Daman Insurance are a large insurance company which services the expat market in the Middle East.
This article will review the solution. If you are looking for expat insurance, you can contact me on this form.
Definition – ‘Health Insurance’ is the type of insurance that covers the medical expenses of a person who is insured.
Usually, Insurance companies either cover the whole expenses or sometimes cover a fraction of the expenses. This can be medical expenses, Surgical expenses, death, accidental expenses, and occasionally dental expenses as well.
Generally, the person who is acquiring insurance policy is required to pay a monthly premium to the insurance company. Sometimes the employer of a specific individual makes a cut in their salary in the form of a payroll tax in order to make an insurance policy in the name of the employee.
Based on the premium, the insurance company develops a financial plan, where if a person is in the requirement of medical expenses, they will acquire the money necessary. The functionality, as well as the terminology related to the health insurance companies is as follows:
- Individuals are required to pay a fee known as Insurance Premium for securing the coverage of expenses as declared by the Insurance Policy. The process goes further while sorting people depending on the risk factors such as Age, Gender, Medical conditions, etc. The premium amount depends on these factors so that it is likely to cope with the medical expenses, which must be equal or less than the total amount paid by the individual.
People having higher risk might have to pay a higher amount of premium and a simultaneously lower amount of premium if they are less likely to make use of it. The underwriting process makes a cross selection of individuals so that neither will it be full of the people who need it nor the people who won’t be needing it.
- Usually, the policies require the individuals to be able to bear a considerable amount of expenses by paying the initially required amount for medical costs in order to lower the risk. The amount that is needed to be paid upfront by the person will be decided before itself. This amount is known as ‘Deductible’.
The deductibles can differ in the case of individuals or whole families. Let us see an example to understand this situation. Let us say that an individual deductible is $5,000 and the family deductible is $10,000. In this case, an individual can be able to claim the medical expenses if the overall amount of the expenses exceeds an amount of $5,000 and similarly in case of the family the expenses should exceed $10,000.
If the amount does not exceed the deductible amount, the person might not be able to claim their insurance.
- Along with the deductible, policyholders are required to pay another portion of the overall expenses, which is known as ‘Copay’. The main objective of the copay is to avoid the superficial use of medical services.
The copay amount is related to the premium amount as they reduce the exposure of the insurance company. Higher copays can be seen very rarely as they would reduce the premium required for a policy.
- To avoid maximum risk and excessive utilization of the policy, insurance companies make the policyholders liable for up to a certain amount of expenses. This is usually around 80% of the overall expenses after deducting the copay.
For example, if a policyholder claims an insurance amount of $1,000. The individual has paid a copay of $50 in it. Then the insurance company pays them 80% of the remaining expenses, which is $810. Now, the total expenses that have to be paid by the individual is $190. This process is called as ‘Coinsurance’.
- Health Insurance companies might have some specific terms and conditions that prevent them to offer the insurance claim for certain situations. The situations depend on factors such as the medical condition, treatment type, medical provider, etc.
An example of the non-covered expenses is cosmetic surgeries. It may be a facelift, abdominoplasty (tummy tuck surgery), or bariatric surgery. However, only under some rare and exceptional cases the policies also cover such types of expenses.
- Insurance companies only pay up to a limit in order to cover for the expenses known as ‘Coverage Limit’. The general amount of coverage limit ranges between $500,000 to $1 million. This can be an annual limit or a life-time limit or in some cases, both.
For example, if a person has an annual coverage limit of $250,000 and life-time coverage limit of $500,000, then the person can claim the expenses within that limit for that period of time. If the amount exceeds the limit, the person is required to deal with the exceeded expenses on their own, and the insurance company won’t be paying them for the rest of the time period.
Even $1 million is a huge amount, sometimes medical expenses can add up without even noticing. Whether it might be treatment for a premature baby or complicated organ transplant operation, hundreds of thousands of dollars might be required to deal with the expenses.
However, higher coverage limits can be accessed by individuals, but they would have to go through additional underwriting processes and have to pay a higher amount of premium. In most cases, Insurance companies won’t be willing to raise the coverage limit as it is certain people who want a higher coverage limit would be intending to use it.
- Just like the maximum amount that will be paid by an insurance company, there is a limit for the amount that needs to be paid by the individual as well. This is usually referred to as Out-of-Pocket Maximum.
