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Problems with your health insurance? Learn how to claim

Faced with a conflict with your health insurance, the first thing you should do is try to solve the problems directly with the company. © Pixabay

Have you taken out health insurance and have problems with the company already started? Do not worry! If you want to file a claim, in this guide we explain all the steps to follow so that the process does not become a nightmare.

Over the years, there are many reasons that can generate conflict with your insurance company and your health policy.

In fact, saving by hiring your health insurance or finding the best company does not guarantee that you will not have problems throughout the duration of your policy.

The non – payment of compensation, sudden changes in the contract, undue charges … the list of problems that are usually generated with health insurers are endless.

In this sense, it is best to file a claim with your company. But, how to carry out this procedure? What are the steps to follow to avoid making mistakes and for your application to be effective?

Let’s review each stage of the process in detail:

Define the reason for your claim

Before submitting any type of claim to your health insurer, you need to be clear about the reasons why you want to carry out this procedure.

It is important that you can determine the main existing problem and whether or not it comes from a failure on the part of the company.

On some occasions, complaints are unleashed after poor attention by the health professions or medical center officials and, in light of this, the claims should not be directed to your insurer.

Now, if you have more than one complaint, you should sort them by importance. When you file the claim, it will be easier for you to explain the problem.

Review the conditions of your contract

The second step before filing a claim is to check the terms and conditions of your health insurance contract.

In a large percentage of cases, the claims are due to a misunderstanding of the contract by the client or misinformation of what is stipulated at the beginning of the policy.

If you realize that, in effect, the company is not incurring any type of failure because everything is contemplated in the document, you will be able to analyze the possibility of changing your insurance or modifying its conditions.

Submit your claim to your company’s SAC

angry person
The last instance of claim in the judicial way. 
© Pixabay

If you are sure that the problems with your health insurer are due to a failure, a breach of contract, or poor management, the first thing you should do is file a claim with the company’s Customer Service (SAC).

For this, you should contact your insurer and inform them of your decision to file a claim. They will explain the different ways available to carry out this management.

It is important that you know that your insurer has the obligation to resolve your claim within a period of no more than two months from the moment it is submitted.

Once the company has resolved your claim, it must notify you of its decision within 10 days after it is made.

Defender of the Insured

It may happen that your insurance company has a Defender of the Insured and that, therefore, you should not contact the SAC.

Your contract stipulates the path you must follow in case of problems or if you want to file a claim.

It is important that you know that each insurer has an Ombudsman, however, he works independently from the company.

In order to file a claim with him, you must send it by certified mail or by any other system that allows you to obtain proof of shipment.

The claim must contain your personal data, the policy data, and the reasons for this. Remember that by sending the document to the Insured’s Ombudsman you will not be able to manage another claim by any other means.

Do not forget to attach all the documents that can substantiate your complaint and serve as evidence for a later resolution.

The Ombudsman has a maximum period of 2 months to declare a sentence and 10 days to send you his answer.

In all cases, the insurer has the obligation to assume the verdict. However, the insured is free to take advantage of the solution or not.

Commissioner for the Defense of the Insured and the Participant of Pension Plans

In case you do not want to accept the resolution of the SAC or the Defender of the Insured, you can contact the General Directorate of Insurance and Pension Funds.

This body has a new figure dedicated to helping users who have conflicts with their insurers. It is the Commissioner for the Defense of the Insured and the Participant of Pension Plans.

To try to resolve your case and find a solution that suits you, the Commissioner will advise you throughout the claim process and will process your complaints and inquiries.

In this way, the Commissioner has a period of 6 months to answer and grant a verdict, however, the insurer has no obligation to comply with the ruling.

Given this, and in case you do not agree with the possibilities proposed by the previous instances, you still have other means of claim: the arbitration route and, ultimately, the judicial route.

Resort to arbitration

Trying to find a solution to your problem through some extrajudicial resolution system can be quite advantageous if you consider that you will not have to pay a euro to make your claim valid.

However, you must remember that to access this system you must have the acceptance of the claimed company. That is, the two parties must be willing to resolve the conflict.

If you are interested in going this way, you will only have to submit a request for arbitration in writing to one of the following organizations:

  • Consumer Information Office of your Community.
  • Associations of consumers and users adhered to the arbitration system.
  • Regional Consumer Arbitration Board.

The last option: the judicial route

If you tried by all means but none of the other options resolved the conflict that you have with your health insurer, the only option you can resort to is the judicial process.

It depends on the type of damage suffered, there are two types of claims to make through the courts:

Claim for property damage


In this case, you must file the claim in the Court of First Instance within the year following the claim.

If you do not agree with the sentence handed down by said Court, you must go to the Provincial Court within three days.

Claim for claims with injuries


In this case, you must file the complaint with the Investigating Court within 60 calendar days from the date of the incident.

If you do not agree with the resolution, you can appeal to the Provincial Court within 24 hours.

Complete guide to optical insurance

Optical coverage allows you to access ophthalmological services and treatments. © iStock

Children, adults, or the elderly, the truth is that no one is free from having a visual problem that leads them to wear glasses or contact lenses. And, although in Spain this problem occurs in a large part of the population, Social Security does not cover all the needs of its inhabitants.

Although wearing glasses or contact lenses is not synonymous with a serious illness, the need to use a visual correction system is an issue that should not be taken lightly.

Indeed, More than 70 million people must use a system that allows them to correct one of the many optical failures that exist today.

So what happens when the Social Security Plan doesn’t cover the cost of these gadgets? How to correct our vision problems?

