Executive
Council Resolution No. (16) of 2013
Concerning
Health Insurance of the
Government
of Dubai Employees[1]
ـــــــــــــــــــــــــــــــــــــــــــــــ
We,
Hamdan bin Mohammed bin Rashid Al Maktoum, Crown Prince of Dubai, Chairman of
the Executive Council,
After
perusal of:
Law
No. (5) of 1995 Establishing the Department of Finance;
Law
No. (6) of 1997 Concerning Contracts of the Government Departments in the Emirate
of Dubai and its amendments;
Law
No. (3) of 2003 Establishing the Executive Council of the Emirate of Dubai;
Law
No. (27) of 2006 Concerning Management of the Government of Dubai Human
Resources and its amendments;
Law
No. (13) of 2007 Establishing the Dubai Health Authority;
Law
No. (31) of 2009 Establishing the Dubai Government Human Resources Department;
Law
No. (35) of 2009 Concerning Management of the Public Funds of the Government of
Dubai and its amendments; and
Decree
No. (9) of 2012 Approving the Procedure for Pricing the Services of Dubai
Health Authority,
Do
hereby issue this Resolution.
The
following words and expressions, wherever mentioned in this Resolution, will
have the meaning indicated opposite each of them unless the context implies
otherwise:
|
UAE: |
The United Arab Emirates. |
|
Emirate: |
The Emirate of Dubai. |
|
Government: |
The Government of Dubai. |
|
Executive
Council: |
The Executive Council of the Emirate of Dubai. |
|
Law: |
Law No. (27) of 2006 Concerning Management of the Government
of Dubai Human Resources and its amendments. |
|
Department: |
The Government departments, authorities, the public corporations,
councils, and agencies to which the provisions of the Law apply, or any other
entity which is determined to be subject to the provisions of this
Resolution. |
|
DGHR: |
The Dubai Government Human Resources Department. |
|
DHA: |
The Dubai Health Authority. |
|
Human
Resources Directorate: |
The organisational unit responsible for the personnel
affairs of a Department. |
|
Employee: |
Any person employed in any job included in the budget
of a Department, which definition includes both males and females. |
|
UAE National: |
Any person holding the nationality of the UAE. |
|
Family
of a UAE National Employee: |
The husband or wife or wives, children and parents of
a UAE National Employee, even if those persons are non-UAE Nationals. |
|
Family
of a Non-UAE National Employee: |
The husband or one wife of a non-UAE National
Employee and three (3) of his children residing with him in the UAE. |
|
Insured: |
A UAE-National or non-UAE National Employee and his
family members who are entitled to Health Insurance. |
|
Health
Insurance: |
The healthcare provided to the Insured by a Healthcare
Provider in accordance with this Resolution. |
|
Health
Insurance Claim Management Company: |
A company responsible for the management of
financial claims arising from the provision of Health Insurance services. |
|
Healthcare
Provider: |
A public or private healthcare provider licensed by
the competent authority to provide healthcare services in the UAE, and which
is engaged to provide services through Health Insurance. |
|
Health
Insurance Card: |
A document issued to an Insured by the Health
Insurance Claim Management Company to be presented to a Healthcare Provider
to evidence the Insured’s entitlement to Health Insurance as prescribed by
the provisions of this Resolution. |
|
Committee: |
The Committee for Management of the Health Insurance
of the Government of Dubai Employees formed in accordance with the provisions
of this Resolution. |
|
Emergency
Case: |
A situation that requires an immediate, urgent, and
direct medical intervention to save life or remove the threat of danger, using
all available medical means. |
a. The
provisions of this Resolution will apply to UAE National and non-UAE National
civilian employees working in a Department, but will not apply to Employees appointed
pursuant to a temporary contact or working on a part-time basis.
b. For
the purposes of the application of the provisions of this Resolution, an Employee
who has been granted preliminary approval to obtain UAE nationality and who has
been issued a valid UAE passport shall be treated as a UAE National Employee.
a. The
Health Insurance category of an Employee will be determined according to his pay
grade as follows:
|
Health Insurance Category |
Employee Pay Grade |
|
Special |
This includes a director general, secretary general,
executive director/ chief executive officer, and similar positions. |
|
A |
For grades twelve (12) to sixteen (16). |
|
B |
For grades eight (8) to eleven (11). |
|
C |
For grades five (5) to seven (7). |
|
D |
For grades one (1) to four (4). |
b. The implementing bylaw of this Resolution will determine
the benefits to which an Insured is entitled according to the category assigned
to him from amongst the categories mentioned in paragraph (a) of this Article.
