Real claims scenarios
Scenario 1: Pre-Authorization of a Medical Procedure - Direct Payment to Medical Facility
- Client contacted Guardian Claims Department to inform us of a necessary surgery and requested pre-authorization and for the insurance provider to pay the expenses directly to the facility.
- Guardian Claims Department contacted the insurance company to inform them of this and to ask what documents we needed to provide.
- The insurance company replied to Guardian Claims Department with the list of the necessary info to proceed with the pre-authorization of the procedure. This info included medical notes on the condition, the medical order from the doctor, the date and place of the procedure, and a medical fees breakdown (surgeon fees, anesthesiologist fees, assistant surgeon fees).
The client sent all documents that were requested to our Guardian Claims Department, but the expense breakdown was missing. We requested that from the client again.
- Client sent us the expense breakdown.
- The insurance company requested further information (MRI and a medical report including info of the beginning of the medical issue, including date of first diagnosis, etc.).
Client submitted MRI and medical report, but it was missing a doctor’s signature and some other information, so we requested that from the client
Client sent the complete medical report with the doctor’s signature and missing info
With all information submitted, the insurance company sent the Guarantee of Payment Letter.
The client had successful surgery, which was paid directly to the facility by the insurance company.
Total amount paid directly to hospital: $35,935.82 USD
Total claim processing time: 33 days
Scenario 2: Reimbursement after meeting deductible
Guardian Claims Department received the medical report, doctor’s prescription, and payment receipt from the client.
Guardian Claims Department sent the documents to the insurance company.
The insurance company replied confirming receipt of the documents.
The insurance company reimbursed the prescription medication expenses in full to the client.
Total Amount Reimbursed to Client: $7,628 MXN ($382 USD)
Total claim processing time: 33 days
Scenario 3: Applying Expenses Toward the Annual Deductible
- Client suffered a minor accident and sent Guardian Claims Department the necessary documents, including payment receipts, itemized bills and medical records.
- Guardian Claims Department sent that documentation to the insurance company.
The insurance company confirmed receipt of the documents.
The insurance company notified Guardian Claims Department that they are missing the hospital intake form. Guardian Claims Department contacted the client regarding this.
Client sent Guardian Claims Department the intake form, which was then forwarded to the insurance company.
The insurance company confirmed receipt of the intake form.
Claim is processed and applied towards the client deductible.
Total Amount Applied Towards Annual Deductible: $2,867 USD
Total claim processing time: 26 days
Scenario 1: Collision insured at fault.
- The insured contacted Guardian Claims Department. Informed of having an accident with a bus.
- Guardian Claims department called the insured and requested a description of the event, his location, and other required information to proceed with making the report to the insurance company
Guardian Claims department calls the insurance to inform them of the insured’s accident. The insurance company takes the information and creates the report number.
The insurance company sends an adjuster to the insured location.
Adjuster arrived at the insured location.
Guardian claims department contacts the insured to ask about the resolution to his accident. Since the insured was at fault the adjuster gave a pass to the third party for his repairs and well to our insured.
Insured visits Guardian insurance office and confirms having his car repaired without issues.
Total time for an adjuster to arrive since the report was made: 35 min
Scenario 2: Collision Insured affected.
Insured contacts the Guardian Claims department through WhatsApp mentioning he was just in an accident.
The insurance company sends an adjuster to the insured location.
Adjuster arrived at the insured location.
Adjuster arrives at the insured location.
Adjuster makes an agreement with the third party which had to pay the costs of damages. The Insured receives an admission note for his vehicle to be paid without a deductible.
Insured confirmed his vehicle had been repaired without issues.
Total time for an adjuster to arrive since the report was made: 35 min