Unified Health Insurance Policy Form (Decision No. 34/19)

Decision
No. 34/19
On the Issuance of The Unified Health Insurance Policy Form ,Based on the Insurance Companies Law promulgated by Oman Sultani Decree No. 12/1979 Oman Sultani Decree No. 90/2004 on the Transfer of the Competencies from the Ministry of ,Commerce and Industry to the Capital Market Authority ,Upon the approval of the Board of Directors of the Capital Market Authority ,And based on the public interest requirements :It has been decided
Article 1
.The Unified Health Insurance Policy Form enclosed with this Decision shall be put into effect
Article 2
This Decision shall be published in the Official Gazette, and shall come into effect on the next .day following the date of its publication Issued on 17 Rajab 1440 H Corresponding to 24 March 2019 Abdullah bin Salim bin Abdullah Al-Salmi Executive President of the Capital Market Authority The Unified Health Insurance Policy Form
Chapter 1
Definitions
Article 1
In applying the terms of the Policy and its annexes, the following terms and expressions shall :have the meaning assigned against each, unless the context requires otherwise .Policy: The Unified Health Insurance Policy and its annexes -1 Insurance Application: The application to be filled by the Policyholder, pursuant to the -2 .information specified in Annex No. (2), attached to this Form

Insured: The Employee or the dependant to whom the Insurer agrees to provide cover, subject -3 .to the terms of the Policy Policyholder: A physical or juristic person who commits to pay the Insurance Premium and in -4 .whose name the Policy is issued for the interest of the Insured Insurer: The insurance company licensed to engage in the health insurance business in the -5 .Sultanate Policy Term: The period of time stated in the Policy as agreed upon between the Insurer and -6 .the Policyholder Insurance Premium: The amount of money payable by the Policyholder in return for the -7 .obligation of the Insurer to cover the healthcare expenses of the Insured under the Policy Insurance Coverage: The Essential Health Benefits and optional benefits, that are available -8 and agreed upon in details between the Insurer and the Policyholder to the interest of the .Insured under the Policy Essential Health Benefits: The available healthcare services from among the healthcare -9 .insurance services provided for the Insured, according to Annex No. (4) attached to this Form Licensed Physician: The Physician licensed by the Ministry of Health to practise the medicine -10 .profession Consultant: The Physician who fulfils the requirements for filling the Consultant Physician -11 .position .Effective Date of Coverage: The date stated in Annex No. (1), attached to this Form -12 Insurance Coverage Limits: The total financial amounts that may be claimed by the Insured -13 .for receiving the appropriate treatment during the Policy Term Employee: Any physical person who is actually employed by the Policyholder and registered -14 .in his record under the said status :Dependant -15 a- A legally married spouse of the Employee, whose actual and legal residence is the Sultanate, provided that he is registered under the said status in the records of the .Policyholder b- The children of the Employee or of the legally married spouse of the Employee, who are .not over (21) years of age, and registered under the said status with the Policyholder c- Any other person not affiliated to any of the Categories (a) or (b), whose actual and legal residence is in the Sultanate, and who is financially Dependent upon the Employee, and .registered under this status with the Policyholder Contribution: The percentage of Contribution of the Insured to the medial expenses, -16 .according to Annex No. (4) attached to this Form Healthcare Service Provider: The healthcare facility accredited by the Ministry of Health and -17 .licensed under the applicable regulations to provide the healthcare services in the Sultanate Healthcare Service Providers Network: A group of Healthcare Service Providers, accredited -18 .and designated by the Insurer to provide the healthcare services for the Insured Disease: The health condition suffered by the Insured and which requires that he receives -19 .the healthcare during the Policy Term

