Information Center

What is my policy?

• The Table of Benefits (TOB) details the services, treatments, limits, and benefits that you are entitled for.
• Online access is available for each and every member detailing benefits of the Policy/Plan.
• The Providers give specific details in accordance with your network tier. Network Tier is detailed in your plan as well as in your medical card. The Network Providers include Hospitals, Polyclinics, Private Practitioner Clinics, Laboratory and Diagnostic Centers and Pharmacies that you may choose to avail your service / treatment from both within Qatar as well as outside of Qatar.
• The Policy Exclusions detail those services that you are not covered for under your Plan/Policy.
• The expenses incurred within the Network Providers shall be on a direct billing basis unless stated otherwise in your TOB/Policy Terms and Conditions.
• The expenses incurred Outside the Network Provider (within and outside Qatar) shall be on a Cash Reimbursement basis, the details ofwhich are explained under Reimbursement Claims/Table of Benefits.
• Should there be any queries or further clarifications, you may contact our call center on the contact numbers provided on the back of your Medical card.
• Our call center is available for your assistance 24/7, throughout the year.

Prior approval may be necessaryfor certain services/treatments for which your Provider shall contact QLM either in written or over the phone.

With this, your Provider as well you may be assured of:

• The eligibility of the stated service under your Policy/Plan
• The extent/limit of cover of the specific service as per the limits specified in your policy.

Out-Patient Services

Services/treatments rendered by the Medical Practitioner in the Out-Patient clinic or that which do not require a stay in the hospital is termed as Out-Patient Service.

The following non –urgent services such as but not limited to require pre-authorisation:

• MRI, CT, PET
• Endoscopic procedures
• Physiotherapy
• Complimentary therapies such as Chiropractic, Acupuncture, Osteopathy, etc.
• Dental services
• Maternity related investigations or Out-patient procedures
• Optical related services

In-Patient /Daycare Services

• Services / treatments rendered by the Medical Practitioner that requires a stay at the hospital for one or more night is termed as In–Patient Service.
• Services / treatments rendered by the Medical Practitioner that are eligible under the Policy benefits wherein an admission is necessary but does not require an overnight stay in the hospital is termed Daycare Service.
• Prior to availing any non – urgent or planned in–patient treatments and / or day care treatments the insured should inform QLM (by email) with but not limited to medical report from the attending Medical Practitioner outlining the diagnosis, plan of management and estimated expense and obtain written pre-authorisation for your proposed In-patient / Daycare admission or procedure minimum 48 hours prior to the planned admission.
• We shall validate in writing to you with a specified Pre-approval Code, the extent of the respective procedure’s coverage and further requirements, if any, subject to your policy terms, conditions and exclusions.
• Verbal confirmation does not constitute pre-authorisation. If in doubt, please contact the medical helpline, as shown on your membership card.
• Planned Treatment under taken without pre-authorisation from QLM may not be eligible for a full refund in accordance with the policy terms and conditions, unless Help Line response is delayed more than the due time. Furthermore, any expenses not related to the treatment shall be borne by the Insured.

The following Elective / Planned services such as but not limited to require pre-authorisation:

• All In-Patient treatments specified or limited to under the Policy
• All Day-care admissions

Emergency Services

In the event of Emergency treatment pre-approval is not required but it is the liability of the Network Provider to inform QLM of the case within 24 hours of admission to the hospital.

The Insured should have a clear understanding of the Policy/ plan of cover and the benefits included prior to submitting a claim.

When treatments are taken outside the designated QLM Network Provider or when the insured has paid all expenses in full at the service provider, the claim should be submitted to QLM via any of the following routes:

• Visiting QLM office at QIC Building, 5th floor, Tamin Street, West Bay, Qatar
• Submit claims online at www.qlm-online.com
• Submit claims through our QLM Mobile App

Documents needed for submission:

When filing a claim,please provide all relevant documents including but not limited to the following –

• Copy of QLM Heath Insurance card
• Original Itemised Invoice with date
• Original Receipt or Payment Proof
• Detailed Medical Report / Discharge Summary duly filled in, signed and stamped by the attending Medical Practitioner
• Copy of result of investigations (Laboratory / Radiology / Endoscopies, etc.)
• Copy of the Prescription
• Copy of birth certificate (Maternity)

All claims must be submitted within 30 days from the date of service wherein the above mentioned documents are appropriately filled. The insured shall be reimbursed subject to the insured’s policy plan, terms and conditions.

The insured shall be liable for any deductible / co-payment / co-insurance and / or excess that is mentioned in the Benefits of your Policy.

Failure to fully substantiate your claim will result in delayed processing and settlement or may invalidate your claim.

Compassionate Visit Claim Reimbursement

• Wherein the policy extends to include the costs of a return economy class ticket fare to and from the home country of an insured employee in the event of critical illness or death of an immediate family member (father, mother, spouse, daughter or son)
• This option is not operative when the insured is travelling to the home country on holiday or business trip.
• The additional benefit provided by this extension shall be limited to the amount per employee as set forth in the schedule and shall form part of the maximum benefit stated in the schedule.

The insured may submit the following but not limited to documents to claim for Air Fare Reimbursement –

• Copy of QLM Health Insurance card
• Original ticket / print out
• Original invoice / receipt
• Original Boarding Pass
• Death Certificate copy / Medical certificate copy (in case of Critical illness)
• Proof of age of the deceased / sick person
• Proof of relation of the deceased / sick person to the insured employee
• Copy of exit & entry stamped page of the passport as well as the front page of the passport.

Reimbursement Settlement Mode

Reimbursement claims are settled in the following modes:

• Payment Cheque issued in the local currency under name of the insured employee / policyholder’s name (as per the request) along with a detailed breakdown summary of the submitted claim.
• Bank Transfer in local currency to the insured employee’s local Bank Account and a detailed breakdown summary shall be emailed to the employee’s mail address.

Outside Qatar

• Please ensure that any expenses for non-emergency inpatient and day-patient treatment are agreed by QLM local/ international call center in writing i.e. fax/ e-mail/ letter before any planned treatment is undertaken.
• Pre-authorisation of any Elective Treatment or non-emergency treatment should be submitted in writing to QLM local/ international call center as soon as reasonable and at least 48 hours prior to admission.
• Planned Treatment undertaken without pre-authorisation from QLM may not be eligible for a full refund in accordance with the policy terms and conditions, unless the Help Line response was delayed more than the due time.
• Verbal confirmation does not constitute pre-authorisation. If in doubt, please contact the medical helpline, as shown on your membership card.
• QLM will grant 24 hours a day, 365 days of the year medical helpline staffed by multi-lingual operators.

We have arranged a direct settlement network with certain Medical Providers in certain countries where you can receive treatment for eligible medical conditions on a direct billing basis. Please note you will still be responsible for payment of any co-Insurance or Excess at the time of your appointment.