Bill of Implementation of Health Co-operative Insurance

Chapter One: Definitions

Article 1:

The following expressions shall have the meanings indicated opposite to each one of them:

1) Law: The Health Co-operative Insurance Law in the Kingdom of Saudi Arabia.

2) Board: The Health Co-operative Insurance Board set up pursuant to the provisions of Article 4 of the law.

3) Secretariat General: The executive organ of the Board.

4) Control Party: The Health Co-operative Insurance Board and the other organs determined by the State to control the insurance activities.

5) Social Insurances: Insurances applicable pursuant to the social insurances law which are implemented by the General Organization for Social Insurance.

6) Employer: Natural or juridical person who employs one or more employees.

7) Policy Holder: Natural or juridical person in whose name the policy was issued.

8) Dependant: Husband, wives, male children under the age of 18 and unmarried daughters.

9) Insurance Company: The insurance company licensed to operate in the Kingdom which has been rehabilitated to carry out health cooperative insurance activities by the Board.

10) Insured (beneficiary): The person covered by the law and insured with an insurance company.

11) Health Insurance: Is the Health Co-operative Insurance referred to in the law.

12) Emergency: Medical treatment that is medically required for the beneficiary following an accident or an emergency health condition requiring rapid medical intervention.

13) Insurance Coverage: Are the basic health benefits available to the beneficiary which are specified in the insurance policy attached to this bill.

14) Policy: Is the basic health co-operative insurance document approved by the Board and attached to this board which contains the outlines, benefits, exceptions and general conditions, and is issued by the Insurance Company pursuant to an insurance application made by the employer (policyholder).

15) Premium (subscription): Is the amount payable to the company by the policyholder against the insurance coverage provided by the policy during the insurance period.

16) Deductible: Is the part which is payable (specified in the policy endorsement) which must be paid by the beneficiary (insured) when visiting a physician.

17) Benefit: Means the expenses to provide the health service under the insurance coverage within the limits indicated in the policy endorsement.

18) Service Provider: A person or health facility that is approved and licensed in accordance with the laws in force to provide health services in the Kingdom e.g. a hospital or a diagnostic center or a clinic or a pharmacy or a laboratory or a physiotherapy center or a radiology center.

19) Approved Service Providers Network: This is a group of health service providers approved by the Health Co-operative Insurance Board specified by the health insurance company to provide service to the employer/policyholder. This takes place by directly debiting it to the account of the insurance company, provided that this network shall include the three levels of health care:

- First level to provide health services (first health care(

- Second level to provide health services (general hospitals(

- Third level to provide health care (specialist or referential hospitals).

Chapter Two: Beneficiaries )Insured(

Article 2:

The following categories shall be subject to health insurance:

(1) All non-Saudis working for a wage, whether with others or for their own account without regard to the standard of their incomes, nature of their work or a period of employment.

(2) All non-Saudis who are not working but living in the Kingdom.

(3) Family members who are the dependents of the persons indicated in paragraph 1 and 2 of this Article and who are in possession of a residence permit in the Kingdom.

Article 3:

The following shall be excluded from national insurance provided for under Article 2 of this bill:

(1) All non-Saudi employees working for government organs and departments whose statutes do not permit the conclusion of contracts with private hospitals for the treatment of their employees so long as the employees are under the sponsorship of such departments, and who are linked by employment contracts with the same provided that their contracts stipulate that medical treatment shall be provided at a government hospital. He whose employment contract does not provide for the rendering of health service is obligated to obtain special insurance to cover his basic health needs.

(2) All non-Saudi employees working with the private sector under employment contracts which provide that medical treatment shall be extended at the competent health facilities of the employer. Should medical treatment be impossible to provide at the utilities owned by the employer, including emergencies, the employer shall be obligated to provide supplementary insurance coverage.

(3) Family members who are the dependent of the employees specified under paragraphs 1 & 2 of this Article.

The scope of the (medical) treatment indicated in the abovementioned paragraphs shall be in conformity at least to the provisions of Article 7 of the law and compatible with the standard of quality contained in this bill.

Article 4:

Pursuant to Article 3 of the bill, the Board shall determine the following:

(1) Government organs and departments.

(2) Employers employing persons who are exempted from health insurance based on an application filed by them. The board shall determine the extent of the conformity of the medical treatment provided by such government organs and departments as well as employers to the scope and standard of health services which must be made available pursuant to this bill.

(3)The cases in which it is not absolutely clear whether the provisions of Article 3 apply to any of the employees or companions then the board shall take the appropriate decision in this regard upon a request to be made by the employer.

(4)The justifications calling for the elimination of the exemption from the provisions of paragraph 2 of this Article, and in such a case the employees and their dependents shall be subject to the provisions of the law within the abovementioned determination.

Chapter Three: Insurance Cover of the Law

Article 5:

a- The employer shall be obligated to conclude a health insurance policy with one of the insurance companies covering the beneficiaries present in the Kingdom or any new recruits who are subject to this law.

b- Qualified insurance companies shall not be allowed to reject any request for cooperative health insurance so long as such was within the limits of its financial capabilities.

Article 6:

Insurance companies shall issue a certificate to the employer (policyholder) indicating that its employees had been provided with insurance for the purpose of submitting the same to the authority that is competent to issue residence permits and to renew the same. The board shall specify the content of such a certificate.

Article 7:

In case that no residence permit is issued to the beneficiary, then his name shall be deleted from the cooperative health insurance policy as of the date of his final exit. The premium due for the insurance period shall be calculated in accordance with the basis provided for in the policy.

Article 8:

The beneficiary shall be given a copy of the insurance policy, the health cover of which must not be lower than the basic cover provided for by the law.

