• Pursuant to the Resolution of His Excellency the Minister of Health, Chairman of the Council of Cooperative Health Insurance, No. (18/5/AR), dated 19/7/2018 AD, approving a new mechanism for settling and paying the dues of healthcare service providers, which provided in paragraph (6) that “if the parties fail to agree on the final settlement, or if no settlement is reached or the settlement fails, the matter shall be referred to the Conciliation Center affiliated with the Council of Cooperative Health Insurance,” and pursuant to the Resolution of His Excellency the Minister of Justice No. (5595), dated 29/11/1440 AH, approving the Rules and Procedures of Work in Conciliation Offices, and based on the principle of conciliation and settlement in resolving disputes, the Regulations of the Conciliation and Settlements Center for Health Insurance Disputes have been prepared in the attached form.

• The provisions of this Regulation shall apply to the parties to the insurance relationship.

• The following words and phrases, wherever they appear in this Regulation, shall have the meanings set forth opposite each of them unless the context requires otherwise:

  • Law: The Cooperative Health Insurance Law issued by Royal Decree No. (M/10) dated 01/05/1420 AH, or any law that may replace it.
  • Implementing Regulation: The Implementing Regulation of the Cooperative Health Insurance Law approved by Ministerial Decision No. (1/35/9/D) dated 13/04/1435 AH.
  • General Secretariat: The executive body of the Council of Cooperative Health Insurance.
  • Council: The Council of Cooperative Health Insurance referred to in Article Four of the Cooperative Health Insurance Law issued by Royal Decree No. M/10 dated 01/05/1420 AH.
  • General Secretary: The General Secretary of the Council of Cooperative Health Insurance.
  • Center: The Settlement and Reconciliation Center at the Council of Cooperative Health Insurance.
  • Regulation: The Regulation of the Center.
  • Dispute or Contest or Medical Insurance Dispute: Any dispute or contest arising between the parties to the insurance relationship as defined by the Implementing Regulation of the Cooperative Health Insurance Law and falling within the jurisdiction of the Center.
  • Center Director: The person appointed by the General Secretary and assigned to supervise the operations of the Center.
  • Settlement: A consensual method undertaken by the conciliator to resolve the dispute in accordance with the provisions of this Regulation.
  • Settlement Applicant: The claim submitted to the Center by one of the parties to the dispute or by their representative or agent.
  • Parties: The parties to the dispute, whether natural or legal persons, whether two or more, excluding the conciliator.
  • Settlement Committee: The committee responsible for resolving the dispute, composed of one or more members.
  • Conciliator: The person who undertakes the settlement work in accordance with the provisions of this Regulation.
  • Settlement Document: A document recording the settlement agreed upon by the parties to the reconciliation, which they ratify as a commitment to implement it, whether issued in paper or electronic form.
  • Insurance Company: The insurance company licensed to operate in the insurance market in the Kingdom and qualified by the Council.
  • Service Providers: The public or private health facility authorized to provide healthcare services in the Kingdom and accredited by the Council.
  • Unified Contract: The contract concluded between insurance companies and healthcare service providers.
  • Policyholder: The employer or equivalent who concludes the insurance policy with the insurance company.
  • Beneficiary: The natural person covered by the policy.
  • Claims Management Company: The claims management company licensed to operate in the insurance field in the Kingdom and qualified by the Council.

• 1- A center for the settlement of financial health insurance disputes between service providers and insurance companies qualified by the Council shall be established by a decision of the Chairman of the Council of Cooperative Health Insurance, called the "Settlement and Reconciliation Center at the Council of Cooperative Health Insurance." It shall be financially and administratively affiliated with the General Secretariat, and the Center Director may, by decision, expand the Center’s jurisdiction to include other types of disputes between parties to the insurance relationship.

• 2- The Center’s headquarters shall be located in the building of the General Secretariat of the Council of Cooperative Health Insurance in Riyadh, and branches may be established in other cities in the Kingdom by a decision issued by the Chairman of the Council.

