Health insurance: networks, cover and treatment costs

Hospitalisation, outpatient care and other covers

Hospitalisation and outpatient care address different needs: an admission is not the same as a consultation or test without admission. Dental care, maternity, serious illness and dental options may have their own rules and limits.

Start with the covers you want to consider and check what each includes. A high overall limit does not mean every treatment has that same limit; sub-limits or specific conditions may apply.

How do provider networks and reimbursement work?

Within a contracted provider network, access follows the terms agreed between the product and providers. Check that the hospital, clinic and specialty you want are included, together with the co-payment due for each use.

Where out-of-network reimbursement is available, check the percentage reimbursed, limits, required documents and submission deadlines. Some products combine both models. The existence of a network does not mean every consultation or treatment at a provider is covered.

Premium, co-payment, excess and cover limit

The premium is the price of the insurance. A co-payment is the amount the insured person pays for a covered use; an excess may require a further contribution, depending on the policy. The cover limit caps the insurer’s benefit for the specified cover and period.

To compare quotations, ask for the terms relating to the care most relevant to you: consultations, tests, hospitalisation or other services. Compare the annual insurance cost alongside treatment costs and limits, rather than looking only at the monthly premium.

Waiting periods, exclusions and authorisations

A waiting period is a period during which a cover cannot yet be used under the policy terms. Different covers may have different waiting periods. Also check exclusions and treatments requiring prior authorisation.

The assessment of illnesses or circumstances predating the policy depends on the information requested and the acceptance terms. Do not assume they are covered. The initial form does not collect diagnoses, tests or clinical reports.

What to check before changing insurance

A new policy may have new waiting periods and acceptance terms, even with the same insurer. Clarify continuity of protection before cancelling the current policy.

For example, if you want to continue using a particular clinic, check the specific product’s network and the terms of the cover you need. The insurer’s name alone does not confirm identical networks and terms.

Preparing your request with RMACHADO GROUP

Enter identification and contact details in the form and select the covers to be considered. The intermediary can clarify household composition and other information needed for the quotation through the appropriate procedure.

Review your details before submitting. The request starts the assessment; it does not amount to acceptance by the insurer or authorise treatment under a policy.

A question to clarify before deciding

How do the network, reimbursement and sub-limits work for the care you want?

The product examples mentioned in the frequently asked questions illustrate possible differences. They are not an offer from RMACHADO and do not show that a particular cover is included in your policy. Availability, acceptance and terms must be confirmed in the specific quotation.

Preparing a request for several people

State how many people you want to insure and each person’s NIF and date of birth. These details allow the assessment to be organised for each person, alongside the policyholder’s contact details and intended covers. Confirm that you may provide the details and make the privacy information available to those concerned. Do not include clinical information in the initial request.

What to compare in a quotation

Use these questions to clarify differences that could affect your decision.

Frequently asked questions