General Condition

MU-F-02
Ver.3

General Conditions of the Group Health Insurance Policy

Article 1: Definitions
The following expressions shall mean:

- The Company	means Syrian International Insurance Co. (AROPE SYRIA), which is the company that issues the health insurance policy.
- Insurance Policy	means the document under which the company undertakes, in accordance with the terms, conditions, exceptions and other conditions contained therein, to pay the treatment expenses according to the described benefits, also referred to as the insurance policy.
- Contracting Party	means the entity and/or the natural person residing in Syria and/or the legal entity who applied for the insurance policy in his personal capacity and/or on behalf and/or in the name of his employees and their legal dependents and who signs the insurance policy (Insurance Policy) issued by the company .
- Subscribers to Insurance	means those who subscribe to the insurance: the persons with whom the contracting party has an interest, such as full-time employee or worker, or a collective association such as a profession or an academic degree, or one beneficiary association of a single interest, which the contracting party includes in his application form at the start of the insurance or those who were added by an official request officially accepted by the insurance company at the commencement of the policy or any endorsement to the policy and who are deemed under the insurance policy to be a qualified insured, hereinafter referred to as the subscribers or the insured.
- The Insured	means the person named in this capacity in the endorsement of the insurance policy, who may be the contracting party, employee, members of his family, or a person with whom he has a contractual relationship.
- Dependents (Dependent of the Insured)	means the wife or husband of the insured included in the insurance policy and his unmarried children, provided that the dependent resides in the insured country of residence who is responsible to support.
- Hospitalization Level	means the level chosen by the contracting party as written in the policy schedule, and the hospitalization level in the hospital means the room and services of treatment level.
- Included Expenditures	means all normal, reasonable and necessary legal medical treatment expenses actually incurred by the insured during the validity of the insurance as a result of an illness or accident covered by this policy and within the limits and exceptions set out in the table of particular conditions.
- Deductible Ratio	means the percentage of the actual medical treatment costs incurred by the insured out of the value of the included expenses incurred, and this percentage is indicated in the particular conditions of the policy.
- Effective Date of Insurance	means the date on which the insurance company accepted the application of the insured to subscribe to insurance and/or the dependents, and upon completing all the required papers, proving their eligibility for insurance, and issuing the policy or endorsement which confirms their acceptance in insurance.
- Expiry Date of Insurance	the insurance expires for the insured at the last minute of the day, month and year in which the coverage ends at the request of the contracting party or the insurance policy cancellation based on the agreement of the two parties of the policy.
- Date of Policy Expiry	the policy expiration date is the last minute of the day, month and year in which the insurance policy expires.
- The Hospital	means any hospital licensed and classified under the law and holds a license from the Ministry of Health, which must be mentioned in the endorsement of hospitals subject to the insurance policy.
- The Physician	means the legally qualified and licensed physician or surgeon, provided that he is uninsured and is not related to the insured in any first degree kinship relationship.
- Medical Insurance	means the personal card issued in the name of the insured to facilitate his benefit from the benefits mentioned in the insurance policy and which must be returned to the insurance company at the end of the insurance.
- Disease	means the insured bad health condition that begins when the insurance policy becomes effective.
- Bodily Injury	means any emergency bodily accident resulting from an external accidental or sudden severe and apparent cause beyond the control of the insured, which may occur during the validity of the insurance policy.
- Emergency Cases	means the medical condition resulting from a disease or accident that requires immediate care and which is treated at the hospital in the emergency department, provided that the hospital card is presented, which covers emergency treatment in the emergency room only in cases that cannot be treated in outpatient clinics.
- Third party administration (TPA)	means the medical expenses management company licensed by the Insurance Supervisory Authority in accordance with the rules and regulations. They are also called as the third administrative party. They are companies that implement the insurance policy in accordance with its content. It also facilitates the contracting party access to services by concluded contracts with medical service providers according to clear references.
- Approved Medical Network	means the centers that provide certain health care services (such as: hospitals, medical centers, integrated clinics, pharmacies, laboratories, physiotherapy centers and doctors) and which have agreed under a specific arrangement and special agreement with the insurance company or medical expense management company to provide medical care services to the insured.
- Out of the Network Coverage	means the non-accredited medical entities, which are those to which the definition of an approved medical network does not apply. Out-of-network treatment means treatment with unaccredited medical bodies, which if the insured needs, he will pay for it directly.
- User Guide	means the guide that explains to the insured how to use the insurance program (the benefits of the insurance policy) in the best way.
- Pre-existing Health Condition	means any diagnosed or known symptoms of the insured and/or the contracting party, or any condition resulting from an injury or disease that was treated by medication or surgery, or for which medical advice was given prior to the date of the insured's coverage of the insurance policy. The automatic referral to a pre-existing health condition does not affect any other exceptions mentioned in the document that remain in effect.
- Chronic Disease	means the long-term disease that appears for the first time at any time when the insurance policy becomes effective, even if its symptoms disappear as a result of receiving treatment for that disease or because of following a certain lifestyle by the patient and in the event that the patient stops receiving that treatment or returns to his normal life, the same disease reappears and its symptoms appear again.
- Waiting Period	means the period starting from the date of the insured joining the policy for the last time with covering certain sickness cases until the expiry of this period during the validity of this policy, unless the particular conditions stipulate otherwise.
- Insurance Application	means the application on which the insured writes information about himself and the beneficiaries who benefit from the required insurance policy, and in which he declares at the time of submitting the application all the information that the insurance company needs to know in order to assess the risks that are the subject of the policy, and to provide all the information and data that affect the importance of the insured risk.

