plan 16 medical plan

This is an extract. Please read the entire policy to get the full picture (spanish version only). Following are the coverages available. Within certain rules, you can select the coverages you need and pay for the ones you get.

I.N.S. “PLAN 16” MEDICAL INSURANCE POLICY.
Extract

WHAT DOES THE POLICY PAY FOR?Expenses due to sickness, accident, or childbirth – up to C.10 million per year. Outpatient services up to 10% of the insured amount. Hospitalization, surgery, pre and post operative care, private room, food, support systems, intensive care, rehabilitation, ambulances, home care, therapy, medication, etc. Death, 50% of insured amount is paid to named beneficiary.

WHAT DOES IT EXCLUDE?   Pre existing conditions. Non-prescribed expenses. AIDS. VD. Medical expenses as a result of cataclysmic events, fighting except in self defense, tournament sports, martial arts and other dangerous activities.  Accidents when under the influence of alcohol or drugs. Mental or nervous disorders. Checkups. Allergies. Stress. Plastic surgery. Only accident‑related eyeglasses, dentists' bills or reconstructive surgery are paid.  Some ailments have a 12 month moratorium during which claims are not allowed. (e.g. glaucoma, cataracts, ENT, women's reproductive organs, breasts, asthma, hernias, pregnancy, prostates, stones, osteoporosis)

HOW MUCH DOES IT COST?Policy goes with the calendar year. INS raises premiums yearly to compensate for inflation and devaluation. Premiums depend on age and sex of insured. Cost of renewal may increase if there is a high claims/premium ratio.

Group policies for companies average 43 less – minimum 10 employees on payroll.

HOW DOES THE POLICY WORK?In case of outpatient services, (hospitalization not needed) you must pay and later submit an INS claim form signed by you and your main doctor, attaching original receipts and corresponding prescriptions. Your Agent will push your claim through INS, which usually pays after 3-6 weeks, based on usual and customary prices. If you require hospitalization or costly tests, a week before, ask your hospital or clinic to obtain a “preauthorization” from INS, which will negotiate a price with the care giver. When released from hospital, you show your insurance card and pay only the deductible. If you didn’t get the “preauthorization” you must pay the entire bill and make a claim as described above. 

DEDUCTIBLES? Care providers are classified in A, B or C. If you go to an A provider, INS will pay 80% of usual and customary prices; B providers, INS pays 75%; C providers, 70%.   CIMA is classified A.   Clínica Bíblica is B.

WHERE DOES THE POLICY APPLY?  Although the policy says it gives worldwide coverage, from a practical standpoint it is of limited value outside Costa Rica.                                              

 Rev.05/10