Appealing a Denied PMI Claim in 2026
Receiving a letter denying your private medical insurance claim can be deeply frustrating, especially when you are unwell. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we believe that understanding your rights is the first step to a successful appeal. This definitive UK guide will walk you through the process, from deciphering the rejection to seeking help from the Ombudsman.
Guide to rejection appeals and ombudsman help
When your insurer denies a claim, it's not necessarily the final word. You have a right to challenge the decision. The process generally follows three key stages:
- Understand the Rejection: Carefully review your insurer's reasoning and compare it against your policy terms and medical evidence.
- Lodge an Internal Appeal: Formally ask your insurer to reconsider their decision by presenting your case with supporting documents.
- Escalate to the Financial Ombudsman Service (FOS): If you're not satisfied with your insurer's final response, you can ask this free, independent body to investigate.
Navigating this path can seem daunting, but with the right information and a structured approach, you can build a strong case and ensure you get the cover you've paid for.
Why Might My PMI Claim Be Denied? Common Reasons for Rejection
Understanding why claims are denied is crucial for avoiding issues in the first place and for challenging a decision effectively. The most fundamental rule of private medical insurance in the UK is that it is designed to cover acute conditions that arise after your policy begins.
An acute condition is a disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Think of conditions like a joint replacement, cataract surgery, or hernia repair.
Conversely, standard UK PMI policies do not cover pre-existing or chronic conditions.
- Pre-existing Conditions: Any illness, disease, or injury for which you have had symptoms, medication, advice, or treatment before your policy started.
- Chronic Conditions: An illness that cannot be cured, but can be managed. Examples include diabetes, asthma, high blood pressure, and Crohn's disease. These conditions require long-term, ongoing care, which falls outside the scope of PMI and is typically managed by the NHS.
Here are the most common reasons insurers give for rejecting a claim:
| Rejection Reason | Explanation |
|---|---|
| Pre-existing Condition | The insurer believes the condition you're claiming for existed in some form before you took out the policy. This is the most frequent cause of disputes. |
| Chronic Condition | The condition is diagnosed as long-term and manageable rather than short-term and curable, making it an exclusion on almost all standard PMI policies. |
| Policy Exclusion | The treatment itself is not covered by your policy. Common exclusions include cosmetic surgery, normal pregnancy, experimental treatments, and organ transplants. |
| Moratorium Period Not Met | On a 'moratorium' policy, you must typically be symptom-free and treatment-free for a specific pre-existing condition for two continuous years after your policy starts for it to become eligible for cover. |
| Non-Disclosure | You failed to declare a previous medical condition or symptom on your application form. Insurers have the right to review your medical records, and any inconsistencies can lead to claim denial or even policy cancellation. |
| Treatment Not Medically Necessary | The insurer's medical team disagrees with your specialist that the proposed treatment is essential. For example, they may deem a procedure to be for cosmetic rather than functional reasons. |
| Financial Limits Reached | You have exceeded the annual financial limit on your policy or the specific cap for a benefit, such as outpatient consultations or physiotherapy sessions. |
| Administrative Error | Simple mistakes like an incorrect claim form, missing information, or failing to get pre-authorisation from the insurer before starting treatment. |
Your First Step: Understanding the Rejection Letter
Before you can fight back, you need to know exactly what you're fighting against. Your insurer's rejection letter is your starting point. Don't just skim it – read it forensically.
Key things to look for:
- The Specific Reason for Denial: The letter must clearly state why the claim was rejected. Is it because of a policy exclusion, a pre-existing condition, or something else?
- The Policy Clause: The insurer should reference the exact section or clause in your policy wording that justifies their decision. Find this clause in your policy documents and read it yourself.
- The Evidence They Used: Did they base their decision on information from your GP, your specialist, or your application form?
- The Appeals Process: The letter must outline how you can appeal their decision and the deadline for doing so (usually within six months).
Once you have this information, gather your own evidence. This file will become the foundation of your appeal.
Essential Documents to Collect:
- Your original policy documents, including the terms and conditions and your application form.
- The rejection letter from your insurer.
- All correspondence with your insurer.
