What to do when your insurer refuses an authorisation

Terms used

• Carencia — A carencia is a waiting period after your policy starts during which certain services are not covered.
• Exclusiones — Exclusiones are services or risks your policy permanently does not cover, such as cosmetic surgery.
• Cuestionario de salud — The cuestionario de salud is the health questionnaire you complete when taking out the policy.
• Preexistencias — Preexistencias are health conditions you had before the policy began, which can limit cover.
• Servicio de Atención al Cliente — The Servicio de Atención al Cliente is the insurer's customer service department, which handles formal complaints.
• Defensor del Cliente — The Defensor del Cliente is an independent complaints body some insurers have, used after customer service.
• DGSFP — The DGSFP is Spain's insurance regulator, which runs a free complaints service for policyholders.

Key rules

• Written reason: Ask for the refusal in writing, with the specific reason and the policy clause; without them you cannot argue back.
• Cost of complaints: Complaints to the insurer and to the regulator are free and need no lawyer.
• Urgent care: Urgent care normally needs no prior authorisation, so use the emergency route rather than waiting.
• Paying privately: If you pay privately and the refusal is upheld, you may not get your money back.
• Waiting period vs exclusion: A waiting period ends and cover then applies; an exclusion never becomes covered.

Start with the reason for the refusal

Ask the insurer for the refusal in writing, with the specific reason and the policy clause it relies on. Everything else depends on that reason. A refusal with no stated reason or clause is weak, so push for both before you do anything else.

Common reasons are:

• The waiting period (carencia) has not finished.
• The service is an exclusion in your policy, such as cosmetic surgery, experimental treatment or certain dental work.
• The condition is pre-existing, or was not declared in your health questionnaire.
• The insurer says the treatment is not medically necessary.
• The provider is out of network.
• The procedure goes over a policy limit.
• Your documents are incomplete.
• Your premium is unpaid or the policy has lapsed.

Match the reason to your policy

Open your policy's general conditions and find the clause the insurer quotes.

• A carencia is temporary. Services are covered once the period ends. Look for the table or section on waiting periods.
• An exclusion is permanent. Look for the section called exclusiones.
• Pre-existing conditions may be an exclusion, a longer waiting period or a surcharge. Look at the clauses on the health questionnaire (cuestionario de salud) and preexistencias.

Clauses that limit your rights must be highlighted and signed. Clear, specific exclusions are enforceable. Ambiguous clauses are read in your favour, not the insurer's. If the refusal is about a missing document, a late premium or the provider's network status, you can often fix the problem and ask again.

Build your evidence

Ask the prescribing doctor for a medical report that explains why you need the treatment. If it is urgent, ask the report to say so. Add test results, such as scans or lab results. Keep every message and letter from the insurer, and any invoices, in one place.

Escalate in this order

1. Complain to the insurer. File a complaint (queja o reclamación) with its customer service department (Servicio de Atención al Cliente). If the insurer has a Defensor del Cliente, take it there next.
2. Go to the regulator. If you get no answer within two months, or the answer is unfavourable, complain to the complaints service of the insurance regulator, the Dirección General de Seguros y Fondos de Pensiones (DGSFP). It is free and you do not need a lawyer. Its report does not bind the insurer, but many disputes settle at this stage or before.
3. Consider mediation, arbitration or court. Mediation is low cost. Court may need a lawyer and procurator, depending on the amount, and carries a risk of costs. For high-value claims, take legal advice first.

Contesting is usually worthwhile when the exclusion is ambiguous or the insurer's reason is weak. Weigh the amount at stake against the cost of each route.

Getting treatment while you challenge

If treatment is urgent, use the emergency route. Urgent care normally needs no prior authorisation, and the insurer must cover it at its network centres. You can also pay privately and claim the money back later, but you may not be reimbursed if the refusal is upheld. If you are entitled to the public health system, you can use it too. A court can order interim measures in urgent cases, but this is costly and uncertain.

