In implementation of the Co-operative Health Insurance Law promulgated by Royal Decree M/10 dated 1/5/1420 H., and the Bill of Implementation thereof passed by virtue of the Resolution of the Minister of Health bearing number _______ dated _______ in this respect, and whereas the policy holder has made a written application to the company (name of the insurance company) (hereinafter referred to as the “Company”), which application shall constitute the basis of such policy and an integral part thereof, for the purpose of effecting the insurance hereinafter described to him and his dependents or to his staff and their dependents whose names are listed on the list attached to this policy hereinafter referred as the “Insured”, and whereas he has paid or accepted to pay the subscription, the company agrees pursuant to what has been indicated above with the policy holder to cover the expenses of providing the insured with health care in accordance with this policy, and to the extent and in the manner indicated therein. through a network of service providers appointed by the insurance company, subject always to the stipulations, definitions, limitations and limits of the cover included in this policy and in any additional endorsements (acknowledged by the Co-operative Health Insurance Section).

Section One- Definitions:

For the purposes of this insurance the following words and expressions shall be interpreted wherever they appear in the policy, endorsements or attachments thereof in accordance with the definitions specified below:

1- “Accident”: An accidental injury or an unexpected accident which takes place during the insurance term.

2- “Illness”: The sickness or disease affecting the person insured which necessarily requires medical treatment by a licensed physician during the term of insurance.

3- “Allergy”: The allergy of an individual, in particular, to certain types of food, climate, dust or other causes such as plants, insects, animals, metals, elements or other substances whereby the individual suffers from physical reactions caused by direct or indirect contact with such substances, thereby resulting in cases such as asthma, indigestion, itching, hay fever, axima and headache.

4- “Beneficiary (insured)”: The person covered by the law (the employee or the dependent listed on the insured persons schedule attached to this policy).

5- “Benefit”: Expenses to provide the health service covered by the insurance within the limits indicated in the policy schedule.

6- “Premium (subscription)”: Is the amount payable by the policy holder against the insurance coverage provided by the policy during the insurance term.

7- “Congenital deformity”: The physiological, chemical or structural defect that is usually inherent prior to delivery, either by inheritance or as a result of environmental factors.

8- “Insurance Coverage”: Are the basic health benefits available to the beneficiary which are specified in the insurance policy attached to this Bill.

9- “Deductible Percentage/Participation in Payment”: Is that part fixed in the policy schedule) which is payable by the beneficiary (insured) in the event of treatment at the out patient department.

10- “Employee”: Any person who is actually carrying out work for the policy holder and registered in that capacity in the policy holder’s records who has not reached the age of 65 at the time of joining the insurance cover.

11- “Dependent”:
a) Husband/Wives registered in this capacity in the policy holder’s records who is/are legally residing in the Kingdom of Saudi Arabia.
b) Children of the employee or children of either the husband or wives or the children who are legally sponsored and living in the Kingdom of Saudi Arabia and who are relying for their subsistence on the employee and are registered in that capacity in the policy holder’s records.

12- “Documents in Support of Claim”: All the documents that prove and support the age of the person insured, his nationality, identity, validity of the insurance coverage, implications of the accident out of which that claim has arisen and payment of the cost. They also include other documents such as police report, invoices, receipts, prescriptions, doctors' report, referral, recommendations and any other original documents that may be requested by the company.

13- “Ground for a Direct Debit or at Company’s Expense”: These are the non-payment facilities made available to the insured person with service providers appointed by the company whereby all those expenses are directly debited against the company’s expense.

14- “Commencement Date”: The date indicated in the policy schedule at which the insurance cover starts.

15- “Validity date”: The date fixed by the Policy holder and agreed to the company for the start of providing cover to the person under this policy or for adding or deleting an insured person from the policy.

16- “Annex”: A document by the company on an official form which is dated and signed by an authorized employee as evidence of the authenticity of any amendment to the policy so that it does not affect the basic cover made in response to a written request by the policy holder.

