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Daman Member’s GuideBasic (Abu Dhabi) Plan

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TABLE OF CONTENTSDaman: Your Health Insurance Specialist...................................................4

Our Specialized Services...........................................................................5

What Is Covered?.......................................................................................6

How To Obtain Your Plan Benefits?.............................................................8

Within Daman’s Network: Use Your Daman Card.................................8

Outside Daman’s Network: Get Your Bills Reimbursed (In Case Of Emergency Only).........................8

Coverage For Emergencies.................................................................9

What Is Not Covered?........................................................................... ....10

Important To Know...................................................................................14

Your Rights and Responsibilities..............................................................17

Definitions................................................................................................19

Contact Us.............................................................................................21

Daman HeadquartersMillennium Tower, Hamdan St. Abu Dhabi, UAETelephone: 02 614 9555Fax: 02 614 9775 P.O. Box 128888

Central BranchAirport Road, Abu DhabiTelephone: 02 417 3609Fax: 02 614 5562P.O. Box 128888

Corporate Sales CenterAl Bateen, Tower C4Bainuna Street, Abu DhabiTelephone: 02 651 8295Fax: 02 614 9770P.O. Box 128888

Mussafah Individual Basic BranchGlobal Ascent Business CenterAl Musaffah 4, Abu DhabiBehind Mercedes-BenzPlot No. 12 behind SEHATelephone: 02 815 0244Fax: 02 614 5443P.O. Box 128888

Corporate Sales MusaffahGlobal Ascent Business CentreAl Musaffah 4, Abu DhabiBehind Mercedes-BenzPlot No. 12 behind SEHATelephone: 02 815 0264Fax: 02 614 5576P.O. Box 128888

Mussafah Group and Enhanced BranchGlobal Ascent Business CenterAl Musaffah 4, Abu DhabiBehind Mercedes-BenzMain Entrance – 1st Floor Next to SEHATelephone: 02 815 0209Fax: 02 614 5530P.O. Box 128888

Abu Dhabi Service PointsInfinity Services-Muroor StreetZones Corp. MussafahAbu Dhabi Immigration (Visit Visa Only)Abu Dhabi MunicipalityAbu Dhabi Chamber of CommerceMarina Mall (Infinity Services)Masdar CityAl-Shahama Municipality

Al Ain BranchUnit 101,202, 203,301,302,303New Clock Tower Traffic SignalEmpost Building, Al AinTelephone: 03 746 4200Fax: 03 755 7700P.O. Box 69988

Al Ain Service PointsInfinity ServicesAl Wagan MunicipalityMazyad MunicipalityAl Hayer MunicipalitySweihan MunicipalityAl Qoaa MunicipalityAl Ain Immigration (Visit Visa Only)Al Khaznah MunicipalityAl Maqam Municipality

JLT OfficeFortune Tower, Ground Floor LevelJumeirah Lakes Towers, DubaiTelephone: 04 436 0222Fax: 04 436 7242P.O. Box 309101

Western Region BranchMadinat Zayed, Saeed Bin Humaid ComplexBlock A, 1st FloorPlot No. 287 Next to Qatar Al Nada SchoolAl Senaaya StreetTelephone: 02 894 4303Fax: 02 614 5610

Western Region Service PointsMadinat Zayed, Tamm CenterGhayathi, Tamm CenterSilaa, Tamm CenterDelma, Tamm CenterAl Marfa’a, Tamm CenterLiwa, Tamm Center

Sharjah Service PointSharjah Immigration (Visit Visa Only)

Ras Al Khaima Service PointsRas Al Khaimah Service PointsRas Al Khaimah Immigration (VisitVisa Only)

www.damanhealth.ae800 4 DAMAN (32626)

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Daman is the first specialized health insurer in the United Arab Emirates. Our strategic partnership with Munich Re, one of the largest and most reputable reinsurer in the world, has helped us develop a renowned stretch of competencies in the region, backed by the strong and reliable support of Abu Dhabi Government.