Article 2: Basis of the Insurance Policy
The written declarations given by the contracting party or the insured in the insurance application or in any declaration or report issued by any entity, in addition to the general and particular conditions and the user guide, are considered as the basis for the health insurance policy and all of them constitute an integral part thereof. The company reserves the right to require proof of the insured age and occupation before paying any amounts under this policy. An unintended error in declaring the age or profession results in either rescinding the policy or offering a new value for the premium in proportion to the age or profession. The company will not be committed to any amendments in the text of the insurance policy unless drafted in writing and signed by the officer in charge qualified to make such amendment. Also, the company is not bound by any declaration related to the insurance policy as long as the declaration is not organized in writing and delivered to its head office.

Article 3: The Validity of the Insurance Policy
The company undertakes to implement its obligations mentioned in the insurance policy, with adherence to the special and general conditions, when the contracting party receives the insurance policy from the company, signs and pays the value of the due premium.

Article 4: Limits of the Insurance Policy
Geographical Limits: Syrian Arab Republic, unless the terms of the policy state otherwise. The company covers hospitalization expenses paid beyond the geographical limits of the mentioned coverage under the particular conditions of the policy arising from a sick condition (emergency or cold) that occurred while the insured was outside the geographical limits of coverage for a period of more than two months for the purpose of tourism or business, provided that it does not exceed three trips in one contractual insurance year. The Company compensates the bills paid by the insured abroad according to the tariff of the Ministry of Health and on the basis of hospital prices in Syria. Deduct an amount that approximates the contribution (payment) of the contracting party/the insured mentioned under the Particular Conditions or any other guarantor institution, if any.

Limits of Coverage: it is the maximum coverage for each insured that the company is obligated to compensate under the insurance policy and during the contractual period specified in the particular conditions of the insurance policy. In the event that the insured chooses, during his stay in the hospital, a hospitalization level higher than his hospitalization level, he shall bear at his own expense the expenditures resulting from the level difference. If the coverage of the insured includes the participation of another guarantor body, then the contracting party / the insured will be responsible for completing the required transactions for this purpose. In the event that the transactions of the other guaranteeing body are not completed, then the contracting party / the insured shall bear the full share of the guaranteeing body. If the insured consumes the limits of his coverage, his contractual rights will expire alone from the insurance policy, and the company can renew his coverage limits if the contracting party / the insured submits a request in this regard. The company has the right to approve or refuse to renew the coverage, provided that the new coverage excludes the disease or accident with all its complications, due to which the insured has consumed the limits of his previous coverage.

Article 5: Hospitalization System relating to the Reimbursement of Hospital Costs
A- IN - Hospital treatment at the Contracted Hospital from the Approved Service Providers Network:
The insured / patient under the insurance policy must follow the special instructions for obtaining approval for admission to the hospital (cold or emergency case, with or without hospital stay) according to the details mentioned in the User Guide. The company shall not be directly or indirectly responsible for bearing any financial or moral burdens as a result of the insured, hospital, doctor or medical service provider's violation of the terms of written approval or any item of the general and particular conditions of the policy. The company / medical expenses manager pays the value of the invoice belonging to the sick insured in accordance with the terms and conditions of the written approval directly to the hospital, and he is therefore not responsible for any additional amount paid by the insured to any party that was directly or indirectly related to his health condition beyond the terms of approval. The insured/patient agrees that the company would inspect the sick insured and his dependents covered by the health insurance policy and to disclose their health status by the company’s medical representative. The company also has the right to investigate their health history and verify the circumstances of all claims without exception to the extent it deems appropriate. The insured and his dependents also agree to lift their medical confidentiality for the benefit of the company while giving absolute authority to review all the medical information available about them at any medical center (hospital, doctor) and/or an insurance company or any other entity that has such information and to receive a copy thereof and use when needed. The insured shall return to the company any amounts that he had paid for a case not covered by the insurance policy or when the amount exceeds the financial limits agreed upon in the particular conditions of the insurance policy.

