Sehhati

Group Health Takaful Contract

CONTENTS
1. preamble 2 10. claim provisions 7
2. definitions 2 10.1. claim settlement 7
2.1. contract definitions 2 10.2. claim limitations 8
2.2. coverage definitions 2 10.3. pre-authorization 8
2.3. operational definitions 3 10.4. arbitration 8
2.4. medical definitions 4 10.5. medical examination 8
10.6. recovery 8
3. scope of healthcare benefits 4
10.7. coordination of benefits 8
4. entire contract 5 10.8. subrogation 8
5. eligibility 6 11. currency 8
6. contract validity 6 12. renewal of contract 9
7. contributions 6 13. termination 9
8. addition of participants 7 14. general exclusions 9
9. deletion of participants 7 15. jurisdiction and limitation of action 11
16. other conditions 11
 1. Preamble
1.1. This Health Takaful Contract is made between the Group, for
and in behalf of the individual Participants, and ALLIANZ
TAKAFUL B.S.C. (Closed), hereinafter referred to as the
Company.
1.2. The Company has been incorporated in the Kingdom of
Bahrain and is authorized by the Central Bank of Bahrain to
conduct takaful business. To ensure compliance with the
rules and principles of the Shari’ah, the Company has
appointed a Shari-ah Supervisory Board for the vetting of all
the Company’s operations. The Board is comprised of
renowned independent Shari-ah scholars.
1.3. By entering into this Contract, the Group appoints the
Company as a Wakeel for the management of the insurance
operations in exchange for the Wakalah fees (a percentage
of the Contribution), and as a Mudarib for the purpose of
investing their funds in a Shari’ah compliant manner for a
pre-agreed share on investment income.
2. definitions
2.1. contract definitions
Actively-at-Work - The work situation of an employee reporting
regularly on a full-time basis to his workplace, performing the
usual and normal duties of his occupation in conformity with the
employment conditions, and being remunerated accordingly,
excluding employees who are disabled, granted a leave of absence,
temporarily laid-off, or placed on part-time employment.
Allianz Takaful
Cash Indemnity - A lump sum payable to a Participant in
connection with covered Healthcare Benefits, which may be
payable on: (a) a healthcare service basis (i.e. type of Treatment);
(b) a specific assessment basis (i.e. type of diagnosis); or, (c) a
per day basis
Claim - A written demand made to the Company by or on behalf
of a Participant for the payment of Healthcare Benefits under this
Contract
Co-Insurance, Co-Participation or Co-Payment - The pre-defined
percentage of incurred healthcare expenses or amount of Claim
which the Participant is obliged to pay at the time the healthcare
service is rendered
Contract Schedules - The schedules which specify the specific
conditions of this Contract and the data on the Group and the
individual Participants. The data includes: Effective, Enrollment,
and Expiry Dates; Plan of Coverage, scope and amount of
Healthcare Benefits, Room Accommodation; amount and mode
of Contributions; amount of charges, if any; Limits, Co-Insurance,
and Deductibles; and additional Exclusions, if any.
Contribution - The amount payable by the Group as a contribution
for the Participants who shall be covered under this Contract
Contribution Due Date - The date upon which any Contribution
falls due
Deductible - The amount which the Participant must pay each
time for healthcare services and is deducted from the Claim
payable by the Company
 Effective Date - The date this Contract commences
Expiry Date - The date this Contract is scheduled to terminate
Group - The corporation or legal entity entering into this
Contract which shall be the sole owner of this Contract
Limit - A Contract provision that sets a cap on types of eligible
healthcare expenses. Limits may be a: (a) monetary amount per
Participant’s lifetime; (b) quantity amount per Participant’s
lifetime; (c) monetary amount per year; (d) quantity amount
per year; (e) monetary amount per Claim; (f) quantity amount
per Claim; or (g) geographical scope of coverage.
