provider by the Company, minusany Co-Insurance, Limits, or other non-eligible healthcareexpenses

Provider - A generic term for Physicians, Hospitals, clinics, medicalcenters, pharmacies, laboratories, physiotherapy centers, dentistsand other paramedical institutions or persons who are licensedto offer healthcare services

Third Party Administrator or TPA - An entity appointed to act inthe name of and on behalf of the Company in administering thisContract. The Administrator interfaces with the Participant throughits Claims Center/Section/Department, which shall be staffedwith a team of medical and claims administrative specialists tosupport and monitor the proper application and administrationof this Contract. The Administrator shall provide the Participantswith: (a) guidance and information through telephone and/ormail inquiries; (b) verifies eligibility, conducts claims adjudication

and grants Free Access in the name and on behalf of the Companyto the specific healthcare service provider under consideration

2.4. medical definitions

Chiropractic - A therapeutic system based primarily upon theinteractions of the spine and nervous system, the method of treatment usually being to adjust the segments of the spinalcolumn

Chronic Condition - A treatment which the Company or any other

party acting on the Companys behalf, determine is palliative, i.e.relieving or soothing the symptoms of a disease or disorderwithout effecting a cure, or a chronic medical condition, i.e.requiring a regular, lifetime treatment.


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Diagnostic Procedure - A test for diagnosing an Illness or Injury,including pathology, laboratory tests, X-rays, ECGs, medicalspanning, imaging techniques, and interpretation of results by a

specialist Physician

Hospital - Any medical institution, public or private, which is legallylicensed to provide Treatment to sick and injured persons. Thefacility must consist of organized premises, possess the necessarytechnical and scientific equipment for diagnoses and surgicaloperations, and provide around-the-clock healthcare services bya staff of at least one resident Physician and qualified professionalnurses. This term excludes Out-Patient clinics, sanitarium,physiotherapy centers, health clubs, retirement homes, nursinghomes, and other non-Hospital institutions, including those

specialized in substance abuseMedically Necessary or Medical Necessity - The appropriate andnecessary healthcare services, as determined by the Company,provided to the Participant for an Illness and Injury which,according to generally accepted principles of good medicalpractice, requires diagnosis, direct care, and Treatment. These donot include services rendered for convenience, aesthetic, andeducation purposes.

Osteopathy - A therapeutic system based upon the premise thatmanipulation of the muscles and bones to promote structuralintegrity could restore or preserve health

Physician - Any medical or surgical doctor duly licensed andqualified to practice medicine or surgery under the law of jurisdiction where the Treatment is given or where the procedureis done

Physiotherapy - The treatment or management of physicaldisability, malfunction, or pain by exercise, massage, hydrotherapy,etc., without the use of medicines, surgery, or radiation.

Treatment - Any medically necessary surgical or medical procedurecarried out by, or any medication prescribed by, a Physician withthe sole intention to cure or rectify a Participants Illness or Injury.Treatments include diagnostic procedures, and consultations.

3. scope of healthcare benefits

3.1.In consideration of the request and declarations made by theGroup and the Participants in their applications, and thepayment of Contribution by the Group, the Company shallcover healthcare expenses reasonably, customarily, andmedically necessarily incurred by the Participants during theContracts validity period for the sole purpose of treating andcuring an Illness or Injury, subject to the terms and conditionsof this Contract and any attachments and/or Endorsementsthereto.

