Private health insurance denied your coverage in Peru: pre-existing conditions, undisclosed history and where to complain

What this page covers

This page is for people with health insurance bought from a private insurer who get a “no”: surgery not authorised, a reimbursement refused, or an illness labelled pre-existing. The general rules for any insurance claim (deadlines to decide, what the insurer’s silence means, the limitation period) are on our page about insurance claims denied or ignored. Here we cover what is specific to health: pre-existing conditions, what you did not declare, and where to complain.

Ley 29946, the Insurance Contract Law, defines health insurance this way:

“Por el seguro de salud el asegurador se obliga, dentro de los límites establecidos en la ley y en el contrato, a reparar las consecuencias económicas producidas por la enfermedad del asegurado. […] Para tal efecto, los planes de seguro de salud y el tratamiento de preexistencias se rigen por la Ley 29344, Ley Marco de Aseguramiento Universal en Salud, su reglamento y normas complementarias.”

(The insurer must cover the financial consequences of the insured’s illness, within the limits of the law and the contract. Health plans and pre-existing conditions are governed by Ley 29344, the universal health insurance framework law.)

“Within the limits of the law and the contract” means your policy matters. We do not review each contract’s limits, exclusions or waiting periods here.

What counts as a pre-existing condition

It is the most common reason for a denial, and article 118 defines it precisely:

“Se entiende por preexistencia, cualquier condición de alteración del estado de salud diagnosticada por un profesional médico colegiado, conocida por el titular o dependiente y no resuelta en el momento previo a la presentación de la declaración jurada de salud.”

(A pre-existing condition is any change in health status diagnosed by a licensed doctor, known to the policyholder or dependant, and not resolved before the sworn health declaration was submitted.)

All four conditions must be met:

1. A change in your health.
2. Diagnosed by a licensed doctor (médico colegiado).
3. Known to the policyholder or dependant.
4. Not resolved before you submitted the declaración jurada de salud.

If the insurer calls something “pre-existing” that was never diagnosed, that you did not know about, or that was already resolved when you signed, the legal definition does not fit. Ask which document they rely on.

If you switch insurers, pre-existing cover does not vanish

The first sentence of article 118 reads:

“Las enfermedades preexistentes están cubiertas dentro del sistema de seguros y de EPS, como mínimo, hasta los límites del contrato original o anterior.”

(Pre-existing conditions are covered within the insurance and EPS system, at least up to the limits of the original or previous contract.)

Ley 30562 calls this “cobertura de las preexistencias cruzadas” (cross cover of pre-existing conditions) and limits what it can cost you:

”[…] las empresas de seguro pueden efectuar recargos por clase o producto, de conformidad con el principio de mutualidad de los seguros […]. Se prohíbe el recargo individual, que se considera práctica prohibida. También está prohibido el recargo individual en las migraciones de los seguros de salud a los planes regulares o potestativos de la EPS, y viceversa.”

(Insurers may add surcharges by class or product. Individual surcharges are prohibited, including when you move between health insurance and EPS plans in either direction.)

In practice: if your illness was already covered and you move to another insurer, or between an insurer and an EPS, that cover goes with you at least up to the limits of the previous contract. And they cannot raise the premium for you alone because of your illness.

What the law does not say in those words: that a first policy, taken out with no previous cover, must cover an illness you already knew about and had not resolved. For that, read your policy. The SBS market conduct regulation requires insurers to get prior SBS approval of their minimum terms on this point:

“2. En el caso de seguros de salud, la cobertura de las enfermedades preexistentes conforme a la Ley de Seguro y demás normas aplicables.”

(For health insurance, cover of pre-existing conditions in line with the Insurance Law and other applicable rules.)

If they say you left something out of your health declaration

The law calls this reticencia or declaración inexacta. The outcome depends on whether there was intent.

With intent (dolo) or inexcusable fault, the contract is void (article 8):

“La reticencia y/o declaración inexacta de circunstancias conocidas por el contratante y/o asegurado, que hubiese impedido el contrato o modificado sus condiciones si el asegurador hubiese sido informado del verdadero estado del riesgo, hace nulo el contrato si media dolo o culpa inexcusable del contratante y/o asegurado.”

(Withholding or misstating known facts that would have stopped the contract or changed its terms voids it if there was intent or inexcusable fault.)

But there are three limits:

• Deadline. The insurer has thirty days from learning of the omission to claim the contract is void, and must notify you by a reliable means (article 9). The law says “todos los plazos previstos en esta sección constituyen plazos de caducidad” (all deadlines in this section are strict caducidad periods).
• Proof. “La carga de la prueba de la reticencia y/o declaración inexacta corresponde al asegurador” (the insurer carries the burden of proof, article 10). You do not have to prove you declared correctly.
• Exceptions. There is no voiding, revision or cancellation when the insurer knew or should have known the true risk when the contract was made, or when the omitted fact reduces the risk (article 15, items a and d).

