To cater to the needs of individuals for the medical expenses in terms of inpatient and outpatient expenses. Souqalmal Insurance presents Individual medical insurance plan. Souqalmal Insurance’s Individual medical insurance is basically an insurance cover that offers to provide relief from the burden of medical expenses.
Outpatient
The scope of cover of outpatient benefit, if covered as per the Policy schedule and Table of benefits, includes the following:
The scope of cover of In-patient benefit, if covered as per the Policy schedule and Table of benefits, includes the following:
Hospital accommodation & services which include:
Dental
The scope of cover of dental benefit, if covered as per the Policy schedule and Table of benefits, includes the following:
Exclusions: The following Treatment and services are excluded:
Optometry/Optical
The scope of cover of dental benefit, if covered as per the Policy schedule and Table of benefits, includes the following:
Plain lenses only for the correction of the above mentioned errors of refraction subject to sub-limit.
If pre-existing condition benefit is included in the policy, then Treatment for the following conditions are covered:
Exclusions:The following Treatment and services are excluded:
Maternity
The scope of cover of maternity benefit, if covered, is as per the Policy schedule and Table of benefits, which includes following:
Exclusions: The following Treatment and services are excluded:
GENERAL EXCLUSIONS The items procedures and medical conditions
listed below and their related or consequential expenses are excluded from the
coverage provided under this policy unless specifically stated to be included
in the table of benefits or endorsement(s) to this policy:
1. All pre-existing conditions, unless agreed otherwise in the
schedule of benefits.
2. Services, accommodation or treatment charges incurred in Health
Hydros, Spas, Ayurvedic Resorts/Centres, Nature Cure Clinics, Rest Homes or any
similar place even if it is registered as a hospital, residential stay in a
hospital or any similar institution arranges wholly or partly for domestic
reasons and which is not directly related to treatment, or beyond the period
required for recovery from treatment. Services received before the effective
date of coverage or during an inpatient stay that began before the effective
date or services received after coverage ends.
3. Routine medical examinations or check-ups, routine eye and ear
examination, routine foot care, optometric examinations (vision tests),
spectacles, contact lenses and correction of vision, vaccinations,
inoculations, medical certificates and examination for residence, employment or
travel. Optical or Maternity or complications of pregnancy or Dental and/or
orthodontic treatment unless listed in the table of benefits.
4. Any pharmaceutical products which are not on the approved list
of drugs and which are not considered to be medically necessary for the
specific treatment of the medical condition or bodily injury as per the list
attached to the policy contract.
5. Elective/cosmetic treatment or circumcision unless medically
necessary and pre-authorized by the insurer.
6.
Bulmia, anorexia nervosa, obesity, baldness, anxiety, insomnia, homesickness,
loss of appetite and any other eating disorders. Health Services and associated
expenses for the surgical treatment and non-surgical, medical treatment of
obesity (including morbid obesity), and any other weight control programs,
services, or supplies.
7.
Tests or treatment related to contraception or sterilization, infertility,
impotency, sexual dysfunction or any similar condition.
8.
Birth defects, congenital illness or hereditary conditions, Deviated Nasal Septem
& Nasal Conchae and associated conditions, Septoplasty, maternity
examinations/complications and any treatment/conditions related to or caused by
pregnancy and childbirth, unless listed in the table of benefits.
9.
Treatment of mental illness and psychiatric and development disorder unless
related to treatment covered by the policy or listed as covered in the table of
benefits.
10. Any
treatment or test for acquired immune deficiency syndrome (AIDS) and AIDS/HIV
related conditions or sexually transmitted diseases, self inflicted injury,
suicide alcohol or drug addiction/abuse
11.
Treatments resulting from racing of any form and professional participation in
hazardous sports.
12.
Treatment for any illnesses or injuries resulting from active participation in
war, riots, civil disturbances, terrorism, acts against any foreign hostility,
whether war has been declared or not treatment for any medical conditions
arising directly or indirectly from chemical contamination, radioactivity or
any nuclear material whatsoever, including the combustion of nuclear fuel.
13.
Unless otherwise provided for under the plan and listed in the table of
benefits, treatment of chronic conditions including palliative treatment. 14.
All vaccinations and routine or preventive medical examinations including
routine follow up consultations.
15.
Treatment received outside the territorial limits described in the table of
benefits and/or expenses incurred where the insured against medical advise.
16.
Costs incurred in connection with locating or the acquisition of a replacement
organ or any costs incurred for the removal of the organ from the donor,
transportation costs of same and all associated administration costs.
17.
Prosthesis corrective devices or durable appliances and medical appliances that
are not surgically required, including hearing aids and/or any substance not
considered as medicine.
18.
Complimentary medicine applications such as chiropractic, KKT and Osteopath.
19.
Treatment of any allergic condition or disorder, however, the initial visit to
diagnose an allergy will be covered.
20. All
substances which are not considered medicines such as but not limited to
mouthwash, toothpaste, lozenges, antiseptic solutions, milk formulas, food
supplements, skincare products, sanitary pad, shampoos etc.
21.
Home visits unless it is an emergency as defined in the policy definitions.
22.
Hormone replacement therapy (HRT) unless carried out as part of or immediately
after a surgical procedure which is covered under the table of benefits to this
plan.
