The terms and expressions mentioned herein shall have the  meanings ascribed thereto hereunder, and expressions that  are not defined herein shall have the same meanings ascribed  thereto in the Law or the Implementing Regulations:  

• Kingdom: Kingdom of Saudi Arabia.

• Council: Council of Cooperative Health Insurance and its General Secretariat.

• Chairperson: Chair Board of Directors of the Council of Cooperative Health Insurance.

• Law: the Cooperative Health Insurance Law.

• Implementing Regulations: the Implementing Regulations of the

• Law.

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• Regulations: Regulations Governing the Protection of Health Insurance Beneficiaries.

• Insurance Parties: Insurance Company, insurance brokerage,  policy holders, Service Providers, revenue cycle management  company, TPA, and others as determined by the Implementing  Regulations.

• Insurance Company: a cooperative Insurance Company licensed by SAMA and qualified by CCHI to operate in the Kingdom.

• Service Provider: a (governmental and non-governmental) health facility authorized or licensed to provide health services in  the Kingdom in accordance with the relevant laws and rules  approved by the Council, for example, a hospital, general and  specialized medical complexes, diagnostic center, clinic,  pharmacy, laboratory, physiotherapy center or radiotherapy  center.

• Policy Holder: the legal person in whose name the Policy is issued.

• Employer the legal person who employs one or more employee.  

• Beneficiary (Insured Person): the person (or persons) for whom  the health Insurance Coverage is approved according to the  Policy. 

• Dependent: Husband or wife and sons till the age of 25 and non married daughters, in addition to orphans whose fostered with  beneficiaries families. 

• Insurance Coverage: the basic health benefits available to the Beneficiary as defined in the Policy.

• Deductible (copayment): amount, if any, payable by the beneficiary upon receiving outpatient treatment as specified in the schedule of benefits, excluding emergencies and inpatient treatment.

• Premium (Subscription): the amount due on the Policy Holder

• to the Insurance Company in exchange for the Insurance Coverage provided under the Policy during the insurance period.

• Policy: the basic cooperative health insurance Policies as approved by the Council which include the limitations, benefits, exclusions, and general conditions, and are issued by the Insurance Company under an application for insurance to be submitted by the Employer (Policy Holder) or the Insured Person.

• Minimum network: a network of health care providers that covers all regions and cities in the Kingdom and its geographical coverage to include all levels of health service.

• Cash reimbursement: the actual expenses incurred for health services, supplies, and equipment that are not excluded under the Policy, if a licensed physician due to an illness suffered by the Insured Person, if such expenses shall be necessary, reasonable and customary in the appropriate time and place, shall prescribe such health services, supplies, and equipment.

• Fraud: When any of the insurance parties intentionally preforms an act of deception those results on obtaining financial incentives or advantages or providing benefits excluded or exceeded the permissible limits to an individual or entity.

• Negligence: Providing insurance or medical procedures without exercising a reasonable measures of the recognized medical and insurance caution, which was a cause of material or moral harm to one of the insurance parties that would not have occurred had it not been for the of negligence act.

• Abuse: a practice by any Insurance Party that may lead to obtaining benefits or advantages that such Party is not entitled to, without having the intention to deceit and deceive or misrepresent and distort facts in order to obtain such benefits.

• Emergency Cases: the emergency medical treatment required by the medical condition of the Beneficiary following an incident, accident, or emergency health condition that requires rapid medical intervention according to the following levels (1- Resuscitation and 2- Emergency 3-Urgent conditions that may lead to death, organ failure, or disability) of the levels of urgent medical care as outlined in the Private Health Institutions Law and its Implementing Regulations approved by the Ministry of Health, which determine the screening of Emergency Cases.

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This regulation is considered as a compilation to what is included in the implementing regulations and does not conflict with its provisions, and shall aim to protect the rights of health insurance Beneficiaries through the following:

• 1. Maintaining and protecting the rights of the Beneficiaries.

• 2. Raising insurance awareness among the Beneficiaries.

• 3. Enabling Beneficiaries to obtain full health coverage as specified in the Policy, by establishing high standards for the practice in the field of cooperative health insurance.

• 4. Achieving excellence in serving the Beneficiaries and providing an appropriate mechanism for dealing with them, by setting a minimum limit for the procedures and obligations imposed on the Insurance Parties.

• 5. Enhancing integrity, transparency and fairness in the field of cooperative health insurance.

1. Beneficiary insurance coverage begins for Saudis from the date of establishing work relationship, and for non-Saudis from the date of transferring the employment to another employer, or from the date of entering the Kingdom- giving that within 10 working days. Furthermore, the application for adding the beneficiary should be submitted from the date that specified by the policyholder and approved by the insurance company in a manner that does not violate this regulation.