Our products are a result of industry knowledge, market research, and a deep understanding of our customer’s health insurance needs. Basic Plan is an

optimal health insurance plan, covering benefits like hospital stays, treatments, and medicines within the Emirate of Abu Dhabi; as well as coverage for emergency services in UAE. This plan offers you health insurance cover of AED 250,000 per person annually. You can use your Daman card to get direct billing facility at health service providers across our plan’s Network which includes hospitals, clinics, pharmacies and diagnostic centres.

We offer you a distinctive set of world class services as listed below:

• Network of more than 600 health service providers in the Emirate of Abu Dhabi

• 24/7 in-house Customer Service Centre staffed with bilingual representatives

• 24/7 access to medical authorizations (pre-approvals required to receive specific medical treatments)

• Automated systems for effective management of your pharmacy benefits

• Efficient claims processing

• Easy access to information on your network directory (including hospitals, pharmacies, clinics, doctors etc.) through our online portal

www.damanhealth.ae

• Wide geographical representation of branches and service points across the United Arab Emirates offering you convenience and choice

• Easy and safe access to our online portal to submit and track your claims, search for health services providers, and ask questions through your “My Daman” account

• Access to Daman Customer Club, an online Daman member community, offering health and wellness tips, and exclusive offers from our trusted partners in the United Arab Emirates.

• Free Tele-coaching programs, through our Health Support services, for members with specific chronic diseases, offering advice and support on treatment facilities, procedures and medications (for more details log onto our web portal or call the Health Support toll free line 800 7 226)

Daman: Your Health Insurance Specialists

Our Specialized Services

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Covered at Network Providers

Notes

Inpatient Benefits

Hospital Charges Including room, meals, nursing,

drugs and dressings.

Inpatient Treatments Surgeries, day procedures,

radiotherapy, chemotherapy, etc.Medical appliances, diagnostic tests

Used as part of inpatient procedures.

Specialist’s or Consultant’s Fee

Outpatient Benefits

Doctor’s consultationIncluding General Physician consultation and Specialist

consultation on referral basis.

Prescribed medicinesCovered as per your Drug

Formulary.

Diagnostic tests Including X-rays, blood tests, ultrasounds, CT Scans, MRI.

Physiotherapy sessions

Maternity Benefits

Inpatient Maternity

Including childbirth, complications of pregnancy

or delivery, new born accommodation and care

Doctor’s Consultation, Prescribed medicines

Additional Benefits

Any emergency treatments or services within UAE

Including Ambulance Services, Dental or Vision Correction

treatments in case of medical emergency.

Emergency treatments or services will also be covered

outside Daman’s Network within the UAE.

What is covered?Main Cover - Your Benefit Summary

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Within Daman’s Network: Use your Daman cardYou will have direct billing access at our Network Providers for health services covered under your policy. Just remember to carry your Daman Card when going to the network provider and comply with the administrative procedures there.

Some health services may have deductibles or co-insurance charges that you will have to pay for. Such charges will be mentioned on your Daman Card and have to be paid either before or after the service is received.

Outside Daman’s Network: Get your bills reimbursed (in case of Emergency only)If you go to a Health Services provider that is not part of Daman’s Provider Network, you will have to pay directly for the services provided. Only in case it is a medical emergency, and if such services are covered in your plan, you will be eligible to reimburse the cost of the health service from Daman.

For reimbursement, you have to submit a claim form, along with documents like original itemized bills, medical or investigational reports, etc. The claim

How to obtain your plan benefits?form and details of our reimbursement requirements are available on our website. These documents must be submitted to Daman within 30 days from the date of service received. You can apply for reimbursement through our website or by visiting any of our branches or service points.

Coverage for Emergencies We are committed to provide you the best coverage for healthcare services, especially when it matters the most. In case of a medical emergency within the United Arab Emirates, you will be eligible to get coverage for your medical bills, whether you were treated at a Network or non-Network Provider. Prior-approval is not required in case of emergency treatments or services. However, you must notify us within 24 hours of the services received so that we can help you with the claims process.

