How Private Policyholders Navigate Rising Claims Rejection Rates
At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we understand that a rejected claim on your private medical insurance in the UK can be distressing. This guide demystifies the process, explaining why claims are denied and empowering you with the expert knowledge to appeal successfully.
Latest ombudsman statistics and expert advice for claim appeals
Receiving a letter stating your private health insurance claim has been rejected can feel like a significant blow, especially when you are unwell. You took out a policy for peace of mind, only to find a barrier when you need support the most. You are not alone.
Recent statistics from the Financial Ombudsman Service (FOS) – the UK’s independent body for settling disputes between consumers and financial firms – shed light on this growing issue. In the latest reporting year, the FOS received thousands of new complaints about private medical and dental insurance.
Worryingly, a significant portion of these complaints are upheld in favour of the consumer. The FOS's latest data shows an uphold rate of 34% for private medical insurance complaints. This means that in over a third of cases escalated to the ombudsman, the independent adjudicator found that the insurer had acted unfairly and overturned their original decision.
This statistic is a double-edged sword. While it highlights that insurers can and do get it wrong, it also offers a beacon of hope: a rejected claim is not the end of the road. With the right approach, you have a very real chance of a successful appeal.
This article will guide you through the common pitfalls that lead to rejections and provide a clear, step-by-step framework for challenging an insurer's decision.
Why Are Private Health Insurance Claims Rejected?
Understanding the 'why' behind a rejection is the first step to building a strong appeal. Insurers aren't trying to be difficult; they operate based on strict contractual terms. Most rejections fall into a few common categories.
The Critical Rule: Pre-existing and Chronic Conditions
This is the most important concept to understand in UK private medical insurance. Standard PMI policies are designed to cover acute conditions that arise after you take out your policy.
- Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Examples include a hernia, cataracts, or a joint injury requiring surgery.
- Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics: it needs ongoing or long-term monitoring, requires palliative care, has no known cure, or is likely to come back. Examples include diabetes, asthma, arthritis, and high blood pressure.
- Pre-existing Condition: Any illness, disease, or injury for which you have experienced symptoms, received medication, advice, or treatment before your policy start date.
Insurers will almost always reject claims for the investigation or treatment of chronic conditions. They will also reject claims for conditions they deem to be pre-existing, based on the type of underwriting you have.
Non-Disclosure: The Perils of an Incomplete Application
When you apply for health insurance, you are entering into a contract based on good faith. You have a duty to disclose your medical history accurately and completely. Failing to mention a past symptom, consultation, or diagnosis – even if it seems minor or happened a long time ago – can be classed as 'non-disclosure'.
If you later claim for a related condition, your insurer may review your medical history. If they find information you didn't declare, they can argue you misrepresented the risk and may void your policy or, more commonly, reject the claim.
Example: You had a few consultations for back pain five years ago but didn't mention it on your application. Two years into your policy, you suffer a slipped disc and need surgery. The insurer could reject the claim on the grounds that the condition was pre-existing and you failed to disclose the earlier symptoms.
Policy Exclusions: The Fine Print Matters
Every policy has a list of standard exclusions. These are treatments and conditions that are never covered, regardless of your medical history.
| Common Policy Exclusions | Description |
|---|---|
| Chronic Conditions | As explained above, long-term conditions are not covered. |
| Pre-existing Conditions | Conditions you had symptoms or treatment for before the policy started. |
| Normal Pregnancy & Childbirth | Routine maternity care is usually excluded, though complications may be covered. |
| Cosmetic Surgery | Procedures for purely aesthetic reasons are not covered. |
| Experimental Treatment | Therapies or drugs not approved by the National Institute for Health and Care Excellence (NICE). |
| Self-inflicted Injuries | Injuries resulting from substance abuse, dangerous hobbies (unless declared and accepted), etc. |
| Emergency Services | PMI complements the NHS; it doesn't replace A&E services. |
Not 'Medically Necessary'
For a claim to be approved, the treatment you are seeking must be considered medically necessary. A consultant recommending a scan or procedure isn't always enough. The insurer's clinical team will assess whether the proposed treatment is the appropriate and established pathway for your specific diagnosis, in line with UK medical best practices. If they believe a less invasive or less expensive treatment is more appropriate, they may decline the initial request.
