Insurer Won't Cover Your Disease? Act Now!

What to Do If an Insurer Does Not Cover a Newly Diagnosed Disease in Dubai?

Having health insurance in Dubai is no longer just a matter of convenience but a legal obligation. Behind the speed, technological advancement, and high standards of the city's healthcare system lies a precisely regulated insurance background. Nevertheless, it can happen that an insurer does not cover part of the treatment costs for a newly diagnosed disease—in such cases, it is crucial to know your rights and the possibilities for filing a complaint.

Legal Background Within Dubai

The Dubai health insurance system is regulated by the Dubai Health Insurance Law No. 11/2013. One of its key provisions, Article 13 (3), stipulates that “the insurer must ensure by all available means that the insured fully receives the rights set out in the health insurance policy.” This means the insurer cannot refuse a contractual service by citing generalities or vague reasons.

Moreover, Article 20 emphasizes that the insurer is obliged to cover the costs of treatments stated in the policy, regardless of whether the patient could assert their claim for reimbursement of treatment costs by other legal means. This ensures that the affected person receives the necessary care quickly and without obstacles.

First Step: Review the Insurance Policy

If a disease is newly diagnosed, the first step is always to review the existing insurance policy in detail. Some insurance packages may exclude certain treatments or only allow services with specific providers. In other cases, the policy may contain waiting periods (e.g., six months) after which certain benefits become valid.

It is important to note that an insurer cannot refuse treatment solely because the disease has recently appeared. The decision must always be based on the specific terms of the policy.

Second Step: Complaint to the Insurer

If you believe the insurer unjustifiably refuses to cover a treatment, you can file a written complaint directly with them. It is advisable to attach the following to the complaint:

- The medical diagnosis,

- The treatment recommendation,

- and any related bills or medical documentation.

The insurer is obliged to investigate the complaint and respond to it within a reasonable period.

Third Step: Contact the Dubai Health Insurance Corporation

If the insurer does not respond substantively or continues to reject the legitimate claim, the next step is to contact the Dubai Health Insurance Corporation (DHIC). The DHIC is part of the Dubai Health Authority (DHA) and is responsible for resolving insurance disputes.

Before submitting a complaint, it is important to consider the rules of Administrative Decision 78/2022, especially the points in Article 28 (b). Accordingly, the complaint must:

- Include the complainant’s personal details,

- Clearly and in detail describe the problem,

- Attach all related documents,

- Be submitted in Arabic or both Arabic and English,

- and meet the formal requirements set by the DHIC.

The DHIC's decision carries legal weight, and often it is mandatory to present the dispute before the DHIC prior to any court or arbitration proceedings. This process may not only be quicker but can also help settle the relationship between the client and the insurer without court intervention.

Special Cases and Exceptions

It may happen that the insurer treats a newly diagnosed disease as a “pre-existing condition,” especially if the first symptoms appeared earlier. In such situations, insurers often try to refer to policy points that exclude treatment for pre-existing conditions.

However, if the disease was documentedly diagnosed for the first time during the current insurance period, the insurer is obliged to cover the treatment—as long as it is not excluded under the policy.

Useful Tips for Those Affected

Do not let it rest: After the first rejection, many do not pursue the complaint, even though some claims are only rejected due to lack of proper documentation.

Document everything: Keep diagnoses, treatment plans, insurer responses, and emails.

Avoid emotional approaches: Complaint handling is a formal procedure, it is advisable to write an objective and well-structured complaint letter.

Consult a legal expert: In case of doubt, it might be worth seeking independent legal advice, especially if the insurer regularly refuses treatments.

Summary

Within Dubai, the health insurance system is highly regulated and fundamentally protects the interests of the insured. If an insurer is unwilling to cover the treatment of a newly diagnosed disease, the client is entitled to first file a complaint and, if necessary, turn to the DHIC. It is crucial that the affected person thoroughly reviews their insurance policy and documents every step. The transparency of the Dubai system and the operation of regulatory authorities ensure that legitimate claims can ultimately be enforced.

(Source of the article: Based on Article 13 (3) of the Dubai Health Insurance Law No. 11 of 2013.)