1. Health Insurance in Saudi Arabia
Lecture 3

2. GOALS Cooperative Health Insurance Policy Section One: Definitions
Section Two: Recoverable Expenses / Benefits
Section Three: Limitations and Exclusions
Section Four: General Conditions
Cooperative Health Insurance Schedule

3. Section Two: Recoverable Expenses / Benefits
Recoverable expenses shall include:
Health benefits:
Expenses of medical examination, diagnosis, treatment and medicine as shown in the policy schedule.
Expenses of hospitalization, including surgeries, same-day surgeries or treatment and pregnancy and delivery.

4. Section Two: Recoverable Expenses / Benefits
Treatment of dental and gum diseases.
Preventive measures, such as vaccinations including seasonal vaccinations and maternity and child care.

5. Section Two: Recoverable Expenses / Benefits
Acute psychological disorders within the limits specified in the policy schedule.
Cases of contagious diseases requiring isolation in hospitals as specified by the Ministry of Health.
Alzheimer cases.

6. Section Two: Recoverable Expenses / Benefits
Autism cases.
Acquired valvular heart disease.
National Newborn Screening Program (NBS) to prevent disabilities.
Costs of organ harvesting procedures.
Disability cases.

7. Section Two: Recoverable Expenses / Benefits
2.Costs of preparation and repatriation of the corpse of an insured individual to the home country specified in the employment contract.

8. Section Three: Limitations and Exclusions
a. The policy shall not cover claims arising from:
Intentional self-inflicted injury.
Illness resulting from abuse of some medicines
Cosmetic treatment or surgery unless necessitated by a bodily injury not excluded in this section.

9. Section Three: Limitations and Exclusions
a. The policy shall not cover claims arising from:
General examinations, inoculations, drugs or preventive measures not required for medical treatment provided for in the policy.

10. Section Three: Limitations and Exclusions
a. The policy shall not cover claims arising from:
Treatment received by the insured free of charge.
Recreational therapy, general physical health programs and treatment in social welfare institutions.

11. Section Three: Limitations and Exclusions
a. The policy shall not cover claims arising from:
Any illness or injury directly resulting from the insured's profession.
Medically recognized venereal or sexually transmitted diseases.

12. Section Three: Limitations and Exclusions
a. The policy shall not cover claims arising from:
Costs related to tooth implant, dentures, fixed or movable bridges or orthodontic treatment, unless resulting from an accident.
Vision or hearing correction tests and visual or hearing aids, unless ordered by the attending physician.

13. Section Three: Limitations and Exclusions
a. The policy shall not cover claims arising from:
Hair loss, baldness or artificial hair.
Any costs or additional expenses incurred by the insured's companion during hospitalization, except for hospital room and board charges for one companion, such as a mother accompanying a child up to the age of twelve or if medically necessary as assessed by the attending physician.

14. Section Three: Limitations and Exclusions
a. The policy shall not cover claims arising from:
Alternative medicine procedures and medications.

15. Section Three: Limitations and Exclusions
b. The policy shall not cover health benefits or corpse repatriation to home country in claims resulting directly from:
War, invasion, acts of foreign aggression; whether or not war is declared.
Riots, strike, terrorism or the like.

16. Section Four: General Conditions
1. Payment of Premiums (Subscriptions):
a.The policyholder shall pay the insurance premium due on each insured person as agreed upon with the company upon commencement of the insurance coverage.

17. Section Four: General Conditions
1. Payment of Premiums (Subscriptions):
b. In the event of non-payment of any portion of a premium, the policy shall not be valid for a period longer than that covered by the portion paid, and the company shall notify the Council accordingly.

18. Section Four: General Conditions
2. Deductible (Co-payment):
The insured shall pay the deductible, if any, specified in the policy schedule at the healthcare center under the agreement between said healthcare service provider and the company. Any attempt by the insured to withhold payment shall be considered breach of the terms and conditions of the policy whose validity shall be suspended in respect of such insured until the deductible is paid.

19. Cooperative Health Insurance Schedule
Benefits and Limitations of Coverage under the Policy
Maximum annual benefit limit per person
SR 500,000

20. Cooperative Health Insurance Schedule
Outpatient Treatment Expenses:
Deductible (Co-payment): the percentage paid by the beneficiary ( insured ) when visiting outpatient clinic physician including all consultations, lab tests, x-rays, medicines and other medical supplies as well as follow-up visits and referral for the same illness.
0-20% per visit with a maximum limit
of SR 100 per visit.

21. Cooperative Health Insurance Schedule
Maximum Physician's Fees: - General Practitioner SR 50 - Specialist (Senior Registrar) SR Specialist (Registrar) SR100 - Consultant SR300 - Rare medical specialties and the like. SR 500

22. Cooperative Health Insurance Schedule
Hospitalization Expenses:
Deductible (Co-payment) None
Limit of daily room and board for the patient which includes charges for bed, nursing, medical visits and supervision, catering services, excluding cost of drugs and medical supplies prescribed by the physician.
Shared Room, Maximum of SR 600/Day

23. Cooperative Health Insurance Schedule
Hospitalization Expenses:
Limit of daily room and board for a patient companion.
Shared Room, Maximum
of SR 150 / Day

24. Cooperative Health Insurance Schedule
Hospitalization Expenses:
Pregnancy/Delivery Cost
Maximum of SR 15,000 during the term of the policy
Premature Babies
Maximum benefit limit under this policy

25. Cooperative Health Insurance Schedule
Hospitalization Expenses:
Cost of Dental Treatment
Maximum of SR 2000 during the term of the policy
Cost of Spectacles
Maximum of SR 400 during the term of the policy