A rejected prior authorisation means that your health insurer does not grant the requested approval for reimbursement. First ask for the precise reason and the applicable policy or statutory condition. Sometimes information is missing, sometimes the medical indication is disputed and sometimes, according to the insurer, the treatment falls outside the insured package. For a follow-up complaint about your health insurance, SKGZ is usually the appropriate disputes body, not Kifid, the Dutch Financial Services Complaints Tribunal.
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Written by Onur Arslan, attorney at Arslan Advocaten. Registered in the specialisation register of the Netherlands Bar for employment law and personal injury. Onur Arslan practised for many years as a corporate lawyer and insolvency trustee (curator) and has extensive experience in financial law disputes. Last updated: 17 September 2026.
Discuss with your treating practitioner which medical information is needed and ask the insurer for a substantive reassessment. Treatment advice is important, but it does not automatically give a right to every desired reimbursement. The legal assessment concerns your entitlement under the law and the policy; medical decisions are taken with your practitioner.
What is prior authorisation from your health insurer?
Prior authorisation (machtiging) is advance approval required for certain care or reimbursement. It allows the insurer to check whether the conditions have been met. Think of a particular treatment, a medical aid, the extent of care or a special situation. Not every form of care requires such approval.
The authorisation may contain limits, for example a period, a provider, a number of treatments or a specific service. So check not only whether it was granted, but also what for. An earlier authorisation for a different treatment or period does not automatically mean that a new application must be approved.
If your application is rejected, ask whether it was complete and what exactly was decided. A request for additional information is not always a final substantive refusal. That distinction determines whether you first need to supplement documents or formulate an objection to the assessment.
Distinguishing basic insurance from supplementary insurance
Entitlements under the basic insurance are largely determined by the Health Insurance Act (Zorgverzekeringswet) and implementing rules. The policy sets out the cover and conditions within that framework. An insurer cannot simply rely on its own preference where a statutory entitlement is at stake.
Supplementary insurance is based on its own contractual cover. Different limits, conditions and exclusions may apply there. The fact that care is not reimbursed under the basic insurance does not automatically mean that it falls under a supplementary policy.
Check in your application which insurance you are relying on. If several types of cover may be relevant, ask for a separate position on each. A rejection under the basic insurance does not in itself answer the question of a supplementary entitlement.
What reason does the insurer give?
| Reason for rejection | What you should have examined |
|---|---|
| Application incomplete | Which necessary information is missing |
| No appropriate indication | Which individual medical data should be assessed differently |
| Not insured care | Which statutory package condition or exclusion is being applied |
| Provider or location does not qualify | Which policy condition and any exception are relevant |
| Extent or duration is limited | Why less care is considered appropriate or sufficient |
| Approval not requested in advance | Whether that requirement applies and what consequence may be attached to it |
A good response addresses the actual reason. If the insurer disputes the effectiveness of a treatment, merely submitting a new cost estimate will not help much. If only a referral is missing, a substantive discussion about the entire basic package may be unnecessary.
The meaning of the established medical science and practice standard
Much of the care in the basic package must meet the standard of established medical science and practice. Zorginstituut Nederland (the National Health Care Institute) explains that effectiveness is an important condition. In addition, factors such as the care that the profession customarily provides and your individual need for that care play a role.
A treatment may therefore exist in general or be offered abroad without this automatically establishing an entitlement under the Dutch basic insurance for your situation. Ask which assessment or position the insurer is using and for which indication it applies.
Have your practitioner explain how your situation relates to the criteria applied. A general reference to success stories is usually less useful than targeted information about the indication, relevant medical data and the conditions applied. The legal complaint must reflect that information correctly.
The practitioner and the insurer have different roles
Your practitioner assesses your medical situation and advises on care. The health insurer assesses the entitlement to reimbursement under the law and the policy. As a result, a practitioner may consider care desirable while there is still a dispute about the insured entitlement.
This does not mean that the insurer can set medical advice aside without adequate explanation. Ask which data were assessed, which criterion has not been met and whether a medical adviser was involved. The reasoning must address the application and the individual information.
Avoid a complaint in which the insured person makes medical assertions that the practitioner does not support. Ask your practitioner for a targeted explanation and use it as substantiation. The aim is a verifiable difference of opinion, not a clash of general views on treatment.
Gathering additional information in a targeted way
Ask which documents are necessary: a referral, treatment plan, needs assessment, medical history or an explanation of previous treatments. Have the insurer explain why missing data are needed for the decision. An extensive medical file is not automatically the best or most appropriate supplement.
Share medical data through a secure and appropriate channel. Ask who will receive the information and, if necessary, have sensitive content sent directly between your practitioner and the medical adviser. A legal complaint does not need to spread every medical detail widely.
