Medical expenses: every procedure, step by step

Step by step

1. Arrive at the network hospital with your insurance card or policy number and an official ID. If a life is at risk, treatment comes first: the paperwork can wait.
2. From admission, notify the insurer, or ask admissions or the insurer's desk at the hospital to do it, and message us on WhatsApp. Write down the claim number.
3. Sign the accident or illness notice (you or a relative) and ask the treating doctor to fill in the medical report.
4. The hospital sends everything to the insurer, which replies with a direct billing authorization letter. Sometimes it authorizes an initial amount and increases it later.
5. While you're in hospital, ask for your account statement every day to see which charges the policy doesn't cover.
6. On discharge you pay the deductible, coinsurance and anything not covered at the cashier. Ask for a copy of the authorization letter and the final bill.
7. Later expenses (medication, follow-up visits, therapy) are claimed as a follow-up claim under the same claim number.

Documents

Tick what you already have:

• Insurance card or policy number
• Valid official ID of the policyholder and the patient; for minors, birth certificate
• Signed accident or illness notice
• Medical report signed by the treating doctor
• Lab and imaging results with their interpretation
• If the authorities were involved (crash, assault): the Public Prosecutor's report or case file

Deadlines and amounts

Notice

As soon as possible. If your policy doesn't set another term, the law gives 5 days (Insurance Contract Law, art. 66).

What you pay

The deductible and coinsurance on your policy schedule, up to the coinsurance cap if your plan has one, plus personal expenses.

Doctors' fees

With direct billing the doctor must be in the network and accept the insurer's fee schedule; MAPFRE's form, for example, says so.

To get paid

• Ask for a standard room: the difference for a higher-category room is usually yours to pay.
• Ask the doctor to write the real date your symptoms started and the full diagnosis in the report. Dates that don't match across documents are the most common reason for a pre-existing condition investigation.
• If the hospital isn't in the network, ask the insurer whether direct billing applies; if not, keep every invoice for reimbursement.
• Personal items, a companion's meals, parking or phone calls are not covered. MAPFRE publishes the full list in its guide to non-covered expenses.

What holds up payment

• Signing blank forms or forms you haven't read.
• Getting care outside the network when your plan only covers inside it: in HDI's Médica Vital, for example, non-serious emergencies are not reimbursed.
• Leaving the hospital without the authorization letter or the final bill.

Step by step

1. Confirm that the policy covers the condition and that its waiting period is over. Hernias, gallbladder, spine, knees, tonsils and maternity often have one.
2. Choose a doctor and hospital in your plan's network and ask whether your doctor accepts the insurer's fee schedule.
3. Ask the doctor for the full medical report: diagnosis, procedure, date, hospital and fees. If materials will be used (prostheses, screws, stent, pacemaker), also the supplier's quote.
4. Fill in the accident or illness notice and the scheduling request if your insurer has one, and gather the test results with their interpretation.
5. Send everything in advance. MAPFRE asks for at least 5 business days before admission, and Zurich's group plan also 5.
6. Receive the authorization letter and check the amount, hospital, date, doctors and deductible.
7. Hand it in at admissions on the day. If the date, hospital or surgery changes, tell the insurer beforehand so they reissue it.

Documents

Tick what you already have:

• Medical report (at Zurich, no more than 6 months old)
• Accident or illness notice
• Test results with interpretation and, if requested, medical history
• Quote for materials, equipment or special medication
• Hospital and fee estimate, if the insurer asks for it
• Official ID and proof of address no more than 3 months old
• Customer identification form (Article 492), if requested
• Letter of remaining sum insured or seniority from your previous insurer, if you switched companies

Deadlines and amounts

Advance notice

Usually 5 business days. Some special treatments need more: Atlas asks for 10 business days for cell therapies.

Authorization

The insurer may ask for more tests or a second opinion before authorizing.

Admission

HDI's Médica Vital doesn't cover being admitted more than 23 hours before scheduled surgery without written authorization.

To get paid

• Scheduling almost always beats reimbursement: the insurer pays directly and you only cover the deductible and coinsurance.
• Ask for the authorization to include every doctor (surgeon, assistant, anesthesiologist) to avoid surprise bills.
• If authorization is denied, ask for the answer in writing with the clause applied, and message us.
• If an additional procedure is done during surgery, report it: MAPFRE doesn't apply the scheduled surgery benefit to anything it didn't authorize.

What holds up payment

• Being admitted before you have the authorization letter.
• Sending an incomplete report or no test results: the process stops until it's complete.
• Changing doctor or hospital without telling the insurer.