The
following persons are entitled to Health Insurance in accordance with the
provisions of this Resolution:
1. A UAE National and his family – The entitlement of family members to Health
Insurance will continue:
a. for spouses, until the termination of the marital
relationship;
b. for sons, until they obtain employment or reach the
age of twenty-one (21), whichever is earlier, unless they are suffering from
infirmity or disability preventing them from working; and
c. for daughters, until they obtain employment or they get
married, unless they become widowed or divorced.
2. A non-UAE National and his family - The entitlement of family members to Health
Insurance will continue:
a. for spouses, until the termination of the marital
relationship;
b. for children, until they obtain employment, get married
or reach the age of twenty one (21), whichever is earlier, unless they are
suffering from infirmity or disability preventing them from working.
a. An Insured will be entitled to Health Insurance from the
date of his employment until the date of the termination of his service.
b. If an event occurs which may affect the Insured’s
entitlement to Health Insurance, his entitlement will be adjusted from the date
of such event.
a. The Health Insurance entitlement stipulated by this
Resolution may not be combined with any other Health Insurance entitlement
provided by the Government.
b. If both the Employee and his spouse are employed by
the Government, the Health Insurance entitlement will be granted to the Employee
in the higher category. In cases of equal entitlement, the entitlement of both
Employees will be according to the category of the husband.
c. The parents of a UAE National Employee will be
entitled to Health Insurance according to the category of the Employee. Where multiple
Employees have the same parents, the parents will be entitled to the same
Health Insurance as the Employee with the highest category.
The
Health Insurance entitlement of an Insured will continue during official
holidays and authorised leave in accordance with the provisions of the Law and the
legislation in force.
An
Employee may request a change of his Health Insurance category to a higher
category, and may also request that his relatives up to the second degree be
added to his Health Insurance, provided that he bears the prescribed cost of this
change or addition. The implementing bylaw of this Resolution will determine
the conditions and rules as well as the prescribed costs that must be borne by
the Employee in either of these two cases.
a. The cost of healthcare for an Insured during an overseas
stay for any reason will be covered in Emergency Cases only.
b. The cost of healthcare provided to an Insured pursuant
to paragraph (a) of this Article will be provided in accordance with the conditions
and procedures determined by the implementing bylaw of this Resolution.
An
Insured must bear a percentage of the cost of the healthcare services provided
in accordance with the provisions of this Resolution, which must be paid
directly to the Healthcare Provider. This percentage will be determined in the implementing
bylaw of this Resolution.
a. As determined in the implementing bylaw of this
Resolution, a Department may recover, in whole or in part, the cost of any healthcare
service provided to an Insured in error, including when an Insured receives a
service which is not covered by his category of Health Insurance, or when he exceeds
the coverage limit of the medical service to which he is entitled.
b. From the commencement of his employment with a
Department, the Health Insurance Claim Management Company will reimburse the
Employee for the cost of healthcare provided to him for:
1. the time period prior to an Insured receiving his
Health Insurance Card; and
2. obtaining overseas healthcare in Emergency Cases.
c. The implementing bylaw of this Resolution will determine
the procedures and rules of the cost recovery and reimbursement referred to in
paragraphs (a) and (b) of this Article.
An
Insured will receive a Health Insurance Card. The implementing bylaw of this
Resolution will determine the details which must be included and the terms of
issuing such Health Insurance Cards.
