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Visitors Health Insurance USA - Claims Procedure FAQ
Scheduled benefit plan: The insurance company has a set limit for each type of treatment/visit, as clearly mentioned in the brochure and the policy. The insurance company will pay the maximum according to the schedule and anything beyond that is your responsibility, e.g., Inbound USA and Inbound Immigrant from Seven Corners. Visitors Care from IMG.
Per policy period coverage plan: After you pay the deductible for covered expenses, the insurance company in most cases pays 80% for the first $5,000 of covered expenses and you will pay the remaining 20%. After $5,000, the insurance company will pay 100% up to the policy maximum limit for all covered expenses. The policy maximum limit is for the lifetime of the policy. E.g., your deductible is $250, maximum coverage is $50,000 and if your covered expense is $14,000, you would first pay the $250 deductible, then you will pay 20% of the first $5,000 which is $1,000. Thus you would end up paying $1,250 and the remaining $12,750 would be paid by the insurance company, for that covered illness/accident. But if your covered expense is $1,400 instead, you pay the $250 deductible, then 20% of $1150, which is $230. In this case, you would end up paying $480 and the insurance company would pay the remaining, $920; e.g. Patriot America from IMG. Atlas America from HCC Medical Insurance Services (HCCMIS). Diplomat America from Global Underwriters and Liaison International from Seven Corners.
Per incident coverage plan: After you pay the deductible once, the plan pays 80% for the first $5,000 of covered expenses per incident and you will pay remaining 20% per incident. After $5,000, the insurance company will pay 100% up to the policy maximum limit for all covered expenses. The policy maximum limit is per incident. E.g., your deductible is $250, maximum coverage is $50,000, and if your covered expense is $14,000, you would first pay the $250 deductible, then you will pay 20% of the first $5,000 which is $1,000. Thus you would end up paying $1,250 and the remaining $12,750 would be paid by the insurance company for that covered illness/accident. If you get sick or injured again and if your covered expense is $15,000, you will not have to pay the deductible again in the same policy period. The insurance company will pay 80% for the first $5,000 in expenses, you will pay 20% ($1,000). Thus you would end up paying $1,000 and the rest of the $14,000 would be paid by the insurance company, for that covered illness/accident;e.g., Visit USA from Travel Insurance Services.
Q: Could you please give an example of how doctor's office visits are paid in fixed coverage plans?
A: Fixed coverage plans pay a fixed amount for every procedure and you have to pay the difference, no matter how high it is.
The deductible is the amount you have to pay first before the plan pays anything at all. The deductible is applied only towards the eligible expenses.
The following are 2 examples that will help you clarify the most frequently asked situation about doctor's office visits. Lets assume that a doctor's office visit is covered at $55/visit and X-rays are covered up to $400 and you have taken a $50 deductible.
Let's assume you visit the doctor's office several times and every time you visit the doctor, he charges you $80 for the visit. Also assume that you are not using any other medical services. As the plan pays only $55/visit, you always have to pay the difference of $25 from your pocket in this case. Again, the insurance company is only concerned about the first $55/visit.
When you visit the doctor for the first time, the insurance company is supposed to pay you $55, you have $50 towards the unsatisfied deductible. Therefore, that $55 goes towards the $50 deductible. That means, the insurance company will pay $5.
When you visit the doctor for the second time, the insurance company is supposed to pay you $55 and you don't have any unsatisfied deductible. Therefore, the plan pays $55.
For all subsequent visits, up to the covered number of visits, it will continue to pay $55/visit.
Let's assume that you visit the doctor's office several times and get one X-ray taken.
When you visit the doctor for the first time, the insurance company is supposed to pay you $55, you have $50 towards unsatisfied deductible. Therefore, that $55 goes towards the $50 deductible. That means, the insurance company will pay $5.
The doctor orders X-rays when you visit for the first time and it costs you $150 for the X-ray. The insurance company will pay all $150 as you have completely satisfied your deductible.
For all subsequent visits, up to all covered number of visits, it will continue to pay $55/visit.
Q: I went to a doctor that did not accept the insurance card and didn't bill the insurance company directly. How do I make a claim?
A: Taking an appointment for any ailment is a time consuming process, hence many hospitals provide an emergency room facility. There are also many urgent care centers around. These are quick medical care services provided by almost all medical centers.
Emergency services are those services required as a result of unforeseen injuries or an acute illness, for which a delay in treatment would result in a permanent physical impairment, or loss of life. Such as heart attacks, strokes, poisoning, sudden inability to breathe etc.
On the other hand, urgent care includes less serious medical conditions which require immediate attention. Such as fever, fractured bone, any cuts which require immediate attention, etc.
** Note: Always make sure from your insurance company as to what situations are treated as urgent and emergency. If possible, it is better to contact your primary care physician in an urgent situation and arrange for your urgent care.
Q: I see that many plans cover everywhere outside the home country, including during travel also. Will your insurance company have a doctor in flight if they get sick in flight?
Q: Do I have to inform the insurance company before visiting the doctor's office or going to the urgent care?
A: No. In most plans, you need to inform the insurance company (called pre-notification or pre-certification) only for major things like hospitalization, surgery, MRI etc.
Q: Whom do I have to make the payment for my out of pocket responsibility (such as deductible, coinsurance or any other non-covered expenses)?
A: You always pay only the insurance premium to the insurance company. When you use any medical services, you owe the money to that service provider. Insurance helps you pay some of those expenses. The remaining amount is your responsibility to the provider. Therefore, you would pay all of the out of pocket expenses directly to the provider (doctor, hospital, urgent care etc.) and not the insurance company.
Q: Do I have to make the payment for my out of pocket responsibility upfront or later after the insurance company has already processed the claim?
A: That depends upon the provider, irrespective of the insurance plan you purchase. Some providers may ask for your payment portion upfront and while others may bill the insurance company first and then bill you later for the remainder.
E.g., if your deductible is $1,000 which you have not yet met, and if you visit a doctor who is going to charge you $140, and when they call the insurance company to verify the benefits and find out the facts, they may want you make the entire payment upfront because they know they are not going to get anything from the insurance company. However, that may not always happen. In that case, you can pay that money upfront and file a claim with the insurance company even though you know that you are not going to be reimbursed for the expenses that fall under the deductible. However, by filing a claim form in that case, you are letting the insurance company know that you have incurred certain eligible expenses. That helps in case you have a bigger claim later because that way, the insurance company would not deduct your deductible once again.
A: No, the deductible amount is your responsibility and you never get it reimbursed from the insurance company. You always have to pay that amount out of your pocket.
Disclaimer: The information within this article is intended as a broad summary of benefits and services and is meant for informational purposes only. The information does not describe all scenarios, coverages or exclusions of any insurance plan. The benefits and services of an insurance plan are subject to change. This is not your policy/certificate of insurance. If there is any discrepancy between the information in this article and the language of your policy/certificate wording, the language of the policy/certificate wording will prevail.