Step by step

1. Open the claim with the accident or illness notice, the medical report and the test results. That way the expenses start counting toward the deductible.
2. Ask for an electronic invoice (PDF and XML) for every expense, itemized or with unit prices, in the name your insurer requires. HDI, for example, wants it in the primary policyholder's name with the patient's name; Zurich, in the insured's or the patient's name.
3. Fill in the reimbursement form with the list of invoices and the bank transfer form with your 18-digit CLABE.
4. Submit everything together through the channel your insurer indicates (portal, email, office or through us) and keep the receipt with date and reference number.
5. If they ask for something else, send it promptly: the deadline to pay you runs from when they have everything.
6. Check the payment letter: deductible, coinsurance, fee schedule and non-covered items applied.

Documents

Tick what you already have:

• Reimbursement form (at Atlas, one per event and per patient)
• Accident or illness notice (initial claim only)
• Medical report from each treating doctor
• Itemized invoices in PDF and XML; no XML is required for expenses abroad (Zurich)
• Proof of payment, if your insurer asks for it (HDI does)
• Prescriptions and test results with interpretation
• Valid official ID of the policyholder and the patient
• Bank statement showing the CLABE and proof of address no more than 3 months old
• Customer identification form (Article 492), if requested

Deadlines and amounts

Payment

30 days from when the insurer receives all the documents (Insurance Contract Law, art. 71). If it's late, it must pay you interest.

To claim

2 years from the event (Insurance Contract Law, art. 81). Don't wait: medical reports are often required to be no more than 6 months old (Zurich).

Amount

Paid according to your plan's fee schedule and limits, minus deductible and coinsurance.

To get paid

• Claim the whole condition under the same claim: the deductible is usually charged once per condition.
• Before paying a doctor outside the network, ask the insurer how much its fee schedule recognizes for that procedure.
• Check the name, RFC and breakdown on each invoice before it's issued: correcting it afterwards takes weeks.
• Scan every document in good quality and keep the originals; many insurers now accept claims by portal or email.

What holds up payment

• Invoices without XML, in the wrong name or issued to the general public («público en general»).
• A medical report without a signature or professional license number.
• Mixing expenses for different patients or conditions in one claim.

Step by step

1. Have the original claim number at hand.
2. Gather the new invoices (PDF and XML), prescriptions and test results related to that condition.
3. Fill in the reimbursement form again. The accident or illness notice is no longer needed (Zurich doesn't require it for follow-up claims).
4. If the treatment changed or months have passed, ask the doctor for an updated report.
5. Submit and keep the receipt.

Documents

Tick what you already have:

• Claim number
• Reimbursement form
• Invoices in PDF and XML
• Bank transfer form and bank statement (Zurich marks them as required)
• Prescriptions, test results or an updated medical report, when they apply

Deadlines and amounts

When

Whenever you've gathered expenses; it's worth grouping them rather than filing small claims.

Deductible

Usually charged once per condition; check whether your policy applies it again on renewal.

To get paid

• If your medication is expensive or long-term, ask whether the insurer supplies it by direct billing. Plan Seguro has a request form for medication and equipment by direct billing.
• Keep a sheet listing every invoice already claimed so you don't duplicate or forget any.

What holds up payment

• Leaving out the claim number: it may be registered as a new claim and take longer.
• Including expenses for another condition.

Step by step

1. Check your policy schedule for the cover, the amount for birth or C-section and the date it starts counting.
2. Confirm the waiting period: it's usually 10 continuous months (as stated, for example, in HDI's Médica Vital and MAPFRE's group plan).
3. A few weeks before the due date, schedule the event with the gynecologist's medical report (due date and hospital), the notice and the prenatal tests.
4. With the authorization letter, the hospital bills the insurer up to the maternity amount and you pay the difference. If you didn't schedule, you claim by reimbursement up to that limit.
5. Add the baby to the policy as soon as they're born.

Documents

Tick what you already have:

• Gynecologist's medical report
• Illness notice or your insurer's form (at MAPFRE, the same direct billing or scheduling request, ticking «Embarazo»)
• Prenatal tests (ultrasounds and lab work)
• Invoices in PDF and XML, if it's a reimbursement
• Official ID and proof of address

Deadlines and amounts

Waiting period

Usually 10 months of continuous coverage. If you switched insurers, ask whether they recognize your seniority.

Amount

Usually a fixed sum for birth or C-section; anything above it is yours to pay.

Complications

They have their own periods: at SURA, 4 months for ectopic or molar pregnancy and 10 months for other complications.

To get paid

• If you're planning a pregnancy, check the cover before you buy or renew: the waiting period counts from when you have it.
• Ask the hospital for its maternity package in writing and compare it with your policy's amount.
• Fertility treatments and their complications are usually excluded (MAPFRE says so in its guide).

What holds up payment

• Assuming the birth is covered before completing the waiting period.
• Not scheduling and having to pay everything up front to claim later.

