Understanding the legal aspects of medical insurance

Understanding the legal aspects of medical insurance

Health insurance plays a major role in our daily lives and in the lives of our loved ones as well. Health insurance complaints and concerns have increased significantly recently. So today we will talk about the most important points that concern us as beneficiaries of health insurance policies.

First, the contracting parties in the insurance contractual relationship are the policyholder and the insurance company.

It is important to go through the categories that the law requires to be subject to the medical insurance system. The list of beneficiaries of medical insurance is headed by non-Saudis working in the non-governmental sector and their families, followed by residents who are not employed in the private or public sector, and their families as well. Another category is Saudis who work at institutions in the private sector under a signed employment contract regardless of the wage they receive.

For family members of Saudis working in the private sector, the law covers the wife, sons under the age of 25 and unmarried daughters. In case of female employees, medical insurance covers her children and her husband, if he works at one of the government agencies that are not subject to compulsory insurance, or in another sector that does not provide medical insurance, or is unemployed.

The system obliges companies to subject all their employees to medical insurance, after applying to one of the insurance companies accredited in the Kingdom for cover. The law states that no medical insurance application may be refused or rejected as long as it complies with the provisions.

The law also obliges the employer to notify the insurance company in case of the termination of any employee contract so that they can be excluded from the insurance policy.

As a company, what if you decide to change the insurance company that you are dealing with and contract with another? A letter should be sent to the insurance company no less than 30 working days before the planned cancelation date, sending a copy of this letter to the Council of Cooperative Health Insurance. You will be entitled to recover part of the premium paid to the insurance company as it is calculated on a pro rata basis.

Furthermore, the insurance policy for employees must clearly state the period covered, the maximum amount of coverage and benefits, the exceptions and general conditions. It is very important to clarify the exceptions clearly, to make sure that the beneficiary understands these exceptions fully and does not fall as a victim to any manipulation, no matter how simple.

People sometimes complain that the insurance provider’s approval of the service has been delayed when it is filed by the hospital, not knowing that the law specifies a timetable for this process. The hospital must submit the approval request within 15 minutes from the time the doctor approves the application. After that, the insurance company must respond within 60 minutes of receipt of the application, and if the application is rejected, the reasons must be formally and clearly communicated to the hospital. The law specifies a maximum period of 30 minutes for the hospital to respond to the reasons for rejection or any inquiries by the insurance company regarding the application submitted.

It is worth mentioning that if there was no response from the insurance company within the specified period, the hospital will consider the application approved, naturally after making sure that the insurance company received the request.

The Council of Cooperative Health Insurance has specialized committees to examine any violations of the law and propose appropriate penalties to be approved by the chairman of the council, the health minister.

The council undertakes the supervision of the parties to this relationship to ensure the comprehensiveness of health insurance coverage and to ensure that the parties of the health insurance relationship are implementing their obligations and responsibilities, whether through reports or supervisory visits.

Finally, the subject of medical insurance is important to each of us, and we must make sure that we understand the rights covered in the policy and inquire about any questions. For the criterion of our knowledge of our rights determines the empowerment of such rights as beneficiaries.

• Dimah Talal Alsharif is a Saudi legal consultant, head of the health law department at the law firm of Majed Garoub and a member of the International Association of Lawyers. Twitter: @dimah_alsharif

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