FAQs

Is GEMS an Insurance Company?
GEMS is not an insurance company. It is a company that outsources business from Insurance Companies. Called a Third Party Administrator (TPA), GEMS offers a range of services to insurance companies among others. These could be anything from setting up and managing a network of providers to claims management and fraud control.

What is a Network Health Care Provider?
GEMS enters into an agreement with a Health Care Provider for the purpose of offering clients a cashless service. These health care providers are called Network providers. Network Providers follow certain guidelines such as providing quality treatment to our valued Insured on a priority basis. We have around 450 strong Network Providers across Bahrain & Saudi Arabia. Direct Billing Facility cannot be extended to non Network Providers. Please refer to Provider Network Section of the Website for updated List.

What is Deductible?

A deductible is the amount of money which the insured must pay before the insurance company's own coverage plan begins at the point of service.

What is Direct Billing Services?
One of the main features of TPA is extending Direct Billing Facility. It is also known as Cashless Benefit. If Direct Billing Facility is availed by an Insured, he/she need not pay any Deposit at the time of visit to a Network Provider. The Insured gets quality treatment without having to pay for the treatment and then getting it reimbursed. The Cashless benefit reduces this financial burden and helps you recover with peace of mind. The Cashless service is granted subject to the Policy terms & conditions.

What is the Procedure for Direct Billing Facility?
At the time of admission the Insured needs to show the Insurance Membership ID Card to the Network Provider. A request for Direct Billing Facility is made by the Insured through the Network Providerl in the format prescribed for the purpose. This is called a Pre-Authorization Form. After due verification of the request and subject to Policy terms, conditions & exceptions, GEMS issues an Approval to the Network Provider, thereby guaranteeing payment. After discharge the concerned provider submits all the required documents in original. The payment is released to the Health Care Provider directly by GEMS.

What is a Reimbursement Claim?
Reimbursement of Claim takes place when, after incurring the treatment expenditure from his pocket, the Insured claims payment under the Policy.

What are the Documents to be submitted under the Reimbursement Claim?

To obtain reimbursement, the member must submit the following original documents (photocopies are not acceptable). 

a: A Medical Expenses Claim Form, completed and signed by the member and the treating physician.

b: A separate Doctor's Report should be provided if a Medical Expenses reimbursement Claim Form is not completed by the treating physician as in "a" above or if the space provided in the Claim Form is insufficient to complete details of the treatment.

c: A separate medical report is required for all cases of in-patient and/or daycare treatment.

d: In addition to the Medical Expenses Claim Form Original prescription & pharmacy bills are required. These must detail the name and cost of each prescribed drug or medication.

e: Original diagnostic investigations (if any) comprising of laboratory investigation(s), X-ray etc., reports and invoices must be submitted.

f: Original receipt of payment must be provided.

What is the mode of payment and the TAT for payment of reimbursement claim?
The mode of payment is by cheque. TAT for reimbursement claim is 5 GU working days.

What is the procedure for pre-approval of reimbursement claims?
If non-emergency treatment is obtained from a provider outside the network the member should obtain pre-authorization from the GU. In this case a GU Approval Request' must be sent to GU helpdesk. The GU Helpdesk will respond to the request as soon as possible and within sixty (60) minutes of the receipt of the request.

If the original pre-authorization time and benefit is exceeded a further pre-authorization for the proposed extension period should be obtained.

When do I need pre-authorization?
Pre-authorization is required for the following:

  • Cost exceed limit on the card
  • In-hospital Admission
  • Extension of Hospital stay
  • Daycare Services
  •  MRI - CT Scan – Doppler – Holter monitor - Endoscopy
  • Physiotherapy 
  • Drugs for over two month stock
  • All dental, maternity and optical treatment
  • Non-emergency out-patient service exceeding the limit

What are the procedures/Documents required for submission of inpatient and day care claims?
For Inpatient /day care Claims:

  • Claim Form duly filled & signed by the patient & the doctor (Must be endorsed by the hospital/ clinic/ doctors stamp)
  • Doctor's prescription for medicines
  • Original Medical Bills / Invoices (detailed breakdown)
  • Membership ID card copy
  • Reports for investigations done
  • Medicines and surgical appliances bills if purchased from outside pharmacy
  • Pre-authorization form and detailed Medical Report
  • Discharge Summary - For Inpatient claim

What is meant by reasonable and Customary charges?
Reasonable and Customary Charges are medical expenses compatible with the level of fees charged by the majority of licensed doctors or Health Care Providers within the member's approved network.

