Balsam

Balsam is provided by Tawuniya, the leading Saudi insurance company with a proven track record in the management of medical insurance plans

  • Tawuniya Medical & Takaful insurance staff members are comprised mostly of medical doctors and professionals in the health industry
  • Provides an excellent heath care through a network includes more than 1,000 medical providers
  • Utilizes advanced information system for the provision of instant services with no administrative or financial obstacles

Balsam Cooperative health insurance

This plan includes all insurance covers, stipulations and limitations of the standard health insurance policy issued by the Cooperative Health Insurance Council within the framework of the Executive Regulations of the Cooperative Health Insurance Act. The cover provided includes the out-patient and in-patient expenses in a special or shared room and a maximum benefit limit of SR 500,000 per each person per policy year as well as delivery benefit, dental benefit up to SR 3,000 and hearing aids benefit. The insurance cover is also available outside Saudi Arabia in emergency cases during a leave or business trip up to 90 days. The beneficiary is required to obtain the prior approval of the company to the in-patient and out-patient expenses starting from SR 1,000 and above. A con-insurance (deductible) of 10%, 15% or 20% of the out-patient expenses is borne by the beneficiary.

BALSAM DIRECT BALSAM BALSAM GOLD Benefit Class
Employee/wife, spouse, &
Children: 0 – 25 yrs.
Employee/wife, spouse, &
Children: 0 – 25 yrs.
Employee/wife, spouse, &
Children: 0 – 25 yrs.
Eligibility/maximum age limit
In/out-patient In/out-patient In/out-patient Type of Cover
SR. 500,000 SR. 500,000 SR. 500,000 Maximum Benefit Limit per each person per policy year
20%
deductible
for each outpatient visit
SR. 100 max
10%, 15% or 20%
deductible for each out
patient visit
Nil or SR. 100 max
10%, 15% or 20%
deductible for each out
patient visit
Nil or SR. 100 max
Out-Patient medical expenses:
  • Deductible/co-insurance (percentage payable by beneficiary per each visit inclusive of all procedures required by the doctor including consultation, examination and medicine and not for each procedure separately)
Full cover Full cover Full cover Max. limit of outpatient doctor’s/consulting fees:
  • At *PPN:
None
Shared Room
None
Private Room, Shared
None
Normal Suite, Private
In-Patient expenses:
  • Deductible/Co-insurance
SR. 600 max.
SR. 15,000 max.
during the
policy period
Room
SR. 600 max.
SR. 15,000 max.
during the
policy period
Room
SR. 15,000 max.
during the
policy period
Max. room & board limit at *PPN
Normal delivery benefit PSPY:
(in case the beneficiary is employed by married-status contract)
Covered up to
policy maximum
limit
Covered up to
policy maximum
limit
Covered up to
policy maximum
limit
Complication of delivery/pregnancy and all pre/post natal care PSPY
(in case the beneficiary is employed by married-status contract)
Covered up to
policy maximum
limit
Covered up to
policy maximum
limit
Covered up to
policy maximum
limit
Premature born babies
SR. 500 SR. 500 SR. 500 Circumcision for male new born babies
Covered Covered Covered Vaccination of children as per MOH specification
Covered Covered Covered Intensive Care Unit (ICU)
Covered Covered Covered Pre-existing and chronic medical conditions
Covered Covered Covered Physiotherapy Treatment
Covered Covered Covered Companion expenses of children less than 12 years
Covered Covered Covered Local road ambulance service
SR. 300 SR. 300 SR. 300 Ears piercing for female new born babies
covered covered covered Life threatening congenital illness
SR. 70,000 SR. 70,000 SR. 70,000 Expenses of complication of cardiac valve replacement
Covered Covered Not covered Organ transplant benefit (in KSA only)
Covered Covered Covered Treatment of illness due to allergy
SR. 50,000 SR. 50,000 SR. 50,000 Expenses of organs donation operation for the donor
SR. 15,000 SR. 15,000 SR. 15,000 Expenses of zahimer disease
SR. 15,000 SR. 15,000 SR. 15,000 Expenses of Autism desease
SR. 100,000 SR. 100,000 SR. 100,000 New born babies national preventive program
SR. 100,000 SR. 100,000 SR. 100,000 Obstruction conditions
SR. 100,000 SR. 100,000 SR. 100,000 Kidney Dialysis benefit
SR. 15,000 SR. 15,000 SR. 15,000 Acute cases of psychiatric treatment
SR 2,000 max.
during the policy
(for teeth extraction, Amalgam/composite (non-cosmetic) fillings, Root Canal treatment and Gum treatment only)
SR 2,000 or SR 3,000 max.
during the policy (for teeth extraction, Amalgam/composite (non-cosmetic) fillings, Root Canal treatment and Gum treatment only)
SR 2,000 or SR 3,000 or SR 5,000 max.
during the policy (for teeth extraction, Amalgam composite (non-cosmetic) fillings, Root Canal treatment and Gum treatment and cleaning once PPPY only)
Dental Benefit:
Maximum limit per person per policy year
SR. 400 max.
during the policy year For normal lenses (excluding contact lenses) when prescribed by the attending physician as medically necessary)
SR. 400 max.
during the policy year For normal lenses (excluding contact lenses) when prescribed by the attending physician as medically necessary)
SR. 400 , SR. 1,000 , SR. 1,500 or
SR. 2,000 max. during the policy year
Optical Benefit:
Maximum limit per person per policy year
Covered Covered SR. 400 PPPY Optical frame
Covered Covered Covered Hearing tests and Optical examinations benefit:
(if prescribed by the attending physician as medically necessary)
SR. 6,000 SR. 6,000 SR. 6,000 Hearing Aids Benefit:
(if prescribed by the attending physician as medically necessary)
SR. 10,000 SR. 10,000 Covered up to policy
maximum
Repatriation of mortal remains to home country
Maximum limit per person:
Direct Billing basis Direct Billing basis Direct Billing basis Claims Administration:
  • At PPN
Reimbursement basis subject
to similar Net PPN cost in
KSA
Reimbursement basis subject
to similar Net PPN cost in
KSA
Reimbursement basis subject
to similar Net PPN cost in
KSA
At Non-PPN
SR. 100,000 SR. 100,000 SR. 100,000 New born babies national preventive program
Not available Not available Medex plus World-wide Health Assistance
Available Available Available Other Services
Special Hotline Service:
Yes
(exceeding SR. 500)
Yes
(exceeding SR. 500)
No Approval Required
/Out-patient
Yes Yes Yes Approval Required
/In-patient
Allowed - as per
Agreed rating
Allowed - as per
Agreed rating
Allowed - as per
Agreed rating
Open Providers Network:
Network 4
Agreed rating
According to the selected network Network Gold
Agreed rating
Preferred Provider Network

