Health Insurance Rules (No. 78/2019)

Decision No. 78/2019 On the Issuance of the Health Insurance Rules ;Based on the Insurance Companies Law, promulgated by the Oman Sultani Decree No. 12/1979 Oman Sultani Decree No. 90/2004 transferring the insurance competencies from the Ministry of ;Commerce and Industry to the Capital Market Authority Implementing Regulation of the Insurance Companies Law, promulgated by the Oman Ministerial ;Decision No. 5/1980 ;Decision of the Regulation of the Licensing Requirements of Insurance Activities no. K/31/2007 ,Form of the unified health insurance policy, promulgated by the Oman Decision No. 34/2019 ,And based on the public interest requirements :The following was decided Article 1 .The provisions of the attached rules concerning health insurance shall come into force Article 2 The valid health insurance policies shall remain in force before the date of entry into force of this Decision until expiry of their period. The provisions of this Decision and the form of unified .health insurance Policy shall apply for all that is not specifically stated in these documents Article 3 The Executive President of Capital Market Authority shall issue the forms, decisions and .instructions necessary for the implementation of the provisions of this Decision Article 4 All that contradicts this Decision and the enclosed rules and violates the provisions thereof shall .be abrogated Article 5 This Decision shall be published in the Official Gazette and shall enter into effect on the day .following the date of publication thereof Issued on:3 Safar 1441 H Corresponding to: October 2, 2019 Abdullah bin Salem bin Abdullah Al Salmi

Executive President of Capital Market Authority Health Insurance Rules Chapter 1 Definitions and General Provisions Article 1 In application of the provisions of these rules, the following terms and expressions shall have the :meanings stated beside them, unless the context requires otherwise .Authority: The Capital Market Authority-1 .Ministry: Ministry of Health-2 .Executive Director: Authority's Executive Director-3 .Licence: Decision issued by the Authority approving the exercise of health insurance activities-4 .Policy: Unified health insurance Policy and its annexes-5 .Company: Insurance Company licensed by the Authority-6 .Insurer: Insurance Company licensed to exercise health insurance activity at the Sultanate-7 Insured: Physical person, Worker or dependent to whom the Insurer performs his obligations-8 .by virtue of the provisions of the Policy Beneficiary: Physical or legal person who shall pay the Insurance Premium and in whose name-9 .the Policy shall be issued in favour of the Insured Health Insurance Claims Management Company: Company licensed by the Authority to-10 exercise the works of health insurance claims management between the insurance services and .health services providers Insurance Coverage: Basic health benefits and optional benefits available and agreed upon in-11 .details between the Insurer and the Beneficiary, in favour of the Insured under the Policy Insurance Premium: An amount of money that the Beneficiary shall pay to the Insurer to bear-12 .the healthcare costs of the Insured under the Policy Worker: Any physical person actually working for the Beneficiary and registered in such-13 .capacity in the records thereof Health Service Provider: Health facility approved by the Ministry of Health and licensed to-14 .provide health insurance services at the Sultanate according to the regulations in force Health Service Providers Network: Group of accredited Health Service Providers, specified by-15 .the Insurer to provide healthcare services to the Insured Insurance Relationship Parties: Insurer, Insured, Beneficiary, Health Service Provider and-16 .(Health Insurance Claims Management Company (TPA Committee: Committee for the Settlement of Health Insurance Disputes-17 Article 2

