Preamble:

In consideration of the payment of the premium as affixed in the following Policy Schedule and in reliance upon the information and statements made by the Policyholder in the application form and subject to the terms, conditions, and exclusions of the insurance policy and amendments and attachments that are forming an integral part of it, the Company agrees with the Policyholder and insured/s named on this Policy and on the application form, and guarantees to provide the benefits and healthcare services or their related expenses incurred by Policyholder and insured/s in accordance to this Policy and to the limits in the Policy Schedule

Definitions:

Words, Terms, Expressions and Abbreviations used in the context of this Insurance Policy and all Additional Benefits, Tables & Application Forms should have the meanings set forth here below:

Company: the Insurance Company duly registered and licensed to operate in the country or issuance of this Insurance Policy (Gulf Insurance Group / Jordan.).

Policy: The contract whereby the Company, subject to the terms, limitations, renewals, exclusions and other conditions, application form, tables of benefits, provider & membership card provided herein, guarantees the payment of the benefits set forth in the Policy Schedule, its Modules and Appendices (referred as Policy Schedule hereinafter).

Policyholder: The applicant for this Insurance Policy acting as the principal in his/her own capacity as well as in the name and on behalf of his/her Legal Dependents whose Application has been formally accepted by the Company subject to Insured not to exceed the age of 65 years.

Legal Dependents: The unmarried children of the Policyholder who are under 18 years old or below 25 years old - if still a full-time university student, and the Spouse(s) of the Policyholder.

Insured: The Policyholder and the Legal dependents listed in the Application for this Insurance Policy or included thereafter, formally accepted by the Insurer and shown in the Policy Schedule or in any subsequent endorsement thereon are considered under this Insurance Policy as eligible Insured and referred to as insured hereinafter.

Program: is the program that is determined for each insured upon contract issuance in the contract schedule or its appendices and in the insurance application form approved by the company, in which the class of the insured and description of his benefits, as well as the insurance premium, are determined.

Effective Date: The first minute of the day, month and year on which the Insurance policy takes effect for the first time or for each subsequent renewal.

Expiration Date: The last minute of the day, month and year on which the Insurance policy expires.

Enrolment Date: The first minute of the day, month, and year when the Insured has been enrolled and covered for the first time under this Insurance Policy or enrolled and covered under an initial Insurance Policy which has been renewed without any interruption.

Renewal Date: The first minute of the day, month and year which coincides with the expiration date.

Termination Date: The last minute of the day, month and year on which the Insured’s coverage is terminated as the result of his/her deletion at the request of the policyholder and/or in case his/her status as legal dependent no longer holds or upon the cancellation of this insurance policy.

Cancellation Date: The last minute of the day, month and year on which this Insurance Policy has been cancelled as a result of the policyholder’s written notice and/or as a result of the non-fulfilment of the policyholder’s obligations as set forth in the general terms herein.

Hospital: Any medical institution, public or private, which is legally licensed and provides medical treatment to sick and injured persons. the facility must consist of organized premises, possess the necessary technical and scientific equipment for diagnosis and surgical operations and should provide healthcare service by a staff of at least one resident Physician and qualified nurses. The term “Hospital” excludes outpatient clinics; sanatoria, physiotherapy centres, health clubs, retirement/nursing homes and similar institutions, including those specialized in substance abuse (drugs, alcohol).

Physician: Any doctor of medicine (MD) who is duly licensed and qualified under the law of jurisdiction in which treatment is provided.

Network: group of physicians, Hospitals, Clinics, Medical Centre, Pharmacies, Laboratories, Radiology Centres and Physiotherapy Centres forming the Network(s) through a special and formal contractual arrangement whereby these Network Providers agree to avail the Insured with Free Access to their healthcare services in conformity with the terms of this Insurance Policy and as set forth in the Policy Schedule.

Membership Card: A personalized card issued in the name of each Insured, facilitating his/her access to the healthcare services covered under this insurance Policy and provided by the network.

Eligible Expenses: All customary and reasonable medical expenses for healthcare services delivered to the Insured, which are identifiable or covered under this Insurance Policy after allowing for any Specific Deductible Excess, defined hereinafter, applicable at the level of such service(s) as provided, noting that the insurance company is not responsible for any medical expenses resulting from completing the treatment or any part of it after the expiry of the insurance contract, even if that treatment was prescribed or medically recommended before the expiry of this contract.

Annual Maximum limit: The total value of the medical expenses payable before subtracting any deductible, co-insurance, or any other deductions, according to the schedule of benefits.

Territory of Occurrence: The country where the Insured’s health condition has required healthcare services and where the related expenses were incurred.