Keep a copy of the application and attachments, or an overview of what was sent. Note when additional information was requested and provided. This makes it possible to establish later whether delay was caused by an incomplete application or by the way the insurer handled it.
Non-contracted care and choice of provider
The choice of healthcare provider and the level of reimbursement may depend on the policy. Authorisation for a treatment does not automatically mean that every provider will be reimbursed in full. Check which location, service and reimbursement have been approved.
If you want to use a non-contracted provider, ask in advance about the financial consequences and applicable conditions. The legal assessment of restrictions and exceptions can be complex. A general preference for a particular clinic does not in itself give a right to full reimbursement.
If timely appropriate care is not available from contracted providers, ask for care mediation (zorgbemiddeling) and a concrete solution. Record waiting times and responses. This may be relevant for relying on the insurer’s obligations, but it still requires an assessment of the facts.
An authorisation with too limited a duration or extent
Partial approval can have as great an impact as an outright rejection. Ask why a certain number of hours or treatments, or a shorter period, has been granted. Check whether the insurer used the correct treatment plan and the current indication.
Have your practitioner explain why the requested extent is necessary and what the consequences of a restriction are. A general statement that more care is desirable is less precise than substantiation that addresses the criterion applied. Also ask how a follow-up application will be handled.
Keep the granted and disputed parts separate. Sometimes available care can continue while the extent is being reassessed. Discuss medical choices with your practitioner and confirm in writing to the insurer that you continue to dispute the restriction if you make use of it.
What if treatment has already started?
If prior approval was required, the lack of it may cause a problem. Examine which requirement applied, how it was communicated and why approval was not requested in advance. An emergency may raise different questions than a planned treatment for which there was ample time.
Ask the insurer whether a retrospective assessment is possible and on what grounds reimbursement is being refused. A healthcare provider’s agreement that treatment can go ahead is not always a guarantee of payment by the insurer. Check what you have agreed with the provider about costs.
In urgent cases, let your practitioner determine the next medical steps. A legal dispute about reimbursement must be conducted carefully, while the consequences of delay are assessed medically. If necessary, ask for an expedited insurance decision, with substantiation of the urgency.
An internal complaint to your health insurer
Submit the complaint in writing through your insurer’s complaints procedure. State the authorisation number, the application date, the rejection and the outcome you want. Include the relevant medical explanation and policy arguments, without unnecessary personal data.
Ask for a substantive reassessment of the specific ground for rejection. If you consider that the decision overlooks information, state which documents you believe were not taken into account. Also ask for a reasoned response and information about the possibility of a follow-up complaint.
The word objection (bezwaar) is used in practice, but a decision by a private health insurer is not automatically an administrative law decision subject to the standard six-week time limit. Follow the applicable policy and complaints rules and also keep track of any civil law time limits.
When can you go to SKGZ?
The Stichting Klachten en Geschillen Zorgverzekeringen (the Health Insurance Complaints and Disputes Foundation) handles certain complaints about health insurers. You must first complain to your health insurer. Under the current procedure, you can turn to SKGZ if you are dissatisfied with the answer or if no response is received within four weeks.
In principle, submit the complaint within one year of the health insurer’s response. The procedure has specific exceptions, including in the case of an incorrect referral. If your complaint is late, have the exact rules assessed rather than assuming that it is always excluded or always possible.
SKGZ does not deal with every healthcare problem. A complaint about the quality of treatment by a healthcare provider or a decision by a municipality usually follows a different route. A dispute that is already before the courts may also affect whether the complaint can be dealt with.
Ombudsman and Disputes Committee
The Health Insurance Ombudsman (Ombudsman Zorgverzekeringen) can try to reach a solution free of charge. If mediation is not appropriate or does not lead to a result, the Health Insurance Disputes Committee (Geschillencommissie Zorgverzekeringen) can give a ruling. You can authorise someone to act on your behalf; a lawyer is not mandatory for this procedure.
On the review date, the entry fee for the Disputes Committee is € 37. Check the current amount when you submit. A procedure can take time; the available route is not automatically fast enough for every medically urgent problem.
A ruling is usually binding if you agree to that procedure. There is no ordinary full reassessment on appeal as there is with a court judgment. Subsequent judicial review of binding advice is limited. Discuss these consequences before you choose a procedure.
Urgency and court proceedings
If delay could have serious consequences, ask immediately for an expedited assessment and substantiate the urgency with appropriate information from your practitioner. A scheduled appointment alone does not make every case legally urgent; the interest at stake must be explained specifically.
Interim relief proceedings (kort geding) may be considered in certain situations. The court then weighs factors such as the plausibility of the entitlement, urgency and the interests involved. A judge does not simply replace every medical assessment and cannot always resolve an incomplete file at short notice.
