Download - Member Guide - Daman · customer’shealth insurance needs. Basic Plan is an optimal health insurance plan, covering benefits like hospital stays, treatments, and medicines within

1800 4 DAMAN (32626) | www.damanhealth.ae

Basic (Abu Dhabi Plan)

Member Guide


Daman HeadquartersNext to Centro Rotana Hotel and Aloft HotelADNEC Area, Abu DhabiTelephone: 02 614 9555Fax: 02 614 9775 P.O. Box 128888

Central BranchAirport Road, Abu DhabiTelephone: 02 417 3609P.O. Box 128888

Mussafah BranchGlobal Ascent Business CenterAl Musaffah 4, Abu DhabiBehind Mercedes-BenzPlot No. 12 behind SEHATelephone: 02 815 0209P.O. Box 128888

Al Ain Branch

G01-G02, Ground Flr, Al Wadi Trading

Centre, Khalifa Bin Zayed Al Awwat St.

Al Ain

P.O Box 69988Tel: 03-7011001/7011002/7011003

Western Region Branch

Saeed Bin Humaid Complex - Block A –

1st Floor

Western Region, Abu Dhabi

Telephone: 02 894 4303

Sharjah Branch

Ground Level, Crystal Plaza, Corniche Road

Sharjah

Telephone: 06 517 15 55

Dubai Office

Al Barsha 1, Next to Sharaf DG Metro Station

Hassanicor bldg. (Roche Bobois Furniture

Shop),

5th Floor Room 501


Dubai Direct Sales Office

Office#601 Capricorn Bldg,

Sheikh Zayed Road, Dubai


Abu Dhabi Service Points

Infinity Services – Moroor Street

Zones Corp. Mussafah

Abu Dhabi Immigration

Dept. of Economic Development

Abu Dhabi Chamber of Commerce

Marina Mall

Masdar City

Al Shahama Municipality

Al Ain Service PointsInfinity ServicesAl Wagan MunicipalityMazyad MunicipalityAl Hayer MunicipalitySweihan MunicipalityAl Qoaa MunicipalityAl Ain Immigration (Visit Visa Only)Al Khaznah MunicipalityAl Maqam Municipality

Western Region Service PointsMadinat Zayed, Tamm CenterGhayathi, Tamm CenterSilaa, Tamm CenterDelma, Tamm CenterAl Marfa’a, Tamm CenterLiwa, Tamm Center

Sharjah Service PointSharjah Immigration

Ras Al Khaima Service PointsRas Al Khaimah Immigration


Table of Contents

Daman: Your Health Insurance Specialist ........................................................................4

Our Specialized Services ..............................................................................................5

What Is Covered? ........................................................................................................6

How To Obtain Your Plan Benefits? ................................................................................7

What Is Not Covered? ............................................................................................8

Important To Know .....................................................................................10

Your Rights and Responsibilities ..........................................................................12

Definitions ..................................................................................................13

Contact Us ...............................................................................................15


Daman:Your Health Insurance Specialists

Daman is the first specialized health insurer in the United Arab Emirates. Our strategic partnership with

Munich Re, one of the largest and most reputable reinsurer in the world, has helped us develop a renowned

stretch of competencies in the region, backed by the strong and reliable support of Abu Dhabi Government.

Our products are a result of industry knowledge, market research, and a deep understanding of our

customer’s health insurance needs. Basic Plan is an optimal health insurance plan, covering benefits like

hospital stays, treatments, and medicines within the Emirate of Abu Dhabi; as well as coverage for

emergency services in UAE. This plan offers you health insurance cover of AED 250,000 per person annually.

You can use your health insurance card (Emirates ID , digital insurance card or Daman card) to get direct

billing facility at health service providers across our plan’s Network which includes hospitals, clinics,

pharmacies and diagnostic centres.


