When an insurer adds an exclusion, surcharge or refusal for a condition

Terms used

• Recargo — The recargo is an extra amount added to your premium because of a declared condition.
• Carencia — The carencia is a waiting period after the policy starts before you can use certain services.
• Defensor del Asegurado — The Defensor del Asegurado is an independent complaints officer that some insurers have for disputes with customers.
• DGSFP — The DGSFP is Spain's insurance regulator, which handles complaints against insurers.
• AEPD — The AEPD is Spain's data protection authority, which handles complaints about personal data.

Key rules

• Written terms: The insurer must give you its terms in writing before the contract, and you can accept or decline.
• Exclusion: An exclusion leaves the declared condition and related complications uncovered.
• Medical exams: Extra reports or exams need your consent, but declining may lead the insurer to refuse you.
• Complaints: Customer service must reply within a maximum of two months, after which you can go to the DGSFP.

What the insurer can do with a declared condition

Once you declare a condition, the insurer chooses one of five outcomes:

1. Standard terms. You get the policy as advertised. A controlled hypertension is often accepted this way.
2. An exclusion. The policy is issued, but the declared condition and related complications are not covered. This is common in health insurance. For example, a chronic disease may be accepted with that disease excluded.
3. A surcharge (recargo). You pay a higher premium. This is more common in life insurance than in health insurance.
4. A longer waiting period (carencia). Some services, such as childbirth or surgery, only become available after a longer wait.
5. A refusal. A previous cancer, for example, may be refused or excluded.

Each insurer applies its own rules. They look at the type, severity, recency and treatment of the condition, and at your age. The same condition can get different answers from different insurers, and from different products of the same insurer.

How to judge an offer

The insurer must give you its terms in writing before the contract starts. You can accept or decline.

• Read the exclusion closely. Check which condition is left out and which related complications go with it. A wide exclusion can remove the very care you bought the policy for.
• Weigh a surcharge against the alternatives. Compare the higher premium with what other insurers offer for the same condition.
• Check the waiting periods. If you plan surgery or a pregnancy, a longer wait may make the policy useless for that need.
• Ask for the reason in writing if the insurer adds a condition or refuses.

Medical reports and exams

Most insurers rely only on your questionnaire for standard health insurance. They may ask for more if you are older, the sum insured is high, you declared a serious condition, or the product is life or income protection. They can ask for a report from your own doctor, extra tests, or an exam by their own doctor.

• Nothing can be requested without your consent.
• The insurer normally pays for an exam it requires itself. Your own doctor or clinic may charge you for a report.
• You can decline, but the insurer may then refuse the application.
• The results can lead to any of the outcomes above.

Agree on who pays before you go ahead.

If you disagree

Start with a written complaint to the insurer's customer service department. It must reply within a maximum of two months. If the insurer has a Defensor del Asegurado, you can take the case there next. Its decisions bind the insurer in some cases.

After a refusal, or two months with no answer, you can complain to the DGSFP, the insurance regulator. Its reports are not binding. You can also try mediation or consumer arbitration, if the insurer joins it, or go to court. Most civil claims now require a prior attempt at an alternative dispute method.

Time limits apply: two years for damage insurance and five years for personal insurance such as health. Complaints about how your data was handled go to the AEPD, the data protection authority. If you think you were treated in a discriminatory way, you can complain to the Autoridad Independiente para la Igualdad de Trato.

The decision, timeline, documents and checklist below walk you through the choice and the steps.

Choosing between options

What should you do with an insurer's offer after you declared a condition?

• Accept the offer as it is: The terms are standard, or the exclusion, surcharge or longer wait only touches things you do not expect to need.

• Decline and compare other insurers: The exclusion covers the very condition you want covered, or the surcharge or wait makes the policy poor value. Insurers set their own rules, so another may offer different terms.

• Challenge the decision: The insurer refused or added a condition you think is wrong. Start with a written complaint to customer service, then the DGSFP if it refuses or does not answer within two months.

Accept only if the written terms still cover what you most need. If not, decline and compare, or challenge the decision in writing.

Timeline and deadlines

• The insurer gives you its terms in writing and you accept or decline them: before the contract starts

• Send a written complaint to the insurer's customer service department: after a refusal or a condition you disagree with

• Wait for the insurer's reply: it must answer within a maximum of two months

• Take the case to the insurer's Defensor del Asegurado (an independent complaints officer), if the insurer has one: after customer service refuses or does not answer

• Complain to the DGSFP, Spain's insurance regulator, in its electronic office or in writing: after the insurer has refused, or has not answered within two months

• Try mediation or consumer arbitration, if the insurer joins it, before going to court: before you file a civil claim

• File a claim in court if the other routes fail: within two years for damage insurance and five years for personal insurance, such as health or life

Documents you need

• The insurer's written offer of terms, showing any exclusion, surcharge, longer waiting period or refusal. The insurer must give it to you before the contract starts, and you can accept or decline it.

• A medical report from your own doctor, only if the insurer asks for it. Your doctor or clinic may charge you for it.

• Results of extra tests or an exam by the insurer's own doctor, only if the insurer asks. The insurer normally pays for an exam it requires itself.

• Your written complaint to the insurer's customer service department (servicio de atención al cliente), if you disagree with a refusal or a condition.

• Your identity document and any evidence for the case (the insurer's reply or refusal, your offer, your medical papers), if you go on to complain to the DGSFP, Spain's insurance regulator.

Checklist

• Ask the insurer for its terms in writing before you accept anything.

• Check whether the offer is standard terms, an exclusion, a surcharge (recargo), a longer waiting period (carencia) or a refusal.

• Read which condition and which related complications an exclusion leaves uncovered.

• Ask whether the insurer wants a medical report, extra tests or an exam by its own doctor.

• Ask who pays for each exam or report before you agree to it. Declining is allowed, but the insurer may then refuse you.

• Ask for the reason in writing if the insurer refuses or adds a condition.

• Send a written complaint to customer service if you disagree, and note the date you sent it.

• Take it to the DGSFP if two months pass with no answer or the insurer refuses again.

Quick answers on underwriting and your medical data

How far back do health questionnaires ask about my medical history?

There is no single legal look-back, but many questionnaires ask about treatments and hospitalisations over the last 5 years. Some ask about tests and consultations over the last 2 or 3 years. Serious or chronic conditions such as cancer, heart disease, diabetes or HIV are often asked about at any time in your life. Read the periods in your own questionnaire and answer only what it asks.

Can I get a copy of the health questionnaire I filled in?

Yes, you can ask your insurer for a copy of your answers, because they count as personal data it holds about you. Write to its customer service or data protection officer and identify yourself. The insurer must reply within one month. Keep a copy when you sign, since the questionnaire is what the insurer would rely on if it later claims you left something out.

Can an insurer get my medical records without my consent?

No, an insurer needs your explicit consent to process your health data and cannot get your clinical history directly from hospitals or public health services without it. It may ask you to sign an authorisation for medical reports, mainly in life insurance or when you make a claim. The request must be limited to what is necessary. Refusing can lead the insurer to decline cover or refuse a claim.

What can I do if the insurer ignores my request about my health data?

You can complain to the Spanish data protection agency (AEPD), usually through its online office, after first contacting the insurer. You can also ask the insurer to correct wrong data or erase it, though it may keep data it needs for legal duties or to defend claims. The insurer must answer within one month, extendable by two months for complex requests.