2. The Insurance Coverage of the Beneficiary shall be expired as of the expiration date specified in the Policy;

• a. When the coverage is terminated;

• b. When the maximum benefits exhausted before 365 days;

• c. When the Beneficiary deceases,

• d. Permanently leaves the Kingdom;

• e. When the contractual agreement between the employee and the employer is terminated.

• f. Transfer employment to another employer for non saudis.

3. As an exception to the provisions of point (2) above in this Article, the cash reimbursements shall continue in relation to any current illness that led to the continued admission of the Beneficiary to hospital with the Service Provider, beyond the date specified for the contract expiration or termination, for the period required for the treatment of such illness, provided that such Expenses shall not exceed:

• a. Three hundred and sixty-five (365) days from the start date of the illness that necessitated admission of the Beneficiary to the hospital.

• b. The maximum limit of the Insurance Coverage set forth in the Policy.

• c. Hospital discharge

The rights of the Beneficiary shall include all of the following:

• 1. The beneficiary has the right to obtain from the employer a health insurance policy that is no less than the unified cooperative health insurance policy according to the link below:

  • https://www.cchi.gov.sa/AboutCCHI/Rules/document/Rules2018.pdf

• 2. The Beneficiaries shall obtain equal rights regarding health care services as intended according to the Policy without any discrimination or prejudice between them based on the insurance level.

• 3. The Beneficiary may access the medical treatment in Emergency Cases from outside the network of approved Service Providers without consulting the Insurance Company and without being obligated to pay any costs for the treatment services, and such costs shall be directly charged to the Insurance Company's giving that Service Provider shall inform the Insurance Company within no later than (24) hours from receiving the Emergency Case. If providers fails then will be responsible for all expenses until the date of notification.

• 4. The Beneficiary has the right to choose any Service Provider within approved network in the Policy. Insurance Company is not entitled to force the Beneficiary to choose a specific Service Provider, if the Beneficiary requests to be transferred to another Service Provider.

• 5. The Beneficiary shall receive the health service as agreed upon in the Policy by the network of approved Service Providers and neither the provider nor the attending physician are entitled to request any financial means or additional fees in return for providing medical services, whether in outpatient clinics or inpatient admissions, except for the service provider's request for deductible amounts, if any, or if the benefit limit has been exhausted .

• 6. The Beneficiary has the right to obtain the minimum network of Service Providers stipulated in the Policy.

• 7. Insurance companies are obliged to respond within maximum of 60 minutes from receiving pre-approvals and in case of rejection, an official justification should be explained to beneficiaries in addition to use MDS denial codes.

1. Provide correct, accurate and non-misleading data when filling out the Medical Disclosure Form, and shall not conceal any of the information when completing the decleration form or any other approved forms requested by the Council or Insurance Company or employer.

2. Immediately notify the Employer of any update on his/her marital status (including dependents).

3. The beneficiary must, within a maximum period of 30 days after the birth of the newborn, inform the employer to add him/her to the policy separate of the mother and notify the insurance company of that and the addition will be from the date of delivery.

4. Pay the deduction amount, if any, specified in the Policy according to the value paid by the Service Provider as agreed upon between the Insurance Company and the policyholder.

5. Assume full responsibility for the correctness of information in any document or form signed thereby in favor of any Insurance Party

6. It is the responsibility of beneficiary to report any suspicious activity that might affect any of the insurance parties.

The Employer or Policy Holder shall:

• 1. Provide health insurance for their employees and their dependent, by concluding a health insurance Policy with a health Insurance Company.

• 2. Explain and clarify to beneficiaries all articles of the Policy and the limits of the coverage provided to the Beneficiaries, through appropriate means like booklets, educational texts.

• 3. Pay the premium agreed upon with the Insurance Company, noting that if any part of this insurance subscription is not paid, the Policy shall not remain valid for a period longer than the period covered by the paid part of the subscription, and the Employer shall be responsible for providing an alternative insurance.

• 4. Provide the Insurance Company with the basic data required to conclude the Policy in accordance with the Medical Disclosure Form, and the Insurance Company may request additional data, or waive the request to fill out all or some of such data and in such case the insurance company has no right to refuse any coverage related to this waiver.
  5. Maintain a record that includes the data and information of their employees and their family members insured under the Policy. In addition, allow the Council or the Insurance Company to access such records whenever they request to verify the validity of information provided by the Policyholder.
  6. If the Employer wants to change the current Insurance Company or cancel the policy, the Employer shall submit a letter to notify the Insurance Company at least (30) working days prior to the date of the required cancellation, and a copy of such letter shall be submitted to the Council, Further, the Employer shall arrange another insurance Policy with a qualified Insurance Company so that the new coverage starts from the date following the cancellation of the previous Policy, provided that the Insurance Company shall notify the Council in this regard.