Participants - Any person eligible and enrolled under this Contract
Pre-Authorization - Prior written approval obtained from the
Company or its appointedThird Party Administrator prior to certain
Treatments and/or other healthcare services as specified in this
Contract
Usual, Customary and Reasonable Charges (UCR) - A charge or
expense for necessary healthcare which, in the sole opinion of
the Company and based on its or its appointed Third Party
Administrator’s experience, does not exceed the general level of
charges being made by other Providers of similar standing in the
Kingdom of Bahrain, when providing like or comparable
Treatments or healthcare services
Utilization - The actual amount of healthcare services covered
by the Company plus allowance for Incurred But Not yet Reported
(IBNR) Claims
Allianz Takaful
Waiting Period - The period of time under this Contract wherein
a Healthcare Benefit is not yet available to an eligible Participant
2.2. coverage definitions
Accident - An unforeseen, unexpected and unintended event
involving an external force or impact to the body
Cause - A term that broadly describes the reason a Participant
seeks healthcare, that is, description of the disease and accident
for an Illness and Accident, respectively
Congenital Disease - All diseases, anomalies, hereditary conditions
including neurological disorders, chromosomal and/or genetic,
defects and deficiencies whether present at birth in either in an
evident manner or in a potential manner triggered at a later stage
Cosmetic - To improve physical appearance and/or treat a mental
condition through change in bodily form
Day-Care - Treatments and/or other healthcare services in a
Hospital or a recognized Day-Care facility where the Participant
is admitted to a hospital bed but does not stay overnight
Elective - Planned Treatment which is medically necessary but
not an Emergency
Emergency - The sudden, unexpected onset of a non-excluded
Illness or Injury, raising a legitimate professional concern that
there may be a significant medical problem necessitating a
Treatment which cannot be delayed and requires immediate
confinement to a Hospital
 Hazardous Activity - Any activity which exposes the Participant
to serious Injury or Illness including but not limited to shooting,
motor sports, water sports (e.g. diving, jet-skiing, power boats,
water ski), horse riding activities (e.g. hunting, jumping, polo),
climbing activities (e.g. mountaineering and rock-climbing),
winter sports (e.g. bob-sleighing, snowboarding, ice-hockey,
snow-skiing, ski-jumping), ballooning, bungee jumping, sky
diving, parachuting, paragliding, and martial arts of all kinds
Healthcare Benefit - The Out-Patient benefits, Hospitalization
Benefits, and other medical benefits as provided for in this Contract
Healthcare Service - Individual medical services, tests,
examinations, consultations, or other items which may be charged
during the care of a Participant by a Provider
Home Nursing - Skilled nursing services given by a registered
nurse at home immediately after an In-Patient Treatment and
deemed to be medically necessary by a Physician
Hospitalization - Confinement in a Hospital for a minimum of
one overnight stay for medically necessary Treatment, or other
care related to an Illness or Injury which cannot be performed on
an Out-Patient basis. The Hospitalization services are subject to
the rules and regulations of the Hospital, including its rules and
regulations governing admission
Illness - A disease, impairment, interruption, cessation or disorder
of bodily function/s, system/s, or organ/s.
Injury - Physical damage other than Illness, including all related
conditions and recurrent symptoms which are usually caused by
an Accident.
Allianz Takaful
In-Patient - Treatments and/or other healthcare services which
are delivered to a Participant in a Hospital and medically
necessitate the Participant’s Hospitalization as a registered bed
patient for at least twenty-four (24) hours. Day-Care admissions
shall be considered as In-Patient.
Out-Patient - Treatments and/or other healthcare treatments
which do not medically necessitate the Participant’s
Hospitalization
Plan of Coverage - Any of the insurance schemes provided by the
Company covering a set of covered healthcare services, subject
to a set of Limits, Co-Insurance, Deductibles, and other conditions
Pre-Existing Condition - Any known Illness or related condition
for which, before the Effective Date of the coverage of the
Participant, he: (a) has been diagnosed; (b) received Treatment;
(c) sought medical advice for, including check-ups; (d) needed
Treatment, including drugs and injections; or, (e) had undiagnosed
symptoms, whether recognized or not
Room Accommodation - The class of room and board service
which the Group has selected on behalf of its Participants to be
applied for In-Patient Treatment or Hospitalizations, and which is
identified in the Contract Schedules according to the following
codes:
a. Class VIP - Suite (private room with sitting, sleeping
accommodations for one companion)
b. Class A - Private room (basic level one bedroom)
c. Class B - Semi-Private room with 2 beds
 2.3. operational definitions
Access Card - A personalized card issued in the name of each
Participant, facilitating Free Access to the covered healthcare
services provided by the Designated Network Providers under
this Contract
Claim Form - A form issued by the Company’s appointed Third
Party Administrator that contains: (a) the medical details of the
Claim as documented by the Participant’s Physician; (b) listing
of chargeable healthcare services which were or shall be rendered,
as requested and documented by the Participant’s Physician; (c)
the claims adjudication decision; (d) the availability of Free Access
for the Participant; (e) the coverage or non-coverage of the
Participant for chargeable healthcare services; and, (f) the
directions for financial settlement
Designated Network Providers - A group of healthcare service
providers contracted by the Company’s appointed Third Party
Administrator for the purpose of providing Participants with Free
Access to their services in conformity with the terms of this
Contract. Listings of Designated Network Providers are subject
to change without advanced notice and may be obtained from
the Company or its appointed Third Party Administrator.
Free Access or Direct Billing - The Designated Network Provider’s
direct billing of eligible healthcare expenses to the Company and
submission of payment to the Provider by the Company, minus
any Co-Insurance, Limits, or other non-eligible healthcare
expenses
Allianz Takaful
Provider - A generic term for Physicians, Hospitals, clinics, medical
centers, pharmacies, laboratories, physiotherapy centers, dentists
and other paramedical institutions or persons who are licensed
to offer healthcare services
Third Party Administrator or TPA - An entity appointed to act in
the name of and on behalf of the Company in administering this
Contract. The Administrator interfaces with the Participant through
its Claims Center/Section/Department, which shall be staffed
with a team of medical and claims administrative specialists to
support and monitor the proper application and administration
of this Contract. The Administrator shall provide the Participants
with: (a) guidance and information through telephone and/or
mail inquiries; (b) verifies eligibility, conducts claims adjudication
and grants Free Access in the name and on behalf of the Company
to the specific healthcare service provider under consideration
2.4. medical definitions
Chiropractic - A therapeutic system based primarily upon the
interactions of the spine and nervous system, the method of
treatment usually being to adjust the segments of the spinal
column
Chronic Condition - A treatment which the Company or any other
party acting on the Company’s behalf, determine is palliative, i.e.
relieving or soothing the symptoms of a disease or disorder
without effecting a cure, or a chronic medical condition, i.e.
requiring a regular, lifetime treatment.