In general words, it means the limit for the amount that needs to be covered by an individual. After exceeding this limit, the individual need not pay any amount except for copays.
For example, if the out-of-pocket maximum for a policy is $1,000 after an individual reaches that limit, the insurance company will cover 100% of the expenses instead of 80% (excluding the copays).
- The huge benefit of having health insurance is the discount on the expenses. This is made possible by the interactions and negotiations between the medical providers and the insurance company. In this type of situation, the actual costs that need to be paid become lesser by up to 30% – 40%.
For example, if the medical expenses were estimated to be $1,000, then with the help of insurance claims, the expenses will only be $600 or $700.
Each insurance company makes a deal with a medical provider based on the number of policyholders and estimation for them to make use of the services. Medical Providers such as doctors, hospitals, etc., are categorized as either ‘In-Network’ or ‘Out-of-Network’.
In-Network Medical Providers are generally kind of affiliated to the Insurance companies and provide great discounts on the expenses. Insurance companies also often motivate the policyholders to make use of the required medical services with the help of In-Network Providers. People who utilize the services of In-Network providers are also given an advantage of discounts over the copays or coinsurance as well.
Out-of-Network Providers generally provide very little to no discounts on medical expenses. Utilizing the services of an Out-of-Network provider usually results in higher expenses, higher copays, and a higher percentage of coinsurance.
- Most insurance companies require pre-approval for a medical procedure or a specialist visit, this process is known as ‘Preauthorization’. This process ensures insurance coverage.
However, the policyholder is not guaranteed whether a service will be covered, when preauthorization is required. Many cases that involve non-critical medical requirements would have the necessity of a preauthorization. The requirement of preauthorization is generally the responsibility of the policyholder. Failure of obtaining the preauthorization can lead to the denial of a claim in most cases.
Attention to the details for preauthorization is necessary when the doctor suggests/recommends a specialist. Most of the In-Network medical providers would suggest another In-Network provider but they can suggest an Out-of-Network provider sometimes being ignorant or when it might be necessary. In such cases, the expenses might be increased, or the claim may be denied entirely.
- Insurance companies generally provide the details regarding a medical claim, once it is successfully adjudicated or approved. This is commonly referred to as ‘Explanation of Benefits (EOB)’. It generally mentions what is covered within a claim and what is excluded.
The fee structure is also explained within this. This fee structure typically includes the details such as the amount that is covered within the claim, the overall amount required for the activity, the amount required to be paid by the policyholder, and explanation about how these were calculated.
Appealing for a claim:
Almost all the insurance companies depend on the older information system that already exists with them in order to review a person’s claim and make the payment. This leads to errors in payments very often. It is estimated that there is a possibility of errors to occur for every 8 – 10 people out of 100. The procedure that needs to be followed by a policyholder in order to raise a dispute on the company’s claim decision is as follows:
First of all, contact the Insurance company. This can either be done in person (if the company is reachable in person) or by a phone call. Generally, a phone number is provided within the EOB provided to a policyholder.
If you have contacted them by phone call, write down the details told by them and the necessary steps that are needed to be taken by you. Make sure you get the details of the individual that you have contacted as well. Gathering the details and mentioning them to the next executive might make them feel more attentive to your details. This will lead to the resolution of your issue in a faster process.
The documentation should be kept up to date. Accurate documentation might be required for the executives to help with your issue. The process of settling a claim dispute could take a significantly longer time and therefore, it is advised to document each step of the process carefully.
If you are not treated well or came across with unpleasant behavior or you are not comfortable with the decision, then approach a higher official or write a letter to the CEO/President of the company regarding your issue.
Being angry or taking any sort of hasty decisions might not help an individual to speed up the process. It is better suggested to be calm and patient while dealing with them in order to get what you want.
Health Insurance can be beneficial to an individual in order to avoid certain types of health hazards such as delayed treatment procedure due to lack of funds, a higher amount of healthcare expenses, bankruptcy during an accident, major health risks, etc. By getting a health insurance policy that is suitable for their needs, a person might be able to protect themselves as well as their family.
