How Pre-Authorisation Works in Private Health Insurance
Understanding pre-authorisation is key to using your private medical insurance in the UK. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we make this process clear. This guide explains how to get approval for your treatment and what steps to take.
When and how to get approval for treatment, and what to do if refused
Getting approval, or 'pre-authorisation', is a vital step before you receive most types of private medical treatment. You should contact your insurer right after your GP has referred you to a specialist, but before you book any appointments or procedures. Your insurer will check your cover, confirm the treatment is medically necessary, and give you an authorisation number.
If your request is refused, don't panic. The first step is to ask your insurer for a clear reason in writing. You can then review your policy, speak to your specialist for more evidence, and launch a formal appeal. If that fails, the independent Financial Ombudsman Service is your next port of call. This guide will walk you through each of these steps in detail.
What Exactly is Pre-Authorisation in Private Health Insurance?
Think of pre-authorisation as getting the green light from your insurance provider before you go ahead with private medical care. It's a mandatory checkpoint where your insurer verifies that the consultation, test, or treatment you need is covered under the terms of your policy.
It is not just a box-ticking exercise; it serves several crucial functions:
- Confirms Medical Necessity: The insurer checks that the treatment is essential for your health and not for cosmetic or lifestyle reasons.
- Verifies Policy Cover: It ensures the specific condition and the proposed treatment are included in your plan. This avoids any nasty surprises with unexpected bills later on.
- Manages Costs: It allows the insurer to confirm the costs with the hospital and specialist, ensuring they are reasonable and customary.
- Guides You to a Recognised Provider: Insurers have networks of approved hospitals and specialists. Pre-authorisation ensures you are treated by a facility and a professional that meets their quality and cost criteria.
Without a pre-authorisation number, your insurer can refuse to pay for your treatment, leaving you responsible for the entire bill.
The Step-by-Step Pre-Authorisation Process Explained
Navigating the pre-authorisation journey can feel daunting, but it follows a logical path. Here’s a breakdown of the typical steps from initial symptom to final payment.
Step 1: Visit Your GP
For most non-emergency conditions, your journey starts at your local NHS GP surgery. You'll discuss your symptoms, and if they feel you need specialist investigation, they will provide you with an 'open referral' letter. This letter will recommend a type of specialist (e.g., a cardiologist or an orthopaedic surgeon) but won't usually name a specific person.
Step 2: Contact Your Insurer to Get Authorisation
This is the most important step. Before you book any private appointments, call your insurer's claims or pre-authorisation helpline. Have this information ready:
- Your policy number
- Personal details (name, date of birth, address)
- The details from your GP referral letter
- A description of your symptoms and when they started
The insurer's clinical team will review your case. They will check your policy to ensure the condition isn't excluded and that you have sufficient benefit limits (e.g., for outpatient consultations).
Step 3: Receive Your Authorisation Number
If your claim is approved, you will be given a pre-authorisation or claims number. This number is your golden ticket. It confirms the insurer has agreed to cover the initial consultation. You will need to give this number to the specialist's secretary and the hospital.
Step 4: Book Your Specialist Consultation
Your insurer will provide you with a list of approved specialists and hospitals in your area. It is crucial to choose from this list. Using a non-approved provider could invalidate your claim. You can then contact the specialist's secretary to book your first appointment, providing them with your authorisation number.
Step 5: The Specialist Recommends Further Tests or Treatment
During your consultation, the specialist may decide you need further diagnostic tests, like an MRI scan, or a specific treatment, such as surgery. For each of these subsequent steps, new pre-authorisation is required. Often, the specialist’s administrative team will handle this on your behalf, contacting the insurer directly with the proposed treatment plan and associated costs (known as procedure codes).
Step 6: Receive Authorisation for the Main Treatment
Your insurer will review the specialist's request. If approved, they will issue a new authorisation for the specific tests or surgery. They will confirm exactly what they are covering and up to what cost.
Step 7: Undergo Your Treatment
With full authorisation in place, you can proceed with your tests or treatment with the peace of mind that the costs are covered.
Step 8: Invoices are Settled Directly
After your treatment, the hospital and specialist will send their invoices directly to your insurance company, quoting your authorisation number. The insurer settles the bill. You will only be responsible for paying any excess that applies to your policy.
The Golden Rule: What UK PMI Does and Doesn't Cover
Understanding the core purpose of private medical insurance is essential. It is designed to cover acute conditions that arise after you have taken out your policy.
- An acute condition is a disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Examples include joint replacements, cataract removal, hernia repair, and most cancer treatments.
