Making a claim can be a daunting prospect, and at times you may be incurring a cost that you might not have been aware was covered under your medical policy. To help make the process easier we have created this info page to provide guidance on a general medical claim process, what information is required, and easy access to claims forms. The team at Aynsley and Associates is here to help, so don’t hesitate to reach out at email@example.com or call us on 03 374 9955 and we can personally help you walk through the claim process.
What is a Medical Claim?
Most medical policies will provide cover for private medical and surgical costs, cancer surgeries/treatment (chemotherapy and radiotherapy), joint replacements, major diagnostic tests, and more. Some policies have optional coverages which can provide additional benefits such as specialist cover, GP cover, dental/optical cover, day-to-day benefits, or even non-PHARMAC cover. For peace of mind, it is best to check your policy benefits to ensure you know exactly what you are covered for. Alternatively, if you're not sure about what cover you have, get in touch - we have access to various policy documents and can provide information on what is and isn't covered.
How to Make a Claim
It is best to seek pre-approval for consultations and procedures as this ensures you are covered ahead of time. Pre-approvals generally take up to 1 - 2 working weeks to be reviewed by an insurer when all the adequate information is provided. Once the insurer has all the information they need they will then be able to confirm if your claim is approved and if any excess will be applied. As it can take time for claims to be processed it is recommended to start the claims process as soon as possible. Your insurer may have alternative ways of making a claim, such as completing a form or submitting an application through an online portal/website.
To help your claim proceed as smoothly as possible, make sure you have the following information:
Your Letter Needs to Include:
Symptoms and date they first started
Reason why GP has referred you to a specialist
The type of specialist you are being referred to
Your Letter Needs to Include:
Symptoms and date they first started
Recommended treatment and date of procedure
Incurred or Estimate of Costs
Specialists can provide you with an estimate of costs which may include: doctor fees, hospital costs, anesthetist costs, radiology fees, prosthesis costs, and more.
OR if you have already had the procedure completed, provide an invoice of the costs you have incurred
Completed Medical Insurance Form
Click on your insurer in order to download the appropriate claim form
Common Hold Ups
Insurer Processing Time
Insurers can become overwhelmed due to various factors such as staff illnesses or an influx in pre-approval applications which can lead to an increase in processing time. Due to this, we recommend you get your claim information in to be processed as soon as you are aware of your procedure.
Unfortunately, not everything can be covered. Every medical policy has different benefit levels, definitions, wordings, and exclusions. While we can do our best to interpret policy wordings to determine if something will be covered, ultimately the insurance company assessing the claim will make the final decision, which may be an unsatisfactory result. These can occur for multiple reasons - some common examples include:
Policy Exclusions - these may have been applied when applying for medical cover or is a general exclusion built into the policy.
Standdown Periods - an insurer may place a standdown period before something can be claimed on (e.g. wisdom teeth).
Benefit Limits - you may have already reached a certain benefit limit for the current policy year.
Medically Necessary - an insurer may decline a claim if the procedure isn't deemed medically necessary (e.g. cosmetic surgery such as nose reshaping).
Specialist Consultations - if you don't have specialist cover on your policy (often an additional benefit), most insurers will cover you for specialist consultations only if you end up having a hospitalisation or medical procedure. Cover for these specialist consults can either be 6 or 12 months on either side of the hospitalisation or medical procedure taking place.
Unhappy with your claim outcome? Give us a call on 03 374 9955 or email at firstname.lastname@example.org and we can review your claim with you.
Claims Approved - What Happens Next?
If approved, the insurer will send you a letter of their decision - this includes their approved amount and if any excess will apply. The only outstanding item on the agenda now is who pays the invoices. Most insurance companies will provide you with two options:
Option 1 – Direct Payment
Pass on your outstanding invoice to your insurers once costs are approved and they will pay the invoice accordingly
Make sure to let your medical provider know who is due to pay the bill
Option 2 – Reimbursement
If you ended up paying the invoice(s), then you can seek reimbursement from the insurer. You can pass on the invoice illustrating that the costs have been paid (include a receipt) along with your preferred bank account and the insurer will organize reimbursement of the approved costs.
Your insurer will confirm what excess will be applied when they approve your costs. Normally you will pay your excess directly to the medical provider, or it will be deducted from your reimbursement.
Is my excess per claim or once per policy year?
Every policy is different - your excess may be applied per claimable event or once per policy year. For information on this please refer to your policy document or contact Aynsley and Associates.
What happens if I have an accident?
ACC is the primary insurer for any treatment relating to an accident. If ACC declines your claim, please enclose a copy of the letter from ACC with your claim form. If ACC is paying a part of the claim, the insurer may be able to top this up.
How long will my prior approval be valid for?
These are generally 6 months, however, some policies will allow for 12 months.
Can I change my insurance company?
Changing medical insurers can be risky - if you have had any changes in your health since your policy was first issued, these may be excluded under a new policy. If changing insurers, ensure you leave the current cover in place until you completed the underwriting process and have been offered satisfactory terms.
Can I modify my cover?
You can increase your excess and/or remove additional benefits (such as specialists) at any time. If you want to add benefits and/or reduce your excess, you will need to be underwritten. This is where the insurer will ask questions about your health and may apply exclusions if you have any 'pre-existing conditions'.
Want to Know More?
Feel free to give us a call at 03 374 9955 or email at email@example.com. We are always happy to assist with a claim, answer questions on a policy, or just have a general chat.
If you would like to look further into your insurer, please refer to the links below: