San José, Costa Rica, since 1956

X-rated Medical Claim: A Personal Report

For the last few years, the best bargain in medical insurance in the country has been the dollar-based INS medical policy. As with most National Insurance Institute (INS) policies, claims entail frightful bureaucracy and paperwork; however, for expensive medical procedures, there is a process called preautorización that allows the client or patient to sidestep most of that nonsense.

If you have to undergo an expensive procedure or spend some days in the hospital because of an accident, tell your doctor or clinic that you have insurance, give them your policy number and ask them to get a preauthorization. This means the doctor and clinic will get in a huddle with IMCS, the claims clearing service used by INS and negotiate a fair price for your treatment.

If you have a preauthorization, not only will you get a better deductible, but you will not have to pay the entire bill and then do the claim paperwork to get your money back. With a preauthorization, when you are released from hospital, you pay only the deductible – nothing else. So there is no claim paperwork, no running back and forth with prescriptions, copies, facturas and all that sort of stuff.

All of this sounds nice and efficient – but, unhappily, nowadays we are encountering factor “X”: the X-cessive greed of some medical practitioners. I had heard of this from several clients with INS Medical policies and had warned them of the possibility of being victimized – but I never thought I would X-perience it first hand.

Late last year, my doctor told me I had a hernia and that I should have it taken care  of. A keyhole operation – no big deal. So Iput myself in the hands of a surgeon who specializes in keyhole surgery, and a date was established for the bloodletting. Naturally, I told the sinister sawbones that I had insurance and asked him to please negotiate a preauthorization. A couple of days later, my insurance agents (a very reputable firm, I must add!) informed me that the cost of the procedure had been established at $1,690 –equivalent to about ¢930,000 at the time.

A few days later, I was admitted to an irreproachable downtown clinic and, after a lot of fuss and several hours, came out of anesthesia sans hernia and avec keyholes.

As I am a gray-haired wrinkly, I had to spend the night. The following afternoon, I was beating on my chest, clamoring to be released, pardoned, paroled and allowed to go home.

My son, Tim, went downstairs, checkbook in hand, to pay the deductible, but he didn’t reappear for a couple of hours. This delay was because the surgeon had presented his factura in the X-orbitant amount of ¢1.65 million – way in X-cess of the preauthorized amount – alleging there had been complications with the surgery, so he  had to charge X-tra. False! My usual doctor, whom I trust, had been present during the surgery and he told me everything had gone like a charm.

The clinic would not release me until the X-tortionate bill was settled and suggested I use my credit card to pay the difference  between the preauthorized amount and the surgeon’s factura – after all, they said, you can claim with INS and get the difference back from them.

I hate to see the ungodly get away with anything. So Tim, in my name, told the clinic nothing doing – we would not pay a bean more than the amount based on the preauthorization. Tim called the insurance  agency (reputable, remember?), which called IMCS and explained what was happening. IMCS contacted the X-ecrable surgeon, who repeated the lie about complications and got IMCS to agree to pay the inflated amount.

So then I paid the deductible based on the higher amount, and was finally released to go home. End of X-posé.

The moral is: If this happens to you, don’t pay the inflated amount; stand your ground and call your insurance agent.

For more information, contact David Garrett at 2233-2455 or david@insurancecostarica. info. Our purpose is to give the reader a better understanding of insurance in Costa Rica. The opinions and viewpoints expressed are those of the writer and do not necessarily represent the official position of INS.


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