- A chronic condition is a disease, illness, or injury that has one or more of the following characteristics: it needs ongoing or long-term monitoring, is managed by medication or tests, has no known cure, or is likely to come back. Standard UK private health insurance does not cover the management of chronic conditions like diabetes, asthma, hypertension, or multiple sclerosis.
Furthermore, PMI policies do not cover pre-existing conditions. How this is managed depends on your underwriting type:
- Moratorium Underwriting: This is the most common type. It automatically excludes any condition you've had symptoms, advice, or treatment for in the five years before your policy began. However, if you go two full years on the policy without any symptoms, advice, or treatment for that condition, it may become eligible for cover.
- Full Medical Underwriting (FMU): With FMU, you complete a detailed health questionnaire when you apply. The insurer assesses your medical history and lists specific exclusions on your policy from day one. This provides more certainty but can be more complex upfront.
Acute vs. Chronic Conditions: A Clear Comparison
| Feature | Acute Condition | Chronic Condition |
|---|---|---|
| Duration | Short-term | Long-term, often lifelong |
| Outcome | Curable, leads to recovery | Manageable, but not curable |
| PMI Cover | Covered | Not Covered |
| Examples | Appendicitis, bone fracture, gallstones, cataracts, most cancers | Diabetes, asthma, high blood pressure, arthritis, Crohn's disease |
Why Might a Pre-Authorisation Request Be Refused?
Receiving a 'no' from your insurer can be disheartening. It almost always comes down to the specific terms written in your policy document. Here are the most common reasons for a refusal:
- It's a Pre-existing Condition: The condition or its symptoms existed before you joined the policy and are therefore excluded under the underwriting terms.
- It's a Chronic Condition: The policy is designed for acute conditions only, and the NHS remains responsible for long-term chronic care.
- The Treatment is a General Exclusion: Nearly all policies have a list of standard exclusions, which often include:
- Cosmetic surgery
- Experimental or unproven treatments
- Fertility treatment (IVF)
- Normal pregnancy and childbirth
- Addiction treatment
- Self-inflicted injuries
- You've Reached Your Benefit Limit: Many policies have annual limits on certain benefits, such as outpatient consultations or therapies. If you've already used your yearly allowance, further claims will be denied.
- The Provider Isn't Recognised: You have chosen a hospital or specialist who is not part of the insurer's approved network.
- Incomplete Information: You or your specialist may not have provided enough information for the insurer to make a decision.
- Treatment Not Deemed Medically Necessary: In rare cases, the insurer's clinical team may disagree with the specialist's recommendation, believing there are less invasive or alternative options.
What to Do If Your Pre-Authorisation is Denied
A denial is not necessarily the end of the road. There is a clear process to follow if you believe the decision is unfair.
- Step 1: Get the Reason in Writing. Ask your insurer for a detailed written explanation for the denial. They must reference the specific clause in your policy terms and conditions that justifies their decision.
- Step 2: Review Your Policy Documents. Carefully read the section your insurer has cited. Compare it with your understanding of your cover. Sometimes, there can be misinterpretations on either side.
- Step 3: Talk to Your Specialist. Discuss the insurer's decision with your consultant. They may be able to provide a supporting letter that clarifies why the treatment is medically necessary and falls within the definition of an acute condition, or why it isn't related to a pre-existing issue.
- Step 4: Launch a Formal Appeal. Every insurer has a formal internal complaints and appeals procedure. Write a clear, concise letter outlining why you are appealing the decision, and include any new evidence from your specialist.
- Step 5: Escalate to the Financial Ombudsman Service (FOS). If your appeal is rejected and you have reached a 'deadlock' with your insurer, you can take your case to the FOS. This is a free and impartial service that resolves disputes between consumers and financial companies. They will review all the evidence from both sides and make a final, binding decision. You must typically approach the FOS within six months of the insurer's final response.
Throughout this process, a knowledgeable PMI broker like WeCovr can provide invaluable support, helping you understand the terminology and advocating on your behalf.
Real-Life Pre-Authorisation Scenarios
Let's look at how pre-authorisation plays out in different situations.
Scenario 1: Smooth Sailing (Knee Surgery)
- Patient: John, 55, a keen runner.
- Problem: Develops persistent knee pain. His GP suspects a torn meniscus and gives him an open referral to an orthopaedic surgeon.
- Action: John calls his insurer, provides his policy details and referral information. He gets an authorisation number for an initial consultation and an MRI scan. He chooses a surgeon from the insurer's approved list.
- Outcome: The MRI confirms a torn meniscus. The surgeon's secretary contacts the insurer with the procedure code for an arthroscopy (keyhole surgery). The insurer authorises the surgery at a specific hospital. John has the operation, pays his £250 policy excess, and the insurer settles the remaining £7,500 bill directly.
