Insurance Claim Denied in Saudi Arabia: SAMA Complaint Guide

Insurance Claim Denied in Saudi Arabia: Your Rights and the SAMA Complaint Process

If your insurance claim has been denied in Saudi Arabia — whether health, motor, life, or general insurance — you have formal regulatory rights to challenge the decision. The Saudi Arabian Monetary Authority (SAMA) regulates all insurance activities in the Kingdom and has a structured consumer protection mechanism that gives policyholders genuine recourse.

Saudi Arabia's mandatory health insurance system, coupled with SAMA's oversight and the specialized role of the Council of Cooperative Health Insurance (CCHI), means that health insurance claim denials in particular are subject to multiple regulatory channels.

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Saudi Arabia's Insurance Regulatory Framework

Saudi Arabian Monetary Authority (SAMA)

SAMA is the primary regulator for the insurance industry in Saudi Arabia under the Cooperative Insurance Companies Control Law (Royal Decree No. M/32 dated 2/6/1424H and its Implementing Regulations). All insurance companies operating in Saudi Arabia must be licensed by SAMA and comply with its regulatory requirements.

SAMA's Insurance Supervision Department oversees:

• Market conduct and consumer protection
• Claims handling standards
• Complaint resolution processes
• Solvency and financial requirements for insurers

Council of Cooperative Health Insurance (CCHI)

The Council of Cooperative Health Insurance (CCHI) is a separate government body that specifically regulates mandatory health insurance in Saudi Arabia. Under the Cooperative Health Insurance Law, health insurance is mandatory for:

• All non-Saudi workers and their dependents (covered by their employer)
• Saudi nationals working in the private sector (under some employer schemes)
• Self-employed and domestics under various provisions

CCHI oversees the Unified Policy terms and conditions for cooperative health insurance, and maintains a complaints mechanism specifically for health insurance issues.

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Mandatory Health Insurance: Know Your Coverage Rights

Under Saudi Arabia's mandatory cooperative health insurance system, your policy must include a minimum benefit package defined by CCHI. Key features:

• Coverage for medical treatment at licensed healthcare providers
• Emergency treatment coverage (including during Hajj and Umrah for pilgrims)
• Coverage for pre-approved medical procedures

Common health insurance denial reasons in Saudi Arabia:

• Treatment at a non-network provider without pre-authorization for emergencies
• Procedures classified as elective not pre-authorized
• Pre-existing conditions excluded under the policy
• Treatment deemed "experimental" by the insurer
• Claim submitted after the filing deadline

If your treatment was medically necessary and your insurer denied it, you have grounds to appeal.

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Step 1: Request the Written Rejection With Policy Grounds

Contact your insurer immediately and request:

• A formal written rejection letter citing the specific policy clause or CCHI condition being applied
• The exact section of your policy under which the claim was denied
• The insurer's formal grievance or complaint process documentation

Insurers licensed by SAMA are required to provide clear, written explanations for claim denials. A verbal denial or a denial without specific grounds is a regulatory violation.

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Step 2: File a Formal Internal Complaint

Before escalating to regulators, you must file a formal complaint with the insurance company itself. Under SAMA's Guidelines for Customer Complaints Handling, insurers must:

• Have a designated complaints department
• Acknowledge complaints within a defined period
• Provide a formal response

File your complaint in writing to:

• The insurer's Customer Service or Complaints Department
• Via their official email address (not just your broker or sales agent)

Include:

• Your policy number and national ID / Iqama number
• The claim reference number and date of denial
• A clear explanation of why you believe the denial is incorrect
• Supporting documents (medical reports, hospital bills, policy excerpts)

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Step 3: Escalate to SAMA (If Unresolved)

If the insurer does not resolve your complaint satisfactorily within 30 days, escalate to SAMA.

SAMA Complaints Channels:

• Online portal: sama.gov.sa — Navigate to "Customer Protection" → "Complaints"
• Phone: 800-125-6666 (toll-free within Saudi Arabia)
• Fax: +966-11-4662966
• Mobile App: SAMA's Nefadhom app (for consumer complaints)
• In-person: SAMA Headquarters, King Fahd Road, Riyadh

What to include in your SAMA complaint:

• Your national ID (for Saudis) or Iqama number (for expats)
• The insurance company name and your policy number
• The claim reference number and denial date
• A copy of the denial letter
• Your internal complaint letter and the insurer's response
• All supporting medical or incident documentation

SAMA typically acknowledges complaints within a few business days and engages the insurer directly on your behalf.

