SCHEDULE OF BENEFITS

Basic Coverage
BENEFITS Group A+ Group A
OUTPATIENT CHARGES inside territory, including:
• Consultations. *COVERED *COVERED
• Diagnostic tests and Procedures.
• Prescribed drugs.

Radiotherapy & Chemotherapy. Covered up to Covered up to

annual limit annual limit

HOSPITAL CHARGES inside territory, including:

• Accommodation.
• Surgeries & Procedures. *COVERED *COVERED
• Physician Services and Nursing.
• Medicines and Supplies.

COMPANION CHARGES
ONE Parent to accompany a child up to 12 years. *COVERED *COVERED

Emergency Local Ambulance Charges in City *COVERED *COVERED

Limits.

EMERGENCY DENTAL TREATMENT Up to annual Up to annual

limit limit
Received within 48 hours, following an accident
(other than work related) for the restoration or
replacement of Sound Natural Teeth (Lost or
damaged in an accident).

Physiotherapy following covered Surgeries, Max. 15 Sessions 15 Sessions

ROOM & BOARD - Private up to Private,

SR.1,000 /day Max.SR.600 /
day
- Suite up to
SR.5,000/day,
if suite is elected
by the patient

MAXIMUM DOCTOR CONSULTATION FEES SR.400 SR.300

(Outside the APN)

VACCINATION for children under 6 years as per *COVERED *COVERED

MOH, Max. SR.300 Per Child Per Year.

REPATRIATION of Mortal remains in case of death *COVERED *COVERED

to home country, Max. SR.10,000.

PRE-EXISTING &CHRONIC annual Sub-Limit , Up to annual Up to annual

limit limit
OUTSIDE KSA COVERAGE Please see Please see
Assumptions & Assumptions
Conditions & Conditions
DEDUCTIBLE: Emp. & Dep.
Outpatient – SR.30 SR.30
Inpatient - NIL NIL
Non Emergency Admission/Surgery Second
Opinion Required Required
 ANNUAL OVERALL LIMIT PER SR.300,000 SR.250,000
MEMBER

MATERNITY B E N E F I T S Group A+ Group A

(ONE pregnancy per wife per year)
Normal pregnancy & delivery SR.12,000 SR.8,000
Pregnacy & Miscarriage / Legal Abortion SR.12,000 SR.5,000

Pregnancy & Cesarean Delivery SR.12,000 SR.12,000

Covered up to Covered up to
Delivery complications
annual limit annual limit
Covered up to Covered up to
Pre-mature babies SR.10,000 per SR.10,000 per
case case
Congenital defects SR.10,000 SR.10,000

Waiting Period for Childbirth: NIL ** NIL **

Covered from day Covered from day

New born babies
one one
WIVES (minimum) NUMBER:
Number of wives to be included for Maternity benefits,
Min. 10 Wives. ALL ALL
Note: Maternity benefits begin after confirmation of pregnancy.
** 280 Days waiting period for childbirth for new entrants only

DENTAL B E N E F I T S Group A+ Group A

Simple Extraction, Amalgam / Composite Fillings ,
*Covered *Covered
one routine check up.
Co-Insurance: 20% 20%

Annual Limit Per Member SR.5,000 SR.2,000

VISION CARE B E N E F I T S Group A+ Group A

Vision test for obtaining (or) upgrading of eye
*Covered *Covered
glasses.
One Pair of Medically Prescribed normal lenses (Anti-
reflective, anti-scratch, Polaroid, contact lenses and Max.SR.250 Max.SR.250
frames are not covered)
No. of Visits for refraction. 2 2

CO-INSURANCE: 20% 20%

Annual Limit Per Member SR.1,000 SR.500

• payable after satisfying deductible (or) Co-payments, if any.

ADDITIONAL PREMIUM PAYABLE DIFF- EMP

Group A+ Group A
BY MEMBER COST
EMPLOYEE 2,462.00 1,539.00 923.00
WIFE 3,900.00 2,438.00 1,462.00
CHILD 2,462.00 1,539.00 923.00