Hospital and income protection insurance: refusals, premium rises and medical disputes

In short

An individual hospital (health) insurance policy is for life. Once it is concluded, the insurer cannot unilaterally change the premium basis or the cover conditions. The premium can only rise with the consumer price index and the medical index (Insurance Act, art. 203-204).

After 2 years, the insurer can no longer rely on an unintentional omission in your health declaration. An illness that showed no symptoms at all when the contract was signed can never be held against you (art. 205).

If the insurer alleges an intentional omission, the insurer must prove the intent (art. 59).

For income protection, the mutualité’s decision does not bind the private insurer. What counts is the definition of incapacity in the policy. An unclear definition is read in your favour (art. 23).

After any refusal, ask for written reasons. Obtain the medical adviser’s report through your own doctor (art. 61). A complaint to the Insurance Ombudsman is free and suspends the limitation period.

This guide covers the five most common disputes in private health insurance (assurance soins de santé / hospitalisation, hospitalisatieverzekering) and income protection insurance (assurance revenu garanti / incapacité de travail, gewaarborgd inkomen). These policies do not replace the mutualité (compulsory health insurance, INAMI/RIZIV); they top it up. The rules are in the health insurance chapter of the Insurance Act of 4 April 2014 (loi du 4 avril 2014 relative aux assurances, the “Insurance Act”), art. 201-211.

My health insurer says the illness existed before the policy and refuses to pay: is that right?

Not necessarily. The starting points are the date the contract began and whether the illness showed symptoms on that date.

Depending on the situation:

No symptoms at all when the contract was signed: if the illness was diagnosed later, the insurer cannot rely on an unintentional omission. The duty to disclose only covers circumstances you knew about (Insurance Act art. 58; art. 205, second paragraph).
Symptoms existed but no diagnosis, and the contract is more than 2 years old: the insurer can no longer rely on an unintentional omission (art. 205, first paragraph).
Within the first 2 years, unintentional omission: the contract remains valid. If the omission cannot be held against you, the insurer pays in full. If it can, payment is reduced in proportion to the premium paid compared with the premium you should have paid. Only if the insurer proves it would never have covered the risk does it limit itself to refunding premiums (art. 60).
The insurer alleges intent: the contract is void (art. 59). But the insurer must prove that a known fact was concealed and that this misled it. According to the Court of Cassation, intent must be separately justified in the light of all the circumstances (Cass. 17.5.2024, C.23.0497.F).
You left a question unanswered and the insurer signed the contract anyway: except in case of fraud, it cannot rely on that gap later (art. 58, second paragraph).
Chronic illness or disability: if you are under 65, you have a right to health insurance. The costs of the existing condition may be excluded, but the premium must be the one you would pay if you were not ill (art. 206).

Practical steps:

Ask for a copy of the health declaration you signed. The insurer must give you a copy of the written information you provided when the contract was made (art. 64 §3).
Ask your treating doctor for a report stating the dates of the first symptoms and of the diagnosis.
Request the medical adviser’s (médecin-conseil) report through your own doctor. Medical information only travels through that channel (art. 61).

The Insurance Ombudsman argues for a time limit rather than a lifelong exclusion for an illness that has healed [Sector source, Ombudsman 2022 and 2024 reports]. For the general logic of refusals see If your insurer refuses to pay.

I moved to Brussels and my hospital insurance premium went up: can they do that?

That depends on the wording of your contract, and the law is not settled. The Insurance Ombudsman’s 2025 report notes that moving to a region with higher costs, such as Brussels, can cause a sharp premium rise [Sector source]. In some tariffs the premium depends on the region where you live. But the law limits premium increases.

What the law says

Once a health contract is concluded, the insurer cannot change the technical basis of the premium or the cover conditions. The exceptions are narrow: an annual adjustment in line with the consumer price index, and in line with medical indices to the extent they exceed that index (Insurance Act art. 204 §1-3).
The provision allowing a “reasonable and proportionate” adjustment for personal changes lists only three cases: a change of occupation, a change of income and a change of social security status (art. 204 §5). A change of address is not on that list.
In its offer, the insurer must state the segmentation criteria it used. It must separate the criteria that set the initial premium from those that may in future affect the conditions (art. 46 §1). A proposal to change the tariff because the risk has changed must be in writing, express and reasoned, and must state the data and criteria used (art. 46 §2).

Depending on the situation:

The contract provides that the premium depends on the region of residence: the Ombudsman treats an increase after a move not as a tariff change but as “the application of contractual provisions” [Sector source, Ombudsman 2025]. In that case the increase is valid in principle. Still ask in writing for confirmation that the region was disclosed in the offer as a criterion with future effect (art. 46 §1) and that the increase follows the tariff.
The contract has no such clause: the insurer cannot change the premium basis afterwards (art. 204 §1). A change of address is not one of the three cases in art. 204 §5, so the increase cannot rest on that provision either. Object in writing and, if that fails, contact the Ombudsman. No published court decision on this question is known.

