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Health Insurance Claim Form Mexico (Reclamación de Seguro de Gastos Médicos)

Health Insurance Claim Form Mexico (Reclamación de Seguro de Gastos Médicos)

RECLAMACIÓN DE SEGURO DE GASTOS MÉDICOS MAYORES

Health Insurance Claim Form (GMM)

Conforme a la Ley sobre el Contrato de Seguro (LCS) Artículos 184–204

I. DATOS DEL ASEGURADO

Nombre completo: [Insured Name]

RFC: [Insured RFC]

CURP: [Insured CURP]

Fecha de nacimiento: [Date of Birth]

Teléfono: [Insured Phone]

Correo electrónico: [Insured Email]

Domicilio: [Insured Address]

II. DATOS DE LA PÓLIZA DE GASTOS MÉDICOS MAYORES

Aseguradora: [Insurer Name]

Número de póliza: [Policy Number]

Número de certificado: [Certificate Number]

Tipo de reclamación: [Claim Type]

III. DATOS DEL PADECIMIENTO O SINIESTRO MÉDICO

Padecimiento / diagnóstico: [Medical Condition]

Fecha de inicio del padecimiento o accidente: [Onset Date]

Fechas de atención médica: [Treatment Dates]

Hospital o clínica: [Hospital Clinic]

Médico(s) tratante(s): [Treating Physician]

¿Relacionado con padecimiento preexistente?: [Pre-Existing Query]

IV. GASTOS MÉDICOS RECLAMADOS

Total de gastos reclamados: $[Total Expenses] MXN

Desglose de gastos:

[Expense Breakdown]

Todos los gastos están respaldados por los comprobantes fiscales digitales (CFDI) emitidos por los prestadores de servicios médicos conforme a los requisitos del SAT.

V. DATOS BANCARIOS PARA REEMBOLSO

CLABE interbancaria: [Bank CLABE]

Banco: [Bank Name]

Titular de la cuenta: [Insured Name]

VI. FUNDAMENTO LEGAL Y SOLICITUD DE PAGO

Con fundamento en los Artículos 184 al 204 de la Ley sobre el Contrato de Seguro (LCS) y en las condiciones generales de la póliza antes identificada, el asegurado solicita respetuosamente a [Insurer Name] el inicio del trámite de la presente reclamación de gastos médicos mayores y el pago o reembolso de la indemnización correspondiente dentro del plazo de 30 días naturales establecido en el Artículo 71 LCS, contado a partir del momento en que el expediente de reclamación quede completo.

El asegurado declara bajo protesta de decir verdad que los hechos y datos contenidos en la presente reclamación son verídicos, que los comprobantes fiscales aportados son auténticos y corresponden a gastos efectivamente realizados con motivo del padecimiento declarado.

FIRMA DEL ASEGURADO

En [Claim City], a [Claim Date].

[Insured Name]

RFC: [Insured RFC]

Firma: _________________________

Insured Person (Asegurado)

________________

Signature

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What Is a Health Insurance Claim Form Mexico (Reclamación de Seguro de Gastos Médicos)?

A Health Insurance Claim Form Mexico (Reclamación de Seguro de Gastos Médicos Mayores) is a formal written request submitted by the policyholder (asegurado) or their authorised representative to their health insurance company (aseguradora de gastos médicos) seeking payment or reimbursement of covered medical expenses (gastos médicos cubiertos) incurred as a result of a covered medical event (padecimiento o accidente cubierto) — including hospitalisation (hospitalización), surgical procedures (intervenciones quirúrgicas), specialist consultations (consultas con especialistas), diagnostic studies (estudios de diagnóstico), prescription medications (medicamentos), rehabilitation therapy (terapia de rehabilitación), and emergency medical care (atención de urgencias).

In Mexico, health insurance contracts (seguros de gastos médicos mayores — GMM) are governed by the Ley sobre el Contrato de Seguro (LCS) Articles 184 through 204, which establish the specific rules for personal accident and health insurance (seguros de personas) including the insurer's payment obligations, the policyholder's disclosure duties, the prohibition on exclusion of pre-existing conditions for certain benefits after the waiting period (período de espera), and the insurer's duty to pay the indemnification within the statutory period. The Ley de Instituciones de Seguros y de Fianzas (LISF, DOF 4 April 2013) Articles 200 through 210 further regulate the solvency requirements, policy terms standards, and consumer protection obligations of health insurers supervised by the Comisión Nacional de Seguros y Fianzas (CNSF).