Step by step

1. Add the baby within your policy's deadline; in Zurich's group plan it's 30 calendar days after birth.
2. To cover congenital conditions and newborn complications, the mother usually needs seniority: 10 months in Zurich's group plan.
3. If the baby needs intensive care or surgery, it's handled as an emergency or a scheduled procedure in the baby's name.

Documents

Tick what you already have:

• Birth certificate (medical or civil registry)
• Request to add the baby to the policy
• Medical report from the pediatrician or neonatologist, if there are complications

Deadlines and amounts

Adding the baby

Usually 30 days. After that they may ask for a medical exam or apply waiting periods.

Limit

Congenital conditions often have their own limit (200 UMAM in Zurich's group plan).

To get paid

• Add the baby even if they're born healthy: if something shows up later, they'll already be covered.

What holds up payment

• Missing the deadline to add the baby.

Step by step

1. There must be an open claim, and the treatment must relate to that condition (MAPFRE requires this).
2. Ask the doctor for a prescription with the medication name, presentation, dose and duration, or the order for the test or therapy with the number of sessions.
3. Request authorization beforehand with your insurer's form, the in-network supplier's quote and the prescription.
4. If direct billing is authorized, the in-network supplier provides the medication or test; if not, you pay and claim by reimbursement.

Documents

Tick what you already have:

• Original prescription with dose and duration
• Doctor's order for the test or therapy
• Supplier's quote (MAPFRE asks for it for tests, chemotherapy and materials)
• Updated medical report if the treatment is long
• Claim number

Deadlines and amounts

Prior authorization

HDI's Médica Vital requires it for specialty medication over MXN 5,000, therapy, nursing and medical equipment.

To get paid

• Ask whether your insurer has a program for serious or chronic illness (Zurich has Paciente Zurich).
• For long treatments, ask for authorizations by period and renew them before they expire.

What holds up payment

• Buying without a valid prescription or for a condition other than the one in the claim.
• Vitamins, supplements and products without health registration: usually not covered.

Step by step

1. Get care as soon as possible. Many policies require the first expense within a set period to treat it as an accident; in Zurich's group plan it's 90 days, after which it's treated as an illness.
2. If there was a crash, a robbery or another event involving the authorities, file a report or ask for one: the insurer may ask for the case file.
3. If it was a car crash, the auto insurance (yours or the at-fault driver's) issues a medical pass. Let us know so we can coordinate it with your medical policy.
4. Then follow the emergency, scheduling or reimbursement procedure, as the case may be.

Documents

Tick what you already have:

• Accident notice explaining how, when and where it happened
• Medical report and test results
• Public Prosecutor's report or proceedings for violent accidents
• Medical pass from the auto insurance, if it applies

Deadlines and amounts

First expense

Within your policy's period for it to count as an accident.

Deductible

Some policies waive it for accidents: Zurich's group plan, if the expense exceeds the deductible, pays without deducting deductible or coinsurance.

To get paid

• Describe the accident the same way in the notice, the police report and to the doctor.
• Check the exclusions: high-risk sports may not be covered (HDI's Médica Vital excludes them).

What holds up payment

• Waiting weeks to get care.
• Giving different versions of the accident.

Step by step

1. Check whether your plan covers you abroad (everything, emergencies only or nothing) and up to what amount.
2. If you can, before getting care call your insurer's international number so they can steer you to a provider and, where applicable, arrange payment.
3. If you pay yourself, keep itemized invoices, payment receipts, the medical report and test results. MAPFRE and Atlas have bilingual forms.
4. When you get back, file for reimbursement; it's paid in pesos at the exchange rate your policy sets.

Documents

Tick what you already have:

• Medical report (in English, if your insurer has a bilingual form)
• Itemized invoices and proof of payment (no XML)
• Passport and travel documents, if requested
• Reimbursement and bank transfer forms

Deadlines and amounts

Long trips

Some emergency covers abroad only apply during the first 90 days of a continuous stay (Atlas Med Plus).

To get paid

• Save your insurance card and your insurer's international number on your phone before you travel.
• For long trips or study abroad, consider travel insurance as well.

What holds up payment

• Having a planned procedure abroad when your plan only covers emergencies.

Step by step

1. Ask for the answer in writing, with the clause or exclusion applied.
2. Go over the policy and what you submitted with us: often a document or a detail in the medical report is missing.
3. Request a reconsideration with whatever was missing (expanded medical report, test results, medical history).
4. If that fails, file a complaint with the insurer's UNE and then with CONDUSEF.

Documents

Tick what you already have:

• Denial or payment letter
• Policy and general terms and conditions
• Copies of everything you submitted, with receipts

Deadlines and amounts

UNE

Must answer you within 30 business days at most.

CONDUSEF

You can go to them up to 2 years after the event or the denial.

To get paid

• Answer with facts and documents, not frustration: a well-prepared reconsideration is resolved faster.

What holds up payment

• Signing a settlement you don't agree with.