17- “Hospital”: An approved health facility acceptable to the policy holder and the company which is licensed to operate as a hospital in accordance with the laws in force for the purpose of extending treatment in respect of the costs of which a claim for compensation may be made under this policy. The word “hospital” in this policy shall not include hotels, motels, guest houses, rest houses, recuperation centers or asylums or places offering care to detained persons or old folks homes or mentally deranged homes or any other place which is basically used for the habilitation and treatment of drug addicts or alcoholics.

18- “Hospitalization”: Registration of the person insured as a patient hospitalized in a hospital until the morning of the following day in accordance with a referral made by a licensed physician.

19- “Insurance”: The evidence showing the existence of an insurance cover under this policy together with the schedule and annexes or attachments thereof.

20- “Licensed Physician”: A medical practitioner following his obtainment of the qualification who is licensed by law to practice medicine and who is qualified and accepted by the policy holder and the company for the purpose of treatment in respect of the material costs of which a claim for compensation may be made under this policy.

21- “Limits of Coverage”: The maximum limit of the company’s liability as indicated in the policy schedule with regard to any insured person before the application of any deductibles.

22- “Service Provider”: The person or health facility which is approved and licensed according to the prevalent laws to extend medical services in the Kingdom e.g. hospital, diagnostic center, dispensary, pharmacy, laboratory, physical therapy center or radio therapy center.

23- “Pregnancy and Delivery”: Any condition of pregnancy and or delivery arising out of a lawful matrimonial relationship.

24- “The One Day Surgery or Treatment”: The surgery or treatment that necessarily requires preparation prior to hospitalization in a hospital, or a one day treatment center but which does not require hospitalization until the following day.

25- “Out-Patient Treatment”: Visits made by the person insured to the out patient departments for the purpose of diagnoses or medical treatment from an illness.

26- “Service Providers Network”: A group of health service providers approved by the cooperative health insurance board and specified by the insurance company for the purpose of extending service to the employer/policy holder and directly debiting the insurance company’s account upon production by the insured of a valid insurance card, provided that this network shall include the three healthcare standards:
• First standard for extending health services (elementary health care).
• Second standard for extending health services (general hospitals).
• Third standard for extending health services (specialist or referential hospitals).

27- “Validity Term”: The number of days during which the policy shall remain valid in the event of non payment of the full subscription indicated in the schedule.

28- “Insurance Term”: Means the period indicated in the policy schedule during which the insurance shall remain valid.

29- “Policyholder”: The natural or juridical person in whose name the policy has been issued.

30- “Reasonable and usual medical expenses”:
a) The medical expenses which are in line with the standard of fees charged by most licensed doctors or hospitals in the Kingdom, provided that such fees shall be for a similar condition and that such licensed doctors or hospitals shall be similar in terms of qualification and status to those who have provided the treatment.
b) Medical treatment that is not radically different from what the licensed physician considers acceptable as normal and natural for any specific illness in respect of the medical expenses of which a claim is made under this policy.

31- “Basis for compensation”: This is a method followed to compensate the policy holder for the refundable expenses borne by the insured and in respect of which he files a claim after applying the deductible percentage.

Section Two- Refundable expenses/benefits:

For the purpose of this policy refundable expenses shall mean the actual expenses paid for services, materials and equipment that are not excluded by section 3 which are prescribed by a licensed physician for an illness affecting the insured person, provided that the expenses shall be necessary, reasonable and customary at the time and place where they had been expended. Consequently, refundable expenses shall include the following:

1. Health benefits a) All expenses for medical examination, diagnosis, treatment and medicaments pursuant to the policies schedule. b) All hospitalization expenses, including surgical operations, one day surgery or treatment and delivery. c) Dental treatment. d) Preventive procedures that are determined by the Ministry Health such as vaccinations, maternal care and child care.