3.2. The following Healthcare Benefits, subject to the Limits, Co-Insurance, Deductible, Pre-Authorization requirement, andother conditions stipulated in the Contract Schedules, shallbe covered under this Contract, unless specifically stated

otherwise in the Contract Schedules:

a. Consultation Charges

i. Physician fees as either In-Patient or Out-Patient


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ii. Pathology, X-ray, and diagnostic procedures, magneticresonance imaging (MRI) and computerized axial tomography(CT) scans, radiotherapy, chemotherapy, as In-Patient or Out-

Patient

iii. Illness or Injury that requires consultations, diagnosticprocedures, physiotherapies, prescribed drugs, or other coveredhealthcare services, which are subject to a Deductible and/orCo-Insurance per visit as specified in the Contract Schedules.

b. Hospitalization Charges

i. Room and board charges according to the type of Room Accommodation stated in the Contract Schedules

ii. Physician fees including theatre charges for the Treatmentof an Illness or Injury

iii. Intensive Care Unit (ICU)

c. Prescribed Drugs as an In-Patient or Out-Patient

d. Emergency Treatment

e. Emergency Local Ambulance Charges, including transportationcosts to and from the Hospital by the most appropriatetransport method, only when considered medically necessaryby a Physician.

f. Cash Indemnity for In-Patient Treatments for Hospitalizationswithin the Designated Network Providers that are notsubmitted to the Company for Claim

g. Physiotherapy Treatment which is referred by a specialistPhysician and deemed to be medically necessary forcontinued recovery from an Illness or Injury

h. Chiropractic Treatment and Osteopathy

i. Organ transplant but as recipient of heart, liver, and kidneysonly, excluding all costs associated with the acquisition of the required organ to be transplanted includingadministrative and transportation costs.

j. Accidental damage to teeth provided Treatment is receivedin a Hospitals Emergency room within forty-eight (48) hoursfollowing the accident, and provided that the damage iscaused to sound, natural teeth and for the initial relief of painand any Treatment necessary to preserve the dental structure.

k. Home Nursing Care

l. Parent Accommodation - Charges for one parent staying witha child Participant who is less than sixteen (16) years old

m. International Medical Emergency Assistance

i. Emergency Evacuation - arrangement and payment for theappropriate mode of transport, equipment and personnel

necessary to evacuate Participant to nearest capable medicalfacility in the event of an emergency Injury or Illness whiletraveling outside the country of residence or employmentand if adequate facilities are not available,

ii. Emergency Message Transmission


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iii. Emergency Family Member Visit - transportation of arelative to the place of Hospitalization when Participant istraveling alone and has been hospitalized for a specific

number of daysiv. Medically Supervised Repatriation - transportation back

home for continuation of Hospitalization when Participantis in stable condition and if medically required

v. Care and Transportation of unattended Minor Children

vi. Repatriation of Mortal Remains of a deceased Participant tohis country of residence or employment, or costs for localburial at place of death

vii. Legal Assistance and Emergency Cash Advances

3.3. Unless selected and purchased by the Group, the followingoptional Healthcare Benefits shall remain uncovered:

a. COBRA Extension - if a Treatment is not available at thecountry of residence or employment:

i. Free Access for such Treatment at an international DesignatedNetwork Provider

ii. Air Transportation for the Participant and accompanyingrelative (wife, child, or parent)

iii. Accommodation for the accompanying relative

b. Routine Dental Benefit - Medically necessary dental

treatments, such as root canal treatment, teeth extractions,and routine fillings (amalgam, resin, plastic, and temporary)

c. Optical Benefit - Optical examinations conducted for thepurpose of obtaining eye glasses or upgrading existing lenses

d. Maternity Benefit (for female Participants only) - Treatmentsrelated to or caused by pregnancy, childbirth, puerperiumconditions or illnesses, miscarriage, or abortions when thelife of the mother would be medically endangered

3.4. Pre-Existing and Chronic Conditions shall not be coveredunless the Group has met the minimum number of enrolledMembers stated in the Contract Schedules

4. entire contract

4.1. The Company issued this Contract in consideration of theapplication made by the Group and the individual Participants,and the receipt of the initial Contribution. This Contract, theapplications, together with all underwriting forms anddeclarations, the Contract Schedules, as well as any otherattachments and/or Endorsements, constitute the entireContract between the Company and the Group.