Allergy: A pathological state resulting from the sensitivity of an individual, particularly to -20 specific kinds of food, weather, pollen, or any other allergens from plants, insects, animals, .minerals, chemicals, and other elements or substances :Chronic Conditions: The Disease or injury having one or more of the following characteristics -21 a- The need for continuing or long-term care through consultancies, medical test and .examination .b- The need for ongoing or long-term control or relief of symptoms .c- The need for rehabilitation or training for coping with the Disease .d- Lasting for a lifetime .e- Expected or likely-to-recur Pre-existing Condition: Any injury, Disease, pathological states or relevant cases whose signs -22 .or symptoms have appeared in the period previous to the Effective Date of Insurance Coverage Reimbursable Expenses: Regular and essential Medical Expenses incurred by the Insured for -23 Necessary Medical Treatments of the cases, not excluded under Chapter 4 of the Policy, outside :the scope of the Healthcare Service Providers Network, and that is in the following cases .a- Emergency cases .b- Upon agreement between the Insurer and the Policyholder Claim-Supporting Documents: The documents proving the identity of the Insured, the -24 .medical reports, invoices, and police report, if any Hospitalisation: The act of keeping the Insured with the Healthcare Service Provider, -25 including hospital day-care or Hospitalisation in accidents and Emergency departments, based on .the advice given by the Licensed or Consultant Physician Inpatient Treatment: The act of keeping the Insured with the Healthcare Service Provider for -26 .an overnight stay to receive treatment Treatment in Outpatient Clinics: The Insured visits to Outpatient Clinics of the Healthcare -27 .Service Provider for diagnosis or medical treatment .Emergency: A health condition requiring prompt medical intervention -28 Necessary Medical Treatment: The healthcare service or treatment which is associated or -29 consistent with the diagnosis, according to the health standards specified by the Licensed or .Consultant Physician Medical Expenses: The financial amount paid by the Insurer to the Healthcare Service -30 Provider for the Necessary Medical Treatment provided to the Insured according to the Policy .terms and clauses .Pregnancy or Delivery Complications: The cases that may arise during pregnancy or delivery -31 Alternative Medicine: A set of healthcare practices not included in the primary healthcare -32 .system approved by the Ministry of Health
Chapter 2
General Terms and Clauses

:Preface
The Policy and the Insurance Application are considered one contract. Any term or phrase shall have the same special meaning given in any part of the Policy or Insurance Application, unless the context requires otherwise. In addition, the material information, data and customary practices associated with the Health Insurance contracts and provided by the Policyholder or his representative and related to the Insurance Coverage, shall be considered the basis that form .this contract The Insurer shall make this Policy available to the Policyholder and ensure that he obtains the .required Insurance Coverage Insurance Application Information: The information provided by the Policyholder shall be -1 .correct Scope and Validity of the Policy: The Policy shall represent the minimum Essential Health -2 Benefits provided to the Insured. The Policy or any subsequent amendment to the same shall .not be valid, unless after such matter is proved in a table signed by both parties Policy Term: The Policy Term shall be valid for one calendar year, unless otherwise agreed by -3 .the parties Records and Reports: The Policyholder shall retain a record for all his Employees and the -4 :Insured persons according to the Policy. The said record shall contain the following information .a- The name, gender, age, nationality, social status, and card number b- Any other essential information requested by the Insurer to be included in the records of the Policyholder. The Policyholder shall commit to provide the Insurer with any information that may be requested on the Insured Persons, and allow access to the said records in order .to verify their validity Eligible Persons for Insurance: The Employee shall be considered from among the categories -5 eligible for insurance by the Policyholder. The Dependent, other than the Employee, shall also be considered among the said categories pursuant to the privileges granted by the employment .contract of the Employee with Dependents Essential Health Benefits: The Policyholder shall have the right to choose the Essential Health -6 Benefits Table (A) or (B) attached to this Form, and to raise the Basic Insurance Coverage Limits in Annex No. (4), attached to this Form, and accordingly the Insurance Premium shall be determined by the Insurer. The Policyholder may add any optional benefits to the Essential .Health Insurance Coverage, according to Annex No. (3), attached to this Form Payment of the Insurance Premium: The Policyholder shall commit to settle the Insurance -7 .Premium within the time limits agreed upon with the Insurer :Addition or Removal of the Insured -8 a- The Policyholder shall notify the Insurer, in writing, upon adding or removing the Insured, provided that his date of employment or dismissal is proved. The Policyholder, upon applying for the removal of any Insured person, shall return the membership card or any other documents requested by the Insurer prior to the removal date. If the membership card is not returned,
the Policyholder shall compensate for the loss incurred by the Insurer for any claim made after the removal date. The removal shall be effective from the date on .which the application is approved by the Insurer b- The Policyholder shall submit, to the Insurer, a proof of the departure of the Insured (foreign national) from the Sultanate, if the application involves the removal of an .Employee from the Policy