The Policy shall determine the limits of Insurance Coverage, provided that the coverage is not .less than the minimum limit of basic health services that shall be provided to the Insured Article 3 No Company shall exercise health insurance activity without obtaining a Licence of the same .from the Authority according to the provisions of these rules Article 4 The Health Service Provider shall not provide health insurance service unless the requirements of .registration at the Authority's register are met, and the prescribed fees are settled Article 5 The Beneficiary may cancel the Policy at any time by virtue of a written notification sent to the Insurer (30) thirty working days at least from the date of cancellation. In such event, the Insurer shall, within (30) thirty working days from the date of cancellation, return to the Beneficiary the remaining part of the Insurance Premium for every Insured who did not benefit from the Insurance Coverage. The remaining part of the Insurance Premium shall be calculated according .to the formula stated in the Policy Article 6 The Insurer shall not own, operate or manage a Health Service Provider or a Health Insurance Claims Management Company. The Health Service Provider shall also not own shares in companies licensed to exercise health insurance activity, insurance brokerage companies, insurance companies agents exercising the same activity, or health insurance claims management companies, unless according to the rules and conditions issued by the Chief Executive Officer in .this regard Article 7 The Insurer and the Beneficiary shall agree on the determination of the value of Insurance Premium, provided that such premium is consistent with the rates of health insurance market at .the Sultanate, and is based on actuarial, technical and objective bases Article 8 :The Insurance Coverage shall be ended in any of the following cases .Expiry of the Policy-1 .Exhaustion of the maximum benefit according to the Policy-2 .Death of the Insured-3 .The foreign Insured leaves the Sultanate permanently-4 Transfer of service of the Insured from one Beneficiary to another-5 Article 9 The Insurer shall retain at least (40%) forty percent of the net health Insurance Premiums inside the Sultanate Article 10 The Authority's employees, determined by a decision from the competent authority shall have, according to the laws in force and in agreement with the Chief Executive Officer, the capacity of

judicial officers within the scope of application of the provisions of these rules, decisions and .instructions implementing the same, concerning the violation of the provisions thereof Article 11 Lawsuits arising from the disputes between the Insurance Relationship Parties shall not be heard after one year from the expiry of the Policy. The limitation prescription shall be interrupted by .taking any of the procedures of claim stated in these rules Article 12 The entities concerned by the provisions of these rules shall apply electronic connectivity system to the health insurance system according to the forms and decisions issued by the Authority in .this regard Chapter 2 Licence to Practice Health Insurance Activity Article 13 Without prejudice to the provisions stated in the above-mentioned Decision on the Regulation of the Licensing Requirements of Insurance Activities no. K/31/2007, in order to obtain the Licence, an application shall be submitted to the Authority according to the form prepared for :this purpose, accompanied with the following documents A strategy approved by the Company's Board of Directors to exercise health insurance activity,-1 :including the following a-The Company's organisational structure, stating the organisational level for the .management of health insurance activity, its capacities and work mechanisms b-An actuarial study to assess the Company's financial position and expected financial flows .for the next three years .c-Customer service Policy and quality assurance .d-Subscription Policy and pricing. e-Policy for dealing with disasters and crises .f-IT Policy and data security and confidentiality .g-Health insurance claims management Policy .h-Re-insurance arrangements for health insurance activity .i-Health insurance risk management Policy Acknowledgment by the Company of its obligation to observe the following clauses according-2 :to the circulars issued by the Authority .a-Appointment of a health insurance director .b-Appointment of technical and administrative personnel .c-Availability of an electronic system .Copy of the agreements concluded with Health Service Providers-3 Copy of the agreements concluded with Health Insurance Claims Management Company (TPA),-4 .if any

.Receipt of the Licence application fee-5 .Any other documents required by the Authority-6 Article 14 The Authority shall study the Licence application within (60) sixty days from the date of submittal thereof. In case the application does not meet any of the required documents, the applicant shall be notified of the same to meet the same within (30) thirty days from the date of notification. In case of failure to do so within the said period, the application shall be considered .cancelled The Company shall not submit another application before (90) ninety days from the date of .cancellation of the previous application Article 15 The Authority's Chief Executive Officer shall issue a decision concerning the Licence within (60) sixty days from the date of meeting the required documents. The expiry of the said period .without issuance of the Licence shall be considered as rejection Article 16 The Authority may, within the framework of organisation of the health insurance sector, stop issuing new Licences for the periods deemed appropriate, provided that its decision in this .regard is justified Article 17 The Authority shall establish a special record to register the companies licensed to exercise health insurance activity. The record shall include the registration name, Company's name, .Licence number, period and location Article 18 The Licence period shall be of (2) two years, renewable for one or other similar periods, upon a request submitted by the Company (30) thirty days at least from the date of expiry of the .Licence, according to the form prepared for this purpose Chapter 3 Obligations of the Insurance Relationship Parties Article 19 :The Insurer shall .Contract with the Health Service Provider registered in the Authority's records-1 Enable the Insured to obtain his rights specified in the Policy by all available means and-2 .maintain the confidentiality and protection of its data Pay the reimbursable expenses according to the provisions of the Policy within a period not-3 .exceeding (15) fifteen days from the date of completion of the documents supporting the claim Notify the Insured or the Beneficiary of the instructions and directives related to health-4 insurance and provide the latter with the forms, documents, publications and booklets issued in .the field of health insurance :Notify the Authority in any of the two following cases-5

