By: Abg. Miguel Ángel Saltos
Introduction
Recently in our office we had the opportunity to attend to the case of an insured person from a prepaid health and medicine insurance company, who had an international medical assistance policy. The insured’s situation is summarized in that because he had suffered from severe lower back pain, he decided to seek treatment from a doctor at a hospital in Miami, which was part of the hospital network on the list designated by the insurance company. Once he was seen, the specialist doctor determined that the insured should undergo emergency surgery, but for reasons of space and logistics, said emergency surgery had to be performed in a different hospital, which was not in the network of the medical centers of the insurance company.
It is important to mention that, within the stipulations of the contract, the benefits included medical treatment coverage for accidents and emergencies outside the provider network in the United States of America, up to an amount of USD 50,000.
The insured, after the emergency surgery performed on him, presented the documentation corresponding to the request for reimbursement of hospital expenses to the health insurance company, which was denied because, in the opinion of the insurer, the insured’s surgery was not treated. of a medical emergency for which, because he had surgery at a hospital that was not part of the insurer’s network, they supposedly had no obligation to offer him coverage.
When controversies in health insurance policies or prepaid medicine focus on medical aspects, as is the case with the determination of a medical emergency, what does the standard say about it? How should you proceed?
The claim process
After the reimbursement process with the insurance company has been exhausted and it has denied it for some reason not justified or accepted by the insured, the legal regulations of Ecuador offer the insured the possibility of presenting their case to the entity. control of the insurance companies to analyze and resolve it, we are referring to the administrative insurance claim process. The Organic Law that Regulates Companies that Finance Comprehensive Prepaid Health Care Services and Insurance Companies that Offer Medical Assistance Insurance Coverage (hereinafter Prepaid Medicine Law), in its article 41, second paragraph, establishes that:
(…) The holders or users of the contracts signed with the companies that finance comprehensive prepaid health care services may present a duly substantiated and documented administrative claim before the Mayor of Companies, of the jurisdiction of their domicile , within a period of one hundred and twenty (120) days, counted from the expiration date of the term established for the direct agreement, if this has not occurred, so that the authority can forward the claim to the other party, to respond within a period of ten days, counted from the notification with the claim.
As can be deduced, the law grants the insured a period of 120 days to file an administrative claim for any disagreement arising from coverage denied by their health insurance company. In this way, the insured could activate the administrative process of the claim before the Superintendency of Companies, Securities and Insurance, so that it can know the case and resolve it.
Now, when the issue of the administrative claim focuses on some aspect of a medical nature, the Prepaid Medicine Law itself, in the aforementioned 2nd paragraph of article 41, establishes that “when the controversy concerns health matters, concomitantly with the transfer, a request will be made for opinion to the National Health Authority that must be issued compulsorily ”, which will be binding on the Superintendency of Companies, Securities and Insurance. That is, in the present case, the determination of whether what happened to the insured was a medical emergency had to be analyzed by “the National Health Authority”, as in fact it happened.
Returning to our initially exposed case, within the processing of the administrative claim process, the control entity identified that it was a health controversy, since for the insurance company the operation to which the insured underwent could not be considered a medical emergency and therefore the expenses incurred at the hospital where the surgery occurred did not have to be covered by the insurer; The Superintendency of Companies, Securities and Insurance had to request the Agency for Quality Assurance of Health Services and Prepaid Medicine (ACESS) to issue its “ opinion regarding whether the medical treatment, subject of analysis in the present case , whether or not to respond to an emergency .” Therefore, the ACESS, after verifying all the pertinent documentation, concluded that the surgical procedures to which the insured underwent “ are considered emergency procedures .”
Thus, the control entity, in the exercise of its powers, resolved this controversy between the insured and the health insurance company, favorably accepting the claim presented by the insured, and as a consequence ordered that the insurer pay the insured all of the medical expenses sustained in the surgery at that hospital located in Miami and which was not within the insurer’s provider network.
Conclusion
As can be seen, the case presented had its legal and medical complexities, given that the disagreements centered on whether the surgery the insured underwent was the result of a medical emergency or whether it was just a regular procedure. The adequate and timely legal support of the lawyers who analyzed the case allowed the administrative claim to be correctly raised and thus the expected results could be achieved, in accordance with the provisions of the legal regulations regarding health insurance and prepaid medicine.
For more information you can contact:
Abg. Miguel Ángel Saltos | Email: miguel.saltos@lince-saltos.com | Telephone: (+593 4) 2630313
