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