Resolution No 34/2019 – For the Issue of Unified Healthcare Insurance Policy Form
The Health insurance market embraces itself for another mandated health insurance law in the Sultanate of Oman. Residents in Oman will be required to have in place a minimum level of medical insurance coverage with minimum benefits pursuant to the prescribed provisions of Resolution No 34 of 2019 For the Issue of Unified Healthcare Insurance Policy Form , which was issued by the Capital Markets Authority (CMA) as at 24 March 2019 and is now in force ("the Law").
The application of the Law is relevant to the employer market and the beneficiaries arising from those relationships including employer, employee and dependents.
The Law applies and has adopted a "Basic Benefits" and "Optional Benefits" coverage, standard form "Policy Schedule" for parties' signature and a standard "Insurance Application" for pre contractual disclosure requirements.
Chapter One of the Law prescribes a "Unified Health Insurance Policy" ("the Policy"). Insured is defined as "natural or unnatural person responsible to pay the insurance premium" and Beneficiary has been defined as "employee or employee dependent to whom the Insurer performs the duties assigned by the provisions of this Policy". Dependents have been defined to include employee's legally wedded spouse, residing in Oman, children of the employee who under 21 years age and any other person who resides in Oman and is dependent on the employee. This may include the employee's parents/other relatives based in Oman, house help or maid who is sponsored by the employee.
Insurer has been defined as "Insurance company licensed to practice health insurance business in the Sultanate" thereby clarifying that the Policy can't be underwritten on non-admitted basis by foreign insurers, which provides welcome clarity to the market.
The Policy must be completed and submitted by the Insured as a legal obligation. The Law, as currently prescribed, addresses application, coverage, mandatory minimum benefits and claims management.
Chapter Two is of interest, as the preamble defines a wide interpretation of what shall constitute the contract of health insurance, which includes all basic information, details and common practices in healthcare insurance contracts etc. Insurers will need to take care with their pre-contractual documents, as these could for all intents and purposes unintentionally constitute the contract of insurance. Chapter Two further sets out the general terms and conditions, places obligations on the insured to disclose correct and accurate information. The Code of Conduct for Insurance Business issued by the CMA requires insurers to inform insureds of their duty to disclose relevant information. Omani Law therefore applies the duty of utmost good faith (uberrimae fidei). Chapter Two also prescribes the excluded conditions from the coverage under the Policy.
The overall combined limit under the Policy is OR 4,500 in terms of financial spend so surprisingly much lower that the UAE and KSA mandated schemes. Inpatient treatment limits for the policy year is capped at OMR 3,000 and includes usual basic cover, i.e. admission in hospital or daycare, cost of treatment, room cost, consultant fees, diagnosis and test, medicine, ambulance cost and companion cost, also including the cost for pre-existing and chronic conditions for in-patient treatment, while the latter is excluded for out-patient treatment.
Hospital admission under the Policy must be in a joint room and is limited to 30 days at each instance, whereas the ambulance cover is limited at OR 100 each trip. Outpatient treatment is limited to OR 500 for each policy year and the cover is limited to consultancy fees, diagnosis and tests, pharmacy fees and lab fee. Additionally, the Policy includes the cost of repatriating a deceased beneficiary to their country of origin, for which a limit of OR 1000 has been allocated.
Any departure from the basic benefits is not permitted unless agreed as a Schedule to the Policy and signed by both parties and should additional benefits be opted for by the insured, they must be set out in the Optional Benefit Schedule format provided in Appendix 3 to the Law.
The Law also sets out specific obligations on how it will be administered, some of which we set out below:
- All Health Insurance Claim Management systems of the Providers must be compatible with the electronic claims system applicable in Oman;
- Insurers will bear the cost of a medical Consultations only if there is prior referral from a licensed physician;
- Providers must seek prior approval for all inpatient treatment and for all outpatient treatment where costs exceed OR 100, however in emergency cases treatment must start immediately;
- For approvals, providers must upload all details in the online application and the insurer must respond within 30 minutes with a decision, failing which it will be deemed as approved;
- Similarly, a Provider is also required to respond to any inquiries or observation by Insurer within 30 minutes of the inquiry/observation being made;
- For all claims made outside the network, the Insured must make the claim within 120 days of the claim and insurer must compensate beneficiary within a period of 15 days of receiving documents in support of a claim; and
- Whenever a claim is rejected by Insurer, the Insurer must provide to the Beneficiary, within 10 days of rejection a written statement highlighting the reasons for which the claim is rejected.
Appendix 4 to the Law sets out the mandatory basic minimum coverage under the Policy, which provides two options to the Insured based on which premium will be determined by the Insurer. While both options have the same coverage terms and limits, the first option provides for deductibles on certain categories and the second option does not require deductibles to be paid by the beneficiary. The deductibles on the first option are limited to outpatient treatment only and are set at 10% for medicine, subject to the limit of OR 5 per visit and 15% for consultancy fees, diagnosis and lab fee for providers within network (with a cap of OR 20 per visit) and at 30% for Providers outside the network (with no cap!).
While the Middle East insurance market is to a large extent geared up for the new mandated health insurance requirements in Oman based on previous experiences with the KSA and UAE markets, they should no doubt see the opportunities for top over coverage in Oman given that the minimum coverage is very basic in nature (i.e. no maternity coverage offered as a minimum benefit). Of interest, Oman has not applied licensing for third party claims administrators at present, which also presents opportunities in this market.
We anticipate many questions and clarifications around the Law both from insurers, reinsurers, intermediaries, third party administrator, clinical providers and others. BSA are well placed to provide support in this area with its expertise in health insurance laws and regulations and its Muscat law office.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.