Can I cancel? You can terminate a health policy every year, on the anniversary of the contract or on the annual premium due date (art. 85 §1, last paragraph). The law sets no separate notice period for this annual termination. The 2-month notice that has applied to non-life contracts since 1.10.2024 does not apply to health insurance (art. 85 §1, Act of 9.10.2023). Check the termination clause in your policy and send your letter well before the due date. According to the Ombudsman, health insurance has no shortened termination period. After indexation or a contractual age or region increase, you can only terminate at the annual due date, by registered letter sent in time. Only a general premium increase across the insurer’s portfolio gives an early right to terminate [Sector source, Ombudsman 2025].

Careful: find a new insurer before you cancel. A new contract will reassess your age and health and may impose a waiting period. In your existing lifelong contract, the premium cannot rise because of illnesses that appeared later.

I cannot work because of burn-out; my mutualité accepted it but my income protection insurer refuses: what can I do?

The mutualité’s recognition does not bind the private insurer. But the insurer’s refusal is not the final word either. A clash between two medical opinions is resolved in a set sequence of steps.

Why a separate assessment? The mutualité applies a statutory test: a reduction of your earning capacity by at least two thirds, measured against the group of occupations matching your work and training, often called “66% incapacity” (compulsory health insurance act, art. 100 §1) [Official, INAMI]. The private insurer applies the policy definition, which often requires “objective symptoms” (symptômes objectifs). The Ombudsman reports a rise in burn-out, depression and long Covid files, where objective symptoms are hard to show; income protection complaints rose by 18% in 2025. It also notes that insurers do not always state their reasons for refusal clearly [Sector source, Ombudsman 2025].

Practical steps:

Ask for written reasons. Obtain the medical adviser’s report through your own doctor (art. 61). For claims made after 1.10.2024, an insurer that disputes cover must give a reasoned answer within 3 months. Otherwise a statutory flat-rate compensation becomes due (art. 73/1).
Strengthen the evidence: a psychiatrist’s or psychologist’s report, test results, treatment and medication records, the decision of the mutualité’s medical adviser.
Use the challenge procedure in the policy. Many policies provide for a joint medical assessment (expertise médicale contradictoire) in which each side appoints a doctor, with a third doctor if they disagree. According to the sector federation Assuralia, if the two doctors cannot agree, a third doctor (tiers-expert) they designated beforehand as arbitrator writes the final report after a meeting at which you are present [Sector source, Assuralia 2024]. Check the time limits and cost sharing in your policy. The Ombudsman notes that this amicable assessment is expensive, cannot be weighed sensibly without knowing the reasons for refusal, and should be a last resort. If you are asked to sign a separate assessment agreement once the dispute has arisen, check whether its outcome binds the parties: the Liège Court of Appeal held that a valid amicable expertise agreement in which the parties accept the expert’s conclusions prevents them from later asking the court for an expert (22.5.2014, 2012/RG/1666; a medical liability case).
Arbitration clauses and a “final” report: a clause in the contract referring future disputes to arbitrators is deemed unwritten (art. 90). Courts, however, treat the third-doctor procedure not as arbitration but as a binding agreement leaving the medical assessment to a third party. If the policy makes the outcome “final”, you can still go to court, but the court generally does not re-examine the medical conclusion; it checks whether the procedure was properly followed and whether the doctors carried out their assignment:
- The Liège Court of Appeal applied, in an incapacity-for-work policy, the rate set by the third doctor, whose conclusions were “decisive and irrevocable”; it held that such an agreement does not breach the right to a fair trial and that the court may carry out a limited review of the procedure’s regularity. Unilateral medical opinions obtained by the insured after the procedure were disregarded; objections should have been made on the third doctor’s preliminary findings (7.2.2017, 2015/RG/1261).
- The same court held a “sovereign and irrevocable” medical expertise clause in a personal accident policy binding on both parties (26.2.2018, 2016/RG/1387).
- The Antwerp Court of Appeal, by contrast, found that the doctors had not fully carried out the assignment set out in the agreement in a disability cover, held their report not binding and upheld the appointment of a court expert (7.6.2006, 2005AR727).
We found no decision on whether art. 90 applies to a third-doctor clause written into the policy in advance. Before taking part, read the doctors’ assignment (which questions, which definition) and send your objections in writing, in time, on the preliminary report.

The 2-year limit for mental illness: many policies cap payments for mental illness only at 2 years. The Antwerp Labour Court of Appeal held that a clause limiting cover for depression, chronic fatigue and fibromyalgia, but not for other illnesses, was discrimination based on health status (Arbeidshof Antwerpen 13.12.2023, 2022/AA/129). The clause in the employer’s collective incapacity insurance was declared void. Faced with a presumption of discrimination, the insurer bore the burden of proving that the difference was objectively justified (Anti-Discrimination Act of 10.5.2007, art. 28) and failed to do so. The court accepted that a psychiatrist can assess a mental illness objectively. This is an appeal decision on specific facts, not a ruling of principle by the Court of Cassation. Before the Insurance Commission attached to the FSMA, the sector undertook to examine continuing cover beyond 2 years where a mental illness is proven by objective symptoms. That undertaking is not binding [Official, Commission opinion C 2024/5].

