Payless Care Table Of Benefits

(Bahraini Dinar)
Medical Insurance PAYLESS

PLAN

Country Of Residence Kingdom of Bahrain

Territorial Limit Worldwide Excluding USA & Canada
Inpatient 10,000
Annual Benefit Limit
Outpatient Unlimited
Pre-existing / Chronic Conditions: - i.e. Oncology,
Chemotherapy, Radium Therapy, etc. - refer to note 3 & 4
100%

Inpatient & Daycare

Accommoda�on Type Private Room
Hospital Accommodation & Services: Per Night
- At Designated/Network Provider 100%
- At Non-Designated/Non-network Provider up to a maximum
per day: 60
Consultant’s, Surgeon’s & Anesthetist’s Fees, etc. Refer to note 1 100%
Ambulance: (followed by Hospital Admission) up to a maximum per trip 100%
Nursing at Home: Primary care services of a registered nurse in the
insured person’s home immediately after, or instead of, in patient or daycare 3,500
treatment. Subject to a maximum of 14 days (Pre-approved after covered
hospitalization)

Parent Accommodation for accompanying an insured child

under 16 years of age 100%

Hospital Cash Benefit: If Inpatient Treatment is received free of charge in 75

a Government Hospital

Psychiatric Treatment: (24 months waiting period for all 5,000

members). As a result of accident or sickness covered by the policy
Deviated nasal septum: only if medically necessary & not for cosmetic 100%
reasons

Reconstructive surgeries: only if medically necessary 100%

Rehabilitation: only if medical necessary followed by surgery &/ or accident 100%
Kidney Failure/ Dialysis: (12 months waiting period for all members)- up N/A
to a max. of 12 sessions per annum

Accidental Damage to Teeth: Refer to note 15 100%

Outpatient

Consultations:
- At Designated/Network Provider 100%
- At Non-Designated/Non-network Provider up to a maximum per
consultation: 15
Pharmaceuticals | Refer to note 1
-Prescribed Drugs & Medications
-Prescribed Herbal Medication/Health Supplements but not limited to Cough
90%
Syrup, Nasal & Mouth Spray, Omacor, Victoza, Hyaluronic Acid, etc.
-Insulin Needles

Diagnostics: | Refer to note 1 90%

(x-ray, MRI, CT-scan, ultrasound, etc.), Laboratory, etc.
-at designated/network Provider
-at Non-Designated/Non-network Provider
 PAYLESS
PLAN

Physiotherapy: Up to a maximum number of sessions per person per 20

policy year
Additional sessions in case of accident or following orthopedic surgery within 5
90 days from the incident
90%
-at Designated/Network Provider
-at Non-Designated/Non-network Provider per session up to a max per 20
session
Coinsurance 10%

Psychiatric Treatment: (24 months waiting period for all

members) N/A
As a result of accident or sickness covered by the policy

Deductible: Per outpatient consultation refer to note 9

Al Amal Hospital / Al Hilal / Aster /KIMS Bahrain / Middle East 3
Medical Center / Al Bayan / Shifa Al-Jazeera / Dar Al Shifa / Al Rayyan
Other Providers 5

Treatment Abroad

Inpatient/Outpatient Emergency Treatment Abroad During

Subject to reasonable and customary
Business Trips and Holidays: (subject to a maximum of 45
consecutive days per trip) charges of Country of treatment.

Inpatient/Outpatient Treatment Abroad other than Subject to the reasonable and

emergency: within Territorial Limit -refer to note 1, 10 & 11 customary charges of KOB

Emergency Evacuation & Repatriation

Emergency Medical Evacua�on BD. 380,000
Emergency Medical Repatria�on Included in the above limit
Repatria�on of Mortal Remain Included in the above limit
Compassionate Visit One Economy Class Return Air
Return of minor children One economy class one-way airfare

Additional Benefits for Emergency Evacuation & Repatriation

Lost Luggage or Document Assistance

Pre-trip Informa�on
Hospital Admission Assistance
Medical Consulta�on Evalua�on and Referral Covered
Medical Monitoring
Prescrip�on on Assistance

