Chapter Four: Benefits: (Benefits in kind and Refund of Cost) 

Article 16: Beneficiary shall be entitled to the benefits specified in the policy as follows:

1-      Diagnosis and treatment provided by the service provider. Deduction! portability amount shall be borne by the beneficiary as shown in the policy i.e. the amounts in excess of the coverage limit.

2- The amounts representing the cost of the necessary medical and emergency treatment if the beneficiary has to bear such costs directly provided that the insurance company is unable to make such services available immediately to the beneficiary or in the event of refusal by the insurance company to provide such services without a valid reason. The refund of cost to those who incur treatment expenses shall be in accordance with the limits set forth in the policy and to those paid by the company to a service provider of similar standard.

Article 17: The right to claim benefits shall commence on the effective date of insurance coverage in accordance with the provisions of article (14) of these rules.

Article 18 : There shall be no waiting periods without the right to benefits at the start of insurance, this includes providing benefits after the commencement of the insurance coverage 'to cases dating back to a period preceding the effective date of coverage. If the beneficiary has come to the Kingdom for treatment and not for work, the insurance coverage shall not extend to the cases preceding the effective- date of insurance coverage.

Article 19: The entitlement to benefits shall terminate with the termination of the insurance coverage according to the provisions of article (15) of these rules, This shall include undecided

         insurance cases. The decisive. factor for the commitment of the insurance .company to service is the date of providing such service by the service provider.

Article 20: The insurance benefits shall cover basic baby inoculations and vaccinations upto school age which, a contracted service provider must provide in accordance with the resolutions of the Ministry of Health.

Article 21: Health Services and Medical treatment shall be provided by the service providers network listed in the schedule attached to the insurance policy which shall be delivered to the 'beneficiaries and approved both by the insurance company and the policy holder.

Article 22: The insurance coverage shall include the stay and cost of food in hospitals for one person escorting the beneficiary such as, the accompanying of the mother of her child (upto age twelve) or when medical requirements necessitate such escort according to the sole discretion of the treating physician.

Article 23: In emergency cases only, the cost of transport of beneficiaries such as, patients or pregnant women to the nearest facility for treatment shall be covered. Transport shall be by ambulances licensed or belonging to the Saudi Red Crescent Association.

Article 24: Every beneficiary benefiting from medical' services shall contribute in the payment of cost of treatment at service centers as shown in the policy with the exception of emergency and hospitalization cases.

Article 25: Medical service provider may not waive the contribution amount by adding such amount to the final sum to be paid by the insurance company or by offering it as a discount to the beneficiary.

Article 26: The contribution in payment to tl1e health service provider by tl1e beneficiary must be made against a receipt.

Article 27: Beneficiaries may not claim benefits under the policy unless such benefits are basically covered as stipulated in the policy or in as stated in the additional coverage tl1ey have obtained under article eight of the cooperative health insurance system.

Article 28: No demand for health services shall be raised in case of illness, if such services were provided following an accident in the place of work or during the break out of occupational diseases within the definition set forth, in the Social Insurance Regulations.

Article 29: If the insurance company is providing such health services and it was found out that the Occupational Hazards Branch of GOS1 must cover such services, GOSI shall indemnify the insurance company for expanses incurred.

Article 30: If GOSI provides health services to a person who has an insurance contract with a health insurance company despite the fact. that the latter shall be obligated to provide such services, the insurance company shall compensate GOSI for the expenses incurred. Compensation shall be within the limits of services the insurance company is committed to provide to those non covered by social insurance regulations.

Article 31: GOS1 and the Insurance Company may conclude mutually a contract providing for taking certain measures to Tender the services set forth in articles (29) and (30).

Article 32: If a beneficiary has any claims against a third party relating ~ to indemnities for damages resulting from a disease or an accident the dues and rights of the beneficiaries "- shall be transferred to the insurance company including costs incurred by the insurance company as a result of providing health services to the beneficiary.

