Expat Health Insurance in Ecuador: The Complete Guide

One of the key considerations of expats moving to Ecuador is health insurance and the quality of healthcare. And, rightly so. This can be especially true for those coming from the US where the price of healthcare continues to soar, making it unaffordable for many retirees to continue to live there. 

This guide provides all of the information you need to make an informed, unbiased decision on what type of Ecuadorian health insurance is best suited to your circumstances. 

What is the cost of health insurance?

I’ve included several plans that were recommended to me by my broker below. These plans are obviously not exhaustive, but I think they cover the most common scenarios and provide a good ballpark of expected costs, coverage amounts and deductibles. 

Low cost of healthcare (even without insurance)

Healthcare costs in Ecuador are generally a fraction of what you’d pay in the US. Many procedures come in at around 15-20% of what you’d pay in the US. The low cost of healthcare is a key contributor to the overall low cost of living in Ecuador, which can be a core reason why expats decide to call Ecuador home. 

The low cost of healthcare actually opens up the option of self-insuring for the small things such as the occasional visit to the doctor. But, if you take this path, I’d still recommend having insurance to cover anything major as these fees can still add up and put you under significant financial stress. 

How much do medical consultations cost? 

Without insurance, you can expect to pay around $30-40 for a consultation with a general practitioner and $40-$50 for a specialist. Often, a quick follow-up visit (to discuss results etc) will be free. 

Dental care is also great value, with the cost of a filling generally around $30-$40, and a basic cleaning around $30. 

Prices tend to be highest in the larger cities, but you also have a lot more options. 

Quality of healthcare

This can be a tricky one to answer and you should be skeptical of any publication that builds Ecuador up as some type of health care utopia. It simply isn’t. Like any developing country that offers universal health care, there are strains on the public health system (IESS) that can affect you if you go down this path. 

I’ve tried to use some health care rankings to provide some level of objectivity when comparing how Ecuador performs against other countries, but I found so much conflicting information that it defeats the purpose. Some have Ecuador in the top 20, others have it struggling below the top 50. 

Numbeo currently has Ecuador ranked at 31 (in 2021), one place behind the US at 30. This is self-reported data, so it also has its limitations. Another popular ranking system is Bloomberg’s Health Care Efficiency, which as of 2020, has Ecuador slipping 6 places to rank 47 (US is ranked 55). 

Whilst tempting, it’s also difficult to base your decision on first-hand, anecdotal data. I’ve seen many first-hand reports from expats that really praise the quality and attentiveness of healthcare in Ecuador. But, I’ve also seen some negative (I also have some of my own I can share). I can say the positive stories substantially outweigh the negative. It can be easy to hear one emotional story and then paint the whole health care system accordingly. 

My personal opinion is that the private healthcare system in Ecuador is high quality and great value. The public health care system still has high-quality care, but it doesn’t allow for the flexibility that I desire. 

High levels of training

Ecuadorian doctors are generally highly trained, with many opting to obtain at least part of their education overseas. This has generally been my experience too, where the knowledge and care of the majority of healthcare professionals I’ve seen here (mainly in Quito & Cuenca) left me feeling like I was in safe hands.

Doctors earn a good salary in Ecuador, but it certainly isn’t as lucrative as in some developed countries. This not only translates to affordable consultations, it also means your doctor’s intentions are more likely to be based on good health outcomes for you and less likely to be tainted by financial reward. 

Equipment

The quality and freshness of equipment ranges from state of the art to almost non-existent. The newer, private hospitals in big cities have high-quality, new equipment. Whereas small, public clinics are likely to be using very dated machines & equipment.

Our current gynecologist mostly uses a very modern ultrasound scanner, but they also pull out an ancient doppler that looks like a VHS machine from the 80’s. If it still works well, Ecuadorians are less likely to replace something just because it’s older.

Hospital buildings

The design and aesthetics of hospitals and clinics are not high priorities. This can be a little off-putting for expats that are used to super expensive, modern, well-designed hospitals. But, I’ve learnt not to judge a hospital here in Ecuador by its cover. 

Some doctors, but not all, speak English

You will find that doctors in Ecuador have a higher chance of speaking English compared with the general public – especially if they’ve studied overseas. But, you should not assume that your doctor will speak fluent English. That said, they will most likely understand many English medical words because these are generally favored by the medical community and not translated. 

Do I need health insurance to enter Ecuador? 

The government has flipped flopped on this a few times. Right now (Mar 2022), you do NOT need health or travel insurance to enter Ecuador. 

What about the Galapagos? 

You do need health (or a travel insurance plan) to visit the Galapagos. Whilst part of Ecuador, the Galapagos have their own rules and regulations that can sometimes be quite different to the mainland. 

Do I need health insurance before I can get a residency visa? 

Maybe. This requirement currently depends on the type of visa you’re applying for.

Rentista & Retirement Residency Visas

You’ll require proof of health insurance when you submit your visa application. This change came into effect on March 10, 2022.

