Policy Schedule ‫ﺟدول اﻟﻌﻘد‬

The following is the table of benefit that should be read, understood & signed by both parties. Details of ‫ أنّ ﻣﻌﻠوﻣﺎت اﻟﻣؤﻣن ﻋﻠﯾﮭم ﺑﻣوﺟب‬.‫ﻓﯾﻣﺎ ﯾﻠﻲ ﺑﯾﺎن ﺑﺟدول اﻟﻌﻘد واﻟذي ﯾﺟب أن ﯾﻘرأ وﯾوﻗﻊ ﻣن ﻛﻼ اﻟطرﻓﯾن‬
Insured members under this policy as stipulated in the schedule of members attached. .‫ھذا اﻟﻌﻘد ھﻲ ﺑﺣﺳب ﻣﺎ ورد ﻓﻲ ﺟدول اﻟﻣﺿﻣوﻧﯾن اﻟﻣرﻓق‬

FAY Table of Benefits ‫ﺟدول اﻟﻣﻧﺎﻓﻊ ﻟﺑرﻧﺎﻣﺞ ﻓﻲ‬

Annual Aggregate Limit 100,000 KD ‫ك‬.‫ د‬100,000 ‫اﻟﺳﻘف اﻟﻣﺎﻟﻲ اﻟﺳﻧوي‬
Territorial Coverage Kuwait Only ‫داﺧل دوﻟﺔ اﻟﻛوﯾت ﻓﻘط‬ ‫اﻟﻣﻧطﻘﺔ اﻟﺟﻐراﻓﯾﺔ‬
Eligibility Kuwait Citizens & Kuwait Residents ‫اﻟﻣواطﻧﯾن واﻟﻣﻘﯾﻣﯾن‬ ‫اﻷھﻠﯾﺔ‬
Network (Optional) Option 1: Fay Network ‫ ﺷﺑﻛﺔ ﻓﻲ‬:‫اﻻﺧﺗﯾﺎر اﻷول‬ (‫اﻟﺷﺑﻛﺔ )اﺧﺗﯾﺎري‬
Option 2: Fay Plus Network ‫ ﺷﺑﻛﺔ ﻓﻲ ﺑﻠس‬:‫اﻻﺧﺗﯾﺎر اﻟﺛﺎﻧﻲ‬
Age Eligibility From day 1 till 65 years ‫ ﺳﻧﺔ‬65 ‫ﻣن اﻟﯾوم اﻷول و ﺣﺗﻰ‬ ‫أھﻠﯾﺔ اﻟﻌﻣر‬
Pre-Existing All pre-existing conditions are excluded ‫ﺟﻣﯾﻊ اﻟﺣﺎﻻت اﻟﻣرﺿﯾﺔ اﻟﺳﺎﺑﻘﺔ ﻟﻠﺗﺄﻣﯾن ﻣﺳﺗﺛﻧﺎة‬ ‫اﻟﺣﺎﻻت اﻟﻣرﺿﯾﺔ اﻟﺳﺎﺑﻘﺔ ﻟﻠﺗﺄﻣﯾن‬
Chronic Conditions 12 months Waiting Period ‫ ﺷﮭر‬12 ‫ﺗﺧﺿﻊ ﻟﻔﺗرة اﻧﺗظﺎر‬ ‫اﻷﻣراض اﻟﻣزﻣﻧﺔ‬
In-Patient - ‫داﺧل اﻟﻣﺳﺗﺷﻔﻰ‬
Accommodation Type Private room ‫ﻏرﻓﺔ ﺧﺎﺻﺔ‬ ‫ﻧوع ﻏرﻓﺔ اﻹﻗﺎﻣﺔ‬
‫ﺗﻐطﻰ ﻓﻲ اﻟﺣﺎﻻت اﻟﺿرورﯾﺔ ﻣن اﻟﻧﺎﺣﯾﺔ اﻟطﺑﯾﺔ و‬
Ambulance Covered if followed by Emergency admission ‫ﺳﯾﺎرة اﻹﺳﻌﺎف‬
‫اﻟﻣﺗﺑوﻋﺔ ﺑدﺧول اﻟﻰ اﻟﻣﺳﺗﺷﻔﻰ‬
Covered 100% %100 ‫ﻣﻐطﺎة‬
Parent Accommodation ‫إﻗﺎﻣﺔ اﻟواﻟدﯾن‬
(up to 16 years children only) ( ‫ ﺳﻧﺔ ﻓﻘط‬16 ‫) ﻟﻸطﻔﺎل دون‬
Confinement Extending (After Expiry Covered for continuation of existing ‫اﺳﺗﻣرار ﺗﻐطﯾﺔ اﻟﻌﻼج ﻟﺣﺎﻻت اﻟدﺧول إﻟﻰ‬
(‫ﻣدة اﻻﺳﺗﺷﻔﺎء )ﺑﻌد اﻧﺗﮭﺎء اﻟوﺛﯾﻘﺔ‬
Of Policy) inpatient treatment ‫اﻟﻣﺳﺗﺷﻔﻰ ﺑﻌد اﻧﺗﮭﺎء اﻟوﺛﯾﻘﺔ‬
Within Network 100% 100% ‫داﺧل اﻟﺷﺑﻛﺔ‬
Outside Network 80% of Network rates ‫ ﻣن أﺳﻌﺎر اﻟﺷﺑﻛﺔ‬80% ‫ﺧﺎرج اﻟﺷﺑﻛﺔ‬
Out-Patient - ‫اﻟﻌﯾﺎدات اﻟﺧﺎرﺟﯾﺔ‬
Visit Limitation 16 Visits ‫ زﯾﺎرة‬16 ‫ﺣدود اﻟزﯾﺎرات‬