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Chapter five: Financing the Insurance Companies

Article 33: Premiums and additional fees being collected and investment returns shall be listed in the insurance companies revenues.

Article 34: Every insurance company shall comply with the resolutions adopted by the Council in coordination with other supervisory bodies to provide technical allocations generally accepted in the insurance sector.

Article 35: A- The insurance premium (contribution) shall be fixed by agreement between the insurance company and the employer.

B- If premium value is different from that stated in the work plan of the company, the latter shall seek the approval of the Secretariat

         General of the Council en the premiums value and the Council may review the premium from time to time.

C- The maximum benefit limit for every beneficiary shall be SR two hundre4 fifty thousand only.

Article 36: Employer shall pay the premiums on behalf of his (contracted) employees and their dependents to the insurance company he selects for this purpose. This applies to persons not working or their dependents. Employer will be solely responsible for payment of premiums that must be paid at the beginning of every new insurance year unless otherwise is agreed upon.

Article 37: In the event of non-payment of premiums on the dates agreed upon, the insurance company may terminate the policy  when its validity date comes to an end, recover the insurance cards and collect the premium due. Insurance company shall notify the Council and the authorized service providers network of such action.

Article 38: A portion of the surplus money coming from insurance operations shall be transferred to the cooperative health insurance fund in accordance with the principles of cooperative insurance. This portion shall be calculated in accordance with the results of the operations of the insurance company after the approval of the other supervisory bodies.

Article 39: The Health Insurance Council shall issue the rules defining the Fund’s objectives governing its operations in accordance with provisions of article (38).

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Chapter Six : The Practice of Health Insurance Operations

Article 40: Insurance Companies licensed to operate in the filed of insurance shall carry out health insurance operations in the Kingdom. The companies regulations and other related regulations in force in the Kingdom will be applicable to any provisions not included in these rules or any subsequent rules to be enforced in the future.

Article 41: Insurance Companies may not practice health insurance operations prior to their preqaulification by the Council. Prequalification shall be limited to three years and shall be renewable for similar periods.

Article 42 : A- The Council shall charge fee for prequalification of the cooperative health insurance companies amounting to SR one hundred fifty thousand.

Article 43: Insurance Companies operating in the field of health insurance may practice other types of insurance provided that the financial matters related to the health insurance activities are separated from those belonging to other activities, as directed by the supervising authority.

Article 44: Insurance companies (authorized to perform insurance activities in the Kingdom) shall be prequalified to practice health insurance activities based on an application to be submitted for this purpose and the Council shall have the right to specify the details that must be incorporated in the application within the limits required, for its evaluation. The .Council shall, within a hundred and eighty days- of date of submission of application, -take a decision in respect of the application for prequalification.

Article 45: The Insurance company shall submit the following documents along with its application for prequalification :

1-      Company name and address.

2-      Articles of association or memorandum of incorporation.

3-      Name of the chairman, members of the board, the managing director aI1d the executive managers.

4-      Annual accounts audited by a certified accountant for the three years period preceding the submission of the application for existing companies and plan of operation for new companies.

5-      Name of the independent actuary or the company specializing in actuarian studies.

6-      Names of Auditors.

Article 46: The plan of operations shall include a 'statement of estimated revenues and' expenses, technical allocations and the projected results for tl1e tl1ree years following the submission of application, all in accordance with the form especially prepared by the Council for this purpose as well as the plan of arrangements made for re- Insurance.

Article 47: The insurance company shall submit a statement issued by the other supervisory authorities stating that the company will observe the minimum requirements of solvency.

Article 48: The Council may select from the applicant companies those ones having:

1-      Authorization to perform insurance operations

2-      Technical, administrative and medical staff as well as systems for approvals, - handling of claims and payment of dues. These functions may be performed through a contract with a medical claims management company licensed by the Council.

