Medical Insurance Claims (My Family and Balsam Programs)
The medical insurance claims comprise the procedures adopted for the payment of medical expenses against the medical treatment to the Assured Person and the beneficiaries whether at the approved medical providers or non approved medical providers in the following manner:
Medical treatment at the approved medical providers (direct billing):
If the Assured Person or beneficiary is provided with the required medical treatment, the medical expenses are directly billed by the medical provider at Tawuniya's account. The beneficiary will only pay to the medical provider the deductible or expenses of medical services not included in the insurance cover or those in excess of the benefit limit. Tawuniya uses the electronic linking system with the medical provider (Waseel) to ensure the instant submitting and settlement of medical claims in accordance with the policy conditions and terms of contract between the two parties and in the manner that satisfies the obligations of both parties to provide the premier service to the customers.
Medical treatment at the non-approved medical providers (reimbursement of medical expenses:
In case of medical emergencies, non-availability of treatment at the approved medical provider or the emergency cases outside KSA whilst on vacation and business trips if covered by the policy, the Assured Person or beneficiary is compelled to visit a non-approved medical provider. In this case, the Assured Person will pay the full medical expenses in cash to the medical provider then apply to Tawuniya to for reimbursement of medical expenses paid. The Medical Insurance Department will take the necessary actions for the reimbursement of these medical expenses and compensate the Assured Person in accordance with the policy's terms, conditions, limitations and exclusions.
Conditions of medical claims
- The procedures of medical claims are subject to the terms, conditions, limitations and exclusions of the policy.
- The deductible/ co-insurance clause will be applicable to the medical claims in accordance with the percentages stated in the policy. The customer will directly pay the deductible to the approved medical provider or deducted by the company from the medical expenses reimbursement request if the medical treatment is received at a non-approved medical provider.
- The reimbursement of medical expenses will be in respect of the cases presented to the company within thirty (30) days from being billed as specified in the policy.
- The amount of medical costs and expenses recoverable by the company to the customer for the medical treatment received at the non-approved medical providers are calculated on the basis of prevailing prices at the approved medical providers.
- The amount of medical costs and expenses recoverable by the company to the customer for the medical treatment received at the non-approved medical providers outside the KSA are calculated on the basis of prevailing prices at the approved medical providers inside KSA, unless otherwise provided for in the policy.
- All necessary documents in support of the claim must be attached with the medical expenses reimbursement form to ensure the instant settlement of the amount payable the customers.
- Some healthcare services are subject to prior medical approval clause from the company. Therefore, the Assured Person shall obtain such prior approval to ensure his/ her right in reimbursement of medical expenses paid.
- The cases of illness excluded from insurance cover are not compensated (please refer to the policy).
- The amount of medical expenses will not be recoverable if exceeded the maximum limit of cover specified in the table of benefits.
Documentation in Support of a Claim
- The medical report detaining the case.
- Laboratory results and radiology reports (in case the patient receives their services).
- Original invoices and receipts.
- A copy of the Medical Identification Card.
- A copy of the Exit &Re-entry visa (accompanied with the medical approval of Tawuniya in case of treatment outside the kingdom).
- To fill in the medical expenses reimbursement form, which is electronically available in all branches of the company.
Channels for submitting medical claims
- Sales offices.
- Call Center Toll Free No.
- By E-mail.
Claims Follow-up Procedures
- The Call Center tool Free Line: 920019990.
- You will receive SMS at your mobile after log in Tawuniya website.
- E-services through Tawuniya website.
- Tawuniya application (Smart mobile phones).