Why Health Insurance Claims Get Partially Approved in UAE

You visit the doctor. You feel terrible. The doctor prescribes you 3 medicines and a bottle of vitamins. You
go to the pharmacy counter and hand over your Emirates ID.

The pharmacist types on his computer. He frowns. He waits. Then he says:

“Medicine A and B are approved. Medicine C and the Vitamins are rejected. Do you want to pay cash?”

This “Partial Approval” is the most confusing aspect of UAE healthcare. Is the insurance company arbitrary?
Are they just trying to save money? Or is the doctor prescribing things you don’t need?

The answer is a mix of strict medical coding and policy exclusions. Here is why the computer says “No.”

1. The “Medical Necessity” vs “Wellness” Wall

Insurance covers Illness. It generally does not cover Wellness.

2. The “Pre-Existing Condition” Waiting Period

If you just joined a new individual insurance plan (not a large company group plan), check your contract for
a 6-Month Waiting Period.

Scenario:

• You buy insurance in January.
• You visit a doctor in February for “Chronic Back Pain.”
• The doctor writes: “Patient has suffered back pain for 2 years.”
• CLAIM REJECTED.

The insurer sees this as a pre-existing condition. Because you are in the “Waiting Period,” they deny it. You
must wait until July (Month 7) to claim for it.

3. The “Cosmetic” Grey Area

Dermatology is the battlefield for partial approvals.

Acne vs. Beauty:

• If the doctor codes it as “Severe Inflammatory Acne” (Medical condition involving infection/pain) ->
  Approved.
• If the doctor codes it as “Hyperpigmentation” or “Scarring” (Appearance issue) ->
  Rejected.

Often, doctors get lazy with the ICD-10 (diagnosis) codes. They pick the first one they see. If that code
implies “Aesthetic,” the automated engine kills the claim instantly.

4. Step Therapy (Generic vs. Brand)

Insurers want you to use the most cost-effective drug.

The Protocol:

1. Doctor prescribes “Panadol” (Brand). Cost: AED 20.
2. Insurer system checks database. Finds “Generic Paracetamol”. Cost: AED 5.
3. Partial Approval: Expected amount approved is AED 5.

At the counter, the pharmacist tells you: “The insurance pays for the generic. If you want the Brand, you
pay the difference.” This is not a rejection; it is a “Copay difference.”

5. “Investigational” Treatments

Doctors love new technology. Insurers love “Proven” technology.

If a doctor orders a “fancy new laser therapy” or a “genetic food intolerance test,” the insurer might flag
it as “Investigational” or “Lack of Medical Evidence.”

Unless standard medical guidelines say “This is the cure for X,” the insurer will refuse to pay for the
experiment.

Case Study: The “Vague” Symptom

The Lesson: “Unspecified” codes are claim killers. The insurer thinks: “We don’t know
what is wrong, so why are we paying for medicine?” The doctor must be specific.

How to Avoid Rejection at the Counter

1. Ask the Doctor: Before you leave the room, ask: “Is this diagnosis code Medical or
   Cosmetic?” Remind them you want it covered.
2. Blood Tests First: Never ask for vitamins without a lab test first. It’s a guaranteed
   “No.”
3. Accept Generics: They have the exact same active ingredient. Don’t fight for the brand
   name unless you have an allergy to the fillers.

FAQ: Fighting Back

Q: Can I pay cash and claim it later?
A: If it was rejected online, it will likely be rejected manually too. Unless the rejection was a “System
Error” (e.g., internet down). If it was “Not Covered,” paying cash won’t change the policy rules.

Q: My doctor wrote a justification letter. Why was it still rejected?
A: The medical team at the insurance company (yes, they employ doctors) reviewed it and disagreed. They
might say, “The justification does not match international guidelines.”