By Victoria Schmidt
Editor’s Note: Victoria Schmidt and her husband Tom came on a Focus on Mexico program in March 2007. They are now permanent lakeside residents, and Victoria has not only become a member of the excellent Lakeside Writer’s Group, but a regular columnist for the Ojo del Lago, one of the English-speaking publications in the Lake Chapala area.
“I have insurance back home, but it doesn’t cover my expenses in Mexico” is an oft-repeated phrase here at Lakeside. But we recently found that this isn’t always the case. It depends upon your carrier.
I am not an insurance agent, nor am I an expert in insurance. But recently my husband had brain surgery in Guadalajara, and his USA insurance carrier covered all but $500 USD. The hospitalization, medical tests, labs, surgery, intensive care, and doctor’s fees were all covered. In addition, the follow-up care was also covered. Many people are astonished to learn that this was the case. They may be further surprised to learn that they, too, are most likely covered.
Although I cannot speak for Canadians, many Americans living here at Lakeside have Medicare as their primary provider. Most Americans found that Medicare only covered 80% of their stateside medical expenses, and chose to expand their coverage by purchasing additional insurance from another carrier. Additional insurance is called “secondary” coverage due to a law that requires Medicare be charged first for medical costs. So Medicare rules of coverage apply. After Medicare processes the charges, then additional carriers, if any, are charged. This process is called “coordination of coverage.” When Americans cross the border, Medicare ignores you. They cover no foreign medical expenses. But this doesn’t mean you don’t have any coverage. When Medicare coverage doesn’t apply, the secondary provider shifts positions and becomes your primary insurance. Now their rules apply. And your secondary carrier may have provisions in your policy that will protect you while you are outside of the United States.
When purchasing health insurance in the United States, a “Certificate of Coverage” is issued along with the policy. This is one of those valuable documents no one ever takes the time to read because it is full of legalese and often difficult to comprehend. A call to the customer service department can clarify some of these nearly incomprehensible clauses. One clause that was clarified for us was “emergency coverage.” We were told that should an emergency befall us while within the borders of a foreign country, our insurance company would cover the expenses.
When I learned that “emergency” expenses would be covered, I expected they meant one of those paramedic-ambulance-ER type of scenarios. It never crossed my mind that it could mean also mean admission to the hospital to run tests, which is how our adventure began. When test results found blood on both sides of my husband’s brain, they performed emergency surgery. The hospital staff and the doctors were professional and incredibly caring, and I am happy to report that my husband has made a complete recovery.
There are caveats, of course. For instance, who gets to define what is an “emergency” that the insurance company will accept? In our case, our local clinic doctor here at Lakeside, knew exactly whose definition they would accept: his. We were sent to a hospital that works with American insurance carriers, and one of our doctors was in contact with our insurance company daily. Our carrier assigned a case manager, a nurse who kept close track of the treatment my husband was receiving, and also pre-approved the follow-up care. This was a completely painless process. As in hospitalizations within the United States, the hospital worked with our insurance company and there was no paperwork for us. We did have to file for reimbursement for the follow-up care, but that was just one simple form and photocopies of our receipts.
The important thing to keep in mind when dealing with any insurance carrier is to understand your coverage. Don’t make assumptions, and don’t accept “no” for an answer. Saying “no” to the insured is often their first inclination and accepting “no” as an answer may be your first inclination, but by knowing your coverage and asking questions, you may be pleasantly surprised by the answers.