 Article 49: The prequalification of an insurance company may be rejected by a letter stating the reasons for such rejection in the following cases:

1-      If the Council gets information from the other supervisory authorities indicating that the executive managers of the company lack proficiency and falls short of the necessary professional requirements.

2-      If the Council gets information from the other supervisory authorities indicating that the company is unable to preserve the interests of the beneficiaries in a proper manner or is unable to meet its obligations permanently.

3- In the event of non-payment of fees prescribed for granting or extending prequalification as stated in article (42) of these rules.

Article 50: Every insurance company must seek the assistance of an actuary or a company specialized in providing actuarial services as directed by the supervisory authority so that such actuary can submit an actuarial report to the supervisory authority about the health insurance activities of the company showing adequacy of allocations and the pricing policy.

Article 51: The independent actuary must ensure adherence to insurance procedures in the calculation of contribution in the insurance and technical allocations. The actuary must in this connection review and audit the company's financial matters, and in particular he shall make sure at all times that the company meets its obligations resulting from the insurance policies and that the company has under its disposal adequate assets within the solvency margin set by the supervisory authority. If the actuary finds out that allocations required are no longer available he must notify the supervisory authority immediately.

Article 52: Every insurance company shall prepare accounts audited by certified accountants authorized to operate in the Kingdom and a business report covering the operations of the previous year for - submission to the Council within the first three months of the year following the end of the financial year of the insurance company.

Article 53: Every licensed insurance company shall submit a statement to the Council confiffi1ing the following:

1-      That the company's capital is free and not encumbered and equals the solvency margin at least.

2-      That the solvency margin is calculated to show the company's ability to meet its ongoing obligation.

3-      Submit a guarantee letter to the Cooperative Health Insurance Council equaling one third of the solvency margin provided that the amount of the guarantee is not less than SR twenty five million.

Article 54: The Council shall approve non-governmental health care providers according to the following criteria :-

1-      That the health care facility is licensed by the Ministry of Health.

2-      That individuals providing health care have been registered by the Saudi Commission for Health Specializations.

3-      That the health care facility meets the minimum requirements of quality stated in articles (109) and (110) of these rules.

Article 55: Health care service providers shall be approved by virtue of a letter issued by the Council and the annual fee for this purpose must be paid to the Council as. follows

1-      SR 2000 for open physician clinic ~

2-      SR 5000 to SR 10000 for a clinic.(dispensary)

3-      SR 10000 to SR 20000 for one day surgery centers -

4-      SR 20000 to SR 50000 for a hospital - depending on number of beds.

Article 56: The Council shall fix the fee for each case based on article (55) as well as the fee for the rest of service providers such as Diagnosis Centers, pharmacies and labs.

Article 57: The authorization of a health facility shall be canceled if the Ministry of Health withdraws the facility’s license and the Council shall notify all insurance companies of this cancellation.

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Chapter seven: Supervision on the relationship between the Health Insurance parties (scope and goals of supervision)

Article 58: The Health Insurance Council shall supervise and monitor the universality of the Health Insurance coverage and shall ensure that the parties in the Health Insurance relationship perform the tasks and responsibilities entrusted to them under these rules.

Article 59: The supervisory authority shall be in charge of the supervision on the insurance companies activities in the field of Health Insurance. This includes ensuring the solvency of the company, adequacy of capital, sound assets, technical allocations and its ability to meet obligations towards the beneficiaries of the Health Insurance provided. The supervisory authority shall notify the Council of any shortcomings in the position of any insurance company in accordance with the requirements of this article..

Article 60: The Council may require the amendment of the plan of operations of the Health Insurance companies prior to concluding of new insurance policies, as deemed necessary, for the protection of the interests of the beneficiaries. The effects of such amendment shall be extended to include existing insurance policies and the policies that have not yet been concluded.

Article 61: The Council may request from the supervisory authority information and data about all the work issues related to Health Insurance. 'The Council in certain cases - especially in cases related to the general provisions of the health insurance, request forms and other printed matter used by the health insurance company in its correspondence with employers, beneficiaries and service providers as well as contracts signed with the health insurance claims management company.

