Fidelidade Insurance Claim Denied in Portugal

Fidelidade is Portugal's largest insurance group, holding a leading market share in both life and non-life insurance. Since 2014, the majority stake has been owned by China's Fosun International. Health insurance is offered primarily through Multicare — Fidelidade's health insurance subsidiary — which is the most widely distributed private health plan in Portugal, frequently provided as an employer benefit. If Fidelidade or Multicare has denied your claim, this guide explains your rights and the steps to challenge the decision.

Fidelidade and Multicare — Products and How They Work

Multicare (multicare.pt) is the dedicated health insurer within the Fidelidade group, covering:

• Primary care and specialist consultations within the Multicare provider network (rede de prestadores)
• Diagnostic tests: blood work, imaging, ECG
• Hospitalisation and surgical care (at network hospitals and through reimbursement for out-of-network emergencies)
• Dental care (with a dental rider — plano dentário)
• Medicines co-payment support
• Optical/vision coverage in some plans

Fidelidade also sells life insurance, accident insurance, and property insurance, with health riders available on life policies.

Most Multicare plans are subscription-based through an employer group policy (apólice de grupo). Individual plans (apólice individual) are also available, typically with longer waiting periods and more stringent underwriting.

Common Reasons Fidelidade/Multicare Denies Claims

Network-related denials:

• Out-of-network provider without prior authorisation: Multicare's reimbursement for care outside its rede de prestadores requires prior approval (autorização prévia) in most cases. Attending a private specialist outside the network without authorisation results in reduced or zero reimbursement.
• Facility not contracted: Some hospitals and clinics are in the Multicare network for specific services only. Verify coverage before treatment.

Coverage exclusions:

• Períodos de carência (waiting periods): Individual plans carry waiting periods of 3–6 months for general health care and up to 12 months for maternity. Claims arising during the waiting period are denied.
• Pré-existências (pre-existing conditions): Conditions diagnosed or treated before policy inception, and related sequelae, may be permanently or temporarily excluded.
• Cosmetic and aesthetic care: Procedures primarily for appearance improvement are excluded even if performed at a medical facility.
• Experimental or non-approved treatments: Therapies not approved by INFARMED (Portugal's national medicines authority) or not in standard clinical practice may be excluded.
• Dental exclusion: Dental care requires a specific plano dentário rider; without it, dental claims are denied.

Administrative denials:

• Late notification: Multicare requires notification of hospitalisation or elective procedures within a specified timeframe (often 24–48 hours before planned admission)
• Inadequate documentation: Missing internamento (admission) records, lack of diagnosis codes (ICD codes), or invoices not meeting Multicare's format requirements
• Claim submitted outside the deadline: Typically 30 to 180 days from the date of service, depending on the plan

Step 1: Review Your Apólice and CGS

Your Apólice de Seguro (policy) and Condições Gerais de Seguro (CGS) — the general policy conditions — are the governing documents. Download them from multicare.pt or request copies from your employer's HR if you hold a group plan. Find the specific exclusion clause cited in the denial and assess whether:

• The exclusion applies precisely to your clinical situation
• Multicare followed the correct procedure
• The definition used in the CGS actually covers your specific case

Step 2: File a Complaint with Fidelidade/Multicare

Submit a formal written complaint (reclamação) directly to Multicare/Fidelidade. Under Portuguese insurance regulations and consumer law:

• The insurer must acknowledge your complaint within 5 working days
• Must respond with a substantive decision within 20 working days (with a possible 10-day extension for complex cases)

Submission options:

• Online: multicare.pt or fidelidade.pt — "Contactos/Reclamações" section
• By registered post (carta registada com aviso de receção): Fidelidade, Largo do Calhariz 30, 1249-001 Lisboa (for Fidelidade) or Multicare's registered address
• In person: At any Fidelidade branch or agent office
• Via the Livro de Reclamações (Complaints Book): Every regulated business in Portugal must have a physical or electronic complaints book — requesting it triggers a legal obligation to respond

Step 3: Provedor do Cliente

Fidelidade maintains a Provedor do Cliente — an internal ombudsman — as required by ASF regulations. If your initial reclamação is rejected or inadequately addressed, formally escalate your case to the Provedor do Cliente. The Provedor reviews the complaint independently from the claims team and aims to provide a final internal decision within the regulatory timeframe.

Contact the Provedor do Cliente through the Fidelidade/Multicare website or by writing to the Provedor do Cliente specifically at the insurer's registered address, marking your correspondence clearly.

Step 4: ASF Complaint

After exhausting Fidelidade/Multicare's internal complaint process, escalate to the Autoridade de Supervisão de Seguros e Fundos de Pensões (ASF) at asf.com.pt. ASF supervises Fidelidade/Multicare and can investigate whether Portuguese insurance law was violated.

File online at asf.com.pt under "Reclamações" with:

• Your policy number
• The denial letter and all correspondence with Fidelidade/Multicare
• The Provedor do Cliente's response
• Your reclamação and supporting documents

ASF's regulatory pressure on a major insurer like Fidelidade is meaningful — ASF findings of non-compliance are published and contribute to supervisory ratings.

Step 5: Alternative Dispute Resolution and Courts

• CACCL or regional consumer arbitration centres: Free or low-cost arbitration for consumer insurance disputes up to certain values
• Julgados de Paz: For claims up to €15,000, peace courts provide fast, informal resolution — often within 60–90 days
• Civil courts (Tribunais de Comarca): For larger claims or complex legal disputes; legal representation advisable

Practical Tips

• Employer group plans: If your Multicare plan is employer-sponsored, contact your HR department — HR teams often have a dedicated Multicare corporate contact who can escalate service issues faster than individual complaint channels
• Multicare app and portal: Check the Multicare digital platform for claim status and supporting documents before assuming a denial is final — some denials are temporary pending receipt of documentation
• Always get prior authorisation for elective care: Before any planned hospitalisation, specialist procedure, or expensive diagnostic (MRI, PET scan), call Multicare's authorisation line or use the digital platform
• Multicare Contact: 214 489 489

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Related Reading:

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Internal vs External Insurance Appeal