New health insurance compensation mechanism: billing and disbursement deadlines
The Council of Cooperative Health Insurance in Saudi Arabia has revealed details of the new regulatory mechanism for disbursing medical expense reimbursements to holders of mandatory health insurance policies. This crucial step aims to regulate the relationship between insurance companies and policyholders, affirming the beneficiary's right to reimbursement for emergency treatment costs when required to seek care at healthcare facilities outside the insurance company's network of approved providers. This ensures that patients' rights are not compromised in critical situations.
Details of the mechanism and binding timeframes
In an official statement, the council clarified that the updated regulations grant insured individuals the full right to receive urgent medical care at any healthcare facility as dictated by the necessity of their medical condition, without being restricted by the limits of the approved medical network. This reinforces the principle of patient safety as a paramount priority that supersedes administrative procedures. The council has established a strict timeframe to guarantee the rights of all parties, requiring beneficiaries to submit all invoices and supporting documents related to their medical condition within a maximum of 30 working days from the date of receiving the service.
In contrast, the council mandated that insurance companies disburse compensation payments to beneficiaries within a period not exceeding 15 working days , commencing immediately upon completion of the required documentation. This short timeframe aims to ensure the swift return of funds to beneficiaries and to mitigate the financial burdens resulting from emergencies that could unexpectedly deplete individuals' savings.
Regulatory context and health sector objectives
These decisions come within the framework of the Council of Cooperative Health Insurance's ongoing efforts to enhance the efficiency of the insurance sector in the Kingdom and align with the objectives of Vision 2030, which focuses on quality of life and facilitating access to healthcare services. Through these regulations, the Council aims to reduce existing disputes between insurance companies and beneficiaries regarding reimbursements, as ambiguity in reimbursement timeframes previously led to delays in claims or the rejection of reimbursements.
The regulatory clarifications also indicated that insurance companies are obligated to bear the reimbursable expenses according to the prevailing and approved market prices, after calculating and deducting the deductible percentage specified in the insurance policy terms for the beneficiary, thus ensuring fairness in pricing and compensation.
The importance and expected impact of the decision
This regulation is of paramount importance both locally and sectorally. On the one hand, it strengthens the confidence of citizens and residents in the mandatory health insurance system, providing them with financial security when facing health emergencies anywhere in the Kingdom without fear of claims being rejected later. On the other hand, this regulation requires insurance companies to develop their financial and administrative systems to expedite the processing and review of invoices to comply with the 15-day deadline, thereby increasing the operational efficiency of the sector as a whole.
This decision is expected to contribute to reducing the rates of complaints submitted to the Council of Cooperative Health Insurance related to delays in compensation, and will encourage beneficiaries to commit to submitting their claims in record time, thus ending the state of financial accumulations pending for long periods.