 Diagnostic Procedure - A test for diagnosing an Illness or Injury,
including pathology, laboratory tests, X-rays, ECGs, medical
spanning, imaging techniques, and interpretation of results by a
specialist Physician
Hospital - Any medical institution, public or private, which is legally
licensed to provide Treatment to sick and injured persons. The
facility must consist of organized premises, possess the necessary
technical and scientific equipment for diagnoses and surgical
operations, and provide around-the-clock healthcare services by
a staff of at least one resident Physician and qualified professional
nurses. This term excludes Out-Patient clinics, sanitarium,
physiotherapy centers, health clubs, retirement homes, nursing
homes, and other non-Hospital institutions, including those
specialized in substance abuse
Medically Necessary or Medical Necessity - The appropriate and
necessary healthcare services, as determined by the Company,
provided to the Participant for an Illness and Injury which,
according to generally accepted principles of good medical
practice, requires diagnosis, direct care, and Treatment. These do
not include services rendered for convenience, aesthetic, and
education purposes.
Osteopathy - A therapeutic system based upon the premise that
manipulation of the muscles and bones to promote structural
integrity could restore or preserve health
Physician - Any medical or surgical doctor duly licensed and
qualified to practice medicine or surgery under the law of
jurisdiction where theTreatment is given or where the procedure
is done
Allianz Takaful
Physiotherapy - The treatment or management of physical
disability, malfunction, or pain by exercise, massage, hydrotherapy,
etc., without the use of medicines, surgery, or radiation.
Treatment - Any medically necessary surgical or medical procedure
carried out by, or any medication prescribed by, a Physician with
the sole intention to cure or rectify a Participant’s Illness or Injury.
Treatments include diagnostic procedures, and consultations.
3. scope of healthcare benefits
3.1. In consideration of the request and declarations made by the
Group and the Participants in their applications, and the
payment of Contribution by the Group, the Company shall
cover healthcare expenses reasonably, customarily, and
medically necessarily incurred by the Participants during the
Contract’s validity period for the sole purpose of treating and
curing an Illness or Injury, subject to the terms and conditions
of this Contract and any attachments and/or Endorsements
thereto.
3.2. The following Healthcare Benefits, subject to the Limits, Co-
Insurance, Deductible, Pre-Authorization requirement, and
other conditions stipulated in the Contract Schedules, shall
be covered under this Contract, unless specifically stated
otherwise in the Contract Schedules:
a. Consultation Charges
i. Physician fees as either In-Patient or Out-Patient
 ii. Pathology, X-ray, and diagnostic procedures, magnetic
resonance imaging (MRI) and computerized axial tomography
(CT) scans, radiotherapy, chemotherapy, as In-Patient or Out-
Patient
iii. Illness or Injury that requires consultations, diagnostic
procedures, physiotherapies, prescribed drugs, or other covered
healthcare services, which are subject to a Deductible and/or
Co-Insurance per visit as specified in the Contract Schedules.
b. Hospitalization Charges
i. Room and board charges according to the type of Room
Accommodation stated in the Contract Schedules
ii. Physician fees including theatre charges for the Treatment
of an Illness or Injury
iii. Intensive Care Unit (ICU)
c. Prescribed Drugs as an In-Patient or Out-Patient
d. Emergency Treatment
e. Emergency Local Ambulance Charges, including transportation
costs to and from the Hospital by the most appropriate
transport method, only when considered medically necessary
by a Physician.
f. Cash Indemnity for In-PatientTreatments for Hospitalizations
within the Designated Network Providers that are not
submitted to the Company for Claim
Allianz Takaful
g. Physiotherapy Treatment which is referred by a specialist
Physician and deemed to be medically necessary for
continued recovery from an Illness or Injury
h. Chiropractic Treatment and Osteopathy
i. Organ transplant but as recipient of heart, liver, and kidneys
only, excluding all costs associated with the acquisition of
the required organ to be transplanted including
administrative and transportation costs.
j. Accidental damage to teeth provided Treatment is received
in a Hospital’s Emergency room within forty-eight (48) hours
following the accident, and provided that the damage is
caused to sound, natural teeth and for the initial relief of pain
and any Treatment necessary to preserve the dental structure.