Throughout
his term of service in a Department, and subject to disciplinary action, an
Employee must:
1. disclose to the Human Resources Directorate if he or
any member of his family is entitled to Health Insurance provided by the
Government;
2. notify the Human Resources Directorate in the event of
loss of or damage to his Health Insurance Card or his family members’ cards, in
which case the Employee will bear the cost of issuing a new Health Insurance
Card;
3. provide the Human Resources Directorate with clear,
accurate data or information related to his Health Insurance entitlement;
4. immediately notify the Human Resources Directorate of any
developments which may impact his Health Insurance entitlement or the entitlements
of any member of his family;
5. not misuse the Health Insurance Card in any way
whatsoever;
6. not authorise others to use his Health Insurance Card or
that of any of his family members; and
7. report to the Human Resources Directorate any misuse, negligence,
or default committed by any Healthcare Provider.
Health
Insurance claims will be managed in accordance with the provisions of this
Resolution through contracting with a company specialising in the management of
such claims, or through any other method approved by the DHA, the DGHR, or the
Department of Finance.
The
DGHR will supervise the implementation of the provisions of this Resolution,
and for these purposes it will:
1. prepare and develop a Health Insurance system for Government
Employees in cooperation with the DHA and the Department of Finance, and
develop the plans required for its implementation;
2. in coordination with the DHA and the Department of
Finance, develop Health Insurance programmes for Government Employees, and submit
them to the Executive Council for approval;
3. in coordination with the Department of Finance and the
DHA, establish the procedures required to migrate the personal data of the
Insured where another company has been contracted to manage Health Insurance claims;
4. ensure that the Human Resources Directorate is
performing the duties stipulated in this Resolution; and
5. in coordination with the Department of Finance and the
DHA, review and re-evaluate the implemented Health Insurance system on an annual
basis and as required, and submit the results of these reviews and any suggestions
to the Executive Council for approval.
The
Department of Finance will have the duty to:
1. provide the funds allocated in the public budget of
the Government to cover the Health Insurance expenses;
2. contract with a Health Insurance Claim Management Company
to manage claims arising from Health Insurance, and, in coordination with the DHA,
verify its compliance with the contract concluded with it;
3. in coordination with the DHA, audit claims submitted
to it from the Health Insurance Claim Management Company and Healthcare
Providers for settlement purposes;
4. follow up with any Department having an independent
budget to pay for the Health Insurance costs of its Employees; and
5. deduct, on a monthly basis, the cost of the Health
Insurance from the approved budget of each Department.
The
DHA will:
1. manage the technical aspects of Health Insurance;
2. verify compliance by the Health Insurance Claim Management
Company with the provisions of this Resolution and the contract concluded with
it;
3. control and audit the Healthcare Providers to verify their
compliance with the provisions of this Resolution and the contracts they conclude
with the Health Insurance Claim Management Company;
4. establish a special database for the Insured and principles,
and rules for data entry, protection, migration, and processing to achieve expedient
and easy access to the healthcare services, and to ensure the confidentiality
and privacy of such data;
5. analyse Health Insurance data and information, and coordinate
with the DGHR and the Department of Finance to propose policies and programmes to
develop Health Insurance;
6. respond to enquiries received from any entity in
relation to Health Insurance; and
7. hear complaints submitted by the Insured against a Healthcare
Provider or the Health Insurance Claim Management Company.
The
Human Resources Directorate will:
1. in coordination with the DHA and the Health Insurance
Claim Management Company, take the necessary measures for the issuance,
renewal, and adjustment of the Health Insurance entitlement of the Insured, and
provide them with Health Insurance Cards;
2. recover an Insured’s Health Insurance Card at the end
of his service or the end of his entitlement;
3. coordinate with the DHA and the Health Insurance Claim
Management Company with respect to all matters related to the Insured;
4. respond to Employees’ enquiries relating to Health
Insurance; and
5. provide clear and accurate data requested by the DGHR,
the DHA, or the Department of Finance. The Human Resources Directorate will
have an obligation to update such data where changes occur.
