Client Name Test Impelox

Reference Number 2024-A-00-00063 Plan Summary

Issuance Date 28/02/2024 Plan Name NLG EASY HEALTH CHROME
Effective Date 29/02/2024
Product ID 44397
Payment Receipt
TPA INAYAH
Payment Amount AED 2,972
Emirate ABUDHABI
Payment Date 28/02/2024
Annual Limit AED 0
Reference Number 2024-A-00-00063

Applicable Network NLG Chrome

Auth ID 4001/846970/65ded06e

Plan Members 1
DETAILED PREMIUM RATES AND
AMOUNTS BY GENDER AND AGE BAND Plan Premium AED 2,830

NLG EASY HEALTH CHROME Total Members 1

Age Band & Male Female
Gender ICP Charges 24
Member Rate Total Member Rate Total

26-30 1 2,830 2,830 Premium Excluding VAT AED 2,830

VAT( 5% of Total) AED 142

Grand Total AED 2,972

Cover: As per NLGIC standard Individual Medical Expenses insurance policy wording, medical clauses, definitions,
general provisions and exclusions to cover the necessary, reasonable and customary In patient & Out Patient medical
expenses incurred by the insured member up to the benefits/limits mentioned in the attached TOB.
TABLE OF BENEFITS FOR NLG EASY HEALTH CHROME
Policy Details
S.No Details Cover
1 Territorial Limit for Elective treatment UAE & Indian Sub Continent subject to reasonable
and customary charges of applicable network in
UAE
2 Territorial Limit for Emergency treatment while on UAE & Indian Sub Continent subject to reasonable
Holidays or on official duty (Maximum 45 days during and customary charges of applicable network in
single journey) UAE
3 Aggregate Annual Limit AED 250,000
4 Network NLG Chrome
5 Pre-existing/Chronic conditions Limit for Inpatient All pre-existing medical conditions should be
and Outpatient declared in the Medical Application Form and is
subject to medical underwriting. Undeclared pre-
existing conditions will not be covered during the
policy period and will be underwritten at renewal.
6 **New Entrant (Entering the Emirate for the first time 20% of annual limit for first 6 months from the
or residency purposes or Resident Expatriate who is inception of the policy and up to annual limit
not in possession of a valid health card for work thereafter
suffers a major, high-cost medical condition(Chronic
condition))
In-Patient With Applicable Network
S.No Details Cover
1 Hospital Accommodation and Services Single private room at network hospital
2 ICU Covered in full
3 Consultants, Physicians, Surgeons and Anesthetists Covered in full
Fees
4 Diagnostics (X-ray, MRI, CT scan, Ultra sound, etc.) Covered in full
5 Laboratory Covered in full
6 Medications Covered in full
7 Organ transplantation and related expenses Covered up to Limit of AED 50,000 if insured is
excluding donors expenses recipient however the expenses incurred in
procurement of organ is excluded. Subject to Pre-
Approval
8 Nursing at Home, for recovery and in lieu of a Not covered
hospital stay up to a maximum of 14 days per
admission or procedure
9 Hospital Cash Benefit if Inpatient Treatment is Maximum AED 250 per day subject to 60 days
received free of charge in a Government Hospital in PPPY
UAE only
10 Parental accommodation for child less than 16 years Maximum AED 100 per day
of age
11 The cost of accommodation of a person Maximum AED 100 per day
accompanying an in-patient in the same room in
cases of medical necessity at the recommendation
of the treating doctor and after the prior approval of
the insurance company providing coverage
12 Ground ambulance services in UAE Covers the reasonable expenses in transporting the
insured member to the nearest medical facility in the
event of medical emergency
13 Healthcare services for work illness and injurires as Covered
per Federal Law No. 8 of 1980 concerning
Reglulation of work relations, as amended, and
applicable laws in this respect
14 Transportation expenses for Inpatient treatment Maximum AED 5000 per person per year subject to:
abroad - Treatment is taken more economically in these
countries - obtaining prior approval from the
insurance company/TPA
15 Accidental damage to natural teeth Covered in full
Out Patient With Applicable Network
 Out Patient With Applicable Network
S.No Details Cover
1 Consultants, Physicians, Surgeons and Anesthetists Covered in full
Fees
2 Diagnostics (X-ray, MRI, CT scan, Ultra sound, etc.) Covered with deductible of AED 25
3 Laboratory Covered with deductible of AED 25
4 Medications 30% Copay with Sublimit of AED 2000
5 Physiotherapy Charges Covered in full subject to prior approval
6 Accidental damage to natural teeth Covered in full
7 Ayurveda and Homeopathy Maximum AED 1600 per person for consultations
and medications only
8 Preventive services, vaccines and immunizations Essential vaccinations and inoculations for newborns
and children as stipulated by HAAD Diabetes
screening: Every 3 years from age 30 High risk
individuals annually from age 18
9 Deductible per each and every claim (1 free follow AED 50 per claim
up within 7 days relating to same illness and same
provider)
Other Conditions
S.No Details Cover
1 Hearing and vision aids, and vision correction by Covered in full
surgeries and laser
2 Complications arising from the maternity / child birth Covered in full
3 Passive war risk Covered
4 Repatriation Benefit on Death By Any Cause (For AED 5,000 based on actuals
members up to the age of 65 years)
5 Second Medical opinion - is a rider aiming at Covered
assisting the insured member with a second medical
opinion in order to determine or reconfirm the
diagnosis and decide on the appropriate treatment
protocols for a medical condition
6 Out-patient ante-natal services Covered in full inside the Emirate of Abu Dhabi with
deductible per each and every claim of AED 50 per
claim
7 New born cover Cover for 30 days from birth. BCG, Hepatitis B and
neo-natal screening tests (Phenylketonuria (PKU),
Congenital Hypothyroidism, sickle cell screening,
congenital adrenal hyperplasia)
8 Elective Treatments (Inside UAE and Outside UAE, Inside network - Covered, even for outside UAE as
as per the geographical coverage) per network. Outside network - Covered
(Reimbursement on Reasonable & Customary
charges of applicable network in UAE with 20%
Coinsurance) (on top of applied deductible inside the
network)
9 Emergency Treatments (Inside UAE and Outside Inside network - Covered, even for outside UAE as
UAE, as per the geographical coverage) per network. Outside network: (WITHIN UAE) -
Covered (Reimbursement with NIL coinsurance)
(OUTSIDE UAE) - Outside network - Covered
(Reimbursement on Reasonable & Customary
charges of applicable network in UAE with 20%
Coinsurance) (on top of applied deductible inside the
network)
Denetal Benefits
S.No Details Cover
1 Diagnostic and treatment services for dental and Covered in full
gum treatments
Maternity Benefits
S.No Details Cover
1 In-patient maternity services Covered in full inside the Emirate of Abu Dhabi with
deductible of AED 500 for both normal delivery and
medically necessary C-section, complications and
 Maternity Benefits
for medically necessary termination
2 Maternity services Outside AUH & Outside UAE Covered up to AED 10000 per eligible female per
year
Preexisting & chronic conditions (PEC)
Coverage: Covered for declared cases only; undeclared pre-existing & chronic conditions are not
covered even after 6
months.

