Tuesday, March 24, 2020

Issuance of Health Insurance Rules

In October 2019, the Capital Market Authority (the “CMA”) issued Ministerial Decision 78/2019 Issuing the Health Insurance Rules (the “Rules”) in respect of the Unified Health Insurance Policy (the “Policy”), the details of which were previously issued under Ministerial Decision 34/2019 and discussed in our July 2019 article, Oman Rolls Out Unified Health Insurance Policy – or ‘Dhamani.’  The Rules set out the obligations of the various stakeholders in the health insurance relationship, i.e., insurers, third-party administrators, health services providers, employees and employers.
Insurance coverage
The Rules provide that the Policy will determine the extent of the health insurance coverage to be provided under the Policy, provided that such coverage should not be below the basic health services the insured should enjoy.
Insured persons are entitled to cancel their health insurance policy at any time by providing 30 working days’ prior written notice, in which case the insurer is required to refund the insured the amounts in respect of the cancelled term in accordance with the terms of the insurance policy.  Such refund should be provided within 30 working days of the date of cancellation of the insurance policy.
The amount of the insurance premium will have to be agreed on between the parties, as long as such premium does not exceed the market pries for health insurance in Oman.
The health insurance coverage will expire under the following circumstances:
          Expiration of the term of the insurance policy.
          Exhausting the maximum limit of the benefits under the policy.
          Death of insured.
          Departure of the insured expatriate out of Oman.
          Transfer of service of insured from one entity to another.
Any claims arising from a health insurance policy shall not be heard until one year has lapsed from the date of expiration of the relevant policy.  Statutes of limitations shall be considered paused by claim measures or procedures stipulated in the Rules.
Issuance of licence
The Rules provide that without prejudice to the provisions of Ministerial Decision E/31/2007 regarding licensing requirements for insurance companies, a company will also need to submit an application in the form stipulated in the Rules.  The CMA will examine the licence application within 60 days of submission.  In the event that the application does not provide all the required documents, the applicant is required to provide the required document within 30 days of being notified to do so.  Failure to provide the documents within the stipulated time period will result in the application being cancelled.  Once an application has been cancelled, another application cannot be submitted for a period of 90 days from such cancellation.  If the application is granted, the Executive President of the CMA will issue a decision granting the licence within 60 days of receipt of all the required documents within the prescribed time period.  If no decision is issued within the 60-day period, the application will be deemed to have been rejected.
A licence will be valid for a period of two years and renewable for similar periods.  The application for renewal will need to be submitted by the insurer at least 30 days prior to the expiration of the licence.
Provision of health insurance
All relevant parties are required to implement the Health Insurance Electronic Platform, as discussed in the Policy and in accordance with other decisions and notifications of the CMA.
Health insurance activities and operations may not be undertaken unless the relevant licence has been obtained from the CMA.  Healthcare providers licensed to provide health insurance services are barred from providing health insurance services unless they have satisfied the CMA’s enrollment requirements and paid the stipulated fees.
Except as permitted in accordance with the terms and conditions issued by the Executive President of the CMA, no insurer may own or operate a health care provider or third-party administrators, and no healthcare provider may own shares in companies licensed to undertake health insurance activities, insurance brokers or agents for health insurance companies, or third-party administrators.
Health insurance providers are required to retain a minimum of forty per cent. (40%) of the net health insurance premiums within Oman.
The Rules also set forth the obligations of the insurers, healthcare providers, and the insured vis-à-vis each other.
Health insurance dispute settlement committee
The Rules provide for a committee to be formed by a decision of the Executive President of the CMA to settle disputes arising from practicing health insurance activities.  The committee will be entitled to consider disputes arising between or among insurance providers, healthcare providers, the insured, third-party administrators and insurance brokers and agents; decide on claims that have been rejected, returned, or deducted by the insurance company; and any other matters which the Executive President deems necessary to bring before the committee.
The committee shall issue its decisions within 30 days from the date of the matter being put before it.  Concerned or interested parties will have the right to appeal against the decision of the committee to the Executive President within 60 days from the date of notification, or the date when the appellant became categorically or undoubtedly aware of the decision.  The appeal must be decided within 30 days from the date of its submission.  The expiry of the said period shall be considered as a rejection of the appeal.
Notwithstanding the sanctions listed under the Insurance Companies Law, the CMA shall be entitled to impose the below sanctions in the event of violation of the Rules:
          Administrative fine of OMR 1000-5000.
          Suspending the licence for a maximum of six months.
          Revocation of licence.
          Cancellation of healthcare service provider enrollment.