Article 62: TI1eCouncil and whoever is nominated by the Council, may during certain periods of time or at any other time, perform reviewing and auditing taslcs in all respect of insurance companies within the sphere of competence of the Council and may also request other supervisory bodies to do so and to provide reports in this regard.

Article 63: The Council shall have the right to make -reservations on any of the executives of any insurance company and shall notify other supervisory bodies accordingly.

Article 64: Members of the Councilor 'any of its staff may not disclose confidential information that come to their knowledge in the course of their implementation of these rules. This also applies to any person who may get to know such information from official reports. The provisions of this article will not apply to disclosure of information where it is not possible to single out the disclosing company.

Article 65: The Council may use the information stated in Article (64) for the following purposes:

1-      Examining the applications submitted by insurance companies for prequalification or renewal thereof.

2-      The directives issued by the Council.

3-      Following up of any violations of the obligations arising out of the insurance policy in accordance with article (14) of the system.

4-      Within the framework of the procedures of handling complaints regarding decisions taken by an insurance company.

5-      Within- the frame work of .the procedures of considering and deciding on violations in accordance with article (14) of the system.

Article 66: The observance of the confidentiality of information as set forth in article (64) shall not prevent providing the following information specifically to:

1-      Judicial authorities, courts or other affiliated bodies.

2-      The authorities in charge of implementation of the system as per its provisions or other related regulations so long as such authorities request the information for the purposes of finalization of their tasks and provided that secrecy requirements set forth in article (64) of these rules are adhered to.

Article 67: The other supervisory authority shall have the right to supervise the settlement of matters related to existing insurance policies in the event of the prohibition of the activity of an insurance company, the suspension of its operations or in the event of withdrawal of its license Company shall coordinate with the Cooperative Health Insurance Council in this regard.

Article 68: The Council may withdraw prequalification for practicing health insurance business if the insurance company breaches the prequalification requirements and conditions. In the event of withdrawal of prequalification, the beneficiaries shall be transferred to another insurance company to be selected by the employer. This also applies in the event of suspension of its operations without the withdrawal of prequalification.

Article 69: The Council may also withdraw prequalification of practicing health insurance business if the insurance company fails to use pre qualification within twelve months or if it expressly waives the prequalification or ceases to practice-its business for six months.

Article 70: With the exception of the cases indicated in articles (68) and (69) withdrawal of prequalification shall be coordinated with the concerned

              authorities.

Article 71: The Council shall be financed by:

1-      The prequalification and the annual renewal fees collected from the Insurance companies.

2-      The tee of the annual authorization of the non-governmental health service providers.

3-      The fees of supervision and control over the insurance companies at the rate of one percent of the health insurance premiums as per the audited financial statements of the previous year.

4-      The fee collected by the Council for studies regarding the exemption of the parties having their own medical facilities taken from the insurance coverage or portions thereof. The Council shall fix such fee.

5-      Other fines due to the Council and fines ~posed by the violations committee of the cooperative health insurance system violations committee as stated in article (111) of these rules.

6-      Donations, gifts and investment returns.

7 -     Any amounts collected from any other sources such as, the issue of journals, manuals, consulting or training activities that may be performed by the Council.

Article 72: The Council shall publish general information on the activities of the insurance companies prequalified by the Council. Coordination in this respect may be made with the other supervisory authorities. Council, when required, may interprete these rules of implementation.

Article 73: The Council shall publish, at its discretion, whatever tables and statistical data related to insurance for any business year without specifically referring to certain insurance companies.

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Chapter Eight: The Relationship between the Insurance Parties

Article 74: The Council shall specify the requirements for the design of the health insurance card and its contents in collaboration with insurance -companies and health service providers,

Article 75: The insurance companies and service providers shall observe tile following:

1-      Provide services in accordance with generally accepted professional and moral criteria that comply with accepted new medical techniques, taking into consideration the achievements made in the field of medicine. Service providers may not demand from insurance companies providing services inconsistent with the above.