You can reach us on the Customer Service toll free number mentioned on your Daman card in case you need further information.

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• Health Services, including treatments and supplies, not medically necessary

• Health Services including pharmaceuticals not prescribed by a physician

• Health Services received outside the plan Network, except in case of an Emergency

• Dental and gum treatment, Vision and hearing correction treatments and aids, except in cases of medical emergency

• Assistance in activities of daily living which do not change the medical condition of the member (for example - custodial care, private duty nursing, etc)

• Vitamins

• Personal comfort and convenience items or services (for example – beauty services)

• Cosmetic procedures, surgeries which are not incidental to any injury, sickness or congenital deformities

• Treatment of obesity and weight management programs

• Experimental, Investigational or Unproven services, treatments, drug and supplies or devices

• Outpatient medical supplies including prosthetic devices and durable medical equipment(for example - bandages, syringes, wheel chair)

• Any services for hair fall, baldness (for example –alopecia)

• All cases resulting from alcoholism, and use of drugs and hallucinatory substances

• Smoking cessation programs

What is not covered?Your policy does not cover you for:

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• Health Services related to sex transformation operations, fertility or infertility

• Hazardous activities or professional sports (for example – bungee jumping)

• Treatment as a result of war, riots, military operations, etc where a member participates in such acts

• Treatment as a result of nuclear risk, natural peril or any terrorist or criminal activities

• Mental health diseases or disorder unless it is transient mental disorder

• Preventive care including any associated test and investigation (for example – vaccinations)

• Alternative treatments (for example – herbal or chinese treatments)

• Any Health Services and associated expenses for HIV, AIDS, sexually transmitted diseases and all related medical conditions

• Birth defects or Congenital Anomalies for new born unless representing a life threat

• All cases related to Maternity in respect of unmarried females

• Any test which is not related to a specific symptom /disease. This includes examinations required for employment, travel, immigration, licensing or insurance and related reports

• More than one physician consultation in a day or during free follow up period unless medically necessary and referred by the initial treating doctor

• Lesions resulting from attempted suicides or self-infliction

• All substances which are not considered as medicines and all equipment not primarily intended to improve a medical condition or injury(for example – food supplements, air purifying systems)

• Growth hormone therapy unless medically necessary

• Enteral feedings and other nutritional and electrolyte supplement, unless medically necessary

• Services related to musculoskeletal treatments except for treatment of fracture and dislocation of extremities

• Nasal septum deviation, nasal concha resection

• Chronic conditions requiring hemodialysis or peritoneal dialysis including related investigations.

• Viral hepatitis and related complications except hepatitis A

• Air ambulance transportation and terrestrial transportation in non-emergency cases or by non-licensed ambulance services

• Circumcision and any related complications, except for newly converted Muslims

• Any pharmaceutical products, which is not considered as specific treatment for a particular disease or not prescribed by an approved Physician

• All cases where appropriate pre-authorization or notification was not carried out as per policy terms and conditions

• Officially recognized epidemics or pandemics

• Complications directly arising from services not covered

• Educational programs or learning disabilities treatments

• Any treatment or services rendered by a family member or any person with the same legal residence.

• Any Inpatient treatment, tests and other procedures, which can be carried out on Outpatient basis without jeopardizing the Insured’s health

• Organ and tissue transplants

Note: This is only an extract from the General Exclusions list that applies to your plan. Please refer to the Policy Wording for the complete list and details of exclusions, definitions, terms and conditions.

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Pharmacy Benefit ManagementPharmacy Benefit Management (PBM) is an internet-based interface between Daman and your pharmacy within Daman’s Network in Abu Dhabi. It is designed to manage your pharmaceutical benefits better.

PBM will help us enhance our service quality by following established frameworks, and best practices related to drug prescription and dispensing. We will be able to review every drug prescribed for consistency with your diagnosis, age, gender, and previous medical history. We can avoid any potential health hazard by rejecting clinically inappropriate drugs or where we suspect negative drug-to-drug interaction.