4.2. Any amendment to this Contract shall not be valid andbinding, unless it has been made in writing and is signedand sealed by the Company. No intermediary or agent isauthorized to make or to amend this Contract or to waiveany of the Companys rights or to bind the Company bymaking any promise or by accepting any representation orinformation not contained in the Contract application.


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5. eligibility

5.1. A Group is eligible for coverage under this Contract provided

all its Members are enrolled on a compulsory basis. TheGroup may choose to include its Members QualifiedDependents in its coverage provided that their enrollmentis on a compulsory basis for all Qualified Dependents. AGroup Member or Qualified Dependent who is eligible forHealthcare Benefit coverage and enrolled is considered aParticipant under this Contract. All Participants must beholders of either a valid passport or residence visa for theKingdom of Bahrain.

5.2. Only Group Members aged sixty-five (65) or below who arecurrently in Actively-at-Work status in the Groups office/s inthe country of coverage as of the date of Membersenrollment into the Healthcare Benefit coverage are eligiblefor coverage.

5.3. Qualified Dependents include the Group Members spouse/saged sixty-five (65) or below, and their unmarried legitimateor legally adopted children residing with them at the EffectiveDate or renewal of this Contract, provided that the childrenare at least fourteen (14) days old but less than eighteen(18) years old, or if full-time students, the children are lessthan twenty-three (23) years old. If eligible, the QualifiedDependents must be in good health, or performing theirnormal activities or occupation and not incapacitated dueto sickness, injury, or other form of disability on thecommencement date of coverage.

5.4. The Group must declare all the eligible Group Members andQualified Dependents, if covered, and provide full details tothe Company. The Company reserves the right at any time

the submission of such documents which the Company maydeem appropriate for the purpose of validating the eligibilityof Participants.

6. contract validity

6.1. The validity of this Contract, with regard to the Plan of Coverage selected by the Group, shall commence on theEffective Date specified in the Contract Schedules upon thefull payment of the Contribution due and its delivery to theGroup, and shall terminate on the Expiry Date specified in

the Contract Schedules.6.2. Each Participant shall be covered under this Contract from

his Enrollment Date as specified in the Contract Schedulesand/or any related Endorsement/s up to the Expiry Date of this Contract.

6.3. If an enrolled Group Member, on account of Illness or Injury,is not actively working in full time employment on theEffective Date of this Contract, his coverage shall not becomeeffective until the date such Member returns to full-timeactive work.

6.4. If an enrolled Qualified Dependent, on account of Injury orIllness, is confined in a Hospital on the Effective Date of thisContract, his coverage shall not become effective until thedate such Qualified Dependent is discharged from theHospital.


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7. contributions

7.1. The Contribution stated in the Contract Schedules, including

the cost of any applicable stamps and/or taxes, are payableto the Company at its registered Head Office, other designatedoffices, or authorized collecting agents, on or before theEffective Date of this Contract. The mode of contributionpayments is as stated in the application for this Contractunless changed subject to rules in effect at the time of suchchange.

7.2. The Company shall have the right to withhold payment of Claims or cancel this Contract if the Contribution is not paid.

7.3. grace period

After the payment of the first Contribution, any Contributiondue must be paid not later than thirty (30) days after its duedate. If a Contribution remains unpaid after the expiry of thegrace period, this Contract terminates immediately and theGroup shall be liable for the amount due until the date of cancellation of coverage.

During the grace period, Free Access to the DesignatedNetwork Providers on direct billing basis shall be suspended.In the event that the Contribution is paid within the graceperiod, Free Access to the Designated Network Providers shallbe reinstated and all eligible healthcare expenses incurredduring the suspended period shall be processed andreimbursed in accordance to the provisions of this Contract.

7.4. The Group shall not offset against any Contribution due theamount owed by or claimed from the Company under thisor any other agreement.

7.5. No confirmation or receipt of payment of any Contributionshall be valid unless printed on the Companys form and dulysigned by the Company.

