The Cooperative Health Insurance Council (CHIC), which oversees health insurance in Saudi Arabia, has drafted a new regulation aimed at protecting beneficiaries.
The proposed regulation aims to lay down procedures to deal with complaints, including a mechanism for following up and verifying them. The draft also proposes procedures to deal with any violation, according to local media reports.
Among other things, CHIC intends to prevent health insurance companies from interfering in the medical treatment regime for the insured. Complaints abound about the pressure exerted on hospitals and private medical centres to reduce treatment costs.
Under the draft regulation, the duties and responsibilities of insurers include:
1. Clarifying the rights and responsibilities of each party to the insurance policy, and information regarding prices, services provided, and policy surrender.
2. Accepting or renewing any request for health insurance.
3. Verifying the validity of the applicant's basic data.
4. Issuing the health insurance policy and uploading the insured's data to the policy issuance system within a period not exceeding 48 hours from the date of paying the premium.
5. Enabling the beneficiary to view the benefits package under the insurance policy and the approved network of service providers, in electronic or hard copy form.
6. Establishing an electronic platform in both Arabic and English to enable the insured to access online services for information such as the network of approved service providers, coverage limits, depleted and remaining benefit balances, limitations and exclusions, medical approvals, and medical advice, etc.
7. Not interfering with the medical treatment plan for the insured after approval has been given.
8. Notifying the beneficiary, the policyholder, and the appointed intermediary (if any) immediately of any change or modification that occurs to the network of service providers, or the beneficiary's insurance category.
9. Responding to the service provider’s request for approval to provide treatment to beneficiaries within 60 minutes of the time the request is received.
10. Notifying the policyholder of the date of renewal or expiry of the policy.
The insurance company is bound by the medical opinion of the CHIC when there is a rejection of a health service request from a health service provider.