k. Home Nursing Care
l. Parent Accommodation - Charges for one parent staying with
a child Participant who is less than sixteen (16) years old
m. International Medical Emergency Assistance
i. Emergency Evacuation - arrangement and payment for the
appropriate mode of transport, equipment and personnel
necessary to evacuate Participant to nearest capable medical
facility in the event of an emergency Injury or Illness while
traveling outside the country of residence or employment
and if adequate facilities are not available,
ii. Emergency Message Transmission
 iii. Emergency Family Member Visit - transportation of a
relative to the place of Hospitalization when Participant is
traveling alone and has been hospitalized for a specific
number of days
iv. Medically Supervised Repatriation - transportation back
home for continuation of Hospitalization when Participant
is in stable condition and if medically required
v. Care and Transportation of unattended Minor Children
vi. Repatriation of Mortal Remains of a deceased Participant to
his country of residence or employment, or costs for local
burial at place of death
vii. Legal Assistance and Emergency Cash Advances
3.3. Unless selected and purchased by the Group, the following
optional Healthcare Benefits shall remain uncovered:
a. COBRA Extension - if a Treatment is not available at the
country of residence or employment:
i. Free Access for suchTreatment at an international Designated
Network Provider
ii. Air Transportation for the Participant and accompanying
relative (wife, child, or parent)
iii. Accommodation for the accompanying relative
b. Routine Dental Benefit - Medically necessary dental
Allianz Takaful
treatments, such as root canal treatment, teeth extractions,
and routine fillings (amalgam, resin, plastic, and temporary)
c. Optical Benefit - Optical examinations conducted for the
purpose of obtaining eye glasses or upgrading existing lenses
d. Maternity Benefit (for female Participants only) - Treatments
related to or caused by pregnancy, childbirth, puerperium
conditions or illnesses, miscarriage, or abortions when the
life of the mother would be medically endangered
3.4. Pre-Existing and Chronic Conditions shall not be covered
unless the Group has met the minimum number of enrolled
Members stated in the Contract Schedules
4. entire contract
4.1. The Company issued this Contract in consideration of the
application made by the Group and the individual Participants,
and the receipt of the initial Contribution. This Contract, the
applications, together with all underwriting forms and
declarations, the Contract Schedules, as well as any other
attachments and/or Endorsements, constitute the entire
Contract between the Company and the Group.
4.2. Any amendment to this Contract shall not be valid and
binding, unless it has been made in writing and is signed
and sealed by the Company. No intermediary or agent is
authorized to make or to amend this Contract or to waive
any of the Company’s rights or to bind the Company by
making any promise or by accepting any representation or
information not contained in the Contract application.
 5. eligibility
5.1. A Group is eligible for coverage under this Contract provided
all its Members are enrolled on a compulsory basis. The
Group may choose to include its Member’s Qualified
Dependents in its coverage provided that their enrollment
is on a compulsory basis for all Qualified Dependents. A
Group Member or Qualified Dependent who is eligible for
Healthcare Benefit coverage and enrolled is considered a
Participant under this Contract. All Participants must be
holders of either a valid passport or residence visa for the
Kingdom of Bahrain.
5.2. Only Group Members aged sixty-five (65) or below who are
currently in Actively-at-Work status in the Group’s office/s in
the country of coverage as of the date of Member’s
enrollment into the Healthcare Benefit coverage are eligible
for coverage.
5.3. Qualified Dependents include the Group Member’s spouse/s
aged sixty-five (65) or below, and their unmarried legitimate
or legally adopted children residing with them at the Effective
Date or renewal of this Contract, provided that the children
are at least fourteen (14) days old but less than eighteen
(18) years old, or if full-time students, the children are less
than twenty-three (23) years old. If eligible, the Qualified
Dependents must be in good health, or performing their
normal activities or occupation and not incapacitated due
to sickness, injury, or other form of disability on the
commencement date of coverage.
Allianz Takaful
5.4. The Group must declare all the eligible Group Members and
Qualified Dependents, if covered, and provide full details to
the Company. The Company reserves the right at any time
the submission of such documents which the Company may
deem appropriate for the purpose of validating the eligibility
of Participants.
6. contract validity
6.1. The validity of this Contract, with regard to the Plan of
Coverage selected by the Group, shall commence on the
Effective Date specified in the Contract Schedules upon the
full payment of the Contribution due and its delivery to the
Group, and shall terminate on the Expiry Date specified in
the Contract Schedules.
6.2. Each Participant shall be covered under this Contract from
his Enrollment Date as specified in the Contract Schedules
and/or any related Endorsement/s up to the Expiry Date of
this Contract.
6.3. If an enrolled Group Member, on account of Illness or Injury,
is not actively working in full time employment on the
Effective Date of this Contract, his coverage shall not become
effective until the date such Member returns to full-time
active work.
6.4. If an enrolled Qualified Dependent, on account of Injury or
Illness, is confined in a Hospital on the Effective Date of this
Contract, his coverage shall not become effective until the
date such Qualified Dependent is discharged from the
Hospital.
 7. contributions
7.1. The Contribution stated in the Contract Schedules, including
the cost of any applicable stamps and/or taxes, are payable
to the Company at its registered Head Office, other designated
offices, or authorized collecting agents, on or before the
Effective Date of this Contract. The mode of contribution
payments is as stated in the application for this Contract
unless changed subject to rules in effect at the time of such
change.
7.2. The Company shall have the right to withhold payment of
Claims or cancel this Contract if the Contribution is not paid.
7.3. grace period
After the payment of the first Contribution, any Contribution
due must be paid not later than thirty (30) days after its due
date. If a Contribution remains unpaid after the expiry of the
grace period, this Contract terminates immediately and the
Group shall be liable for the amount due until the date of
cancellation of coverage.