Daman (Health Insurance Company):
Introduction – ‘Daman’ is a Health Insurance company based in ‘Abu Dhabi, UAE’. It was established in the year 2006 by the Abu Dhabi government along with the Munich Re (Munich Reinsurance company) located in the UAE and is a government-affiliated company. 80% of this company is owned by the Abu Dhabi government and the rest 20% is owned by the Munich Re.
Having the highest market share in Aby Dhabi, Daman is known to be offering insurance policies to more than 3 million people approx. by the year 2016. Health Insurance has been made mandatory for the residents of Abu Dhabi, and Daman offers insurance plans with excellent advantages, extended policy limits as well as large geographical coverage.
The ‘Health Authority of Abu Dhabi (HAAD)’ provides the citizens of Abu Dhabi with a basic coverage plan, which is also commonly referred to as ‘Abu Dhabi Basic Plan’. This Abu Dhabi Basic Plan is generally managed by Daman insurance companies. Daman offers a wide range of health insurance plans to the citizens of the UAE such as the ‘Thiqa Plan’.
Thiqa Program – Thiqa means ‘Trust’ in Arabic. Thiqa program is a health insurance program specially designed for the UAE citizens and citizens of the Emirate of Abu Dhabi. On behalf of the Abu Dhabi government, the Thiqa program is managed by Daman.
The Thiqa program usually provides full medical expenses for the citizens of Abu Dhabi and UAE. Citizens are generally provided with a Thiqa card, with the help of which, individuals might be able to have access to many hospitals (both public and private). The individuals can choose the medical provider which can either be a large hospital or small clinics.
In order to qualify for the Thiqa scheme, people would have to undergo a screening process known as ‘Weqaya’, which is conducted by the Department of Health in Aby Dhabi. People who are exempt from cardiovascular risk are only eligible for this scheme. However, in some rare cases, people who are suffering from cardiovascular diseases might also qualify for this.
Rights of a Thiqa member – People who have enrolled in the Thiqa program will gain broader geographical coverage as well as extra benefits. The rights that can be enjoyed by a Thiqa member are as follows:
- Members are provided with the full details regarding the coverage plan, terms and conditions, services provided, network providers (full details including hospitals, pharmacies, and clinics), and benefits made available.
- The details of the individual are maintained with confidentiality.
- Upon the request by the individual, information about the Thiqa benefits (including benefits) will be provided.
- Customer service can be contacted, and their services can be utilized in the languages: Arabic as well as English, based on personal preferences.
- The confidentiality will be maintained as per the Federal and Emirate laws of the UAE and the person can opt to receive an explanation in the case of a breach of confidentiality.
- In accordance with the Health coverage laws in Abu Dhabi, individuals can be able to exercise their rights.
Responsibilities as a Thiqa member – there are some responsibilities that have to be performed by an individual upon becoming a Thiqa member in the United Arab Emirates. They are:
- Individuals should get familiar with all the essential details regarding the Thiqa scheme such as details of benefits, terms & conditions, etc. If a person has any sort of difficulty understanding the details, they can be able to approach the customer service and become clarified of their doubts.
- People who are utilizing the health services with the help of the Thiqa scheme should provide the Thiqa card in order to do so.
- Individuals should always be aware of the coverage details, benefits details, pharmaceutical benefits, etc., upon becoming a member of the Thiqa program.
- In some cases, the individual is also required the pay the necessary coinsurance required while utilizing the services.
Medical/Network Providers – Daman also has contracts with more than 2,000 network providers all over the UAE, which offer discounted prices over medical expenses. These network providers also have the availability of direct billing services in the UAE.
Daman Online Services – Daman also started providing their services online, known by the name of ‘e-Daman’. These online services provided by them generally include online claims submission process, the ability to request a quote online, online endorsements, the ability to renew the policy online, etc.
They can get details such as search functionality, navigation for medical providers, and their prices. Since January 1st, 2019, the requirement for a plastic insurance card is no longer necessary. They can be able to access details with the help of a mobile app.
Daman is known to provide insurance plans that are beneficial to individuals, families as well as corporates in the UAE. They offer health insurance plans to individuals and families depending on their emirate and visa status. For example, they provide cover for the people having a considerably low amount of salary (should be less than 4,000 United Arab Emirate Dirham (AED)) or non-working dependent people. The insurance plans offered to individuals as well as families is as follows:
- Essential Benefits Plan – This is an insurance plan available for the resident visa holders of Dubai whose income is lower than or equal to AED 4,000. This is considered to be a basic health insurance coverage plan, which is beneficial to the low-income earning individuals according to the Dubai Health Authority.
