Insurance Claim Denied in Taiwan: FSC Complaint and Appeals Guide

Insurance Claim Denied in Taiwan: Your Rights and Remedies

Taiwan has one of the highest insurance penetration rates in Asia, with the insurance industry deeply embedded in Taiwanese personal finance and risk management culture. If your insurance claim has been denied — whether for life insurance, health insurance, car insurance, or travel coverage — you have clearly defined legal rights and formal dispute resolution channels available under Taiwanese law.

This guide explains Taiwan's insurance regulatory structure, common reasons for claim denial, the step-by-step appeals process through the Financial Supervisory Commission (FSC) and the Financial Ombudsman Institution (FOI/保險事業發展中心/金融消費評議中心), and practical advice for building a successful challenge.

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Taiwan's Insurance Regulatory Framework

Insurance in Taiwan is governed by the Insurance Act (保險法) and supervised by the Financial Supervisory Commission (FSC — 金融監督管理委員會). The FSC's Insurance Bureau (保險局) is specifically responsible for the supervision of insurance companies operating in Taiwan.

FSC Website: https://www.fsc.gov.tw

FSC Insurance Bureau: https://www.ib.gov.tw

FSC Consumer Hotline: 1998 (free, available Monday-Friday 9:00 AM – 5:00 PM)

For formal dispute resolution, Taiwan established the Financial Ombudsman Institution (FOI — 財團法人金融消費評議中心) in 2012 under the Financial Consumer Protection Act (金融消費者保護法). The FOI provides free mediation and evaluation services for insurance disputes.

FOI Website: https://www.foi.org.tw

FOI Hotline: (02) 2506-5018

FOI Address: 5F., No. 1, Section 2, Zhongshan North Road, Zhongshan District, Taipei 10441, Taiwan

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Why Insurance Claims Get Denied in Taiwan

Common reasons for insurance claim denial in Taiwan include:

1. Non-disclosure or misrepresentation. Under the Insurance Act (保險法), policyholders have a duty to truthfully disclose all material facts. Life and health insurance claims are frequently denied on grounds that the policyholder did not disclose a pre-existing condition when applying for coverage.

2. Policy exclusions. Taiwan insurance policies commonly exclude pre-existing conditions (for health and accident policies), suicide within two years of policy commencement (life insurance), self-inflicted injuries, and criminal acts. Exclusion disputes are common.

3. Accidental death and injury disputes. Whether a death or injury was "accidental" under a policy is frequently contested in Taiwan. Insurers sometimes characterize deaths as illness-related rather than accidental to avoid paying the higher accident benefit.

4. Critical illness criteria. Critical illness insurance (重大疾病/重大傷病) pays benefits when the insured is diagnosed with a qualifying condition. Disputes arise about whether the specific diagnosis meets the policy's definition of the covered condition.

5. Disability classification. Permanent disability insurance pays based on disability grades. Disputes about the correct disability grade are common in Taiwan.

6. Documentation disputes. Missing or uncertified medical records, diagnosis certificates, or death certificates from NHI-registered facilities can result in claim delays or denials.

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Your Rights Under Taiwan's Financial Consumer Protection Act

Taiwan's Financial Consumer Protection Act (金融消費者保護法, 2011) and the Insurance Act provide policyholders with the following key rights:

• The right to receive a written explanation of any claim denial with the specific policy clause cited.
• The right to file a formal complaint with the insurance company and receive a written response within 30 days.
• The right to file a complaint with the FSC Insurance Bureau.
• The right to apply to the Financial Ombudsman Institution (FOI) for free mediation and evaluation.
• Protection against unfair or unclear policy terms under the Consumer Protection Act (消費者保護法).

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Step-by-Step: How to Appeal an Insurance Claim Denial in Taiwan

Step 1: Request a Detailed Written Denial Explanation

If your insurer has provided only a brief denial notice, write to the claims department requesting a full written explanation identifying:

• The specific policy clause(s) invoked
• The factual basis for applying the exclusion or denial ground
• A list of the documents and evidence considered

Step 2: File a Formal Internal Complaint

Submit a formal complaint (客訴) to your insurer's complaints department or consumer service team. The insurer is required to investigate and respond in writing within 30 days. Your complaint should:

• Reference the policy number and claim reference
• Explain why the denial is incorrect, addressing the specific grounds cited
• Attach all supporting documents: discharge summaries, diagnosis certificates (診斷書), medical records, police reports (for accidents), death certificates
• Cite the relevant Insurance Act provision if you believe the insurer has acted unlawfully

Step 3: File with the Financial Ombudsman Institution (FOI)

If the internal complaint does not resolve the dispute, file an application with the FOI (財團法人金融消費評議中心).