Our Specialized Services

We offer you a distinctive set of world class services as listed below:

Network of more than 600 health service providers in the Emirate of Abu Dhabi

24/7 in-house Customer Service Centre staffed with bilingual representatives

24/7 access to medical authorizations (pre-approvals required to receive specific medical treatments)

Automated systems for effective management of your pharmacy benefits

Efficient claims processing

Easy access to information on your network directory (including hospitals, pharmacies, clinics, doctors etc.) through our online portal www.damanhealth.ae

Wide geographical representation of branches and service points across the United Arab Emirates offering you convenience and choice

Easy and safe access to our online portal to submit and track your claims, search for health services providers, and ask questions through your “My Daman” account

Access to ActiveLife Program, a community engagement platform designed to give our membersand the community at large a platform to support them in leading a healthier, more active life.


What is covered? Main Cover-Your Benefit Summary

Covered at Network Providers

Notes

Inpatient benefits

Hospital Charges Including room, meals, nursing, drugs and dressings.

Inpatient Treatments Surgeries, day procedures, radiotherapy,chemotherapy, etc.

Medical appliances, diagnostic tests

Used as part of inpatient procedures.

Specialist’s or Consultant’s Fee

Outpatient Benefits

Doctor’s consultation Including General Physician consultation and Specialist consultation on referral basis.

Prescribed medicines Covered as per your Drug Formulary.

Diagnostic tests Including X-rays, blood tests, ultrasounds, CT Scans and MRI.

Physiotherapy sessions

Maternity Benefits

Inpatient Maternity Including childbirth, complications of pregnancy or delivery, newborn accommodation and care.

Doctor’s Consultation, Prescribed medicines

Additional Benefits

Any emergency treatments or services within UAE

Including Ambulance Services, Dental or Vision Correction treatments in case of medical emergency. Emergency treatments or services will also be covered outside Daman’s Network within UAE.


Within Daman’s Network: Use your health insurance card

You will have direct billing access at our Network Providers for health services covered under

your policy. Just remember to carry your health insurance card (Emirates ID , digital

insurance card or Daman card) when going to the network provider and comply with the

administrative procedures there.

Some health services may have deductibles or co-insurance charges that you will have to

pay for. Such charges will be clearly mentioned on your Schedule of Benefits and will be due

and payable to the provider on the date that the service is provided.

Outside Daman’s Network: Get your bills reimbursed (incase of

Emergency only)

If you go to a Health Services provider that is not part of Daman’s Provider Network, you

will have to pay directly for the services provided. Only in case it is a medical emergency,

and if such services are covered in your plan, you will be eligible to reimburse the cost of the

health service from Daman.

For reimbursement, you have to submit a claim form, along with the documents like original

itemized bills, medical or investigational reports, etc. The claim form and details of our

reimbursement requirements are available on our website. These documents must be

submitted to Daman within 180 days from the date of service received. You can apply for

reimbursement through our website or by visiting any of our branches or service points.

How to obtain your plan benefits?

Coverage for Emergencies

We are committed to provide you the best coverage for health care services,especially when it matters the most. In case of a medical emergency within theUnited Arab emirates, you will be eligible to get coverage for your medical bills,whether you were treated at a Network or Non-network Provider. Prior approvalis not required in case of emergency or services. However, you must notify uswithin 24 hours of the services received so that we can help you with theclaims process. You can reach us on the Customer Service toll free numbermentioned on Daman website, digital app or Daman card in case you needfurther information.


What is not covered?

Your policy does not cover you for:

Health Services, including treatments and supplies, not medically necessary

Health Services including pharmaceuticals not prescribed by a physician

Health Services received outside the plan Network, except in case of an Emergency

Dental and gum treatment, Vision and Hearing Correction treatments and Aids, except in caseof medical emergency

Assistance in activities of daily living which do not change the medical condition of themember (for example-custodial care, private duty nursing, etc.)