Additional Optional Benefits

Maternity: ( 280 days waiting period) - limited to 1 pregnancy per year 100%
Complications 750
Normal Delivery
Cesarean
1200
Abortion/Miscarriage 500
Outpatient (ante-/postnatal - outpatient deductible option applies and to 300
cover HIV, Hepatitis, 4D congenital anomalies, STD, Genetics, Sexual
Transmitted disease (VDRL & RPR)) | Refer to note 7

Dental: Consultations, Extractions, X-Ray, Composite Fillings, Root 200

Canal Treatment, Gum Treatment, Amalgam Fillings, Glass Lonomer and
Medication (Painkiller, Antibiotics).
1 Cleaning per annum
Covered
Crown & bridges coverage (part of Dental limit) N/A
Co-insurance: Refer to note 7 20%
 PAYLESS
PLAN

Optical:
Vision tests for errors of refraction & One Pair of Lenses for Spectacles
100
or Contact lenses.
Frames 25% of the benefit limit
Co-insurance: Refer to note 7 & 17 20%

Supplementary Benefit

Vitamins: (when prescribed for a sever deficiency) 100%

Prostheses (as a result of accident or sickness covered by the policy)

Plates, nails and K-wires for repair of bone fracture and insertion of 100%
Stents to coronary artery as a treatment of Ischemic heart disease

HIV/AID in the case of blood transfusion only as a lifetime

N/A
limit
(24 months waiting period for all members)

Allergy: An abnormal reaction of the body to a previously encountered

allergen introduced by inhalation, injection, or skin contact, often 100%
manifested by itchy eyes, runny nose, wheezing, skin rash, or diarrhea
excluding of allergy testing and desensitization treatment for allergy.

1 Vision test for errors of refraction per annum restricted 100%

to network only (applicable if optical is not covered)
Second Opinion Medical Services Refer to note 16

Life Riders

Accidental Critical Illness Benefit: (Applicable to members from

ages 3 to 65) | Refer to notes 3 & 18
Covered Conditions: Paralysis, Loss of Limbs, Blindness, Coma, Loss of 5,000
Hearing, Loss of Speech, Severe Burns, Loss of one Limb and Loss of one
Eye, and Major Head Trauma.
Waiting Period NIL
Survival Period 28 Days

Accidental Death Benefit (Applicable to members from ages 3 to 65)

| Refer to note 19 2,500
Cover all members 24hours against death due to accident within (90)
ninety days

Non-Designated Provider Deductible 20%

Kingdom of Bahrain Premium NW
Network
Allowing free access at designated provider subject to Bahrain, Kuwait, Qatar, KSA, UAE, Oman, Jordan, Kurdistan,
prior approval Egypt, Romania, India

Afghanistan, Algeria, Djibouti, Egypt, Iran, Iraq, Jordan, KSA,

Territorial Arab Countries Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine,
definition Qatar, Somalia, Sudan, Syria, Tunisia, UAE, Yemen

