What does a major medical insurance policy cover in Mexico?

Family receiving medical guidance at a hospital as part of their major medical expenses insurance.

A Major Medical Insurance in Mexico helps cover costs arising from illnesses or accidents that require specialized medical care. It is a key tool to protect both your health and finances.

What are the benefits of a Major Medical Insurance in Mexico?

Major medical policies typically include the following coverages:

1. Hospitalization

   Stay in a standard private room, meals, intensive care, nursing services, use of operating room, and medical supplies, according to the contracted "red hospitalaria" (hospital network).

   
   

2. Medical and surgical fees

   Surgeon, anesthesiologist, and surgical assistants during surgery, as per the contracted "tabulador de honorarios médicos" (allowed amount).

   
   

3. Laboratory and surgical fees

   X-rays, MRI, blood tests, electrocardiograms, etc.

   
   

4. Medications

   Prescribed by the attending physician, both during hospitalization and outpatient consultations.

   
   

5. Prosthetics and orthopedic devices

   When medically necessary, such as prosthetics resulting from a covered accident or illness.

   
   

6. Ground ambulance

   In case of medical emergencies or if referred by a physician.

   
   

7. Reconstructive surgery

   Resulting from a covered accident, not for aesthetic purposes.

   
   

8. Transplants

   Of vital organs such as kidneys or bone marrow, including certain donor expenses.

   
   

9. Optional Additional Coverages

   • "Maternidad" (Maternity).

   • "Enfermedades graves" (Critical illnesses), like cancer, heart attack, etc.

   • "Atención médica en el extranjero" Medical care abroad.

   • "Exención de deducible por accidente" (Deductible waiver in case of accident.

   • "Disminución de coaseguro en pago directo" (Coinsurance reduction for direct payments).

   • "Ambulancia aérea" (Air ambulance).

Common Exclusions

Although coverage is broad, there are common exclusions. These include:

• Cosmetic surgeries or treatments for aesthetic purposes.

• Undeclared pre-existing conditions.

• Experimental treatments or those not approved by COFEPRIS.

• Self-inflicted injuries.

• Damages arising from participation in criminal acts.

• Treatments not medically prescribed.

Practical Example

María, 42, was diagnosed with gallstones. The total cost of her laparoscopic surgery was $110,000 MXN.

Her policy included a deductible of $15,000 and 10% coinsurance capped at $20,000.

The insurer paid $85,500, and María only paid $24,500.

Without insurance, she would have covered the full amount.

Recommendations

• Verify whether your hospital and physician are within the insurer’s medical network.

• Consider optional coverages based on your needs. For instance, if you travel frequently, get international or emergency medical coverage abroad.

• Always ask about waiting periods.

• If you switch insurers, check which conditions they will recognize as part of your prior coverage. Avoid being uninsured for over 30 days, as this may cause you to lose your accumulated coverage continuity.

• Compare deductibles and coinsurance rates to balance premiums and protection.

• Carefully review the general terms and conditions of the policy.

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.

• "Periodo de espera" (Waiting Period): The uninterrupted period that must pass from the start of the policy for certain conditions to be covered.

• "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.

• "Reconocimiento de Antigüedad" (Coverage Continuity Recognition): The period that the insurance company acknowledges as prior coverage when the insured has been continuously and uninterruptedly insured under a major medical policy with another insurer.

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