Prepaid medicine insurance in Ecuador consists of different processes than ones you may be used to. This is because the reimbursement process in Ecuador is carried out by the affiliate. Additionally, “the organic law of Ecuador regulates companies that finance comprehensive care services of prepaid health and insurance companies that offer medical assistance insurance coverage,” in order to support the insurance company and the affiliate. This law was created with the intention of regularizing the operation of prepaid medicine companies in Ecuador, through regulations that define the commitments made by both parties.
The regulations contain key articles that you must know to correctly document your claims with a company, and be able to demand your rights as an affiliate. Next, I will share the most important ones, and at the end I will provide you with a link where you can find the complete document in Spanish (one of the limitations of the law is the prohibition of the translation into other languages of this document and the contract of health that you acquire with the insurer).
Art. 34 - Pre-existence: Any disease, pathology or health condition that has been known by the user, beneficiary, affiliate, dependent or insured, and medically diagnosed prior to the signing of the contract, or the incorporation of the beneficiary will be considered pre-existing. (Official, R. Organic Law that regulates companies that finance comprehensive prepaid health care services and insurance companies that offer medical assistance insurance coverage, October 2016. [Online].)
In the case that one of your claims is denied for not declaring a pre-existing condition that you suffered from without medical knowledge or diagnosis, you can present an appeal to the company through documentation in which the treating doctor declares that you were unaware of this disease. Additionally, you must present medical records from your country of origin so that the company can confirm that the claim presented is not an undeclared pre-existing condition, in spite of the fact that the disease could have developed over the years, as in the case of cancer. The suffering of a disease without diagnosis and knowledge on your part cannot be denied. This condition will be analyzed again before a committee to determine whether or not your claim should be paid.
If the company continues to deny the appeal, despite the fact that your documentation shows that it is not an undeclared pre-existing condition, you can take your claim to the administrative headquarters, which in Ecuador is the Superintendency of Companies, Securities and Insurance. This process does not require a lawyer. You will only have to present all the regulatory documentation along with a letter, written by you, explaining your case.
Article 40 - Claim in administrative headquarters: The claims on the application and fulfillment of the contracts that were raised by the contracting parties, will be substantiated by observing the procedure foreseen in this chapter. Procedures will prevail due to their specialization over the constants in other legal bodies. The user may go to the Ombudsman's Office (People’s Advocate) to receive guidance and advice regarding the protection and guardianship of their rights within the framework of the provisions of this law. (Official, R. Organic Law that regulates companies that finance care services comprehensive prepaid health insurance and insurance companies that offer medical assistance insurance coverage, October 2016. [Online].)
To submit your claim to administrative headquarters, one must first submit an appeal letter to the company after the initial refusal.
Article 35 - Common obligations of the companies: 3. Notify the user, within five business days after the request, when the benefit is not covered or exceeds the amount of coverage (Official, R. Organic Law that regulates companies that finance comprehensive care services prepaid health services and insurance companies that offer medical assistance insurance coverage, October 2016. [Online].)
This article explains that both the affiliate and the company must meet certain requirements, such as in the case of reimbursements. The affiliate must present the following documentation: reimbursement form, medical certificate, orders and results of your tests, medicine prescriptions, and the original bills of your medical expenses in your name. Depending on each diagnosis and type of care, this documentation may vary. Once your case has been presented to the company, it will have a maximum response period of five business days. If you do not receive a settlement or letter of return or refusal, you can request this document from your broker or the company. In the case that you do not receive a response, you can notify the control entity.
Article 38 - Obligations of the users: The following are the obligations of the users: 1. Fulfill their contractual obligations, 2. Pay the financial charges within the terms established in the contracts, and 3. Act in good faith when completing contractual obligations; presumption that admits evidence to the contrary, made through a claim, substantiated in accordance with the provisions of this Law, will be cause for termination of the contract. (Official, R. Organic Law that regulates companies that finance comprehensive prepaid health care services and insurance companies that offer medical assistance insurance coverage, October 2016. [Online].)
Finally, the last article points out the contractual obligations of the affiliates, one of them being the presentation of documentation to the company.
Our pieces are intended to inform you about insurance, reimbursement and coverage processes. In a future article we will give you more details about the internal reimbursement processes of insurance companies. If you have any concerns, you can leave us your questions and comments on our social networks and we will work to answer them in the best way.