B- Treatment in the Hospital not contracted with the Approved Service Providers Network
In the event that the contracting party / the insured chooses a non-contracted hospital, he must, at the risk of losing the right in coverage, adhere to the relevant instructions contained in the User Guide. The insured has the right to choose the doctor, hospital or medical center that suits him and in this case the insured pays the bills directly to the doctor, hospital or center, then the company has the right to pay the whole or part of the bills paid according to the tariff issued by the Ministry of Health and on the basis of the prices of the centers contracted from a network of service providers affiliated to the medical expenses manager. The amount of compensation shall be paid to the contracting party/insured within a maximum period of (30) working days from the date the company receives the required documents, provided that all documents are correct and complete. However, if the insured, in bad faith, exaggerates the value of hospitalization expenses, hides or withdraws any medical report or document, or deliberately uses fraudulent means or incorrect documents with the intent of proving his claim, then he will lose his right to any possible compensation. Every right that may arise from the insurance policy shall expire by the passage of time after three years from the date of the accident that caused those rights. The insured must return to the company any amounts that it had paid for any case not covered by the insurance policy or when the amount exceeds the financial limits agreed upon for each insured in the insurance policy, or in the event of hospitalization at any hospital not mentioned in the list of hospitals attached to the insurance policy.

Article 6: Premiums of Insurance
The premiums are annual. The entire premium will be due and paid upon signing the insurance policy. Premiums include expenses, taxes and fees. In the event of non-payment of the entire premium, then the insurance policy shall be deemed void without the need for any notice or judicial proceedings. If the two parties agree to pay the insurance premium in stages, then the premiums will be paid according to the terms and conditions stipulated in the particular conditions or the premiums annex to the insurance policy. But in the event that the contracting party/insured refuses to pay the due premium, then the company has the right to terminate the insurance policy after ten days without the need for any notice or letter, and the contracting party/insured will be responsible for paying the due premium until the date of cancellation, as well as any other amounts payable by him . The company has the right to reconsider calculating prices if the change in the number of subscribers exceeds, by increase or decrease (25%), without including the dependents.

Article 7: Renewal of the Insurance Policy
The insurance policy will be renewed by the both parties agreement for a period of one year when the contracting party agrees in writing to the renewal notice. Paying the premium in full or part upon submitting the insurance application or upon renewal does not commit the company to any liabilities. The company's liabilities are only realized by issuing the official, duly signed and stamped insurance policy. The company shall pay all its liabilities at its head office, and every dispute that may arise due to the interpretation or implementation of the insurance policy shall be referred to the competent courts in Damascus, Syria.

Article 8: Incorrect Statement
The insurance application and the documents notified to the company on the date of insurance policy entry into force are all valid without modification during the term of the insurance policy, as long as the company is not notified in writing by the contracting party of the change that has occurred to the him or the insured. In the event of incorrect statements or concealment of any information in the insurance application about an undeclared previous health condition and/or during the validity period of the policy, then the company shall have the right to collect the full premiums for the entire period of insurance that was noted in the insurance policy, and the insurance policy shall be considered null and void and not necessary for the insurance company with its full effects. The company also has the right to rescind the policy without resorting to the judiciary or issuing any notice or letter in this regard.

Article 9: Double Insurance:
the insurance with this policy may not be a source of profit for the insured, i.e. that the purpose is to compensate him for the expenses he actually incurs according to their real value and as the policy allows. In the event that there are other insurance policies similar to the present one from which the insured benefits, he must inform the company, and then the principle of solidarity and collectivity between the guarantors or those responsible in money is required, whereby the company pays its share in the actual medical expenses claimed in proportion to the other insurance policies.

Article 10: The Company Subrogates the Contracting Party / Insured:
upon paying any claim in accordance with the terms of this policy, the contracting party / the insured gives the insurance company the right to replace him with all the rights and claims arising to him against other persons or towards any third party responsible for this claim or expenses incurred for any reason, especially the car accident, in accordance with the provisions of Article 303 of the Syrian Civil Law. The contracting party and the insured undertake to cooperate with the company and provide all information and facilities in order to preserve its rights.

Article 11: Change the Hospitalization Level:
the contracting party has the right to change the level of hospitalization only upon renewing the insurance policy, and all persons whose names appear in the insurance policy must benefit from that. In the event the contracting party requests an increase in the level of hospitalization, from what it was in the previous insurance year, then the general exceptions to the insurance policy shall apply to all insured on the basis of the current hospitalization level only, if the current hospitalization level is higher than the level specified in the particular conditions of the previous insurance policy.

Article 12: Terminator of the Insurance Policy
The Syrian International Insurance Company (AROPE SYRIA) has the right to terminate the insurance policy at any time it wants according to the following mechanism and conditions:

In the event that the insurance premium is not paid by the contracting party / the insured, the insurance company has the right to terminate the policy without the need to send any notice or letter in this regard.
In the event of a wrong declaration or any false information is given by the contracting party / insured, the company shall return to the contracting party/ insured a portion of the premium paid having deducted the portion proportional to the period during which it remained in effect. But if the value of the claims paid since signing the insurance policy is equal to or greater than the value of the premium paid, the latter shall remain entirely in favor of the company.
In the event that the insured misuses the AROPE Hospitalization Card, he must bear the material, moral and legal burdens resulting from the misuse.