Approved prices: are the prices of the official medical authorities (the Doctors Syndicate, the Ministry of Health) in the Hashemite Kingdom of Jordan.

Pre-Hospitalisation Form: A mandatory form that must be completed by the attending physician of the Policyholder / Insured and submitted to the Company prior to any Hospital admission within a period of not less than 72 hours, except in emergency cases, which is a mandatory procedure that must be taken before benefiting from any coverage of hospital treatment expenses.

Surgery: Any medical manual and/or instrumental treatment of injuries or disorders of the body.

Day-Case: Same day In-Hospital service comprising all Surgical and other procedure related to non-excluded health conditions, not requiring an overnight stay at a Hospital but nevertheless necessitating specialized medical attention and care in a Hospital.

Emergency: A health condition sustained as result of sudden, non-excluded sickness or bodily injury, raising a legitimate concern that there may be a significant medical problem necessitating immediate treatment (medical or Surgical) to be performed exclusively within the Territory of Occurrence which must not be delayed, and which requires confinement to a Hospital Emergency Room/Facility. Emergency treatment in an emergency room is only covered in case treatment cannot be performed on an outpatient basis. In all cases emergency treatment is considered as outpatient treatment and shall be deducted from the annual outpatient limit.

Accident: An unexpected violent and sudden event causing the Insured a Physical bodily injury.

Hospitalisation: Any Hospital confinement for a minimum of (24 Hours) due to any non-excluded health condition and which cannot be performed on an Outpatient basis.

Cancer: Any malignant growth or tumor caused by abnormal and uncontrolled cell division; it may spread to other parts of the body through the Lymphatic system or the blood stream.

Hospitalisation Class: The class of Hospital Room and board which the policyholder has selected on behalf of the Insured to be applied for his/her Hospitalisation and which is identified in the Policy schedule.

Out-Of-Hospital Benefits: All benefits that may be offered under this Policy in respect of services such as doctor’s consultation, Prescribed Drugs, Diagnostic Tests, Physiotherapy Treatment etc. that do not require Hospitalisation or any In-hospital treatment/observation.

Deductible Excess (Co-Participation): The amount and/or percentage of healthcare cost as stated in the Policy Schedule to be borne by the Policyholder.

Pre-Existing Condition: Any health condition known to the Insured and/or Policyholder which was diagnosed or is a consequence of injury or illness for which medical, surgical and/or Pharmaceutical treatment or advice was provided prior to the Insured’s Enrolment Date.

Non-Network: Providers that do not apply to what is stated in point (15) of the definitions. If any insured visits a non-network provider, the insured has to pay cash and send the claim the company to be studied and settled, according to the terms and conditions of contract within a maximum period of two weeks from the date of treatment. This clause extends to cover any visit to a provider within the medical network and pays cash for obtaining medical service.

Waiting Period: The period starting from the enrolment Date of the Insured during which a specific or general medical condition shall not be covered under this Insurance Policy.

Individual Contract: An insurance contract in which the insured in addition to his dependents (if any) is obligated to pay the premiums for all those covered in the contract.

Group Contract: An insurance contract in which the insured is a company, authority, official governmental body, or legally licensed institution …. etc. where the participants in the contract are all employees (who work full time) and/or their dependents, and the insured is obligated to pay the full premiums arising from the contract.

Premium: The amount of the financial allowance paid or to be paid by the insured in return for the insurance coverage agreed upon in the contract. Issuance fees and stamps are not considered among the premium and are not refundable in case of cancellation.

Illness Condition: Any disease, complaint, or incident covered under policy and requires the insured to be admitted for treatment in hospital. It includes all medical expenses resulted from that admission or those that follow throughout the insurance period, including any direct medical expenses incurred by that admission.

Insurance Policy:

The information and declaration in the application form, the census list of proposed insured/s, the preamble, the definitions, general terms and conditions, limitations and exclusions, policy schedule, and any additional benefits or attachments or amendments to any of the aforementioned, constitute the entire contract herein referred to “the policy”.
This policy shall be void, unless it has been made in writing, sealed and signed by the company as well as policyholder paid full payment of the first affixed premium payment.

General conditions:

Policyholder:
The insured person/s or body who the company has accepted to insure under this policy or any of his/her dependents in accordance to point (3) of definitions, and the list of insured/s in the application form subject to premium payment and all dependents to be included. Additions, during the policy period, of new insured/s or dependent are subject to:
1.Newborn additions: subject to be discharged from hospital and after approval of the company to be added within a maximum period of 30 days from the date of birth, unless otherwise specified in the benefits schedule.
2.New employee additions: in-group scheme, newly hired employee after the effective date of policy and/or his/her dependents subject to acceptance by the company.

