Appeal against the insurer's decision - how to write it?

A denial of a benefit, an underpayment, or information that an event „does not fall within the scope of coverage” can come as a surprise. For many people this is the end of the subject, but in practice it is often just the beginning of the conversation with the company. If you have a policy (for example, insurance for medical expenses of a foreigner in Poland) and do not agree with the settlement, you can file an appeal, or complaint, against the insurer's decision.

The key is to act calmly and methodically: check the basis for the denial, gather documents, and write a letter that addresses the T&C and the facts. In this guide, we show you step-by-step how to prepare an effective appeal of an insurer's decision on a policy, what deadlines usually apply (often 30 days for a response), and what to do if the insurer maintains its position.

Before you write an appeal, read carefully the letter of denial or the decision to pay out in a lower amount. The insurer should indicate the circumstances and the basis (e.g., a provision in the T&C) that justify the refusal or a different calculation of the benefit. If the decision lacks specifics, this is already a valid argument to clarify the case.

Then refer to the T&C (General Terms and Conditions of Insurance) and product sheet. In health policies for foreigners, definitions of events, limits and sublimits, exclusions of liability (e.g., treatment outside Poland) and the requirement to contact an emergency center are often key. It's also sometimes helpful to have a breakdown of the coverage of medical expenses and assistance benefits to compare with bills and medical records. If you want to sort out the topic, see also the guides on the site, such as. medical expenses of a foreigner.

An appeal against an insurer's decision is most often made by way of a complaint related to the conclusion or execution of an insurance contract. A complaint can usually be made in writing, electronically (form) or orally on the record/telephone. In practice, it is best to choose written or electronic form, because you have proof of content and date of sending.

In the letter itself, stick to the facts and structure. Indicate the policy number, the claim number (if there was one), the date of the decision, and clearly write what you expect: payment of the benefit in full, payment of the difference, acknowledgement of liability, or correction of the position. Then address the insurer's arguments and show why the insurer's decision is incorrect in light of the T&Cs and evidence.

If the problem is that the policy was amended or annexed (e.g., before entry into Poland), also include confirmation of the changes: a new certificate, annex, e-mail from the seller. This may resolve whether a particular version of the T&Cs was in effect on the date of the incident. Check the manual if necessary: change of policy before entry.

The insurer usually has a maximum of 30 days from receipt to respond to a claim. In particularly complicated cases, the deadline can be extended to 60 days, but the insurer should inform you of the reason for the delay and the expected response date. It is advisable to send the appeal by registered mail or e-mail with confirmation, so that deadlines can be easily counted.

In practice, denial is often based on two categories of arguments: (1) the event is not covered because it is subject to an exclusion; (2) the benefit is due, but the documents are missing or the limit is lower. In an appeal, it is useful to separate these threads and respond to each of them.

If an insurer cites an exclusion, check whether it actually fits your situation. For example, in medical expenses insurance for foreigners, medical expenses incurred outside the territory of the Republic of Poland or events resulting from illegal activities may be excluded. If an exclusion is described in general terms, ask for a specific point in the T&C and an explanation of how the insurer applied it to your facts.

If the dispute is over a limit or variant, compare the policy certificate with the table of benefits. Sometimes the problem stems from the fact that a policy was purchased for a visa or residence card with narrower coverage. It can be helpful to compare variants, such as on the website: insurance for visa and residence card.

When you receive a response and the insurer upholds the decision, it does not mean that the topic is closed. Depending on the situation, you can use further paths. The most common, in practice, are a request to the Financial Ombudsman for intervention or amicable proceedings, mediation/arbitration at financial market institutions, or a lawsuit to a general court.

If you are a consumer, you can also seek help from the city or county consumer ombudsman. In formal matters (e.g., insurance for a Schengen visa), it is worthwhile in parallel to ensure the completeness of your residence documents, as insurance is sometimes only one element of the application. For additional information, see the guide: Schengen visa type C.

If you are considering litigation, collect all correspondence, decisions, T&Cs, claim confirmations and medical evidence. In many cases, details are key: dates, contact with the emergency center, and documentation of costs incurred. Before you go any further, be sure to use the claims procedure, as this often organizes the evidence.

It's a good idea to treat an appeal of an insurer's decision on a policy like a structured pleading: facts, T&Cs, documents and a specific request. First, find out exactly what the insurer disputed. Then gather the missing evidence and file the complaint in a form that gives proof of service. Remember, too, the response time limits (usually 30 days, exceptionally up to 60 days).

If the insurer's decision is still negative, you can use the Financial Ombudsman or take your case to court. And if you are just choosing a policy, go back to guide and compare options and exclusions to avoid disputes at future events.