The outlay for the purchase of an ophthalmological device, whether glasses or contact lenses, is quite high. However, some insurers include special optical coverage in their medical policies that will allow you to cover those needs.

What is called optical coverage?

As with dental insurance or other special policies, optical coverage is the one that the insured subscribes and through which they can access ophthalmological services and treatments that will then be fully or partially reimbursed.

Who can subscribe an optical coverage?

Although each insurance company establishes its own conditions, most set an age limit when contracting policy of this type, ranging between 65 and 75 years.

What does optical coverage include?

The coverage normally offered by optical insurance are:

  • Comprehensive eye exams
  • Glasses
  • Contact lenses
  • Graduated crystals
  • Prescription sunglasses
  • Optical glasses frames

In other words, the optical coverage covers the expenses you have to make on glasses and contact lenses in the event that there is a medical need.

Certain companies may also include in their policies certain additional and infrequent coverages such as contact lenses to modify the color of the eyes, intraocular corrective lenses, prosthetics or implants.

What should you pay attention to?

Hiring the best health insurance, whether general or specific, involves reviewing and searching within what the market offers us.
Given this, it is important that you take into account certain points when deciding on one coverage or another.

Coverage limits

As with any type of insurance, companies set limits for each of their policies. As a general rule, most insurers set this limit to one prescription and one bill per year.

However, depending on the type of premium you want to pay, it may be that the company does not cover 100% of the expenses but only takes 50%.

Lack

The grace period is the time that must elapse from when you contract your policy until you can make use of its coverage.

Some insurers set the grace period at 6 months, however, there are others that offer you the coverage contracted from day one.

Exclusions

In most insurance policies, insurers set certain exclusions that, in no case, may be covered by the contracted premium. Among them are:

  • Medical consultations with an ophthalmologist
  • Medical or surgical treatment for the eyes
  • Orthoptic exercises
  • Low vision
  • Aniseiconia
  • Tomographs
  • Replacement of frames or glasses as a result of loss, theft, abuse or breakage
  • Medicines

Pre-stocks

It is important that you remember that a large part of the insurers will not assume the expenses of optical services in the event that the condition has begun on a date prior to the beginning of the contract.

How to compare health insurance?

Do not forget to choose an insurance company that you trust. © Pixabay

The Health policy is one of the coverage that Americans contract with the greatest care and regularity. For this reason, it is very important to take the time to properly analyze the different offers that the market offers. Check in this guide how to compare this type of insurance to make the best choice.

Didn’t you get the coverage you expected? Your health insurance does not guarantee dental benefits? Does the medical chart not accommodate your needs? …

Many people are surprised when using their health insurance when they realize that the coverage or compensation does not correspond to their calculations.

However, and despite the claims and long waits, most of the time the problem lies in the ignorance of the contract and the poor choice of the policy.

Given this, the most important thing before hiring health insurance is to compare the different policies offered by the market and evaluate the one that best suits your own needs.

Here we give you five tips to compare in the best way.

Write down your needs and those of your family

Before launching into the comparison of the different policies offered by the market, it is important that you take into account the medical needs that your family group presents.

All people are different and, therefore, not all require the same attention. Some must go to the doctor frequently because they have a particular symptom, others are content with making the mandatory visits.

Some of the points that you can take into account when analyzing the particular needs of your family are:

Choice of medical staff

If you always visit the same doctor and you like to personally choose the professionals who will give you care, then you should choose an insurer that includes them in their medical chart.

Take a good look at the lists of the doctors and clinics that work with your insurer, otherwise, you will have to change companies or pay the cost of the consultation in a private way.

Frequency of medical visits

If you are one of those who visit the doctor periodically, we advise you to opt for medical insurance without copayments. This modality allows you to access all health services in exchange for the payment of a monthly premium.

On the contrary, if you are one of those who never go to a visit of this type, you may want to opt for a policy with a copayment.

In this case, the monthly premium is much cheaper and you only have to pay a small supplement when you need to go to the doctor.

Look only for trusted insurers

When hiring your best health insurance, you should not look only at the value of the premium and the coverage they offer you. The choice of the insurance company is also very important.

Remember that there are insurers that do not market certain types of insurance and others that are specialists in a specific market.

To be sure that you are selecting the best companies, we advise you to:

  • Make sure it is a serious company with a long history in the market.
  • That works with a wide range of clinics, doctors, and specialists.
  • That it gives you different options to customize your policy.
  • To present to you the conditions and the fine print of the contract from the beginning of the negotiations.

Check the coverage that each insurance includes

© Pixabay

Even if you think that you already have all the necessary elements to choose the best health insurance, the truth is that there are still some steps that you should take into account.

One of the most important aspects of a policy of this type is the type of coverage that you will obtain after being hired.

Do not forget that in addition to the traditional guarantees, there are coverages that can be adapted very well to your specific needs, and that, therefore, would be important to hire.

We are talking, for example, about women’s health insurance or those that offer a greater guarantee in terms of optical devices.

Analyze well the coverage provided by each of the insurance that you have on your list and do not forget to review those additional or special guarantees.

Ask about grace periods and other special conditions

It is important that you inform yourself about all the conditions of the contract because many times the policies include certain points that can make you change your mind.

Some of the issues that you should take into consideration are:

Grace periods

This means that you will not be able to use certain medical benefits until the term stipulated in the policy has expired.

Generally, grace periods are included in benefits such as pregnancy, childbirth, and postpartum and comprise a period of time between 6 and 12 months.

Pre-existing diseases

Compare prices and decide on the best

You have reached the last stage, where the most important thing will be to compare the different policies that you have selected according to their coverage and the price of each of their premiums.

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