Application Forms:
Both the initial insurance application and any subsequent applications by persons proposed for insurance must be submitted using the special forms provided by the company.
In case a deposit or a payment on account is made before the acceptance of the application, this payment does not constitute consent to the submitted application.
The company reserves the right to reject the application and refund the advanced amount to the application for insurance.

Scope of Coverage:
The applicable scope of coverage in respect of an insured is the set of healthcare benefits along with their limitations, extensions, and exclusions (the plan as selected by the policyholder and accepted by the company), and the provisions of these benefits are subject to general terms and conditions, exclusions of the policy, and any underlying health fund or insurance co-participation and/or any deductible excess, provided that expenses related to an eligible claim are being incurred by the insured whilst this policy is in force.
In case of treatment requiring uninterrupted hospital confinement which starts during the validity of this policy, the related expenses incurred after the termination date or the cancellation date of this policy are also covered subject to the definition of point (17) in this policy.
The applicable scope of coverage per insured is set forth in the corresponding policy schedule which frames the coverage provided for insured and specify the basis of indemnity, class, limits, co-participation, deductible/s excess, company’s participation, any exclusion/s, any special terms applicable at each level of service or benefit depending on the nature of health services the provider and territory of occurrence.

Premium:
Due premium payment is to be paid by the policyholder to the company’s head-office, branches or as specified by the company.
In case of non-payment of premium in due date, the coverage shall automatically seize and will not require any notification or warning subject to a maximum of seven days after the due premium payment date, excluding the first premium payment that shall be settled in advance prior the effective date.
Policyholder is obliged to fulfil all due premium payments of the insured/s whilst this policy is in force as insured has been accepted in this policy depending upon the relation between the insured/s and the policyholder unless otherwise agreed by the company.
The company reserves the right to review premium if the number of insured/s increases or decreases by 10% from the initial list of insured/s excluding dependents from this calculation whilst this policy is in force, and/or in the event of an increase in the wages of the Jordanian Medical Association for the year 2008 or the application of a new wage list. As for the due premium form the policyholder resulting from additions, the premium id due on the date of the addition and/or as soon as the policyholder receives the debit note. To that effect, the policy will automatically deemed to be cancelled once such payments are not settled within seven days of the policyholder is notified of the due amount.
In all cases, the policyholder is not allowed to cancel any insured member retroactively.
This policy shall not be in effect if the first premium payment is not fully settled.

Addition & Deletion:
The policyholder has the privilege to include in this policy any insured and his/her dependents through a formal advise from the policyholder to the company who will undertakes automatically issue an endorsement of the addition. The company reserves the right to decline or accept on standard or sub-standard terms the addition of the proposed with a given reason or justification. Any additions to the policy shall be void unless it has been formally acknowledged and accepted in writing, signed and sealed by the company.
The premium related to any formal addition, which shall be due by the policyholder to the company, shall be calculated on pro-rata basis starting from the newly added insured/s enrolment date up to the expiration date.
The policyholder can formally request the deletion of an insured and his/her dependents covered under this policy from the company prior or at the expiration date, in case of death of the insured or in case of any proven duplication of coverage caused by the transfer of the insured the deletion of whom has been required under another health scheme, in the case of service termination for employees working for policyholder and covered under this policy.
The policyholder is obliged to formally request the deletion of covered under this policy from the company prior to or at expiration date, in the case that insured’s status is not any more in conformity with the definition of legal dependent.
Any deletion within the policy shall be void unless it has been formally acknowledged and accepted in writing, signed and sealed by the company.
The premium related to any formal deletion, which shall be due by the company to the policyholder, shall be calculated on pro-rata basis starting from the termination date up to the expiration date excluding stamp and issuance fees which are not refundable.