During the grace period, Free Access to the Designated
Network Providers on direct billing basis shall be suspended.
In the event that the Contribution is paid within the grace
period, Free Access to the Designated Network Providers shall
be reinstated and all eligible healthcare expenses incurred
during the suspended period shall be processed and
reimbursed in accordance to the provisions of this Contract.
Allianz Takaful
7.4. The Group shall not offset against any Contribution due the
amount owed by or claimed from the Company under this
or any other agreement.
7.5. No confirmation or receipt of payment of any Contribution
shall be valid unless printed on the Company’s form and duly
signed by the Company.
8. addition of participants
8.1. The addition of Group Members and/or their Qualified
Dependents to this Contract shall be subject to submission
of a subsequent application together with supporting
documents relating to the required addition which are
satisfactory to the Company, within thirty (30) days of the
date of which the Member and/or Dependent becomes
eligible to be added in the Group’s coverage.
8.2. The Enrollment Date of any approved additional Participants,
which shall be stated in an Endorsement to the Contract,
shall be:
a. For newly-eligible Member or his enrolled Qualified
Dependents - the official date of membership or employment
in accordance with the Group’s policies and guidelines;
b. For new spouse - the date of marriage;
c. For newborn child - the date of birth; and,
d. For new adopted child - the date of official adoption.
 8.3. New Contribution shall be charged for such additional
Participants on a pro-rata basis for the unexpired period of
this Contract.
9. deletion of participants
9.1. The Group may, at any time, delete Members and/or their
Dependents from this Contract who cease to be eligible for
coverage, subject to submission of a subsequent application
together with supporting documents relating to the required
deletion request which are satisfactory to the Company,
including return of the Access Card of the deleted Participant.
9.2. Deceased Members, terminated Members (due to retirement,
resignation, or dismissal), and totally and permanently disable
Members, including their Qualified Dependents, shall be
deleted from the Group’s coverage. The effective date of
deletion shall be the day following the date of death,
termination, or total and permanent disability of the Member.
9.3. The Company shall refund to the Group a pro-rata amount
of the paid Contribution for the unexpired coverage period
of deleted Participants.
9.4. If the Access Card of the deleted Participant was not returned
to the Company, any Free Access of such Participant after the
date of deletion shall be charged to the Group’s account and
form part of the Group’s total Utilization.
9.5. No reinstatement of coverage shall be granted for the deleted
Participant within the Contract year.
Allianz Takaful
10. claim provisions
10.1. claim settlement
a. At Designated Network Providers
The Company and its appointed Third Party Administrator have
an agreement that allows for direct billing or submission of the
Claim by the Designated Network Providers.
To use the Provider’s facility, the Participant must present
his Access Card to the Provider. The available and/or his
selected Physician shall attend to his healthcare needs and s
hall also arrange to contact the Third Party Administrator,
who will arrange the settlement of all covered healthcare
expenses.
Should a Participant pay for Treatment at a Designated Network
Provider, the Company shall reimburse only the charges agreed
between the Company,Third Party Administrator, and the Provider
for such Treatment.
b. At Non-Designated Network Providers
The Participant must settle the invoiced amounts for Treatments
and/or other healthcare services that were provided by a
Non-Designated Network Provider. Written proof of the
Claim must then be submitted by the Participant to the
Company or its appointed Third Party Administrator within
thirty (30) days after the expiration of the period of the
Treatment and/or healthcare services for which Claim for
benefits is being made; otherwise, the Claim shall not be
considered.
 The original itemized invoices, the diagnosis, details of
the Treatment received, and when applicable, all related
reports such as laboratory and radiology test results and
prescription copies must be submitted together with a
fully-accomplished prescribed Claim Form that is issued by
the Company, completed and signed by the treating or attending
Physician. Photocopies of the required documents shall not
be accepted.
The Company and its appointed Third Party Administrator may
request for additional documentations before approving any
Claim. The Participant shall authorize the Providers to release
medical information to the Company and/or to the Third Party
Administrator.
All Healthcare Benefits that pertain to a Member or a Qualified
Dependent of a Member shall be paid by check to the order of
said Member, unless a Member requests otherwise. In case of
death of a Member, any Healthcare Benefit due but remaining
unpaid shall be paid to the first surviving class of the following
classes of successive preference of beneficiaries: the Memberís:
(i) widow or widower; (ii) surviving children; (iii) surviving
parents; (iv) surviving brothers and sisters; and (v) executors
or administrators.
The amount of Claim payable shall be, in the opinion of the
Company, the Usual, Customary, and Reasonable Charge for the
Treatment provided, less a Co-Insurance deduction after the
application of any Deductible.
Allianz Takaful
In the event that the total cost of Treatment is equal to or lower
than the Deductible amount, the Participants shall bear all the
healthcare expenses incurred.
10.2. claim limitations
The Claim for Healthcare Benefits for In-Patient Treatment shall
be limited to the eligible healthcare expenses arising from In-
Patient admissions that have admission dates, which refer to the
period from Provider facility admission to discharge for the same
corresponding admission, occurring within the Contract’s validity
period. The liability of the Company shall cease on date of
discharge, not exceeding thirty (30) days beyond the Expiry Date
of this Contract.