Exceeding Your Benefit Limits
Your policy is not a blank cheque. It will have specific limits on what it will pay out.
- Annual Overall Limit: A cap on the total value of claims you can make in a policy year (e.g., £500,000 or 'unlimited').
- Outpatient Limits: A common restriction. Your policy might cover specialist consultations and diagnostic tests up to a certain amount, such as £1,000 per year.
- Therapy Limits: Limits on the number of sessions for treatments like physiotherapy or osteopathy (e.g., 8 sessions per year).
If a claim takes you over one of these limits, the insurer will only pay up to the cap, and you will be liable for the rest.
Failure to Follow Claim Procedure
You cannot simply see a specialist and send the bill to your insurer. All non-emergency private treatment requires pre-authorisation.
The typical process is:
- Visit your GP for a diagnosis and an open referral to a specialist.
- Contact your insurer with your GP's referral letter to get the consultation pre-authorised.
- After seeing the specialist, if further tests or treatment are needed, you or the specialist's office must contact the insurer again for pre-authorisation before proceeding.
Skipping this process is a guaranteed way to have your claim rejected.
Understanding Your Policy: A Proactive Approach to Avoiding Rejection
Prevention is always better than cure. By thoroughly understanding your policy from day one, you can significantly reduce the chances of a future claim being rejected. Working with an expert PMI broker like WeCovr can be invaluable here, as they can translate the jargon and ensure you choose a policy that truly fits your needs.
The Devil is in the Detail: Read Your Documents
When you take out a policy, you'll receive several documents. The two most important are:
- Insurance Product Information Document (IPID): A simple, standardised summary of the key features, benefits, and exclusions.
- Policy Terms and Conditions: The full contract. It's long, but it contains all the rules your insurer will use to assess a claim. Pay close attention to the definitions and exclusions sections.
Underwriting Types Explained
The way an insurer assesses your pre-existing conditions is determined by the type of underwriting on your policy. This is a critical choice you make at the start.
| Underwriting Type | How It Works | Pros | Cons |
|---|---|---|---|
| Full Medical Underwriting (FMU) | You complete a detailed health questionnaire, disclosing your full medical history. The insurer then explicitly lists any conditions that will be excluded from cover. | Clarity. You know from day one exactly what is and isn't covered. | Lengthy Application. Can be intrusive and requires you to remember past health issues. |
| Moratorium (Mori) | You don't complete a detailed health questionnaire. Instead, the insurer automatically excludes any condition you've had symptoms, advice, or treatment for in the last 5 years. This exclusion may be lifted if you go 2 continuous years on the policy without any symptoms, advice, or treatment for that condition. | Quick & Easy. No long forms to fill out. | Uncertainty. You may not be sure what's covered until you claim. "Rolling" moratoria can be complex. |
| Continued Personal Medical Exclusions (CPME) | This is only for people switching from another PMI provider. Your new insurer agrees to carry over the same exclusions you had on your previous policy. | Seamless Cover. No new medical exclusions are added for conditions that developed while you were on your old policy. | Limited to Switchers. Only an option if you already have private medical insurance. |
Key PMI Terms at a Glance
Navigating policy documents can feel like learning a new language. Here’s a simple glossary of essential terms.
| Term | Plain English Definition |
|---|---|
| Excess | The fixed amount you agree to pay towards a claim in each policy year. For example, if you have a £250 excess and a £2,000 claim is approved, you pay £250 and the insurer pays £1,750. |
| Pre-authorisation | Getting approval from your insurer before you have any consultation, test, or treatment. This is mandatory. |
| Hospital List | The list of private hospitals and clinics your policy allows you to use. Using a hospital not on your list will result in a rejected claim. |
| Outpatient Cover | Cover for consultations and diagnostic tests that do not require an overnight hospital stay. This is often an optional add-on or has a monetary limit. |
| Inpatient Cover | Cover for treatment that requires you to be admitted to a hospital bed, including surgery and nursing care. |
| Day-patient Cover | Cover for a planned medical procedure that requires a hospital bed for the day, but not an overnight stay. |
Step-by-Step Guide: How to Appeal a Rejected Claim
If your claim is rejected, stay calm and get organised. A methodical, evidence-based approach gives you the best chance of success.