Other Residency Visas

For all other common residency visas (Professional, Investor etc), you won’t require health insurance as part of your visa application, but you’ll need it before you can apply for your Ecuadorian identity card (cedula) – more on this below. We’ve previously covered Ecuador residency visas & recent visa changes (2021 & 2022) in detail.

Health vs travel insurance

We’re predominantly covering domestic health insurance available in Ecuador in this article. If you’re a foreign resident only visiting for a short period of time, then you’ll most likely just want to stick with the travel insurance you’ve purchased from outside of Ecuador. 

Note, some Ecuadorian health insurance plans also offer a limited amount of travel insurance which can be a great value-add. 

Public (IESS) vs private health insurance

Ecuador has two distinct healthcare systems. The public healthcare system (IESS) is based on universal health care models – similar to Medicare in the US. And, the private health care system competes with the public system, helping to keep the costs low. 

A recent trend that might sound a little weird at first, but can be effective in some circumstances, is to combine both public and private cover. 

IESS

IESS Pros

• Cheap (approx $70 per month)
• No cost. No deductible or copayment. Everything is essentially free once you’ve paid to be in the IESS system.
• 3 month waiting period on pre-existing conditions

IESS Cons

• Need to use IESS network.
• No choice in doctors or facilities
• System can be difficult to navigate (consider a medical facilitator if this is your first time)
• No choice in pharmacies. The IESS pharmacy can run out of medicines, meaning you’ll need to pay out of pocket, wait or go without.
• Some treatments will not be available due to a lack of facilities & doctors
• Facilities are not as modern or well-funded as the private hospitals

The current public health insurance system was formed in 2008 when the constitution was re-written, and for the first time recognized health care as a human right.

The Instituto Ecuatoriano de Seguridad Social (Ecuadorian Institute of Social Security), or IESS system has come under pressure recently, with the COVID pandemic adding even more strain to a system that could definitely use more government funding. 

If the IESS hospitals are full, they may opt to send you to a private clinic or hospital. But, this needs to be organized by IESS beforehand. They won’t reimburse you if you decide to use a non-public hospital. 

Whilst you are covered for emergency care straight away, you’ll need to wait 3 months before you’re eligible for many benefits. 

How much is the IESS monthly premium? 

Public care with IESS can either be mandatory through your Ecuadorian employer, or voluntary. If you don’t work for an Ecuadorian employer, then you’ll want to apply for the voluntary contribution. Many expats use the basic minimum salary of $400 as their declared income, which equates to a monthly premium of around $70 payable to IESS (see screenshot below)

Private Insurance

Pros

• Modern hospitals and equipment
• Flexibility to choose your hospital & doctors
• Many plans with varying premiums & deductibles to choose from
• No waiting period for emergency medical care

Cons

• Can be more expensive than IESS
• Pre-existing conditions only covered after 2 years, even then coverage may be limited

Ecuador has around 30 private health insurance companies to choose from. Some of these are part of bigger international health insurance companies, whilst others only operate within Ecuador. 

They are all regulated by the Superintendencia de Companias, which also acts as an adjudicator should you run into any problems. 

Health insurance for cedula

Depending on the type of residency visa you’re applying for, you may not require health insurance as part of your application. But, you’ll definitely need it before they’ll give you a cedula. 

The catch? You need your cedula before you can obtain insurance via IESS, leaving private insurance as your only option. 

Some opt for the most basic cover they can find simply to fulfill this requirement and obtain their cedula. This can be a good option if your preference is to obtain IESS as soon as possible.

But, if you actually want to use it, then I’d suggest taking a little more time to choose the plan that works best for you in the long run rather than having to go through the process twice (once for cedula, once when looking for ‘real’ insurance). 

If healthcare matters, choose your city carefully

I’ve witnessed a very strong trend amongst retired expats that choose to base their retirement location primarily on access to quality healthcare. And I completely get it as I’d most likely do the same. 

If you’re also in this boat, you need to know that this will put significant limitations on the towns and cities within Ecuador that you can comfortably retire in. Notably, those that want to live by the sea generally choose to live near Manta or Guayaquil, and those that want to live in the mountains choose Cuenca or Quito. 

This is not to say other areas are not worthwhile checking out, but I suggest paying particular attention to how close you’ll be to a major hospital. This can literally end up being a life or death choice for any medical emergencies. 

How are monthly premiums calculated?

There are various factors that affect the monthly price you’ll pay for the premium, including: 

Age

Premiums increase as you age.  Unfortunately, the plans generally don’t lock in your age at the time of purchase, so you may pay more as you get older. 

Sex

Females can sometimes pay more than males as they’ve been deemed to be more at risk. Maternity cover in particular will push up your premium significantly.

Location

Private insurance companies generally divide Ecuador into 3 different locations; Austro, Costa and the Sierra which can affect the overall price of the contract. 

Pre-existing conditions

Finding a quality plan that covers pre-existing conditions (even after the 2 year waiting period) can be difficult and will most likely push the price up.