Our Exclusive and Added-Value Services

In addition to benefits provided by the policy, Tawuniya also provides a number of exclusive and added value services that help you get the health care you deserve, these include:

  • Smart Helpline
  • The phone number of our call center 920019990 is associated with a smart system that quickly recognizes the customer as soon as it is connected, offering a unique, fast service that accurately responds to any inquiry, at any time around the clock, from inside and outside of the kingdom.

  • Dawae Online Service
  • Dawae is an online service provided by Tawuniya to its members of networks (Gold, 1+, and 1) and gives you the opportunity to refill your medication for chronic diseases through Tawuniya’s website and to receive it from any of our approval pharmacy branches.

  • e-Services
  • We offer a number of quality services through the website that assists you in managing your insurance policy, following up on medical approvals, tracking your medical claims, adding & deleting beneficiaries, as well as updating personal information.

  • Tawuniya Health Zone Program
  • It is a collaborative platform set up by Tawuniya ate the premises of its key clients to provide their employees with advice on health, nutrition and fitness. As well as offering vital measurement and consulting expertise.

  • Mobile Application
  • The smart phone application service provided by Tawuniya allows you to be able to view your policy benefits, view the approved list of medical providers, and receive the notification of medical approvals and claims requests.

  • Worldwide Assistance
  • It is offered to you through Tawuniya’s international partners for emergencies.

  • SMS Notifications
  • For medical approvals and claims.

  • Tabibi
  • Tabibi is a medical consultation service by phone and free of charge provided by Tawuniya to all of its medically insured clients by calling 920033404.

  • Health & Wellness
  • Tips, information and more will be sent to clients via SMS, email and social media.

  • Instant and Temporary Eligibility Letter
  • Tawuniya will immediately issue a temporal approval in the form of an official letter addressed to the service provider indicating its consent for the beneficiary to receive the necessary treatment in case the lost of Medical Card, providing an expired card, or the other administrative reasons not related to eligibility to receive the medical treatment. This procedure is done through the Call Center, by sending an SMS to 0501492222 containing the (ID Card No. of the main beneficiary#Fax No. of the medical Provider), or by entering Tawuniya website to facilitate receiving the treatment required.

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