Surgery - Medical Insurance Benefits

[Chirimoya]

So I get this right, you are saying always get the authorization from the clinic or hospital while you are there and not through the agent.

No - the clinic will go through the routine approval procedure on the day anyway. This is what happened in our case and we thought it would be sufficient.

As MA explains - getting your agent to call in advance of the appointment and confirm that the procedure, the doctor, the overnight stay, etc. are covered appears to be a better way of ensuring you're not shafted after the event.

Outpatient would mean that you were not admitted to the hospital overnight- say for something like a broken arm or stitches or the like.

I know what it means, but what I was asking was why would this make a difference? In our case the procedure did involve an overnight stay, which they also "approved".

 

[cobraboy]

No - the clinic will go through the routine approval procedure on the day anyway. This is what happened in our case and we thought it would be sufficient.

As MA explains - getting your agent to call in advance of the appointment and confirm that the procedure, the doctor, the overnight stay, etc. are covered appears to be a better way of ensuring you're not shafted after the event.

I know what it means, but what I was asking was why would this make a difference? In our case the procedure did involve an overnight stay, which they also "approved".

What specifically does the policy itself outline about pre-authorization requirements?

 

[mountainannie]

I guess that what we are saying is GET AN INSURANCE AGENT - not just a policy-- so that you have someone who will go to bat for you.

I used Alvarez Serra who has an offices in SD and Las Terrenas. (office in SD is 809 333 2369 - but he does not speak English. Perhaps other posters have agents that do?

Plus - if possible - at least contact your agent that you are going in to the hospital and have him working for you at the time.

Those of us who are used to the US health care/insurance system are perhaps more accostomed to having the insurance companies routinely deny payments - that seems to be their business. But for those of you coming from Europe the whole thing can be a bit frustrating, I can imagine.

 

[waytogo]

Great information everyone, thank you all. At least now I am more aware of a proper procedure.Is Las Terrenas in Santiago?

 

[cobraboy]

I guess that what we are saying is GET AN INSURANCE AGENT - not just a policy-- so that you have someone who will go to bat for you.

This should be a sticky. And get an agent who does a LOT of business with the insurance company fo choice, whether health or auto.

This country and culture is ALLLLLLLLLLLLLL about relationships. Approach it as a foreigner doing business like back home at your own peril.

 

[Chirimoya]

What specifically does the policy itself outline about pre-authorization requirements?

Officially, the routine authorisation by the clinic is all that is required. Basically the company are breaching the contract if they refuse to pay having granted authorisation (we have the code and the number of the staff member who gave the approval). But they know it is not worth our while to take legal action, so they can do whatever they like.

This should be a sticky. And get an agent who does a LOT of business with the insurance company fo choice, whether health or auto.

This country and culture is ALLLLLLLLLLLLLL about relationships. Approach it as a foreigner doing business like back home at your own peril.

That's precisely it. The legal, official part is never enough. It is just theory. Practice is another matter, so if you have the backup of someone (i.e. an Agent) fighting your corner who has A Relationship and Leverage with The Company, you're in a much better situation.

 

[Robert]

Have I missed something? When you get approval at the clinic, that usually means you are only paying any additional or copayment at the clinic. It's the clinics job to get their money from the insurance company.

I have never had to pay upfront and then claim back.

Maybe it's different if the clinic is out of their network?

 

[MikeFisher]

this is one of the best Topics we have on the Bord,
and a Important Theme for Everybody,
Robert!/Chiri,
I 2nd that it should be worth a Sticky.

the usual procedure I always found been:
you enter a Hospital/Doctor's office,
explain at the Counter/Reception, Before even seeing the Doctor Himself, what your health problem is,
they ask for your Insurance Card,
You hand the Card over,
they Call the Insurance Company and get their Codes,
Then You go to see the Doc.

around 2 years ago I had big pain in my right Arm/Shoulder,
the above procedure applied for the Consultation of the Doctor, still nobody knew what the problem would be nor what the further treatment would be.
so I waited my Turn to see the Doc, explained my problem/Pain, he did minor checks and ordered an X-Ray of the Shoulder, which been done right there in the next Room.
but before the X-Ray been done the secretary/Assistant been on the Phone again with the Insurer and got her Code for the X-Ray, the same as prior with the Consultation Fee, she informed me it is full covered, no extra cost left for Me.
after the X-Ray been done I waited a very short time to see the Doc again, he checked it and informed me about the Problem with the Liquid in my shoulder and told me it will be solved very quick by Injection of %$@(I don't remember the name of the Medicine injected in my shoulder, sorry) and wrote me the Receipt to get the stuff at the attached Pharmacy.
before I went to the Pharmacy the Secre been on the Phone again and got a Code, for that she gave me a additional paper for the pharmacy where I did not pay the full Rate, part been covered by the Insurance.
back to the Doc, injection set, more Pain for the next 2hrs like promised by the Doctor, and since then all is fine.

the Point is,
for every additionally to the Consultation appearing treatment the Clinic/Doctor will contact the Insurer and get His/Her Code for the payment, and they inform You/the Patient right away about extra costs/coverage of the specific treatmen.
at least that is our past experience with consulting a Medic/Hospital.

keep the Info about that Theme coming Guys,
the good and the Bad,
this is almost more Important than asking the Weather for next X-mas.