Physician Consultation Deductible: KD 5 ‫ك‬.‫ د‬5 : ‫ﻣﺑﻠﻎ اﻟﺗﺣﻣل‬ ‫اﺳﺗﺷﺎرة اﻟطﺑﯾب‬
Diagnostic Test 80% OR 90% 90% ‫ أو‬80% ‫اﻟﺧدﻣﺎت اﻟﺗﺷﺧﯾﺻﯾﺔ‬
Pharmaceuticals 80% OR 90% 90% ‫ أو‬80% ‫اﻷدوﯾﺔ‬
Physiotherapy 80% OR 90% (6 sessions per visit/year) (‫ ﺟﻠﺳﺎت ﻟﻛل زﯾﺎرة‬6) 90% ‫ أو‬80% ‫اﻟﻌﻼج اﻟطﺑﯾﻌﻲ‬
100% 100%
Within Network ‫داﺧل اﻟﺷﺑﻛﺔ‬
(Note: co-payment is applied) (‫ ﺗطﺑق ﻧﺳﺑﺔ اﻟﺗﺣﻣل‬:‫)ﻣﻼﺣظﺔ‬
80% of Network rates ‫ ﻣن أﺳﻌﺎر اﻟﺷﺑﻛﺔ‬80%
Outside Network ‫ﺧﺎرج اﻟﺷﺑﻛﺔ‬
(Note: co-payment is applied) (‫ ﺗطﺑق ﻧﺳﺑﺔ اﻟﺗﺣﻣل‬:‫)ﻣﻼﺣظﺔ‬
Maternity - ‫اﻟﺣﻣل و اﻟوﻻدة‬
‫)داﺧل‬ ‫اﻟﺳﻘف اﻟﻣﺎﻟﻲ اﻟﺳﻧوي‬
Annual Limit (IP + OP) KD 1,200 ‫ك‬.‫ د‬1,200
(‫وﺧﺎرج اﻟﻣﺳﺗﺷﻔﻰ‬
Delivery Waiting Period 12 months ‫ ﺷﮭر‬12 ‫ﻓﺗرة اﻻﻧﺗظﺎر ﻟﻠوﻻدة‬
Diagnostic Test - Maternity 80% OR 90% 90% ‫ أو‬80% ‫اﻟﺧدﻣﺎت اﻟﺗﺷﺧﯾﺻﯾﺔ‬
Pharmaceuticals - Maternity 80% OR 90% 90% ‫ أو‬80% ‫اﻷدوﯾﺔ‬
100% 100%
Delivery Within Network ‫اﻟوﻻدة داﺧل اﻟﺷﺑﻛﺔ‬
(Note: co-payment is applied) (‫ ﺗطﺑق ﻧﺳﺑﺔ اﻟﺗﺣﻣل‬:‫)ﻣﻼﺣظﺔ‬
80% of Network rates ‫ ﻣن أﺳﻌﺎر اﻟﺷﺑﻛﺔ‬80%
Delivery Outside Network ‫اﻟوﻻدة ﺧﺎرج اﻟﺷﺑﻛﺔ‬
(Note: co-payment is applied) (‫ ﺗطﺑق ﻧﺳﺑﺔ اﻟﺗﺣﻣل‬:‫)ﻣﻼﺣظﺔ‬
Congenital and hereditary conditions are
New Born Baby Coverage ‫اﺳﺗﺛﻧﺎء اﻟﺣﺎﻻت اﻟوراﺛﯾﺔ و اﻟﺧﻠﻘﯾﺔ‬ ‫ﺗﻐطﯾﺔ ﺣدﯾﺛﻲ اﻟوﻻدة‬
excluded
Prematurity is covered up to maternity (‫ﺗﻐطﯾﺔ ﺣدﯾﺛﻲ اﻟوﻻدة ﻏﯾر ﻣﻛﺗﻣﻠﻲ اﻟﻧﺿﺞ )اﻟﺧدج‬
Addition of New Born ‫إﺿﺎﻓﺔ ﺣدﯾﺛﻲ اﻟوﻻدة‬
benefit limit ‫ﺣﺗﻰ اﺳﺗﻧﻔﺎذ ﺳﻘف ﻣﻧﻔﻌﺔ اﻟﺣﻣل و اﻟوﻻدة‬
Dental - ‫اﻷﺳﻧﺎن‬
Annual Limit 300 KD ‫ك‬.‫ د‬300 ‫اﻟﺳﻘف اﻟﻣﺎﻟﻲ اﻟﺳﻧوي‬
Waiting Period 3 months ‫ أﺷﮭر‬3 ‫ﻓﺗرة اﻻﻧﺗظﺎر‬
Coverage 80% 80% ‫اﻟﺗﻐطﯾﺔ‬
Consultations, X-ray, Extractions, ‫ اﻟﺗﺧدﯾر‬، ‫ اﻟﺧﻠﻊ‬، ‫ اﻷﺷﻌﺔ‬، ‫اﻻﺳﺗﺷﺎرات اﻟطﺑﯾﺔ‬
Amalgam/Composite, Glass Ionomer filling, root ‫ اﻷدوﯾﺔ‬، ‫ اﻟﺣﺷوات‬، ‫ ﻋﻼج اﻟﻌﺻب‬، ‫اﻟﻣوﺿﻌﻲ‬
Covered Services ‫اﻟﺧدﻣﺎت اﻟﻣﻐطﺎة‬
canal, local anesthesia, & prescribed drugs.

