Group Health Insurance Solutions

TABLE OF POLICY BENEFITS

Insurance Company : QLM LIFE & MEDICAL INSURANCE COMPANY QPSC
Insured : QATAR ENERGY
Policy No : P2109000180-R1
From January 1, 2022 To December 31, 2024 ( 3 YEARS )
Period of Insurance :
Both Days Inclusive

TABLE OF BENEFITS

BENEFITS DETAILS BENEFITS LIMITS

PLANS PREMIER PLUS PLAN

ELIGIBLE MEMBERS EMPLOYEE, SPOUSE/S & CHILDREN

SCOPE OF COVER WORLDWIDE

EMERGENCY COVER OUTSIDE AREA OF COVER: WORLDWIDE

NETWORK CATEGORY PRESTIGE

OVERALL ANNUAL LIMIT / PERSON / POLICY YEAR QAR 3,500,000/ PPPY

IN- PATIENT & DAY-CARE BENEFITS:

▪ Hospital accommodation Private Room

▪ Accidents and Emergencies, Intensive Care & Theatre Costs Covered

▪ Surgical Operations & procedures Covered

▪ Second Medical Opinion Covered

▪ Nursing fees, Medical Expenses & ancillary Charges Covered

▪ Surgeons, Anaesthetists & Physicians fees (Visiting doctors will be subject to Covered
reasonable and customary cost at the at the country of treatment)

▪ Prescribed Medicine & drugs & Dressings Covered

▪ Vitamins and Herbal Medicines Covered

▪ Blood, plasma & blood substitutes Covered

▪ Oxygen and other medical gases Covered

▪ Post hospitalisation treatment received within 90 days of being discharged from Covered
hospital

▪ Reconstructive Surgery following an accident or surgery for an eligible medical Covered

condition, including Maxillofacial Surgery

▪ Artificial Limbs and Eyes, when necessitated by accidental bodily injuries or Covered
diseases occurring while under cover

▪ Casts, Splints, Trusses, Braces and Crutches Covered

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▪ Prostheses and Surgical Appliances Covered

▪ Limousine transportation expenses for emergency cases to the nearest in-patient Covered
provider up to QAR 50 / trip

▪ Diagnostic tests (e.g., X-rays, MRI, PET, CT scan, US, Angiography, ECG, Stress Covered
test, Echo and Lab. services including hormonal tests)

▪ Pathology, x-rays, diagnostic tests Covered

▪ Treatment of allergic conditions Covered

▪ Sport Related Accident (Non-professional) Covered

▪ Treatment of injuries resulting from terrorism Covered

▪ Ophthalmology & Eye care such as consultation, eye test, medical, surgical Covered
therapy, amblyopia treatment, laser treatment & cataract)

▪ Acute (reversible kidney failure) Covered

▪ Physiotherapy, Oculomotor therapy, acupuncture therapy, occupational therapy Covered

as requested by medical practitioner

▪ In-patient rehabilitation Covered

▪ Psychiatry treatment: (without waiting period) regardless of the nature of disease QAR 10,000/ PPPY

▪ Hospice care & Palliative care Covered

▪ Terminal Illness Covered

▪ Accidental damage to natural teeth, immediately post an accident (Treatment as Covered

an in-patient or day care patient) and all related treatment

▪ Surgical treatment for obesity (Gastric Sleeve, Gastric By Bass, Gastric Banding, Covered
Gastric Balloon)

▪ Complications of pregnancy treatment of a medical condition which arises during

the antenatal stages of pregnancy, or a medical condition which arises during Covered
childbirth

▪ Accommodation costs for one parent staying in hospital with insured dependent QAR 400/ Night
child
IN-PATIENT DEDUCTIBLE NIL

OUT-PATIENT BENEFITS:

Benefits Limit: Up to the overall annual limit / person / policy year

▪ Diagnostic tests (e.g. Thyroid and liver tests, hormonal assay, x-rays, MRI, PET,
CT scan, US, Angiogram, ECG, Stress test, Echo and Lab. services including Covered
hormonal tests & pathology diagnostic tests and procedures).