PBM will further help us with automated checks for cases like a particular drug is not covered in your policy (Drug Formulary) or you have already consumed your pharmacy benefit limit or the drug is not medically necessary or you requested for a prescription refill too soon.

However, you may get a refill approved on an exceptional basis. You may contact our Customer Service Centre (by calling the toll free number mentioned on your Daman Card) if you require further information or wish to file for an appeal in case of exceptional circumstances.

Pre-Authorization Your policy may contain specific services that require prior-approvals or pre-authorizations. This is necessary to ensure that your Health Services Provider has appropriate information on services covered under your policy.

You would need pre-authorization before availing any of the following health services:

• Inpatient and day treatment services

• Outpatient Physiotherapy

• MRI, CT Scans and Endoscopies

• Prescription Drugs above AED 500 or medication to be consumed for more than 60 days

Your Network Provider, along with Daman, will carry out the pre-authorization

process (where necessary) and notify you once the approval is granted. If the authorization is not granted, you have the right to ask for an explanation by calling our Customer Service Centre at the toll free number mentioned on your Daman Card.

Coverage for Specific ConditionsYour policy covers these listed conditions after a waiting period of 6 months, from the effective date as mentioned on your Daman Card. The waiting period applies to inpatient treatment only for the following medical conditions: Diabetes mellitus, Arterial diseases, COPD (Chronic Obstructive Pulmonary Disease), all cancer cases, Neurosurgery, Cerebro Vascular diseases, all delivery cases (Maternity). The waiting period is

Important To Know

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not applicable if you were continuously covered without any break for atleast 6 months under a health insurance plan approved by Health Authority Abu Dhabi (HAAD).

Member Cost SharingFor health services covered within Daman’s Network, there may be some services where a deductible or co-insurance is payable. In such cases, you will have to pay the specified amount (as mentioned on your Daman Card) directly to the Provider. The deductible and co-insurance amounts for applicable services are listed in your Schedule of Benefits.

Network DirectoryBefore going for a treatment or service, we recommend that you refer to your Network Directory and confirm if the provider is listed in Daman’s Network. Our Network Directories are continuously updated as we establish new agreements with health service providers within the territories specified in your plan. Going to a Network Provider would ensure that you can enjoy the direct billing facility and avail cashless benefits for Health Services covered in your policy. You can check the Provider details on our website or call our Customer Service Centre on the toll free number mentioned on your Daman Card for any assistance.

Drug FormularyIf your policy covers outpatient prescription drugs, these drugs will be subjected to a Drug Formulary. A Drug Formulary details the pharmaceuticals covered under your policy as decided by Health Authority-Abu Dhabi (HAAD).

Your Drug Formulary covers both brand-name and generic drugs. Generic drugs have the same active ingredients as brand-name drugs and are equally safe and effective.

In case the prescribed drug is not covered in your Drug Formulary, you will have to pay the drug bill directly to the Provider. You can refer to our website to check if the medicines prescribed for you are covered in the Drug Formulary of your policy.

Complaints and AppealsDaman is committed to address members’ coverage issues, complaints and problems. For any general inquires related to your policy benefits, or specific complaints concerning your pharmacy benefits such as adjudication of your claims (declining the pre-authorization request for a drug) , dispensing oversight or provider related issues (access, quality and safety), you can call our Customer Service toll free number mentioned on your Daman Card. You can also contact us through our website.

For cases where a drug cannot be found with your Network Provider or does not exist in your Drug Formulary, you have the option to request exceptional consideration for coverage. If your request is declined, you may further approach us through our appeal process. Daman will discuss the merits of your case internally and externally and will communicate the decision to you within 30 calendar days from the date of appeal. Details of appeals process and the Appeals/Exception Request Form are available on our website.

As a Daman member you have the Right to:

1- Receive information about Daman’s health insurance plans and services including but not limited to health insurance plan benefits, exclusions, policy terms and conditions, Pharmacy Benefit Management (PBM) services, details of network providers (including hospital, pharmacy, dental clinic etc), online services, list of medications covered under your health insurance plan (Drug List) and your Rights and Responsibilities.