The liability of the Company shall be limited and restricted, under
this Contract, to any eligible healthcare expenses incurred under
the Plan of Coverage
10.3. pre-authorization
The following shall be excluded unless a Pre-Authorization, which
is the evaluation of the medical necessity of proposed healthcare
services, has been obtained by the Participant from the Company
or its appointed Third Party Administrator:
a. In-Patient and Day Care Treatments;
b. Diagnostic procedures, pathology, X-ray, MRI and CT scans,
radiotherapy, chemotherapy
 c. Physiotherapy, Chiropractic Treatment, and Osteopathy;
d. Home Nursing Care;
e. Second or subsequent medical opinion; and
f. International Medical Emergency Assistance.
The Company shall authorize such Treatments as they fall within
the scope of this Contract. A Claim shall be reimbursed in
accordance with this Contract provided that the Participant has
obtained proper Pre-Authorization and has followed required
Company procedures.
10.4. arbitration
Any differences in respect of medical opinion in connection with
the results of an accident, illness, or injury shall be settled between
two (2) medical experts appointed in writing by the Company
and the Group separately. Any difference of opinion between
these medical experts shall be referred to an umpire who shall
have been appointed in writing at the outset by the medical
experts and whose decision shall be final and binding on the
Company and the Group.
10.5.medical examination
The Company may, at its own expense, request a medical
examination of any Participant whenever and as often as
reasonably necessary. All medical information shall be treated as
strictly confidential.
Allianz Takaful
10.6. recovery
The Company shall be compensated by the Group for all Claims
made:
a. In excess of the Participant’s Healthcare Benefit Limits;
b. For excluded Treatments;
c. By individuals who are not eligible for coverage;
d. By the Participants during any period when a Contribution is
in arrears; and,
e. By deleted Participants as from effective date of his deletion
from the Group
f. In respect of fraudulent use of the Access Card.
10.7. coordination of benefits
The Company shall not pay for healthcare expenses if there is or
may be any other insurance or indemnity that may cover those
expenses. If the other insurance or indemnity does not cover all
such healthcare expenses, the Company shall then pay the balance
subject to the terms and conditions of this Contract.
If a Participant has two or more Healthcare Benefit coverage with
the Company, the maximum liability of the Company for each of
the Illnesses or Injuries and the complications thereto shall be
the amount provided in that coverage with highest maximum
aggregate benefit limit. Any healthcare expense that has already
 been covered by and/or paid by the Company under one coverage
can no longer be claimed from the Company under other
coverage.
10.8. subrogation
Once the Claim has been paid in accordance with the terms and
conditions of this Contract, the Group and its Participants shall
subrogate the right to the Company every relevant substantial
and legal right. The Group and its Participants shall provide the
Company with all possible assistance should the Company
exercise the above right of subrogation; otherwise, they shall be
liable for any losses incurred by the Company.
11. currency
11.1. All payments in this Contract are in the currency stated
in the Contract Schedules. Claims for Healthcare Benefit
submitted in other currencies shall be converted to the
Contract currency at the exchange rate prevailing at the
time of settlement of the Claim or at the rate agreed by
the Company and the Group at the commencement of
this Contract.
12. renewal of contract
12.1. This Contract may be renewed on a year to year basis
under such terms and conditions as the parties may agree,
provided that all outstanding receivables including the
corresponding charges were paid to the Company as may
be applicable.
12.2. Renewal of this Contract shall be subject to the
Allianz Takaful
submission of a confirmation letter and listing of
Participants or approved form where applicable,
the payment of renewal Contribution, any taxes and
pertinent charges, and the Group’s compliance with
other terms and conditions set forth by the Company
for renewal of this Contract.
12.3. At the end of every Contract year, Contributions shall be
subject to renewal rating, guided by the Group’s Utilization
experience.
13. termination
13.1. The Company may terminate this Contract, with immediate
effect, or vary the terms of this Contract at any time,
notwithstanding any other provision of this Contract,
should the Group and/or the Participants, violate any of
the eligibility requirements, act fraudulently, commit
a breach of the terms and conditions of this Contract,
or act in bad faith by withholding any facts material
to the coverage. In such case, the coverage of such
Participants and his Qualified Dependents, if any, shall
be cancelled immediately and their Healthcare
Benefits and contributions shall be forfeited in favor of
the Company.
13.2. The Group may cancel this Contract by giving the Company
thirty (30) days notice in writing. In such case, the Company
shall refund the pro-rata amount of the paid Contribution/s
for the unexpired coverage period to the Group, less the
Group’s Utilization during the Contract year. The release of
 the refund shall be made upon the receipt of all the Access
Cards issued to Participants.
13.3. A Participant’s coverage shall cease when he cease to
physically reside in the country of residence as stated in the
applications for more than one hundred eighty (180) days
under any one year of coverage.
13.4. A Qualified Dependent’s coverage shall automatically cease
on the same date as that on which his related Group
Member’s coverage ceases.
14. general exclusions
14.1. The conditions, illnesses, treatments, healthcare services,
causes, circumstances, and other items listed below and
their related or consequential expenses shall be excluded
from the coverage provided under this Contract unless
specifically stated to be included in the Contract Schedules
and/or Endorsements to this Contract.
