Insurance Claim Denied in Brazil: SUSEP and PROCON Complaint Guide

Insurance Claim Denied in Brazil: SUSEP and PROCON Complaint Guide

Brazil has a well-developed insurance sector regulated by multiple government bodies. If your insurance claim has been denied, you have concrete legal rights and official channels to pursue your appeal. This guide explains the Brazilian insurance regulatory framework, the roles of SUSEP and PROCON, and the practical steps you can take to challenge a claim denial.

The Brazilian Insurance Market: An Overview

Brazil is the largest insurance market in Latin America, with tens of millions of active policies covering life, health, property, motor, and liability risks. Brazilian insurers are primarily regulated at the federal level, with consumer protection available through both federal and state agencies.

The Brazilian Civil Code and the Consumer Protection Code (Código de Defesa do Consumidor, Law No. 8,078/1990) both apply to insurance contracts. The Consumer Protection Code is particularly important because it establishes a robust framework of consumer rights that courts and regulators apply broadly to insurance disputes.

Why Insurance Claims Get Denied in Brazil

Pre-existing conditions (doenças preexistentes): Health and life insurance denials often cite undisclosed or pre-existing medical conditions. However, Brazilian law limits the insurer's ability to use non-disclosure as grounds for denial if the insurer did not conduct a proper medical examination before issuing the policy.

Technical exclusions: Property and motor insurers often deny claims based on technical exclusions buried in the policy wording. These are subject to challenge under the Consumer Protection Code, which requires contractual terms to be clear and unambiguous.

Aggravation of risk (agravamento do risco): Insurers may deny claims if they argue the insured's actions aggravated the risk of the insured event beyond what was contemplated at the time of policy issuance.

Late notification: Most Brazilian insurance contracts require prompt notification of a claim event. However, courts have repeatedly held that the insurer must demonstrate actual prejudice from late notification before it can use this as grounds for denial.

Alleged fraud: Brazilian insurers routinely flag suspicious claims for investigation, particularly in motor insurance (where vehicle theft and fraud are significant issues) and health insurance.

SUSEP: Brazil's Insurance Regulator

SUSEP (Superintendência de Seguros Privados) is Brazil's federal insurance regulator, established under Decree-Law No. 73/1966. SUSEP operates under the Ministry of Finance and is responsible for:

• Licensing and supervising insurance companies, reinsurers, and brokers
• Establishing regulatory standards for insurance products and contracts
• Monitoring insurer solvency and market conduct
• Receiving and processing consumer complaints against insurers

SUSEP's website is susep.gov.br. SUSEP operates a consumer service (Serviço de Atendimento ao Consumidor, SAC) that receives complaints from policyholders. You can file a complaint via the SUSEP website or by calling the national consumer hotline.

Filing a complaint with SUSEP:

Complaints to SUSEP should include:

• Your policy number and the insurer's name
• A description of the denial and the grounds cited by the insurer
• Copies of all relevant correspondence, the denial letter, and your policy
• A description of any previous attempts to resolve the matter directly with the insurer

SUSEP will investigate and may require the insurer to provide a response. While SUSEP does not directly award compensation, its intervention often prompts insurers to reconsider unjustified denials to avoid regulatory sanctions.

PROCON: Consumer Protection at State Level

PROCON (Programa de Proteção e Defesa do Consumidor) operates at the state level and applies the Consumer Protection Code to disputes between consumers and businesses, including insurers. Each state has its own PROCON office, with São Paulo's PROCON (Procon-SP) being the largest and most active.

PROCON can:

• Mediate disputes between consumers and insurers
• Issue fines against companies that violate consumer protection law
• Pursue collective or class action remedies for systemic violations
• Coordinate with the federal consumer protection system (Senacon/SINDEC)

You can file a complaint with your state's PROCON office in person or, in most states, online. The consumidor.gov.br platform (managed by Senacon) is an increasingly important federal online complaint platform that many large insurers participate in and are required to respond to within a set timeframe.

Filing on consumidor.gov.br:

The consumidor.gov.br platform is a direct mediation service between consumers and registered companies. If your insurer participates (most major Brazilian insurers do), you can file a complaint and the insurer is obligated to respond within 10 calendar days. The platform has a strong track record of securing voluntary resolutions.

Step-by-Step: How to Appeal an Insurance Denial in Brazil

Step 1: Request a Formal Denial Letter

Ensure you have the insurer's denial in writing (notificação de recusa), clearly stating the grounds for denial. If the denial was communicated verbally or informally, request written confirmation.

Step 2: Review Your Policy and the Consumer Protection Code

Read your policy wording carefully, paying attention to exclusion clauses and notification requirements. Then consider whether the denial is consistent with the Consumer Protection Code's requirements of transparency and clarity. Ambiguous contractual terms are construed against the insurer under Brazilian law.

Step 3: Submit a Formal Internal Complaint

Write to the insurer's formal complaints channel (Ouvidoria). Under Brazilian Central Bank and SUSEP regulations, insurers must have an Ouvidoria (internal ombudsman) that is independent of the commercial area and is required to review and respond to complaints escalated from the SAC (customer service). The Ouvidoria must respond within 10 business days, extendable by 5 days with notice.

To draft a compelling appeal letter tailored to Brazilian insurance disputes, use ClaimBack at claimback.app. The tool generates professional appeal letters that reference the correct legal framework and structure your argument effectively.

Step 4: File on consumidor.gov.br

If the insurer's Ouvidoria does not resolve your complaint satisfactorily, file a complaint on consumidor.gov.br. This platform is monitored by Senacon and provides a strong incentive for insurers to resolve disputes quickly.

Step 5: File with SUSEP

File a formal regulatory complaint with SUSEP at susep.gov.br. SUSEP complaints are particularly effective when the denial appears to be based on ambiguous or improperly drafted policy terms that violate SUSEP's own circular regulations on minimum policy standards.

Step 6: File with PROCON

If the matter involves clear consumer rights violations, file with your state PROCON. PROCON can impose significant fines on insurers and has strong mediation powers.

Step 7: Consider Legal Action

Brazilian civil courts handle insurance disputes, and the Consumer Protection Code provides for the recovery of moral damages (danos morais) in cases of wrongful denial, which can significantly increase the insurer's exposure. Consult a Brazilian insurance law specialist (advogado especialista em direito securitário) for claims involving substantial amounts.

Common Mistakes in Brazilian Insurance Appeals

Not using the Ouvidoria before escalating: SUSEP and PROCON generally expect you to have exhausted the insurer's internal complaint process first. Skipping this step can delay your complaint.

Missing the limitation period: Brazilian civil law provides a general limitation period of one year for insurance claims (Código Civil, Article 206, §1, II). Do not delay.

Accepting verbal resolutions: Always insist on written confirmation of any settlement or resolution.

Not claiming moral damages: In cases of particularly egregious or unjustified denials, Brazilian courts routinely award moral damages on top of the insured amount. This is worth discussing with a lawyer.

Conclusion

A denied insurance claim in Brazil is not the end of the road. Between SUSEP, PROCON, the consumidor.gov.br platform, and the courts, Brazilian consumers have multiple powerful channels to challenge unjust denials. Start with the insurer's Ouvidoria, escalate systematically, and use professional tools like ClaimBack at claimback.app to build the strongest possible case at every stage.

Useful Links

• SUSEP: susep.gov.br
• consumidor.gov.br (Senacon platform): consumidor.gov.br
• Procon-SP: procon.sp.gov.br
• Senacon (national consumer secretariat): justica.gov.br/senacon