| 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:
|
None
Shared Room
|
None
Private Room, Shared |
None
Normal Suite, Private |
In-Patient expenses:
|
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:
|
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 |