Using private health insurance in an emergency

Terms used

• Cuadro médico — The cuadro médico is your insurer's list of approved hospitals and doctors, where the insurer is billed directly.
• Copago — The copago is a fixed amount you pay towards a service, with the insurer covering the rest.
• Reembolso — A reembolso policy lets you use any provider, then refunds a percentage of the cost up to a limit.
• Tarjeta sanitaria — The tarjeta sanitaria is the card showing you are entitled to public healthcare in your region.
• Urgencias — Urgencias are hospital emergency departments.

Key rules

• Life-threatening emergency: Call 112 or go to the nearest emergency room without waiting for insurer approval.
• Notification window: Notify your insurer within the window in your policy, most commonly 24 to 72 hours.
• Network hospitals: Network hospitals normally bill the insurer directly, and you pay only any copago.
• Outside the network: You normally pay first and claim back, and refunds depend on your policy wording.

The short answer

In a life-threatening emergency, go to the nearest emergency room or call 112. Do not wait for your insurer's approval. Tell the insurer afterwards, as soon as you can.

Whom to call

Your insurer has a 24-hour emergency line, open every day of the year. The number is on your insurance card and in the insurer's app. Save it in your phone now, before you need it.

Call it to report the case. For a hospital admission, ask for an authorisation number or a guarantee of payment. True emergencies at network centres normally need no prior authorisation, but the insurer still expects to hear from you.

Where to go

Most policies work through a closed list of hospitals and doctors, called the cuadro médico. Use a hospital on that list whenever you can reach one safely.

If you cannot, many insurers cover urgent care at the nearest hospital, even outside the network, until you can be moved to a network centre. Non-urgent care outside the network is normally excluded. The decision below sets out your options.

When to tell the insurer

Most policies require notice of an emergency admission within a short window, most commonly 24 to 72 hours. Check the exact window in your policy wording. Missing it is a common reason for a claim to be denied.

Who pays: direct billing or reimbursement

• Network hospital: the hospital normally bills the insurer directly. You pay only any copago your policy sets.
• Outside the network: you normally pay first and then claim the money back. Refunds are mainly available under a reembolso policy, or when a genuine emergency meant you could not reach network care. Some insurers pay non-network emergencies directly, so ask on the call.
• Reembolso policies: these refund a percentage of the cost, up to the policy limit. They let you use any provider.

Keep every report, invoice, receipt and prescription. For a claim, the invoice should be itemised and in your name. The steps below show the full claim process.

Public emergency care

If you are entitled to the public system and have a tarjeta sanitaria, you can use public urgencias even if you also have private insurance. It is free at the point of use. Private insurers generally do not refund public care, because you paid nothing.

Anyone can get public emergency care, but people not entitled to the public system may be billed. Many expat private policies do not give access to the public system. Check your entitlement with your regional health service.

Choosing between options

Where should you go for emergency care under your private policy?

• A network hospital: Choose this if you can reach one safely. It normally needs no prior authorisation for a true emergency, and the hospital bills the insurer directly.

• The nearest hospital, even if outside the network: Choose this if the emergency is real and you cannot reach a network centre in time.

• Any provider, if you have a reembolso policy: Choose this if your policy refunds a percentage of costs at any provider. You pay first and claim back, up to the policy limit.

If it is a true emergency, go to the nearest hospital and tell the insurer promptly. Non-urgent care outside the network is excluded unless you have a reembolso policy.

Steps after an emergency treated under your private policy

• If your life is at risk, call 112 or go to the nearest emergency room without waiting for approval: Straight away, before anything else

• Call your insurer's 24-hour line to report the case, get an authorisation or guarantee-of-payment number, and be directed to a network centre: As soon as you can after the emergency starts

• Show your insurance card at admission: When you arrive at the hospital or clinic

• Keep every document: reports, invoices, receipts and prescriptions: During treatment and until your claim is paid

• If you paid, send the claim form with the itemised invoice in your name, the medical or discharge report and proof of payment, plus your policy number and bank details: Within your policy's claim window, which is commonly from about 15 days to a few months after treatment or discharge

• Follow up on the refund and keep copies of everything you sent: After you submit the claim

• If the insurer denies or delays the claim, send a written complaint to its customer service department: After a refusal or a long delay; the insurer must answer within 2 months

• If the complaint is rejected or unanswered, take it to the insurance complaints commissioner at the Spanish insurance regulator, or try consumer arbitration or your regional consumer office: After the insurer's 2 months or its refusal, and within 1 year of your complaint to the insurer

• As a last step, take the claim to the civil courts: Within 5 years

Checklist

• Call the emergency line to report the case, and ask for an authorisation number or guarantee of payment if you are admitted.

• Notify the insurer within the window in your policy, most commonly 24 to 72 hours after an emergency admission.

• Check your policy wording to see whether network hospitals bill the insurer directly and what copayment (copago) you owe.

• Ask your insurer whether your policy is a reembolso policy, which refunds a percentage of costs, before paying any bill yourself.

• Check with your regional health service whether you are entitled to public urgencias, since private insurers generally do not refund public care.

Frequently asked questions

How soon must I tell my insurer after an emergency admission?

Most insurers want to hear within 24 to 72 hours of an emergency admission, or as soon as reasonably possible. Your policy sets the exact window, so check it on your card, in the app or by calling the 24-hour line.

Will my insurer pay if I go to a hospital outside its network?

Often only for a true emergency, and only until you can be moved to a network centre.

Does my private insurer refund public emergency room care?

No, private insurers generally do not reimburse public care, because if you are entitled to the public system you pay nothing there.

Do I pay at a network hospital or does the insurer?

At a network hospital, the hospital normally bills the insurer directly and you pay only any copayment (copago) in your policy. Outside the network you normally pay first and then claim a refund, if your policy allows it.