Eligibility conditions:

• You must have first filed a formal complaint with the financial institution (the insurer) and received its final written response, or 30 days must have elapsed since your complaint without a response.
• You must file with the FOI within 60 days of receiving the insurer's final response.

How to apply:

• File online through the FOI website (foi.org.tw) — available in Traditional Chinese.
• File by post or in person at the FOI office in Taipei.
• Attach all documents: policy, denial letter, internal complaint, insurer's response, supporting evidence.

FOI Process:

1. Application review: The FOI reviews whether your case is eligible.
2. Mediation: The FOI attempts mediated settlement between you and the insurer.
3. Evaluation (評議): If mediation fails, an FOI evaluator (a specialist panel including insurance law experts) issues a formal evaluation recommendation.

The insurer is bound to accept FOI evaluations where the disputed amount is below NT$1,000,000 (approximately USD 30,000). For amounts above this threshold, the evaluation is a recommendation rather than a binding decision, but it carries significant weight.

The FOI process is free for consumers.

Step 4: FSC Complaint

If the dispute involves the insurer violating the Insurance Act or FSC regulations — for example, refusing to pay a valid claim in a timely manner or using unfair policy terms — file a complaint with the FSC Insurance Bureau through the 1998 hotline or the FSC website. The FSC can investigate and impose sanctions on non-compliant insurers.

Step 5: Court Proceedings

For disputes that cannot be resolved through the FOI, the district courts in Taiwan have jurisdiction over insurance contract disputes. Small claims procedures are available for lower-value matters. Legal representation is recommended for court proceedings.

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National Health Insurance (NHI) vs. Private Health Insurance

Taiwan's universal National Health Insurance (NHI — 全民健康保險) provides comprehensive basic health coverage. Most disputes involving NHI coverage go through the National Health Insurance Administration (NHIA) rather than the private insurance complaint channels.

Private supplemental health insurance (商業健保) — which covers co-payments, private room upgrades, higher benefit limits, or specific conditions not covered by NHI — is regulated by the FSC and falls within the FOI's jurisdiction.

When filing a health insurance complaint, clarify which type of coverage is involved: NHI (NHIA jurisdiction) or private supplemental (FSC/FOI jurisdiction).

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Life Insurance Disputes in Taiwan

Life insurance is extraordinarily widespread in Taiwan, and disputes — particularly over accident vs. illness classification of deaths, and over non-disclosure — are among the most litigated insurance matters in Taiwanese courts. Key points:

• Suicide exclusion: Most Taiwanese life insurance policies exclude suicide within the first two years. After two years, suicide is typically covered. The two-year calculation runs from the policy commencement date.
• Non-disclosure disputes: The Insurance Act grants insurers the right to void policies within two years of discovering non-disclosure (五年的除斥期間 — a five-year period from commencement for the right to avoidance, which cannot be extended). If more than two years have passed since the insurer could have discovered the non-disclosure, the policy generally cannot be voided.
• Accident definition: FOI evaluation and court decisions in Taiwan have developed a substantial body of precedent on what constitutes a covered "accident." Cases involving unexpected medical events (such as a fall during illness) are frequently contested.

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Common Mistakes to Avoid

Not filing the internal complaint before approaching FOI. The FOI requires proof of an internal complaint. Without it, your FOI application will be rejected.

Missing the 60-day FOI filing deadline. You have 60 days from the insurer's final response to file with FOI. Do not miss this deadline.

Submitting uncertified medical records. Taiwanese insurers typically require original or officially certified diagnosis certificates (診斷書) from licensed medical facilities. Photocopies or overseas medical records may require additional certification.

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Drafting Your Appeal Letter

Whether you are filing an internal complaint or submitting to the FOI, a clear, professional appeal document significantly improves your chances of success. ClaimBack at claimback.app can generate a structured, evidence-based appeal letter tailored to your Taiwan insurance dispute. Even if you ultimately need to translate it into Traditional Chinese for formal submission, having a clear framework saves significant time and effort.

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Conclusion

Taiwan's financial dispute resolution system — anchored by the FSC Insurance Bureau and the Financial Ombudsman Institution (FOI) — provides accessible, free, and effective mechanisms for challenging unfair insurance claim denials. File your internal complaint promptly, then escalate to the FOI within 60 days if the insurer does not resolve your dispute. Use ClaimBack at claimback.app to help draft your appeal, and exercise the strong consumer rights Taiwan's insurance laws provide.