How to claim reimbursement from your health insurer

Terms used

• Cuadro médico — A cuadro médico policy gives you a network of doctors and hospitals that the insurer pays directly.
• Reembolso — A reembolso policy lets you use any doctor, pay yourself, and claim back a percentage.
• Baremo — The baremo is the insurer's scale of maximum fees it will refund per procedure.
• Copago — A copago is a fixed amount you pay yourself towards each service.
• IBAN — The IBAN is your bank account number, which the insurer needs to pay you by transfer.

Key rules

• 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.
• Invoice deadline: Your policy sets its own deadline to submit invoices, often 3 to 12 months, and late claims can be refused.
• Legal action: Legal action over a refused claim expires after five years.
• Payment: The insurer pays by bank transfer, so give your IBAN with the claim.

When you need to claim

You only claim if you paid for care yourself. Which policy you have decides this.

• Cuadro médico policy: you use doctors in the insurer's network and the insurer pays them directly. You usually don't claim, though tests and procedures often need prior authorisation.
• Reembolso policy: you choose any doctor or hospital, pay the bill, then claim a percentage back.
• Mixed policy: direct billing in the network, reembolso outside it. You claim only for out-of-network care.

What you will get back

Reembolso plans usually refund a fixed percentage of the invoice. 80% is common, and some plans pay 70% to 90%. The refund is capped by the insurer's scale of maximum fees (the baremo). Many plans also have annual or per-service limits, and some add a copago. You get the lower of the percentage and the scale limit. On an 80% plan, a 100 euro consultation within the scale pays back 80 euros. Check your own percentage and caps in your policy.

Steps to claim

1. Receive the care and pay the provider.
2. Collect the invoice, the medical report and proof of payment. The documents list and checklist below show exactly what to get.
3. Fill in the insurer's claim form, on paper or in the app or online area.
4. Submit everything.
5. Answer quickly if the insurer asks for more documents.
6. The insurer pays by bank transfer to the account you gave, so include your IBAN.

Where to send it

The insurer's mobile app (you upload photos) and the customer area on its website are the simplest routes. Most insurers also accept email to the claims department, post, a visit to a branch, or sending it through your broker. Some insurers still want originals for large claims. Your policy conditions list the accepted channels.

Deadlines

Two deadlines matter, and the shorter one is the one that catches people.

• Tell the insurer about the loss within 7 days of learning of it, unless your policy gives you longer. Missing this can let the insurer claim damages. It can reduce or refuse cover only if you acted on purpose or were seriously at fault.
• Submit your invoices by the policy's own deadline. This is in the general conditions. It is commonly a few months after treatment, often 3 to 12 months. A late claim can be refused. Send claims as soon as you have the documents.

If a claim is refused, you can take legal action, but time is limited. The limit for health insurance is five years. It usually runs from the refusal or the insured event. A court claim or a written demand can interrupt it.

Common mistakes

• Paying without getting a proper itemised invoice in your name.
• Sending a bank transfer receipt but no medical report.
• Leaving out the prescription or referral for tests and therapies.
• Waiting until the policy deadline has passed.

The questions below cover paying first, how much you get back and sending claims by app or email.

Timeline and deadlines

• Pay the provider and collect the invoice, medical report and proof of payment: on the day of treatment or as soon as you can

• Tell the insurer about the loss: within 7 days of becoming aware of it, unless your policy gives you longer

• Submit your claim with all documents: within the deadline in your policy, commonly 3 to 12 months from the treatment date

• Answer any request for more documents while the insurer reviews the claim: as soon as the insurer asks

• Expect a refusal if you submit after the policy deadline: if the policy deadline has passed

• Take legal action over a refused claim: within five years

Documents you need

• Claim form from your insurer, or the app or online equivalent. You fill it in yourself.

• Itemised invoice from the doctor or clinic. The original or a legible copy is accepted.

• Medical report from your treating doctor stating the diagnosis and the treatment.

• Prescription or referral for any tests or therapies, issued by your doctor.

• Proof of payment: a bank statement, a card receipt or a "pagado" (paid) stamp on the invoice.

• Copy of your ID and your policy number.

• Your bank account number (IBAN) so the insurer can pay by transfer.

• Accident report, only if the claim is for an accident and the insurer asks for it.

Documents to gather for a health insurance claim

• Fill in the insurer's claim form, either the paper version or the app or online equivalent.

• Get the itemised original invoice, or a legible copy, addressed to the insured patient by name. It should show the invoice number and date, the tax ID (NIF) and address of both the provider and the patient, and the amount.

• Check that the invoice lists each service separately (consultation, tests, procedures) with dates, and gives the name and registration number of the professional or centre.

• Check that the invoice says the care is VAT-exempt, if it is. Most medical care is.

• Ask the treating doctor for a signed medical report on the centre's letterhead, with the doctor's collegiate number (professional registration number).

• Check that the report gives your identity, the date of the consultation or procedure, the diagnosis, the treatment performed and why it was needed.

• Attach the doctor's prescription or referral for any tests or therapies. If your insurer has a model report form, give it to the doctor to complete.

• Attach proof of payment: a bank statement, a card receipt or a "pagado" stamp on the invoice.

• Add a copy of your ID, your policy number and your IBAN (bank account number) for the transfer.

• Add the accident report if the claim follows an accident.

• For treatment abroad, add proof of your trip dates, such as tickets or passport stamps, and ask the insurer if it needs a translation of any document not in Spanish. Some insurers ask for a sworn translation (traducción jurada).

• For foreign payments, show the amount paid in the foreign currency. It is converted at the exchange rate on the date of payment.

• Keep copies of everything you submit, plus proof that you sent it, such as the app confirmation, the sent email or a registered post receipt.

• Write down the claim reference number, the dates and any insurer replies or authorisations, and keep all of it for at least 5 years.

Frequently asked questions

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

It depends on your policy type: with a reembolso policy you pay the provider first and claim a percentage back. With a cuadro médico (network) policy you use network providers and the insurer pays them directly. Mixed policies work both ways: direct billing in network and reimbursement out of network.

How much money will I get back from a reembolso claim?

Reembolso policies usually refund a fixed percentage of the invoice, and 80% is common, though some plans pay 70% to 90%. The refund is the lower of that percentage and the policy's scale of maximum fees, so an 80% plan refunds 80 euros on a 100 euro consultation if the fee is within the scale. Annual caps and co-payments (copago) can reduce it further.

How long do I have to submit my invoices?

Many policies set a deadline of a few months from the treatment date, often between 3 and 12 months, and late claims can be refused. Submit as soon as you have the invoice, report and proof of payment. Your policy conditions give your exact deadline.

Can I send my claim by app or email instead of going to an office?

Yes, most insurers accept claims through their mobile app or the customer area of their website, and many also take email, post or a visit to a branch. The app lets you upload a photo of each document. For large claims some insurers still ask for the original invoices, so keep them.