The major benefits provided to the individuals within this plan are inpatient, outpatient, maternity services, emergency services, etc. the coverage limit for this plan is up to AED 150,000.
- Care Essential Plan – The annual aggregate/overall limit for the Care Essential Plan is AED160,000 including the coinsurance amount. Local cover, which means it is the cheapest and basic level insurance plan.
Similar to the Essential Benefits Plan, Care Essential Plan also provides some major benefits like inpatient, outpatient, services related to maternity, emergency, etc. 80% coverage for the in-patient services in the UAE. Medicines can be acquired up to a limit of AED 1,500 involving 30% of the amount as coinsurance.
- Care Chrome Plan – The annual overall limit for the Care Chrome Plan is AED 160,000. This is also a local cover plan.
The major benefits provided to the individuals are the same as the before-mentioned two plans along with dental services too. Prescribed medicines can be acquired up to a limit of AED 5,000 involving 10% coinsurance.
- Care Bronze Plan – The annual overall limit is AED 250,000. It is a regional cover plan, out-of-pocket payments needed would be a little bit less when compared to the previously discussed plans.
The primary benefits of this plan include inpatient, outpatient, maternity, emergency, and dental services. The limit for prescribed medicines is AED 5,000 with 10% coinsurance.
- Care Silver Plan – The annual overall limit is AED 300,000. This is also a regional cover type of insurance. Primary benefits and the limit for prescribed medicines are the same as the Care Bronze Plan.
- Care Gold Plan – The annual aggregate limit of AED 2.5 million. This is a worldwide cover that covers individuals all over the world, except for the people residing in the US and Canada.
The core benefits covered are inpatient, outpatient, maternity, dental, and emergency services. The bill for prescribed medicines can be paid off completely with the help of this cover.
- Care Platinum Plan – The annual aggregate limit is AED 5 million. It is a worldwide cover with no exceptions. The primary benefits are the same as the Care Gold Plan. This plan covers the complete bill for the prescribed medicines too.
- Premier Plan – The annual aggregate limit is AED 20 million. This is also a worldwide cover. Along with the core benefits offered in the Care Platinum Plan, it also offers optical services, health screening tests, and services related to infertility.Prescribed medicines can be paid in full, with the help of this plan too.
Daman offers corporate health insurance plans similar to the individual and family health insurance plans. These range from Essential Benefits Plan (for the individuals earning less than AED 4,000) to worldwide plans. The corporate plans are highly beneficial and flexible for almost all companies. Plans that are in compliance with the Health Authority of Abu Dhabi (HAAD) are also available within Daman and can be accessed from their website.
Advantages and Disadvantages of Daman:
- It is the leading insurance company in the UAE (especially in Abu Dhabi).
- It is a stable company as it is backed up and regulated by the government.
- Accessibility of a wide range of plans from which an individual might choose, based on the features that are advantageous for them.
- One of the best insurance company that provides insurance plans for low income earning individuals (less than AED 4K).
- Online App facility to access the Services such as submitting claims, navigating to the medical providers, etc., very easily.
- Good Customer Support. It can be approached through the app, phone call, email, etc.
- Technologically developing insurance company with great benefits offered to the people.
- It largely focuses on the big corporate companies and hence, attention shown towards the individuals is a little bit less.
- Time taken to resolve issues is a little bit slow.
- When compared to the other regional insurance companies available, it is a little bit pricey.
- Increases that are significant and beyond medical inflation.
Daman is a very good insurance company in Abu Dhabi which offers great benefits to the people in the UAE. Although it is considered a bit pricey, we can say it is value for price for the features.
During this emerging COVID-19 situation, they are also taking the necessary steps required to make people aware of the precautions and safety measures. They are also supporting the members located outside the UAE and offering medical services related to COVID-19 (under the rules and regulations of the government).
That being said, if you are looking for an insurance company in the UAE in order to create a medical policy, Daman can offer a quite advantageous insurance plan that can be beneficial to you. Health Insurance can be useful in times of difficulty and it is suggested to have medical insurance regardless of the necessity as certain situations happen unexpectedly.