Emirates: Question: I have a medical condition that requires certain procedures. Although my doctor has deemed these procedures essential, some of them are being rejected by the insurance company. How can I address this legally?

Answer: In Dubai, the provisions of the Dubai health insurance law and the administrative resolution are applicable.

An insurance company is required to pay for health benefits, cover emergency treatment from out-of-network providers until the beneficiary’s life is no longer at risk, and ensure the beneficiary can access all rights granted under the health insurance policy. This is in accordance with Article 13 (1) (2) and (3) of Dubai Health Insurance Law No. 11 of 2013.

“An insurance company must:

1. Pay the cost of health benefits;

2. Pay the cost of the health benefits provided by a health service provider that is not part of the health service provider network in an emergency case until the beneficiary’s life is no longer threatened;

3. Allow the beneficiary to obtain, by all means available, all his rights as determined in the health insurance policy;”

The insurance company must pay for the insured person’s medical treatment as per the policy. This is in accordance with Article 20 of the Dubai Health Insurance Law.

“Without prejudice to his right to have recourse against the entity legally responsible for payment of the cost of health benefits, the coverage provider will bear the cost of the health benefits provided to a beneficiary in accordance with the health insurance policy.”

Furthermore, the Dubai Health Authority (DHA) is to create a system for resolving disputes related to health insurance, requiring parties to utilise this system before seeking judicial or arbitral remedies. This is in accordance with Article 21 of the Dubai Health Insurance Law.

“The DHA may establish a system for the settlement of disputes arising out of health insurance, and may make it mandatory for health insurance parties, prior to recourse to the courts or arbitration.”

In addition, when filing a complaint with the Dubai Health Insurance Corporation (DHIC), affiliated to the DHA, the complaint must include the personal details of the person making the complaint, clearly describe the issue and what the complainant is requesting, be accompanied by all supporting documents, be written in Arabic, or both Arabic and English, follow any additional requirements set by the DHIC. This is in accordance with Article 28 (b) of the Administrative Resolution No. (78) of 2022 Issuing the Implementing Bylaw of Law No. (11) of 2013 Concerning Health Insurance in the Emirate of Dubai.

“a. The DHIC will consider the complaints filed with it regarding the health services covered by the health insurance system or health insurance policies.

b. A complaint filed with the DHIC must:

1. contain the personal details of the complainant;

2. contain the details of the complaint, including a clear and precise description of the complainant’s requests;

3. be accompanied by all the documents that support the complaint;

4. be written in Arabic or in both the Arabic and English languages; and

5. meet any other requirements prescribed by the DHIC.”

Based on the aforementioned legal provisions, if your insurance company has refused to cover essential medical procedures prescribed by your doctor, which are covered in your insurance policy, you may first submit a written complaint to the insurer along with the medical documentation.

If the insurer continues to deny the claim without a valid, lawful justification, you may escalate the matter to the DHA. You may also consider seeking independent legal advice to evaluate whether the insurer’s conduct constitutes a breach of its contractual and statutory obligations.