South East Asia Bangladesh, Bhutan, Burma India, Indonesia, Malaysia,

Nepal, Pakistan, Philippines, Sri Lanka, Thailand, Vietnam
Terms and Conditions:
1. Non-Designated provider deductible is applicable for any treatment outside the designated providers,
outpatient and inpatient treatment abroad. This deductible will not be applied to benefits with sub limits
and additional benefits other than maternity (e.g. IP Non-Designated/Non-network Provider
accommodations and OP Physiotherapy and Consultation) in addition to emergency treatment abroad. This
will be applicable on any diagnostics procedures taken within the network if the initial treatment takes place
outside the designated network without seeking an arrangement at any of our designated network. However this
can be arranged on direct billing and waiving this coinsurance through calling our hotline. This will be applied
on the reasonable and customary charges of Country of Treatment (depending on the territorial limit of the plan)
for any claim outside the designated network &/or outside Country of Residence
2. Only principle, their spouses, and unmarried children (up to 18 years old) may be covered subject that they are
still full-time student and unmarried. Parents and siblings are not covered.
3. Pre-existing conditions and chronic illnesses are covered from day one without any waiting period or sub-limits
subject to underwriting. Major medical conditions (e.g. heart disease & cancer… etc.) need to be declared prior
to policy confirmation in order to review & confirm the provided terms.
4. New additions are subject to submission of SNIC alteration request form & medical application form. Only new
born baby or newly married spouse will be added during the policy year, otherwise the addition should be
effective at the next renewal date only.
5. No Premium refunds for mid-term deletions in case claims have been incurred.
6. The policyholder or the insurance company may terminate the Policy at any time and for any reason, giving a 30-
day notice to the other party.
7. Pre-authorization is required towards any in-patient treatment within the network (other than emergency) and
any outpatient Surgical Procedures above BHD. 150. Pre-authorization is NOT required towards outpatient
diagnostic procedures with an exception for MRI/CT/Endoscopies, Hepatitis, Physiotherapy, Vitamins, all
Additional &/or Supplementary Benefits with sublimit i.e. Dental, Optical, etc. Pre-authorization outside
designated providers is not a mandatory requirement.
8. Lost card replacement/correction BD. 5.
9. A free follow-up without the outpatient deductible (i.e. BD.3 or 5) will only be applicable subject that the
treatment is at the same provider of the initial consultation and condition from first consultation date based
on the free follow-directory.
10. Kingdom of Bahrain (KOB) Reasonable and Customary Charges: The charges of medical care are based on the
general level or average cost of KOB American Mission, Bahrain Specialist Hospital and Bahrain Defense Force.
This is applicable to all treatment outside the designated providers.
11. Any non- emergency treatment abroad will be subject the KOB Reasonable and Customary Charges.
12. Client reimbursement claims submission period 30days within and outside Bahrain from the treatment date.
13. Medical Evacuation and Repatriation while traveling abroad: The transportation costs of an insured person to the
nearest center where adequate medical facilities are available. Payment of this benefit, including treatment
incurred, will be subject to the insured person suffering from a medical emergency; (a) that is critical, and, (b) for
which, in our opinion, adequate treatment is not available in the insured person's location and, (c) not a pre-existing
condition. The compassionate visit & return of minor children a services are subject to a Limit of Indemnity of
USD10,000 for any insured for any one event in addition to the emergency medical evacuation, emergency
medical repatriation and repatriation of mortal remains benefits. In the event of any IP treatment is not
available in Kingdom of Bahrain according to the medical opinion of Assist America doctors and subject to
submission of a certificate from the medical commission of Bahrain, Medical Evacuation to the nearest location
where adequate medical facilities are available will be arranged.
14. General Exclusions: Medical check-up, elective surgery, cosmetic treatment, circumcision, birth defects, infertility
treatment, menopause, prostheses (other than plates, nails and K-wires for repair of bone fracture and insertion
of Stents to coronary artery as a treatment of Ischemic heart disease) mental illness, self-inflected injury.
15. Accidental Damage to Teeth: In case of accidental injury, where damage has occurred to sound natural teeth.
Services are covered for initial pain relief & for any treatment necessary to preserve the dental structure for future
permanent restoration for damages done to sound natural teeth.
16. Second Opinion Medical Services: is provided for Participants and such services are available when:
- A Participant's medical condition is undiagnosed by a treating physician;
- A Participant seeks an additional medical opinion following an original diagnosis;
- The determination of the most appropriate course of medical treatment is required based on a current diagnosis.
A Participant seeking a medical second opinion must contact SNIC/AAAL's operation center.
- All Participants are responsible for gathering, obtaining, and submitting to SNIC/AAAL all required medical
reports, charts, data, and medical history pertaining to the Participant's condition and responding to follow up