Amount of cover

A higher amount of cover per incident will generally equal a higher monthly premium. 

Smoking habits

You may pay more if you’re a smoker. 

Travel insurance

Some of the more comprehensive plans include travel insurance. If you don’t need travel insurance, then choosing a plan that doesn’t include this may provide better value for you. 

We provide some example plans & pricing in the table above.

What about pre-existing conditions?

This can be a significant deciding factor in whether to choose IESS which only has a 3 month waiting period for pre-existing conditions vs a private plan which won’t cover these for 2 years. 

Even after the 2 years, you may find that private plans offer limited coverage per incident for any pre-existing conditions.

It definitely pays to shop around as some insurance policies are much better than others in how they treat pre-existing conditions. 

You’ll be required to go through a questionnaire with your agent or broker to disclose any pre-existing health conditions.

In-network vs out of network

Knowing which hospitals and clinics are included as “In-network” can be a deciding factor. For example, one of the reasons I chose my plan was because it included Hospital del Rio in its network. This hospital is my favored one here in Cuenca mainly because it is the closest one to us. 

You will generally be reimbursed 90% if you use In-network facilities, whereas you’ll receive 80% if you go outside of the network. 

What about dental and optometry? 

Dental and optometry are not covered by private insurance. You’ll need to pay for teeth and eye care out of pocket or use the IESS network. 

How to choose your preferred company?

Given there are around 30 health insurance companies in Ecuador, choosing the one that’s best for you can be a little intimidating. We suggest basing your decision on the following: 

Reputation

Not all insurance companies are created equal. Some companies can be a lot easier to work with than others. Some have more English-speaking staff than others, whilst others have reputations for not reimbursing. 

Compare plans

Obviously, price is one key factor. But, you also need to consider whether you want a high or low deductible, and what exactly the cover is for (comprehensive or just major surgery etc). 

Other expats

I suggest talking to other expats about their experiences with private care and getting reimbursed by each company. This is especially important for hospital visits as you may need to pay upfront before they’ll let you leave the hospital. You don’t want to be waiting and hoping that the insurance company is going to reimburse you. 

Contract cancellation

The ease at which you can cancel a contract should you need to can be an important consideration. Ecuadorian companies are notorious for continuing to direct debit your account, even if you’ve canceled (or tried to cancel) the contract. 

Trust your gut

Is it clear that the insurance agent (or broker) is in a rush to make you sign the contract? Have they made any effort to cater to your specific needs and circumstances? These are pretty clear red flags and you shouldn’t be surprised if these same agents provide zero after-sales support. 

What exclusions you can expect?

Perhaps it’s the lawyer in me, but I absolutely recommend going through the exclusions with a fine-tooth comb. You may be quite surprised at what is not covered. Some possible exclusions: 

• Accidents caused by natural phenomena like earthquakes, floods, cyclones & volcanic eruptions. 
• Mental illness
• Dietary or nutritional supplements
• Plastic surgery (except to correct accident lesions when medically necessary)
• Sexual reproduction treatment

Is COVID covered? 

Yes – so long as it is not a pre-existing condition. ie If you buy insurance today, but go to the hospital tomorrow presenting symptoms, you will not be covered. You’ll generally need to wait around 10 days for COVID to be covered. 

Reimbursement process

To get reimbursed, you have 90 days to submit your claim. After this time they will NOT reimburse your claim. It’s important to try and get these submitted earlier than the 3-month deadline in case they ask for more documents. 

What if the insurance company denies your claim? 

This is where it’s important to choose a reputable insurance broker that isn’t just a puppet for the insurance companies. If your claim is denied, you should be able to lean on your broker for assistance in submitting an appeal to the Superintendencia de Companias who will then assess your case, including all of the documents, before ruling whether the insurance company must pay your claim. This can take between 3-6 months for the decision to be made. 

Mixed insurance plan strategies

It might actually make more financial sense to combine IESS & private insurance. To illustrate this I’ve provided several different possible scenarios below. 

Scenario A: 65 Years Old with Pre-Existing Conditions

Scenario B: 65 Years Old with Minimal Pre-Existing Conditions

Scenario C: 65 Years Old with Minimal Pre-Existing Conditions

Scenario D: 45 Years Old with Minimal Pre-Existing Conditions

Scenario E: 45 Years Old Insurance Mainly for Cedula

Wrapping up + next steps

There’s a lot for new expats to take in when deciding which health cover is appropriate for them in Ecuador. Hopefully this guide has answered many of your questions, but if you need more guidance feel free to contact us and we’ll do our best to point you in the right direction.

If you’d prefer to talk to an expat-friendly insurance broker or would like a quote, Blue Box Insurance offers YapaTree Cardholders 5% off health insurance. We’ve deliberately chosen them as our insurance partner because of their wide range of plans, reputation amongst expats & their after-sales service.

Already have insurance? We’re interested in your experience, so feel free to comment below.

This article was first published on Expats Ecuador.