Indonesia (EN) 
UAE (EN) 
Vietnam (EN) A member becomes an in-patient when a doctor ‘hospitalises’ them. That is, the doctor formally admits a member to a hospital for treatment and the member stays in hospital accommodation for at least one night. ‘Day-patients’ are similar to ‘in-patients’; day-patients are formally admitted to hospital for treatment, but they don’t stay in hospital accommodation overnight.
Claims
How members make claims in Africa
We’ve been helping people access private healthcare in Africa for 30 years, and we now have members in 30+ countries. Our award-winning claims team have handled all manner of situations, including complex in-patient cases and international medical evacuations at the height of the COVID-19 pandemic.
Definitions
A quick look at the key terms we use on this page
Making a claim for out-patient treatment
Step 1
Member attends medical provider for treatment
If a member needs out-patient treatment, they can seek medical assistance immediately. There is no need for the member to contact us to arrange pre-authorisation.
Member pays the bill
The cost of out-patient treatment is often negligible and some medical providers may not have the means to send invoices internationally. We ask members to settle treatment bills themselves.
Member submits a reimbursement claim
Once the treatment is complete the member submits a reimbursement claim to us, and we’ll settle the money into the member’s bank account.
Common challenges with out-patient treatment in Africa
1/ Cost of treatment
For most out-patient consultations or procedures in Africa, the member’s bill is usually well under US$500. We often see invoices for blood tests that come to a few US dollars. For the medical provider, it’s not administratively efficient to bill the insurance provider directly. Sometimes, providers may not have the payment technology to send invoices domestically, let alone internationally.
Making a claim for in-patient treatment
Step 1
Call us
It’s essential for members to call us prior to undergoing in-patient medical treatment.
We arrange the member’s admission
We confirm the member’s coverage for the proposed treatment. Then we arrange admission at the nearest centre of excellence, issuing the hospital or clinic with a GOP.
We settle bills directly with the hospital
With the GOP already issued, the member doesn’t have to pay anything. We’ll settle all invoices and bills directly with the hospital or clinic.
Common challenges with in-patient treatment in Africa
1/ Network reach
We have pan-African network coverage (5,000+ medical providers through our network and our partners’ networks) to make sure we can provide for all medical eventualities our members might find themselves in on the African content.
In our experience, 80% of members receive treatment in major urban areas. In these locations, our members can access centres of medical excellence through our direct network or through the network of our trusted, long-term partner, CEGA.
To maximise our coverage in the more remote regions of the African content, we also engage with specialist local strategic agents who maintain their own networks. These strategic agents are better known to remote medical facilities, and are best placed to issue GOPs on our behalf to ensure efficient admission for our members.
2/ Hospitals not recognising William Russell as an insurance provider
If a member contacts us prior to arranging their in-patient treatment, there won’t be any issues with the treating hospital recognising William Russell. We’ll contact the most appropriate centre of medical excellence for the member’s condition to place a GOP (or engage CEGA or a local strategic agent on our behalf). The process is seamless and has worked well for our members in Africa for over 30 years.
It’s important to note that Africa is a large content with hundreds of thousands of medical providers, only a small percentage of which are located in urban areas. It’s entirely reasonable that not all medical providers will be aware of William Russell. So if a member contacts a medical provider (particularly one in a remote region) directly to arrange their in-patient treatment without involving us, there may be instances where the claims processes does not run smoothly.
We stress that we have a detailed understanding of medical providers across the Africa continent, bolstered by our relationship with CEGA and strategic local agents. We are best place to make sure that our members are accessing the right medical providers for their treatment, with the right technology, expertise, and standard to ensure the best clinical outcomes. This goal (which is are only goal for members receiving medical treatment) may be compromised if a member arranges in-patient treatment directly with a medical provider.
3/ Contracts with medical providers vs case volume
Typically in Africa, case volume with a hospital is more important than a formal contract with that hospital. With case volume and regular interactions come a good working relationship with a hospital. A contract alone doesn’t necessarily mean a good working relationship.
On one hand, we’ve experienced cases when a hospital has turned away a member seeking in-patient treatment without our involvement, even though there was a contract in place with the hospital.
On the other hand, we’ve happily placed GOPs for our members with hospitals to which we’ve never contracted.
Contracts, and a large formal network, are not always the solution.
4/ Pre-admission and post-admission consultations
Hospitals generally bill the patient directly for such consultations because the cost is negligible.
5/ Members paying cash for in-patient treatment
In 5% of in-patient cases, members pay-and-claim for their treatment. In Southeast Asia or the Middle East, such behaviour would be unthinkable! The cost of in-patient treatment is prohibitively high in those regions. But in Africa, in-patient treatment is often quite affordable to expats.
Pay-and-claim for in-patient treatment is the worse case scenario. We can avoid this from happening if the member contacts us in the first instance; we can then secure their admission with a suitable hospital.
Frequently asked questions about claims
Answers to the most common questions on claims are here, but feel free to get in touch and speak to our team. We’d be glad to help.
Do you have direct billing for in-patient treatment?
Yes. If a member contacts us as soon as they know they need in-patient treatment, we’ll secure their admission at a suitable hospital and we’ll settle any bills directly with the hospital’s billing department.
Do you have direct billing for out-patient treatment?
For most out-patient consultations or procedures in Africa, the member’s bill is usually well under US$500. In fact, we often see invoices for blood tests that come to a few US dollars. For the medical provider, it’s not administratively efficient to bill the insurance provider directly. Sometimes, providers may not have the payment technology to send invoices domestically, let alone internationally.
For this reason, it’s not possible to have an extensive network for direct billing of out-patient treatment. It’s much simpler for the member, the hospital, and for us if the member pays and claims for out-patient treatment.
Does William Russell have a big network in Africa?
We do have a large network, with over 5,000 hospitals and clinics. This includes most hospitals that are popular with expats and wealthy local nationals. We cannot add every hospital to our network. Some (particularly the smaller hospitals in more rural locations) do not have the billing capabilities to join an insurance provider’s network.
If my client needs in-patient medical treatment, what should they do?
In all cases where a member needs in-patient treatment, the member should call us. We’ll check to see whether the proposed treatment is eligible under the member’s plan. If the treatment needs pre-authorisation, we’ll issue it and secure the member’s admission at a suitable hospital.
Does CEGA have multi-lingual speakers?
Yes. CEGA have staff who speak English, Spanish, Mandarin, and Arabic.
Should my client pay-and-claim for in-patient treatment?
No. All members should contact us as soon as they know they need in-patient treatment. This is the best way to secure the member’s efficient admission to hospital.
In a minority of cases, pay-and-claim for in-patient treatment may be the only option. For example, the member might be stuck in a rural location where the only suitable hospitals do not have advanced billing capabilities. In these cases, the member should still call us as early as possible and we can help them to keep the claim as simple as possible.