Article 13: Medical Error
The Syrian International Insurance Company (AROPE Syria) does not bear any responsibility for any harm resulting from any medical professional error incurred by the insured as a result of his treatment with any of the contracted or non-contracted medical entities, without prejudice to the right of the subscriber to compensation in such cases by those entities. In accordance with the rules, limits and their responsibility as stipulated by the general laws in force in the Syrian Arab Republic.

Article 14: Modifications
The modifications that may occur during the validity of the insurance policy are either the addition or deletion of the insured. This must be done at the written request of the contracting party and with the Company's approval.

Addition of the Insured:

Spouse or children having completed the insurance application and according to the company's conditions.
A new subscriber or employee having completed the insurance application and according to the company's conditions.
A new baby, after fourteen days from the date of birth, provided that to submit a medical report will be issued by the supervising pediatrician. In the event that the birth is covered by the company, then he will be insured under the same conditions as the mother’s coverage without paying the insurance premium for the remainder of the insurance policy, unless the particular conditions stipulate otherwise. The newborn must meet the conditions of medical insurance and be of good health.

Deleting the Insured:

Cancellation of the Insurance Policy:

Article 15: Solve Disputes
The contracting party and the insurance company agreed to refer any disputes that may arise between them regarding the insurance policy to the competent courts in the City of Damascus.

Article 16: Scope of the Insurance Policy
Hospitalization Coverage: the Company will cover the following medical cases:

All surgeries as mentioned in the general conditions and exceptions of the insurance policy, unless otherwise stated in the specific conditions of the insurance policy.
Medical conditions that require in-hospital treatment that cannot be treated within the outpatient program.
Emergency cases that require treatment within the emergency department and cannot be postponed resulting from a sudden illness or accident covered by the conditions of this policy.
Surgical procedures and endoscopic diagnoses related to medical conditions covered by the insurance policy that do not require hospital stay.
The required pre-operative examinations that take place during the uninterrupted stay in the hospital that are related to the same disease to be treated.
Physical therapy related to a covered hospitalization, whether the treatment is conducted inside or outside the hospital during the period of the contractual policy having obtained a prior approval from the company.
Birth-Delivery: when the delivery is covered under this policy, the insurance company will cover by itself the following costs:
1. The cost of hospital stay for a maximum of two days in the case of a natural birth-delivery.
2. The cost of hospital stay for a maximum of three days in the event of a caesarean birth-delivery.
3. The cost of a newborn Nursery or Incubator for the newborn from birth and for a maximum period of 6 days, regardless of the length of the mother's stay in the hospital.
4. AROPE Syria covers the medical treatment inside the hospital for temporary neonatal jaundice (jaundice) of the newborns within the health insurance program for those eligible to the insurance since their birth and regardless of the mother’s stay in the hospital.
5. One consultation by the treating pediatrician.
6. Circumcision provided that to be performed before discharge from the hospital and by a specialist doctor (Urology).
7. The cost of epidural or (lumbar) anesthesia is covered if it is used instead of general anesthesia in the case the caesarian birth-delivery only.
8. Coverage includes one birth-delivery case / person (insured) in the insurance policy including complications that may arise.

Out-Hospital Medical Services Coverage: It is an outpatient treatment plan.