▪ Pathology, X-ray and diagnostic tests Covered

▪ Surgeons, Anaesthetists & Physicians fees (Visiting doctors will be subject to Covered
reasonable and customary cost at the at the country of treatment)

▪ Vaccination of children as per the immunization schedule and any mandatory Covered
vaccination for adults issued by the Ministry of Public Health

▪ Post hospitalisation treatment received within 90 days of being discharged from Covered
hospital

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▪ Prescribed Medicine & drugs & Dressings & Medical Appliances Covered

▪ Prescribed Vitamins Covered

▪ Blood, plasma & blood substitutes Covered

▪ Oxygen and other medical gases Covered

▪ Day Care Treatment & Surgery Covered

▪ Out-patient surgical operations Covered

▪ Acute (reversible kidney failure) Covered

▪ Costs for treatment by therapists and complementary medicine practitioners &

Complementary therapy (e.g., Chiropractics, Osteopathy and Acupunctures,), Covered
requested by medical practitioner

▪ Accident (e.g., Road Traffic Accident Covered

▪ Palliative ongoing treatment & Medication Covered

▪ Physiotherapy, Oculomotor therapy, occupational therapy, Speech Therapy as Covered

requested by medical practitioner

▪ Ophthalmology & Eye care such as consultation, eye test, medical, surgical Covered
therapy, amblyopia treatment & laser treatment etc.

▪ Treatment of allergic conditions Covered

▪ Hormonal therapy other than infertility Covered

▪ Aging illness (e.g., Parkinson) Covered

▪ Psychiatric treatment, Consultants’ fees and psychologists’ fees for psychiatric

treatment regardless of the nature of disease. Also, speech therapy, learning QAR 15,000/ PPPY
disabilities, autism, and ADHD

▪ Coverage of recommended vaccines as per Ministry of Health in Qatar Energy Covered

Clinics

▪ Coverage of online consultation for Chronic (excluding acute) and Maternity Covered

DEDUCTIBLE PER EACH OUT-PATIENT CONSULTATION:

NIL
Per out-patient visit
ROUTINE OUT-PATIENT DENTAL CARE BENEFITS: (With No selection)

Overall annual sub-limit per insured per policy year: QAR 7,500/ PPPY

Dental Benefits:

▪ Examination, X-ray & Dental Medicine Covered

▪ Simple & Surgical Dental Extraction Covered

▪ Non cosmetic Dental Fillings (Composite Filling & Amalgam filling) Covered

▪ Root Canal Treatment Covered

▪ Gum treatment, Periodontal treatments & preventive fluoride treatments for Covered
children (Whitening & Polishing not covered)

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▪ Orthodontics treatment & Dental prostheses, without age restrictions of the Covered
patients in accordance with patient’s medical requirements

▪ Bridges Covered

▪ Non-Precious Crown “Porcelain Crown” Covered

▪ Dental Implant Covered

▪ Maxillofacial Surgeries Covered under basic up to policy limit

▪ Emergency treatment for the immediate relief of dental pain & accidental Covered under basic up to policy limit
damage to natural teeth

DENTAL CO-PAYMENT: 0%

MATERNITY CARE BENEFITS: (Delivery/ Lady/ PY) these benefits are available for married female staff and spouses of male staff members w/ no
selection & without waiting period)
Overall annual sub-limit per insured Lady per policy year: QAR 30,000/ Lady/ PY

MATERNITY BENEFITS:

▪ Normal pregnancy and childbirth comprising normal pre-natal treatment and

examinations, normal childbirth or caesarean section, normal post-natal Covered
treatments and examination

▪ New-born accommodation; hospital accommodation costs for a healthy new born

child to accompany his/her mother while she is receiving treatment as an in-
patient in a hospital for a medical condition covered under the complications of
pregnancy and childbirth up to the mother discharge date or 14 days earlier from Covered
delivery date whichever is earlier
▪ Benefits includes physical examination, Vitamin K, Hepatitis B, BCG vaccine,
Hearing Test, TFT & G6PD

▪ Termination of pregnancy when medically necessary Covered

▪ Complications from postpartum Covered under basic up to policy limit

MATERNITY CO-PAYMENT: 0%

OPTICAL BENEFITS: (With No selection)

Overall annual sub-limit per insured per policy year: QAR 1,000/ PPPY

OPTICAL BENEFITS:

▪ Refraction & Vision tests to be prescribed by Ophthalmologist Covered up to policy annual limit

▪ Pair of regular medical lenses, regular medical contact lenses (Daily,

Weekly, Monthly, Quarterly & Biannually) and Frames (Cosmetic/Other Covered
Disposable contact lenses & sunglasses are excluded).