• All Pre-Existing and Chronic Conditions
• All pregnancy, maternity, prenatal, perinatal, and/or postnatal
related Treatments and services, including complications
related thereto
• Treatments related to eating disorders, obesity, removal of fat
or surplus tissue, bulimia, anorexia nervosa, and other similar
disorders
• Organ, tissue, cell, blood and bone marrow donations or
Allianz Takaful
banking including complications related thereto
• Routine medical examinations and tests including but not
limited to preventative checks, screening tests, check-ups,
prophylactic Treatments, routine pap smears, allergy testing,
pre-operative infectious disease screenings, heart scans, and
bone densitometries
• Treatments for nearsightedness, farsightedness, astigmatism,
and cross-eyes
• Procurement or use of prostheses, corrective devices or
appliances, durable equipment, including but not limited to
hearing aids or devices, eye glasses and contact lenses, braces
and crutches
• Senility related conditions including but not limited to
Alzheimer’s disease
• Services, accommodations, or Treatments in any long term
care facility, rehabilitation centre, spa, hydro clinic, nature cure
clinics, rest cures, sanatorium, home care, nursing home or
home for the aged, periods of quarantine, or any other similar
institution, even if it is registered as a Hospital, arranged wholly
or partly for domestic reasons and which is not directly related
to Treatment or beyond the period required for recovery from
Treatment
• All gum and dental related Treatments (e.g. orthodontic or
endodontic treatments, dentures, any cosmetic alterations,
bridges, crowns, gingivitis, periodontitis or any related
conditions, scaling and polishing of teeth) unless resulting
 from accidental injuries and those dental benefits as specified
in this Contract
• Elective, plastic, or cosmetic surgeries (e.g. circumcision, any
sinus or nasal surgeries, lipomas, warts, acnes, corns, bunions,
molluscum contagiosum, nevus, mole, pigmentation
disorders) and Treatments unless pre-authorized by the
Company
• All conditions, testing, procedures related to determining,
diagnosing or treating congenital diseases or malformations,
as well as any complications related thereto
• Psychological and psychiatric illnesses, mental retardations,
attention deficit disorders, developmental delays and/or
advances and/or abnormalities whether physical,
psychological, emotional, behavioral, speech or intellectual,
including precocious puberty, hearing difficulties
• All Treatments and services related to sexually transmitted
diseases and related complications, including but not limited
to gonorrhea, syphilis, HPV, Hepatitis other than Type A, HIV,
AIDS, herpes, pubic lice, trichomoniasis, whether or not active
sexual transmission is documented or known
• Male and female reproductive system disorders (e.g.
impotence, erectile or sexual dysfunction, priaprism,
varicoceles, frigidity, menstrual cycle disorders, hysterectomies,
ovarian cysts, polycystic ovarian disease, endometriosis, uterine
fibroids, and menopause), as well as treatments or follow-up
in relation to sex-change procedures or operations
• Tests or treatments related to contraception, sterilization or
Allianz Takaful
reversal of sterilization, sub-fertility, infertility or fertility, in-
vitro fertilization, surrogacy procedures, assisted reproduction
(e.g. GIFT)
• Any pharmaceutical product not considered as medicine
including but not limited to vitamins, lozenges, mouthwashes
or gargles, baby formula, soaps, lotions, and shampoos (both
medicated and non-medicated), cosmetic preparations,
antiseptic solutions, dietary supplements, skin care products,
and slimming products
• Immunomodulators and/or immunotherapy treatments or
drugs including but not limited to Remicade, Interferon,
enzyme preparations, anti-oxidants, and liver tonics
• Any drug, device, medical treatment or procedure that in the
sole discretion of the Company is deemed to be experimental
or has not been established as being effective
• Alternative medicines or therapies
• Treatments of any condition that is caused by natural changes
to a person’s body that cannot be reversed (e.g. hormone
replacement therapy for menopause or osteoporosis,
deafness)
• Vaccinations and inoculations
• Alopecia, wigs, toupee and all hair or hair fall treatments and
products
• Any organ transplantation, other than heart, liver and kidneys;
 costs incurred in connection with locating, acquiring, and
transporting a replacement organ, removing the organ from
the donor, and all associated administration costs
• Genetic engineering and cloning
• Diseases defined by the World Health Organization (WHO) as
epidemic
• General health examinations, medical examination and other
related services required for obtaining or continuing
employment, residence, travel, insurance, government
licensing
• Attempted suicide, judicial sentence, resisting legal arrest, any
act of intentional self injury, committing or attempting to
commit any felony or violation of the law, or participation in
any brawl
• Any illness or injury resulting from alcoholism or taking of
alcoholic beverages, abuse of drugs, or illegal use of any
substance
• Treatments for injuries sustained while rendering military,
paramilitary, naval, police, fire-fighting or aviation service,
unless pre-authorized by Company
• Treatments for injuries sustained while traveling in any
form of air or sea transportation, except as a paying
passenger in an aircraft or ship operated by a commercial
airline or shipping line on a scheduled passenger trip over its
Allianz Takaful
established passenger route, unless pre-authorized by
the Company
• All treatments of injuries and sickness consequent to the