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Step 4: Escalate Health Insurance Complaints to CCHI

For health insurance disputes specifically, the Council of Cooperative Health Insurance (CCHI) provides an additional complaint channel:

• Website: cchi.gov.sa
• Phone: 920001177
• Email: info@cchi.gov.sa

CCHI can investigate disputes about:

• Denial of covered health services
• Disputes about network adequacy (no in-network provider available)
• Violations of the Unified Policy terms
• Employer failure to provide mandatory coverage

Filing with both SAMA and CCHI simultaneously (for health insurance disputes) is possible and can accelerate resolution.

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Step 5: The Insurance Dispute Committee

For insurance disputes that cannot be resolved through the regulatory complaint process, Saudi Arabia has an Insurance Dispute Resolution Committee established under the Cooperative Insurance Companies Control Law. This committee:

• Has jurisdiction over insurance disputes
• Can adjudicate binding decisions on insurers
• Provides an alternative to civil litigation

Disputes may be referred to the Committee through SAMA or by direct application. Legal representation is advisable for formal committee proceedings.

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Step 6: Sharia Compliance Considerations

Saudi Arabia's insurance industry operates on a Takaful (cooperative/mutual) model that is compliant with Islamic Sharia principles. Most insurance policies in Saudi Arabia are structured as Takaful. This affects:

• How premiums are managed (Takaful surplus vs. traditional premium)
• Policy terms in some product types
• Regulatory requirements under Sharia Supervisory Boards

When reviewing your policy and the basis for denial, check whether the denial reason conflicts with the cooperative principles of Takaful — which emphasize mutual benefit and solidarity among participants.

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Expat Workers: Key Additional Considerations

As an expatriate worker in Saudi Arabia, your employer is legally responsible for providing mandatory health insurance under the cooperative health insurance law. If your claim was denied:

• Your employer's HR department may be able to intervene directly with the insurer
• Your employer may have a group insurance account manager who can escalate internally
• If the employer has failed to provide valid coverage or the policy has lapsed, the employer may bear direct liability for your medical costs

Document any communication with your employer about coverage — this may be relevant if the dispute escalates.

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Motor Insurance Denials in Saudi Arabia

For third-party motor insurance (mandatory under Saudi law) or comprehensive motor insurance denials:

• SAMA handles motor insurance complaints
• The National Centre for Traffic Safety (Ey'aat) may be relevant for traffic incident disputes
• Disputes about fault determination or accident reports should be supported by the traffic police report (Al Moroor report)

Always obtain the official traffic police report immediately after any accident — this is the foundational document for motor insurance claims in Saudi Arabia.

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Documentation Checklist for SAMA Complaint

Prepare these documents:

• Copy of your insurance policy and schedule
• Copy of your national ID (Saudi) or Iqama (expat)
• Claim submission form and attached medical reports/receipts
• Written denial letter from the insurer
• Your formal internal complaint and the insurer's response
• Medical specialist reports supporting the necessity of treatment
• Correspondence log with the insurer
• Any pre-authorization approvals or denials

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Common Mistakes in Saudi Arabia Insurance Appeals

1. Not filing in writing. Verbal complaints to customer service don't trigger formal complaint processes. Always write.

2. Not understanding your coverage tier. Saudi mandatory health insurance has different coverage levels (categories). Treatments available at higher categories may not be covered in your tier.

3. Using a non-network provider without emergency status. Using an out-of-network provider without pre-authorization (except in genuine emergencies) typically leads to denial. If the care was urgent, document the emergency nature thoroughly.

4. Not involving your employer. For employer-provided mandatory coverage, your employer has leverage with the insurer that individual employees don't.

5. Delaying the complaint. SAMA complaint rights exist within defined time periods. File as soon as the internal complaint fails.

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Getting Help With Your Appeal Letter

A formal, structured appeal letter citing Saudi regulatory requirements and SAMA's consumer protection guidelines significantly increases your chances of resolution. ClaimBack can generate a professional appeal letter for Saudi insurance denials that references the appropriate regulatory framework. Visit claimback.app to create your letter.

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Summary: Saudi Arabia Insurance Appeal The Full Fight

1. Request the written rejection with specific policy clause and CCHI condition citations
2. File a formal internal complaint to the insurer's Complaints Department
3. Escalate to SAMA online, by phone (800-125-6666), or via their portal if unresolved in 30 days
4. File with CCHI for health insurance disputes specifically (simultaneously with SAMA if needed)
5. Refer to the Insurance Dispute Committee for formal adjudication if regulatory complaints fail
6. Involve your employer for employer-provided mandatory health insurance disputes
7. Retain all documentation — traffic reports, medical invoices, denial letters, correspondence