Personal Lines Claims
Disability Claim Forms
Medical Expense Reimbursement Forms
Life and Accident Forms
Disability Claim Forms
Once the medical expense has been incurred or the hospitalization has ended, you must submit to ASSA Compañía de Seguros the Medical Expense Claim Notification form, together with the required documents according to your expense.
The deadline for submitting your claim is 90 days from the date it occurred.
Required Documents
Insured Party
- Medical Expense Claim Form duly completed and signed by the Insured Party and the Treating Physician.
- Original receipts and proof of payment with the proper detail of the services received and individual costs
- Medical orders for laboratory tests, X-rays or any other procedure
- Prescriptions for medications (in cases where long-term medications are prescribed, you must have the diagnosis and information on the medication and its dosage, which must be renewed every 6 months).
Important: In the event of a major case in which more information about the medical care provided is required, you must submit a medical report with the relevant notes on the case.
Medical Expense Reimbursement Forms
Once the medical expense has been incurred or the hospitalization has ended, you must submit to ASSA Compañía de Seguros the Medical Expense Claim Notification form, together with the required documents according to your expense.
The deadline for submitting your claim is 90 days from the date it occurred.
Required Documents
Insured Party
- Medical Expense Claim Form duly completed and signed by the Insured Party and the Treating Physician.
- Original receipts and proof of payment with the proper detail of the services received and individual costs
- Medical orders for laboratory tests, X-rays or any other procedure
- Prescriptions for medications (in cases where long-term medications are prescribed, you must have the diagnosis and information on the medication and its dosage, which must be renewed every 6 months).
Important: In the event of a major case in which more information about the medical care provided is required, you must submit a medical report with the relevant notes on the case.
Pre-Authorizations
Pre-Authorizations are required in the event that the Primary Insured or an Insured Family Member needs to undergo a special procedure such as:
- Magnetic Resonance Imaging
- Cardiac Catheterization
- MIBI
- Computed Axial Tomography
- Amniocentesis
- Other special tests
The Insured Party must submit a report from the Treating Physician detailing the diagnosis and clinical picture so that coverage for such tests or procedures can be evaluated.
To obtain a pre-authorization, you can write to us at our email: [email protected].
Required Documents
- Complete the Benefits Pre-Authorization form .
- Medical Order.
- Treating Physician’s report describing the clinical picture and diagnosis, and the required procedures.
Health Claim Reimbursement - ACH
Our company guarantees that you can receive reimbursement of your medical expenses in the bank account you indicate, as long as the information in the documents is complete.
To enjoy this benefit, simply complete the ACH payment form for individuals o ACH payment form for legal entities, attach a copy of your ID card and submit it through your insurance broker or at any of our branches in our Customer Service Department.
Once your health claim has been processed, we will send to your email address the payment details and the processing sheet for the amount we are depositing into your account.
For any questions, please contact our call center at 2276-9000 Ext 1284.