If your health insurer does not fully reimburse treatment, a device or a bill, first clarify the reason. Missing authorisation, a non-contracted provider and care outside the insured package are different problems. A deductible or statutory personal contribution may also explain paying yourself despite cover existing. This guide helps investigate the insurance decision and complaints procedure. It concerns reimbursement and evidence; discuss which treatment suits you with your treating practitioner.
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1. Ask precisely which decision was made
Request a written decision stating the rejection reason, disputed amount and policy terms used. A statement containing only a brief code sometimes offers insufficient insight. Record the care, provider and treatment date concerned. Also establish whether the decision concerns a prior application or a bill for care already provided. Your reassessment request must address that specific decision.
Keep the policy for the relevant insurance year, application, referral, claim and earlier messages. Do not rely only on terms currently on the website. A bill may be submitted later than when care began. If in doubt, ask which year and contractual rules apply. Then make a chronology so, for example, prior authorisation remains connected with the final statement.
2. Separate basic and supplementary insurance
Basic insurance is bounded by the Dutch Health Insurance Act and related regulations. Not every available treatment therefore constitutes insured care. According to the Zorginstituut, factors include the care definition, the state of science and practice and whether someone reasonably needs that care. Ask which condition the insurer says is unmet and which information that assessment lacks.
For supplementary insurance, the insurer determines content and reimbursement conditions itself. These may include maxima, numbers or specific provider requirements. Rejection under basic insurance therefore does not fully answer supplementary cover, or vice versa. Compare both elements separately with your application. Request a breakdown of a combined overview so you do not inadvertently object to a limit belonging to another insurance element.
3. Check referral, authorisation and substantiation
Certain care may require referral or prior consent. Ask where this requirement appears, when consent should have been requested and which data were required. A practitioner’s referral is not automatically equivalent to insurer authorisation. Also check whether the application specifies the correct treatment, provider and period. An administrative mismatch may require a different solution from a substantive disagreement over the insured package.
Where needed, have the provider supplement missing factual information. Request a focused explanation of the point the insurer disputes. Sending complete medical records without selection is not always necessary; ask which data are relevant and through which secure channel to supply them. This approach does not determine medical treatment. It helps ensure insurance assessment uses the correct documents.
4. Examine consequences of a non-contracted provider
Under a benefits-in-kind policy, lower reimbursement may apply when using a provider without a contract. The terms explain calculation. A combination policy may provide different entitlements for different forms of care. Therefore check the specific care type and contract in the relevant year. An institution having a contract somewhere does not prove every treatment there falls under that contract for your policy.
For partial reimbursement, request the rate, percentage and applicable maximum used. A percentage says little without the amount to which it applies. Keep earlier written insurer information about contract status and financial consequences. If told something different beforehand, specify by whom, when and based on which data. Have the significance of that communication assessed separately.
5. Distinguish deductible, personal contribution and uninsured costs
The deductible applies to most care under basic insurance, subject to statutory exceptions. A statutory personal contribution is a separate amount payable personally for certain care. Both may apply to the same care. Supplementary insurance has no compulsory deductible. Therefore request an overview identifying which part the insurer classified as deductible, personal contribution or uninsured care.
Check the cost overview for amounts previously allocated to the deductible and the year to which care was attributed. Request itemisation for an unclear bundle of bills. Do not use an amount from another calendar year in your objection without checking. A fictional example: a bill feels rejected although the insurer reimbursed the care but charges a remaining deductible. The dispute then concerns calculation.
6. Request reassessment with a complete file
First submit your complaint to the health insurer and ask it to reconsider. State which elements you dispute and what outcome you seek. Add only documents helping answer the question, such as authorisation, a relevant policy passage or itemised invoice. Request a reasoned response to every independent issue. Preferably keep written records of contact about claims problems, even where a telephone call is the first practical step.
A reimbursement complaint differs from one about treatment quality. Where they overlap, identify the question submitted to the insurer and the one discussed with the provider. Rejection does not automatically cancel a provider’s bill. Therefore contact the provider about a disputed bill or payment arrangement and do not silently let deadlines expire. Keep medical choices with the practitioner and financial disputes in the insurance file.
7. Choose between SKGZ and court
If you cannot resolve matters with the health insurer, the Stichting Klachten en Geschillen Zorgverzekeringen may be a next step. The Health Insurance Ombudsman can mediate free of charge. The Disputes Committee can issue a binding decision and charges for handling. Check handling conditions and consequences beforehand. SKGZ is the designated specialised route for this kind of health insurance dispute; do not use the Kifid procedure for other insurance products without investigation.
The Zorginstituut specifies one year after the health insurer’s decision for submitting a complaint to SKGZ. Check which decision and date matter in your file and do not wait until that period ends. You can also approach the civil court. In urgent cases or for a substantial financial interest, promptly have the appropriate route and monitoring of overlapping deadlines assessed. Filing a complaint does not guarantee reimbursement.
Frequently asked questions
Does a referral mean my care is reimbursed?
Not automatically. Additional conditions may apply, such as insured care, authorisation or provider requirements. Ask the insurer which condition is decisive in your case.
Why do I pay personally if treatment is insured?
This may result from a deductible, personal contribution or restriction for non-contracted care. Request a breakdown before substantively disputing the statement.
Where can I go after my complaint is rejected?
After the internal complaint, you may be able to approach SKGZ for mediation or a dispute, or the civil court. Check handling conditions, deadlines and the binding nature of a decision.
Sources
These sources relate to this page. For a specific case, check current rules and your own documents.
- Zorginstituut Nederland — hoe werkt de Zorgverzekeringswet? Accessed: 2026-10-23
- Rijksoverheid — polissen zorgverzekeraar Accessed: 2026-10-23
- Rijksoverheid — eigen bijdrage en eigen risico Accessed: 2026-10-23
- Rijksoverheid — klacht over zorgverzekeraar Accessed: 2026-10-23
- Zorginstituut Nederland — klachten over vergoedingen Accessed: 2026-10-23
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Editorial team Insurance law in the Netherlands
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