What to do if I need hospitalization and have a major medical insurance policy in Mexico?

Hospitalized patient presenting their major medical expenses insurance ID.

If you have a major medical insurance policy and are hospitalized due to illness or accident, it’s important to follow certain steps to ensure the insurer covers the expenses according to your plan.

Step-by-step process

Planned hospitalization

1. Send the required documentation to the insurance company

   The "aviso de accidente o enfermedad" (accident and illness notification form), the "informe médico" (attending physician’s) report, and the results of any supporting tests are essential documents to formally request coverage. The insurer will use them to determine whether the condition or accident is covered, and if so, proceed with direct payment to the hospital or reimbursement.

   Sending this documentation in advance allows you to confirm whether the condition is covered, schedule the procedure, and request a "carta pase" (guarantee of payment letter), which you must present at the hospital. (You may be required to fill out additional forms or submit further information.)

2. Check whether the hospital is in your provider network

   Whenever possible, go to hospitals that are part of the network included in your policy. If you go to a hospital outside the contracted network, penalties may apply, such as an increase in "coaseguro" (coinsurance) or denial of payment.

3. Present your insurance ID card or certificate

   This document is required to begin the hospital admission process and confirm you have active coverage.

4. Pay the applicable amounts

   Once the case has been reviewed and your hospital stay is over, if your condition or accident is covered, you will need to pay the applicable amounts according to the terms of your policy. Examples include the deductible, coinsurance, and personal expenses.

Emergency hospitalization

1. Check whether the hospital is in your provider network

   Whenever possible, go to hospitals that are part of your contracted network. Using an out-of-network hospital may lead to penalties, such as higher coinsurance or even denial of coverage.

2. Present your insurance ID card or certificate

   This is necessary for the hospital to verify that you have valid coverage and begin the admission process.

3. Notify your insurer

   Contact your insurer’s assistance line as soon as possible. You will be assigned a claim or incident number.

4. Send the required documentation to the insurance company

   Submit the "aviso de accidente o enfermedad" (accident and illness notification) form, the "informe médico" (attending physician’s report), and the results of any diagnostic tests. These are necessary for the insurer to evaluate coverage and process the payment directly or by reimbursement.

5. Pay the applicable amounts

   Once the case has been reviewed and your hospital stay is over, if your condition or accident is covered, you will need to pay the applicable amounts according to the terms of your policy. Examples include the deductible, coinsurance, and personal expenses.

Example

Daniel, 38, was in a motorcycle accident and taken to the hospital.

He had an active policy. His wife called the insurance company, presented his insurance card, and submitted all required forms.

They paid the deductible ($15,000 MXN) and coinsurance ($7,800 MXN). The insurer covered the rest.

Thanks to the insurance, Daniel avoided paying over $120,000 MXN in medical expenses.

Recommendations

• Save your insurer’s customer service phone number on your cellphone and share it with your family.

• Always carry your insurance ID card with you.

• Check which hospitals are in your contracted network and which physicians are affiliated with your insurer.

• If the admission is due to an emergency, notify your insurer as soon as possible.

• Keep invoices and medical records in case reimbursement is needed.

  
  

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