In implementation of the cooperative health insurance system issued by Royal Decree No. M/10 dated 1/5/1420 H and the rules of implementation thereof issued by Minister of Health Resolution No.__________ " dated _________. Whereas the policy holder has submitted to (name of insurance company) (referred to hereinafter as the "Company") a written application (which will be deemed a basis and an integral part of this policy) for the purposes of insuring the policy holder and his dependants or his employees and their dependants whose names are listed in the schedule attached to this policy and who a):e referred to hereinafter as the "insured", and has paid the premium or agreed to pay it.
Therefore, the company agrees based on the above - with the policy holder to cover the costs of providing health care to the insured under this. Policy, to the extent and in the manner shown therein, through a network of service providers appointed by the insurance. company provided always that such insurance shall subject to the conditions, definitions, designations and limits of coverage incorporated this policy any additional schedules (already approved by the cooperative health insurance council) or those that will be agreed upon later.
Part one: Definitions
For the purposes of this insurance the following work, phrases and expressions shall be interpreted and construed-wherever mentioned in this policy, appendixes or attachments - in accordance with the following definitions:
1- Accident: Unexpected accident injury or an accidental incident taking place during the insurance term.
2- Ailment: An illness or disease caught by the insured person that necessarily requires medical treatment by a licensed physician during the insurance period.
3- Allergy: The person's allergy to certain kinds of food, weather, pollen, in particular, and any other agents such as. plants, insects, animals, metals and other elements and materials, where the individual suffers from reactions in tile body caused by tile direct or indirect contact with such materials leading to cases of asthma, , indigestion, itching, hay fever, eczema and headache.
4- Beneficiary (The insured): A person covered by the System (employee or dependant) whose name is listed in the schedule of the insured persons attached to this policy.
5- Benefit: Cost of providing health services included in the insurance coverage within the limits shown in the schedule of the policy.
6- Premium (contribution): The amount payable by the policy holder in return for the insurance coverage provided by the policy during the term of insurance.
7- Congenital Deformation: The functional, chemical or constructional disorder usually existing before, birth, hereditary or caused by environmental factors.
8- Insurance Coverage: The basic health benefits available to the beneficiary as specified in the insurance policy attached to these rules.
9- Percentage of Deduction I Portability (Contribution in Payment):
The portion payable (as specified in the policy schedule) by the beneficiary (the insured) in the event of medication in out-patient clinics.
10- Employee: Any person actually working for the policy holder, and is entered in such capacity in the latter's registers, who has not yet reached the age of 65 years when joining the insurance coverage.
11- Dependent:
A- The husband / wives entered in this capacity in the registers of the policy holder who are residing legally in the Kingdom of Saudi Arabia.
B- Children of the employee, children of the husband or wives or the children legally sponsored and residing in the kingdom of Saudi Arabia, who are supported by the employee .and entered in this capacity in the registers of the policy holder.
12- Claim Supporting Documents:
All documents proving and evidencing: age. of the insured person, his nationality, ill, validity of insurance coverage, the circumstances of tl1e accident for which "the claim is raised and the payment of cost as well as other documents such as the police report, bills, receipts, prescriptions, physician' s report, referral, recommendations and any other original documents that may required by the company.
13- Direct Debit Basis or Debiting the account of the Company:
The non-payment facilities available for the insured persons by the service provider / providers appointed by the company where all such expenses are directly debited to the account of the company.
14- Commencement Date:
The date shown in the policy schedule on which the insurance coverage starts.
15- Effective Date: The date designated by policy holder and agreed upon by he company for the commencement of the coverage of the person under the policy or for adding or omitting of an insured person from the policy.
16- Appendix: A document issued by the company using an official form dated and signed by an authorized' officer proving the authenticity of any amendments in the policy and not. prejudicing the basic coverage - based on a request in writing from the policy holder.
17 - Hospital: An authorized health facility acceptable to the policy holder and the company, and is licensed to operate as a hospital under regulations in force for providing reimbursable treatment under this policy. Hospital in this policy will not include hotels, guest houses, dormitories, rest houses, recuperation houses, sanitariums, care houses for the persons in custody, infirmaries, asylums or any other places used for accommodating and treating alcohol and drug addicts.
18- Hospitalization (in-patients): Admittance of an insured person as an in-patient in a hospital until the morning of the following day based on a referral from a licensed physician.
