When the insurer says no: what Spanish law actually gives you

First, work out which argument you are actually having

Refusals come in two shapes, and people routinely fight the wrong one.

A cover dispute is the insurer saying the policy never promised this. An exclusion applies; the treatment falls outside the benefit; a waiting period had not expired; the condition was one the policy was never underwritten to accept. The question is whether.

A quantum dispute is the insurer agreeing it owes something and disagreeing about how much. On a reimbursement product this is the common one: the invoice says one figure, the settlement says another.

The reason to separate them before writing anything is that Spanish law treats them differently. A quantum dispute has its own procedure, set out below, that does not require anyone to go to court. A cover dispute does not — it turns on the wording of your conditions and on whether the clause the insurer is relying on was presented to you the way the law requires.

The clocks the insurer is running against

This is the part most people do not know, and it changes the tone of the conversation.

Forty days. Under art. 18, the insurer must pay a minimum amount within forty days of receiving notification of the claim — not forty days from agreeing it, and not forty days from the end of its investigation. The full indemnity is due when the investigations needed to establish the claim and its amount are complete, but that minimum is not contingent on the investigation finishing.

Three months. Under art. 20, if the insurer has not paid within three months of the loss, penalty interest starts to run. It also runs if the forty-day minimum was not paid.

And the interest is not nominal. The legal rate increased by 50%, and once two years have passed, a floor of 20% a year. That is a deliberate design: the legislator made delay expensive so that delay is not a negotiating tactic.

None of that decides whether you are owed anything. What it does is put a cost on silence. An insurer that has neither paid nor properly refused is not in a neutral position, and saying so — with the article numbers — usually changes who replies to your emails.

Make the refusal do some work

A refusal that says “not covered under the terms of your policy” has told you nothing you can test. Ask, in writing, for three specific things.

Which clause. Not which section, which clause. You cannot check a reason you cannot locate.

Where it appears in your documents. Art. 3 requires general and particular conditions to be drafted clearly and precisely, and — this is the operative part — requires clauses limiting the rights of the insured to be highlighted in a special way and specifically accepted in writing. A limitation buried in continuous text, never signed for, is in a materially weaker position than one you initialled. Which policy document governs explains how the document stack fits together.

What would change the answer. A report, a code, a pre-authorisation that was missing. Sometimes the refusal is procedural rather than substantive, and nobody has said so.

Put all three in one message, dated, and keep the reply. If the insurer’s answer names a clause that does not say what the insurer claims, you have moved from a disagreement to a documented discrepancy — which is a different conversation.

If the refusal is about what you declared

This is the refusal that frightens people most, and the one where the law is least like the letter suggests. An insurer says the claim is declined because something was not disclosed when the policy was taken out. The implication is that the policy was void from the start and nothing is payable.

Art. 10 does not work that way, and the distinctions are worth knowing before you accept the framing.

The duty was to answer the questionnaire. The pre-contractual duty is to declare the circumstances known to you in accordance with the questionnaire the insurer puts. It is expressly discharged where the insurer put no questionnaire at all, and where the circumstance falls outside the questions it did put. A policy sold with three casual questions cannot later be treated as though it had asked forty. The medical questionnaire covers what that duty involves at application.

The default consequence is reduction, not refusal. Where the claim event occurs before the insurer has declared rescission, the benefit is reduced in proportion to the difference between the premium charged and the premium that would have applied had the true risk been known. That is a proportionate adjustment, not a forfeiture.

Total release requires dolo or culpa grave. The insurer is freed from payment entirely only where there was deliberate concealment or gross negligence on the policyholder’s part. An honest omission on a question that was ambiguous is not that, and the insurer asserting it is making a specific allegation it has to stand behind.

There is a one-month clock on the insurer too. It may rescind by declaration to the policyholder within one month of learning of the inaccuracy. An insurer that has known for a year and said nothing is in a different position from one that acted promptly.

If the argument is about the amount

Art. 38 gives you a procedure most policyholders never hear about, and it is worth knowing before you accept a figure out of fatigue.

Each side appoints an expert. If one side is asked to appoint and does not do so within eight days, it is taken to accept the other side’s valuation — a deadline that cuts both ways, so do not let it pass. If the two experts disagree, they appoint a third, whose report is due within thirty days.

That third report binds, unless it is challenged in court: thirty days for the insurer, one hundred and eighty days for the insured. The asymmetry is deliberate and it is in your favour.

This is not a route to reach for casually — it has costs and it takes time. But its existence is why an insurer’s “final” figure is not always final, and why it is worth saying out loud that you are aware of it.

The order to escalate in

The insurer’s own complaints department first. Spanish insurers maintain a customer service department or ombudsman for exactly this, and the external routes generally expect you to have used it. Complaints about healthcare and insurers sets out the wider landscape.

Then the supervisor. The Dirección General de Seguros y Fondos de Pensiones handles complaints about insurers once the internal route is exhausted.

Court, last. With the interest position under art. 20 in mind, because it materially changes what a delayed claim is worth.

At every stage, the file matters more than the argument. Dates of notification, what you sent, what came back, and when. Claiming medical expenses covers how to assemble that in the first place, which is much easier done before a dispute than during one.

What a refusal tells you about the policy

Once the immediate question is settled, there is a second one worth asking calmly: was this refusal wrong, or was it correct and the policy simply narrower than you believed?

If it was correct, the problem is not the claim — it is the cover, and it will happen again. What is excluded, and why is the page to read before renewal rather than after the next claim.

If it was wrong and the insurer conceded slowly, that is information too. It does not always justify leaving; a policy with the right network and an accumulated history has real value that a bad month does not erase. But it belongs in the decision.