- Copies of referral letters from your GP.
- Reports and letters from your specialist consultant.
- Results from any tests, scans, or investigations.
The Internal Appeals Process: How to Challenge Your Insurer
Every insurer regulated by the Financial Conduct Authority (FCA) must have a formal complaints and appeals procedure. This is your first port of call.
Step 1: Start with a Phone Call
For simple issues, a phone call to the claims department can sometimes clear things up. It might be a straightforward administrative error or a misunderstanding that can be resolved quickly. When you call:
- Have your policy number and claim reference ready.
- Be polite and calm, but firm.
- Clearly state that you disagree with the decision and why.
- Take detailed notes of the conversation, including the date, time, and the name of the person you spoke to.
Step 2: Write a Formal Appeal Letter or Email
If a phone call doesn't work, you must submit a formal written appeal. This letter is your chance to present your case logically and professionally.
What to Include in Your Appeal Letter:
- Your Details: Your full name, address, and policy number.
- Reference the Claim: State the claim reference number and the date of the rejection letter.
- State Your Intent: Begin with a clear sentence, such as: "I am writing to formally appeal the decision to deny my claim for [name of treatment/condition]."
- Address the Rejection Reason: Go directly to the reason your insurer gave for the denial and explain, point by point, why you believe they are wrong.
- Provide Your Evidence: This is the most important part.
- If denied for a pre-existing condition: Explain why you believe it is a new, acute condition. For example: "You have stated my knee pain is a pre-existing condition. However, as Dr. Smith's enclosed letter confirms, this is a new meniscal tear in my right knee caused by a recent sporting injury. It is entirely unrelated to the mild arthritis I had in my left knee five years ago."
- If denied as a chronic condition: Ask your specialist to provide a letter explaining why the treatment is intended to resolve an acute flare-up, rather than simply manage a long-term illness.
- Reference Your Policy: If you believe the insurer has misinterpreted their own policy, quote the relevant clause and explain how it supports your claim.
- Enclose Supporting Documents: List all the documents you are including with your letter (e.g., "Please find enclosed: a supporting letter from my consultant, Mr. Jones; the results of my MRI scan dated 15th January 2026").
- State Your Desired Outcome: Clearly state what you want to happen – for the claim to be approved and the treatment costs to be covered.
- Keep it Professional: Avoid emotional or angry language. A factual, evidence-based argument is far more powerful.
Always send your letter by a tracked method, such as Royal Mail Signed For, or request a read-receipt for emails. Keep a copy for your records.
Step 3: The Insurer's Response
The FCA gives insurers up to eight weeks to provide a "final response" to a formal complaint. During this time, they will review your appeal and all the evidence.
- Best Outcome: They agree with you and overturn their original decision, approving your claim.
- Partial Success: They may agree to cover part of the claim but not all of it.
- Rejection Upheld: They stick to their original decision and provide a final response letter explaining why. This letter must also inform you of your right to take your complaint to the Financial Ombudsman Service.
When Your Internal Appeal Fails: Escalating to the Financial Ombudsman Service (FOS)
If your insurer rejects your appeal or you don't hear back within eight weeks, do not give up. Your next step is to take your case to the Financial Ombudsman Service (FOS).
The FOS is a free, independent, and impartial organisation that settles disputes between consumers and financial services companies, including insurance providers.
How to Complain to the FOS
You can start a complaint with the FOS if:
- You have received a final response from your insurer that you are unhappy with.
- More than eight weeks have passed since you first made your formal complaint, and you haven't received a final response.
You must contact the FOS within six months of the date on your insurer's final response letter.
The process is straightforward:
- Go to the FOS website: You can fill out their online complaint form, which guides you through the process.
- Provide All Your Evidence: You will need to submit everything you sent to your insurer, plus their final response letter. This includes your appeal letter, medical reports, policy documents, and any other correspondence.
- Explain Your Case: Clearly tell the FOS what happened, why you think your insurer's decision was unfair, and what you want them to do about it.
What Happens Next?
An FOS case handler will be assigned to your complaint. They will look at both sides of the argument, considering the law, regulations, and what is fair and reasonable in your specific circumstances. They may ask you or the insurer for more information.