a-Violations committed by the other Insurance Relationship Parties, or in case of presence of any conflict of interests or any direct or indirect interests with the Health Service .Provider b-Change or amendment occurring to any of the documents under which the Licence is issued, within (7) seven days from the date of occurrence thereof, and providing the Authority with any information, data or statistics required or deemed to be perused, .including the databases, records and health insurance contracts concluded Maintain financial records related to health insurance for a period of (10) ten years and-6 provide statistics and reports related to Insurance Coverage provided to the Insured upon .request from the Authority Pay the medical expenses to the Health Service Provider within (45) forty-five days from the-7 .date of receipt of the claim, unless in case of another agreement between both parties Contract with Health Insurance Claims Management Company (TPA), with the exception of the-8 .Insurer having an independent system to manage such claims Article 20 :The Beneficiary shall .Pay the due Insurance Premiums to the Insurer within the dates agreed upon-1 Notify the Insurer in writing of any changes it wishes to make to the Policy whether by addition-2 .or deletion, according to the provisions and procedures stipulated in the Policy Notify the Insurer in writing in case of cancellation of the residence permit of the foreign-3 Insured and his departure from the Sultanate, to recalculate the Insurance Premium reimbursed .according to the provisions of the Policy Article 21 :The Insured shall Receive treatment services at the Health Service Providers Network, with the exception of the-1 :following cases a-Emergency cases requiring prompt treatment, whether suddenly or as a result of a worsening condition resulting into a medical condition requiring urgent medical intervention, with the absence of a Health Service Provider in the area where the Insured is .present b-Unavailability of treatment at the Health Service Providers Network, provided that the .treatment is within the limits of Insurance Coverage .c-Absence of a Health Service Providers Network in the area where the Insured is located Notify the Beneficiary immediately in case of loss or damage of its health insurance card, not-2 .to misuse it in any way, including allowing others to use it Notify the Beneficiary or the Insurer of any exploitation, manipulation, neglect or negligence by-3 .the Health Service Providers .Refrain from any act that would lead to unlawfully obtaining health benefits or material gains-4 Re-conduct medical examination upon the request of the Insurer and enable the latter to-5 access all the data and documents related to the insurance claim, provided that the Insurer .bears the costs of medical re-examination