2-      Medical procedures shall' be restricted to necessary treatment required for performing the task.

Article 76: The insurance parties i.e. policy holders, insurance companies and service providers shall, each within his sphere of interest, follow the generally accepted professional criteria for:

1-      The Payment of premiums by policy holders, on time to the Insurance companies.

2-      Expedite the giving of approvals by insurance companies to service providers for providing treatment to beneficiaries and the settlement of the claims of the service providers,

3-      Expedite and facilitate the providing of treatment services to the beneficiaries by service providers and the submission of claims to insurance companies for speedy settlement of dues.

Article 77: Insurance Companies may not own or operate health care facilities for the treatment of the insured, nor may the private health facilities own health insurance companies.

Article 78: The contracted parties in the insurance policy shall be the policy holder (Employer) and the insurance company.

Article 79: Employer shall provide the insurance company with all information it requests. If the insurance company has reasonable justifications to suspect the correctness of such information, the company may refer the matter to the Health Insurance Council for verification. Employer shall based on the Council's request provide all required documents and shall let the representatives of the Council review such documents at its headquarters.

Article 80: Employer shall explain and clarify policy contents and the limits of coverage of beneficiaries included in the policy.

Article 81: Without prejudice to the requirements of regulations and instructions, the employer shall impose penalties on the beneficiary has been legally proved to have abused the service.

Article 82: Employer shall return the insurance card to the insurance company when the beneficiary leaves work or upon the expiry of the term of the insurance policy. Employer shall be held responsible for any expenses arising from his non-compliance with such condition.

Article 83: The insurance company shall, in order to meet its obligations and provide the benefits, conclude health service contracts with authorized service providers. Hospitals and governmental health care facilities, open to all patients, may treat the beneficiaries and the cost of such treatment shall be Dome by insurance companies.

Article 84: In emergency cases only, treatment may be provided by specialists and hospitals without a referral from a primary healt care facility, This provision also applies to treatment by service providers who have no health service contracts with the insurance companies. If the insurance company disapproves on the continuation of treatment in this center, patients shall - when their health conditions stabilize - be transferred to one the service providers network centers.

Article 85: The Service provider shall be held responsible when one of his employees or physicians commits forgery, fraud or abuses the service provided.

Article 86: The health service contract shall as a minimum requirement incorporate the following and the Council may propose a guideline service contract to regulate the relationship between the parties concerned.

1-      Mutual rights and obligations and the penalties to be imposed in the event of violation.

2-      The compliance of service providers with quality standards according to conditions and' procedures set forth in articles (109) and (110) of these rules.

3-      Service providers obligation to observe the requirements of cost efficiency according to the provisions of article (75) of these rules. Service provider shall prescribe all medicaments and male all prescriptions in accordance with such requirements.'

4-      Procedures for settlement of wages and settlement of amounts due for prescriptions dispensed.

5-      Preconditions concerning notices and the periods of such notices.

6-      The method of settlement of disputes arising out of health service contracts.

Article 87: The health service provider shall verify the identity of the beneficiary. If a service provider treats a person other than a beneficiary, he shall bear the cost of such treatment.

Article 88: The service provider shall demand his dues related to the treatment of beneficiaries in the manner agreed upon with the insurance company within a period not exceeding 90 days from date of maturity.

Article 89: The service provider shall abide by the coding system drawn up by the Council for describing cases of treatment, their cost and request for payment of dues.

Article 90: The services provider may terminate the health service providing contract with, insurance company with the observance of the termination conditions in the event of delay of payment of dues. In this case the insurance company shall notify employers accordingly.