The decision, timeline, documents, checklist and warnings below set out these options in more detail.

Choosing between options

How should you get treatment and challenge the refusal?

• Pay privately and claim back: You cannot wait and accept the risk of no reimbursement if the refusal is upheld.

• Use the public health system: You are entitled to it and the treatment cannot wait for the dispute.

• Complain to the insurer and the regulator: The treatment can wait, because these routes are free and need no lawyer.

• Go to court: A lot of money is at stake or the case is urgent enough to ask for interim measures, though this is costly and uncertain.

If the treatment is urgent, use the emergency route first. If it can wait, start with the free complaint steps, especially where the exclusion is ambiguous or the insurer's reason is weak.

Timeline and deadlines

• Ask the insurer for the refusal in writing, with the specific reason and the policy clause: as soon as you are refused

• Get a medical report from the prescribing doctor justifying the treatment: while you wait for the written refusal

• File a complaint with the insurer's customer service department, then with its Defensor del Cliente if it has one: once you have the refusal and the report

• Take the complaint to the insurance regulator, the DGSFP: if the insurer rejects you or stays silent for two months from the day you file

• Consider mediation, arbitration or court action: if the regulator's route does not solve it

Documents you need

• The insurer's written refusal, stating the specific reason and the policy clause it relies on. Ask your insurer to issue it.

• A medical report from the prescribing doctor explaining why you need the treatment. If the case is urgent, it should say so.

• Your policy's general conditions, including the sections on waiting periods (carencias), exclusions (exclusiones) and the health questionnaire (cuestionario de salud).

• Test results that support the medical report, such as scans or lab results.

• Copies of all your communications with the insurer, plus invoices if you paid privately.

Checklist

• Check whether the service needs prior authorisation under your policy, such as hospital admission, scheduled surgery, MRI or CT scans, or physiotherapy courses.

• Compare the insurer's reason with your policy wording to see whether the clause is clear or ambiguous.

• File a complaint with the insurer's customer service department.

• Keep every document and message in one place.

What to watch out for

• Paying privately may not be refunded: If you pay for treatment yourself and the refusal is upheld, you may not get your money back. Keep the medical report stating the urgency, the invoices and the refusal letter, and use the emergency route if the case is truly urgent.

• Refusal without a stated reason: A verbal or vague refusal leaves you unable to challenge the actual reason.

• Incomplete documents: An authorisation can be refused simply because the paperwork is incomplete, or because the provider is out of network. Send the doctor's report with the request and check that the provider is in your insurer's network.

• Mixing up waiting periods and exclusions: A waiting period ends and then cover applies, while an exclusion never does. Challenging an clear exclusion is unlikely to succeed. Read the carencias and exclusiones sections of your policy before you complain.

• Unpaid premiums: A lapsed policy or unpaid premium can lead to refusal. Check that your premiums are up to date before you challenge.

Frequently asked questions

Can I get treatment now while I challenge the refusal?

Yes, if the treatment is urgent you can use your policy's emergency route, because urgent care normally needs no prior authorisation and the insurer must cover it at network centres.

What is the difference between a waiting period and an exclusion?

A waiting period (carencia) is temporary, while an exclusion is permanent. Once the waiting period ends, the service is covered. An excluded service, such as cosmetic surgery, never becomes covered. Pre-existing conditions can be handled by either route, or by a surcharge, depending on what you declared in the health questionnaire.

Where in my policy do I find the clause the insurer relies on?

Look for waiting periods in the table or section on carencias, and exclusions in the section titled exclusiones. Pre-existing conditions are covered in the clauses on the health questionnaire (cuestionario de salud) and preexistencias. Limiting clauses must be highlighted and signed, so an unsigned or hidden one is worth challenging.

Is it worth contesting a refusal?

Usually yes when the exclusion is ambiguous or the insurer's reason is weak. Internal complaints and the regulator's complaint are free and need no lawyer.