Weigh the choice between SKGZ and the courts carefully. Litigating in parallel may affect admissibility and costs. An internal complaint may remain useful in the meantime for a quick reconsideration, but it does not automatically protect all other time limits.
A fictional example of a targeted reassessment
An insurer rejects an authorisation because, in its view, a particular earlier treatment has not been tried. The practitioner states that this treatment was not medically appropriate and that this was already set out in an attachment. The insured person then does not simply ask for approval again, but points precisely to the criterion and the missing assessment.
The practitioner explains in writing why the earlier treatment was not indicated in this individual situation. The insurer must then assess whether this is sufficient under the applicable conditions. The outcome may change; a substantive difference of opinion may also remain.
This example shows that the complaint must address the reason for rejection. An additional general letter about the severity of the symptoms does not always answer the missing question. The combination of the right criterion, individual data and a clear request makes the reassessment easier to carry out.
Organising your file
Collect the policy for the relevant year, the application, the rejection, the medical explanation and the response to your complaint. Draw up a timeline of applications, additional questions and answers. Also state whether treatment has already started and which costs may be at your own expense.
Define the outcome you want precisely. Do you want approval for a treatment, a longer period, a different provider or reimbursement of costs already incurred? Authorisation for the future and repayment of old invoices are not always the same entitlement.
After a favourable decision, ask for clear confirmation stating the extent, period and conditions. Check whether the healthcare provider has also received the information. An oral commitment without clear boundaries may later lead to a new dispute.
A repeat application must make clear what has changed
If an earlier authorisation was rejected, it helps to state explicitly in a new application which information is new. Think of additional medical advice, clarification of the requested treatment or a change in the extent applied for. Have your practitioner explain why that information is relevant to the specific ground for rejection.
Keep the first decision separate. A new application does not automatically mean that an earlier complaint time limit stops or starts again. So ask which decision the insurer is reconsidering at that moment and keep track of the dispute about the earlier period separately. Authorisation for future care does not in itself settle the dispute about costs you have already incurred.
Medical necessity and policy conditions
Ask which condition for authorisation is missing: insured care, indication, referral, provider or prior approval. A practitioner who considers care necessary does not automatically satisfy every insurance condition. A rejection must, however, be based on the correct information.
Have your practitioner respond specifically to the substantive criterion. In urgent cases, the medical necessity and consequences of delay must be substantiated in concrete terms. The complaints route for health insurance can run via SKGZ; do not automatically refer every healthcare dispute to Kifid.
The current procedure is available from SKGZ. Also read about medical data and limitation periods for insurance claims.
Frequently asked questions about rejected authorisations
Does the insurer have to pay if my doctor considers the treatment necessary?
Treatment advice is important, but the law and the policy impose additional conditions on reimbursement. Ask which criterion the insurer considers has not been met and have your practitioner respond to it specifically. Medical desirability and insured entitlement do not always coincide.
Do I have to object within six weeks?
A private health insurer does not automatically follow the administrative law objection procedure. Check the policy and complaints rules and any other time limits. For SKGZ, the limit is in principle one year after the insurer’s response, subject to specific conditions and exceptions.
Should I go to Kifid or SKGZ?
For a dispute about your health insurance, SKGZ is usually the appropriate specialised route. The internal complaint to the health insurer comes first. A complaint about the healthcare provider itself or a municipality requires a different assessment.
Is a procedure at SKGZ free of charge?
Mediation by the Ombudsman is free of charge. For the Disputes Committee, an entry fee of € 37 applies as at 16 September 2026. Check the current fee when you submit; any costs of your own representation are a separate matter.
May I start treatment while my complaint is pending?
Discuss the medical necessity and consequences of delay with your practitioner. In addition, establish clearly who bears the costs as long as approval is lacking. A pending complaint does not automatically provide cover or guarantee reimbursement afterwards.
How does Arslan Advocaten help with an authorisation dispute?
Arslan Advocaten can assess the ground for rejection, the policy, the procedure and the legal substantiation. Medical information is taken into account through appropriate documents from your practitioner. Send us the application and the rejection; urgency, costs and possible next steps are discussed in advance.
Further reading on this topic
- Water damage claim rejected by the insurer: leak, maintenance or cover after all?
- Travel or cancellation insurer rejects your claim: how do you object?
- Prevention clause not complied with: may the insurer reject the claim?
Sources and legal basis
- Zorginstituut Nederland on medical specialist care and prior authorisation.
- Zorginstituut Nederland on the Health Insurance Act.
- SKGZ on the complaints procedure, time limits and costs.
Sources checked on 16 September 2026. The entitlement depends on the type of care, the individual indication, the applicable statutory rules and the policy for the year concerned.