Waiting Period
6 months waiting period is applicable for new entrants & members without continuity of coverage
for the declared Pre-existing & the newly discovered chronic conditions.
Nil waiting period for members with continuity of coverage for the declared Pre-existing & Chronic
conditions.

Maternity Waiting Period:

6 months waiting period for non-working married females without continuity of coverage who are
confirmed pregnant after time of enrollment.
Nil waiting period for employees & non-working married females with continuity of coverage.
MEDICAL APPLICATION FORM

No Questions TEST IMPELOX

1 Height 123

2 Weight 23

3 Gender Male

4 Has your health insurance/life insurance request been ever NO

declined or accepted on substandard terms?

5 Is there any eligible family member not included in this insurance NO

request?

6 Have you insured with NLGIC/LIVA earlier or on an ongoing policy? NO

7 Are you under any medical observation/undergoing any medical/ NO

surgical/ treatment or have been advised for the same?

8 Do you have any chronic illness/ Pre-existing medical condition (s)? NO

A chronic condition is defined as a disease, illness, or injury that
has one or more of the following characteristics: It needs ongoing
or long-term monitoring through consultations, examinations,
check-ups, and /or tests. It needs ongoing or long-term control or
relief of symptoms. It may require rehabilitation or the patient to
be trained to cope with it. It continues indefinitely. Symptoms /
medical condition may recur or likely to recur.

