Understanding Health Insurance in Mexico

June 24, 2015

Health insurance in Mexico covers individually (or a family policy) or being part of a group, expenses due to hospitalization due to sickness or to accident and includes doctors visits, medicines, lab studies, x rays & blood tests and surgery always and as long as the claim amount be over the deductible agreed in the policy.

If there is a preexisting condition, the insured has to declare it in the application before insurance is in force and might be declined depending the specific case, but also since there are sickness and conditions such as pregnancy, that have a waiting period, some diseases even for more than 12 months, such as AIDS among others, all these questions have to be dully filled out. Very important is to point out that individual or family policies are far more expensive but have the big advantage that renewals are guaranteed for life time, as long as these are paid. In case of covered losses, the insurance company can not increase the price of insurance individually, but to cover on the average cost plus their expenses and profit, which is negotiated with the insurance commissioner, for the five year ranges of ages, such as from 41 to 45, 46 to 50 etc., some companies differ from this specific criteria but the principles are the same.

When being part of a group and for whatever reason the person is separated from it, if it had losses that need to continue to be paid, or just the person gets old enough (usually over 74) the insurance companies can refuse or decline nor have the obligation to assume coverage. Lately, there are new ways to continue to be covered, even when insured not part of a specific group.

Keep in mind there are some standard exclusions such but not limited to schizophrenia, bipolar disorders, anxiety, depression, to mention just a few; mostly mental diseases. All policies have a deductible (accidents is usually cero deductible) and most have a co-payment depending if you are using hospitals and doctors of the network and payment is handled directly from the insurance company to the hospital, when appointed has been made in advance; instead, when using other hospitals, payment is handled by reimbursement, once surpassing the deductible.

When we know surgery has to be conducted is very important to call the insurer to negotiate with hospitals and doctors to ensure their honoraries fall within the brackets that the company is willing to pay for such operation.

In case of sickness, the first contact doctor, which can be one of your family or trusted doctor, it is critical to fill out the insurance company form, stating what’s wrong, always thinking in terms of how to describe the disease to avoid wrong interpretations and avoid being declined if the insurance company doctor sees a potential declination of coverage due an exclusion or to preexisting (before the first year policy incepted) condition.

Our recommendation to clients is to always try to purchase as much sum insured as possible keeping always in mind catastrophic coverage such as organs transplants, cancer treatments, etc. since sum insured diminishes as the company makes payments and rolls over next year renewal for one specific disease.