Insurance dispute: what to do when your insurer refuses to reimburse treatment
An insurance refusal is not final: first you ask for the reasons in writing, then you compare the reason for the refusal with a specific clause of the policy and, if the reasoning is weak, you file a complaint first with the company itself, then with the State Insurance Supervision Service or the court. Some refusals are reversed at exactly these stages, because a company sometimes interprets an exclusion more broadly than the policy allows. Complaints and lawsuits are drafted by partner lawyers of Advocat.Ge, while we collect the documents and translate foreign invoices and the discharge summary.
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The policy clause by clausethe reason for refusal compared with the exact text of the contract
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A lawyer against the companycomplaint, supervisory body and, where needed, court
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Travel insurance tooforeign invoices and the discharge summary for a reimbursement claim, translated
In short: first steps after a refusal
- Ask for the refusal in writing. A "you are not entitled" said over the phone cannot be appealed; the letter should cite a specific clause of the policy.
- Get the full text of the policy. The insurance certificate and the brochure are not enough; the dispute turns on the rules and the annexes.
- Compare the reason with the text. An exclusion, a pre-existing condition, a waiting period and a limit apply exactly as written, not broadly.
- First the company, then the supervisor and the court. An internal complaint is quick and often enough; the later stages build on its reply.
- For treatment abroad, keep every original. The itemised invoice, proof of payment and the discharge summary are the basis for reimbursement.
Why do insurers refuse, and when can the refusal be disputed?
The reasons for refusal are few and almost always fall into one of these categories. Each has its own way of checking it and its own weak point.
| Reason for refusal | What it means | What to check | When it can be disputed |
|---|---|---|---|
| Exclusion | The policy does not cover this condition, service or circumstance | The exact list of exclusions and their wording | When the company interprets vague or general wording broadly against you |
| Pre-existing condition | The condition existed before the insurance began | What the company asked in the questionnaire and what you answered; when the diagnosis was first made | When the diagnosis was made after the policy started, or the company never asked about what it now holds against you |
| Waiting period | Certain services are reimbursed only after a set time from the start of the policy | The length of the waiting period and when it starts, especially on renewal | When the policy was renewed without a break, or the case was an emergency to which the period does not apply |
| Limit or sub-limit | The annual limit or the limit for a specific service has been used up | The amount of the limit, sums already reimbursed, the excess and the co-payment | When the calculation was wrong, or a single case was wrongly split into several |
| Procedural breach | You notified the insurer late, did not get prior approval or were treated outside the network | The deadline and form for notification, the prior approval requirement, the network list | When the breach did not affect the company's costs, or the situation was an emergency |
If the refusal comes from a state programme, for example the Universal Healthcare Programme or City Hall, it is not an insurance dispute and is challenged under administrative procedure; we cover that route on the page on finding funding sources.
How to read the policy once you have been refused
You read a policy differently after a refusal than when you bought it. Now you are looking for the answer to one specific question: did the contract cover this very case?
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The definition of an insured event
Start with how the policy defines an insured event. If your situation fits that definition, the burden shifts to the company: it must show which exclusion removes the cover.
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Comparing the exclusions word for word
Take the clause cited in the refusal letter and compare it with the diagnosis and treatment. An exclusion is read narrowly: if it says "cosmetic surgery", that does not automatically include reconstructive surgery after an injury.
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Deadlines and periods
Check the policy start date, the waiting periods, the renewal dates and the notification deadline. Often the very point in dispute is when the count should have started.
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Financial terms
The limit, sub-limits, excess, co-payment percentage and the basis for reimbursement: the network price or the actual cost. Use these figures to recalculate what should have been reimbursed.
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Dispute resolution rules
The end of the policy usually states how and within what deadline a decision must be challenged and which court has jurisdiction. That deadline is the starting point of your plan.
The appeal route: from the company to the supervisor and the court
Each stage relies on the document from the previous one, so skipping the sequence and relying on oral agreements weakens the case.
| Stage | What you do | Possible outcome |
|---|---|---|
| 1. Requesting a reasoned refusal | You ask in writing which clause the decision relies on and which document was missing | Sometimes it already becomes clear at this stage that the issue was a missing document, not the cover |
| 2. Internal complaint to the company | A complaint drafted by the lawyer, with the policy text, medical justification and additional documents | The decision is reviewed, with full or partial reimbursement |
| 3. State Insurance Supervision Service | A complaint that the company has breached the law or its own rules | The company's conduct is examined and acted upon; this often speeds up negotiations |
| 4. Court | A lawsuit seeking an order for insurance reimbursement | A binding decision on payment of the amount |
Which documents should you collect for an insurance dispute?
Companies often justify a refusal precisely by a missing document. A complete package takes the force out of that argument from the start.
- The policy in full: the contract, the insurance rules, annexes, the table of cover and every renewal version.
- The completed insurance questionnaire, if you answered health questions when the insurance began. In a pre-existing condition dispute this is the key document.
- Medical documents: Form 100, the discharge summary, imaging reports and a doctor's letter explaining why the treatment was necessary and urgent.
