Médis Insurance Claim Denied in Portugal: Appeal

Médis is one of Portugal's major private health insurers, owned by Millennium BCP — one of the country's largest banks. Médis plans are popular both as standalone individual health insurance and as employer group benefits, particularly in financial services and banking sectors. When Médis denies a claim or reimbursement, you have clear rights under Portuguese insurance law and ASF regulations to challenge that decision.

Understanding Médis Health Plans

Médis (medis.pt) offers several plan families:

• Médis Total: Comprehensive health coverage including hospitalisation, surgery, specialist care, and diagnostics
• Médis Forma: Focused outpatient care, specialist consultations, and preventive health
• Médis Dental: Dedicated dental insurance plans
• Employer group plans: Often customised packages for corporate clients with Millennium BCP banking relationships

Médis operates a network of contracted providers (rede de prestadores Médis) that includes private hospitals, specialist clinics, and diagnostic centres across Portugal. Plans differ significantly in their network scope, reimbursement limits, and exclusions.

Common Reasons Médis Denies Claims

Out-of-network care without authorisation: Like other Portuguese health insurers, Médis distinguishes between in-network (rede convencionada) and out-of-network care. Seeking specialist care outside the Médis network without prior authorisation (autorização prévia) typically results in reduced or no reimbursement. Check your network access at medis.pt before treatment.

Waiting periods (períodos de carência): Médis plans, particularly individual plans purchased directly rather than through an employer, carry waiting periods before certain benefits activate:

• General illness: typically 3–6 months
• Maternity: often 9–12 months
• Some specialist conditions: up to 24 months in individual plans Claims arising during these carências are denied and cannot be appealed on the merits — they are structural exclusions during the defined period.

Pre-existing condition exclusion: Conditions diagnosed, treated, or symptomatic before the policy start date are excluded during the initial period (usually 12–24 months for individual plans) or permanently depending on the severity and the application disclosures made. If Médis believes a claim relates to a pre-existing condition, it will investigate medical history to determine whether the condition existed before policy inception.

Documentation failures: Médis requires specific documentation for reimbursement claims:

• A detailed invoice (fatura) from the provider with NIF (tax number), service itemisation, and the treating physician's details
• Diagnosis report (relatório médico) specifying the condition code (ICD)
• For hospitalisation: admission and discharge summary (episódio de internamento)
• For surgery: operative report (relatório operatório) Missing any of these documents typically results in delay or denial.

Plan limit exceeded: Many Médis plans set annual limits on specific benefits — for example, a maximum number of specialist consultations per year or a monetary cap on physiotherapy. Once the limit is reached, further claims in the same policy year are denied. These are structural plan limits, but disputes arise when Médis miscounts prior claims or applies limits incorrectly.

Step 1: Get the Denial in Writing

Request a written denial (comunicação de recusa de cobertura) from Médis with:

• The specific policy clause (condição particular or condição geral) relied upon
• The amount denied
• Instructions for filing a reclamação

If you received only a phone call or brief email, follow up in writing requesting the formal decision.

Step 2: File a Reclamação with Médis

Submit a formal reclamação to Médis under Portuguese insurance law. Médis must:

• Acknowledge within 5 working days
• Respond with a substantive decision within 20 working days (extendable to 30 working days in complex cases with written notification)

Submission methods:

• Online: medis.pt — "Área de Cliente" → "Reclamações"
• By registered post (carta registada): Médis — Seguros de Saúde, SA, Alameda do Parque, no. 14 A 15, 2794-531 Carnaxide
• In person: Médis's main office or via Millennium BCP branches that sell Médis products
• Livro de Reclamações: Request the electronic complaints book for an immediate formal record

Your reclamação should include:

• Your policy number and ID
• The service denied, date of treatment, provider details, and amount
• Why you believe the denial is incorrect — referencing the specific CGS clause Médis cited and explaining why it does not apply to your situation
• All supporting documents: referral, medical report, invoices, hospitalisation records

Step 3: Provedor do Cliente

If Médis's reclamação response is unsatisfactory, escalate to the Provedor do Cliente — the internal customer ombudsman Médis is required to maintain under ASF regulation. The Provedor reviews complaints independently of the claims department.

Contact the Médis Provedor do Cliente through the channels listed on medis.pt under the complaints section. The Provedor's decision is Médis's final internal position, after which you may go to ASF.

Step 4: ASF Complaint

File a complaint with the Autoridade de Supervisão de Seguros e Fundos de Pensões (ASF) at asf.com.pt. ASF supervises Médis and can investigate whether Médis violated Portuguese insurance regulations. ASF can issue regulatory sanctions against Médis and creates significant pressure on insurers to resolve individual complaints to avoid formal findings.

ASF complaint portal: asf.com.pt → "Consumidores" → "Reclamações"

Include: your Médis policy, all reclamação correspondence, Provedor do Cliente response, denial letter, and supporting documents.

Step 5: Arbitration and Courts

For a binding compensation order:

• Consumer arbitration (CACCL or regional centres): Free or low-cost; binding for amounts within the centre's jurisdiction
• Julgados de Paz: Claims up to €15,000; informal, fast, free to file
• Tribunal de Comarca: Civil claims under standard Portuguese civil procedure; legal representation advisable for claims above €5,000

Practical Tips for Médis Disputes

• Employer plan holders: Contact your HR or benefits administrator — Médis corporate account managers often resolve individual disputes faster through the B2B channel
• Médis app: Available on iOS and Android; use it to submit and track reimbursement claims with all documentation attached digitally from the start
• Annual benefits reset: If you are approaching an annual consultation or physiotherapy limit, ask Médis to confirm the exact count in writing before your next appointment — this prevents disputes over whether limits have been reached
• Médis Contact Centre: 707 20 40 20

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Related Reading:

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