2- Be treated with respect and dignity and have the right to privacy.

3- Preserve the confidentiality of your treatment records to the extent protected by Federal and Emirate

laws in the UAE. You are also entitled to receive an explanation regarding exceptions to confidentiality.

4- Voice complaints or to appeal to Daman on benefits offered, claim settlement, services offered, PBM services or any other grievance.

5- Be provided, upon request, with information about your plan’s benefits including limitations and exclusions applicable and details related to your health plan Drug List.

6- Receive services in English and Arabic when contacting Daman Customer service.

7- Make suggestions and give comments on ways Daman can improve its services.

Your Rights and Responsibilities

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8- Exercise your rights in accordance with the Health Insurance Law of the Emirate of Abu Dhabi.

As a Daman member, your Responsibilities are:

1- To read your insurance policies for the details of benefits, exclusions, other terms and conditions applicable under your health insurance plan. If you do not understand the information, you should contact Daman Customer Service for explanations on the covered benefits, limitations and authorization procedures.

2- To present your Daman Card (health insurance card) when accessing covered health services from our Network Providers.

3- To know how to access covered health services and pharmacy benefit you are entitled to as part of your health insurance plan benefits.

4- To pay any applicable co-insurance and deductible at the time of availing a health service.

5- To demonstrate mutual respect and courtesy towards providers (including hospitals, pharmacies, dental clinics etc) and Daman personnel.

Daman Card - the identification card issued by Daman for every member (Eligible Person).

Co-insurance - the percentage of eligible expenses that you need to pay for specified medical services availed under your policy.

Deductible - the defined fixed amount that you need to pay for the specified medical services received under your policy.

Eligible Expenses - Reasonable and Customary Charges for Covered Health Services, incurred while the Policy is in effect.

Emergency - A sudden development of a medical or surgical condition where lack of immediate medical treatment at a health service provider might result in

a life threatening situation or seriously affect member’s bodily functions.

Drug Formulary - A list of medications or drugs covered under your policy

Health Services - the health care services and supplies covered under the Policy, unless such health care services and supplies are not limited or not excluded in the policy.

Inpatient Benefit - Hospitalization or Day Treatment or observation or treatment in an Emergency room or facility which cannot be carried out on an outpatient basis.

Network - Used to describe a Health Services Provider, which holds an agreement in effect with Daman to provide Health Services to members.

Definitions

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Non-Network Benefits - Coverage available for Health Services obtained from the non-Network Providers. Coverage for the Non-Network Benefits is only provided if the services are assured in Schedule of Benefits.

Outpatient Benefit - are those services which do not require Hospitalization or Day treatment or necessitate specialized medical attention and care in a Hospital before, during or after the delivery of the service.

Pre-authorization - a prior approval or official permission, granted by Daman to the Network Provider, before initiating certain medical procedures.

Pre-Existing Condition - any known or unknown injury, sickness, disease or other medical, mental or nervous condition, disorder or ailment that

with reasonable medical certainty that existed at the time of applying for this policy.

Provider - a Physician, Hospital, group practice, pharmacy or any facility, individual or group of individuals that provides a health care service.

Refill-too-soon - Replenishment or dispensing of a prescribed medicine before the previous dispense of the same pharmaceutical is consumed.

Appeal - A request contesting a denial or reduction of coverage for services which have been availed or are intended

to be availed

Contact Us For any product related queries or general inquiries, kindly contact us on:Toll Free: 800 4 DAMAN (32626) Website: www.damanhealth.aeFax: +971 2 614 9775P.O. Box 128888, Abu Dhabi, UAE

DisclaimerThis document is for information purposes only and does not form part of the policy. The complete list of benefits, definitions, exclusions, policy terms and conditions are set out in the Letter of Acceptance, Schedule of Benefits, and the Policy Wordings. While every effort is made to ensure the accuracy of the content as of the print date, Daman cannot be held accountable for any typographical errors, errors of fact or any other error or inconsistency found in this document.

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