c- The additional Insurance Premium shall be calculated in accordance with the agreement .between the Insurer and the Policyholder d- The refundable Insurance Premium related to the Insured, who has not benefitted from the Insurance Coverage shall be calculated according to the following equation: Refundable Premium= Insurance Premium × Remaining Period/Policy Term The Insurer shall return the refundable Insurance Premium within a period not exceeding thirty .(30) days from the date on which the removal is approved :Effective Date of Coverage -9 a- With respect to the Employee: Starting from the Effective Date of Coverage specified in
Annex No. (1), attached to this Form, or from the addition date to the Policy with respect to
.the Employee who is employed after the said date b- With respect to the Dependent: Starting from the date on which the Employee with Dependents becomes Insured, or from the date of acquisition of the Dependent status with .the Policyholder Cancellation of the Policy: The Policyholder may cancel the Policy at any time, by a written -10 notice to be sent to the Insurer within at least thirty (30) business days prior to the desired cancellation date, on condition that he submits a proof of the conclusion of another Insurance Policy, which includes the effective date of the new Insurance Coverage as from the next day .following the cancellation of the previous Policy In this case, the Insurer shall remain obliged, during a period not exceeding thirty (30) business days from the cancellation date, to return to the Policyholder, the remainder of the Insurance Premium for each Insured person who has not benefitted from the Insurance Coverage. The remainder of the Insurance Premium shall be calculated according to the equation set out in .Clause (8) of this Chapter Confidentiality of the Claim-Supporting Documents: The Policyholder and the Insured shall -11 approve to make available, to the Insurer or his representative, all the ClaimSupporting Documents, provided that the Insurer commits to maintain the confidentiality of the information .comprised in the said Documents Complaints: The Policyholder or the Insured shall have the right to file complaints according -12 .to the procedures specified by the Capital Market Authority Medical Expenses: The Insurer shall commit to settle the Medical Expenses to the Healthcare -13 Service Provider during the Policy Term and according to its terms. The Insurer shall verify whether or not the said Medical Expenses have been incurred during the Policy Term by :following the basis indicated in the following table Healthcare Sevices .No The Basis for the Calculation of the Date of IncurringtheMedical Expenses Date of the actual visit of the Insured The consultations of Licensed Physician or Consultant 1

Date of service Laboratory and diagnostic radiology 2 Pharmaceutical drugs 3 Date of purchase of the drug pursuant to the dosage prescribed by the Physician or Consultant Date ofactual admission to the hospital and dismissal date Hospital room rate 4 Date of surgery Surgery oraesthesiatechnician fees 5 Date ofactual receipt of the services Other medical services for Inpatient Treatment 6 Insurance Coverage Limits: The liability of the Insurer shall be limited to the amounts -14 .specified for the Insurance Coverage in Annex No. (4) attached to this Form Scope of Validity of the Policy: The Policy shall be applicable to the Medical Expenses -15 incurred within the territorial boundaries of the Sultanate, unless otherwise agreed by the .parties Judicial Jurisdiction: The courts of the Sultanate shall be competent to adjudicate the -16 .disputes that may arise from the application of the terms of the Policy

