Health insurance approval rejected: your rights and what to do

How does pre-approval work?

Some tests, procedures and medicines need prior approval from your insurer before they are carried out. The hospital or clinic sends the request electronically with the diagnosis and reports, and the insurer approves, rejects or asks for more information.

Your key rights as a beneficiary

According to the health insurance beneficiary rights document in Saudi Arabia:

• Fast response: the insurer must respond to a pre-approval request within a maximum of 60 minutes of receiving it.
• A reason for rejection: if a request is rejected, an official justification must be explained to you.
• Emergencies: you may receive emergency treatment even outside the approved network, without paying for it, provided the provider notifies the insurer within 24 hours.
• Choice within the network: you may choose any provider within your approved network.
• No extra fees: you should not be charged beyond the co-payment in your policy, unless your benefit limits are exhausted.

These rights may be updated, so check the latest version published by the Insurance Authority.

Why are approval requests often rejected?

• Missing medical information or reports with the request.
• The medical necessity of the procedure is not clear from the written diagnosis.
• The service is not covered by your policy, or coverage limits have been reached.
• The provider is outside your network in a non-emergency case.

Practical steps after a rejection

1. Ask for the reason: ask the hospital for the rejection reason and code as received from the insurer.
2. Check your policy: review your table of benefits and policy class to see whether the service is covered.
3. Ask your doctor for a supporting report: many rejections are due to missing information, and the request can be resubmitted with a report explaining the medical necessity and supporting tests.
4. Contact the insurer: file an appeal through its customer service channels, and keep the request number and dates.
5. Escalate to the Insurance Authority: if the issue is not resolved, you can complain to the Insurance Authority's consumer protection department, the regulator of the health insurance sector since March 2024.

Tips before any planned procedure

• Ask before the appointment: does the procedure need pre-approval, and when will the request be sent?
• Keep copies of reports and tests; they speed up appeals and resubmissions.
• In an emergency, do not delay treatment because of approval. Call 997 or go to the nearest emergency department.

Frequently asked questions

How long does insurance approval take?

According to the beneficiary rights document, the insurer must respond to a pre-approval request within a maximum of 60 minutes of receiving it.

Do emergencies need pre-approval?

No. You may receive emergency treatment even outside the network without prior approval, and the provider notifies the insurer within 24 hours.

Where can I complain about my health insurer?

Start with the insurer itself, and if the issue is not resolved, complain to the Insurance Authority’s consumer protection department.

How HealTrip can help

HealTrip is being built to help you organise your medical file and reports, which speeds up approval requests and appeals. The platform is currently in pre-launch and does not provide medical, insurance or legal services before licensing is complete. How to choose a hospital · Second medical opinion guides · اقرأ بالعربية.