Inpatient means an individual (patient) whose condition requires admission to a hospital and the consulting Doctor wants to visit the patient frequently to evaluate the improvement in the treatment.

Emergency treatment which is unscheduled and patient need immediate medical attention due to potentially serious acute illnesses or injuries where his life is under threat without the immediate medical attention.

The area within where treatment may be received and are stated in the Policy and Table of Benefits.

The Benefit limit the insured member can utilise maximum in the policy period.

1. Direct Billing basis: – It means the insured member can get the treatment/service under the Medical insurance by submitting the Medical insurance card to the Provider such as Hospitals/Clinic/Pharmacy, etc.

1. Reimbursement basis: – It means the insured member paid the medical expense from his side and recovering the same from the insurer as per the Policy terms & conditions. 

A third-party administrator (TPA) is an organization that processes insurance claims &/ other insurance administration works such as issuance of Medical cards & policies etc, they also arranging the contract or agreement with the Hospitals/Clinics etc. The TPAs are working with insurance companies on contract/agreement basis. Examples of TPA: – Nextcare, Mednet, NAS, Globalnet, etc. 

The list of Hospitals/Clinics/Pharmacies etc where the Insurer or TPA has made the contract to serve their clients/insured members on Direct Billing basis. 

There are various ‘Network panels’ which is made by the Insurer or TPA as the grade of the providers which included in it. Example: – Nextcare TPA has various Networks such as ‘GN’ (General Network), ‘RN’ (Restricted Network), ‘RN2’ (Restricted Network 2) etc. For our easy understanding to know the difference between GN & RN, we can say the premier hospitals such as Al Zahra Hospital, Mediclinic City Hospital, Mediclinc Welcare hospital etc are included in GN in addition to other middle class Hospitals where RN has NMC speciality Hospitals, Zulekha Hospitals etc only included in that. 

Network rate means the rate what is agreed between the Provider and Insurer. 

Eg :- If you are visiting a Hospital/Clinic without having an insurance then Hospital will charge their standard rate, say AED 100 for consultation, where as the rate for the same consultation agreed by Hospital & Insurance company will be AED 60 (indicative) based on the agreement between them considering the huge volume of business. So if you are taking a treatment from a provider which is not listed in the insurer’s ‘Network panel of providers’ and you have spent AED 100, where you are submitting such a claim for reimbursement you will not be getting AED 100 reimbursed but you will be getting the rate what a similar provider charge for the same treatment if you would have visited in a provider listed in the insurer’s ‘Network panel of providers’.

Excess / Deductible means the portion of amount the insured member has to contribute from his side towards the claim.

Co-insurance is similar to Excess/Deductible, co-insurance is the % of cost the insured member has to contribute, this is usually applicable in addition to the Excess/Deductible.