0012314566
Chapter I: Definitions

​Article (1):

The following terms shall have the meanings assigned to them:

  1. system: the cooperative health insurance system in the Kingdom of Saudi Arabia.
  2. Board: The Cooperative Health Insurance Council established under the provisions of Article IV of the system.
  3. Secretariat: the Executive Council.
  4. Organization: Saudi Arabian Monetary Agency.
  5. Social Insurance: Insurance applicable under the social security system, and implemented by the General Organization for Social Insurance.
  6. Health Insurance: Health Insurance is a cooperative referred to in the system.
  7. The employer or sponsor: the natural person or legal entity that uses one or more workers.
  8. Policyholder: The person or entity who issued the document in his name.
  9. the insured (the beneficiary) is the person covered by the System and the insured with an insurance company.
  10. dependent / dependents: the husband or wife and male children under the age of eighteen and unmarried daughters.
  11. the insurance company: cooperative insurance company authorized to operate in the Kingdom of Saudi Arabia by the institution and that have been rehabilitated for the exercise of the cooperative health insurance by the Council.
  12. Service Provider: the health facility (government / non-government) adopted by the Council, in accordance with applicable regulations, to provide health services in the Kingdom, for example, a hospital or diagnostic center, clinic, pharmacy or laboratory or a physical therapy center or radiation therapy.
  13. network service providers supported: is a group of health service providers accredited by the Council of Cooperative Health Insurance designated by the health insurance company to provide service to the employer / policyholder is the constraint directly at the expense of the insurance company upon presentation of the insured insurance card valid to include This network of the three levels of health care: - The first level of provision of health services (primary health care). - The second level of provision of health services (public hospitals). - The third level of provision of health services (specialized hospitals or reference).
  14. claims management company health insurance: the insurance companies settle claims and authorized to work in Saudi Arabia by the institution and that were qualified to practice management cooperative health insurance claims by the Council.
  15. Index: is a cooperative health insurance policy adopted by the Council's core attached to this list, which includes the benefits and limitations and exceptions and general conditions issued by the insurance company provides insurance under the request of the employer (policy holder).
  16. the premium (subscription): is the amount due performance of the company by the policyholder against the insurance coverage provided by the policy during the period of insurance.
  17. insurance coverage: is a basic health benefits available to the beneficiary specified in the insurance policy attached to these Regulations.
  18. Utility means the expenses of providing the service covered by health insurance coverage within the limits set forth in the policy schedule.
  19. percentage deduction / endurance (co-payments) are to be part of performance (specified in the table of the document) that must be paid by the beneficiary (the insured) when you visit the doctor.
  20. of the emergency: medical treatment required by medical necessity for the beneficiary after an accident, or a health emergency requiring rapid medical intervention.
  21. claim: is the set of financial and medical documents provided by the service provider (and in some cases, the insured or policy holder) to the insurance company to collect the costs of health services obtained by the insured.
  22. Fraud: deliberate deception by a person or entity for the utilization of health care and distort the facts, or intentional deception resulting in access to benefits or the provision of benefits are excluded or exceed the permissible limits to the individual or entity.
  23. abuse: a deliberate practices by individuals or entities may lead to the benefits or advantages is not eligible for them, but without intent of fraud, fraud, or deliberately lying and distorting facts in order to obtain benefit.
  24. Model contract to provide health care services: is the contract of work approved by the Council, the Parties to the relationship of insurance, use it to regulate the relationship between the company and the service provider Subject to the provisions in the text of Article No. (78) of these Regulations.

Last Update : 11/30/2016 12:16 PM