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.
Sanctions
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:
• Warning.
• Administrative
fine of OMR 1000-5000.
• Suspending
the licence for a maximum of six months.
• Revocation
of licence.
• Cancellation
of healthcare service provider enrollment.