OPTICAL CO-PAYMENT: 0%

WELLNESS BENEFITS:

Overall annual sub-limit per insured employee per policy year: QAR 1,500/ PPPY

▪ Cardiovascular Exam
▪ WELLNESS BENEFITS
▪ Neurological Exam

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▪ Cancer Screening
▪ Annual Pap Smear
▪ Prostate Screening
▪ Mammogram
▪ Diagnostic Tests
▪ Choric related diseases

WELLNESS BENEFIT CO-PAYMENT ▪ NIL

OTHER BENEFITS:
CHRONIC AND PRE-EXISTING MEDICAL CONDITIONS:
In & Out-patient
▪ Maintenance includes palliative treatment and prescribed medicine Covered
▪ Stabilization of acute exacerbations/ episodes chronic medical
conditions
ONCOLOGY: Covered
HELPLINE SERVICES: Provided

DESENSITIZATION AND ALLERGEN TESTS Covered

ALOPECIA AREATA Covered

TREATMENT OF PRP, HEPATITIS C & HIV in accordance with HMC
Covered
Protocol
MEDICAL EXPENSES OF ILLNESS OR INJURY RELATED TO WORK
Covered
NATURE (the illness, Injury should incur during the policy period).
DURABLE MEDICAL APPLIANCES: (e.g., Gluco-meter, sleep pap and/ or
BP Monitor) based on medical practitioner advice and necessitated by existing QAR 1,000/ PP
chronic medical condition
HEARING AIDS REQUIRED FOR HEARING IMPAIRMENT DUE TO WORK
QAR 10,000/ PPY
RELATED CASES
NEWBORN BABY:
Covered
▪ Eligibility from day one of birth

CIRCUMCISION FOR A NEWBORN MALE: Covered

BIRTH DEFECTS AND CONGENITAL ABNORMALITIES:

▪ Investigations and treatment of birth defects and congenital conditions,
including birth trauma, provided that such become apparent in the first
(6) months from birth Covered under basic up to policy limit
▪ This benefit is available per pregnancy for a period of (12) months from
initial diagnosis date, up to the specified limit shown
▪ If life threatening or loss of function of organ
ORGAN TRANSPLANT: Cost of the surgical procedures in performing an
organ transplant (kidney, liver, cornea, heart, lung or heart and lung), in Covered
respect of the insured person as recipient and not organ donor.

NURSING AT HOME:
Primary care services of a registered nurse in the insured’s home or QAR 400/ Night
Convalescent home immediately after or instead of in-patient or day-care
treatment as per doctor's advice.

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EMERGENCY LOCAL AMBULANCE:

Transport required due to emergency or medical necessity to the nearest Covered
available and appropriate local hospital via land, sea or air
HOSPITAL (In-patient) CASH BENEFITS:
Cash payment payable for each night where the medical expense is received QAR 400/ Night
by an insured person as a non-paying patient.

PCR Test for QP Clinic (as on date QR 160/-) Covered

INTERNATIONAL EMERGENCY ASSISTANCE*:

MEDICAL REPATRIATION:
When our consulting physician and the Eligible Insured’s attending physician
determines that transportation is medically necessary, we will arrange for Covered
transportation under medical supervision to the Eligible Insured’s residence or
to a medical or rehabilitation facility near the Eligible Insured’s residence, at
such time as the Eligible Insured is medically cleared for travel.
REPATRIATION OF MORTAL REMAINS:
In the case of an Eligible Participant’s death, we will arrange and pay for the
return of mortal remains to an authorized funeral home proximate to the
Covered
Eligible Participant’s legal residence** and if applicable, arrange and pay for
one way economy common carrier transportation for a family member to
accompany the remains to the Eligible Participant’s legal residence.
EMERGENCY MEDICAL EVACUATION:
When an adequate medical facility is not available proximate to the Eligible
Insured, as determined by our consulting physician and the Eligible Insured’s
attending physician, we will arrange transportation under appropriate medical Covered
supervision, by an appropriate mode of transport to the nearest medical facility
capable of providing the required care. Travel cost by appropriate mode of
transport for family members (spouse plus maximum of two children) shall be
covered.
PRESCRIPTION ASSISTANCE:
If an Eligible Insured needs replacement prescription medicine while travelling, Covered
we will help with replacing the prescription, when possible and legally
permissible and upon consulting with the attending physician.

CO-INSURANCE:

▪ For Medical Expenses inside the Designated Network Provider on Direct 0%

Billing Basis only.