Vitamins

Personal comfort and convenience items or service (fro example-beauty services)

Cosmetic procedures, surgeries which are not incidental to any injury, sickness or congenitaldeformities

Treatment or obesity and weight management programs

Experimental, investigational or Unproven services, treatments, drug and supplies or devices

Outpatient medical supplies including prosthetic devices and durable medical equipment (forexample- bandages, syringes , wheel chair)

Any services for hair fall (for example- alopecia)

All cases resulting from alcoholism , use of drugs and hallucinatory substances

Smoking cessation programs

Health Services related to sex transformation operations, fertility or infertility

Hazardous activities or professional sports (for example- bungee jumping)

Treatment as a result of war, riots, military operation, etc. where a member participates insuch acts

Treatment as a result of nuclear risk, natural peril or any terrorist or criminal activities

Mental health diseases or disorders unless it is transient mental disorder

Preventive care including any associated test and investigation (for example- vaccinations)

Alternative treatments (for example- herbal or Chinese treatments)

Any Health Services and associated for HIV, AIDS, sexually transmitted diseases and allrelated medical conditions. Birth defects or Congenital Anomalies for newborn unlessrepresenting a life threat

All cases related to Maternity in respect of unmarried females


Any test which is not related to a specific symptom/disease. This includes examinations requiredfor employment, travel, immigration, licensing or insurance and related reports

More than one physician consultation in a day or during free follow up period unless medicallynecessary and referred by the initial treating doctor

Lesions resulting from attempted suicides or self infliction

All substances which are not considered as medicines and all equipment not primarily intendedto improve a medical condition or injury (for example-food supplements, air purifying systems)

Growth hormone therapy unless medically necessary

Enteral feeding and other nutritional and electrolyte supplement, unless medically necessary

Services related to musculoskeletal treatments except for treatment of fracture and dislocationof extremities

Nasal septum deviation, nasal concha resection

Chronic conditions requiring hemodialysis or peritoneal dialysis including related investigations

Viral hepatitis and related complications except hepatitis A

Air ambulance transportation and terrestrial transportation in non-emergency cases or by non-licensed ambulance services

Circumcision and any related complications, except for newly converted Muslims

Any pharmaceutical products, which is not considered as specific treatment for a particulardisease or not prescribed by an approved Physician

All cases where appropriate pre-authorization or notification was not carried out as per policyterms and conditions

Officially recognized epidemics or pandemics

Complications directly arising from services not covered

Education programs or learning disabilities treatments

Any treatment or services rendered by a family member or any person with the same legalresidence

Any inpatient treatment, tests and other procedures, which can be carried out on Outpatientbasis without jeopardizing the insured ‘s health

Organ and tissue transplants

Note: This is only an extract from the General Exclusions list that applies to your plan. Please

refer to the Policy Wording for the complete list and details of exclusions, definitions, terms andconditions.


Pharmacy Benefit Management

Pharmacy Benefit Management (PBM) is an internet-based interface between Daman and yourpharmacy within Daman’s Network in Abu Dhabi. It is designed to mange your pharmaceutical benefitsbetter.

PBM will help us enhance our service quality by following established frameworks and best practicesrelated to drug prescription and dispensing. We will be able to review every drug prescribed forconsistency with your diagnosis, age, gender and previous medical history. We can avoid any potentialhealth hazard by rejecting clinically inappropriate drugs or where we suspect negative drug-to-druginteraction.

PBM will further help us with automated checks for cases like a particular drug is not covered in yourpolicy (Drug Formulary) or you have already consumed your pharmacy benefit limit or the drug is notmedically necessary or you requested for a prescription refill too soon.

However, you may get a refill approved on an exceptional basis. You may contact our CustomerService Centre (by calling the toll free number mentioned on Daman website, digital app or Damancard if you require further information or wish to file for an appeal in case for exceptionalcircumstances.

Pre-AuthorizationYour policy may contain specific services that require prior-approvals or pre-authorizations. This isnecessary to ensure that your Health Services Provider has appropriate information on servicescovered under your policy.