8. addition of participants

8.1. The addition of Group Members and/or their QualifiedDependents to this Contract shall be subject to submissionof a subsequent application together with supportingdocuments relating to the required addition which aresatisfactory to the Company, within thirty (30) days of thedate of which the Member and/or Dependent becomeseligible to be added in the Groups coverage.

8.2. The Enrollment Date of any approved additional Participants,which shall be stated in an Endorsement to the Contract,shall be:

a. For newly-eligible Member or his enrolled QualifiedDependents - the official date of membership or employmentin accordance with the Groups policies and guidelines;

b. For new spouse - the date of marriage;

c. For newborn child - the date of birth; and,

d. For new adopted child - the date of official adoption.


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8.3. New Contribution shall be charged for such additionalParticipants on a pro-rata basis for the unexpired period of this Contract.

9. deletion of participants

9.1. The Group may, at any time, delete Members and/or theirDependents from this Contract who cease to be eligible forcoverage, subject to submission of a subsequent applicationtogether with supporting documents relating to the requireddeletion request which are satisfactory to the Company,including return of the Access Card of the deleted Participant.

9.2. Deceased Members, terminated Members (due to retirement,resignation, or dismissal), and totally and permanently disableMembers, including their Qualified Dependents, shall bedeleted from the Groups coverage. The effective date of deletion shall be the day following the date of death,termination, or total and permanent disability of the Member.

9.3. The Company shall refund to the Group a pro-rata amountof the paid Contribution for the unexpired coverage periodof deleted Participants.

9.4. If the Access Card of the deleted Participant was not returnedto the Company, any Free Access of such Participant after thedate of deletion shall be charged to the Groups account andform part of the Groups total Utilization.

9.5. No reinstatement of coverage shall be granted for the deletedParticipant within the Contract year.

10. claim provisions

10.1. claim settlement

a. At Designated Network Providers

The Company and its appointed Third Party Administrator havean agreement that allows for direct billing or submission of theClaim by the Designated Network Providers.

To use the Providers facility, the Participant must presenthis Access Card to the Provider. The available and/or hisselected Physician shall attend to his healthcare needs and shall also arrange to contact the Third Party Administrator,who will arrange the settlement of all covered healthcareexpenses.

Should a Participant pay for Treatment at a Designated NetworkProvider, the Company shall reimburse only the charges agreedbetween the Company, Third Party Administrator, and the Providerfor such Treatment.

b. At Non-Designated Network Providers

The Participant must settle the invoiced amounts for Treatmentsand/or other healthcare services that were provided by aNon-Designated Network Provider. Written proof of theClaim must then be submitted by the Participant to theCompany or its appointed Third Party Administrator withinthirty (30) days after the expiration of the period of theTreatment and/or healthcare services for which Claim forbenefits is being made; otherwise, the Claim shall not beconsidered.


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The original itemized invoices, the diagnosis, details of the Treatment received, and when applicable, all relatedreports such as laboratory and radiology test results and

prescription copies must be submitted together with afully-accomplished prescribed Claim Form that is issued bythe Company, completed and signed by the treating or attendingPhysician. Photocopies of the required documents shall notbe accepted.

The Company and its appointed Third Party Administrator mayrequest for additional documentations before approving anyClaim. The Participant shall authorize the Providers to releasemedical information to the Company and/or to the Third Party Administrator.

All Healthcare Benefits that pertain to a Member or a QualifiedDependent of a Member shall be paid by check to the order of said Member, unless a Member requests otherwise. In case of death of a Member, any Healthcare Benefit due but remainingunpaid shall be paid to the first surviving class of the followingclasses of successive preference of beneficiaries: the Members:(i) widow or widower; (ii) surviving children; (iii) survivingparents; (iv) surviving brothers and sisters; and (v) executorsor administrators.

The amount of Claim payable shall be, in the opinion of theCompany, the Usual, Customary, and Reasonable Charge for theTreatment provided, less a Co-Insurance deduction after theapplication of any Deductible.

