The Council of Cooperative Health Insurance in Saudi Arabia announced significant updates to the regulatory mechanism for disbursing medical expense reimbursements to holders of mandatory health insurance policies. This step comes as part of the Council's ongoing efforts to regulate the relationship between the parties involved in the insurance process and ensure that beneficiaries receive their full rights easily and conveniently, especially in cases requiring urgent medical intervention.
Details of the new compensation mechanism
In its latest statement, the Council affirmed the primary beneficiary's right to reimbursement for emergency treatment costs when forced to seek care at healthcare facilities outside their insurance company's approved network of providers. The regulations clarified that policyholders have the full right to receive urgent medical care at any healthcare facility necessitated by their critical condition, without being bound by the medical network limits specified in the policy. This reinforces the principle of "patient safety first" as a paramount and non-negotiable priority.
Binding time periods for the parties
To ensure the discipline of the process and the regulation of financial and documentary flows, the council established a specific and binding timeframe for all parties:
- Beneficiary's obligations: The policyholder must submit all original invoices and supporting medical documents (such as medical reports and test results) within a maximum period of 30 working days from the date of receiving the treatment service and paying its costs.
- Insurance company obligations: The Council obligated insurance companies to study the claim and disburse the compensation amounts due to the beneficiary within a period of time not exceeding 15 working days , starting immediately upon completion of the required documents submitted by the beneficiary.
Method of calculating compensation
Regarding the financial aspect, the Council clarified that insurance companies are obligated to cover reimbursable expenses according to prevailing market rates, after calculating and deducting the deductible percentage specified in the policy terms for the beneficiary. This measure aims to protect the beneficiary from exorbitant costs and ensure that companies do not evade their obligations in emergency situations.
Context of developing the health insurance sector
These decisions are part of the Council of Cooperative Health Insurance's strategy to empower beneficiaries and enhance the efficiency of the private healthcare sector, in line with the goals of the Kingdom's Vision 2030, which prioritizes quality of life and healthcare. The Council continuously works to address regulatory gaps that could lead to delays in patients' rights or conflicts of interest between healthcare providers and insurance companies.
This decision is expected to contribute to strengthening confidence in the Saudi health insurance market, as it guarantees citizens and residents a quick return of funds and reduces the burdens resulting from emergency cases, which also pushes insurance companies to expand their approved medical networks to cover as many health facilities as possible to avoid direct compensation procedures.
