How to request reimbursement under a major medical insurance policy?

Man in front of his laptop, scanning medical bills and documents to request a reimbursement from his insurance.

When the insured person pays medical expenses out of pocket and wants the insurance company to reimburse part or all of the covered amount, they must initiate a reimbursement process. This is common when care is received at out-of-network hospitals, with non-affiliated doctors, or in emergencies that did not allow for direct payment.

Steps to request a reimbursement

1. Notify the insurance company

   Inform the insurer about the medical event. In many cases, there is a deadline for doing so.

   
   

2. Gather the required documents

   • Official ID with signature and photo.

   • Invoices in PDF and XML formats.

   • Test results and lab reports supporting the diagnosis made by the treating physician.

   • "Aviso de accidente y enfermedad" form, completed and signed by the policyholder and the affected person.

   • "Informe médico" form, completed and signed by the treating physician, as well as by the policyholder and the affected person.

   • "Solicitud de pago por transferencia interbancaria" form.

   • Bank statement showing the CLABE account number.

   
   

3. Submit your complete application

   Through the online portal, by email, or in person at an office.

   
   

4. Follow up on the process

   Request a tracking number (folio), ask for estimated response times, and confirm the receipt of your documents.

Practical Example

Roberto visited a private doctor and paid MXN $12,000 for consultation, tests, and treatment.

He submitted the invoice, medical summary, and proof of payment to his insurer.

Result: He was reimbursed MXN $7,600, after deductions for the "deducible" (deductible), coaseguro (coinsurance), "tabulador de honorarios médicos" (allowed amount), and non-covered expenses.

Common mistakes to avoid

• Not submitting complete and accurate documentation. Reimbursements cannot be processed until the insurer has received all required documents.

Recommendations

• Ask whether your insurer allows digital submission of documents.

• Double-check your invoices.

• Keep copies of all documents and receipts sent.

• Check if your policy has a deadline for submitting reimbursement requests after the medical event.

Key Concepts

• "Deducible" (Deductible): A fixed amount paid by the insured, as stated on the policy cover page, applicable to the initial expenses incurred for each covered accident or illness. After this amount is exceeded, the insurance company begins covering the remaining costs.

• "Coaseguro" (Coinsurance): A fixed amount or percentage stated in the policy cover page, paid by the insured, representing their share of the total covered medical expenses per illness, after applying the deductible.

• "Tabulador de Honorarios Médicos" (Allowed Amount): A list of surgical procedures and medical treatments indicating the maximum percentage the insurance company will pay for each covered accident or illness.

At Sáas, we have a team of consultants who can guide you through the process of contracting and using your policy.