Can an insurer refuse you for a health condition?

Key rules

• Lawful refusal: An insurer may refuse, limit or price cover by health risk, but not by discrimination or on unasked questions.
• Questionnaire: You only have to answer what the insurer asks, and the insurer must prove any concealment.
• Insurer's deadline: If the insurer finds an omission or inaccuracy in your answers, it has one month to propose a change or end the policy.
• Complaint first: Put your complaint in writing to the insurer before going to the regulator, which can act after two months without a reply.

Where the line is

Yes, an insurer can refuse you, charge more or limit cover because of a health condition. Judging risk is part of how insurance works. What it cannot do is break anti-discrimination or consumer rules, or punish you for something it never asked about.

What you must tell the insurer

Before the contract starts, you must answer the insurer's questionnaire honestly. Tell it every circumstance you know of that could affect how it judges the risk, as far as the questionnaire asks.

• If the questionnaire does not cover a point, you do not have to volunteer it.
• Vague questions or general health clauses are not enough in practice. The insurer is expected to ask specific questions.
• If the insurer says you hid something, it must prove it.

What happens if you got an answer wrong

If the insurer finds an omission or inaccuracy in your answers, it has one month to propose a change or end the policy.

If a claim happens before the insurer acts, it usually pays only part of the benefit. The part is the share that the premium you paid bears to the premium the true risk needed.

If you hid something on purpose or with serious fault, the insurer can refuse to pay at all. It keeps the premiums for the period in progress.

When a refusal or limit becomes a problem

Treat a decision as challengeable if it rests on a question you were never asked, on a vague clause, or on treating you worse because of who you are rather than your actual risk. A rejected claim based on an alleged omission is also worth challenging, since the insurer carries the burden of proof.

How to complain

Do it in this order. The timeline below sets out the steps.

1. Send a written complaint to the insurer's customer service department (servicio de atención al cliente). It must reply within two months.
2. If the insurer has a Defensor del Asegurado, you can use it too. Ask the insurer whether it has one.
3. If the insurer refuses or does not answer within two months, complain to the DGSFP, the insurance regulator, through its electronic office or in writing. Include your identity documents and evidence. Its reports are not binding on the insurer.
4. Try mediation or consumer arbitration, which works only if the insurer joins. Or go to court. Most civil claims now require a prior attempt at an alternative dispute method, so try one first.

Other routes: complaints about your data go to the AEPD, and discrimination complaints can go to the Autoridad Independiente para la Igualdad de Trato.

Time limits

You have two years to bring a dispute over damage insurance and five years for personal insurance, which includes health and life. Do not wait that long: complain in writing as soon as you get a refusal.

Timeline and deadlines

• Send a written complaint to the insurer's customer service department: As soon as the insurer refuses or disputes your case

• Wait for the insurer's reply: Up to two months after you complain

What to watch out for

• Wrong answers on the questionnaire: A deliberate or seriously careless wrong answer can let the insurer refuse a claim and keep your premiums for the current period. Smaller mistakes lead to a reduced payout. Answer every question on the form fully and truthfully, and keep a copy of the questionnaire you signed.

• Accepting a refusal without a written complaint: A refusal or a limit on your cover is lawful when it rests on real risk, but it is not final. Complaints that go unmade can run past the time limits. Complain in writing to the insurer's customer service first, then to the DGSFP if the reply is a refusal or does not arrive within two months.

• Treating a regulator report as a ruling: A DGSFP report does not bind the insurer, so it may not change the outcome. If the insurer still refuses, consider mediation, consumer arbitration or a court claim within the time limits.

Frequently asked questions

What happens if I did not mention a condition the insurer never asked about?

You are not at fault for leaving out a condition the questionnaire did not ask about, because you only have to answer the questions the insurer puts to you. The insurer must prove you hid something, and vague or general health questions usually do not count. Specific questions are what matter.

What if I made a serious omission on purpose?

If you hid something on purpose or through serious fault, the insurer can refuse to pay a claim and keep the premiums for the current period. If the omission was not deliberate, a claim is usually paid in proportion: the premium you paid compared with the premium the true risk would have cost.

Who can I complain to if my insurer refuses me or rejects a claim?

Start with a written complaint to the insurer's customer service, which has up to two months to reply. If it refuses or stays silent, you can complain to the DGSFP, the insurance regulator, whose reports are not binding.