Diagnostic tests:
Radiology - CT - MRI – Ultrasound Images - Laboratory analyzes - Hormonal tests - Electroencephalogram - ECG - muscles and nerve electrocardiography - audiogram - cardiac stress test - Cardiac Holter – while the osteo-densitometry test is done at the medical centers contracted with the company, and only once a year. The company covers 2 obstetrical ultrasound and 1 Echo-morphology and for medical necessity only during pregnancy. The company covers the physical therapy related to a covered medical condition having obtained the prior approval of the company. Diagnostic examinations are covered to a maximum year/person (as defined by the policy specific conditions) for each insured.
Physician Visits:
The company covers the medical examinations that took place with the doctors contracting therewith in accordance with the terms of the insurance policy. The company compensates the insured (as specified in the specific conditions of the policy) according to the maximum medical examinations with doctors who are not contracted with the company in accordance with the general and particular conditions of the insurance policy.
Note: The number of visits should not exceed the number mentioned in the particular conditions of the insurance policy.
Medications:
- The Company compensates under the medications coverage those medicines licensed by the Syrian Ministry of Health at the prices set by the latter, and which the treating doctor has specified in his prescription.
- The company covers analgesic medicines, vitamins and herbal medicines that contain medicinal herbs, within a regular prescription that meets the conditions for dispensing (patient's name - diagnosis - signature - seal - validity) and within a satisfactory medical reason covered by the insurance policy.
- In the case of covering chronic diseases or pre-existing diseases such as (diabetes mellitus - high blood pressure - high serum cholesterol - epilepsy - heart diseases - asthma - all types of cancer), then a chronic disease medication application form will be filled out, to dispense to the patient having obtained the Company approval.
- Medications are covered for the maximum year/person (as defined in the policy specifics) for each insured.
- Vaccines: If the vaccines are covered according to the specific conditions of the policy, then the vaccines covered by the insurance are the vaccines recommended by the World Health Organization and the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia and as recommended by the Syrian Ministry of Health, which are: Coverage of essential vaccines:
  1. Hepatitis, measles, BCG, triple paralysis, rubella and mumps.
  2. Diphtheria, pertussis and tetanus.
  3. The Infanrix Vaccine against diphtheria, pertussis and tetanus.
  4. Newborn BCG vaccine.
  5. Hemophilus Influenza B for children and the insured over the age of fifty (once a year only).
  6. Staphylococcaceae for insured persons over the age of sixty five (once every five years).
Coverage of Dental Therapy:
- If this coverage is covered by insurance according to the terms of the policy, it will be exclusively within the approved medical network only and up to the maximum financial limit, as stated in the terms of the policy:
- The insurance company covers the following dental procedures:
  1. simple tooth or molar image.
  2. Metal filling without pulling the tooth nerve.
  3. Composite or white filling without pulling the tooth's nerve.
  4. Single canal filling with pulling the tooth nerve.
  5. Filling two or three channels with pulling the nerve of the tooth.
  6. Retreatment with a single canal filling and with pulling the tooth's nerve.
  7. Extraction of a normal tooth or root.
  8. Extraction of a normal tooth or root (2 times during the same session).
  9. Extraction of a normal tooth or root (more than 2 times during the same session).
  10. Excision from the alveolar fossa.
  11. Curettage and Apicoectomy.
  12. Deep wisdom tooth extraction.
  13. Dental scaling (once a year).
Coverage of Medical Glasses / Lenses:
- If this coverage is covered by insurance according to the terms of the policy, it will be exclusively within the approved medical network only and up to the maximum financial limit as stated in the terms of the policy.
- The insurance company covers the cost of the eyeglass frame if broken due to a sudden accident beyond the control of the insured.
- The insurance company covers lenses of more than half a degree and for medical necessity, according to the following:
  1. Plastic and glass lenses.
  2. Compact lenses.
  3. Anti-Reflex lenses.
  4. Bifocal lenses.

Other Benefits:

Death during the hospitalization period: in the event of the insured death after admission to the hospital and during his recovery from a health condition included in the insurance policy, the company shall pay a minimum amount of 100.000 SYP (one hundred thousand Syrian pounds only) for burial and refrigerator expenses according to official clear documents. The cost of the refrigerator is paid as part of this amount directly to the hospital. The rest of the amount is paid to the legal heirs for burial expenses only.
The company covers the following::
- Heart surgery valves.
- The Stent which is placed inside all the arteries which is covered according to the conditions of the policy for each insured during one insurance contractual year for the policies with geographical limits contracted inside Syria.
- The devices installed internally and externally (such as plates and screws) are covered provided that they are the result of a bodily injury (accident) that occurred during the validity of the insurance policy or its renewal, and provided that these devices are installed immediately after the accident during the one insurance contractual year and according to the terms of the policy.
- Mesh of the hernia surgery.
Acute dialysis sessions that take place during the first hospitalization period until discharge from the hospital.
Dental and jaw surgery or treatment, including orthodontics, plastic surgery, artificial dressing, meals, and temporomandibular joint dysfunction if resulted from an insurance-covered emergency accident that occurred after the beginning of the insurance policy, provided that it takes place within a maximum period of six months from the date of the accident and during the validity or renewal of the insurance policy. The prior approval of the company is required.
Aesthetic and plastic surgery if resulted from a covered emergency accident that occurred after the beginning of the insurance policy, provided that it takes place within a maximum period of nine months from the date of the accident and during the validity or renewal of the insurance policy. the prior approval of the company is required.
Nasal treatment resulting from an emergency accident that occurred after the beginning of the insurance policy is directly covered by the company, provided that the treatment is carried out within a maximum period of nine months from the date of the accident and during the validity or renewal of the insurance policy. The prior approval of the company is required.
Eye treatment resulting from an emergency accident that occurred after the beginning of the insurance policy is directly covered by the company, provided that the treatment is carried out within a maximum period of nine months from the date of the accident and during the validity or renewal of the insurance policy. The prior approval of the company is required.
Congenital anomalies: these are diseases, disabilities, malformation, and defects present at birth, whether clearly or potentially that may appear later. The following congenital cases are considered to be covered only in cases where the birth of the insured is covered within AROPE SYRIA system. Further, the new-born shall be insured from birth, and insured within AROPE SYRIA system since he reaches (14) days of age and without interruption. These cases are: Hernia, Thyroiglossal Cyst, Pyloric Stenosis, Urinary Reflux, Gastro-Esophageal Reflux, Epispadias, Hypospadias, Bladder Extrophy and Extrophy of Lower Abdomen, Posterior Urethral, Megaureter, Hydronephrosis and U-P Junction, Diaphragmatic Hernia, Esophageal Atresia, Omphalocele & Laparoschisis, Duodenal Atresia, Intestinal Atresia, Hirschprung Congenital Megacolon, Imperforate Anus, Biliary Atresia, Bronchogenic Cysts, Cystic Adenomatoid Malformation, Tongue Time and Testicular Ectropion.