- Financial documents: an itemised invoice, the payment receipt and a bank statement if you paid the cost yourself.
- A record of correspondence: the date and time of hotline calls, emails, the claim number and every reply from the company.
- A written refusal citing the policy clause; if you do not have one, requesting it is the first legal step.
A Solidaroba.ge coordinator assembles the package, requests missing documents from the clinic and the bank and puts the material in chronological order. The legal assessment, complaint and representation are handled by an Advocat.Ge lawyer. The cost depends on the stage of the case, and we tell you it in writing before you order. If you also need other sources to cover the rest of the treatment cost, see the financial mediation service.
Travel insurance: treatment abroad and recovering the cost
Illness or injury while travelling is the most common source of insurance disputes, because the clinic, the language, the currency and the insurer are in different countries.
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The assistance hotline
Most travel policies require you to contact the assistance company before going to a clinic or immediately afterwards. Note the time of the call and the operator's instructions: a failure to notify is a common reason for refusal.
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Direct payment or reimbursement
If the insurer did not pay the clinic directly and you covered the cost yourself, you claim reimbursement afterwards. In that case keep every original document and proof of payment.
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Language and translation
A Georgian insurance company usually asks for a foreign invoice and discharge summary together with a Georgian translation. A foreign insurer, in turn, needs Georgian documents in its working language.
For a reimbursement claim, a foreign clinic's invoices, bank statements and card payment confirmations must be translated precisely, keeping the amounts and currency unchanged; for this we offer translation of invoices and bank documents. For the medical part, a discharge summary translation is prepared. If a dispute with a foreign insurer goes to court, or a Georgian court decision has to be presented to a foreign company, you will need a translation of court decisions and procedural documents, checked by an Advocat.Ge lawyer.
Frequently asked questions about insurance disputes
How long does the insurance company have to reply?
The deadline for a decision on reimbursement is set by law and by the policy itself, and runs from the day the company received all the documents it requested. So it is important that delivery of the documents is confirmed in writing: by an email reply, a claim number or a signature. If the company asks for documents piece by piece and extends the deadline that way, this should be visible in the correspondence. A separate deadline applies to the reply to an internal complaint. If a deadline has been missed, the lawyer also bases the complaint to the supervisory body on that fact.
The insurer says I had the condition before the policy. How do I prove otherwise?
First it must be established what the company relies on: an old medical record, the questionnaire you filled in, or merely a doctor's assumption about how long the condition has existed. If the diagnosis was first made after the policy started and you had no symptoms before, this is confirmed by medical records and a letter from the treating doctor. If the questionnaire did not ask you about this condition, your silence does not count as concealing information. It also matters how the policy itself defines a pre-existing condition, because definitions differ between companies.
The Universal Healthcare Programme or City Hall refused me. Is that an insurance dispute?
No. The Universal Healthcare Programme and municipal funding are state programmes, not insurance contracts. Their refusal is an administrative decision, challenged by an administrative complaint and, where necessary, in the administrative court, with strict deadlines. An insurance dispute, by contrast, arises from a private contract and is heard under civil procedure. Often you have both at once: the universal programme covers part of the cost and a private policy the rest. In that case the lawyer runs both processes in parallel, so that you do not miss one deadline because of the other.
I paid for treatment abroad myself. How do I get the money back from travel insurance?
You submit the reimbursement claim to the insurer within the deadline set by the policy, together with a description of the insured event, the discharge summary or doctor's report, an itemised invoice, proof of payment, tickets or another document confirming your travel dates, and a record of your communication with the assistance company. Foreign-language documents usually need translating. A common mistake is submitting a general receipt instead of an itemised invoice. We check the package before submission and translate it, and if a refusal still comes, the lawyer starts the appeal.
Is it worth going to court over a small amount?
It depends on the balance between cost and outcome, and the lawyer will give you an honest answer. With a small amount, the dispute usually ends at the internal complaint stage or with a complaint to the supervisory body, which costs relatively little. Two circumstances favour going to court: when the ground for refusal will recur in the future, for example with annual treatment of a chronic condition, and when the refusal plainly contradicts the text of the policy. The lawyer will also explain in advance how court costs are allocated, so that you decide with the full picture.
Can I dispute a corporate policy if my employer signed the contract?
Yes. In corporate insurance the contract is between the employer and the company, but you are the insured person and the recipient of the reimbursement, so you have the right to make a claim and to appeal. The first problem is usually getting the policy text: employees often have only a short summary. Ask for the full rules and annexes from the human resources department or directly from the insurance company. Sometimes the employer's involvement speeds up the dispute, because keeping a corporate client matters to the company and it is more willing to negotiate.
Related to insurance disputes
- Medical disputes and complaints When the problem is with the clinic: an inflated bill, an error or a refusal of service.
- Form 100 translation The medical certificate in a foreign insurer's working language, with notarisation.
- Protection of patient rights How to get from the clinic the copies of medical records that the insurer asks for.
Been refused? Let us read the policy first
Send us the policy and the company's letter. The lawyer will assess how solid the refusal is, what arguments you have and which deadline is already running.