Chapter 3
Management of Claims
The requirements for the management of the Insurance Health Claims: a- The Healthcare -1 Service Provider shall commit to submit a notification for any claim pursuant to the form :prepared by the Insurer, accompanied with the following documents Full and detailed medical and diagnostic reports on the description of the Disease and -1 .relevant treatment .The Form of Prior Authorisation for Treatment -2 .Any other medical information that may be deemed essential -3 b- All claims notification shall be consistent with the applicable e-claims systems in the .Sultanate The Basis for Coverage of the Consultant Fees: The Insurer shall not cover the consultation or -2 treatment costs provided by the Consultant without a prior referral decision from the Licensed .Physician The Prior Authorisation for Treatment: The Healthcare Service Provider shall commit to obtain -3 the prior authorisation for treatment from the Insurer before the Insured undergoes any .treatment, according to Annex No. (5), attached to this Form Reimbursable Expenses: The Insurer shall commit to reimburse the Insured for the -4 Reimbursable Expenses within a period not exceeding fifteen (15) business days, from the date of provision of the Claim-Supporting Documents to the Insurer, provided that the Insurer is provided with the Claim-Supporting Documents within a period not exceeding one-hundred and twenty (120) business days from the date of incurring said costs. The costs shall include the :following .a- The expenses for Treatment in Outpatient Clinics .b- Inpatient Treatment expenses including surgeries c- The expenses for returning the corps or remains of the deceased person to his country of origin mentioned in the employment contract, except for the cases involving death resulting .from the injuries mentioned in Clause (37) of Chapter 4 of this Form Refusal of Claims: The Insurer shall have the right to refuse or return the claims submitted, as -5 :the case may be, in any of the following cases .a- Failing to submit a fulfilled original claim form .b- Absence of the signature and stamp of the Licensed or Consultant Physician c- If the tests undergone by the Policyholder and the treatment received were not based on .the request or determination of the Licensed Physician or Consultant .d- If the diagnosis and treatment are irrelevant to the health problem e- Claims submitted after one-hundred and twenty (120) business days from the treatment .date. f- The costs incurred in excess of the Insurance Coverage Limits g- The treatments made prior to the date of addition of the Insured to the Policy or after its .expiration Upon the refusal of the claim submitted by the Insured, the Insurer shall commit to deliver him a

statement, in writing, of the reasons of refusal, within ten (10) days at most from the claim filing .date. The Insured shall have the right to resort to the competent authorities to decide the claim
Chapter 4
Exclusions
:The following cases shall be excluded from the terms of the Policy .Intentional self-inflicted injury committed by the Insured -1 .Experimental treatment -2 The Pre-existing Condition and Treatment in Outpatient Clinics with respect to Chronic -3 .Diseases .Full exams not requiring a medical treatment included in the Policy -4 Any healthcare tests or services performed for non-medical purposes, such as the medical -5 .exam for employment, travel, licensing and insurance Personal risks that are the personal activities involving high risks for the Insured or that may -6 expose him to a Disease or accident or which may negatively affect his health problem or .previous injury .Epidemic Diseases pursuant to the classification of the World Health Organisation -7 .Drugs and therapy through the Alternative Medicine -8 The Diseases that may arise due to misuse of some drugs, stimulates, tranquilizers or due to -9 .the use of alcohols or narcotics or psychotropic substances Cosmetic surgery or therapy, unless required by an incidental physical injury which is not -10 .excluded .Therapeutic recreation and general physical health programs -11 Treatment of venereal Diseases or sexually transmitted Diseases that are medically -12 .recognised The expenses of treatment following diagnosis of (Human immunodeficiency virus infection) -13 HIV or any HIV related Disease, including AIDS (acquired immune deficiency syndrome), its .derivatives, alternatives or other forms All expenses related to dental implants, dentures, fixed or removable bridges, or orthodontic -14 .treatment not resulting from an accident Tests and operations for vision and hearing correction, and visual or hearing aids not -15 .resulting from an accident Septoplasty and ciliary turbinate surgery and prosthesis, unless intended for the treatment -16 .of a health problem, such as nose blockage or difficulty breathing or resulting from an accident .Treatment of health loss or baldness or hair implant -17 .Physiological therapy or mental disorders treatment, except in Emergency cases -18 Allergy tests and therapy, of whatever nature, other than the conditions relating to Allergy -19 .from certain kinds of drugs and supplies used in the treatment