Time limit: claims under an insurance contract are time-barred after 3 years (art. 88). See Deadlines.

Long Covid: I only receive partial benefits. Should my rate be assessed against my own occupation?

The policy definition decides. The law has no single test. If the test is unclear, it is read in your favour.

Depending on the situation:

The policy defines “occupational” incapacity (incapacité professionnelle): the assessment is made against your own occupation, the work you actually did. The insurer cannot reduce the rate by saying you could do lighter work.
The policy defines “physiological” or “economic/general” incapacity: the insurer may take into account other work suited to your training and experience. The Ombudsman reports files in which insurers assessed incapacity against any activity on the labour market, not only the current occupation [Sector source, Ombudsman 2025]. The concepts of “economic” and “physiological” incapacity appear in the law (art. 61/9), but their definition is left to the policy.
The definition is mixed or unclear: in case of doubt the clause is read in favour of the insured (art. 23 §2). The Court of Cassation has held that this rule takes precedence over a search for the parties’ common intention (Cass. 8.10.2021, C.21.0070.F).

How is the partial benefit calculated? Most policies pay in proportion to the rate of incapacity above a set threshold. Note the threshold, how the rate is determined and the “partial return to work” rules in your policy.

Practical steps:

Ask for the definition clause and the method used to set the rate.
Ask your doctor for a report describing your loss of function against the concrete demands of your former job (screen time, physical load, cognitive fatigue). Discuss with your doctor which tests can show your symptoms objectively.
If you dispute the rate, ask for the joint medical assessment in the policy or contact the Ombudsman.

Age limit: incapacity contracts in principle run until age 65 (art. 203 §1). The sector’s code of conduct, in force from 1.1.2024 to 1.1.2027, provides for extending cover to the statutory retirement age. It does not grant an extension to someone already unable to work when the offer is made [Official, Commission opinion C 2026/1]. The proposal to write “statutory retirement age” instead of 65 into the law is a draft; to be confirmed in Justel.

My hospital insurer calls my treatment “experimental” and refuses to pay: isn’t my doctor’s report enough?

A doctor’s report is strong evidence, but it may not be enough on its own. What matters is whether the insurer relies on a condition of cover or on an exclusion. That determines who must prove what.

Depending on the situation:

The policy only covers “medically necessary” treatment: that is a condition of cover. You must prove that the treatment was necessary to preserve or restore your health (Civil Code art. 8.4). The statutory definition of health insurance also refers to treatment “necessary to preserve and/or restore health” (Insurance Act art. 201 §1, 1°).
The policy excludes “experimental” or “scientifically unrecognised” treatment: that is an exclusion. The insurer must prove that the treatment falls within it. Exclusions must be clear and understandable; any ambiguity is read in your favour (art. 23).
“Non-reimbursed treatment”: some policies only cover procedures on the INAMI reimbursement list (nomenclature) or pay items outside it up to a cap. The question is then contractual rather than medical: what does the policy wording cover? On the market, “costs of experimental treatments and medicines” are expressly excluded in many policies. Some policies also do not pay for a stay that compulsory health insurance does not cover [Sector source, insurers’ product information].
Conditions narrowed later: cover conditions in a health contract cannot be changed to your detriment after it is concluded (art. 204 §1). Compare the definition in the original version of your contract with today’s.

How do you prove medical necessity?

Ask your specialist for a detailed indication report: diagnosis, standard treatments tried and why they failed, the scientific guidelines and publications supporting the proposed treatment.
Document whether the treatment is reimbursed by INAMI in Belgium and in what setting the hospital provides it. A clinical trial and an established but non-standard treatment are different things.
Ask the insurer in writing which scientific sources its medical adviser relied on (through the art. 61 channel). An unexplained “experimental” label is not enough.
Where possible, send a prior approval request (accord préalable) before treatment. Challenging a decision after a refusal is harder.

No published Belgian court decision on how this exclusion is interpreted is known. If opinions differ, you can use the joint medical assessment in the policy, then the Ombudsman or the courts. Your right to choose your own doctor is protected (art. 200).

Checklist

I have identified the type of policy: health care, incapacity, invalidity (art. 201), and whether it is individual or an employer group policy.
I checked the start date of the contract and whether the 2-year rule applies (art. 205).
I asked for a copy of my signed health declaration and the proposal (art. 64 §3).
I asked in writing for the basis of the premium increase: index, art. 204 §5 or region? Was the region listed in the offer as a criterion with future effect (art. 46)?
I asked for the reasons for refusal and the medical adviser’s report through my doctor (art. 61, art. 73/1).
I noted the policy’s definition of incapacity (own occupation or general), the rating method and the assessment procedure.
If there is a cap for mental illness, I compared it with the rules for other illnesses.
I wrote to the insurer’s complaints department, then to the Ombudsman. I am tracking the 3-year limitation period.

You can search case law on “income protection” or “health insurance” on the Decisions page. For credit and life insurance, see the separate guide: Credit and life insurance.

Sources

This guide is general information, not legal advice. Current as of 09.10.2026.