The FOS's decision is binding on the insurer if you, the consumer, accept it. You are not bound by their decision and can still choose to take the matter to court if you wish, although this is rare.
According to the FOS's 2023/24 annual data, they received 12,793 new complaints about private medical and dental insurance. The uphold rate – the percentage of cases where they found in favour of the consumer – was 30%. This shows that a significant number of insurer decisions are overturned upon independent review.
The Role of a PMI Broker in the Claims Process
Dealing with a denied claim is stressful. This is where having a good PMI broker on your side from the beginning can be invaluable.
- Prevention: When you first take out a policy, an expert broker like WeCovr will take the time to understand your medical history and budget. We can help you navigate the complexities of different underwriting options and ensure you choose a policy with the right level of cover, minimising the risk of future surprises.
- Advocacy: If you do face a denied claim, we can act as your advocate. As experts in private medical insurance in the UK, we understand the policy jargon and can often liaise directly with the insurer's broker support teams. This can help resolve issues more quickly and with less stress for you. This support is part of our service, at no extra cost to you.
Customers who use WeCovr consistently report high satisfaction with our service, valuing the peace of mind that comes with expert guidance.
Tips for a Successful PMI Application to Avoid Future Denials
The best way to handle a denied claim is to prevent it from ever happening.
- Be 100% Honest on Your Application: The single most important rule is to declare everything. Even minor symptoms or consultations from years ago should be mentioned. Insurers can request access to your full medical records via the Access to Medical Reports Act 1988, and any failure to disclose information can be used to void your policy.
- Understand Your Underwriting: Know how your policy has been underwritten.
| Underwriting Type | How it Works | Pros | Cons |
|---|---|---|---|
| Moratorium (MOR) | You don't declare your full medical history upfront. Instead, the insurer automatically excludes any condition you've had in the 5 years before the policy start date. These can be covered later if you go 2 continuous years without symptoms or treatment for them. | Quick and easy to set up. | Lack of certainty. A condition you thought was minor could be excluded. |
| Full Medical Underwriting (FMU) | You complete a detailed health questionnaire. The insurer reviews your medical history and states upfront exactly what is and isn't covered. | Provides complete clarity from day one. You know where you stand. | The application process is longer. Pre-existing conditions are likely to be permanently excluded. |
- Read Your Policy Documents: When your documents arrive, read them. Pay close attention to the list of exclusions and the financial limits for different benefits like outpatient care or therapies.
- Always Get Pre-Authorisation: Before you receive any treatment or even have a specialist consultation, you must call your insurer to get the claim pre-authorised. They will give you an authorisation number, confirming that the procedure is covered.
Beyond the Appeal: Wellness and Maintaining Your Health
While private medical insurance is there for when things go wrong, taking proactive steps to manage your health is always the best strategy. A healthy lifestyle can reduce your risk of developing many acute conditions.
- A Balanced Diet: Focus on a diet rich in whole foods, fruits, vegetables, and lean proteins. Reducing processed foods, sugar, and saturated fats is key to maintaining a healthy weight and cardiovascular system. As a WeCovr client, you'll receive complimentary access to CalorieHero, our AI-powered calorie and nutrition tracking app, to help you stay on track.
- Regular Physical Activity: The NHS recommends at least 150 minutes of moderate-intensity activity (like brisk walking or cycling) or 75 minutes of vigorous-intensity activity (like running or swimming) a week.
- Prioritise Sleep: Most adults need 7-9 hours of quality sleep per night. Poor sleep is linked to a range of health issues, including a weakened immune system and high blood pressure.
- Manage Stress: Chronic stress can have a physical impact on your body. Techniques like mindfulness, yoga, or even just regular walks in nature can help manage stress levels.
At WeCovr, we believe in a holistic approach to your wellbeing. That’s why when you purchase PMI or life insurance with us, you can often access discounts on other forms of cover, helping you build a comprehensive protection plan for you and your family.
What is the difference between a chronic and an acute condition in PMI?
Can I appeal if my claim is denied for non-disclosure?
How long do I have to make a complaint to the Financial Ombudsman Service?