.Any expenses related to immunomodulator and immunotherapy -20 .Therapy and services for transitioning, sterilisation, infertility and sexual disfunction -21 .Any costs for the treatment of sleep disorders -22 Therapy related to participation in dangerous sports or activities, including but not limited -23 to, scuba diving, parachuting, mountaineering and rock climbing, sand dune riding on vehicles .and motorcycles Birth defects or congenital disorders, including functional, chemical or structural disorders, -24 usually existing prior to delivery whether genetic disorders or as a result of environmental .factors .Skin disorders such as warts, smallpox or acne -25 .Overweight and obesity treatments -26 Organ transplantation, bone marrow or artificial organs transplant to fully or partially -27 .replace another organ in the body .The natural changes of menopause age, including menstrual disorders -28 Genetic disorders claims, cryopreservation, cell or tissue culture, including but not limited to, -29 .stem-cell therapy, whether autologous or offered by a donor Treatment of anorexia nervosa, bulimia, loss of appetite, and other eating disorders, or any -30 .other form of treatments by the psychiatrist Any additional costs or expenses incurred by the accompanying person of the Insured, during -31 Hospitalisation or accommodation at the Healthcare Service Provider, except for the room and board charges for one accompanying person, such as the mother accompanying her child under sixteen (16) years of age, or as required by Necessary Medical Treatments, at the discretion of .the Licensed Physician or Consultant The costs incurred for complications resulting directly from a Disease, injury or treatment -32 .excluded from the Insurance Coverage All supplies not considered drugs, including but not limited to, mouth wash, tooth paste, -33 soap, lotions, creams, disinfectants, dairy prescriptions, dietary supplements, children food, skin￾care products, infants supplies and multi-vitamins unless prescribed as treatment alternative, in case of vitamins deficiency), and all equipment not intended to improve the health problem or .injury Any external medical tools, devices and equipment, including but not limited to, breast -34 pumps, massage machines, training equipment, thermostat, blood pressure and sugar monitors, .and glucose patches .Mouth masks, bandages, compression socks and long socks -35 External supports, including but not limited to, walking sticks, stretchers, cushions, lifts, back -36 support belts, waist belts, cervical collar, and other articular supports, belts and wheelchairs, .foot cushions, and orthopaedic shoes :Injuries resulting from the following cases -37 .a- Military operations of any kind .b- Natural disasters

.c- Criminal acts or resistance offered by the Insured against the authorities .d- Ionising radiation or radioactive contamination by nuclear fuel or wastes .e- Radioactive, poisonous or explosive materials .f- Riots, strikes or acts of terrorism .g- Chemical, biological or bacteriological reactions
Annex No. 1
Table of Policy
:Policy Number -1
:Insurer Name -2
:Insurance Type -3
:Policyholder Name -4
:P.O Box-6 :Address -5
:Postal Code -7
/ / Insurance Term: From / / To -8
:Insurance Premium -9
.a- Basic Insurance Premium
.b- Optional benefits premium c- Supervision and control fees (sixten- .thousands of the net Insurance Premium d- Emergency fund fees (1% of the net .(Insurance Premium (Omani Rial (OMR (Omani Rial (OMR (Omani Rial (OMR (Omani Rial (OMR (Omani Rial (OMR Total paid premium Policyholder Signature Insurer Signature Effective Date of Coverage
Annex No. 2
Insurance Application
Applicant Information -1
Name as in
Identity Card
Tribe Third Second First
:Company Business Name
:Company place of business :Commercial Register Number :Permanent Address :Governorate :(Province (Wilayat :City: Village :Electronic mail Work phone number :Postal Code :P.O Box :Number of Insured Persons -2 Identify Card Professions Gender Age Name Number/ Place of Employment

Resident Card
Do you have a previous health insurance? ( )Yes ( ) No -3 ?Previous Insurers -4 A B c Policyholder Signature Insurer Signature Date
Annex No. 3
Table of Optional Benefits
Additional .No
Insurance
Coverages
Insurance Yes
Premium
Signature
Pregnancy and 1 delivery benefits
Dental Benefits 2
Vision Benefits 3
Child healthcare 4 services, accordingto the applicable standards of the Ministry of Health Work injuries 5 treatment Other optional 6 benefits Amount of Insurance Premium payable for the additional benefits (Omani Rial (OMR Policyholder Signature Insurer Signature Effective Date of Coverage
Annex No. 4
Table of Essential Health Benefits
Essential Benefits Table A
Limits Contribution Description Basic Coverage a- Hospitalisation or day￾care for diagnosis or .treatment or surgery b- Accommodation in the .hospital / room rate c- Accommodation and