19- Insurance: The evidence of the implementation of the insurance coverage under this policy, schedules, appendices or attachments thereto.
20- Licensed physician: A medical practitioner in position of a degree who is legally licensed to practice medicine, prequalified and acceptable to the policy holder and the company for providing cost reimbursable treatment under this policy.
21- Limits of Coverage: The maximum limit of liability of the company as set forth in the schedule of the policy for any insured person before any deductions/ portability.
22- Service Provider: The authorized and licensed person or health facility, under the regulations in force, to provide medical services in the Kingdom such as a hospital, a diagnostic center, a clinic, a pharmacy, a laboratory, a physiotherapy or a radiotherapy center.
23- Pregnancy & Delivery: Any pregnancy and / or birth arising from a legitimate martial relationship.
24- One day surgery or Treatment: A surgery or a treatment that necessarily requires pre-arrangements for one day stay only in a hospital or a treatment center.
25- Treatment in Out- Patient Clinics: The frequent calling - by an insured person - on out-patient clinics for the purposes of diagnosis or medical treatment of a disease.
26- Service Providers Network: A group of health service providers authorized by the Cooperative Health Insurance Council and designated by the insurance company for providing services to the employer / policy holder by debiting .cost directly to insurance -company account upon furnishing a valid insurance card for the insured. Such network shall include the following three health car categories:-
unexcluded under part three - prescribed by a licensed physician for an illness caught by the insured, provided that such expenses are necessary, reasonable and customary at the time and in the place in which they have been incurred.
Based on the above, reimbursable costs shall include the following:
A- All medical check up, diagnosis, treatment, medicament costs as per policy schedule.
B- All hospitalization expenses including operations, and one day surgeries and treatment as well as delivery .
C- The treatment of teeth and-gingival diseases.
D- Preventive measures specified by the Ministry of Health such as, vaccinations and maternity & childhood care.
2- The expenses of repatriation of the remains of the insured to his country of origin.
Part Three: Designations and Exemptions
A- This policy will not cover claims arising out of the following:-
1- Injury caused deliberately by the person.
2- Illnesses, caused by misuse of certain medicaments, stimulants, tranquilizers or by consumption of alcoholic drinks, drugs and the like.
3- Plastic surgery or treatment unless necessitated by an accidental bodily injury not excluded in this part.
4- Full checkups, vaccinations, drugs or preventive procedures that do not require any medical treatment stipulated in this policy (with the exception of the preventive procedures stated by the Ministry of Health such as, vaccinations and maternity & childhood care).
5- Treatment related to pregnancy and delivery for a woman on a single status contract.
6- Free of charge treatment of an insured person.
7- Rest, general body health programmes and treatment at social welfare houses.
8- Any illness or injury resulting directly from the profession of the insured.
9- Treatment of genital diseases and the medically recognized diseases usually communicated by sexual intercourse. '
10- The treatment expenses for the period following the diagnosis or HIV or the diseases related to HIV including AIDS (Acquired Immunity Deficiency Syndrome) their dirivatines, synonyms or other fon11S thereof.
11- All costs related to teeth transplanting, dentures, bridgework fixed & removab1e), orthodontics- excluding those caused by violent external actions.
12- Tests for correction of sight & hearing and audio - visual aids, unless ordered by a licensed physician.
13- Expenses of transportation of an insured by. local or authorized ambulances or by ambulances belonging to the Saudi Red Crescent Association.
14- Hair falling, baldness or wigs.
15- Psychotherapy, mental or neurotic disorders excluding acute cases.
16- Allergy tests of whatever nature excluding those related to drugs, diagnosis or treatment.
17- Equipment, aids, drugs, procedures or treatment by hormones for birth control, inducing or preventing pregnancy, sterility, impotency, lack of fertility, tube fertilization or any other means of artificial linsemination.
18- Any defects or congenital deformities existing before the effective date of policy and posing no threat to life. ..
19- Any additional costs or expenses incurred by the person escorting the insured during his hospitalization or stay in hospital with the exception of hospital room & board costs for one escort per an insured, i.e. the accompanying of the mother of her child - upto twelve years old or whenever this is medically necessary, all at the discretion of the treating doctor.
20- Treatment of acne or any other treatments relating to obscenity or overweight.
21- Transplant of organs taken from other persons bone marrow and artificial limbs replacing any organ in the body.
B- This policy- will not cover the health benefits and repatriation of the remains to country of origin if claims are directly arising- from the following.