What is a Claim Form?
It is a prescribed form, which is required to be submitted when Claim is lodged with GEMS for payment. It is designed to elicit all the relevant information about the claim. It is a compulsory document and should be placed on the top of claim documents. A Claim Form can be downloaded from our Website.

When can a Claim be rejected?
The claims are processed as per the Policy Terms, Conditions & Exclusions. The claims may be rejected in case of discrepancy in documents, due to non-compliance with the policy conditions and as per the Exclusion clause of the Policy.

How do I address a grievance or feedback that I may have?
GEMS makes all the efforts to ensure that the policyholders are given the utmost priority. Processing and settlement of claims with other allied activities are done at the earliest. However, even after putting in enough efforts to satisfy our valued Insured, the possibility of a grievance cannot be avoided. We have established a dedicated cell to redress such grievances. You may mail to: feedback@gemstpa.com to report any grievances.

What are the timings of your Call Centre Service:
We have got a dedicated, round the clock Call Centre for assistance to all Policy Holders throughout Bahrain and Saudi Arabia. The toll free numbers are as follows:

Bahrain: 80044367

What is the area of cover as per the policy?

Area of cover refers to the countries that you are entitled to avail treatment from as per the policy benefit/terms and conditions.

For details, please refer to "Area of cover" in your table of benefits.

What are the services covered under Dental/Maternity/Optical benefit for CCHI policies?
-Dental Benefit

The scheme covers following dental benefits for sublimit please refer table of benefits
Dental Consultation, X-ray, normal and Surgical Extractions, Root canal treatment, Gum diseases (Gingivitis/ Gingival abscess-incision and drainage/scaling for Gingivitis) and appropriate prescribed medications. All other treatments including cosmetic treatments are excluded.

Please refer to table of benefits for sub-limits.
- Optical Benefit

The scheme covers expenses for optical consultation, prescription and cost of one set of regular frame and medical lenses. Please refer to table of benefit for sublimit.
Please note Optical appliances, photo chromatic/Progressive/Anti-scratch/Multi-coating lenses, Contact lenses and other related expenses are not covered.

Please refer to table of benefits for sub-limits.
- Maternity Benefit

The scheme covers benefits from day one (1) up to expiry of the policy. Cover includes pre and post natal treatment, normal delivery, cesarean section, miscarriage and termination of pregnancy on medical grounds.

Please refer to table of benefits for sub-limits.

What is the procedure to be followed for elective treatment in their home country?
The Elective treatment is an additional benefit and refers to the treatment where in the member is entitled to avail treatment at their home country.

a) The medical condition and the procedure should have been established and procedure recommended by the treating doctor in the principal country of residence (KSA/Bahrain).

Before the member travels to the home country for treatment, the member has to get estimated quote for the procedure from the hospital in his/her home country.

b) Pre-authorization for elective treatment is mandatory.

c) The procedure and the cost has to be agreed before hand by GU.

d) If the estimated procedure/cost changes, the member has to intimate to GU and only if it is agreed and authorized by GU only then the cost would be reimbursed.

What is the procedure to be followed for emergency treatment outside the network and outside KSA/Bahrain during vacation and on business trip?
a) In case of Emergency you should use the nearest medical provider.

b) If the medical provider is non designated/Outside KSA/Bahrain you must advise Gulf Union promptly taking into account your physical condition. Gulf Union will then advise you on pre-authorization and will liaise with you and the medical provider regarding your treatment.

c) In an emergency we would not expect the insured to contact us before hand. However please ask someone to contact us as soon as practical so that we are made aware of your case.