▪ For Medical Expenses outside the Designated Network Provider and/or 0%

any Cash Re-imbursement actual cost or the reasonable and customary cost at the
country of treatment, whichever is lower

▪ For Medical Expenses incurred by students/trainees and their dependents Either (i) the actual cost or (ii) 150% of reasonable and
living outside Qatar and/or any Cash Re-imbursement customary cost in the place where their study/traineeship is
based, whichever is lower.

▪ For Medical Expenses at Al Ahli Hospital. 0%

**Legal residence shall mean the permanent place or residence of the Eligible Participant in the country registered in Qatari ID or in his/her home country
as per QatarEnergy records.

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ALLOWED POLICY EXCLUSIONS

The items procedures and medical conditions listed below and their related or consequential expenses are
ALLOWED as excluded from the coverage:
1- Services, accommodation or treatment charges incurred in health hydrous, spas, rejuvenation cures,
massage, exercise, long term rehabilitative therapy, isolation, rest homes or any similar place even if it is
registered as a hospital. Residential stay in a hospital or any similar institution arranged wholly or partly for
domestic reasons and which is not directly related to treatment, or beyond the period required for recovery
from treatment.
2- Cosmetic treatment unless medically necessary and pre-authorized by the Insurers( Cosmetic or
reconstructive operations which are related to injury, sickness or congenital anomaly when the primary
purpose is to improve the function of the involved part of the body or organ will be covered )
3- Tests or treatment related to contraception, or sterilization, infertility, impotence, sexual dysfunction,
contraceptive measures, Ovulation induction, IVF, or any similar condition.
4- Birth defects, congenital illness/genetic hereditary conditions, maternity examinations/complications and
any treatment/condition related to or caused by pregnancy and childbirth, unless listed in the Table of
Benefits. This means, any charges for treatment related to Birth defects, congenital diseases, and
deformities, unless it represents a direct threat to member’s life leading to immediate emergency
hospitalization are excluded.
5- Treatment of Mental or nervous disorder, learning difficulties treatment, hyperactivity, autism, attention
deficit disorder, and behavioural problem unless listed in the Table of Benefits.
6- Developmental disorder.
7- Treatments resulting from professional sports
8- Treatment for any illnesses, diseases or injuries resulting from Active Participation in war, riots, civil
disturbances, terrorism, acts against any foreign hostility, whether war has been declared or not treatment
for any medical conditions arising directly or indirectly from chemical contamination, Radioactivity or any
Nuclear Material whatsoever, including the combustion of Nuclear Fuel.
9- Treatment received outside the territorial limits described in the Table of Benefits and/or expenses incurred
where the Insured has traveled against medical advice.
10- Costs incurred in connection with locating or the acquisition of a replacement organ/tissues or any costs
incurred for removal of the organ from the donor, transportation costs of same and all associated
administration costs, unless agreed otherwise in your Schedule of benefits.
11- Any treatment or test for Acquired Immune Deficiency Syndrome (AIDS) and AIDS / HIV related conditions;
or sexually transmitted diseases other than HMC guidelines.
12- Benefits recoverable under Workmen’s Compensation Act Insurance, and/or any work related injury and/or
illness.
13- Claims directly or indirectly, occasioned by, happening through, or in consequence of, aviation, other than
as a fare paying passenger in a fully certified passenger carrying aircraft, flown in the course of licensed
operation for the transportation of passengers by properly licensed crew.
14- Experimental unproven treatment or drug therapy and stem cell therapy.
15- Sex change operations and related treatments.
16- Expenses incurred because of complications directly caused by an illness, injury or treatment for which
cover is excluded or limited under your plan.
17- Over the counter medicine and the medicine purchased without a licensed physician’s prescription
18- Transportation expenses for out of country treatment without pre approval
19- Home help, Family help, or similar household assistance unless listed in the Table of Benefits.

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20- Transportation other than local licensed ambulance services or for emergency medical evacuation under
section D. No reimbursement for transportation expenses to travel out of Qatar for medical treatment
without pre-approval.
21- Suicide or attempted suicide, willfully self-inflicted bodily injury or illness or injury sustained directly or
indirectly as a result of the Insured Person committing a criminal offence.
22- Treatment of sleep related breathing disorders, including snoring, sleep apnea, jet lag or work related
stress and any related condition unless listed in the Table of Benefits.
23- Nasal septum deviation and nasal concha resection unless non cosmetic medically necessary
24- All cases resulting from the use of alcohol, drugs and hallucinatory substances.
25- All healthcare services for internationally and locally recognized epidemics except overseas inpatient
serious cases .
26- Termination of pregnancy or any consequences of it unless medically necessary.

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