1- War, invasion, foreign enemy actions, aggressive actions (whether war declared or not) and civil war.
2- Ionic radiation and contamination with radio active material resulting from nuclear fuel or any nuclear waste resulting from the burning of nuclear fuel.
3- The radioactive, poisonous, explosive properties or any other hazardous properties of any nuclear materials stored or any of their components.
4- The insured involvement or participation in the service of the armed forces, police or in any of their operations.
5- Riots, strikes terrorism or nay similar acts.
Chapter Four - General Conditions
1- Substantiating validity: This policy hall represent the basic limit of insurance coverage offered to the insured. Policy shall not be valid unless substantiated by a schedule singed by an officially authorized officer of the company.
No additions thereto will be valid unless proved by an addendum signed by an officially authorized officer of the company.
2- Registers & Reports: Under this policy holder shall maintain a register for all insured employees and their dependents, containing for every person, his full name, sex age, nationality, classification and other basic infoffi1ation that may affect the management of this insurance and the report concerning rates of contribution. Company shall be given the chance - Whenever so desires - to review such registers to ensure the correctness of information provided by the policy holder. Further, company shall- whenever required do so provide the policy holder with any data in respect of the insured he may wish to review.
3- Persons Qualified for Insurance:
A - F or employees - any person falling under the definition of employee - shall be eligible for insurance as stipulated in the policy schedule.
B- For dependents: Any person falling under the definition of " dependent - shall be eligible for insurance as stipulated in the policy schedule, provided that such person is supported by a qualified employee.
If any person is defined as dependent and is at the same time qualified as an employee, his qualification for insurance as dependent shall cease under the policy. And when the husband and wife reside peffi1anently together and enjoy insurance coverage in their capacity as employees, their children shall only be qualified as dependents of the husband.
4- Payment of Premiums:
A- Policy holder shall pay insurance premiums due from any insured person upon the commencement of the insurance coverage or as otherwise agreed upon with .the company.
B- In the event of non-payment of any portion of a premium, the policy will not be valid for a period longer than that covered by the portion paid and the company shall notify the cooperative health insurance council accordingly.
5- The effective Dates of Coverage. A- For the employees:
The coverage of the employee who is actually on the job shall commence as from date of commencement stated in the policy - schedule,- and any person who joins work at a later date shall be covered as from date of joining work with policy holder or date of arrival in the Kingdom.
B- For Dependents:
The effective date of insurance coverage for dependents shall be the date of insuring the employee - who supports them - or the first date on which they enjoy the status of dependents.
6- Addition & omission of insured persons and contributions thereof:-
A- Policy holder shall immediately notify the company in writing of all employees or dependents to be covered by insurance after the effective date of the policy, and company shall immediately calculate additional contribution payable for persons incorporate in the insured persons schedule on a proportional basis starting from date of their coverage.
B- Policy holder shal1 notify the company in writing within thirty days of date of termination of al1 the insured persons (emp1oyees and / or dependents) whose insurance coverage showed expire before the end of the insurance period. .
The company may not return the proportionate portion of contribution related to such persons for the remaining period of insurance, unless policy holder .provides the company with a proof of the departure of the insured person in the event of his 1eaving the Kingdom for good, or his inclusion in another insurance coverage progran1l11e acceptable to the Cooperative Health Insurance Council in case of transfer of sponsorship. .
7 - The Expiry of Insurance Coverage of the Insured:
A- For employees: The insurance of any employee under this policy shall automatically terminate in the following cases :-
1- When this policy expires as specified in the schedule.
2- When the employee becomes sixty five years old.
3- When the maximum benefit stipulated in the policy is used up.
B- For Dependents: The .coverage of the dependant under this policy shall automatically expire in the following cases:-
1- When the dependent losses his insurance status in accordance with provisions of clause 11 (B) of definitions, under part one of policy.
2- When the policy term expires as stated in the schedule.
3- When the dependent becomes sixty year old.
4- When maximum benefit stipulated in the policy is used up.
C- Reimbursable costs for any persisting illness requiring stay in hospital at the date of expiry of coverage shall be valid for a period not exceeding 365 days from date of inception that necessitated hospitalization, within the limits of amounts for coverage set forth in the policy schedule.