Cancellation:
The company has the right to cancel this policy in case of:
Non-payment of premium according to the terms in Clause (4) of general conditions and in case of policy holder not singed the policy within two months from policy delivery date.
1.In the case of proven false statements.
2.Intentional concealing of information according to the terms of Clause (7) of general conditions.
3.In case of any proven abuse of insurance services.
Any premium refund related to a cancellation and being due by the company to the policyholder shall be calculated on a pro-rata basis starting from the cancellation date up to the expiration date.
The insurance coverage, automatically, seize in the case that insured’s status is not any more in conformity with the definition of legal dependent, in case of death of the insured, in case insured/s reaches the age of 65, and in case of service termination for employees working for policyholder and covered under this policy. noting that the insurance company is not responsible for any medical expenses resulting from completing the treatment or any part of it after the expiry of the insurance contract, even if that treatment was prescribed or medically recommended before the expiry of this contract. Policyholder’s Declarations
This policy, including its related additions, deletions and amendments has been and shall be issued by the company on the basis of the statement and declaration made by the policyholder on the initial application form and on the subsequent written formal requests.
Any proven false statement/s made by the policyholder and/or intentional concealing of material information related to the proposed insured’s state of health, professional activities and place of residence, shall result in the company’s right to cancel the policy as from the effective date. The company also has the right to recover all medical claims resulting from the diseased condition that occurred during the insurance period at the expense of the insured.
The policyholder must immediately inform the company of any alteration that may occur during the validity of this policy or at renewal date regarding the profession, activities and place of residence of the insured covered under this policy. The company reserves the right to reconsider accordingly the policy terms, conditions and premiums. This reconsideration includes the deletion of the insured.

Claims Notification:
In case of in-hospital admission to a non-network provider, the insured is obliged to notify (in writing or verbally) the company during a maximum period of 48 hours after admission.
All non-network claims (In or Out patient) shall be submitted to the company within a maximum period of 14 days from the treatment date. Claims shall be submitted along with the original reports and receipts from the medical provider copies are NOT accepted.
In the case of individual policy, if any non-network legible claim incurred by the insured and any premium or part of the premium payment due or not due, settlement will be made against the annual premium amount with the eligible claim amount.

Medical Malpractice:
It is known and agreed upon that the company does not hold any responsibility against any medical malpractice due to treatment provided by a network or non-network provider to any insured/s under this insurance policy.

Subrogation:
Once the insurance claim has been paid in accordance with the current terms, the insured/s subrogates the right to the company to pursue any third party responsible for any injury. The policyholder and the insured/s transfer to the company every relevant, substantial and legal right. Both the policyholder and the insured/s shall provide the company with every possible assistance in the case the company exercises the above right of subrogation. Should the policyholder and the insured/s breach the obligation, they shall be responsible for any losses incurred by the company.

Geographical Coverage:
This policy covers policyholder and insured/s inside Jordan only.

Currency:
Any money payable to or by the company shall be in Jordanian Dinar.

Tax and Fees:
Any Levis on this policy, tax stamp or duty shall be borne exclusively by the policyholder.

Second Medical Opinion:
The policyholder and the insured has the privilege to formally request from the company on its expense a second medical opinion prior any surgical operation or treatment. The company reserves the right for approval and arrangement with one of its medical consultants. However, the company has the right to seek a second medical opinion from a medical provider of its choice whenever it believes that such an opinion is necessary and prior to any surgical or medical treatment.
In such case the beneficiary shall respond upon the request at the company as soon as he\she receives an official request to that effect.

In-hospital Treatment Post Date of Termination:
In case of treatment requiring uninterrupted hospital confinement which starts during the validity of this policy, the related expenses incurred after the termination date or the cancellation date of this policy are also covered subject to policy general terms and conditions, extensions, exclusions, co-payment affixed in the policy schedule until discharge date of insured/s or a maximum period of (30) days from the admission date which is first.

Non-duplication of compensation:
If the insured is covered or eligible to benefit from a medical insurance policy or from any other source, the responsibility of the company is limited to the difference between what he/she is eligible to obtain from that entity and the limits specified under this policy for that case.

Claims Settlement:
Any settlement for medical expenses, claims, and any other expenses resulted from sickness; disease or injury covered under this policy is considered as final and full settlement by the company for the specific related case and will free the company from any obligation.
The policyholder (the insured) also bears full responsibility for paying the total receivables resulting from all the treatments that the company has covered, and then it turns out that the people who were covered are not covered by the coverage as a result of an error or as a result of fraud and/or as a result of impersonation and/or forgery or any similar use or for any other reason, whether the insured was aware of this or without knowledge.
The policyholder (the insured) bears the full responsibility for paying the total receivables or the deductible amounts resulting from all the beneficiaries under this contract, whether they are actively at work or not when these receivables or the deductibles are received or otherwise, and whether these receivables have been achieved due to the exceeding use of forms or ceilings established or due to cases not covered.

Change of Law:
The insurance contract is subject to the laws in force in the Hashemite Kingdom of Jordan. In the event that other laws are issued according to which our company is obligated to amend the terms and conditions of this insurance contract. The company has the right to change and/or amend the terms and conditions of the insurance contract immediately, as of the date of these laws entry into force.

Legal and Legislative Jurisdiction:
This policy is subject to the laws of the Hashemite Kingdom of Jordan and its courts without any interruption with the Arbitration condition under this policy.