The
Health Insurance Claim Management Company must:
1. comply with the provisions of this Resolution and the
contract concluded with it;
2. not own or be owned by, be a partner in, or have the
right to manage, any Healthcare Provider during the contractual period;
3. enter into contracts on behalf of the Government with Healthcare
Providers approved by the DHA using the contract template approved by the DHA
and the Department of Finance for this purpose;
4. verify Healthcare Providers’ compliance with the
provisions of this Resolution and the contract concluded with them, including observing
the rates approved by the DHA for healthcare services;
5. provide the DHA and the DGHR with a list of the names
and addresses of Healthcare Providers, and update such list on a regular basis;
6. issue Health Insurance Cards for the Insured and deliver
such cards to the Human Resources Directorate;
7. immediately notify the DHA of any violations committed
by Healthcare Providers;
8. provide the Department of Finance, the DHA, and the DGHR
with the electronic information and personal details of the Insured, and any
other information requested by these entities in accordance with the functions assigned
to it by law;
9. in coordination with the DHA and the Human Resources
Directorate, publish and distribute to the Insured instructions, guidance notes,
forms, documents, publications, and manuals relating to Health Insurance;
10. in coordination with the DHA and the Human Resources
Directorate, prepare and implement health awareness and education programmes for
the Insured;
11. maintain financial and statistical records and reports
relating to the healthcare provided to the Insured;
12. protect the privacy of the data of the Insured and
return it to the DHA immediately upon the expiry of the contract concluded with
it;
13. provide technical support to the DHA, the Department,
and the DGHR in any matter relating to Health Insurance;
14. propose measures required to develop Health Insurance
services, and to avoid any related obstacles; and submit these to the DGHR, the
Department of Finance, and the DHA;
15. prepare reports on cases of the most common and
recurrent diseases contracted by the Insured, propose appropriate preventive measures,
and submit these to the DHA and the DGHR; and
16. submit claims
in accordance with the procedures, instruments, and methods adopted by the DHA
and the Department of Finance.
A
Healthcare Provider must:
1. comply with the provisions of this Resolution and with
its concluded contract, including the rates of healthcare services adopted by
the DHA;
2. provide healthcare services to the Insured in accordance
with the approved and recognised professional code of conduct and professional
ethics;
3. not manipulate the medical or financial records of the
Insured or deal with these records in a negligent manner;
4. provide the DHA and the Health Insurance Claim Management
Company with all the information, data, and documents relating to any healthcare
service provided to the Insured;
5. cooperate with the law enforcement officers of the DHA
and provide them with any information relating to the Insured or to any healthcare
service;
6. not act in a way which may lead to unlawful material
gains through the provision of healthcare services covered by Health Insurance;
and
7. in Emergency Cases, provide healthcare service to an Insured
even if it is not covered by his Health Insurance category, provided that the
Department bears the cost of this service.
a. A committee named the “Committee for Management of the
Health Insurance of the Government of Dubai Employees” (the “Committee”)
will be formed pursuant to a resolution of the Chairman of the Executive
Council under the chairmanship of the Director General of the DGHR, with a membership
of representatives from concerned Government entities in the Emirate, including
the DHA and the Department of Finance. This resolution will also determine the
mode of operation and decision-making procedures of the Committee.
b. The Committee will:
1. consider the applications for admission submitted by
Health Insurance companies, and submit the appropriate recommendation in this
regard to the Director General of the Department of Finance for approval;
2. issue the required Health Insurance resolutions; and
3. determine the grievances submitted to it from the
Health Insurance Claim Management Company, Healthcare Providers, and Employees.
c. The Committee may, in performing the duties assigned
to it pursuant to this Resolution, seek the assistance of experts and
specialists, as it deems appropriate.
a. Without prejudice to any stricter penalty prescribed in
any other resolution, any person who commits any of the violations stipulated in
Schedules (1) and (2) attached to this Resolution will be punished by the fine indicated
for each violation. Upon repetition of the same
violation within one (1) year from the date of the previous violation, the
amount of fine will be doubled, provided that the fine does not exceed two
hundred thousand Dirhams (AED 200,000.00).
b. Based on a technical report issued by the DHA, the Committee
may exclude permanently or temporarily any Healthcare Provider from the Health
Insurance network.
c. An Employee who violates any of the provisions of this
Resolution, its implementing bylaw, or the resolutions or instructions issued hereunder
in accordance with the Law, will be subject to disciplinary action.
d. A violator must repay any amounts he receives in error.
