Have you taken out health insurance and have problems with the company already started? Do not worry! If you want to file a claim, in this guide we explain all the steps to follow so that the process does not become a nightmare.
Over the years, there are many reasons that can generate conflict with your insurance company and your health policy.
In fact, saving by hiring your health insurance or finding the best company does not guarantee that you will not have problems throughout the duration of your policy.
The non – payment of compensation, sudden changes in the contract, undue charges … the list of problems that are usually generated with health insurers are endless.
In this sense, it is best to file a claim with your company. But, how to carry out this procedure? What are the steps to follow to avoid making mistakes and for your application to be effective?
Let’s review each stage of the process in detail:
Define the reason for your claim
Before submitting any type of claim to your health insurer, you need to be clear about the reasons why you want to carry out this procedure.
It is important that you can determine the main existing problem and whether or not it comes from a failure on the part of the company.
On some occasions, complaints are unleashed after poor attention by the health professions or medical center officials and, in light of this, the claims should not be directed to your insurer.
Now, if you have more than one complaint, you should sort them by importance. When you file the claim, it will be easier for you to explain the problem.
Review the conditions of your contract
The second step before filing a claim is to check the terms and conditions of your health insurance contract.
In a large percentage of cases, the claims are due to a misunderstanding of the contract by the client or misinformation of what is stipulated at the beginning of the policy.
If you realize that, in effect, the company is not incurring any type of failure because everything is contemplated in the document, you will be able to analyze the possibility of changing your insurance or modifying its conditions.
Submit your claim to your company’s SAC
If you are sure that the problems with your health insurer are due to a failure, a breach of contract, or poor management, the first thing you should do is file a claim with the company’s Customer Service (SAC).
For this, you should contact your insurer and inform them of your decision to file a claim. They will explain the different ways available to carry out this management.
It is important that you know that your insurer has the obligation to resolve your claim within a period of no more than two months from the moment it is submitted.
Once the company has resolved your claim, it must notify you of its decision within 10 days after it is made.
Defender of the Insured
It may happen that your insurance company has a Defender of the Insured and that, therefore, you should not contact the SAC.
Your contract stipulates the path you must follow in case of problems or if you want to file a claim.
It is important that you know that each insurer has an Ombudsman, however, he works independently from the company.
In order to file a claim with him, you must send it by certified mail or by any other system that allows you to obtain proof of shipment.
The claim must contain your personal data, the policy data, and the reasons for this. Remember that by sending the document to the Insured’s Ombudsman you will not be able to manage another claim by any other means.
Do not forget to attach all the documents that can substantiate your complaint and serve as evidence for a later resolution.
The Ombudsman has a maximum period of 2 months to declare a sentence and 10 days to send you his answer.
In all cases, the insurer has the obligation to assume the verdict. However, the insured is free to take advantage of the solution or not.
Commissioner for the Defense of the Insured and the Participant of Pension Plans
In case you do not want to accept the resolution of the SAC or the Defender of the Insured, you can contact the General Directorate of Insurance and Pension Funds.
This body has a new figure dedicated to helping users who have conflicts with their insurers. It is the Commissioner for the Defense of the Insured and the Participant of Pension Plans.
To try to resolve your case and find a solution that suits you, the Commissioner will advise you throughout the claim process and will process your complaints and inquiries.
In this way, the Commissioner has a period of 6 months to answer and grant a verdict, however, the insurer has no obligation to comply with the ruling.
Given this, and in case you do not agree with the possibilities proposed by the previous instances, you still have other means of claim: the arbitration route and, ultimately, the judicial route.
Resort to arbitration
Trying to find a solution to your problem through some extrajudicial resolution system can be quite advantageous if you consider that you will not have to pay a euro to make your claim valid.
However, you must remember that to access this system you must have the acceptance of the claimed company. That is, the two parties must be willing to resolve the conflict.
If you are interested in going this way, you will only have to submit a request for arbitration in writing to one of the following organizations:
- Consumer Information Office of your Community.
- Associations of consumers and users adhered to the arbitration system.
- Regional Consumer Arbitration Board.
The last option: the judicial route
If you tried by all means but none of the other options resolved the conflict that you have with your health insurer, the only option you can resort to is the judicial process.
It depends on the type of damage suffered, there are two types of claims to make through the courts:
Claim for property damage
In this case, you must file the claim in the Court of First Instance within the year following the claim.
If you do not agree with the sentence handed down by said Court, you must go to the Provincial Court within three days.
Claim for claims with injuries
In this case, you must file the complaint with the Investigating Court within 60 calendar days from the date of the incident.
If you do not agree with the resolution, you can appeal to the Provincial Court within 24 hours.