If my private medical insurance will not authorise a test or an operation, what should I do?
Ask for the refusal in writing, with the reasons for it. Check the policy to see whether the test is covered, whether you were still within the waiting period (“período de carencia”) and whether it was requested by one of the doctors on the insurer's list. If the refusal is unfounded, complain in writing straight away. If it is urgent, do not wait, because the law does not allow the policy to exclude necessary emergency treatment. If you have the test done at your own expense, keep the invoices so that you can claim the cost back later.
Alburquerque Abogados
José Manuel AlburquerqueWhat to check
- Whether the test or the operation is covered by the policy or falls under its exclusions.
- Whether you were still within the waiting period.
- Whether it was prescribed by a doctor on the insurer's list, as policies usually require.
- Whether the exclusion or limit applied to you is highlighted and signed separately, where it cuts back what you could expect from the policy. A clear and reasonable waiting period can be a normal part of private medical insurance.
What to do
- Ask for the refusal in writing, stating the clause on which it is based.
- If the objection is that it was requested by a doctor who is not on the list, ask one of the doctors on the list to prescribe it.
- Provide a report from your doctor explaining why you need it and, if necessary, your medical records.
- Complain in writing to the insurer's customer service department, which has one month to reply. If it does not reply or rejects the complaint, take it to the “Dirección General de Seguros y Fondos de Pensiones”, Spain's insurance regulator.
- In the meantime, you can have the test done in the public health system.
If it is an emergency
Go to accident and emergency and notify the insurer as soon as you can. The policy cannot exclude necessary emergency treatment, so, if there was no other option, claim reimbursement afterwards. If the insurer is late in paying what it owes, it must pay late-payment interest here too. You have five years to bring a claim.
This answer is provided for educational purposes and offers initial guidance on the question raised. Every matter has its own circumstances and nuances that require individual assessment. For that reason, before taking decisions with significant consequences, it is advisable to consult a professional and not to rely solely on this information. Personalised advice makes it possible to apply these explanations to the specific case and to assess the options available with greater certainty.