You would need pre-authorization before availing any of the following health services:

• Inpatient and day treatment services• Outpatient Physiotherapy• MRI, CT Scans and Endoscopies• Prescription Drugs above AED 500 or medication to be consumed for more than 60 days

Your Network Provider, along with Daman, will carry out the pre-authorization process (wherenecessary) and notify you once the approval is granted. If the authorization is not granted, you havethe right to ask for an explanation by calling our Customer Service Centre at the toll free numbermentioned on Daman website, digital app or Daman card.

Coverage for Specific ConditionsYour policy covers this listed conditions after a waiting period for 6 months. The waiting period appliesto inpatient treatment only for the following medical conditions:

Important To Know


Diabetes mellitus, Arterial diseases, COPD (Chronic Obstructive Pulmonary Disease), all cancer cases,Neurosurgery, Cerebro Vascular Diseases all delivery cases (Maternity). The waiting period is notapplicable if you were continuously covered without any break for atleast 6 months under a healthinsurance plan approved by Health Authority Abu Dhabi (HAAD).

Member Cost SharingFor health services covered within Daman’s Network, there maybe some services where a deductibleor co-insurance is payable. Such charges will be clearly mentioned on your Schedule of Benefits andwill be due and payable to the provider on the date that the service is provided.

Network DirectoryBefore going for a treatment or service, we recommend that you refer to your Network Directory andconfirm if the provider is listed in Daman’s Network. Our Network Directories are continuouslyupdated as we establish new agreements with health service providers within the territories specifiedin your plan. Going to a Network Provider would ensure that you can enjoy the direct billing facility andavail cashless benefits for Health Services covered in your policy. You can check the Provider detailson our website or call our Customer Service Centre on the toll free number mentioned on Damanwebsite, digital app or Daman card for any assistance.

Drug FormularyIf your policy covers outpatient prescription drugs, these drugs will be subjected to a Drug Formulary.A Drug Formulary details the pharmaceuticals covered under your policy as decided by HealthAuthority-Abu Dhabi (HAAD). Your Drug Formulary covers both brand-name and generic drugs.Generic drugs have the same active ingredients as brand-name drugs and are equally safe andeffective. In case the prescribed drug is not covered in your Drug Formulary, you will have to pay thedrug bill directly to the Provider. You can refer to our website to check if the medicines prescribed foryou are covered in the Drug Formulary of your policy.

Complaints and AppealsDaman is committed to address members’ coverage issues, complaints and problems. For any generalinquires related to your policy benefits, or specific complaints concerning your pharmacy benefits suchas adjudication of your claims (declining the pre-authorization request for a drug) , dispensingoversight or provider related issues (access, quality and safety), you can call our Customer Servicetoll free number mentioned on Daman website, digital app or Daman card.

For cases where a drug cannot be found with your Network Provider, you have the option to requestexceptional consideration for coverage. If your request is declined, you may further approach usthrough our appeal process. Daman will discuss the merits of your case internally and externally andwill communicate the decision to you within 30 calendar days from the date of appeal. Details ofappeals process and the Appeals/Exception Request Form are available on our website. You can submityour Appeal/Exception request Form along with all supporting documents at any of the DamanBranches or via email to [email protected].


As a Daman member you have the Right to:

1. Receive information about Daman’s health insurance plans and services including but not limited

to health insurance plan benefits, exclusions, policy terms and conditions, Pharmacy Benefit

Management (PBM) services, details of network providers (including hospital, pharmacy, dental

clinic etc), online services, list of medications covered under your health insurance plan (Drug

List) and your Rights and Responsibilities.

2. Be treated with respect and dignity and have the right to privacy.

3. Preserve the confidentiality of your treatment records to the extent protected by Federal and

Emirate laws in the UAE. You are also entitled to receive an explanation regarding exceptions to

confidentiality.