2. Cost for transporting the body of the insured person to his home country.

Section Three- Restrictions and Exceptions:

a) This policy shall not cover the claims that arise out of the following:

1. Injury intentionally caused by the person to himself.

2. Illness that arises out of misuse of some medicaments, stimulants, depressants, or as a result of using alcohol, drugs or the like.

3. Cosmetic surgery or treatment unless necessitated by an accidental physical injury that is not excluded under this section.

4. Comprehensive check ups, inoculations, drugs or preventive means that are not required by medical treatment provided for in this policy (with the exception of the preventive measures determined by the Ministry of Health such as vaccination, maternal and child care).

5. Pregnancy and delivery treatment of a female under contract on the basis that she is not married.

6. Treatment received by the insured person free of charge.

7. Recuperation and general physical health programs and treatment in social welfare homes.

8. Any illness or injury arising out as a direct result of the profession of the person insured.

9. Treatment of venereal diseases or those that are contracted by sexual contact and are medically known.

10. Expenses for post diagnostic treatment (HIV or HIV related illnesses such as aids, the derivatives or equivalents thereof or their other forms).

11. All costs relating to tooth implant, prosthodontics, fixed or moveable dentures or orthodontics with exception of those caused by external violent means.

12. Vision or hearing correction tests and auxiliary audio visual aids unless required by the order of a licensed physician.

13. Costs of transport of the person insured by means of transport other than local ambulances that are licensed or that belong to the Saudi Red Crescent Society.

14. Loss of hair or bolding or wigs.

15. Physiological treatment or mental or nervous disorders with exception of acute cases.

16. Allergy test regardless of the nature thereof with exception of those relating to medicaments, diagnoses or treatment.

17. Equipment, means, drugs, procedures or hormone treatment with the aim of birth control, termination of pregnancy, sterility or sexual weakness or infertility or insemination by tubes or other means for artificial insemination.

18. Any congenital weakness or deformity existing prior to the commencement of the policies validity and does not pose a danger to life.

19. Any additional costs or expenses incurred by the person accompanying the insured while hospitalized or while staying at a hospital except for accommodation costs and catering at the hospital for one companion for the insured such as when a mother is a companion to her child is below 12 or when it is medically necessary according to the discretion of the treating doctor.

20. Treatment of pimples (acne) or any treatment relating to obesity.

21. a) Cases of transplants, marrow transplant or implants of replacement artificial, parts that replace any part in the body.
b) This policy shall not cover health benefits and repatriation of the body to the home country in the case of claims or directly arising out of:

1. War, invasion, acts of foreign enemy, acts of aggression (whether war has or has not been declared), civil war.

2. Ironic radiation or pollution by radio activity generated by any nuclear fuel or waste resulting from nuclear fuel combustion.

3. Radio active, poisonous or explosive characteristic or any other dangerous characteristics for any nuclear complexes or any of their nuclear components.

4. Engagement by the person insured or participation in the service of the armed forces, police or the operations thereof.

5. Acts of riots, strikes, terrorism or the like.

Section Four- General Conditions:

1. Proof of validity: This policy represents the basic limit of insurance coverage extended to the insured persons. This policy shall not be valid unless that is proven by a schedule signed by an employee who is officially authorized by the company. Furthermore no addition to it shall be valid unless proven by an addendum signed by an employee who is officially authorized by the company.

2. Records and Reports: The policyholder shall maintain a register for all the employees and their dependents who are insured under this policy which register shall contain in respect of every person the full name, sex, age, nationality, classification and other basic information which may have an effect on the management of such insurance and on the report in relation to the subscription rates. The company should have the chance - whenever it so desires - to inspect these records and to insure that the information given by the policyholder is authentic. The company also undertakes - whenever required to do so - to provide the policyholder with any information that he may wish to have in relation to the persons insured.

3. Those eligible for insurance:
a) As regards employees - Any person who satisfies the definition of an employee shall be eligible for insurance pursuant to what has been provided for by the schedule to this policy.
b) As regards dependents - Any person who satisfies the definition of a dependent shall be eligible for insurance pursuant to what has been provided for in the schedule of the policy provided that that person is being maintained by an eligible employee.