Provide the Insurer with the documents supporting the claim within a period not exceeding-6 (120) one hundred and twenty working days from the date of incurring such expenses in case of .treatment outside the Health Service Providers Network Article 22 :The Health Service Provider shall Provide treatment and medical examinations to the Insured according to the provisions of the-1 Policy, and shall not neglect or manipulate medical records or financial statements related to the .health benefits provided to the Insured Not make the Insurer bear the costs of consultation or treatment provided through the-2 .consultant without prior referral decision from the licensed physician Verify the identity of the Insured before providing treatment service. Its right of insurance-3 claim shall be forfeited in case it was proved that a treatment service was provided to other than .the Insured Submit its financial claims related to health insurance to the Insurer according to the-4 mechanism agreed upon, and notify the Authority of any change or amendment occurring to any of the registration requirements in the record within (7) seven working days from the date of .occurrence Abide by the principles of legitimate competition and not take any action that would-5 circumvent the health insurance system or obtain material gains illegally. It shall notify the Authority in case of any conflict of interests or any direct or indirect interests with the Insurance .Relationship Parties Provide the Authority with the required information, data and documents related to health-6 benefits submitted by it to the Insured whenever required, and provide the Authority with any .information, data or statistics required or deemed necessary Abide by the provisions and dates stated in the Policy concerning the relationship with the-7 Insurer, and provide the latter with the information related to the Insured in the cases requiring .the same Chapter 4 Health Insurance Disputes Settlement Committee Article 23 A Committee shall be formed under a decision from the Executive Director to settle the disputes arising from the exercise of health insurance activity. The decision for the formation thereof shall .determine the Committee's Chairman, Deputy Chairman, Secretary and members Article 24 :The Committee shall .Study the disputes arising from any of the Insurance Relationship Parties-1 .Decide on the claims that were rejected, returned or litigated by the insurance Company-2 .Any other matters deemed by the Executive Director to be presented to the Committee-3 Article 25 The Secretary of the Committee shall prepare a statement of the disputes to be presented to the

Committee, accompanied with a detailed memorandum of each dispute, provided that he distributes a copy thereof to each of the Chairman and members of the Committee, (3) three days at least before the meeting, unless the meeting is held to discuss an urgent matter, at the .request of the Executive Director Article 26 The Committee shall convene at the invitation of its Chairman or Deputy Chairman. The meeting shall be considered valid in the presence of the majority of members, provided that the Chairman or Deputy Chairman is present. The deliberations shall be confidential and the decisions of the Committee shall be issued by the majority votes of the members present, and .upon equality of votes, the side for which the President of the meeting voted shall prevail The Chairman of the Committee or any of its members shall not attend the deliberations and vote thereon in case the subject presented to the Committee is related to him in person or to his .spouse or any of his relatives up to the fourth degree Article 27 The Committee's Secretary shall record the minutes of meeting, which shall include a statement of the names of members present, the absent members, the subjects presented to the Committee, the deliberations made thereon and the decisions taken in their regard. These minutes shall be signed by the President of the meeting, the members present and the Secretary .of the Committee Article 28 The Committee shall issue its decisions within (30) thirty days from the date of presentation of the subjects thereto. The Committee's Secretary shall notify the concerned persons of the Committee's decision in writing within a period not exceeding (7) seven working days from the .date of issuance of the decision Article 29 The concerned persons may appeal the decision of the Committee before the Executive Director within (60) sixty days from the date of notification or knowledge thereof. The appeal shall be decided upon within (30) thirty days from the date of submittal thereof. The expiry of the said .period without any response shall be considered as rejection of the appeal Chapter 5 Administrative Penalties Article 30 Without prejudice to the criminal penalties prescribed under the said Insurance Companies Law, the Authority may take one or more of the following procedures in case of violation of the :provisions of these rules .a-Warning b-Imposing an administrative fine of not less than (1,000) one thousand Omani Riyals and not .exceeding (5,000) five thousand Omani Riyals .c-Suspension of the Licence temporarily for a period not exceeding (6) six months .d-Cancellation of the Licence .e-Removal of the Health Service Provider record

Chapter 6 Fees Article 31 :The Authority shall collect the following fees Fee in Omani Riyals Type ofFee S one thousand five hundred (1,500) Study of the Licence application 1 two thousand (2,000) Registration of the health insurance activity 2 two thousand (2,000) Renewal of registration of the health insurance activity 3 twenty (20) Dataamendment 4 twenty (20) Request of perusal of the papers and records 5 twenty (20) Request of copies or extracts 6 (two hundred) 200 Registration of Health Service Provider 7 (two hundred) 200 Renewal of registration of Health Service Provider 8 Article 32 The Executive Director shall, in case of delay in the renewal of registration according to the specified time limits, impose an administrative fine of (5%) five percent of the amount of fee due .per each week of delay