9 Are you taking any medication (pharmaceutical/alternative NO

medicine) or have been advised?

10 Do you have any physical problems/ disability for which you are NO
undergoing physiotherapy or have been advised for?

11 Have you been admitted in the hospital in the last 10 years? NO

12 Do you have any previous surgical history or are you advised to NO

undergo any kind of surgeries in the near future?

13 Have you undertaken any lab/blood tests, imaging tests viz. scan/ NO
MRI in the last 5 years other than routine health check-up or pre-
employment check-up?

14 Have you been ever diagnosed/treated and cured or undergoing NO

treatments for cancer?

15 Do you have hypertension? NO

16 Do you have diabetes? NO

17 Is there any other medical condition or disorder or any symptoms NO

that you should be declared, and you are unable to relate to the
above-mentioned Questions?
 No Questions TEST IMPELOX

18 Have you, or your family members been in close contact with NO

anyone who has been either quarantined or diagnosed with novel
coronavirus (SARS-CoV-2/COVID-19) in the last 14 days?

19 Are you awaiting the result of a test which has already been NO
submitted for the novel coronavirus (SARS-CoV-2/COVID-19)?

20 Please state current consumption of Alcohol NO

21 Please state current consumption of Tobacco NO

22 If you do not smoke cigarettes now but did so previously, when did NO
stop?

*This MAF has been generated electronically on: 28/02/2024

Excluded (Non-Basic) healthcare services: Healthcare services:

Healthcare Services, which are not medically necessary Not Covered
All expenses relating to dental treatment, dental prostheses, and orthodontic treatments. Not Covered
Domiciliary care; private nursing care; care for the sake of travelling. Not Covered
Custodial care includes
(1) Non-medical treatment services; or
(2) Health related services which do not seek to improve or which do not result in a change in the medical condition
of the patient. Not Covered
Services which do not require continuous administration by specialized medical personnel. Not Covered
Personal comfort and convenience items (television, barber or beauty service, guest service and similar incidental
services and supplies). Not Covered
Healthcare Services and associated expenses for replacement of an existing breast implant. Cosmetic operations
which improve physical appearance and which are related to an Injury, sickness or congenital anomaly when the
primary purpose is to improve physiological functioning of the involved part of the body. Breast reconstruction
following a mastectomy for cancer is covered. Not Covered
Surgical and non-surgical treatment for obesity (including morbid obesity), and any other weight control programs,
services, or supplies. Not Covered
Medically non- approved experimental, research, investigational healthcare services, treatments, devices and
pharmacological regimens. Not Covered
Healthcare Services that are not performed by Authorized Healthcare Service Providers, apart from Healthcare
Services rendered in a Medical Emergency. Not Covered
Healthcare services, treatments & associated expenses for alopecia, baldness, hair falling, dandruff or wigs. Not
Covered
Supplies, Treatment and services for smoking cessation programs and the treatment of nicotine addiction. Not
Covered
Non-medically necessary Amniocentesis. Not Covered
Treatment, services and surgeries for sex transformation, sterility and sterilization Not Covered
Treatment and services for contraception Not Covered
Treatment and services related to fertility / sterility (treatment including varicocele / polycystic ovary / ovarian cyst /
hormonal disturbances / sexual dysfunction). NotCovered
Prosthetic devices and consumed medical equipment's, unless approved by the insuranceCompany Not Covered
Treatments and services arising as a result of hazardous activities, including but not limited to, any form of aerial
flight, any kind of power-vehicle race, water sports, horse riding activities, mountaineering activities, violent sports
such as judo, boxing, and wrestling, bungee jumping and any professional sports activities Not Covered
Growth hormone therapy Not Covered