Article 91: The Insurance Company shall, on the effective date of insurance coverage furnish policy holder with beneficiaries insurance cards and explanatory manuals including scope of insurance coverage of policy, limits thereof and authorized service providers network. Employer shall officially and actually hand these over to the beneficiaries on the effective date of insurance coverage. Insurance Company shall notify authorized service providers network or the joining of the policy holder of the insurance coverage as well as additional coverage, if any.

Article 92: The insurance company and the policy holder shall take care - of beneficiaries circumstances by introducing a service providers network that can meet the needs of the beneficiaries and the conditions at their places of work so that beneficiaries will not" be forced to seek service from service provider outside of the network.

Article 93: Insurance company shall not be required to conclude health service contracts with every service provider authorized by the Council. The company may select any authorized service provider that is capable of providing the best of services to meet the requirements of the health service contract.

Article 94: Insurance company shall not be required to use the service of all service providers with whom contracts are signed for a given policy.

Article 95: Insurance company shall respond to the request for approval on treatment cost within sixty minutes, and in the event of non- approval reasons for disapproval shall be put in writing. The Council shall draw up the service criteria in this connection.

Article 96: Insurance companies may appoint Saudi physicians, jointly or severally, to monitor compliance with treatment conditions within the limits of cost effectiveness set forth in article (75) of tl1ese rules during the treatment of a beneficiary. If the appointment of Saudi physicians is not possible, insurance companies may request an exemption the Council for contracting non-Saudi physicians. However, the extinguished medical staff, must be selected from Saudi Specialists and consultants. In the event of requiring part time consultants insurance companies shall seek to employ Saudi specialists and consultants from those working for the public sector.

Article 97: Physicians appointed to work for insurance companies shall be professionally independent and their views during their supervision shall only be subject to the medical requirements. They may not interfere in the medical treatment of beneficiaries.

Article 98: Service providers and beneficiaries shall provide physicians working for the insurance companies with all information required and shall put at their disposal all documents required for the performance of in accordance with the provisions of article (96) of these rules. Physicians shall be given access to hospital wards, medical supervision offices and medical file~ of any authorized hospital in which a beneficiary was treated or is being treated whenever the need arises for carrying out supervision functions entrusted to them and this shall be in coordination with the hospital concerned.

Article 99: The Council shall have the right to have objections on anyone who proves to be unqualified medically or whoever violates the ethics of the profession.

Article 100: Insurance company shall pay the dues of the service providers within a peri9d not to exceed sixty days of date of request for payment.

Article 101: Insurance company and service providers shall agree on the settlement of requests for payment. In case of disagreement either party may refer the dispute to the Cooperative Health Insurance Council.

Article 102: Insurance Company may terminate a health service contract with a service provider after the approval of the policy holder and the appointment of a replacement of same standards provided that the notice period as well as the. conditions of termination set forth in the contract signed by them are observed, if the service provider breaches, in full or in part, the conditions of providing service.

Article 103: Beneficiary shall provide the insurance company with all information it requires for defining the details of an emergency or service obligations. shouldered by the insurance company and the extent of such obligations.

Article 104: Beneficiary shall present himself for check up by a licensed physician authorized by the Council and appointed by the company if the latter wishes him to do so. The company shall bear the cost of check up in this case.

Article 105: Beneficiary shall, when requesting treatment, furnish his insurance card and I.D. to the service provider, who will hand them back to the beneficiary after taking the necessary data for the treatment.

Article 106: Beneficiary shall call on one of the primary health care facilities or physicians working for the service providers network designated for him. Referral to a specialist or a hospital shall be decided by an omnipractitiner.

Article 107: Beneficiary shall bear the difference in cost in the event of hi~ calling directly on a specialist or consultant for check up as shown in the policy.

Article 108: Recommendations for hospitalization shall be limited to cases where treatment in out-patient clinics is inadequate. In this case one day surgery or treatment service shall be used and if the beneficiary reports to a hospital other than that specified in the referral documents, he shall bear the difference in the cost of treatment.

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