GES Coverage Denied in Chile: Your Rights

The GES — Garantías Explícitas en Salud (formerly known as AUGE) is one of the most powerful patient protection systems in Latin America. Established in Chile to guarantee that the most burdensome and prevalent health conditions receive timely, affordable, quality care, the GES covers 90 specific conditions with legally enforceable rights. If your ISAPRE or FONASA denied GES-covered care, the denial is a direct legal violation — and the Superintendencia de Salud (SuperSalud) has authority to order immediate remediation.

What Is the GES?

The Garantías Explícitas en Salud is a Chilean health law program that defines four specific guarantees for a list of 90 health conditions:

1. Access (Acceso): Every Chilean with a GES condition — regardless of whether they are FONASA or ISAPRE — has the right to access defined treatment. This access cannot be denied based on plan tier, pre-existing condition clauses, or network restrictions.

2. Timeliness (Oportunidad): Each GES condition has a legally defined maximum waiting time for both diagnosis and treatment. For example, a cancer diagnosis must trigger treatment within a specific number of days. If your insurer or provider exceeds the waiting time, you can demand immediate referral through the GES network.

3. Financial Protection (Protección Financiera): Each GES condition has a legally defined maximum copayment. You cannot be charged more than this limit — regardless of your ISAPRE plan terms or FONASA tier. Any charges above the GES cap are unlawful.

4. Quality (Calidad): Treatment for GES conditions must meet minimum quality standards defined in the GES clinical guidelines.

The 90 GES Conditions: A Sample

The GES list covers the most prevalent and high-burden health conditions in Chile. A sampling includes:

Oncology:

• Breast cancer
• Cervical cancer
• Colorectal cancer
• Prostate cancer
• Stomach cancer
• Leukemia (in adults and children)
• Testicular cancer
• Lymphoma

Cardiovascular:

• Acute myocardial infarction (heart attack)
• Hypertensive disease
• Heart failure
• Stroke (ACV)
• Coronary artery bypass surgery

Chronic conditions:

• Diabetes mellitus type 1 and type 2
• Chronic kidney disease
• Chronic obstructive pulmonary disease (COPD)
• Rheumatoid arthritis

Mental health:

• Major depression (adults)
• Schizophrenia
• Alcohol and drug dependency

Pediatric:

• Congenital heart disease in newborns
• Cleft lip and palate
• Childhood cancers
• Autism spectrum disorder (in children)

Other:

• HIV/AIDS
• Tuberculosis
• Orthopedic conditions (hip replacement, knee arthroplasty)
• Visual impairment (cataract surgery, refraction)
• Oral health (preventive dental care for children and pregnant women)

For the complete and current list of all 90 GES conditions, visit supersalud.gob.cl and navigate to the GES section.

How Insurers Violate GES Rights

Common GES violations by ISAPREs and FONASA:

• Outright denial: The insurer refuses to authorize coverage for a GES-guaranteed condition, citing plan exclusions or pre-existing condition clauses. GES overrides all of these.
• Waiting time exceeded: Your treatment is delayed beyond the GES maximum waiting time. This violates the oportunidad guarantee.
• Excess copayment: You are charged more than the GES maximum copayment for your condition. This violates the protección financiera guarantee.
• Referral refusal: Your insurer refuses to refer you to a GES-covered specialist or facility within the required timeframe.
• Incomplete treatment: Your insurer authorizes initial care but then denies a component of the GES treatment protocol.

Step 1: Confirm Your Condition Is on the GES List

Before filing any complaint, verify that your condition is covered by GES and identify the specific guarantees that apply. Go to supersalud.gob.cl, navigate to Garantías GES, and search for your condition. The GES guide for each condition specifies:

• Who is covered (all FONASA and ISAPRE members)
• The maximum waiting time for diagnosis and treatment
• The maximum copayment you can be charged
• The treatment protocol (what must be covered)

Step 2: Document the Violation

Once you have confirmed the GES violation, document it:

• Your diagnosis (CIE-10 code from your physician) confirming the GES condition
• The date the violation occurred (denial date, or the date the waiting time was exceeded)
• The excess charge amount (if it is a copayment violation)
• Your physician's clinical documentation supporting the GES-covered treatment

Step 3: Reclamo With Your ISAPRE or FONASA

File a formal written complaint (reclamo) with your insurer citing the specific GES guarantee that has been violated. Reference:

• The GES condition by name and condition number
• The specific guarantee violated (access, timeliness, financial protection, or quality)
• The legal citation: Ley 19.966 and the corresponding GES Decree

ISAPREs must respond to GES-related reclamos within the timeframes specified by the GES guarantee itself — in some urgent cases, within days.

Step 4: SuperSalud GES Complaint

Escalate immediately to SuperSalud if your insurer does not resolve the GES violation. File your complaint at supersalud.gob.cl and clearly mark it as a GES complaint.

SuperSalud treats GES complaints as priority matters and can:

• Order immediate authorization of GES care
• Refer you to an alternative GES-covered provider if your insurer cannot provide timely care
• Impose significant financial penalties on the ISAPRE or FONASA administrator for GES violations
• Refer egregious violations to the Ministry of Health

What If Your ISAPRE Cannot Provide GES Care Within the Waiting Time?

If your ISAPRE cannot provide a GES service within the legally required waiting time — for example, a specialist appointment or surgery — SuperSalud can authorize a "prestación de cargo" (cost-covered treatment) at any accredited provider, with your ISAPRE required to pay the cost. You should not wait beyond the GES time limit without filing a complaint.

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