If any person who is defined as a dependent is also eligible for insurance in his capacity as employee, then his enjoyment of the insurance as a dependent would cease under this policy and when either a husband or a wife are permanently living together and enjoy insurance coverage in their capacity as employees, then the children would become only eligible as dependents of the husband.

4. Payment of subscription:
a) The policyholder undertakes to pay the insurance subscription which is payable for every insured person at the beginning of the insurance coverage or as agreed with the company.
b) In event of non-payment of any part of the subscription, the policy shall not remain valid for a period longer than that covered by the paid part of the subscription, and in such a case the company shall be obliged to inform the cooperative health insurance board of the same.

5. Dates of validity of coverage:
a) As regards employees: The validity of the coverage shall start as regards an employee who is actually at work as of the commencement date fixed in the policy schedule. Any person who joins work at a later time shall have his coverage start as of the date of joining work with the policyholder or upon arrival in the Kingdom.
b) As regards dependents: The validity of the insurance coverage as regards dependents shall start as of the date on which the employee and the person responsible for their maintenance becomes insured or on the date at which they have acquired the capacity of dependents for the first time.

6. Addition and deletion of “insured persons” and “subscription” relating to that:

a) The policyholder shall immediately inform the company in writing of all the employees or dependents who are intended to be covered by insurance following the commencement date of the policy, and the company shall calculate the additional subscription that is immediately payable in respect of the persons who are listed in the schedule of the insured persons on pro-rata basis as of the date of their inclusion in the coverage.

The policyholder must inform the company in writing within 30 days of the required date of termination about all the insured persons (employees and/or dependents) whose insurance coverage expires before the expiry of the insurance term, the company shall not have the right to refund the pro-rata part of the subscription relating to these persons in respect of the remaining period of insurance unless the policyholder provides the company with evidence that the insured person has left the Kingdom in the event of leaving the Kingdom for good or evidence that the insured is covered by another insurance coverage program acceptable to the cooperative health insurance board in the event of the transfer of his sponsorship.

7. Expiry of the Insurance Coverage of the Insured:

A) As regards employees: The insurance of any employee under this policy shall automatically come to an end in the following cases:
1) If the policy term expires as indicated in the schedule. 2) On the date on which the employee reaches the age of 65. 3) Upon the exhaustion of the maximum benefit provided for in the policy.

B) As regards dependents: The dependents coverage under this policy shall automatically come to an end in the following cases: 1) When the dependent has lost his insurance capacity as a dependent pursuant to the provisions of Article 11/b of the definition as per Section 1 of the policy. 2) If the policy term ends as indicated in the schedule. 3) On the date on which the dependents reaches the age of 65. 4) Upon the exhaustion of the maximum benefit provided for under this policy.

c) Payment of the refundable expenses as regards any existing illness which has led to the continuation of hospitalization upon the expiration date of the coverage shall remain for the period required by the illness provided that it shall not exceed 365 days as of the commencement date of that illness which necessitated hospitalization and within the coverage amounts contained in the policy schedule.

d) In the case of terminating this policy for any reason that makes it incumbent upon the policyholder to immediately return to the company all of the issued health insurance cards relating to the ground of directly debiting the company’s account with the appointed service providers network. This is also the case with regard to any insured person whose coverage term ends whereby the policyholder shall be responsible for reimbursing the company for all the medical expenses and costs resulting out of his negligence to comply with the same.

8. Subrogation in rights:
a) The company shall have the right - and must have the opportunity - through an approved medical authority to examine the person insured in respect of whom a claim for refundable expenses had been presented, twice at the most within 60 days of the date of receiving the claim.
b) The policyholder or the person insured shall cooperate and allow at the company’s expense the necessary work that is reasonably required by the company for the purpose of consolidating any rights, claims or legal compensation from a third party.