Does using an expert PMI broker like WeCovr cost me extra?
A denied claim can feel like a setback, but it's important to remember you have rights and a clear path to appeal. By understanding your policy, gathering your evidence, and following the correct procedure, you stand a strong chance of a successful outcome.
Feeling overwhelmed by the complexities of private health cover? Let the experts help. Get a free, no-obligation quote from WeCovr today to compare the UK's leading providers and find the right plan for you and your family.
Related guides
Why private medical insurance and how does it work?
What is Private Medical Insurance?
Private medical insurance (PMI) is a type of health insurance that provides access to private healthcare services in the UK. It covers the cost of private medical treatment, allowing you to bypass NHS waiting lists and receive faster, more convenient care.How does it work?
Private medical insurance works by paying for your private healthcare costs. When you need treatment, you can choose to go private and your insurance will cover the costs, subject to your policy terms and conditions. This can include:• Private consultations with specialists
• Private hospital treatment and surgery
• Diagnostic tests and scans
• Physiotherapy and rehabilitation
• Mental health treatment
Your premium depends on factors like your age, health, occupation, and the level of cover you choose. Most policies offer different levels of cover, from basic to comprehensive, allowing you to tailor the policy to your needs and budget.
Questions to ask yourself regarding private medical insurance
Just ask yourself:👉 Are you concerned about NHS waiting times for treatment?
👉 Would you prefer to choose your own consultant and hospital?
👉 Do you want faster access to diagnostic tests and scans?
👉 Would you like private hospital accommodation and better food?
👉 Do you want to avoid the stress of NHS waiting lists?
Many people don't realise that private medical insurance is more affordable than they think, especially when you consider the value of faster treatment and better facilities. A great insurance policy can provide peace of mind and ensure you receive the care you need when you need it.
Benefits offered by private medical insurance
Private medical insurance provides numerous benefits that can significantly improve your healthcare experience and outcomes:Faster Access to Treatment
One of the biggest advantages is avoiding NHS waiting lists. While the NHS provides excellent care, waiting times can be lengthy. With private medical insurance, you can often receive treatment within days or weeks rather than months.
Choice of Consultant and Hospital
You can choose your preferred consultant and hospital, giving you more control over your healthcare journey. This is particularly important for complex treatments where you want a specific specialist.
Better Facilities and Accommodation
Private hospitals typically offer superior facilities, including private rooms, better food, and more comfortable surroundings. This can make your recovery more pleasant and potentially faster.
Advanced Treatments
Private medical insurance often covers treatments and medications not available on the NHS, giving you access to the latest medical advances and technologies.
Mental Health Support
Many policies include comprehensive mental health coverage, providing faster access to therapy and psychiatric care when needed.
Tax Benefits for Business Owners
If you're self-employed or a business owner, private medical insurance premiums can be tax-deductible, making it a cost-effective way to protect your health and your business.
Peace of Mind
Knowing you have access to private healthcare when you need it provides invaluable peace of mind, especially for those with ongoing health conditions or concerns about NHS capacity.
Private medical insurance is particularly valuable for those who want to take control of their healthcare journey and ensure they receive the best possible treatment when they need it most.
Important Fact!
We can look at a more suitable option mid-term!
Why is it important to get private medical insurance early?
👉 Many people are very thankful that they had their private medical insurance cover in place before running into some serious health issues. Private medical insurance is as important as life insurance for protecting your family's finances.👉 We insure our cars, houses, and even our phones! Yet our health is the most precious thing we have.
Easily one of the most important insurance purchases an individual or family can make in their lifetime, the decision to buy private medical insurance can be made much simpler with the help of FCA-authorised advisers. They are the specialists who do the searching and analysis helping people choose between various types of private medical insurance policies available in the market, including different levels of cover and policy types most suitable to the client's individual circumstances.
It certainly won't do any harm if you speak with one of our experienced insurance experts who are passionate about advising people on financial matters related to private medical insurance and are keen to provide you with a free consultation.
You can discuss with them in detail what affordable private medical insurance plan for the necessary peace of mind they would recommend! WeCovr works with some of the best advisers in the market.
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