In the event that the total cost of Treatment is equal to or lowerthan the Deductible amount, the Participants shall bear all thehealthcare expenses incurred.

10.2. claim limitations

The Claim for Healthcare Benefits for In-Patient Treatment shallbe limited to the eligible healthcare expenses arising from In-Patient admissions that have admission dates, which refer to theperiod from Provider facility admission to discharge for the samecorresponding admission, occurring within the Contracts validityperiod. The liability of the Company shall cease on date of discharge, not exceeding thirty (30) days beyond the Expiry Dateof this Contract.

The liability of the Company shall be limited and restricted, underthis Contract, to any eligible healthcare expenses incurred underthe Plan of Coverage

10.3. pre-authorization

The following shall be excluded unless a Pre-Authorization, whichis the evaluation of the medical necessity of proposed healthcareservices, has been obtained by the Participant from the Companyor its appointed Third Party Administrator:

a. In-Patient and Day Care Treatments;b. Diagnostic procedures, pathology, X-ray, MRI and CT scans,

radiotherapy, chemotherapy


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c. Physiotherapy, Chiropractic Treatment, and Osteopathy;

d. Home Nursing Care;

e. Second or subsequent medical opinion; and

f. International Medical Emergency Assistance.

The Company shall authorize such Treatments as they fall withinthe scope of this Contract. A Claim shall be reimbursed inaccordance with this Contract provided that the Participant hasobtained proper Pre-Authorization and has followed requiredCompany procedures.

10.4. arbitration Any differences in respect of medical opinion in connection withthe results of an accident, illness, or injury shall be settled betweentwo (2) medical experts appointed in writing by the Companyand the Group separately. Any difference of opinion betweenthese medical experts shall be referred to an umpire who shallhave been appointed in writing at the outset by the medicalexperts and whose decision shall be final and binding on theCompany and the Group.

10.5.medical examination

The Company may, at its own expense, request a medicalexamination of any Participant whenever and as often asreasonably necessary. All medical information shall be treated asstrictly confidential.

10.6. recovery

The Company shall be compensated by the Group for all Claims

made:a. In excess of the Participants Healthcare Benefit Limits;

b. For excluded Treatments;

c. By individuals who are not eligible for coverage;

d. By the Participants during any period when a Contribution isin arrears; and,

e. By deleted Participants as from effective date of his deletionfrom the Group

f. In respect of fraudulent use of the Access Card.

10.7. coordination of benefits

The Company shall not pay for healthcare expenses if there is ormay be any other insurance or indemnity that may cover thoseexpenses. If the other insurance or indemnity does not cover allsuch healthcare expenses, the Company shall then pay the balancesubject to the terms and conditions of this Contract.

If a Participant has two or more Healthcare Benefit coverage withthe Company, the maximum liability of the Company for each of the Illnesses or Injuries and the complications thereto shall bethe amount provided in that coverage with highest maximumaggregate benefit limit. Any healthcare expense that has already


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been covered by and/or paid by the Company under one coveragecan no longer be claimed from the Company under othercoverage.

10.8. subrogation

Once the Claim has been paid in accordance with the terms andconditions of this Contract, the Group and its Participants shallsubrogate the right to the Company every relevant substantialand legal right. The Group and its Participants shall provide theCompany with all possible assistance should the Companyexercise the above right of subrogation; otherwise, they shall beliable for any losses incurred by the Company.

11. currency

11.1. All payments in this Contract are in the currency statedin the Contract Schedules. Claims for Healthcare Benefitsubmitted in other currencies shall be converted to theContract currency at the exchange rate prevailing at thetime of settlement of the Claim or at the rate agreed bythe Company and the Group at the commencement of this Contract.

12. renewal of contract

12.1. This Contract may be renewed on a year to year basisunder such terms and conditions as the parties may agree,provided that all outstanding receivables including thecorresponding charges were paid to the Company as maybe applicable.