Mike

 

[cobraboy]

No - the clinic will go through the routine approval procedure on the day anyway. This is what happened in our case and we thought it would be sufficient.

As MA explains - getting your agent to call in advance of the appointment and confirm that the procedure, the doctor, the overnight stay, etc. are covered appears to be a better way of ensuring you're not shafted after the event.

I know what it means, but what I was asking was why would this make a difference? In our case the procedure did involve an overnight stay, which they also "approved".

With thanks and credit to mido, here are the folks you need to be complaining to: Superintedencia de Seguros de la Republica Dominicana > Inicio

 

[Chirimoya]

Many thanks!

 

[Frank the Tank]

This thread has been very informative. Thanks Robert.

 

[georgig]

Health insurance

Hi all,
My family's insurance with QBE expires soon so I visited Universal office in Cabarete in order to sign a Dominican health insurance with them as we live here and use the health system of the country. It was a great surprise for me to understand, that the coverage starts two months after signing policy/first installment. It was a Paragraph 22 situation - we expect baby within 1,5 month, current insurance expires in 1 month, the new coverage starts after 2 months. The officer at Universal advised me to wait with baby's delivery :cross-eye Has anybody heard something like this or I just didn't understand the rules? Is there ARS Humano office in Sosua/Cabarete in order to compete the terms?

 

[waytogo]

The officer at Universal advised me to wait with baby's delivery

LOL, Was this insurance agent serious?
How does your wife feel about this?.... Still LOL...

 

[cobraboy]

Hi all,
My family's insurance with QBE expires soon so I visited Universal office in Cabarete in order to sign a Dominican health insurance with them as we live here and use the health system of the country. It was a great surprise for me to understand, that the coverage starts two months after signing policy/first installment. It was a Paragraph 22 situation - we expect baby within 1,5 month, current insurance expires in 1 month, the new coverage starts after 2 months. The officer at Universal advised me to wait with baby's delivery :cross-eye Has anybody heard something like this or I just didn't understand the rules? Is there ARS Humano office in Sosua/Cabarete in order to compete the terms?

Probably a form of an acute pre-existing condition clause. They don't want to be responsible for paying for something you KNOW will happen. Can't blame them, really.

Why not just extend the coverage on your current policy?

 

[Shiraz72]

In Canada you probably would had to wait 6 months just for the first appointment. Same reason I love DR, without appointment you can; see specialist, get x-rays, blood test, etc all in the same day, and some insurances like Palic pays 80% of your prescriptions.

It depends on which province you live in Canada. I have belly button sergury scheduled as well and saw my family Doc in July, she referred me to a surgeon in August just before my last trip to DR and they called me wanting to do the surgery right after Labour Day weekend! I rescheduled it for October. But if you need something like an MRI here... forget it... or blood test results...again forever. I had a blood test when I was in POP and got results back the same day and it only cost me around $20.

 

[georgig]

Probably a form of an acute pre-existing condition clause. They don't want to be responsible for paying for something you KNOW will happen. Can't blame them, really.

Why not just extend the coverage on your current policy?

Hi Cobraboy,
In order to extend existing policy coverage my family needs to go to Europe for medical tests, which is impossible now. Again Paragraph 22 situation.

 

[cobraboy]

Hi Cobraboy,
In order to extend existing policy coverage my family needs to go to Europe for medical tests, which is impossible now. Again Paragraph 22 situation.

So it's a foreign policy?

 

[georgig]

So it's a foreign policy?

Yes, its QBE policy. We are relatively new in DR and QBE don't accept medical tests performed in DR.

 

[MikeFisher]

I don't know about the rules in your country on that matter, but I had myself to change the insurer for med insurance during my prior excessive travels around the Globe quiet a few times, one Rule been (back in the Day, lol) that the insurances could not be taken for a total of over 3 years. i traveled often for 6-8months of consecutive Travels, so when I reached the 3 years total I had to change twice. I don't know how that is ruled todays, since long I have my DR Insurance with ARS Humano and the same Time I pay med insurance in Europe. Yes, the European one is the expensive PITAzz, since a short while ARS Humano has in my Platinum Plan also Travel Insurance included, but I still did not check out how far/how much/whatsoever they would cover when I would need them over there on the other side of the Ocean, I am a bit picky on that theme and will sure leave my European Insurance for a longer while, but next time over there I need to visit a Doc for some Minor Issue I will run it over ARS Humano just to see how it works out.
If your policy is a foreign One You may also need to prepay here first and hand them over your Bills to get reimbursed later, a Travel Insurance, but they are not the best to deal with when staying in a foreign country permanently, that may be a reason why they require you to come back home for your medic check.
good luck
and find a way to have that Mommy and preborn Baby insured,
there is much to much sh$t out there that could happen to leave such uncovered.
Mike