9. Non duplicity of benefits: In case of a claim for refundable expenses payable to an insured person under this policy who is also covered with respect to such expenses under any other scheme, program, insurance or the like, then the insurance company shall be responsible for covering such expenses and shall subrogate the insured person in claiming from the third parties payment of their proportional share of such claim.

10. Ground for direct debiting of the company’s account with the appointed service provider’s network. The company shall issue a health insurance card to every insured person who shall have the right there under to receive health service with the appointed service provider network without being asked to pay costs for such services.

The appointed service providers shall send to the company monthly all of the medical expenses incurred under the policy. The company shall assess and process such expenses and inform the policyholder when the expenses have reached the maximum limit of benefit and should this limit be exceeded then the company shall have the right to claim the recovery of such expenses within a period not exceeding 60 days of the date of notifying him of the same.

Where a policyholder fails to return such expenses to the company within the period specified then the company shall have the right to put the matter before the cooperative health insurance board to take necessary action. The company shall have the right to delete or replace any or all of the appointed service providers for the purpose of this policy within the term of validity thereof provided that the policyholder shall agree, and appoint a replacement for them of the same standard.

11. Deductible: Without prejudice to the facilities granted under the direct debiting of the company’s account, it is a binding and obligatory stipulation for the insured person to pay the deductible amount at the service center. Any attempt on the part of the insured person to abstain from payment shall be regarded as a breach of the provisions and conditions of the policy and shall render it null and void as regards that person until such deductible amount has been paid.

12. Ground for payment of fee: In emergencies the person insured may obtain emergency medical treatment outside the centers and hospitals approved on the ground of the payment of a fee, and in such a case the company shall - pursuant to the provisions, conditions, restrictions and exceptions of the policy - compensate the policyholder for the refundable costs and expenses on the conditions that the company shall be provided within 30 days of incurring such expenses with the supporting documents requested by it.

13. Cancellation: It shall be permissible for the policyholder to terminate this insurance at any time by a written notice to be sent to the company at least 30 days before the required date of termination. In such a case the policyholder shall be obliged to provide the insurance company with proof of:

a) Conclusion of another insurance policy with a qualified company or that the insured persons are medically covered by virtue of another insurance coverage scheme acceptable to the cooperative health insurance board so that the new coverage shall start on the day following cancellation of the previous policy in the event of a transfer of sponsorship.

b) Final departure of the person insured from the Kingdom. In such case the company shall be obliged within 60 days of the termination date to return to the policyholder that remaining part of the subscription in respect of every insured person whose claims have not exceeded 75% of the annual subscription value so that the returned part of the subscription shall be calculated on the pro-rata basis: (returned part equals annual subscription over 365,25 days * no. of remaining days)

Should the policyholder stop return of the expenses exceeding the maximum benefit line within the period fixed under condition no. 10 of the general conditions of the policy which has a reason as a result of work on the basis of directly debiting the company’s account, then the company shall have the right to refuse the return of refundable subscriptions, if any, and to use the same primarily for compensating the expenses paid to the treatment providers which the policyholder should have paid to the company.

14. Approvals: Reply to the request for approval by the insurance company to the service providers to provide health service to the beneficiaries must be made within a period not exceeding 60 minutes from the time of requesting the approval.

15. Gender: For the purposes of this policy the words used in the masculine gender shall also apply to the feminine gender.

16. Notifications:
a) Every notification or other correspondence of the company required under this policy shall be in writing or printed.
b) The company is not obligated at all to inform the policyholder of the date of termination of the policy term.

17. Compliance with the policy provisions: It is a condition precedent for the realization of any obligation on the company for the policyholder and the persons insured to have executed and fully complied with all of the stipulations, conditions, duties and obligations contained in this document.

18. Settlements of disputes: Any difference or dispute that arises out of or that relates to this policy shall be decided upon by the cooperative health insurance board and the committees set up by a resolution of the Chairman of the Cooperative Health Insurance Board to consider violations against the provisions of the law in accordance with Article (14) of the cooperative health insurance law.