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Customer Table of Benefits ‫ﺟﺪول ﻣﻨﺎﻓﻊ اﻷﻋﻀﺎء‬

Date : 12 February 2018


Attention: Insurance Relations Office ‫ ﻣﻜﺘﺐ اﻟﺘﺄﻣﯿﻦ و ﻋﻼﻗﺎت اﻟﺸﺮﻛﺎت‬:‫ﻋﻨﺎﯾﺔ‬
Please provide necessary medical treatment to this group based on the ‫ﻧﺮﺟﻮ ﺗﻘﺪﯾﻢ اﻟﺨﺪﻣﺎت اﻟﻄﺒﯿﮫ ﻟﻸﻋﻀﺎء ﺑﻨﺎء ﻋﻠﻰ‬
Bupa Standard Table of Benefits (New CCHI Policy) plus the following extra benefits. ‫ﺑﺎﻻﺿﺎﻓﮫ إﻟﻰ اﻟﺨﺪﻣﺎت اﻟﻤﺪرﺟﮫ‬ ???? ???????(????? ???? ??????
Yours Sincerely ?????
‫اﻹﺟﺘﺮام‬ ???????)
‫ﺑﻘﺒﻮل ﻓﺎﺋﻖ‬ ‫وﺗﻔﻀﻠﻮ‬

Mohammad Al Saeed ‫ﻣﺤﻤﺪ اﻟﺴﻌﯿﺪ‬


Provider Relations Director ‫ﻣﺪﯾﺮ ﻋﺎم ﻋﻼﻗﺎت اﻟﻤﺴﺘﺸﻔﯿﺎت‬

Policy Number 30592100 ‫رﻗﻢ اﻟﺒﻮﻟﯿﺼﺔ‬ Effective From 12 February 2017 ‫ﺳﺎرﯾﺔ ﻣﻦ‬
Company Name Innovative Contractors For Advanced Dimensons ‫أﺳﻢ اﻟﺸﺮﻛﺔ‬ Effective To 11 February 2018 ‫إﻟﻰ‬
Policy Holder Innovative Contractors For Advanced Dimensons ? ???????? Extended To 21 February 2018 ‫ﺗﻢ اﻟﺘﻤﺪﯾﺪ اﻟﻰ‬