4. Voice complaints or to appeal to Daman on benefits offered, claim settlement, services offered,

PBM services or any other grievance.

5. Be provided, upon request, with information about your plan’s benefits including limitations and

exclusions applicable and details related to your health plan Drug List.

6. Receive services in English and Arabic when contacting Daman Customer service.

7. Make suggestions and give comments on ways Daman can improve its services.

8. Exercise your rights in accordance with the Health Insurance Law of the Emirate of Abu Dhabi.

As a Daman member, your Responsibilities are:

1. To read your insurance policies for the details of benefits, exclusions, other terms and conditions

applicable under your health insurance plan. If you do not understand the information, you

should contact Daman Customer Service for explanations on the covered benefits, limitations

and authorization procedures.

2. To present your health insurance card (Emirates ID, digital insurance card or Daman card) when

accessing covered health services from our Network Providers.

3. To know how to access covered health services and pharmacy benefit you are entitled to as part

of your health insurance plan benefits.

4. To pay any applicable co-insurance and deductible at the time of availing a health service.

5. To demonstrate mutual respect and courtesy towards providers (including hospitals, pharmacies,

dental clinics etc.) and Daman personnel.

Your Right and Responsibilities


Definitions

Co-insurance - the percentage of eligible expenses that you need to pay for specified medicalservices availed under your policy.

Deductible - the defined fixed amount that you need to pay for the specified medical servicesreceived under your policy.

Eligible Expenses - Reasonable and Customary Charges for Covered Health Services, incurredwhile the Policy is in effect.

Emergency - A sudden development of a medical or surgical condition where lack of immediatemedical treatment at a health service provider might result in a life threatening situation orseriously affect member’s bodily functions.

Drug Formulary - A list of medications or drugs covered under your policy

Health Insurance Card - the identification card (Emirates ID or Daman digital insurance card orDaman Card) that Eligible Person must show every time they request Health Services fromNetwork Providers.

Health Services - the health care services and supplies covered under the Policy, unless suchhealth care services and supplies are not limited or not excluded in the policy.

Inpatient Benefit - Hospitalization or Day Treatment or observation or treatment in anEmergency room or facility which cannot be carried out on an outpatient basis.

Network - Used to describe a Health Services Provider, which holds an agreement in effect withDaman to provide Health Services to members.

Non-Network Benefits - Coverage available for Health Services obtained from the Non-Network Providers. Coverage for the Non-Network Benefits is only provided if the services areassured in Schedule of Benefits.


Outpatient Benefit - are those services which do not require Hospitalization or Day treatment ornecessitate specialized medical attention and care in a Hospital before, during or after the delivery ofthe service.

Pre-authorization - a prior approval or official permission, granted by Daman to the NetworkProvider, before initiating certain medical procedures.

Pre-Existing Condition - any known or unknown injury, sickness, disease or other medical, mentalor nervous condition, disorder or ailment that with reasonable medical certainty that existed at thetime of applying for

this policy.

Provider - a Physician, Hospital, group practice, pharmacy or any facility, individual or group ofindividuals that provides a health care service.

Refill-too-soon - Replenishment or dispensing of a prescribed medicine before the previousdispense of the same pharmaceutical is consumed.

Appeal - A request contesting a denial or reduction of coverage for services which have beenavailed or are intended to be availed.


Contact UsFor any product related queries or general inquiries,

kindly contact us on:

Toll Free: 800 4 DAMAN (32626)

Website: www.damanhealth.ae

Fax: +971 2 614 9775

P.O. Box 128888, Abu Dhabi, UAE

DisclaimerThis document is for information purposes only and does not form part of the Policy. Thecomplete list of benefits, definitions, exclusions, terms and conditions are set out in the Policy.While every effort is made to ensure the accuracy of the content, Daman cannot be held liable forany typographical errors, errors of fact or any other error or inconsistency found in thisdocument.

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