Article 17: Insurance Policy Exclusions

A- Exclusions IN-Hospital coverage :
1. Attempted suicide, injuries of war, misdemeanors, civil disturbances, terrorism, radiation, nuclear and bacterial contamination, epidemics, sexually transmitted diseases, AIDS, plastic surgery, Parkinson, Alzheimer, genetic testing, sleep disorders, periodic general examination, mental illness, participation in dangerous competitions and sports, the price of hearing aids, means to improve and correct vision and developmental disorders.
2. The cost of implanted organs and prosthetic substitutes price (including prosthetics) used in organ transplant surgery.
3. Periodontal disease and surgery.
4. Chronic (blood and peritoneal) dialysis and its related arteriovenous operation.
5. Expenses of ground and air ambulances, unless the conditions of the insurance policy stipulate otherwise.
6. Osteoporosis treatment by using Acalasta.
7. Everything related to fertilization, childbearing, infertility, varicocele and Amniocentesis.
8. Hair loss treatments and related operations and all the resulting complications.
9. Illegal abortion and abortion without medical indication.
10. Congenital cases and the resulting complications: all cases of congenital anomalies are not covered by insurance except for the cases mentioned previously (and covered by insurance) in the Article 17 (the subject of the insurance policy, other benefits clause).
11. Work accidents and occupational hazards, unless the terms of the insurance policy or its endorsements stipulate otherwise. Persons engaged in the administrative work only are excluded from this clause.
B- Exclusions Out-Hospital Medical Services :
1. All exclusions applicable to the hospitalization plan (in-hospital) apply to the medical program (out-of-hospital).
2. Diagnostic examinations carried out for the purpose of Check Ups and premarital examinations or for non-medical reason.
3. PT, Scan and CT Multi Slices image unless the particular conditions stipulate otherwise.
4. All of the following medications are not covered by insurance:
  - All types of treatments which are preventive not curative.
  - General antiseptic solutions (Savlon, Dettol, Povidone), sanitary napkins and all hair care products such as soap, shampoo and gum, dental and facial care products, cosmetics and diet medications.
  - Toothbrushes, surgical sutures, and toothpaste.
  - Mouthwash, throat sprays, lozenges and gargling solutions...etc.
  - Orthodontic aids and oral protection.
  - Gum, dental and facial care products and cosmetics with diet.
  - All medications that can be obtained without a prescription (Pendulum, Tylenol, Cetamol, Vicks, Strepsil, Aspirin, Calcivita, nutritional supplements…etc) in addition to vitamins of all kinds, unless included in a regular prescription and for medical necessity.
  - Serums.
  - Acne-related treatments.
  - Hormonal treatments (HRT) in the period of Menopause.
  - Sexual stimulants of all kinds and forms, contraceptive drugs, treatment of infertility and impotence.
  - Dermatological preparations, except those related to the treatment of inflammatory diseases and burns resulting from accidents.
  - All hearing or vision correction devices and their preparations.
  - Preparations and medicines for the treatment of sexually transmitted diseases and acquired immunodeficiency diseases.
  - All kinds of baby food and its derivatives, such as milk, rice…etc. and baby towels.
  - All kinds of drugs that calm the nerves and affect the mood.
  - Walking crutches, braces, suspensions, pelvic supports, waist braces, joint braces, stretch stockings and abdominal braces.
  - Breast pumps, massage tools and exercise equipment.
  - Sports shoes, heel support and forearm support.
  - Ties and braces of any kind and neck collar.
  - Yeasts and digestive enzymes.
  - Immunosuppressants used in organ transplantation.

Annex of Accidental Death Coverage

Article 1: Scope of the Insurance
The insurance policy guarantees the payment of the benefits stipulated in the particular conditions in the event that the contracting party / the insured, mentioned in the particular conditions, suffers an accident that occurs to him while performing his profession or in his private life, the direct cause of which is a sudden external factor beyond his control that led to his death, within a period of twelve months from the date of its occurrence.

Article 2: Extent of the Insurance
In the event of bodily injury leading to death, according to the definition in Article 1 above, the benefits mentioned in the Particular Conditions shall be due on the Syrian International Insurance Company (AROPE SYRIA) according to the following:
In the event of the insured death as a direct and exclusive result of a insured accident, the full amount mentioned under particular conditions shall be paid to the beneficiaries appointed by the insured, if appointed. Or in the event of the death of the beneficiaries appointed by the insured, this shall be done to the latter’s legal heirs who hold the necessary supporting documents.