Article 9:

An employer may change the insurance company with which it had concluded a contract for the purpose of providing insurance cover, provided that it shall direct a letter to this effect to the insurance company at least one month before the date of the required cancellation. That part of the insurance premium that has been returned shall be calculated on pro-rata basis, and the employer (policyholder) shall be obligated to return the insurance cards on the cancellation date and to conclude another insurance policy to provide insurance cover so that it shall start as of the date following the cancellation of the policy.

Article 10:

Upon the transfer of a person who is subject to cooperative health insurance to work for another employer, the new employer shall be obligated to insure him as of the date of his transfer and shall extend the insurance certificate as one of the grounds for the transfer of sponsorship.

Article 11:

The health insurance cover shall include the benefits specified in Article 7 of the law and the scope of the provisions contained in Chapter 4 of this bill. The policy shall fix the time for the treatment and the maximum limits of the amount of the insurance cover, the restrictions, benefits, exemptions and general conditions of the insurance cover.

Article 12:

The benefits of insurance cover shall include pregnancy and delivery of those under contract on the basis of married - person contract within the limits indicated in the policy.

Article 13:

The health insurance cover shall be confined to the services rendered in the Kingdom of Saudi Arabia which are made available by the approved service provider’s network with which the insurance company is linked by health services contract.

Article 14:

The employer shall be obligated to affect insurance cover to the beneficiary as of the arrival date to the Kingdom, and to deliver to him the insurance card within a period not exceeding 10 working days as of the date of his arrival. However, newly born babies born in the Kingdom of Saudi Arabia during the validity of the policy shall be retrospectively under the insurance cover as of the date of delivery.

Article 15:

Insurance shall terminate upon the death of the beneficiary or the expiration of the policy period or the cancellation thereof or upon the departure of the beneficiary from the Kingdom for good.

Article 4: Benefits (Benefits in kind and recovery of cost)

Article 16:

The beneficiary shall obtain the benefits indicated in the policy in the following manner:

1) Diagnoses and treatment by the service provider provided that the beneficiary shall bear the deductible amount specified in the policy as a share payment or in the amounts that exceed the limits of the cover.

2) The sums of money for the costs of necessary and emergency medical treatment where he had directly borne these costs provided that the insurance company was not able to make such service urgently available within the reach of the beneficiary or where the insurance company had wrongly refused to provide him with the service. The return of the costs shall be to he who had borne the treatment expenses within the limits provided for in the policy and within the limits that are paid by the company to a service provider of the similar standing.

Article 17:

The right to claim the benefits shall start as of the date of the beginning of the insurance cover pursuant to the provisions of Article 14 of this bill.

Article 18:

There shall be no waiting periods as regards the entitlement to the benefit at the beginning of the insurance. The extension of the benefit after the start of the insurance cover shall include the conditions which had arisen in the period preceding the start of the insurance cover, so that if the beneficiary arrived in the Kingdom to receive treatment from an illness and not for work then the insurance cover shall not extend to the cases which had arisen prior to the start of the insurance cover.

Article 19:

The right to make use of the benefits shall cease upon the expiration of the insurance cover pursuant to the provisions of Article 15 of this bill and this shall include the insurance case which have not been decided upon and where the decisive factor in providing the service by the insurance company is date of benefiting from the services provider.

Article 20:

The insurance benefits shall cover basic vaccination and inoculations of children up to the age of joining school and as per the decisions of the Ministry of Health which vaccinations and inoculations shall be given by a contracting services provider.

Article 21:

Health service and medical care shall be rendered by a network of service providers included on the list attached to the insurance policy handed out to the beneficiaries and approved by the insurance company and policyholder.

Article 22:

The insurance cover shall include accommodation and catering at hospitals for one companion of the beneficiary such as a mother accompanying her child up to the age of 12 or where there is a medical necessity as per the discretion of the treating physician.

Article 23:

Only in emergencies shall the cost of transporting beneficiaries such as patients or pregnant women to the nearest appropriate site to receive treatment shall be covered. The transportation should be by licensed ambulance services or those of the Saudi Red Crescent Society.

Article 24:

Every beneficiary who benefits from medical services shall be obligated to share in the payment of the treatment costs at the service centers according to what is indicated in the policy with the exception of first aid cases and hospitalization.

Article 25:

It shall not be permissible for a medical service provider to waive the amount of participation in payment either by adding to the final amount payable by the insurance company or by giving it as a discount to the beneficiary.

Article 26:

The participation in payment by the beneficiary must be paid to the health service provider against a receipt.

Article 27:

Beneficiaries may not claim the benefits under the policy unless such benefits are of the basic covers provided for in the policy or in the additional covers which the beneficiary had obtained in accordance with Article 8 of the cooperative health insurance law.

Article 28:

There shall be no claims for health services in the case of an illness if such services were rendered following an accident at the place of work or occupational illnesses within the definition contained in the social insurance law.

Article 29:

Should the insurance company provide such health services and should it become clear later that the occupational hazards branch of the general social insurance organization must cover such services, then the general social insurance corporation shall reimburse the insurance company for the expenses it had paid.

Article 30:

Should the General Social Insurance Organization extended health services to a person who is under an insurance contract with the health insurance company even though the later is obligated to perform such services, the insurance company shall be obligated to reimburse the General Social Insurance Organization for the expenses that had risen in this regard, and the reimbursement shall be within the limits undertaken by the insurance company in providing services not included in the social insurance law.

Article 31:

The General Social Insurance Organization and the Insurance Company may conclude a contract between them which provides for the taking specific measures to meet the services contained in Article 29 & 30.

Article 32:

If any beneficiary has any claim against a third party relating to compensation for damage caused an illness or an accident, then the rights of beneficiaries in such a case shall be transferred to the insurance company as regards the costs that had been borne by the insurance company resulting from the extension of health service to the beneficiary.