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 News from Around Banderas Bay | September 2007 
Understanding Mexican Medical Insurance
 Bob Cohen - PVNN
After five years, I finally understand my Mexican medical insurance policy.
As I near my 5 year anniversary of living full-time in Puerto Vallarta, it seems to be a good time to reflect on decisions I have made since I moved here. Of course I haven't regretted moving here, but before I did decided to be here full-time I had to be sure that certain personal business was in order and would be in order in Mexico as well.
What did I need to have? A qualified doctor and dentist, medical insurance, a car and auto insurance, a place to live that had American sized bathrooms and fully equipped kitchens, cable TV and computer access. These were my personal requirements and all were met, some before moving and the others within my first year in PV.
Medical issues were at the top of my list. I had so many questions because I was very well aware that I was leaving the United States health system (that I didn't like but understood) to another country that had policies and procedures in another language and utilizing different methods.
Yes, medical insurance was a must for me. I know many ex-pats that either self insure themselves (put savings aside for medical procedures), purchase very expensive international medical coverage, purchase IMSS insurance, buy private Mexican medical insurance, do a combination of the above or do nothing and hope for the best.
When I left the states my annual medical insurance costs were $5,000 per year and moving higher at a double digit percentage. Not naming companies, this was a typically well known traditional HMO insurance company that we have all come to know, accept and dislike (as well as the U.S. healthcare system) over the past 10+ years.
Actually I didn't know that Americans could actually purchase and use Mexican insurance, but upon asking people I met here, I acquired a stack of business cards given to me by friends of insurance people here. And always I was told to "make sure you tell them I sent you," as if this would actually help me.
I made my first contact who was a well-to-do Mexican doctor that sold insurance on the side. I guess his house in the Marina should have been a tip. The paperwork and background checks were much more than I expected, the price seemed high and they still had to "accept me" if I met their standards. After receiving notice that they needed more information about my medical past in Mexico City sealed it for me. I went to the next name on my stack of business cards and met with an insurance salesman and although he spoke very little English, he was the same as any insurance salesman in the U.S.; a nice personable guy, quick talker, good smile and of course someone I could trust.
Actually I bought a medical insurance policy from him and he explained how well I was covered in all of Mexico if I used one of the plan's hospitals. All but one of Vallarta's hospitals was on the list, so I felt as if I could choose where to go I case I needed hospitalization. The maximum that the policy would pay was $3 million pesos (approx $275,000 USD) and to my understanding it was all covered by the policy. The annual cost of the policy was also 20% of my medical insurance in the states.
I had a foot surgery earlier this year and when time came to set it up I realized that I had no idea what I needed to do to have my insurance cover the procedure. My agent told me to call the local administrator and they told me to call my agent. Then he told me to call the main office in PV and they told me to call someone else in Spanish spoken so rapidly that I had little comprehension of what I was told. The doctor I selected to do the operation wound up contacting the hospital's billing office to pre approve the surgery. I went in for the surgery and found that the hospital would pay "X" amount and the balance was my responsibility.
Anyone that has had to run around and collect facturas, doctor's statements and other documents to submit for reimbursement (after the surgery) will understand my growing frustrations. I had to submit and re-submit paperwork a number of times, because the paperwork had to be EXACTLY CORRECT. Finally after my final submission I received a phone call six weeks later telling me to pick up my reimbursement check. Then off to the bank to cash the check and another surprise. I didn't have an account in the bank the check was drawn on, so I needed to open an account and deposit the check.
Then I contacted Pamela Thompson, who I have known for years, and she put me in contact with her partner Emmanuel Gonzalez in their new company, Health Care Resources - Puerto Vallarta. Emmanuel is the insurance specialist, speaks perfect Spanish and English and we met two weeks ago to go through my medical policy from cover to cover for a number of reasons. I didn't really know if it really was a good policy and should I keep it or make a change. I also didn't want to have to go through the same frustrating experiences should I be hospitalized again.
After Emmanuel read through my policy, he told me I had more than ample coverage and could utilize all but one of the six main hospitals in Vallarta, or even go to Guadalajara or another city if I needed to or if I found a better specialist there. If I went to a plan approved hospital, I would incur a standard plan $2500 peso deductible as well as a 10% co pay, regardless of the price of the medical procedure. Thus, if I had a surgery that cost $80,000 pesos, my net cost would be $10,500 pesos and insurance would pay the balance. Formula - $80,000 - $8000 - $2500 = $69,500.
I do need to add that I did some research on some basic surgery costs in Mexico and the same surgery costs if I paid out of pocket in the United States. I have been in the hospital overnight in both countries and I can assure you that in a "normal" hospital the care is much better in Mexico from my experience. I got to see my doctor a number of times in a day and the nurses are absolutely spectacular, always attending to me when I asked. Oh yes, the cost in Mexico ranged from 10% - 30% less than in the states, usually closer to 10%-20%.
Emmanuel also instructed me what exactly I needed to do if I needed to be hospitalized in order to have the insurance company approve a procedure I might need. The most important thing is to call the proper person IN ADVANCE and have them tell you if the surgery or procedure is covered under the plan. Anything cosmetic is generally not covered at all, and a Mexican standard for payment is that you need to stay in the hospital for at least 24 hours. Outpatient surgeries are very marginal as far as payment and to be sure to have coverage, spend the night in the hospital.
So, five years later, hoping I never needed to use the medical insurance policy I had neatly filed away, I finally understand how the process works and what the policy actually covers. It did take a small surgery for me to get my butt in action to find out what I was paying for and what exactly to do in the future.
I would highly recommend the services of Health Care Resources - Puerto Vallarta, and for any insurance questions to contact Emmanuel. There is no charge to the customer for his services, in fact we met a second time a week later because I had a question that he needed to research and the question was answered. Emmanuel and Pam are in the process of getting a website for the company's many services to the English speaking public and I will pass the site address along when available. I highly suggest utilizing their services.
If you need medical or health insurance assistance of any kind, please do yourself a favor and contact Emmanuel Gonzalez on landline at Medasist Hospital at 223-0747, on his cell # 044-322-133-0867 or send him an email at ulisesemmanuel@hotmail.com. Oh yes, be sure to tell him I sent you. |
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