One rule works against you: if the claim arises before those thirty days run out, “este se encuentra liberado del pago de la prestación” (the insurer is released from paying, article 12).

Without intent or inexcusable fault, there is no voiding:

• If the insurer finds out before a claim, it must offer to revise the contract within thirty days (article 13): a change in premium or cover, which you can accept or refuse.
• If it finds out after a claim, “la indemnización debida se reduce en proporción a la diferencia entre la prima convenida y la que se hubiese aplicado de haberse conocido el real estado del riesgo” (the payment is reduced in proportion to the gap between the agreed premium and the one that would have applied, article 14). You get paid less, but you get paid.

Can they cancel your policy because you got sick?

Not without cause. The SBS market conduct regulation removes health insurance from the insurer’s right to cancel without giving reasons:

“34.4 En el caso de seguros de vida, con excepción de los seguros de vida en la modalidad de renta particular irrevocable, así como en los seguros de salud y cauciones, la resolución sin expresión de causa solo puede ser invocada por el asegurado y/o contratante.”

(In health insurance, cancellation without cause can only be invoked by the insured or policyholder.)

You can leave without giving reasons. The insurer cannot.

The denial letter: what it must contain

The SBS treats health insurance as “personal insurance” (seguros personales), so its Claims Management and Payment Regulation applies. Article 15 requires the insurer to explain “detalladamente […] los motivos que sustentan el rechazo del siniestro, adjuntando copia de los documentos tomados en cuenta para fundamentar su decisión” (the reasons in detail, with copies of the documents behind the decision). Article 17 requires this wording in the letter:

“En caso de disconformidad con los fundamentos del rechazo del siniestro, usted podrá acudir a las vías de solución de controversias, como son la Defensoría del Asegurado (www.defaseg.com.pe), el Instituto Nacional de Defensa de la Competencia y de la Protección de la Propiedad Intelectual – INDECOPI (www.indecopi.gob.pe), o el Poder Judicial o instancia arbitral, según se haya pactado. […]”

(If you disagree with the reasons, you can go to the Defensoría del Asegurado, Indecopi, or the courts or arbitration, as agreed.)

Where to complain, in order

Your insurer is an IAFAS: the TUO of Ley 29344 lists among them “Empresas de Seguros […] que oferten cobertura de riesgos de salud” (insurance companies offering health cover, item 6 of article 7). That matters because of a rule in SUSALUD’s complaints regulation (D.S. 002-2019-SA, article 4.2):

“En el caso de la IAFAS señaladas en los numerales 6) y 7) del artículo 7 […], los procedimientos para la atención de consultas y reclamos son determinados por la Superintendencia de Banca y Seguros y Administradoras de Fondos de Pensiones.”

(For the IAFAS in items 6 and 7, the procedures for queries and complaints are set by the SBS.)

So a complaint against an insurer follows SBS rules, not SUSALUD’s.

1. Complaint (reclamo) to the insurer. The SBS complaints regulation says: “Los reclamos deben ser resueltos por las empresas en un plazo no mayor a quince (15) días hábiles” (complaints must be resolved within 15 business days at most). If they rule against you, they must give reasons and make the supporting documents available.
2. SUSALUD. The insurer’s answer must list where you can go next, including “la Superintendencia Nacional de Salud – SUSALUD, en el caso de reclamos sobre aspectos relacionados a coberturas de riesgos de salud” (SUSALUD, for complaints about health cover). SUSALUD’s regulation applies to private IAFAS, and a denuncia can be filed when you disagree with the outcome of your complaint (article 27.2 of D.S. 002-2019-SA). How that works, and what it does not give you, is on our page about complaints to SUSALUD.
3. Indecopi. It is also among the bodies the insurer must name. See how to file a complaint with Indecopi.
4. Defensoría del Asegurado, arbitration or the courts, as the denial letter and your policy say.

If your cover comes from an EPS (item 5 of the same article 7), the article 4.2 exception does not name it, so your complaint follows SUSALUD’s regulation. This follows from the text; it is not written in those words.

What this page does not cover

We do not cover waiting periods, deductibles, caps or the exclusions in each policy, which depend on the contract. Nor the specific rules for EPS and their optional plans, cancer insurance in particular, or the Defensoría del Asegurado’s own rules. We did not review SUSALUD, Indecopi or Defensoría del Asegurado decisions in individual cases. For the insurer’s deadlines to accept or deny a claim and what its silence means, see our page on insurance claims denied or ignored.