Mexican health insurance (seguro de gastos médicos mayores or GMM) is private supplemental insurance that operates in parallel with Mexico's social security health systems. The Instituto Mexicano del Seguro Social (IMSS) provides mandatory healthcare coverage for formal private-sector employees under the Ley del Seguro Social (LSS); the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) covers federal government employees; Pemex, CFE, and SEDENA operate their own employee health schemes. Private GMM insurance covers services not available through or excluded from these public systems — private hospital rooms, elective specialists, procedures at private hospitals (sanatorios privados), international medical evacuations, and access to premium medical networks.

The major health insurance providers in Mexico operating under CNSF supervision include: AXA Salud México, GNP Seguros, Metlife México, Allianz México, Mapfre México, BUPA México, Cigna México, and Seguros BBVA. Each operates under policy terms (condiciones generales) approved by the CNSF, which establish the specific covered events, exclusions (padecimientos excluidos), waiting periods (períodos de espera), deductibles (deducibles), co-insurance percentages (coaseguros), and maximum coverage limits (suma asegurada) applicable to each policyholder's plan.

The NOM-004-SSA3-2012 — Norma Oficial Mexicana on the clinical record (expediente clínico) — is directly relevant to health insurance claims because the medical records that substantiate claims must comply with this standard. Health insurance companies routinely request the complete expediente clínico from the treating hospital or clinic as part of the claims documentation review, and claims supported by non-compliant medical records may be delayed or disputed. The Ley General de Salud (LGS) Articles 51 through 54 establish patient rights (derechos de los pacientes) in Mexico that are relevant to the health insurance claim context — including the right to informed consent (consentimiento informado) for procedures, which may affect pre-authorisation requirements for elective procedures covered by GMM policies.

When Do You Need a Health Insurance Claim Form Mexico (Reclamación de Seguro de Gastos Médicos)?

A Health Insurance Claim Form Mexico is needed whenever a policyholder with a private Seguro de Gastos Medicos Mayores (GMM) incurs covered medical expenses and seeks reimbursement or direct payment from the insurer under the Ley sobre el Contrato de Seguro (LCS) Articles 184 through 204.

The claim form is required following hospitalisation (internamiento hospitalario) in a private hospital or clinic covered by the GMM policy network — whether for emergency admission (hospitalizacion de urgencia) or scheduled surgery (cirugia programada). Most Mexican GMM insurers such as AXA Salud Mexico, GNP Seguros, Metlife Mexico, and Allianz Mexico require pre-authorisation (preautorizacion) for non-emergency scheduled procedures under their policy terms approved by the Comision Nacional de Seguros y Fianzas (CNSF).

The form is needed when a policyholder incurs out-of-pocket medical expenses at a covered provider and seeks reimbursement (reembolso) rather than using the insurer's direct payment (pago directo) network. Reimbursement claims are common when emergency care is received at a hospital outside the insurer's network (hospital fuera de red) or when the policyholder pays costs upfront pending the insurer's processing of the claim.

The claim is required when a policyholder wishes to claim the costs of covered specialist consultations, laboratory tests (analisis clinicos), imaging studies (estudios de imagen — tomografias, resonancias magneticas, ultrasonidos), and prescription medications prescribed in connection with a covered medical condition under the policy's condiciones generales.

A health insurance claim is needed to invoke international coverage (cobertura internacional) of policies that cover medical expenses incurred abroad — these claims typically require additional documentation including foreign-language medical records with certified Spanish translations and may require prior notification to the insurer before receiving care outside Mexico.

Under LCS arts. 184 and 186, the claim must be filed within the policy's notification period — most Mexican GMM policies require notification within 30 to 60 days of the medical event. The insurer then has 30 days to respond to a complete claim under LCS art. 71. The underlying legal action to enforce a denied claim prescribes in 2 years from the date of the medical event under LCS Article 81 — prompt documentation and filing protect the policyholder's rights.

What to Include in Your Health Insurance Claim Form Mexico (Reclamación de Seguro de Gastos Médicos)

A valid Health Insurance Claim Form Mexico under the Ley sobre el Contrato de Seguro Articles 184 through 204 must contain the following essential elements to be accepted and processed by the insurer within the 30-day statutory payment period established by LCS Article 71.

Policyholder and Insured Information: Full legal name, RFC, CURP, date of birth, address, telephone number, and email of the asegurado (insured person claiming the benefit); the insurance policy number (numero de poliza) and certificate number (numero de certificado) for group policies issued by the employer; and the insurer's name (nombre de la aseguradora de GMM) regulated by the Comision Nacional de Seguros y Fianzas (CNSF).

