Health Insurance

i.Policy statement The Company facilitates both management and Non-Management employees by
covering their hospitalization expenses. Details of the policy include the entitlements of plan for each
employee according to their levels.
ii. Objective to provide insurance cover to permanent employees of the Company and their dependants
in order to enable them to live a healthy life style and thus perform at their best levels.
iii. Scope of the Policy This policy is applicable to all permanent Management employees according to
the Health Insurance Policy Plan based on their levels.
The policy covers the employees of the company and their immediate family members including the
legal wife or husband of an employee and dependent children 25 years of age or below.
This policy does not cover:
The spouse who has been legally separated
Adopted children (unless they have been legalized by due authorities)
iv. Details of the policy

There are five policy plans defined with limits relating to different category of treatment covered in the
policy for the employee. Each employee is entitled to a plan according to their Level.
This policy provides details for the eligibility criteria pertaining to the employees which are:
i.Employee & Legal Spouses
Maximum eligibility age for employees and their legal spouses is sixty (60) years. Cover shall cease in
respect of an Insured Member at the first date following the sixtieth (60 th) birthday.
ii.Dependent Children

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b.
c.
d.
e.
f.

a.
b.
c.
d.
e.
f.
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b)
c)
d)
e)
f)
g)
g.
h.
i.

Maximum eligibility age for the dependent children is twenty five (25) years. However, no age restriction shall apply
to unmarried daughters till they get independent by the way of marriage.
Geographical Limitations:
This policy covers expenses incurred in Pakistan only. However, in case of Medical Emergency, an Insured Member
may be entitled to claim reimbursement (in PKR Only), subject to availability of Annual Limit and provided that:
Insured Member did not travel solely for the purpose of getting this treatment
Expenses are incurred on emergency and medically necessary treatment
Insured Member travelled for the purpose of getting medical treatment but only because such treatment was not
available in Pakistan at any network or non-network hospital
The treatment is covered under the policy and does not fall under the exclusions
Insured Member has cleared all the bills of the hospital outside Pakistan and then applies for reimbursement along
with all the original documents
Claim reimbursement will be in accordance with the treatment cost at a network hospital
v.Coverage

Hospitalisation Benefits are covered under the policy. These include surgical and miscellaneous hospital
expenses as mentioned below:
Daily Room and Board Charges
Intensive Care Unit (ICU) Charges
Physicians Visit (In-Patient) Charges
Specialist Consultation (In-Patient) Charges
Surgical Operation Charges
Miscellaneous Hospital Expenses
Drugs, dressing and medicines prescribed by the attending physician;
Laboratory examinations and other diagnostic procedures;
Physiotherapist;
Intravenous injections and solutions;
General nursing services;
Patient meals; and
Such other charges approved in writing by the company
Day-care Procedure Charges
Pre-admission Diagnostic Testing and Post-Hospitalisation Consultation Charges
Emergency Accidental Outpatient Cover

j.
k.

Emergency Accidental Dental Treatment

Specialized Investigations Outpatient Cover

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b)
c)

MRI
CT Scans
Thallium Scans

d)

Pet Scans

vi.Procedure
An employee is eligible for health insurance from the date joining. Upon issuance of SAP ID, he/she adds his / her
dependents through ADP Portal Human Resource Module. An employee gets registered for Health Insurance Plan
when HR Comp & Ben sends his/her name to the Insurance Company. A health Card is issued for usage by the
employee. For non-management employees, additions/deletions of dependents is done by their FLM on ADP Portal.
Employee can use their health card for treatments in hospitals which fall under the network approved for the policy.
However, if the employee is receiving treatment at a hospital which is a non-network hospital, then the
reimbursements can be claimed through Health Insurance Claim Form. Attachment of all original documents and
receipts is mandatory for the claim to be processed.
Submitting a fake claim or attaching a forged receipt is a serious violation of CoBEC and will be dealt as such.

a)
b)
c)
d)
e)
f)
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h)
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p)

q)
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vii.Exclusions
The policy does not cover and no claims shall be reimbursed for or on account of:
Any expenses directly or indirectly incurred for the treatment of any Pre-existing Medical Conditions.
Any charges in respect of the donor for organ transplant claims.
Services or Treatment in any spa, hydro clinic, sanatorium, nursing home or long term care facility that
is not a Hospital.
All dental treatment and oral surgery apart from Emergency Dental Treatment.
Any Out Patient Treatment, except arising that arising out of an Accident
Cosmetic or plastic surgery unless Accidental and necessitated by an Injury covered under the policy
Routine medical examinations or check-ups
Birth defects or congenital illness
Prosthesis, corrective devices and medical appliances which are not surgically required
Test or treatment relating to fertility, infertility, contraception or sterilisation
Experimental treatment and treatment not approved by FDA-USA
Self-inflicted injury, attempted suicide, abuse of alcohol or drug addiction
Participation in or training for any dangerous or hazardous sport, pastime or competition or riding or
driving in any form of race or competition or any professional sport
Aviation other than as a fare-paying passenger of a recognized airline or charter service
Treatment received in a location other than the Insured Members geographical area of coverage
Injury resulting from war, riots, invasion, act of foreign enemies, hostilities, warlike operations (whether
war is declared or not), civil war, mutiny, civil commotion, military uprising, insurrection, rebellion, any
act of any person acting on or behalf of or in connection with any organization directed towards the
overthrow or influencing of any government or ruling body by force, terrorism or violence
Injuries as a result of an illegal act other than a minor misdemeanour or minor delinquency
Ionising radiation or contamination by radioactivity from any nuclear fuel or nuclear waste
Any increase in the expenses incurred for treatment due to admission to a more expensive room than
allowed in the policy plan of the employee
Cost of non-medically necessary goods or services, for e.g.: telephone, TV, newspaper or
accommodation for the insured persons family members
Weight management services and treatments related to weight reduction programs including
treatment for obesity
Natural catastrophes, epidemic, including, but not limited to, flood, earthquake, avalanche and cyclone
Any disability directly or indirectly related to or resulting from HIV, AIDS or any other sexually
transmitted disease
Air ambulance or evacuation or repatriation expenses