Costs associated with hearing tests, vision corrections, prosthetic devices or hearing and vision aids. Not Covered
Mental Health diseases, in-patient and out-patient treatments, unless the condition is a transient mental disorder or
 an acute reaction to stress. Not Covered
Patient treatment supplies (including elastic stockings, ace bandages, gauze, syringes, diabetic test strips, and like
products; non-prescription drugs and treatments, excluding such supplies required as a result of Healthcare Services
rendered during a Medical Emergency). NotCovered
Preventive services, including vaccinations, immunizations, allergy testing and desensitization; any physical,
psychiatric or psychological examinations or testing during these examinations. Not Covered
Services rendered by any medical provider relevant of a patient for example the Insured person and the Insured
member's family, including spouse, brother, sister, parent or child. Not Covered
Enteral feedings (via a tube) and other nutritional and electrolyte supplements, unless medically necessary during
treatment. Not Covered
Healthcare services for adjustment of spinal subluxation, diagnosis and treatment by manipulation of the skeletal
structure, by any means, except treatment of fractures and dislocations of the extremities. Not Covered
Healthcare services and treatments) by acupuncture; acupressure, hypnotism, Rolfing, massage therapy,
aromatherapy, homeopathic treatments, and all forms of treatment by alternative medicine. Not Covered
All Healthcare services & Treatments for in- vitro fertilization (IVF), embryo transport; ovum and male sperms
transport Not Covered
Elective diagnostic services and medical treatment for correction of vision. NotCovered
Nasal septum deviation and nasal concha resection. Not Covered
All chronic conditions requiring hemodialysis or peritoneal dialysis, and related test/ treatment or procedure. Not
Covered
Treatments and services related to viral hepatitis and associated complications, except for treatment and services
related to Hepatitis A. Not Covered
Birth defects, Congenital diseases for newborn &/or Deformities unless life-threatening. Not Covered
Healthcare services for Senile dementia and Alzheimer's disease. Not Covered
Air or Terrestrial Medical evacuation except for Emergency cases or unauthorized transportation services. Not
Covered
Circumcision healthcare services. Not Covered
Inpatient treatment received without prior approval from the insurance company including cases of Medical
Emergency which were not notified within 24 hours from the dateof admission. Not Covered
Any inpatient treatment, tests and other procedures, which can be carried out on outpatient basis without
jeopardizing the Insured Person's health. Not Covered

Any test or treatment, for purpose other than medical such as tests related for employment, travel, licensing or
insurance purposes. Not Covered
All supplies which are not considered as medical treatments including but not limited to: mouthwash, toothpaste,
lozenges, antiseptics, milk formulas, food supplements, skin care products, shampoos and multivitamins (unless
prescribed as replacement therapy for known vitamin deficiency conditions) and all equipment not primarily
intended to improve a medical condition or injury, including but not limited to air conditioners or air purifying
systems, arch supports, convenience items / options, exercise equipment and sanitary supplies. NotCovered
More than one consultation or follow up with a medical specialist in a single day unless referred by a physician. Not
Covered
Health services and associated expenses for organ and tissue transplants, irrespective of whether the Insured Person
is a donor or recipient. Not Covered
Services and educational program for handicaps.
DOH standard benefit exclusions apply among all DOH plans.
Quotation is valid for only Abu Dhabi Visa holders.

Healthcare Services outside the Scope of Health Insurance

Injuries or illnesses suffered by the Insured Person as a result of military operations of whatever type. Not Covered
Injuries or illnesses suffered by the Insured Person as a result of wars or acts of terror of whatever type. Not Covered
Healthcare services for injuries and accidents arising from nuclear or chemical contamination. Not Covered
Injuries resulting from natural disasters (including but not limited to) earthquakes, tornados and any other type of
natural disaster. Not Covered
Injuries resulting from criminal acts or resisting authority by the Insured Person. Not Covered
Healthcare services for patients suffering from AIDS and its complications. Not Covered
All cases resulting from the use of alcohol, drugs and hallucinatory substances. Not Covered
Any test or treatment not prescribed by a doctor. Not Covered
Injuries resulting from attempted suicide or self-inflicted injuries. Not Covered
Diagnosis and treatment services for complications of exempted illnesses. Not Covered
 All healthcare services for internationally and locally recognized epidemics. Not Covered
Venereal sexually transmitted diseases. A list with respect thereto will be set out by the General Authority of Health
Services. Not Covered