12.2. Renewal of this Contract shall be subject to the

submission of a confirmation letter and listing of Participants or approved form where applicable,the payment of renewal Contribution, any taxes and

pertinent charges, and the Groups compliance withother terms and conditions set forth by the Companyfor renewal of this Contract.

12.3. At the end of every Contract year, Contributions shall besubject to renewal rating, guided by the Groups Utilizationexperience.

13. termination

13.1. The Company may terminate this Contract, with immediate

effect, or vary the terms of this Contract at any time,notwithstanding any other provision of this Contract,should the Group and/or the Participants, violate any of the eligibility requirements, act fraudulently, commita breach of the terms and conditions of this Contract,or act in bad faith by withholding any facts materialto the coverage. In such case, the coverage of suchParticipants and his Qualified Dependents, if any, shallbe cancelled immediately and their HealthcareBenefits and contributions shall be forfeited in favor of the Company.

13.2. The Group may cancel this Contract by giving the Companythirty (30) days notice in writing. In such case, the Companyshall refund the pro-rata amount of the paid Contribution/sfor the unexpired coverage period to the Group, less theGroups Utilization during the Contract year. The release of


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the refund shall be made upon the receipt of all the AccessCards issued to Participants.

13.3. A Participants coverage shall cease when he cease tophysically reside in the country of residence as stated in theapplications for more than one hundred eighty (180) daysunder any one year of coverage.

13.4. A Qualified Dependents coverage shall automatically ceaseon the same date as that on which his related GroupMembers coverage ceases.

14. general exclusions

14.1. The conditions, illnesses, treatments, healthcare services,causes, circumstances, and other items listed below andtheir related or consequential expenses shall be excludedfrom the coverage provided under this Contract unlessspecifically stated to be included in the Contract Schedulesand/or Endorsements to this Contract.

All Pre-Existing and Chronic Conditions

All pregnancy, maternity, prenatal, perinatal, and/or postnatalrelated Treatments and services, including complicationsrelated thereto

Treatments related to eating disorders, obesity, removal of fator surplus tissue, bulimia, anorexia nervosa, and other similardisorders

Organ, tissue, cell, blood and bone marrow donations or

banking including complications related thereto

Routine medical examinations and tests including but not

limited to preventative checks, screening tests, check-ups,prophylactic Treatments, routine pap smears, allergy testing,pre-operative infectious disease screenings, heart scans, andbone densitometries

Treatments for nearsightedness, farsightedness, astigmatism,and cross-eyes

Procurement or use of prostheses, corrective devices orappliances, durable equipment, including but not limited tohearing aids or devices, eye glasses and contact lenses, braces

and crutches Senility related conditions including but not limited to

Alzheimers disease

Services, accommodations, or Treatments in any long termcare facility, rehabilitation centre, spa, hydro clinic, nature cureclinics, rest cures, sanatorium, home care, nursing home orhome for the aged, periods of quarantine, or any other similarinstitution, even if it is registered as a Hospital, arranged whollyor partly for domestic reasons and which is not directly related

to Treatment or beyond the period required for recovery fromTreatment

All gum and dental related Treatments (e.g. orthodontic orendodontic treatments, dentures, any cosmetic alterations,bridges, crowns, gingivitis, periodontitis or any relatedconditions, scaling and polishing of teeth) unless resulting


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from accidental injuries and those dental benefits as specifiedin this Contract

Elective, plastic, or cosmetic surgeries (e.g. circumcision, anysinus or nasal surgeries, lipomas, warts, acnes, corns, bunions,molluscum contagiosum, nevus, mole, pigmentationdisorders) and Treatments unless pre-authorized by theCompany

All conditions, testing, procedures related to determining,diagnosing or treating congenital diseases or malformations,as well as any complications related thereto

Psychological and psychiatric illnesses, mental retardations,attention deficit disorders, developmental delays and/oradvances and/or abnormalities whether physical,psychological, emotional, behavioral, speech or intellectual,including precocious puberty, hearing difficulties