Services ICAD - VIP ICAD - A ICAD - C ICAD - B+ ‫اﻟﺨﺪﻣﺔ‬


Contribution (OP) Nil 20.00% up to max 100.00 SAR 20.00% up to max 100.00 SAR 20.00% up to max 100.00 SAR (‫اﻟﺘﺤﻤﻞ )ﻋﯿﺎدات ﺧﺎرﺟﯿﺔ‬
Accommodation Standard Suite Single Room Shared Room Shared Room ‫ﻏﺮف اﻟﺘﻨﻮﯾﻢ‬
Maternity Covered Covered Covered Covered ‫اﻟﻮﻻدة‬
Dental SR 4,000.00 SR 3,000.00 SR 2,000.00 SR 2,000.00 ‫اﻷﺳﻨﺎن‬
SR 1,000.00 SR 750.00 SR 400.00 SR 400.00
Optical ‫اﻟﺒﺼﺮﯾﺎت‬
Frame Limit--SR750.00 Frame Limit--SR750.00 Frame Limit--SR400.00 Frame Limit--SR400.00
Acquired Heart Valve SR 70,000.00 SR 70,000.00 SR 70,000.00 SR 70,000.00 ‫ﻋﻤﻠﯿﺎت اﻣﺮاض ﺻﻤﺎﻣﺎت‬
Disease Surgery ‫اﻟﻘﻠﺐ اﻟﻤﻜﺘﺴﺒﺔ‬
Donor Organ Harvestiing SR 50,000.00 SR 50,000.00 SR 50,000.00 SR 50,000.00 ‫زراﻋﺔ اﻷﻋﻀﺎء‬
Hearing Aids SR 6,000.00 SR 6,000.00 SR 6,000.00 SR 6,000.00 ‫اﻟﻮﺳﺎﺋﻞ اﻟﻤﺴﺎﻋﺪة ﻋﻠﻰ اﻟﺴﻤﻊ‬
Newborn Disability ‫اﻟﻜﺸﻒ اﻟﻤﺒﻜﺮ ﻟﻼﻋﺎﻗﺔ ﻋﻨﺪ‬
SR 100,000.00 SR 100,000.00 SR 100,000.00 SR 100,000.00
Screening ‫اﻷﻃﻔﺎل ﺣﺪﯾﺜﻲ اﻟﻮﻻدة‬
Alzheimer's Disease SR 15,000.00 SR 15,000.00 SR 15,000.00 SR 15,000.00 ‫ﻋﻼج اﻟﺰھﺎﯾﻤﺮ‬
Autism SR 15,000.00 SR 15,000.00 SR 15,000.00 SR 15,000.00 ‫اﻟﺘﻮﺣﺪ‬
Disability Cases SR 100,000.00 SR 100,000.00 SR 100,000.00 SR 100,000.00 ‫ﺣﺎﻻت اﻹﻋﺎﻗﺔ‬
No Pre-authorisation Required Standard Standard Standard
Approval ‫اﻟﻤﻮاﻓﻘﺎت اﻟﻤﺴﺒﻘﺔ ﻏﯿﺮ ﻣﻄﻠﻮﺑﺔ‬. ‫ اﻟﺒﺮوﺗﻮﻛﻮل اﻟﻌﺎم ﻟﻠﻤﻮاﻓﻘﺎت اﻟﻤﺴﺒﻘﮫ‬. ‫ اﻟﺒﺮوﺗﻮﻛﻮل اﻟﻌﺎم ﻟﻠﻤﻮاﻓﻘﺎت اﻟﻤﺴﺒﻘﮫ‬. ‫ اﻟﺒﺮوﺗﻮﻛﻮل اﻟﻌﺎم ﻟﻠﻤﻮاﻓﻘﺎت اﻟﻤﺴﺒﻘﮫ‬. ‫ﻃﻠﺐ اﻟﻤﻮاﻓﻘﺎت اﻟﻤﺴﺒﻘﺔ‬.
All out-patient services do not require Follows the Standard Follows the Standard Follows the Standard
pre-authorisation irrespective of the Pre-authorisation Protocol Pre-authorisation Protocol Pre-authorisation Protocol
cost and type of the service as long ‫ﯾﺘﺒﻊ اﻟﺒﺮوﺗﻜﻮل اﻟﻌﺎم ﻟﻠﻤﻮاﻓﻘﺎت اﻟﻤﺴﺒﻘﮫ‬. ‫ﯾﺘﺒﻊ اﻟﺒﺮوﺗﻜﻮل اﻟﻌﺎم ﻟﻠﻤﻮاﻓﻘﺎت اﻟﻤﺴﺒﻘﮫ‬. ‫ﯾﺘﺒﻊ اﻟﺒﺮوﺗﻜﻮل اﻟﻌﺎم ﻟﻠﻤﻮاﻓﻘﺎت اﻟﻤﺴﺒﻘﮫ‬.
as it is covered under the customers
ToB. However, approval is required
for inpatient admissions and benefits
with sub-limits such as Dental,
Optical, Hearing aids, dialysis and
maternity (as per the related protocol)
َ ‫ﯾﺘﻢ ﺗﻘﺪﯾﻢ ﺧﺪﻣﺎت اﻟﻌﯿﺎدات اﻟﺨﺎرﺟﯿﮫ اﻟﻤﻮﺻﻮﻓﺔ وﻓﻘﺎ‬
‫ﻟﺤﺪود اﻟﺘﻐﻄﯿﺔ واﻷﺳﺘﺴﻨﺎءات ﺑﺪون اﻟﺤﺎﺟﺔ إﻟﻰ ﻣﻮاﻓﻘﺔ‬
‫ﻣﺴﺒﻘﺔ ﻓﯿﻤﺎ ﻋﺪا اﻻﺳﻨﺎن و اﻟﺒﺼﺮﯾﺎت واﻟﺤﻤﻞ و ﻏﺴﯿﻞ‬
‫اﻟﻜﻠﻰ و اﻟﻤﺴﺎﻋﺪات اﻟﺴﻤﻌﯿﮫ ﻓﺘﺤﺘﺎج إﻟﻰ اﻟﻤﻮاﻓﻘﺔ‬
‫ اﻟﻤﺴﺒﻘﺔ‬.

