• The following terms shall have the meanings set forth next to each of them:

  • 1- Kingdom: The Kingdom of Saudi Arabia.

  • 2- Law: The Cooperative Health Insurance Law applicable in the Kingdom.

  • 3- Council: The Council of Cooperative Health Insurance.

  • 4- Chairman of the Council: Minister of Health.

  • 5- General Secretariat: The executive body of the Council.

  • 6- Bank: The Saudi Central Bank.

  • 7- Social Insurance: The insurance applied under the Social Insurance Law, implemented by the General Organization for Social Insurance.

  • 8- Health Insurance: Means the health insurance established by the Law and its executive regulations and practiced by cooperative insurance companies licensed to operate in the Kingdom in accordance with the Insurance Companies Control Law.

  • 9- Policy: The basic cooperative health insurance policy approved by the Council and annexed to these regulations (Annex No. 1), which includes definitions, benefits, exclusions, and general conditions, and is issued by the insurance company upon an insurance application submitted by the employer (policyholder).

  • 10- Insurance Coverage: The basic health benefits available to the beneficiary as specified in the policy.

  • 11- Benefit: The expenses of providing the health service covered by the insurance coverage within the limits shown in the policy schedule.

  • 12- Parties to the Insurance Relationship: Policyholders, health insurance companies, health insurance claims management companies (TPA), and service providers.

  • 13- Policyholder: The natural or legal person in whose name the policy is issued.

  • 14- Employer: The natural or legal person who employs one or more workers.

  • 15- Employee: Any natural person working for the benefit of an employer under his management or supervision in return for a wage, even if working outside his supervision.

  • 16- Insured (Beneficiary): The natural person(s) for whom coverage is determined under the policy.

  • 17- Dependent: The spouse, male children up to the age of twenty-five, unmarried daughters, in addition to orphans cared for by sponsoring families benefiting from mandatory health insurance.

  • 18- Citizen’s Husband: A non-Saudi married to a Saudi citizen woman.

  • 19- Citizen’s Wife: A non-Saudi woman married to a Saudi citizen man.

  • 20- Orphans: Orphans – with special circumstances – whose parents are unknown or whose mother is known, born on the territory of the Kingdom of Saudi Arabia, whose care has been assigned by the Ministry of Human Resources and Social Development to sponsoring families covered by mandatory health insurance and who remain under the care of the sponsoring family.

  • 21- Basic Data: Data determined by the General Secretariat related to the policyholder or beneficiary, for example (national identity data / worker residency data).

  • 22- Insurance Company: The cooperative insurance company authorized to operate in the Kingdom by the Institution and qualified by the Council to practice cooperative health insurance activities.

  • 23- Health Insurance Claims Management Company (TPA): Companies authorized to settle insurance claims and licensed to operate in the Kingdom by the Institution and qualified by the Council to manage cooperative health insurance claims.

  • 24- Service Provider: The health facility (governmental/non-governmental) authorized to provide health services in the Kingdom in accordance with relevant laws and regulations and approved by the Council, for example: hospital, diagnostic center, clinic, pharmacy, laboratory, physical therapy center, or radiation therapy center.

  • 25- Approved Service Provider Network: The group of health service providers approved by the Council and designated by the health insurance company to provide health services to the insured, with these services being directly charged to the insurance company’s account upon presentation of a valid insurance card by the insured.

  • 26- Rejection of Accreditation Request: A procedure related only to the accreditation request phase, when the Council finds any information provided by the service provider to the Council for accreditation to be incorrect (such as forgery of some documents or licenses submitted, providing false information, or similar).

  • 27- Cancellation of Accreditation: A decision taken due to a serious violation committed by the service provider of the Law and its regulations.

  • 28- Emergency Case: Emergency medical treatment required by the beneficiary’s medical condition following an event, symptom, or urgent health condition necessitating rapid medical intervention.

  • 29- Saudi Health Insurance Exchange Program (SHIB): A program supervised by the Council aimed at exchanging information, data, and transactions related to health insurance between service providers, insurance companies, claims management companies, and the Council according to insurance data standards in a secure and reliable electronic manner.

  • 30- Regulatory Rules of the Electronic Transactions Program (SHIB): The rules governing the exchange of information, data, and transactions related to health insurance between health service providers, insurance companies, health insurance claims management companies (TPA), and the Council through this program for the Saudi health insurance market approved by the Council, and these rules are an integral part of these regulations and annexed thereto (Annex No. 8).

  • 31- Policy Record: The record handled or circulated by the National Health Insurance Network, including the following cases:

    • A) Activated: The record whose issuance date is valid.
    • B) Not Activated: The record whose validity start date is later than its activation date or has not been used in the issuance or renewal of residency.
    • C) Expired: The record whose validity has ended.
    • D) Suspended: The record whose activation has been suspended by the Council or the insurance company for some reason.

  • 32- National Cooperative Health Insurance Network: The devices, programs, and persons connected through it to transfer information and data related to cooperative health insurance.