Notes
Coverage is subject to annual maximum limit and sub limits per person.
For non-emergency inpatient treatments, at the discretion of the insurer and subject to preauthorization.
Treatment for emergency conditions shall not require pre- authorization, but such cases are to be notified to the
company within 48 hours of the emergency treatment.
Terms and conditions are as per policy wording.
This benefit schedule is not applicable for members (visa holders) based in the emirate of Abu Dhabi and Al Ain.
National Life & General Insurance Company or its TPA reserves the right to include/ exclude/ upgrade banding/
degrade banding of any clinic at any time from the designated provider network list.
Direct billing shall be provided only at the listed hospital network and the reimbursement at non designated clinics /
hospitals shall be restricted to reasonable and customary charges of applicable network.
VAT (Value Added Tax) computed on Gross Premium at the rate stipulated as per the applicable VAT laws and
regulations applicable at the time of inception of the policy shall be fully borne by the Insured. The VAT amount as
per the tax invoice issued becomes payable and shall be collected in full immediately, irrespective of the agreed
payment terms for the underlying premium.
Quoted terms are subject to National Life and General Insurance Company SAOG being informed of any major chronic
and pre-existing condition or major illness or any condition diagnosed to develop into major condition at inception of
the policy and at addition of a member subsequent to inception of the policy. Failure to disclose such material facts
may result in claim denial or render the contract null and void ab-initio.

Sanction Limitation and Exclusion Clause

No insurer shall be deemed to provide cover and no insurer shall be liable to pay any claim or provide any benefit hereunder
provision of such cover, payment of such claim or provision of such benefit would expose that insurer to any sanction, pro
under United Nations resolutions or the trade or economic sanctions, laws or regulations of the Europea Union, Japan, Unite
States of America.

Duty Of Disclosure
When you apply with NLGIC, you have a legal duty of disclosure to NLGIC. This means:

All the statements you make to NLGIC (both written and oral) including the answers in this application must be true
and correct.
You must disclose everything that you know, or could reasonably be expected to know, that is relevant to NLGIC
decision on what basis they accept your application and how much it will cost.
This duty of disclosure continues from the time you complete the application until the commencement date of the
policy, the same duty of disclosure will be applicable at the time you extend, vary or reinstate your contract.
If you do not comply with your duty of disclosure, and NLGIC would not have accepted your application on the same
terms if you had made full disclosure, then NLGIC may:

Decline any claim you make; and/or

Retain all payments made and recover any benefits paid; and/or
Alter the terms of any benefits under the policy; and/or
Remove any benefits under the policy; and/or
Void your contract from inception.

I/ We declare that I/ we have read and understood the above declaration and agree to be bound by these terms and
conditions to be signed below by every person to be covered by this contract and all Policy Owners (to be signed by the
parent/legal guardian if the applicant is a child under 18 years).

Declarations:
I/We hereby declare with respect to both, myself and my dependents that to the best of my knowledge and belief,
the statement on application are full, true and correct and have declared all material facts related to this application.
I/We understand that non-disclosure or misrepresentation of any material fact may invalidate the quoted terms. I/We
agree that all the documents issued in connection with the policy shall be read together.
The Coverage of Health Services provided by the Insurer is described in the policy wording. By signing this for, I/we
acknowledge that I/we read, understood and agree to the terms and conditions as stated in the policy wording.
I/We hereby declare and agree, with respect to, myself that I am/we are aware of the general terms of this insurance
and I/we accept them. With the above, I authorize my doctor, health institution or other organization or person that
has any information about my health and/ or activities to provide the Insurer with the said information. This shall
include hospital and any other records pertaining to medical advice, diagnosis, treatment or disturbances. A
photocopy of this authorization has the same validity as the original.
I/ We agree that after acceptance of the quoted premiums in the quotation, I/ we shall be liable to pay all the
premiums to the Insurer as per the specified and selected plan of our choice.
I/ We do hereby confirm that the source of income which is being used for the payment of the premium is from
legitimate business sources. I/We do hereby certify that the documents provided along with this form are correct and
complete, to the best of my knowledge. I/We further undertake to update the Insurer whenever there is any change
in the information provided above.
I/ We authorize the Insurer to share information pertaining to my/ our proposal including records of proposer or
insured for the purpose of underwriting and/ or claim settlement and with any government and/ or regulatory
authority.