requests for additional information.
- All information provided to SNIC/AAAL must be legible and produced in the required format. The medical
review will be undertaken by a physician licensed to practice medicine in the United States of America and within a
practice discipline that relates to the condition/diagnosis.
SNIC/AAAL will send the medical second opinion to the Participant in electronic format and such opinion will be
reached only after all required medical history, data, reports, charts are properly submitted for consideration and
review. The service relates solely to the provision of a written medical opinion and it does not include personal visits or
follow up discussions for the implementation of course of treatment.
If a Participant seeks further involvement from the physician rendering the opinion or seeks to converse with or visit
the physician, such must be arranged on a fee for service basis with SN IC/AAAL facilitating such arrangements. All
opinions rendered by the physician are the opinions of the physician who are not under the control or employment of
SNIC/AAAL and SNIC/AAAL is not responsible or liable for the content of such opinions.
17. Treatment within or outside the network for contact lens will be covered subject to:
• Monthly quantities (i.e. daily/monthly/weekly lens) only, unless it is an annual lens which are bought once a year.
• First prescription is to be attached with an error refraction report.
• Colored or cosmetic lens are not part covered
• Any members prescribing for lens (daily, monthly, weekly or annual) will not be entitled for the purchase of
spectacles lens or frames.
• All standard policy exclusion relating complication of contact lens will be maintained & unaltered.
18. Following exclusions shall be applicable to the Accidental Critical Illness Benefit
Accidental critical illness benefit is on diagnosis of one of the covered Accidental Critical Illnesses subject to all
conditions set out in the policy being fulfilled. There can be no more than one payment of sum insured for each insured
under this cover.
• Flying in any form of aircraft, unless the insured is travelling as fare-paying passengers in a civilian aircraft which is
certified for transporting passengers.
• The insured actively participates in war, rebellion, anarchy, sabotage and the intensity events defined as a crime or
actively participates in illegal events causing illnesses/accidents which is covered by the policy.
• Chronic alcohol abuse or the use of drugs (excluding at doctor’s orders).
• Intentionally self-inflicted injury, regardless of whether or not the Insured is sound of mind and committing suicide.
• Boxing, wrestling, or any kind of physical combat, skiing (water or on snow), gliding, parachuting, bungee jumping,
mountaineering, professional sports activities, diving using equipment.
• Illnesses or conditions which are mutations or variations of AİDS, HTVL and HIV.
• Injury from non-conventional weapons (such as atomic, chemical or biological weapons) or from conventional ballistic
missiles.
• Nuclear fusion, nuclear fission, nuclear waste, where the illnesses and injuries stem from radioactive or ionizing
radiation.
• Illegal acts by the policy beneficiary that lead to an Accidental Critical Illness of the insured.
• Pre-existing conditions are excluded.
• At entry level members attaining is below age of 3 and exceeding age of 64.
19. Accidental Death Benefit is applicable to members from age of 3 to 65. The following exclusions shall be applicable:
• War, invasion, act of foreign enemy, hostilities or warlike operations (whether war be declared or not), civil war,
military rising, insurrection, rebellion, revolution, military or usurped power, martial law, acts of terrorism, mutiny or
riot or civil commotion assuming the proportions of or amounting to a popular rising.
• AIDS if it was contracted prior the insurance cover with SNIC.
• Atomic, Biological, and Chemical contamination
• Criminal Acts committed by the insured
• Suicide within the first 12 months
20. The policyholder shall be liable for any liability arising to SNIC due to misuse of the cards that is not returned back
by the policyholder against the requirement of clause 3.6 of Medical Policy Wording.
21. The table/schedule of benefits (i.e. limits, additional benefits, deductibles, co-insurance, special extensions, etc.)
supersedes the policy wording. All other terms pertaining to policy and claims administration, terms and conditions etc.
follow the standard policy wording.
22. These terms, conditions and limitations are based on the information provided and communicated. It is duty of
client to disclose all material facts and it is agreed that in the event of any miss-presentation or miss-declaration and
discovered either at the point of claim or during period of cover by SNIC, we will have the right to terminate the policy,
decline the claim or charge additional premium. The duty of disclosure is re-imposed after inception of cover when
there are changes or variations in cover and when the policy is renewed or extended. In addition, changes which
substantially increase the risk, or relate to compliance with a warranty or condition in the policy must be notified at
once.
23. Any waiting period will be considered and counted from the member’s joining date and not from the policy
inception date
24. Member’s age is calculated based on the joining date and will not be changed during the policy year (i.e. age change
will be reflected at the next renewal only)
25. Policy inception date can be either 1st day or 15th of the month.
26. Refer to policy wording for the comprehensive terms and conditions.