Scenario 2: The Grey Area (Back Pain)
- Patient: Emily, 42, with moratorium underwriting.
- Problem: Suffers from severe lower back pain and sciatica. She saw a physio for a minor back strain four years ago, before her policy started. Her GP refers her to a spinal specialist.
- Action: Emily calls her insurer. The claims handler notes the previous back trouble and flags it as potentially pre-existing. They request more information from Emily's GP.
- Outcome: Emily's GP writes a letter confirming the previous issue was a simple muscular strain in the upper back and is entirely unrelated to the current nerve-related problem in her lower back. After reviewing this new evidence, the insurer's clinical team agrees this is a new, acute condition and provides pre-authorisation for the consultation.
Scenario 3: The Refusal (Chronic Condition)
- Patient: Mark, 60, recently diagnosed with Type 2 Diabetes.
- Problem: His GP refers him to a private endocrinologist for ongoing management and monitoring of his condition.
- Action: Mark calls his insurer to get pre-authorisation for the specialist appointment.
- Outcome: The insurer politely explains that as Type 2 Diabetes is a chronic condition requiring long-term management, it is not covered under the terms of his private medical insurance policy. The pre-authorisation request is denied. Mark will continue to receive his diabetes care through the NHS.
How a Specialist PMI Broker Like WeCovr Can Help
Navigating the world of private health insurance can be complex, but you don't have to do it alone. An independent PMI broker acts as your expert guide.
At WeCovr, our service is about more than just finding a cheap price.
- Personalised Advice: We take the time to understand your needs, budget, and health concerns to recommend the policy that offers the right level of cover, from the right provider.
- Market Comparison: We compare plans from a wide range of leading UK insurers, explaining the key differences in their cover, hospital lists, and claims processes.
- Claim Support: Should you need to make a claim, we are on hand to offer guidance. If you run into issues like a denied pre-authorisation, we can help you understand the insurer's reasoning and formulate your appeal.
- No Extra Cost: Our expert service is completely free for you. We are paid a commission by the insurer you choose, so you get our expertise without paying a penny more.
What's more, WeCovr clients get complimentary access to our AI-powered nutrition app, CalorieHero, to help support their health goals. You may also be eligible for discounts on other insurance products, such as life or income protection cover, when you take out a PMI policy with us.
Proactive Health & Wellness in the UK
While having private medical insurance provides a crucial safety net, prevention is always better than cure. With NHS waiting lists in England affecting several million people, taking proactive steps to manage your health has never been more important.
- A Balanced Diet: The NHS Eatwell Guide provides a fantastic blueprint for a healthy diet. Aim for five portions of fruit and veg a day, incorporate lean proteins, and choose wholegrain carbohydrates. Tools like the CalorieHero app can make tracking your intake simple and effective.
- Regular Physical Activity: According to the Office for National Statistics (ONS), around one in four adults in the UK are classified as physically inactive. The official recommendation is for at least 150 minutes of moderate-intensity activity (like brisk walking or cycling) or 75 minutes of vigorous-intensity activity (like running or tennis) each week.
- Prioritise Sleep: Consistently getting 7-9 hours of quality sleep per night is vital for both physical and mental recovery. Poor sleep is linked to a higher risk of developing chronic conditions.
- Mental Wellbeing: Many modern PMI policies offer excellent mental health support, from therapy sessions to digital wellbeing apps. Don't be afraid to use them. Simple daily practices like mindfulness, spending time in nature, and staying connected with loved ones can also make a huge difference.
Comparing Pre-Authorisation Across Major UK Insurers
While the core principle is the same, different insurers have unique approaches and tools for managing pre-authorisation.
| Insurer | Key Pre-Authorisation Feature | Digital Tools |
|---|---|---|
| Bupa | Often offer 'Open Referral' where Bupa helps find and book you in with a recognised consultant, speeding up the process. | Excellent Bupa Touch app for managing policies, starting claims, and finding specialists. |
| AXA Health | Guided Care pathway for complex claims, where a dedicated case manager supports you from start to finish. | Doctor@Hand digital GP service is often the first step. Strong online customer portal. |
| Aviva | Strong emphasis on their 'Expert Select' hospital network, which can help manage costs and may reduce your premium. | Aviva Digital GP app provides quick access for referrals. Well-regarded online claims centre. |
| Vitality | Process is linked to their 'ABC' referral system (A=Adviser, B=Body, C=Consultant). The Vitality GP app is a key part of the journey. | Market-leading app that integrates claims with their wellness and rewards programme. |
Disclaimer: Insurer processes and features are subject to change. An expert broker like WeCovr can provide the most current and detailed comparison based on your specific needs.
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Can my specialist's secretary handle pre-authorisation for me?
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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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