Bupa Arabia for Cooperative Insurance Page 1 of 2


CR Number 4030178881 / Authorised Capital: SR400,000,000.00 / Paid Up Capital: SR400,000,000.00
Services ICAD - VIP+ ICAD - Parent A ‫اﻟﺨﺪﻣﺔ‬
Contribution (OP) Nil 20.00% up to max 100.00 SAR (‫اﻟﺘﺤﻤﻞ )ﻋﯿﺎدات ﺧﺎرﺟﯿﺔ‬
Accommodation Standard Suite Single Room ‫ﻏﺮف اﻟﺘﻨﻮﯾﻢ‬
Maternity Covered Covered ‫اﻟﻮﻻدة‬
Dental SR 4,000.00 SR 3,000.00 ‫اﻷﺳﻨﺎن‬
SR 1,000.00 SR 750.00
Optical ‫اﻟﺒﺼﺮﯾﺎت‬
Frame Limit--SR750.00 Frame Limit--SR750.00
Acquired Heart Valve SR 70,000.00 SR 70,000.00 ‫ﻋﻤﻠﯿﺎت اﻣﺮاض ﺻﻤﺎﻣﺎت‬
Disease Surgery ‫اﻟﻘﻠﺐ اﻟﻤﻜﺘﺴﺒﺔ‬
Donor Organ Harvestiing SR 50,000.00 SR 50,000.00 ‫زراﻋﺔ اﻷﻋﻀﺎء‬
Hearing Aids SR 6,000.00 SR 6,000.00 ‫اﻟﻮﺳﺎﺋﻞ اﻟﻤﺴﺎﻋﺪة ﻋﻠﻰ اﻟﺴﻤﻊ‬
Newborn Disability ‫اﻟﻜﺸﻒ اﻟﻤﺒﻜﺮ ﻟﻼﻋﺎﻗﺔ ﻋﻨﺪ‬
SR 100,000.00 SR 100,000.00
Screening ‫اﻷﻃﻔﺎل ﺣﺪﯾﺜﻲ اﻟﻮﻻدة‬
Alzheimer's Disease SR 15,000.00 SR 15,000.00 ‫ﻋﻼج اﻟﺰھﺎﯾﻤﺮ‬
Autism SR 15,000.00 SR 15,000.00 ‫اﻟﺘﻮﺣﺪ‬
Disability Cases SR 100,000.00 SR 100,000.00 ‫ﺣﺎﻻت اﻹﻋﺎﻗﺔ‬
No Pre-authorisation Required Standard
Approval ‫اﻟﻤﻮاﻓﻘﺎت اﻟﻤﺴﺒﻘﺔ ﻏﯿﺮ ﻣﻄﻠﻮﺑﺔ‬. ‫ اﻟﺒﺮوﺗﻮﻛﻮل اﻟﻌﺎم ﻟﻠﻤﻮاﻓﻘﺎت اﻟﻤﺴﺒﻘﮫ‬. ‫ﻃﻠﺐ اﻟﻤﻮاﻓﻘﺎت اﻟﻤﺴﺒﻘﺔ‬.
All out-patient services do not require Follows the Standard
pre-authorisation irrespective of the Pre-authorisation Protocol
cost and type of the service as long ‫ﯾﺘﺒﻊ اﻟﺒﺮوﺗﻜﻮل اﻟﻌﺎم ﻟﻠﻤﻮاﻓﻘﺎت اﻟﻤﺴﺒﻘﮫ‬.
as it is covered under the customers
ToB. However, approval is required
for inpatient admissions and benefits
with sub-limits such as Dental,
Optical, Hearing aids, dialysis and
maternity (as per the related protocol)
َ ‫ﯾﺘﻢ ﺗﻘﺪﯾﻢ ﺧﺪﻣﺎت اﻟﻌﯿﺎدات اﻟﺨﺎرﺟﯿﮫ اﻟﻤﻮﺻﻮﻓﺔ وﻓﻘﺎ‬
‫ﻟﺤﺪود اﻟﺘﻐﻄﯿﺔ واﻷﺳﺘﺴﻨﺎءات ﺑﺪون اﻟﺤﺎﺟﺔ إﻟﻰ ﻣﻮاﻓﻘﺔ‬
‫ﻣﺴﺒﻘﺔ ﻓﯿﻤﺎ ﻋﺪا اﻻﺳﻨﺎن و اﻟﺒﺼﺮﯾﺎت واﻟﺤﻤﻞ و ﻏﺴﯿﻞ‬
‫اﻟﻜﻠﻰ و اﻟﻤﺴﺎﻋﺪات اﻟﺴﻤﻌﯿﮫ ﻓﺘﺤﺘﺎج إﻟﻰ اﻟﻤﻮاﻓﻘﺔ‬
‫ اﻟﻤﺴﺒﻘﺔ‬.

Other Special Instruction ‫اﻟﺘﻌﻠﯿﻤﺎت اﻟﺨﺎﺻﺔ اﻷﺧﺮى‬


ICAD - VIP Allergy tests are covered
ICAD - A Allergy tests are covered.
ICAD - C No Special Instruction
ICAD - B+ No Special Instruction
ICAD - VIP+ Allergy tests are covered
ICAD - Parent A Allergy tests are covered.

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