Denied a Medical Insurance Claim in Dubai? Here’s What You Can Do

Dubai, UAE : Denial of a medical insurance claim can be stressful, especially when the treatment is essential. Under Dubai law, insurers are legally obligated to honour valid claims, but denials do occur. Here’s a comprehensive guide on how to dispute a denial, your rights, and the steps to take if your insurer turns you down.

The Legal Basis: What Dubai Law Says

Under Dubai Health Insurance Law No. 11 of 2013, insurers must:

1. Pay for health benefits covered by the policy.
2. Cover emergency treatments even if performed by out-of-network providers, until the beneficiary’s life is no longer at risk.
3. Allow the policyholder to access all rights and benefits defined in their health insurance policy. 

If an insurer refuses a legitimate claim, the insured individual has the right to lodge a dispute.

When Can You Challenge a Denial?

You may have grounds to dispute a denial if:

• The treatment is covered under your policy and meets the insurer’s criteria.
• The insurer has refused emergency care from an out-of-network provider, contrary to legal requirements.
• The insurer fails to justify the denial with valid reasoning consistent with your policy’s terms.

It’s essential to examine your policy terms, definitions, and exclusions so you know where you stand.

Step-by-Step Dispute Process

Here’s how to proceed if your claim is denied:

1. Request a detailed explanation
   Contact your insurer and ask for a written explanation of the denial, including which policy clause was applied and why.
2. Gather supporting documents
   Collect all relevant documents: policy contract, medical reports, diagnostic test results, invoices, referral letters, and your communications with the insurer.

3. File a complaint with the Dubai Health Insurance Corporation (DHIC)
   The DHIC, affiliated with the Dubai Health Authority (DHA), handles complaints under Article 21 of the Health Insurance Law. Many disputes must go through this channel before they can be taken to court or arbitration. 

   A complaint submitted to the DHIC must:

   • Include your personal details.
   • Clearly outline the nature of the complaint and your requested remedy.
   • Be accompanied by supporting documents.
   • Be submitted in Arabic or bilingually (Arabic and English).
   • Meet additional procedural requirements outlined in Administrative Resolution No. 78 of 2022. 
4. Await DHIC mediation or ruling
   The DHIC may mediate or issue guidance. If the denial is found unjustified, insurers may be directed to reverse the decision.
5. Pursue judicial or arbitration remedies
   If mediation fails or is inapplicable, you may escalate to court or arbitration. But keep in mind that in many cases, you must first exhaust the DHIC route.

Things You Should Keep in Mind

• Timeliness matters: Submit your complaint and supporting documents promptly; delays might complicate your case.
• Understand policy exclusions: Even a valid claim can be denied if the procedure is excluded by your policy.
• Language requirements: The complaint to DHIC must follow language rules; incorrect linguistics can delay acceptance.
• Open communication: Keep a record of all correspondence. That trail will be crucial if matters escalate.

Why Claims Are Denied (Common Grounds)

Some common reasons insurers reject medical claims include:

• Treatment or provider not covered in the network (unless it's an emergency).
• Missing referrals or prior authorizations required under the policy.
• Insufficient documentation or mismatch in billing codes.
• Exceeding coverage limits or when certain services are explicitly excluded.
• The insurer disputing the necessity or medical appropriateness of the procedure.

Knowing these reasons upfront can help you prepare a stronger challenge.

Real-World Example & Legal Context

An example from recent case law: a hospital in Dubai sought Dh 283,000 after a patient’s daughter defaulted on covering non-insured portions of her mother’s treatment. The court held them jointly liable, illustrating that providers enforce payment when insurance or promises fail. While this example is about patient-provider liability, it underscores that medical bills and insurance denials can escalate into legal battles.

Final Thoughts

Being denied a medical insurance claim doesn’t mean you've lost all recourse. The UAE’s legal infrastructure allows you to dispute denials through the Dubai Health Insurance Corporation, and, if necessary, escalate to courts or arbitration.

Your best defence is informed action: know your policy, collect all evidence, follow proper channels, and be persistent. In doing so, you safeguard your rights and may succeed in reversing an unjust decision.