If I have income protection insurance and they do not pay me, what do I do?

Question

José Manuel Alburquerque · Accepted Answer

Ask for the reason in writing and compare it with the policy. The most common grounds for refusal are an illness predating the policy, the waiting period (“periodo de carencia”) of the first few months, the initial days that are not paid or an exclusion, such as certain mental illnesses or back pain with no objective injury. Many exclusions are only valid if they are highlighted and signed separately. And if they hold a pre-existing illness against you, the insurer can only refuse to pay altogether if it asked you about that illness and your concealment involved wilful misconduct or gross negligence, or if the policy excludes it in a clause that is highlighted and signed separately. If the refusal does not stand up, you have five years to bring a claim. Common grounds for refusal An illness predating the insurance, either because you did not declare it in the questionnaire or because the policy excludes pre-existing illnesses. If that exclusion is so broad that it renders the insurance almost meaningless, it is not valid even if you signed it. Waiting period. Certain types of sick leave, such as for illness or pregnancy, are not covered in the first few months. Excess. The first few days of each period of sick leave are not paid. Exclusions. Anxiety, depression or lower back pain with no objective injury, depending on the policy. Payment by scale. Some policies pay a fixed number of days according to the diagnosis, not the actual days of sick leave. What to do Ask for the refusal in writing and read the clause they are applying to you. If it is an exclusion or a waiting period that cuts back what you could expect and it is not highlighted and signed separately, it cannot be applied to you. Unclear clauses are interpreted in your favour. Provide the sick notes and your doctor's reports and cooperate with any examination requested by the insurer's doctor. Complain in writing to the insurer's customer service department, which has one month to reply. If it does not reply or rejects your complaint, you can go to the “Dirección General de Seguros y Fondos de Pensiones” —Spain's insurance regulator— and, if necessary, take legal action. Notify the insurer of the sick leave within seven days, or within any longer period set by the policy. If you are late, you do not lose your right, but late-payment interest only runs from the date of notification. If you are self-employed Many policies require you to stop working completely while on sick leave. If you carry on running your business, even a little, the insurer may refuse to pay for those days. Keep evidence that you stopped working.