Employees
of the DHA nominated pursuant to a resolution of the director general of DHA in
coordination with the Director General of the Government of Dubai Legal Affairs
Department will have the capacity of law enforcement officers to record the
acts committed in breach of the provisions of this Resolution, its implementing
bylaw, and the resolutions and instructions issued in pursuance hereof. In this
capacity, they may issue the relevant violation reports, and seek the
assistance of police personnel where required.
Proceeds
of the fines collected in accordance with the provisions of this Resolution will
be paid to the Public Treasury of the Government.
The
Director General of the DGHR will, in coordination with the Department of
Finance, and the DHA, issue the resolutions required for the implementation of
the provisions of this Resolution. Such resolutions will be published in the
Official Gazette of the Government.
This
Resolution will be published in the Official Gazette and will come into force
one (1) month from the date of its publication.
Hamdan
Mohammed bin Rashid Al Maktoum
Crown
Prince of Dubai
Chairman
of the Executive Council
Issued in Dubai on 26 June 2013
Corresponding
to 17 Shaban 1434 A.H.
Schedule
(1)
Violations
and Fines of Healthcare Providers
|
SN |
Description |
Fine
in Dirhams |
|
1 |
Disclosure of financial data related to Health
Insurance services |
100,000.00 |
|
2 |
Failure to provide the DHA with required information
or data or impeding the work of its inspectors |
50,000.00 |
|
3 |
Manipulating the medical or financial records of the
Insured or dealing with these records in a negligent manner |
30,000.00 |
|
4 |
Splitting claims to avoid exceeding the financial threshold
specified for a healthcare service |
100,000.00 |
|
5 |
Providing healthcare services that are not appropriate
for the health condition of the Insured for financial gain |
20,000.00 |
|
6 |
Transferring the Insured from one Healthcare
Provider to another, or prescribing specific brands of medicine or medical equipment
for material gain |
20,000.00 |
|
7 |
Exempting the Insured from co-insurance,
overcharging him, or exaggerate the final cost of a healthcare service |
100,000.00 |
|
8 |
Presenting false invoices or manipulating Health Insurance
claims |
100,000.00 |
|
9 |
Charging for a healthcare service resulting from a condition
caused by Healthcare Provider’s negligence or default |
100,000.00 |
|
10 |
Issuing false invoices for a healthcare service
which was not provided to the Insured |
100,000.00 |
|
11 |
Prescribing medicines which are covered by Health
Insurance but which are not needed by the Insured |
30,000.00 |
|
12 |
Failure to perform an obligation stipulated in this
Resolution or the resolutions issued hereunder. |
20,000.00 |
Schedule
(2)
Violations and Fines of the
Health
Insurance Claim Management Company
|
SN |
Description |
Fine
in Dirhams |
|
1 |
Non-compliance with the terms of the contract
concluded with the Health Insurance Claim Management Company |
100,000.00 |
|
2 |
Acceptance of any amount of money or of a material
benefit from a Healthcare Provider |
100,000.00 |
|
3 |
Inaccurate and incomplete documentation of claims
and invoices |
100,000.00 |
|
4 |
Failure to provide required information or providing
unclear or inaccurate information to the Department of Finance, the DHA, or
the DGHR |
100,000.00 |
|
5 |
Failure to report violations committed by Healthcare
Providers |
100,000.00 |
|
6 |
Failure to perform an obligation stipulated in this
Resolution or the resolutions issued hereunder |
25,000.00 |
©
2015 The Supreme Legislation Committee in the Emirate of Dubai
[1] Every effort has been made to produce an accurate and complete English
version of this legislation. However, for the purpose of its interpretation and
application, reference must be made to the original Arabic text. In case of conflict,
the Arabic text will prevail.