Article 3: Guarantee Extent Limits
Death by accident only.
The amount of death is paid once to the legal heirs having fully verified the occurrence of the accident and fulfilled the conditions of the accident covered under the personal accident insurance policy.

Article 4: Exclusions

Diseases of any kind, occupational or not, as well as injuries and impairments not resulting from or caused by an accident.
Suicide or attempted suicide of the insured, assassinating and killing him intentionally or with the intention of fraud by the insured or the beneficiaries designated in the particular conditions.
The insured’s abuse of morphine, cocaine or other similar substances if not prescribed to him medically.
The results of surgeries performed on the insured not derived from the insured accident.
X-rays, radium and its compounds and its derivatives, unless their effect on the person being treated resulted from a defect in the functioning of the devices or poor function or as a result of the treatment of the insured due to the insured accident.
The direct or indirect results of transforming the formation of an atom, nuclear fission or radioactive force.
A pre-accident impairment, drunkenness, alcoholic delirium, insanity or any other case of paralysis, stroke, brain explosion or epilepsy (Apoplexy).
The insured's participation in a brawl (except in the case of self-defense) or in an intentional crime or misdemeanor.
Navigation under the sea level.
The use of any means of air transportation, unless as a passenger on regular commercial airliners that are officially prepared for transporting passengers by air.
Participation of the insured as a contestant in matches, races, fencing, competitions or rallying in the following sports: motorcycles, cars, aerial games, water games with the use of an engine and games on snow or ice.
The insured’s practice, even as a hobby, of any individual or team sport not declared by him in the insurance application and accepted by the Syrian Insurance Company (AROPE Syria) in the terms of the special insurance policy.
Driving motorcycles of any power by the insured or using them as a passenger.
Asphyxia.
Use of explosive materials.
Invasion, foreign wars with a foreign state, civil wars, Martial Law, insurrection, general mobilization, the insured joins the military service, revolutions, military or political seizure of power, terrorist or sabotage acts, rebellion, strikes, popular movements, looting, any kind of projectiles or any kind of explosives, bullets, artillery shells and missiles or other war tools, whatever their source and kind, or any abnormal actions or operations carried out by armed persons affiliated or not to political, military or paramilitary organizations or parties and/or under the authority of real or legitimate authorities working for their own account or for the organizations for which they are responsible.

Article 5: Statements of the insured upon concluding the contract (Insurance Policy))
In the event of any concealed information or false statement by the insured that would affect the idea of risk with the Syrian International Insurance Company (AROPE Syria), the latter has the right to declare the insurance policy invalid.

Article 6: Obligations of the insured in the event of an accident

Declaration:
In the event of an accident that led to the death of the insured, which would make the guarantee of the Syrian International Insurance Company (AROPE Syria) obligatory, the insurance beneficiaries, at the risk of losing their right to insurance, shall give the company within thirty days from the date of the accident or from the date of being aware of the accident occurrence, a written statement that includes the date of the accident, the place of its occurrence, its causes, circumstances and consequences, in addition to the names and addresses of witnesses and officials, if any. A medical report stating the cause of death must be attached to this declaration.
the Company Right to Inspection
The doctors of the Syrian International Insurance Company (AROPE Syria) and/or its representatives have the right to verify the cause of death under the penalty to lose the right to benefit from the insurance if the beneficiaries refused.
Conceal Information and Incorrect Statement
The use of false documents or means, and each concealment or incorrect information about the accident with the aim of changing the nature of its consequences, exaggeration, hide its causes, or extend its consequences, will inevitably lead to lose all rights of the insured or the insurance beneficiaries in the contributions related to the accident which must be returned to the Syrian International Insurance Company (AROPE Syria) if paid thereby.

User Guide

(Medical claims inside Syria are managed through the Third party administration (TPA).

(Medical claims outside Syria are managed through coordination with AROPE Syria).

How to benefit from the insurance policy services

In order to make the optimal use of the health insurance policy, please follow the instructions below and according to each case:

Within the approved medical network

In cases of referring to a doctor licensed by the approved medical network:
- - The insurance card must be presented.
- - The attending physician fills out a medical examination form, which is available to every doctor within the network.
- - The patient does not pay any amount if the examination is done by a doctor within the network.
- - Ensure that there is a clear diagnosis, the date and the stamp in case any additional service is requested (for example: medicines, tests and x-rays).

In case of visiting the licensed pharmacies within the approved medical network:
- - Show the medical prescription which dated, signed and stamped with mentioning the diagnosis by the treating physician along with the benefits card.
- - The pharmacy determines the drugs that can be covered, according to the exceptions specified in the general and particular conditions.
- - The pharmacy keeps the prescription, so the prescription must be copied before giving to the pharmacy if the insured wishes to review later.
- - The insurance company covers the cost of the medicines covered by the insurance, and the insured bears a percentage, if any, as mentioned in the particular conditions of the policy.