participation either as amateur or professional in hazardous
activities
• Work related injuries or accidents
• Loss, damage, cost or expense of whatsoever nature directly
or indirectly caused by, resulting from or in connection with
any act of terrorism (i.e. an act, including but not limited to
the use of force or violence and/or the threat thereof, of any
person or group/s of persons, whether acting alone or on
behalf of or in connection with any organization/s or
government/s, committed for political, religious, ideological
or similar purposes including the intention to influence
any government and/or to put the public, or any section
of the public, in fear), regardless of any other cause or
event contributing concurrently or in any other sequence
to the loss
• War or warlike operations (active or passive, whether declared
or not), or invasion, act of foreign enemy, intervention of foreign
power, hostilities, mutiny, strikes, riots or civil commotion, civil
war, civil uprising or looting, sabotage, rebellion, revolution,
insurrection, conspiracy, usurp of power whether by political
or military means, state of siege or emergency, martial law, or
any of the events or causes which determine the proclamation
or maintenance of state of siege or emergency and martial
law, every kind of projectile, explosives, including accidental
 explosion and/or deliberate explosion of weapons of war,
during war or directly as a result of previous war, bullets, bombs
or other military devices, acts or criminal acts by armed persons
whether affiliated or not to any organization or political party,
or militia, or military or paramilitary organization and/or the
state becoming under the control of de facto or de jure
authorities acting on their own behalf or for and on behalf of
other organization/s, also murder or assault or any attempt
thereat, and all malicious acts of any nature whatsoever
• Radioactive contaminations, ionizing radiation, radioactive,
toxic, explosive or other hazardous properties of nuclear
material thereof, and/or polluting, hazardous or poisoning
chemicals
• Any Claim in its entirety where the Participant goes against
medical advice
• Any Treatment by a family member, relative member, or a
Physician not licensed to operate in the country where medical
treatment is delivered
• AnyTreatment not related to specific symptom and/or disease;
not required or prescribed by a Physician; or not considered
by the Company as a medical necessity
15. jurisdiction and limitation of action
15.1. This Contract, and all rights, obligations and liabilities arising
herein, shall be construed, determined and enforced in
accordance with the applicable laws, regulations, and
Allianz Takaful
directives of the Kingdom of Bahrain and the Shari’ah. In
the event of any changes in laws, regulations, practices or
customs which may affect the Company’s ability to perform
under this Contract, the Company may adjust this Contract
to any extent required by such changes after notifying the
Group.
15.2. Any disputes arising from out of or in relation to this Contract
shall be settled amicably between the parties. Failing
amicable settlement, any such disputes shall be referred to
the exclusive jurisdiction of the competent courts of law of
the Kingdom of Bahrain.
15.3. The Company shall not be liable under this Contract for
compensation and/or damages in respect of judgments
delivered or obtained otherwise than through a court of
competent jurisdiction within the Kingdom of Bahrain for
costs and expenses of litigation recovered by any claimant
from the Group (or the Group’s Executors, Administrators
and Assigns) which are not incurred in and recoverable in
the Kingdom of Bahrain.
15.4. No failure or delay by the Company in exercising any
right, power or remedy under this Contract shall impair
such right, power or remedy, or operate as a waiver thereof,
nor shall any single or partial exercise of any right, power
or remedy preclude any further exercise thereof or the
exercise of any other right, power or remedy under this
Contract.
15.5. No legal proceedings shall be commenced prior to the
 expiration of sixty (60) days after proof of Claim has been
filed in accordance with this Contract. Neither shall any
action be brought at all unless commenced within one (1)
year from the expiration of the period within which proof
of Claim is required by this Contract.
15.6. The Company shall not assume responsibility for acts of
Providers.
CONTACT INFORMATION
For inquiries about the Allianz Sehhati, please contact:
Allianz Takaful, B.S.C (Closed)
P.O.Box 31397, Manama, Kingdom of Bahrain
Tel.: +973 17 568222; Fax: +973 17 582114
E-mail: health.takaful@allianz.com.bh

For claims assistance 24-hours a day, please contact:

16. other conditions
NEXtCARE Claims Center
16.1. This Contract shall be written in both the Arabic and English
Tel.: +971 4 6056800; Fax: +971 4 6056801
language. In the event of any discrepancies, the Arabic
Toll Free No.: 8000-1151
version of this Contract shall prevail. E-mail: nextcare@emirates.net.ae
16.2. Reference to time and date shall be according to the
Gregorian Calendar.

16.3. In the event any provision in this Contract or portion thereof

is found to be invalid or unenforceable, the remainder shall
remain in full force and effect.

16.4. Any notice or communication to the Company shall not

affect the Company unless it is in writing and is delivered
by hand, registered post or facsimile transmission, evidenced
with receipt of delivery or transmission by the Head Office
of the Company.

January 2009

Allianz Takaful
Allianz Takaful, B.S.C (Closed)
P.O.Box 31397, Manama, Kingdom of Bahrain
Tel.: +973 17 568222; Fax: +973 17 582114
E-mail: health.takaful@allianz.com.bh