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Okay, you’ve got a good level of cover from an established insurer with a good track record in the industry, but things can still go wrong in comparison to what you were expecting.
Here are some situations to be aware of:
Pre-authorisation – irrespective of your cover if you are planning a visit to the doctor always phone or email (if they have an email service) the insurer to gain confirmation you are covered. If you don’t they could refuse to cover the claim or may only cover a proportion of it. There are some exceptions to this, such as if you are unconscious and can’t communicate or the situation is very serious and you don’t have time to contact the insurer. In these instances the hospital will usually/should contact the insurer on your behalf.
- Direct-billing – for in-patient treatment direct payment by the insurer to the medical facility is usual and after being authorised is facilitated by means of a treatment guarantee (more on this below). This means you usually pay nothing to the medical facility (unless you have an excess/deductible which you need to pay yourself) and instead the bill is settled direct. For out-patient treatment you may have been expecting the same to be true.
Unfortunately it is likely that there will be limitations on whether you can have direct-billing in the first place for out-patient treatment and then if you can there is likely to be a limitation on the number of hospitals than you can do this with. As such you need to be aware that you may need to claim back money you have laid out for treatment/consultations. Some insurers are faster than others at reimbursing claims and the claims process is also easier with some rather than others. Being aware of the insurers direct billing network and claims reimbursement process is a useful area to familiarise yourself with.
Treatment guarantees – some hospitals/medical facilities won’t provide you with treatment unless you can guarantee payment. More often than not this is for in-patient treatment. After having contacted the insurer and they are aware you are going to have specific treatment for which you are covered – they can provide the hospital/medical facility with a treatment guarantee which means that the insurer will settle the bill directly with them. On the rare occasion you may find a specific hospital/medical facility does not accept a treatment guarantee from the insurer – this is usually due to an on-going issue between the insurer and the hospital/facility.
In this instance you would then need to decide if you still wanted to be treated there which would mean settling the bill yourself (to claim back later from the insurer) or choose a different facility. If the bill is going to be quite sizeable and you plan to pay it yourself you should discuss this with your insurer to agree speedier reimbursement.
- Paying deposits/Buying packages – Some hospitals/clinics can offer special discounted packages. Maternity is a good example of this.
PREGNANCY ANNUAL LIMITS
Due to benefit limits applied by insurers sometimes all your associated pregnancy costs might not fall within the total benefit. So you could have some additional costs to pay if you don’t buy a discounted package and even if your full costs would be covered you may feel buying a package gives you a better idea of what to expect from the hospital/clinic, and you’re also getting the insurer a better deal.
Unfortunately it most instances the insurer won’t pay for such a package direct with the hospital/clinic. You would need to pay for the package yourself and then claim back the package cost once the baby was born. The reasons behind this include:
- You may not be happy with the service/treatment and decide to change hospital/clinic. The insurer would then potentially face a battle to recover a refund for unused elements if there are any as many such packages come with no refund.
- Something may happen during the pregnancy which means the package you have purchased or the facility you are using is no longer sufficient for your needs.
- Your circumstances change and you need to move location part way through the package you have purchased.
Sometimes as well even when a treatment guarantee is issued the hospital/clinic can still request a deposit. This is usually down to their internal policy and is not relating to the insurer’s payment policy.
- Excess/Deductibles/Co-Pay – do you fully understand how this works – if not you may incur unnecessary additional expense. Is your excess/deductible set per the plan year or per illness and do you have a co-pay on any of your benefits?
Claim Denied/Not fully refunded – assuming you have already gained authorisation for the treatment you are planning everything should be fine, unless:
- The insurer discovers this is relating to a pre-existing condition which you don’t have cover for/haven’t disclosed previously;
- Some of the expenses you are claiming for are not covered. These might include such things as over the counter medicines or medical aids as examples;
- You have paid for the costs in a local currency and the insurer repays you in foreign currency – this may lead to an exchange rate loss which means you end up getting back less than you’ve paid.
If for some reason a claim has been denied or cover has been refused but you are certain this should not have happened, then query it with the insurer, make a written complaint if still unsatisfied and continue to escalate this until resolved to your satisfaction. If you still feel this is not being resolved timely or fairly ask your broker to assist and if all these avenues fail take the complaint to the relevant ombudsman.