23.
Skin disorders like warts, keloid, acne, Lipoma and Mollusum contagiosum
24. Any
treatment or test, second or subsequent opinion for which the required
insurer’s pre-authorization is not obtained. 25. Benefits recoverable under
Workmen’s compensation act insurance.
26.
Claims directly or indirectly occasioned by happening through, or in
consequence of, aviation, other than as a fare paying passenger in a fully
certified passenger carrying aircraft, flown in the course of licensed
operation for the transportation of passengers by properly licensed crew.
27.
Consultations or Treatment of speech and voice problems.
28. All
Auditory Accessories, Eyeglasses and contact lenses.
29. Loss
of hearing unless caused by a medical condition covered under the policy,
hearing aids, ear and body piercing.
30. Any
medical prescription relative to a special diet, weight control, children’s
food, baby supplies, slimming pills, scalp and hair lotions and shampoos etc.
31.
Vitamins or multivitamins are not covered. However, vitamins prescribed by a
doctor along with antibiotic are covered. Also, in case of severe vitamin
deficiency, wherein injectible vitamins are prescribed, same would be covered.
32. All
maternity related benefits unless provided for under the plan and listed in the
table of benefits.
33.
Claims for cryopreservation, implantation of living cells or living tissue,
whether autologous or provided by a donor.
34.
Medical practitioner fees for the completion of a claim form or other
administration charges.
35.
Expenses incurred because of complications directly caused by an illness,
injury or treatment for which cover is excluded or limited under your plan.
36.
Road Traffic Accidents where the claim is payable under Motor Insurance Policy
37. All
Hepatitis except Hepatitis A are not covered
38.
Upper and lower jawbone surgery (including that related to the
tempanomandibular joint) except for direct treatment of acute traumatic Injury
or cancer. No Coverage is provided for orthodontic surgery, jaw alignment, or
treatment for the tempanomandibular joint.
39.
Custodial care; domiciliary care; private duty nursing; respite care; rest
cures. (Custodial care means (1) non health related services, such as
assistance in activities of daily living, or (2) health related services which
do not seek to cure or which are provided during periods when the medical
condition of the patient is not changing or (3) services which do not require
continued administration by trained medical personnel.)
40.
Personal comfort and convenience items or services such as television,
telephone, barber or beauty service, guest service and similar incidental
services and supplies.
41.
Health Services and associated expenses for cosmetic and/or reconstructive
treatment and procedures.
42.
Health Services and associated expenses for Experimental, Investigational or
Unproven Services, treatments, devices and pharmacological regimens, except for
Health Services which are otherwise Experimental, Investigational or Unproven
that are deemed to be, in the Company’s judgment, Covered Health Services. The
fact that an Experimental, Investigational or Unproven Service, treatment,
device or pharmacological regimen is the only available treatment for a
particular condition will not result in Coverage if the procedure is considered
to be Experimental, Investigational or Unproven in the treatment of that
particular condition.
43.
Health Services that are performed outside of the country in which this
contract is issued, unless prior approval is received from the Company, or
International Coverage is provided through a separate Rider.
44. Any
Health Services and associated expenses for alopecia, baldness, hair falling,
dandruff, wigs, or toupees. 45. Services and supplies for smoking cessation
programs and the treatment of nicotine addiction are excluded.
46.
Non-Medically Necessary amniocentesis.
47.
Health Services and associated expenses for sex transformation operations,
voluntary sterilization and for reversal of sterilizations. Contraceptive
supplies or services. All services related to fertility/infertility as
varicocele or polycystic ovary/ ovarian cyst or hormonal disturbances etc. and
sexual dysfunction. VaricoCele and associated conditions in Males are not
covered. PCOD & associated conditions in Females are not covered
48.
Growth hormone therapy.
49.
Outpatient prescribed or non prescribed medical supplies including elastic
stockings, ace bandages, gauze, syringes, diabetic test strips, and like
products; non-Prescription Drugs and treatments. (Bandages, gauze etc. are
covered as a part of emergency treatment given at any medical facility)
50.
Mental Health and/or Substance Abuse Services, including pharmaceuticals,
in-patient and out-patient treatments.
51.
Services rendered by a Provider with the same legal residence as a Covered
Person or who is a member of a Covered Person's family, including spouse,
brother, sister, parent or child.
52.
Enteral feedings (infusion formulas via a tube into the upper gastrointestinal
tract) and other nutritional and electrolyte supplements, unless done as a
consequence to other Medically Necessary Inpatient care.
53. All
cases resulting from alcoholism use of drugs & hallucinatory substances.
54.
Senile dementia, Alzheimer’s disease, Menopause and Osteoporosis
55.
Acupuncture; acupressure; hypnotism, Rolfing; massage therapy; aromatherapy;.
56.
Health Services and associated expenses for in-vitro fertilization (IVF),
gamete intra-fallopian transfer (GIFT) procedures, and zygote intrafallopian
transfer (ZIFT) procedures, and any related prescription medication treatment;
embryo transport; donor ovum and semen and related costs, including collection
and preparation.
57. Elective
non-accident related surgery for correction of refraction errors and/or
Improvement of vision (quantitative or qualitative).
58. Charges by a provider for telephone consultations.
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