Policy Schedule:

It is understood and agreed upon that cancer related diseases (diagnosis and / or treatment and / or surgical operation) are covered within this insurance policy according to the following table of benefits:

Exclusions:

It is understood and agreed upon that this insurance policy (program) covers only cancer related diseases (diagnosis and / or treatment and / or surgical operations), consequently all cases, reasons, services, treatments, injuries, diseases, complications, incapability resulting due to any case which is not related directly or indirectly to cancer diseases are to be excluded.
- All medical cases related to cancer disease prior to the date of contract are excluded whether declared or not.
- All medical expenses related to cancer are excluded from this contract in the event that the insured was diagnosed with cancer before the date of this contract and/or if it was found that the insured had concealed any information related to his condition.

Additional Benefits:

•Full coverage of nursing home visits and telemedicine services.
•Full coverage of all medical expenses related to cancer upon diagnosis.
•Coverage of companion fees in case of admission to the hospital (night stays and meals only).
•Coverage of post-operative plastic and reconstructive surgery for breast cancer cases.
•Direct access to all hospitals within gig-Jordan’s network.
•Age bands covered from day one to 65 years.

Arbitration

The Policyholder agrees that all disputes arising out of or in connection with this policy shall be referred to arbitration as follows:

1.The arbitral panel shall be composed of three (3) arbitrators; each party will appoint an arbitrator and the third arbitrator will be appointed by the two arbitrators. In case the two arbitrators fail to agree on appointing a third arbitrator, such arbitrator shall be appointed by the competent court.
2.The third arbitrator shall be considered as the Umpire and the decision of the arbitral panel shall be made unanimously.
3.In case an arbitrator resigns or passes away (including the Umpire) the party that appointed such arbitrator shall have the right to appoint another one.
4.This Annex is subject to the laws of the Hashemite Kingdom of Jordan.
5.The seat of arbitration shall be Amman and the procedures of the current Jordanian arbitration law shall apply.
6.This Arbitration Annex is made of six (6) clauses and is signed by both the Company and Policyholder.

ملحق مكافحة غسل الأموال وتمويل الإرهاب

وفقاً لأحكام القوانين والتعليمات المتعلقة بمكافحة غسل الأموال وتمويل الإرهاب المعمول بها في الأردن، تقوم شركة الشرق العربي للتأمين بتطبيق كافة إجراءات العناية الواجبة بشأن التعرف على هوية العميل والتحقق منها قبل وأثناء نشوء العلاقة التأمينية. وفي حال اشتباه الشركة بوجود أي نشاط أو عملية مرتبطة بغسل الأموال و/أو تمويل الإرهاب من قبل العميل، تقوم الشركة باتخاذ كافة الإجراءات القانونية اللازمة بما في ذلك إخطار جميع الجهات الرقابية المعنية بذلك.

وفي حال وافقت الشركة على تأجيل إجراءات التحقق من هوية العميل إلى ما بعد إبرام عقد التأمين ولم تستوف الشركة من قبل العميل الوثائق الكافية التي تمكنها من التعرف على هويته في أقرب وقت ممكن، تقوم الشركة بفسخ عقد التأمين فوراً ودون الحاجة لأي إنذار أو إعذار أو حكم قضائي، مع الإشارة إلى أنه على الشركة أن تقوم باستكمال الإجراءات المشار إليها أعلاه قبل قيامها بدفع أية تعويضات للعميل أو قبل أن يقوم العميل بممارسة أي من الحقوق الممنوحة له بموجب عقد التأمين.

Anti-Money Laundering and Countering the Financing of Terrorism Annex

In accordance with the provisions of the laws and instructions relating to Anti-Money Laundering and Countering the Financing of Terrorism in force in Jordan, GIG-Jordan Company shall take all due diligence procedures regarding the identification and verification of the customer’s identity prior to and during the formation of the insurance relationship with him/her. In the event the Company suspects any activity or operation related to money laundering and/or terrorist financing by the customer, the Company shall take all necessary legal measures, including notifying all relevant regulatory authorities of such activity.

In the event the Company agrees to postpone the procedures of verifying and identifying the customer’s identity until after the conclusion of the insurance policy and the Company does not receive from the customer the sufficient documents to enable it to verify and identify the customer’s identity as soon as possible, the Company shall immediately terminate the insurance policy, without the need to serve any notarial notice or obtain a court order, noting that the Company must complete the aforementioned procedure before paying to the customer any sort of compensation or before the customer exercises any of the rights granted to him/her under the relevant insurance policy.