Health Insurance Claim Denied in Romania: Guide

Romania operates a mandatory public health insurance system managed by CNAS alongside a growing private health insurance market regulated by ASF. Millions of Romanians rely on their CNAS contributions for hospital care and prescription coverage, while private plans from Allianz-Țiriac, Groupama, and others supplement access to faster, higher-quality care. When a claim is denied under either system, Romanian law provides a clear path to challenge the decision.

Romania's Health Insurance System

CNAS — Casa Națională de Asigurări de Sănătate

The Casa Națională de Asigurări de Sănătate (CNAS) at cnas.ro is Romania's national health insurance house, administering the public health insurance system funded by social contributions from employees and employers. CNAS works through 41 county-level health insurance houses (case județene de asigurări de sănătate — CJAS) plus the Bucharest Health Insurance House (CASAOPSNAJ for certain public sector employees).

CNAS covers:

• GP (medic de familie) consultations
• Specialist consultations with referral
• Hospitalisation and surgery at contracted facilities
• Prescription drugs from the national compensated list (Lista medicamentelor compensate și gratuite)
• Preventive care (vaccination, screening programmes)
• Emergency medical care

Entitlement to CNAS services depends on being an asigurat — a person who has paid (or whose employer has paid) health insurance contributions. Those who are exempt from contributions (children, pensioners, the unemployed) are generally also entitled.

Private Health Insurance in Romania

Private insurers provide supplementary and complementary health coverage. Major players include:

• Allianz-Țiriac Asigurări — one of Romania's largest and most established private insurers
• Omniasig Vienna Insurance Group — large non-life insurer
• Groupama România — covers health, auto, property
• AXA Romania — health and life products
• Signal Iduna România — health-focused private plans
• Generali România — health and life coverage

Private health insurance is regulated by the Autoritatea de Supraveghere Financiară (ASF) at asf.ro.

Common Reasons Claims Are Denied in Romania

For CNAS:

• Not enrolled / inactive insured status: Contributions not up to date; self-employed individuals who missed payment deadlines are frequent victims
• Missing referral (bilet de trimitere): Specialist consultations and most diagnostic tests require a referral from your medic de familie; without it, CNAS will not reimburse
• Non-contracted provider: The hospital, clinic, or pharmacy does not have a contract with your CJAS for the specific service
• Drug not on the compensated list: The prescribed medication is not included in the national reimbursement list, or the prescription does not meet the clinical criteria for compensation
• Service not in the basic benefit package: Certain dental procedures, cosmetic treatments, and experimental therapies are excluded

For private insurers:

• Pre-existing condition: Medical history not disclosed at application or conditions arising during the waiting period
• Exclusions in policy: Cosmetic, dental (without rider), experimental, or excluded procedures
• Claim submitted late: Most private insurers require notification and documentation within 30 to 60 days
• Insufficient documentation: Missing diagnosis codes, specialist reports, or itemised invoices

Appealing a CNAS Denial

Step 1: Written Contestație (Administrative Challenge)

Under Romanian administrative procedure law, you can file a contestație (written challenge) against a CNAS or CJAS decision within 30 days of receiving the denial notice.

Address your contestație to the CJAS (county health insurance house) that issued the decision, or to CNAS for central decisions. Your contestație should include:

• Your CNAS insurance number (CNP — Cod Numeric Personal)
• Reference to the specific decision being challenged
• Legal and factual grounds: e.g., you are an active asigurat (attach recent contribution records), you had a valid bilet de trimitere, the drug is on the compensated list
• Supporting documents: contribution records, referral, medical records, prescription, invoices

CJAS/CNAS must respond within 30 days with a new administrative decision.

Step 2: Administrative Court (Contencios Administrativ)

If the contestație is rejected, file a legal challenge in the competent Tribunal (section for administrative and fiscal disputes) under Romania's Legea nr. 554/2004 (Law on Administrative Litigation). Legal representation (avocat) is advisable.

Appealing a Private Insurance Denial

Step 1: Internal Complaint

File a written complaint with your insurer. Romanian law requires a response within 30 days.

Step 2: ASF Complaint

File a complaint with the Autoritatea de Supraveghere Financiară (ASF) at asf.ro. ASF can investigate regulatory violations and requires insurers to respond. While ASF does not award individual compensation, regulatory pressure often prompts settlement.

Step 3: Mediation or Court

Romania has a mediation framework that can resolve insurance disputes faster than civil litigation. Civil courts (judecătorie or tribunal, depending on the claim value) handle contractual insurance disputes. Claims up to 200,000 RON go to the judecătorie; larger claims to tribunal.

Key Contacts in Romania

• CNAS central: cnas.ro | Calea Călărașilor 248 Bl. S19, București | Tel: 021 313 9775
• ASF: asf.ro | Splaiul Independenței 15, 050092 București | Tel: 021 659 6000
• ANPC (Consumer Protection): anpc.ro — for consumer rights issues beyond insurance
• Your county CJAS: Find your local house at cnas.ro under "Case județene"

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Related Reading:

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