Description of the Medical Event: A clear description of the covered medical condition (padecimiento), accident (accidente), or emergency (urgencia) that gave rise to the medical expenses — including the date of onset or occurrence of the condition (fecha de inicio del padecimiento), the date(s) of medical treatment received, the names and specialties of treating physicians (medicos tratantes), and the names and addresses of hospitals or clinics where treatment was received.

Pre-existing Condition Declaration: Where applicable, confirmation of whether the medical event relates to a condition that was pre-existing (padecimiento preexistente) at policy inception — Mexican GMM policies typically exclude pre-existing conditions for waiting periods of 3 to 24 months under the policy's condiciones generales approved by the CNSF. Accurate disclosure is critical — misrepresentation may void the relevant coverage under LCS Article 8's duty of disclosure (deber de declaracion del riesgo).

Itemised Medical Expenses: A complete list of all covered expenses for which reimbursement or direct payment is claimed — including hospitalisation fees, surgical fees, anaesthesiologist fees, specialist consultation fees, diagnostic study costs, prescription medication costs, and rehabilitation therapy costs. Each item must be supported by the corresponding original invoice (factura original — CFDI) from the medical provider.

Required Medical Documentation: The supporting medical documentation typically includes: the treating physician's clinical summary (resumen clinico) or discharge summary (nota de egreso) in compliance with NOM-004-SSA3-2012; laboratory and imaging study results (resultados de estudios); original invoices (CFDI) and receipts (recibos de honorarios) from all medical providers; the hospital admission and discharge record (hoja de ingreso y egreso hospitalario); and, for surgical claims, the operative report (nota quirurgica).

Bank Account for Reimbursement: The policyholder's bank account details for direct deposit of reimbursement — CLABE interbancaria (18-digit standardised bank code) and bank name. Mexican insurers pay reimbursements by bank transfer under the SPEI (Sistema de Pagos Electronicos Interbancarios) system operated by Banco de Mexico.

Pre-authorisation Requirements: For non-emergency procedures, most Mexican GMM insurers require pre-authorisation (preautorizacion) before the insured undergoes the treatment. The pre-authorisation request must be submitted by the treating physician to the insurer's medical director (director medico) with supporting clinical documentation. Failure to obtain pre-authorisation for non-emergency procedures may result in partial or full denial of the claim under the policy's condiciones generales. Emergency care is exempt from pre-authorisation requirements under LCS Article 192 — the insurer must cover emergency treatment at any hospital regardless of network status when the insured's life or physical integrity is at immediate risk, subject to the applicable deductible and co-insurance.

Dispute Resolution: If the insurer denies the claim or the amount offered is insufficient, the policyholder must first file a written claim with the insurer's Unidad Especializada de Atencion a Usuarios (UNE). If the UNE does not resolve the dispute within five business days or its response is unsatisfactory, a CONDUSEF complaint may be filed within 15 business days under the LPDUSEF.

Forms-legal.com provides this Health Insurance Claim Form Mexico template as a practical guide. For claims involving disputed coverage, denial based on alleged pre-existing condition exclusions under LCS Article 8, delays beyond the 30-day payment period under LCS Article 71, or significant monetary amounts, consulting a Licenciado en Derecho specialised in derecho de seguros or filing a CONDUSEF complaint before the Comision Nacional para la Proteccion y Defensa de los Usuarios de Servicios Financieros are the appropriate next steps.

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APA

Forms Legal. (2026). Health Insurance Claim Form Mexico (Reclamación de Seguro de Gastos Médicos) (Mexico) [Legal document template]. Forms Legal. https://forms-legal.com/mexico/personal/insurance/health-insurance-claim-mexico

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BibTeX
@misc{formslegal-health-insurance-claim-mexico,
  author       = {{Forms Legal}},
  title        = {Health Insurance Claim Form Mexico (Reclamación de Seguro de Gastos Médicos) (Mexico)},
  year         = {2026},
  howpublished = {\url{https://forms-legal.com/mexico/personal/insurance/health-insurance-claim-mexico}},
  note         = {Free legal document template}
}

Frequently Asked Questions

Statute-referenced template — Template last modified June 2026

This template is provided for informational purposes only and does not constitute legal advice. Laws vary by jurisdiction and change over time. Consult a qualified attorney for advice specific to your situation.Full disclaimer

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