Refused a health card or billed for care: how to challenge it

Terms used

• Padrón — The padrón is the town hall's register of residents, and proof of it is often needed for public healthcare.
• Recurso de alzada — A recurso de alzada is an administrative appeal to the superior of the body that made the decision.
• Recurso de reposición — A recurso de reposición is an administrative appeal to the same body that made the decision.
• Contencioso-administrativo — The contencioso-administrativo is the court that reviews decisions of public authorities.

Key rules

• Emergency care: Urgent care stays guaranteed until medical discharge, whatever your card status or any dispute.
• Appeal deadline: You have 1 month to appeal a refusal with a recurso de alzada, and 2 months to go to the contencioso-administrativo court after an express decision.
• Silence: No answer to your card application is not an approval; it usually counts as a refusal you can appeal.
• Invoices: Contest a wrong invoice in writing with the body that issued it, and send insurer-covered bills to the insurer.

Emergency care continues while you challenge

Urgent care is guaranteed to everyone in Spain, with or without a health card or legal residence, until medical discharge. Pregnant women are covered during pregnancy, childbirth and the weeks after. Anyone under 18 is covered in all cases. A refusal or a disputed bill does not change this. Go to urgent care if you need it.

If your health card is refused

A refusal must be in writing. It must give the reasons, name the appeals open to you, say which body hears them and give the deadlines. Common reasons are missing proof of residence (your padrón registration), no social security cover or missing documents. If your letter leaves out the reasons or the appeal information, ask for a corrected decision and still appeal on time.

Your route is a recurso de alzada. You file it with the superior of the body that refused you. Some regions set their own route, so follow what your refusal letter says.

The deadline is 1 month from the express decision. If nobody answers your application, silence usually counts as a refusal, not an approval. The time limit to appeal then runs longer, up to 3 months. The authority has 3 months to answer your appeal.

If the appeal fails or gets no answer, you can go to the contencioso-administrativo court. You have 2 months after an express decision, or 6 months when the authority stayed silent. Appealing first is optional. You can also ask your regional ombudsman to step in, and that does not cost you anything.

If you are not insured, ask about the regional route for people without resources. It usually asks for proof of residence in Spain for 90 days or more and proof that you have no cover elsewhere.

If you are billed for care

Some bills are lawful. A public hospital can charge people with no right to free care, such as visitors and non-entitled foreigners. This includes emergency care, which is billed afterwards at regional rates. It can also bill third-party payers, such as insurers or another country's health system. If you are entitled to care, you should not be charged for covered services. Only authorised co-payments, such as the pharmacy contribution, are allowed.

To contest a wrong invoice:

1. Read the invoice notice for the appeal route and deadline. Note the day you received it.
2. Write to the hospital or health service that issued it. State the facts and your grounds, for example that you are entitled to care, that you have insurance, or that there is an error.
3. Attach supporting documents and keep copies of everything.
4. Ask for a reasoned written answer.

For a public-price charge, the usual route is a recurso de reposición with the same body, or an alzada. The deadline is generally 1 month from receiving the invoice. In some regions the charge can go to an economic-administrative tribunal instead, also generally within 1 month. Going straight to court allows 2 months. If an insurer should pay, send the claim to the insurer instead.

The documents and deadlines below show what to gather and when.

Timeline and deadlines

• Read the refusal for its grounds, the appeal body and the deadlines: as soon as you receive it

• File a recurso de alzada before the superior of the body that refused: within 1 month of an express refusal, or within 3 months after silence takes effect

• Wait for the answer to your alzada: the authority has 3 months to resolve

• Challenge a hospital invoice for a public price by reposición or alzada: within 1 month of the notification

• Go to the contencioso-administrativo court after a refusal: within 2 months of an express decision, or 6 months from when silence takes effect

Documents you need

• The written refusal decision from the health authority, which must state the grounds, the appeals open to you, the body to appeal to and the deadlines.

• Proof of residence in Spain, such as your padrón registration (empadronamiento), usually for 90 days or more, if you apply through the regional route for people without resources.

• Proof that you have no health coverage elsewhere, for the same regional route.

• The invoice you are contesting, issued by the hospital or health service.

• Documents backing your grounds, such as proof of entitlement or insurance cover, attached to your written challenge.

Required documents differ by region, so ask your health centre or regional health service what they need.

Checklist

• Go to urgent care if you need it, whatever your card status; it is guaranteed until medical discharge.

• Check the invoice's notice for the appeal route and the deadline, and note the date you received it.

• Write to the hospital or health service that issued the invoice, stating the facts and your grounds, such as entitlement, insurance or an error.

• Send your challenge within 1 month of receiving the invoice.

What to watch out for

• Missing the appeal deadline: The time to appeal is short, and an invoice challenge can also lapse after 1 month from notification. Note the date you received the decision or invoice and file within 1 month. Use the deadlines in the notice.

• A refusal without reasons or appeal information: A valid refusal must be in writing, give its grounds, and name the appeals, the body and the deadlines. If any of this is missing, ask the office for a complete written decision and appeal anyway.

• Silence is not an approval: If nobody answers your card application, it is usually treated as a refusal, and time to appeal starts running. Appeal within 3 months after the silence takes effect rather than waiting.

• Some bills are lawful: A public hospital can bill you if you have no right to free care and no valid cover, even after an emergency. Before contesting, check whether you are entitled or covered by an insurer, and if so, send proof.

Frequently asked questions

Will I still get emergency care while my card is refused?

Yes, emergency care is guaranteed to everyone in Spain, even without a health card or legal residence, until you are medically discharged. Pregnant women are also covered during pregnancy, childbirth and the weeks after, and children under 18 are always covered.

Can a public hospital send me a bill after an emergency?

Yes, if you have no right to free public care and no valid cover, the hospital can bill you afterwards at regional rates. Patients with an insurer or an EU health card are usually billed through that insurer or their home country instead.

What happens if the health authority never answers my card application?

Silence on a card application is usually treated as a refusal, so you can still appeal. You can also ask the regional ombudsman to step in, or go to court within 6 months from when the silence takes effect.

Do I have to appeal before going to court?

No, the administrative appeals (alzada or reposición) are optional before the court route. If you skip them, you have 2 months from an express decision to go to the contencioso-administrativo court.