All Treatments and services related to sexually transmitteddiseases and related complications, including but not limitedto gonorrhea, syphilis, HPV, Hepatitis other than Type A, HIV, AIDS, herpes, pubic lice, trichomoniasis, whether or not activesexual transmission is documented or known

Male and female reproductive system disorders (e.g.impotence, erectile or sexual dysfunction, priaprism, varicoceles, frigidity, menstrual cycle disorders, hysterectomies,ovarian cysts, polycystic ovarian disease, endometriosis, uterinefibroids, and menopause), as well as treatments or follow-upin relation to sex-change procedures or operations

Tests or treatments related to contraception, sterilization or

reversal of sterilization, sub-fertility, infertility or fertility, in- vitro fertilization, surrogacy procedures, assisted reproduction(e.g. GIFT)

Any pharmaceutical product not considered as medicineincluding but not limited to vitamins, lozenges, mouthwashesor gargles, baby formula, soaps, lotions, and shampoos (bothmedicated and non-medicated), cosmetic preparations,antiseptic solutions, dietary supplements, skin care products,and slimming products

Immunomodulators and/or immunotherapy treatments ordrugs including but not limited to Remicade, Interferon,enzyme preparations, anti-oxidants, and liver tonics

Any drug, device, medical treatment or procedure that in thesole discretion of the Company is deemed to be experimentalor has not been established as being effective

Alternative medicines or therapies

Treatments of any condition that is caused by natural changesto a persons body that cannot be reversed (e.g. hormonereplacement therapy for menopause or osteoporosis,deafness)

Vaccinations and inoculations

Alopecia, wigs, toupee and all hair or hair fall treatments andproducts

Any organ transplantation, other than heart, liver and kidneys;


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costs incurred in connection with locating, acquiring, andtransporting a replacement organ, removing the organ fromthe donor, and all associated administration costs

Genetic engineering and cloning

Diseases defined by the World Health Organization (WHO) asepidemic

General health examinations, medical examination and otherrelated services required for obtaining or continuingemployment, residence, travel, insurance, governmentlicensing

Attempted suicide, judicial sentence, resisting legal arrest, anyact of intentional self injury, committing or attempting tocommit any felony or violation of the law, or participation inany brawl

Any illness or injury resulting from alcoholism or taking of alcoholic beverages, abuse of drugs, or illegal use of anysubstance

Treatments for injuries sustained while rendering military,paramilitary, naval, police, fire-fighting or aviation service,unless pre-authorized by Company

Treatments for injuries sustained while traveling in anyform of air or sea transportation, except as a payingpassenger in an aircraft or ship operated by a commercialairline or shipping line on a scheduled passenger trip over its

established passenger route, unless pre-authorized bythe Company

All treatments of injuries and sickness consequent to theparticipation either as amateur or professional in hazardousactivities

Work related injuries or accidents

Loss, damage, cost or expense of whatsoever nature directlyor indirectly caused by, resulting from or in connection withany act of terrorism (i.e. an act, including but not limited tothe use of force or violence and/or the threat thereof, of anyperson or group/s of persons, whether acting alone or on

behalf of or in connection with any organization/s orgovernment/s, committed for political, religious, ideologicalor similar purposes including the intention to influenceany government and/or to put the public, or any sectionof the public, in fear), regardless of any other cause orevent contributing concurrently or in any other sequenceto the loss

War or warlike operations (active or passive, whether declaredor not), or invasion, act of foreign enemy, intervention of foreignpower, hostilities, mutiny, strikes, riots or civil commotion, civilwar, civil uprising or looting, sabotage, rebellion, revolution,insurrection, conspiracy, usurp of power whether by politicalor military means, state of siege or emergency, martial law, orany of the events or causes which determine the proclamationor maintenance of state of siege or emergency and martiallaw, every kind of projectile, explosives, including accidental


