What to do if a claim was denied by the health company?

On several occasions we encounter refusals or refunds by the company that are not always well taken by the user, but wonder what are the reasons why companies do not pay for your claims? The most usual thing is to blame the company that does not want to pay because it does not fulfill its obligations, but the reality can be very different from what you think.

When a claim is returned or denied on several occasions it may be a problem of documentation. The prepaid medicine companies in Ecuador establish certain guidelines in their contracts as obligations of the user, these documents are the following in general for all insurance companies:

reimbursement request
medical certificate or medical record
orders for examinations
test results
original invoices in the client’s name

These are the basic documents that you must submit to receive your reimbursement for outpatient medical care, remember that companies do not accept payment vouchers or strips only receive electronic invoices in the case of purchase of medicine, laboratory tests, if your center does not have electronic billing you can submit a normal invoice in your name, this is the most important thing, one of the common mistakes is to receive invoices to final consumer or they tell us that they felt sick and someone else bought the medicine for this reason they will not pay you the values of your invoices, it is vital to remember that you only have 90 days to present your documentation to the companies.

Well, those are the basic guidelines regarding medical appointments. Now I will explain the documentation to receive a reimbursement for surgery. When you have a surgery you can have two options: if you have a company that pre-authorizes your surgeries you can submit only the documents that I explained before but with the variation of the reimbursement request that now will be called hospital credit application and, in addition, a medical certificate with the approximate value of your surgery and the company will pre-authorize this amount in the clinic of agreement that you have chosen and only cancel the values of guarantee, co-payment and deductible, but if your company does not have these benefits or your doctor is not in the network, you must collect all the documentation described above and additionally these documents:

medical records of your surgery
original bills from your surgery
pre-surgical test orders
preoperative test results
original invoices for preoperative examinations

in case of emergencies the documentation is minimal you will only need:

sheet 008
medical history in case of hospitalization
original invoices

If you consider that you presented all the documentation properly and even if the company denied your reimbursement, please verify that your diagnosis is not related to any pre-existing condition that you forgot to declare or that you did not declare. This is usually a common problem of refusals in reimbursements. That is why the declaration of pre-existing conditions is the most important document when hiring an insurance. Another possible option is that the person who filled out your documentation at the clinic put the wrong time of your diagnosis because he did not manage to understand you. For this reason it is recommended that before surgery you go to the hospitalization room with a translator who can describe your pre-existing conditions and your symptoms with exact dates. If you have a broker, he is required to review your documentation before sending to the company so they can advise you before submitting your documents or you could recommend not to submit this claim to avoid being denied undeclared diseases.

As a plus, if none of the scenarios I present correspond to your denial and the process was done in a good way and was not related to pre-existing conditions, you can submit a letter to the superintendence of companies, securities and insurance of Ecuador to analyze your case and if necessary request a payment to your company for your medical expenses. This process can take more than a year.

If you have or have had problems with your claims or have any questions about this publication please do not hesitate to contact us. We are Bluebox and we are ready to attend all your requirements.

Carlos Ramirez: blueboxasesores@gmail.com 098 246 5168. Call after: 9 AM.

City: Cuenca

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