  • 33- Premium (Subscription): The amount payable to the insurance company by the policyholder in exchange for the insurance coverage provided by the policy during the insurance period.

  • 34- Co-payment (Cost Sharing): The portion paid by the beneficiary when receiving outpatient treatment services as stipulated (if any) in the policy schedule, except for emergency cases and hospitalization.

  • 35- Reimbursable Expenses: Actual expenses incurred for services, materials, and devices not excluded under Section Three of the policy annexed to these regulations (Annex No. 1), provided they are prescribed by a licensed physician due to an ailment suffered by the insured, provided that such expenses are necessary, reasonable, and customary at the time and place they were incurred.

  • 36- Claim: A request submitted to the insurance company or its representative by a service provider, insured, or policyholder for reimbursement of the cost of health services covered under the policy, accompanied by supporting financial and medical documents.

  • 37- Regulation for Supervisory Field Visits: A regulation aimed at organizing the work of supervisory field visit teams for the parties to the insurance relationship to verify the commitment of all parties to the Law, its executive regulations, the unified policy, and annexed to these regulations (Annex No. 7).

  • Supervisory Field Visit Team: A team composed of members from the General Secretariat to conduct supervisory field visits to the parties to the insurance relationship.

  • 38- Fraud: Any party to the insurance relationship deliberately deceiving resulting in obtaining benefits, money, or providing excluded or exceeding allowed advantages to the individual or entity.

  • 39- Misuse: Any party to the insurance relationship engaging in practices that may lead to obtaining benefits or advantages they are not entitled to, but without intent to deceive, commit fraud, or deliberately lie and distort facts to obtain the benefit.

  • 40- Misleading: Behaviors by persons or entities that do not fall under the definition of fraud.

  • 41- Model Contract for Providing Healthcare Services: A contract approved by the Council that parties to the insurance relationship may use to organize the relationship between the company and the service provider, taking into account the provisions of Article No. (95) of these regulations.

• The following categories are subject to mandatory health insurance:

  • 1- Non-Saudi employees in the non-governmental sector.

  • 2- Non-Saudi residents in the Kingdom who do not work in the public or private sectors, except for children of a Saudi mother and a non-Saudi father, whether the children are under the father's or the mother's sponsorship. Also excluded is the non-Saudi wife married to a Saudi citizen.

  • 3- Family members financially dependent on persons subject to health insurance as defined in paragraphs (1) and (2) of this article, who hold a residence permit in the Kingdom.

  • 4- All Saudi nationals working in companies, private institutions, and equivalent entities with whom employment contracts have been concluded, regardless of the form of remuneration they receive. This provision also applies to the categories mentioned in paragraph (2) of this article.

  • 5- Family members of Saudis referred to in paragraph (4) of this article, detailed as follows:

    • 5-1 If the employee is male, the health insurance includes his wife (or wives) and all his children under the age of twenty-five and his unmarried daughters.
    • 5-2 If the employee is female and married, the health insurance includes her husband if he works in a governmental sector exempted from mandatory health insurance or works in another sector that does not provide mandatory health insurance, or if he is unemployed. In this case, the health insurance also includes the working wife and her male children up to the age of twenty-five and unmarried daughters.

  • 6- Orphans fostered by sponsoring families benefiting from mandatory health insurance.

If the applicant for insurance is not covered by the law, they are entitled to obtain health insurance.

Subject to the categories stipulated in Article No. (2) of this Regulation, all non-Saudi employees working for government agencies and institutions and their family members are exempted from being subject to mandatory health insurance, unless it is stipulated in the work contract or pursuant to the regulations of those government agencies and institutions to provide health services to the non-Saudi employee and his family.

• A) The employer is obligated to conclude a health insurance policy with one of the insurance companies covering all employees subject to this law and their family members referred to in Article Two of this regulation.
• B) The owners of companies and institutions that own private medical facilities are subject to the law, and they must obtain the insurance coverage stipulated in the policy as a minimum for their employees, through health insurance companies.
• C) The insurance company may not refuse any health insurance request as long as this request complies with the law and its regulations.
• D) The insurance company insuring the employees of institutions and companies that own accredited private medical facilities is obligated to contract with the concerned facility to treat the employees of these institutions and companies within the scope of the approved health services provided by this facility.
• E) The employer must provide the insurance company with all necessary data to register its employees in the National Information Center, who have a contractual relationship at the start of the policy’s validity. The insurance company is not entitled, after the issuance of the policy, to add any insured person with a different registration number except those who joined the employer after the policy was concluded.
• F) The employer must provide the insurance company with proof of the insured persons’ final departure from the Kingdom, transfer of sponsorship, or death, to exclude them from the policy.

The insurance company issues an attesting document to the employer (policyholder) upon request, certifying the insurance of its employees to be submitted to the relevant authority for the issuance and renewal of residence permits, and the council specifies the content of the attesting document.

If the residence permit for the beneficiary is not issued, their name will be removed from the document from the date of their final exit from the Kingdom, and the premium due for the insurance period will be calculated according to the provisions stipulated in the document.