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explosion and/or deliberate explosion of weapons of war,during war or directly as a result of previous war, bullets, bombsor other military devices, acts or criminal acts by armed persons

whether affiliated or not to any organization or political party,or militia, or military or paramilitary organization and/or thestate becoming under the control of de facto or de jureauthorities acting on their own behalf or for and on behalf of other organization/s, also murder or assault or any attemptthereat, and all malicious acts of any nature whatsoever

Radioactive contaminations, ionizing radiation, radioactive,toxic, explosive or other hazardous properties of nuclearmaterial thereof, and/or polluting, hazardous or poisoningchemicals

Any Claim in its entirety where the Participant goes againstmedical advice

Any Treatment by a family member, relative member, or aPhysician not licensed to operate in the country where medicaltreatment is delivered

Any Treatment not related to specific symptom and/or disease;not required or prescribed by a Physician; or not consideredby the Company as a medical necessity

15. jurisdiction and limitation of action15.1. This Contract, and all rights, obligations and liabilities arising

herein, shall be construed, determined and enforced inaccordance with the applicable laws, regulations, and

directives of the Kingdom of Bahrain and the Shariah. Inthe event of any changes in laws, regulations, practices orcustoms which may affect the Companys ability to perform

under this Contract, the Company may adjust this Contractto any extent required by such changes after notifying theGroup.

15.2. Any disputes arising from out of or in relation to this Contractshall be settled amicably between the parties. Failingamicable settlement, any such disputes shall be referred tothe exclusive jurisdiction of the competent courts of law of the Kingdom of Bahrain.

15.3. The Company shall not be liable under this Contract for

compensation and/or damages in respect of judgmentsdelivered or obtained otherwise than through a court of competent jurisdiction within the Kingdom of Bahrain forcosts and expenses of litigation recovered by any claimantfrom the Group (or the Groups Executors, Administratorsand Assigns) which are not incurred in and recoverable inthe Kingdom of Bahrain.

15.4. No failure or delay by the Company in exercising anyright, power or remedy under this Contract shall impairsuch right, power or remedy, or operate as a waiver thereof,nor shall any single or partial exercise of any right, poweror remedy preclude any further exercise thereof or theexercise of any other right, power or remedy under thisContract.

15.5. No legal proceedings shall be commenced prior to the


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January 2009

expiration of sixty (60) days after proof of Claim has beenfiled in accordance with this Contract. Neither shall anyaction be brought at all unless commenced within one (1)

year from the expiration of the period within which proof of Claim is required by this Contract.

15.6. The Company shall not assume responsibility for acts of Providers.

16. other conditions

16.1. This Contract shall be written in both the Arabic and Englishlanguage. In the event of any discrepancies, the Arabic version of this Contract shall prevail.

16.2. Reference to time and date shall be according to theGregorian Calendar.

16.3. In the event any provision in this Contract or portion thereof is found to be invalid or unenforceable, the remainder shallremain in full force and effect.

16.4. Any notice or communication to the Company shall notaffect the Company unless it is in writing and is deliveredby hand, registered post or facsimile transmission, evidencedwith receipt of delivery or transmission by the Head Officeof the Company.

CONTACT INFORMATION

For inquiries about the Allianz Sehhati, please contact:

Allianz Takaful, B.S.C (Closed)P.O.Box 31397, Manama, Kingdom of BahrainTel.: +973 17 568222; Fax: +973 17 582114

E-mail: [email protected]

For claims assistance 24-hours a day, please contact:

NEXtCARE Claims CenterTel.: +971 4 6056800; Fax: +971 4 6056801

Toll Free No.: 8000-1151E-mail: [email protected]


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Allianz Takaful, B.S.C (Closed)P.O.Box 31397, Manama, Kingdom of BahrainTel.: +973 17 568222; Fax: +973 17 582114E-mail: [email protected]

Documents

Allianz Health