In cases of requesting laboratory or radiological diagnostic tests within the approved medical network:
- - Present the dated, signed and stamped examination request with mentioning the diagnosis by the treating physician along with the benefits card.
- - The center or the laboratory shall take the necessary measures according to the coverage permitted in the document and request the necessary approval, if necessary.
- - The insurance company covers the cost of the examinations covered by the insurance, and the insured bears a percentage, if any, as mentioned in the particular conditions of the policy.

In emergency cases that do not require hospitalization within the approved medical network:
In cases where a health service is requested at the emergency department (first aid) in the hospital, and which does not require a stay in the hospital for any night, the insured must present his benefits card and personal card to the said hospital in order to verify his identity, and then the hospital requests approval for coverage from the medical expenses management.

In emergency cases that require hospitalization within the approved medical network:
The insured or any of his companions must request the hospital to inform the Medical Expenses Management of the insured’s condition within 48 hours of his admission to the hospital, provided that this is not later than the next working day if the end of the period falls on a holiday.

In non-emergency cases that require hospitalization within the approved medical network:
- - Obtain the approval for coverage from the Medical Expenses Management before benefiting from the covered health services by submitting a duly filled out medical report for admission to the hospital, whether the patient’s condition requires a stay at least one night in the hospital or more.
- - Submit the medical report to the hospital to be admitted along with the hospitalization card.
- - The hospital sends the documents to the Medical Expenses Management in order to obtain approval within a period of no less than five days.
- - When it is time for hospitalization treatment, the approval will be available at the hospital's reception department.

Out of the Medical Expenses Management Network

In cases of visiting a doctor who is not licensed by the Medical Expenses Management Network:
- The insured pays the value of the examination directly to the treating physician.
- Carry out the repayment procedures described later.

In cases of using pharmacies not licensed by the Medical Expenses Management Network:
- The insured pays the value of the drug directly to the pharmacy.
- Carry out the repayment procedures described later.

In the case of visiting a diagnostic/laboratory or radiological examination center not licensed by the Medical Expenses Management Network:
- The insured pays the value of the examination or image to the laboratory or the radiography center directly.
- Carry out the repayment procedures described later.

In emergency cases that do not require hospital stay which are not licensed by the Medical Expenses Management Network:
- The insured pays the hospitalization value directly to the hospital.
- Carry out the repayment procedures described later.

In emergency cases that require a hospital stay which are not licensed by the Medical Expenses Management Network:
- The insured pays the hospitalization value directly to the hospital.
- Carry out the repayment procedures described later.

In non-emergency situations that require a hospital stay which are not licensed by the Medical Expenses Management Network:
- When the licensed centers are not available in the governorate in which the insured works or resides, the insurance company must be informed of his desire to enter the hospital.
- When the required hospital treatment is not available in a licensed center within the medical expenses management network in the governorate in which the insured works or lives, the insurance company must be informed of his desire to enter the hospital.

We depend on the daily average of fees and expenses incurred for normal hospitalization and/or in intensive care at a parallel center participating in the medical expenses management network for services in Syria for all types of surgeries (in case the bill, the subject of the claim, is related to a surgical operation) or for all types of medical procedures ( If the bill, the subject of the claim, is related to a medical procedure).

Re-imbursement Procedures:

(For medical incidents claims that were treated outside the approved network).

In the event of requesting the repayment of doctors charges :
1. Original receipts and invoices issued by the treating physician.
2. Medical examination results and the prescription.
3. Copy of the insurance card.

In the event of requesting the repayment of the drugs expenses
1. The insured must submit the application with the original medical report and the prescription in addition to an invoice stamped the pharmacy in addition to the empty medicine boxes.
2. The insured shall bear an additional (20%) of the amount to be paid by AROPE Syria on the basis of repayment.

In the event of requesting the repayment of the diagnostic expense (Laboratory or Radiological)
1. Request for examinations by the attending physician with a detailed report explaining the medical condition.
2. Detailed original invoice, original receipts, reports, medical documents and test results with the doctor's request for a pathological diagnosis.
3. Copy of the insurance card.
4. The insured shall bear an additional (20%) of the amount to be paid by AROPE Syria on the basis of repayment.

In the event of requesting the repayment of the hospital charges:
A written request must be directed to refund the paid amounts directly to the insurance company, accompanied by all the following supporting documents: (the original detailed invoice, original receipts, medical report upon discharge, medical reports and documents, test results in addition to a copy of the insurance card). The paid amounts shall be refunded provided that the insured has submitted a claim to the insurance company within:
- 20 days from the date of discharge from the hospital if health care services are provided in Syria.
- 30 days from the date of discharge from the hospital in case the services were provided in the rest of the world or the date of his return to Syria.

The insured shall bear an additional 20% of the amount to be paid on the basis of repayment according to the prices approved by the hospitals contracting with the Medical Expenses Management in Syria.

MU-F-02
Ver.3