• 3- The Center shall have a Director appointed by a decision issued by the Council’s General Secretary, who shall have, in particular:

  • A) Implementing the Center’s policies and objectives.
  • B) Representing the Center in its relations with relevant entities.
  • C) Proposing the organizational structure of the Center and selecting its members and employees.
  • D) Developing, enhancing, and organizing the Center’s activities.
  • E) Proposing any amendments to these regulations.
  • F) Monitoring and supervising the performance of the Center’s employees and working to improve their productivity.
  • G) Supervising the preparation of the Center’s annual report in preparation for submission to the General Secretary.
  • H) Signing agreements and contracts with entities related to the organization and operation of the Center.

• 1- The center is competent to settle the following health insurance disputes:

  • A) Financial disputes arising between insurance companies and healthcare service providers.
  • B) Financial disputes arising between claims management companies and healthcare service providers.
  • C) Any other financial disputes related to health insurance activities added by a decision of the Secretary-General of the Council of Cooperative Health Insurance.

• 2- The center is not competent to consider any dispute or part of a dispute related to a criminal matter or related to public order.

• The parties to the contest shall be obligated to resort to the Conciliation Center before proceeding to the competent litigation authorities according to the following:

  • 1- Upon the acceptance by the parties to the contest or their legally authorized representatives of the terms of the unified contract approved by the Council and signing it, which includes a clause obligating both parties to the contract to refer any dispute or contest to the Center within its jurisdiction before resorting to the litigation authority.
  • 2- By virtue of a unilateral acknowledgment made prior to or after the emergence of the contest, provided that the other party explicitly or implicitly consents to resorting to the Center to settle the contest.
  • 3- By a decision issued by His Excellency the Minister of Justice.

1- The acceptance by the parties to resort to the center, in accordance with what is stated in Article Four of this Regulation, entails that none of the parties shall present the dispute to the competent authority legally authorized to adjudicate it except after exhausting the stages of settlement or reconciliation at the center and issuing a settlement record/document.

2- In the event that one of the parties presents the dispute to the competent authority legally authorized to adjudicate it despite previously accepting to resort to the center or being obligated to do so, the other party shall immediately notify the center of that, and may request the center to issue a certificate proving the parties' acceptance to resort to the center first, to be submitted to the authority to which the dispute is presented. The center may, on its own initiative, communicate with the authority to which the dispute is presented to inform it of the prior acceptance by the parties to resort first to the center.

3- The center has the right to obtain a financial fee from the parties to the reconciliation or some of them, as the case may be, before commencing the reconciliation procedures. The center shall notify the parties of this before starting the reconciliation procedures and specify the amount of the financial fee for the settlement according to the nature of each dispute.

4- The amount of the financial fee for the settlement shall be deposited into the account of the General Secretariat of the Council of Cooperative Health Insurance, and the center shall be provided with the document evidencing that.

1- If one of the parties to the contest wishes to reconcile, they shall directly submit to the "Taradi" platform and follow the steps outlined on the platform.

2- The applicant must be legally authorized to conduct the settlement and accept the reconciliation.

3- If it is verified through the "Taradi" platform that the contest falls within the jurisdiction of the center, the request shall be referred to the center, and both parties to the contest shall be notified of this request through one of the technical means.

4- The center may request additional information or documents from the applicant to complete any deficiencies or to clarify the subject of the contest.

5- The center shall determine the mechanism for accepting the request.

1- Both parties to the contest requesting reconciliation shall receive a text message via the mobile phone registered on the platform with the date and time of the remote reconciliation meeting.

2- The reconciler, during the remote or in-person reconciliation session, may request from the other party or parties in the contest additional information or documents to clarify the response.

3- If the reconciler determines, based on the response of the other party or parties in the contest, that the matter is outside his jurisdiction, he shall notify the parties accordingly and suspend the reconciliation procedures.

4- If the other party in the contest does not respond within the period specified by the reconciler, or does not show any cooperation, or if the parties or any of them are absent from the reconciliation session, the reconciler shall set another date within seven days from the first appointment. In case of the parties' or any of their second absence or if they cannot be notified, the reconciliation request shall be archived.