Inpatient Treatment treatment in intensive care .units d-Fees of Physicians /Consultants, medical and .medical assistant categories e- Diagnostic radiology /computerised tomography (CTScan)and magnetic resonance imaging(MRI)/ .ultrasound .f- Drugs and solutions g- Pre-existingconditions and chronic Diseases. h￾Treatment and accommodation in .Emergency rooms .i- Ambulance expenses j- Accommodation of patient companion (for patients .(under (16)years ofage N/A Inpatient maximum - treatment limit of three thousand (3,000) Omani rials for the Insured during the Policy Term. - Hospitalisation for maximum of thirty (30) days in asingle period. -Shared room accommodation. - Patient transport to the hospital of maximum (100) .Omani rials per ride Treatment in Outpatient Clinics .a- Consultation fees b- Diagnostic radiology /computerised tomography (CTScan)and magnetic resonance imaging(MRI)/ .ultrasound .c- Laboratory charges d- Pharmaceutical fees (generic drugs, or otherwise othe for the designated (15%) - Healthcare Service Providers Network, for maximum of twenty (20) Omani rials per visit - (30%) for non￾designated Healthcare Service Providers Network - (10%) for drugs of maximum of five (5) Omani rials per visit Maximum Treatment in Outpatient Clinics, of five hundred (500) Omani rials duringthe Policy Term Returningthe corps or remains of the deceased to his country of origin Expenses for returningthe corps or remains of the deceased to his country of origin N/A Maximum limit for returning the corps or remains of the deceased to his country of origin, of one thousand (1,000) Omani rials Essential Health Benefits Table B Limits Description Basic Coverage Inpatient Treatment k- Hospitalisation or day care for .diagnosis or treatment or surgery l- Accommodation in the hospital / .room rate m- Accommodation and treatment in .intensive care units n-Fees of Physicians/Consultants, medical and medical assistant .categories o- Diagnosis/ radiology/computerised tomography (CTScan)and magnetic .resonance imaging(MRI)/ ultrasound .p- Drugs and solutions Inpatient maximum treatment limit - of (3,000) Omani rials for the Insured duringthe Policy Term. - Hospitalisation for maximum of thirty (30) days in asingle period. -Shared room accommodation. - Patient transport to the hospital for maximum of (100) Omani rials per

q- Pre-existingconditions and chronic
.Diseases r-Treatment and accommodation in
.Emergency rooms s- Ambulance expenses t- Accommodation of patient companion (for patients under (16) .(years ofage ride Treatment in Outpatient Clinics e- Consultation fees f- Diagnosis/ radiology/computerised tomography (CTScan)and magnetic .resonance imaging(MRI)/ ultrasound g- Pharmaceutical fees (generic drugs, or otherwise other drugs shall be .(administered .h- Laboratory charges Maximum Treatment in Outpatient clinics of five hundred (500) Omani .rials duringthe Policy Term Returningthe corps or remains of the deceased to his country of origin Expenses for returningthe corps or remains of the deceased to his country of origin Maximum limit for returningthe corps or remains of the deceased to his country of origin, of one thousand (1,000) Omani rials (Following: Table of Basic Concerns (A Limits Contribution Description Basic coverage Treatment in outpatient clinics A- Consulting fees B- Diagnosis / radiation / magnetic resonance imaging / CT scan / ultrasound transmission C - Laboratory for the 15% - network of beneficiary health service providers, with a limit of (20) twenty Omani .riyals per visit for the 30% network of unspecified health service providers The maximum limit for outpatient treatment is (500) five hundred Omani riyals during the policy .period D- Pharmacy fees (generic medicines, and if they are not available, other medicines are (.dispensed for 10% medicines applies, with a maximum of (5) five Omani riyals .per visit Returning the body and remains Expenses for returning the body The maximum - limit for returning