D- In the event of termination of this policy for any reasons whatsoever, policy holder small immediately return to the company all healt11 insurance cards issued, relating to the direct indebting of company account with the nominated service providers network. Same shall apply to any insured person whose coverage period expires. Policy holder shall be liable for compensating the company for all medical expenses and costs arising from his failure to adhere to this requirement.
8- Subscription:
A- The company shall have the right - and must be given the chance - to examine the insured for whom a claim was raised for reimbursable costs through an authorized medical body within sixty days of date of receipt of claim, provided that such claim shall not exceed two folds of cost.
B- Policy holder and the insured-shall cooperate and allow the company - at its expense - to take any reasonable and necessary actions the company may require for the substation of any rights, claims or indemnities pressed against a third party.
9- Non-Duality of Benefits:
In the event of raising claims for reimbursable costs payable to the insured and covered under this policy under any other insurance plan, programme the insurance company shall then be responsible - for payment of such costs and shall subrogate the insured in respect of requesting third parties of pay their propitiate share to such claim.
10- Direct debit basis on company account with nominated service providers net work: Company shall issue a health insurance card to every insured person entitling him to receive health services provide by the health service providers network nominated for the company on a monthly basis including all medical costs incurred under this policy. Company shall assess such costs, work them out and notify policy- holder when such costs reach the maximum benefit limit. If costs exceed - such limit the company may request recovery of such costs within a period not exceeding 60 days of notification.
If policy holder fails to refund such costs within the period specified, the company may refer the matter to the Cooperative Health Insurance Council for taking the necessary action. Company may add or remove any or all service providers appointed for the purposes of this policy during its validity, .provided that policy holder approves such action and a replacement of same standards is appointed.
11- Deduction / Portability:
Without prejudice to the facilities granted under direct debit of company account, it is a binding and obligatory requirement that
the insured shall pay deduction I portability amount at the service center. Any attempt by the insured to abstain from such payment shall be deemed a breach of the provisions and conditions of the policy whereby policy shall be invalid for the insured until payment is made.
12- Cost Reimbursable Basis:
In emergency cases, the insured may receive emergency medical treatment at centers and hospitals other than those authorized by the company on cost reimbursement .basis. In this case tl1e company shall - in accordance with the provisions, conditions, designations and exemptions of the policy - compensate policy holder for all reimbursable expenses and costs provided that, company shall be provided - within 30 days of incurring such costs - with all supporting documents required.
13- Termination:
Policy holder may terminate this policy at any time by virtue of a written notice sent to the company thirty days at least of the date of such termination. In this case policy holder shall provide the company with the following evidences:--
A- The conclusion of another insurance policy with a prequalified company or the coverage of the insured under another insurance coverage programme acceptable to the Cooperative Health Insurance Council where the new coverage will become effective as of the day following the termination of the previous policy in the event of transfer of sponsorship.
B- The Insured Departure Kingdom on exit visa only: In this- case the company shall within sixty days of date of termination, return to the policy holder the remaining portions of contributions for each insured person whose claim was less than 75 % of annual
contributions. The returned portion shall be calculated on a proportional basis:
(portion returned - Annual contribution - 365.25 day x number of days remained).
If policy holder suspends the return of costs the maximum benefits limit during the period specified in clause (10) of the policy general conditions, resulting from the application of the direct debit of company account system, company may abstain from returning such refundable contributions, if any, and shall use such contributions for the reimbursement of costs" paid to treatment providers i.e. the costs that must have been paid to the company by policy holder.
l4- Approvals:
Responses to requests for approval received by the insurance company from service providers for providing health services to beneficiaries shall be made within sixty minutes at most from time of making such requests.
l5- Gender:
For the purposes of this policy, words used in the masculine shall also include the feminine.
16- Notices:
A- All notices or correspondence addressed to the company under this policy must be printed or in writing.
B- The company shall not be bound, in 'any way, to notify policy holder of date of expiry of this policy.
- Compliance with the provisions of this policy:--
It is a precondition for the company to meet its obligations that policy holder and the insured persons shall implement and comply
Fully with all requirements, conditions, duties and obligations set forth in this policy.
18. Settlement of Disputes:
All conflicts and disputes arising out of or relating to this policy shall be settle through the Cooperative Health Insurance Council and the committees formed by resolution from its chairman for looking in violations to the provisions of the system in accordance with article (14) of the Cooperative Health Insurance System.
Policy holder has read and agreed on the provisions and the schedule of this policy.
Date: ____________________
Signature of Policy Signature of the Insurance Company
Holder & Date