Claims, refusals and complaints

It is for people who are considering, planning or carrying out a move to Spain. It does not cover general consumer complaints or finding a lawyer.

Start with "Escalating a complaint to the insurer's defender and regulator". It shows the complaint routes in order, and the other pages build on it. Then pick the page that matches your problem:

• "How to claim reimbursement from your health insurer", to submit a claim correctly.
• "Claims for out-of-network or foreign treatment", to recover costs outside the network.
• "What to do when your insurer refuses an authorisation", to challenge a refused approval.
• "A claim refused as a pre-existing condition: your options", to contest that kind of refusal.
• "When your insurer is slow to pay: deadlines and interest", to enforce payment timelines.

Key rules

• Time to sue: Legal actions under a health insurance contract expire after five years.
• Insurer reply time: The insurer has two months from the day you file a complaint to answer, and if it rejects you or stays silent for those two months you can take the complaint to the insurance regulator.
• Payment deadline: The insurer must pay within 40 days of receiving your claim notification.
• Who claims: You claim only when you paid a provider yourself, under a reembolso policy or for out-of-network care on a mixed policy.
• Loss notice: Tell the insurer within 7 days of learning of the loss, unless your policy allows longer.
• Written reason: Ask for the refusal in writing, with the specific reason and the policy clause; without them you cannot argue back.

Claims, refusals and complaints: the whole process, step by step

• Tell the insurer about the loss or emergency. For an emergency at a non-network centre, use the 24-hour phone line. Read: Claims for out-of-network or foreign treatment: as soon as possible, often within 24 to 48 hours for an emergency; otherwise within 7 days of becoming aware of the loss unless your policy allows longer

• Pay the provider if you are on a reimbursement policy, then submit the claim with invoice, medical report and proof of payment. Read: How to claim reimbursement from your health insurer: within the deadline in your policy, commonly a few months after treatment

• Wait for the insurer to pay. Read: When your insurer is slow to pay: deadlines and interest: the insurer must pay within 40 days of receiving your claim notification

• If an authorisation is refused, ask for the refusal in writing with the reason and get a report from your doctor. Read: What to do when your insurer refuses an authorisation: as soon as you get the refusal

• If a claim is refused as a pre-existing condition, check what you declared and the exact wording of the exclusion. Read: A claim refused as a pre-existing condition: your options: after the refusal, before you file a complaint

• File a complaint with the insurer's customer service or its defender. Read: Escalating a complaint to the insurer's defender and regulator: within two years of when you learned of the events

• Wait for the insurer's answer to your complaint: the insurer has two months from the day you file to answer

• Take the complaint to the insurance regulator's complaints service, free and without a lawyer: after a rejection or two months of silence, and within four years of the events

• Consider mediation, arbitration or court action. Court is open at any time: legal actions under a health insurance contract expire after five years

Documents you may need

Identity and residence

• Copy of your ID and your policy number — How to claim reimbursement from your health insurer

The home and the lease

• Your policy contract — A claim refused as a pre-existing condition: your options

Payments and receipts

• Itemised invoice from the doctor or clinic — How to claim reimbursement from your health insurer, Claims for out-of-network or foreign treatment
• Proof of payment — How to claim reimbursement from your health insurer, Claims for out-of-network or foreign treatment

Other documents

• Medical report from the treating doctor with the diagnosis and treatment — How to claim reimbursement from your health insurer, Claims for out-of-network or foreign treatment
• Prescription or referral for any tests or therapies — How to claim reimbursement from your health insurer
• Proof of your trip dates for treatment abroad — Claims for out-of-network or foreign treatment
• The insurer's written refusal — What to do when your insurer refuses an authorisation
• A medical report from the prescribing doctor explaining why you need — What to do when your insurer refuses an authorisation
• Your policy's general conditions — What to do when your insurer refuses an authorisation
• Copies of all your communications with the insurer — What to do when your insurer refuses an authorisation

Each article lists the other documents it asks for, where you need them.

Claims, refusals and complaints: questions that cross several articles

Do I have to pay first and claim the money back?

It depends on your policy type: reembolso policies make you pay and claim back, while network (cuadro médico) policies bill the insurer directly. Mixed policies do both, with reimbursement used out of network, usually at a set percentage and up to a cap.

How long do I have to send in a reimbursement claim?

Your policy sets the deadline for sending invoices, commonly a few months after treatment, so check its general conditions. Late claims can be refused under the policy terms. Read How to claim reimbursement from your health insurer, and for what happens after a refusal, Escalating a complaint to the insurer's defender and regulator.

How do I tell a waiting period from an exclusion when a claim is refused?

A waiting period (carencia) is temporary and cover starts once it ends, while an exclusion never becomes covered. A pre-existing-condition limit depends on what you declared in the health questionnaire. Read A claim refused as a pre-existing condition: your options and What to do when your insurer refuses an authorisation.

How long do I have to take legal action over a refused claim?

Legal actions under a health insurance contract expire after five years. A court claim or a written demand to the insurer can interrupt that period. Read Escalating a complaint to the insurer's defender and regulator and When your insurer is slow to pay: deadlines and interest.