of the deceased to his place of origin and remains of the deceased to his country of .origin the body and remains of the deceased to his country of origin is (1,000) thousand .Omani riyals
Table of basic health benifits
Limits Description Basic coverage
H- Hospitalization or day care Inpatient treatment for diagnosis, treatment, or .surgery I - Hospital accommodation / .room rent J- Accommodation and treatment in intensive care .rooms K-Fees for doctors/consultants, medical .and allied medical categories L- Diagnosis / Radiology / .MRI / CTscan / Ultrasound .M- Medicines and solutions N- Pre-existingconditions .and chronic diseases O-Treatment and accommodation in .emergency rooms .P- Ambulance expenses Q-Establishment of facilities (for patients under the age of .((16) sixteen years The maximum limit for inpatient treatment is (3,000) three thousand Omani Riyals for the insured person during the period of stay Hospitalization fora￾maximum of (30) thirty days at atime Accommodation in ashared - room Transportingthe injured - person to the hospital with a maximum of (100) one hundred Omani Riyals for each transport (Following : Table of basic health benifits (B Limits Description Basic coverage Treatment in outpatient clinics The maximum limit for .R - Consultingfees outpatient treatment is (500) five hundred Omani riyals duringthe policy period

S-
.Diagnostics/Radiology/MRI/CT/Ultrasound
T- Pharmacy fees (generic medicines,and if they are not available, other medicines are (.dispensed .U- Laboratory fees Returningthe body and remains of the deceased to .his place of origin Expenses for returningthe body and remains of the deceased to his country of origin The maximum limit for returningthe body and remains of the deceased to his country of origin is (1,000) thousand Omani .riyals (Following : Table of basic health benifits (C Limits Contribution description Basic coverage A- Hospitalization or .Inpatient treatment day care for diagnosis, .treatment, or surgery B- Hospital stay/room .rent C- Accommodation and treatment in .intensive care rooms D- Fees for doctors/consultants, medical and allied .medical categories E- Diagnosis / Radiology / MRI / CT .scan / Ultrasound F- Medicines and .solutions G- Pre-existing conditions and .chronic diseases H- Treatment of work .injuries I- Treatment and The maximum limit - for inpatient treatment (4,000) is four thousand Omani Riyals for users inside or outside homes duringthe policy period Hospitalization fora maximum of (30) thirty days at atime Accommodation in a shared room, except in cases that require isolation Transport the injured person to the hospital with a maximum of (100) one hundred Omani Riyals for each transport

accommodation in
.emergency rooms
J- Ambulance
.expenses
Treatment in
.outpatient clinics
The maximum limit - for outpatient treatment is (500) five hundred Omani riyals duringthe policy period Returningthe body and remains of the deceased to his place .of origin Expenses for returningthe body and remains of the deceased to his .country of origin The maximum limit - for returningthe body and remains of the deceased to his country of origin is (1,000) thousand Omani riyals
Annex No. 5
Prior Authorisation for Treatment
The Health Service Provider shall submit the request for treatment approval of the Insured, in -1 :the following cases a- Treatment in Outpatient Clinics, if the total costs of consultations, laboratory, diagnosis, .radiation, drugs, or treatment procedures exceed one hundred (100) Omani rials .b- Inpatient Treatment and surgeries for non-urgent cases In Emergency conditions, the treatment of the Insured shall commence immediately with no -2 delay, and then the procedures to request the approval shall be performed, provided that the .request is submitted within forty-eight (48) hours from the admission to hospital The Health Service Provider shall insert, in writing, all the necessary medical information on -3 .the approval request form, as well as the date and time The Insurer shall answer the request for approval within thirty (30) minutes from the time of -4 receipt of the request, and in case of refusal, the decision shall be justified. No response within .the specified time shall be considered an implied approvalon the request If the Health Service Provider has not received the answer to the approval request within the -5 specified period for answer, then the Insurer shall be considered to have impliedly approved the case, after verifying that the Insurer has received the request for approval during the said time .limit The Health Service Provider shall answer the inquiries or remarks of the Insurer, if any, within -6 .thirty (30) minutes from the time of taking receipt of the said inquiries or remarks The Insurer shall immediately, after receiving the approval request sent by the Health Service -7 .Provider, confirm receipt of the request