Health Insurance Claim Denied in Lithuania? Here's How to Appeal

Lithuania's healthcare system combines compulsory public health insurance with a growing private insurance sector. Whether your denial came from the Territorial Health Insurance Fund (TLK), the national public insurer, or a private company like ERGO or If P&C, you have specific legal rights and appeal paths available to you.

Lithuania's Health Insurance Structure

Compulsory health insurance (privalomasis sveikatos draudimas) is administered through five Territorial Health Insurance Funds (Teritorinės ligonių kasos, TLK) — Vilnius, Kaunas, Klaipėda, Šiauliai, and Panevėžys — overseen by the National Health Insurance Fund (Valstybinė ligonių kasa prie SAM, VLKK). All employed persons, social benefit recipients, and certain categories of residents are mandatorily insured through this system.

VLKK contracts healthcare providers to deliver state-covered services. Patients access free or reduced-cost care through their registered GP (šeimos gydytojas) and specialist referrals.

Private health insurers provide supplemental coverage for faster service, wider choice, and services not publicly funded. Key private insurers include:

• ERGO Insurance SE Lithuania — part of the Munich Re Group
• If P&C Insurance (If Lithuania) — Sampo Group subsidiary, popular for employer plans
• Compensa Vienna Insurance Group — VIG subsidiary with significant Lithuanian presence
• BTA Insurance Company SE — Baltic-focused insurer
• Gjensidige — Norwegian insurer operating in Lithuania

Common Reasons for Denial

• Not registered with TLK — gaps in contributions or registration causing coverage loss
• Service not in the reimbursement basket — treatment not listed in the Basic and Additional Health Insurance Programme (BPAP)
• Referral chain not followed — seeing a specialist without TLK-required GP referral
• Private insurer: pre-existing condition — non-disclosure alleged at the time of application
• Treatment outside contracted network — private plan not covering out-of-network provider
• Abroad treatment without Prior Authorization Denied: How to Appeal" class="auto-link">prior authorization — EU/EEA treatment under S2 form not pre-approved

Step 1: Obtain the Written Decision

TLK and VLKK decisions are administrative acts subject to the Law on Public Administration (Viešojo administravimo įstatymas). You are entitled to a written decision with stated reasoning and appeal instructions. Private insurers must provide written denial grounds under Lithuanian Civil Code insurance provisions and the Law on Insurance (Draudimo įstatymas).

Step 2: Internal Appeal

For TLK/VLKK denials: File a written complaint (skundas) with the relevant TLK within 20 business days of the decision. Include medical documentation supporting your position. TLK must respond within 20 working days.

For private insurer denials: Submit a formal written complaint to the insurer. Under Lithuanian law, insurers are required to resolve complaints within a reasonable period. Include all policy documentation, denial letters, and medical evidence.

Step 3: Lietuvos bankas — The Bank of Lithuania

The Lietuvos bankas (Bank of Lithuania) is the financial regulator for all insurance companies operating in Lithuania. For private insurance disputes, the Bank of Lithuania operates a Supervisory Service for Consumer Protection that handles complaints about insurers.

More importantly, Lithuania has a Financial Dispute Resolution Service (FGTS — Finansinių ginčų sprendimo tarnyba) operating under the Bank of Lithuania. This free, independent body can adjudicate insurance disputes between consumers and financial institutions. Decisions are binding if the consumer accepts them. To file, visit lb.lt.

For unresolved TLK/VLKK appeals, you can escalate to the Vilnius Regional Administrative Court (or the relevant regional court), which has jurisdiction over administrative decisions.

Step 4: Patient Rights and Healthcare Advocacy

Lithuania's Law on the Rights of Patients and Compensation of Harm to their Health (Pacientų teisių ir žalos sveikatai atlyginimo įstatymas) guarantees rights to information, quality care, and redress. The State Patient Rights and Health Insurance Inspectorate (Valstybinė pacientų teisių ir žalos sveikatai atlyginimo tarnyba) investigates complaints about patient rights violations, care quality, and TLK insurance disputes.

This inspectorate is a particularly powerful resource — it can investigate TLK decisions, order corrections, and report systemic issues to the Ministry of Health.

Building a Strong Appeal

• Obtain a detailed medicinos pažyma (medical certificate) confirming necessity from your treating specialist
• For VLKK/TLK cases: confirm your insurance contributions were correctly paid and registration is current
• For private cases: challenge the medical reviewer's assessment with your own specialist's opinion
• Reference the Sveikatos draudimo įstatymas (Law on Health Insurance) for your rights under compulsory coverage
• For EU treatment: document emergency nature or submit proper S2 form in advance for planned care

Fight Back With ClaimBack

Whether the Vilnius TLK denied your benefit or ERGO Lithuania rejected your private health claim, ClaimBack helps you build a structured, compelling appeal.

Start your appeal at ClaimBack

We help you identify the grounds for denial and write an appeal that Lithuanian insurance regulators and courts take seriously.

Related Reading

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Insurance Ombudsman Guide