Notes:
1.Treatment Outside Kuwait is not covered.
2. Reimbursement submission within 30 days starting from treatment date.
3. Addtion requests will be accepted within 10 days of eligiblity.
4. the premium due by the policyholder to the insurer as metioned in the schedule of insured
members should be 100 % payable in advance prior to issuing the policy.
5. the annual financial limitations are defined as per above Table of benefit for each benfit and
on which the deductibles or Co-Payments will apply
:‫ﻣﻼﺣظﺎت‬
.‫ اﻟﻌﻼج ﺧﺎرج اﻟﻛوﯾت ﻏﯾر ﻣﻐطﻰ‬.1
.‫ ﯾوم ﻣن ﺗﺎرﯾﺦ اﻟﻌﻼج ﻛﺣد أﻗﺻﻰ‬30 ‫ ﻣطﺎﻟﺑﺎت اﻟدﻓﻊ واﻻﺳﺗرداد ﯾﺟب أن ﺗﻘدّم ﺧﻼل‬.2
.‫ اﯾﺎم ﻛﺣ ّد اﻗﺻﻰ ﻣن اﺳﺗﺣﻘﺎق اﻻھﻠﯾﺔ‬10 ‫ طﻠﺑﺎت اﻻﺿﺎﻓﺔ ﯾﺟب أن ﺗﻘدّم ﺧﻼل‬.3
‫ أنّ اﻻﻗﺳﺎط اﻻﺟﻣﺎﻟﯾﺔ اﻟﻣﺳﺗﺣﻘﺔ ﻟﻠﺷرﻛﺔ ﻋﻠﻰ ﺣﺎﻣل اﻟﻌﻘد ﺑﺣﺳب ﻣﺎ ورد ﻓﻲ ﺗﻔﺎﺻﯾل ﺟدول‬.4
.‫( ﻗﺑل اﺻدار اﻟﻌﻘد‬%100) ‫اﻟﻣؤﻣن ﻋﻠﯾﮭم ﺗﻛون ﻣﺳﺗﺣﻘﺔ اﻟدﻓﻊ ﺑﺎﻟﻛﺎﻣل‬
‫ ﺗﺣﺗﺳب اﻟﺳﻘوف اﻟﻣﺎﻟﯾﺔ ﻟﻠﻣﻧﺎﻓﻊ اﻟﻣﺣددة أﻋﻼه ﺑﺣﺳب ﺗﺣدﯾدات اﻟﺟدول ﻟﻛل ﻣﻧﻔﻌﺔ وﻋﻠﯾﮭﺎ‬.5
.‫ و أو ﻣﺑﺎﻟﻎ اﻻﻗﺗطﺎع‬/ ‫ﺗطﺑق ﻧﺳب اﻟﺗﺣﻣل‬

This Policy is issued in Kuwait on -- / -- / ---- ---- / -- / -- ‫ﺻدر ھذا اﻟﻌﻘد ﻓﻲ اﻟﻛوﯾت ﺑﺗﺎرﯾﺦ‬

For the Company ‫ﻋن اﻟﺷرﻛﺔ‬

For the Policyholder ‫ﻋن ﺣﺎﻣل اﻟﻌﻘد‬