By Carlos Ramirez
Reimbursing medical insurance in Ecuador involves different processes than the ones probably used in your country of origin. Because of this, our goal in this article is to give you information about how to access your reimbursements without complications. In a previous article we shared with you that the responsibility of the claim process, according to the law, is that of the health plan member. This process is similar with all insurers, one only has to submit required documentation to the insurance broker or to the company directly, in the case that you do not have an insurance advisor.
Once your claim is filed, the company will have five business days to send you a letter of return, refusal, or settlement. When your claim is settled, the value of your annual deductible will be deducted first from your reimbursement, depending on the policy you have purchased. For example, if your claims total $300 and your annual deductible is $100, the company will subtract the amount of the annual deductible and then the remaining value will be settled at 80% for care outside the medical network of your insurer, and 90% within the network.
The documentation needed to submit your claim will depend on the type of medical care you have received:
OUTPATIENT CARE
Outpatient care refers to the medical appointments that you keep with your doctor for a specific diagnosis. The documents required for reimbursement are:
Refund request form
Medical certificate (in case of serious and chronic illnesses or those that require continuous medicine)
Orders and test results
Prescriptions
Original invoices in the member’s name
NOTE: Preventive annual check-ups are not covered when test results return within normal parameters. In invoices for medicine, you must attach an electronic invoice which is sent to your email. Make sure to check that your email is correctly written.
EMERGENCIES & URGENT CARE
In case of emergencies and urgent care, the documentation varies. An emergency is considered any condition that represents a risk to the life of the individual, while urgent care is related to pain or physical discomfort for any reason which does not compromise the life of the insured, but requires immediate medical attention. In this case, the documentation to be submitted is as follows:
Form 008
Itemized bills
Medical history (in case of hospitalization)
Orders and test results
Prescriptions
HOSPITALIZATION AND SURGERY
Hospitalizations can occur for two reasons. The first reason is due to a medical emergency and the second is that of a planned surgery or medical procedure (in this case, the 90-day grace period for surgery must be considered). The documents required for reimbursement are:
Refund request form
Medical certificate
Medical history of surgery
Orders and test results
Prescriptions
Original invoices in the member's name
PHYSICAL THERAPY
In the case of physical therapy, post-surgery may be requested or required by your treating physician. In the case of surgery, your expenses for physical therapy will be entered as a settlement scope and you must present only a medical certificate from your physiotherapist. This medical certificate should detail your sessions, the type of sessions carried out with the dates on which you have attended, and an invoice with the cost of each session.
If your physical therapy was requested by a traumatologist or other health professional, you must present all the documents detailed in the outpatient medical care section of this article. This includes the medical certificate from your treating doctor specifying your diagnosis, time of diagnosis, and the reason for physical therapy, in addition to the physical therapy order. After that, you will ask your therapist for a medical certificate and the invoices for your physiotherapy sessions to submit for reimbursement.
If your claims are denied despite having submitted complete documentation, it could be for any of the following reasons:
Lack of documentation to support your diagnosis
Invoices with an unauthorized RUC or registered for an operation not related to medical purposes
Present cases that are a contract exclusion in Ecuador such as ozone therapies, natural medicine without medical registration, or aesthetic dermatological treatments
Claims submitted outside the time established in your contract, normally 90 days
Cases related to undeclared pre-existing medical conditions or that have not passed waiting periods
In any of these cases, you can submit an appeal to the company with the requested documentation so that you can obtain reimbursement for your medical expenses.
One thing to keep in mind once you receive the settlement of your claim is the price of your medical expenses. In Ecuador the law does not regulate the cost of services or procedures carried out by doctors. Because of this, one can run the risk of being overcharged for a service, especially a surgery. One way to ensure this does not happen is by getting two quotes from two separate doctors, for the same procedure, in order to verify the general price of the procedure.
Understanding the reimbursement process in Ecuador can be tricky, but working with a bilingual professional who is knowledgeable about your specific insurance, has experience in international portfolio management, and has an active license to manage and sell insurance will allow the process to be as quick and easy as possible!