Step 1: Review the Rejection Letter Carefully
The first thing to do is read the insurer's explanation in detail. They are required by the Financial Conduct Authority (FCA) to explain their decision clearly. Identify the specific reason for the rejection. Is it because they believe the condition is:
- Pre-existing?
- Chronic?
- A policy exclusion?
- Not medically necessary?
- Related to something you didn't disclose?
Understanding their reasoning is your starting point for building a counter-argument.
Step 2: Gather Your Evidence
This is the most critical phase. You need to build a case file to challenge the insurer's decision. Your file should include:
- The Rejection Letter: The basis of your appeal.
- Your Policy Documents: To check the exact wording of the terms the insurer is relying on.
- A Letter from Your GP or Consultant: Ask your doctor to write a letter that directly addresses the insurer's reason for rejection. For example:
- If the claim was denied as 'pre-existing', your doctor could clarify that your current symptoms are new and unrelated to any past issues.
- If denied as 'not medically necessary', your consultant can provide a detailed clinical justification for the proposed treatment, referencing NICE guidelines if possible.
- Your Medical Records: You have a right to request a copy of your medical records from your GP surgery. These can be used to prove or disprove links to past conditions.
Step 3: Launch an Internal Appeal with Your Insurer
Every insurer has a formal internal complaints procedure. You must go through this process before you can escalate it to the Ombudsman.
- Write a Formal Complaint Letter/Email: Address it to the insurer's complaints department.
- State Your Case Clearly: Begin by stating "I wish to make a formal complaint regarding the rejection of claim number [your claim number]."
- Explain Why You Disagree: Systematically address the insurer's points from their rejection letter. Use your evidence to support your argument.
- Be Factual and Polite: Avoid emotional language. Stick to the facts of your case.
- Enclose Your Evidence: Attach copies of your consultant's letter, relevant policy clauses, and any other supporting documents.
- State Your Desired Outcome: Clearly state that you want them to reconsider and approve the claim.
The insurer has up to eight weeks to provide you with a 'final response'. Many appeals are successfully resolved at this stage.
Step 4: Escalate to the Financial Ombudsman Service (FOS)
If the insurer rejects your internal appeal or fails to respond within eight weeks, you have the right to take your case to the Financial Ombudsman Service.
- It's Free: The service is completely free for consumers.
- It's Independent: The FOS is an impartial umpire and is not on either side.
- Their Decision is Binding: If the FOS finds in your favour, the insurer is legally obliged to comply with their ruling, which could mean paying the claim and potentially offering compensation for distress and inconvenience.
To start a case, you simply fill out a form on the FOS website and upload the insurer's final response letter along with your evidence. An adjudicator will review the case from both sides and make a decision based on what is fair and reasonable in the circumstances. As the 34% uphold rate shows, there is a strong chance of success if your case has merit.
The Role of an Expert PMI Broker in Preventing and Appealing Claims
Navigating the complexities of the private medical insurance UK market can be daunting. This is where an independent broker adds immense value. A specialist broker works for you, not the insurer.
From the outset, an expert at WeCovr can help you avoid the common pitfalls that lead to rejected claims. We take the time to:
- Understand Your Needs: We discuss your health, lifestyle, and budget to find the right level of cover.
- Explain the Jargon: We demystify underwriting, benefit limits, and exclusions so you know exactly what you're buying.
- Ensure Correct Disclosure: We guide you through the application process to ensure your medical history is declared accurately, minimising the risk of future non-disclosure issues.
Should you ever need to make a claim, our job isn't over. If you face a difficult or rejected claim, our team can provide invaluable support, liaising with the insurer on your behalf and helping you structure a compelling appeal. Our expertise can make a real difference in turning a 'no' into a 'yes'.
Maintaining Your Health and Wellness: A Pillar of Your Health Strategy
While private health cover is there for when things go wrong, the best strategy is to proactively manage your well-being. A healthier lifestyle can reduce your risk of developing many acute conditions, meaning you'll need to claim less often.
- Balanced Diet: Focus on whole foods, including plenty of fruits, vegetables, lean proteins, and whole grains. A balanced diet supports your immune system and overall physical resilience. To help with this, WeCovr provides complimentary access to our AI-powered calorie and nutrition tracking app, CalorieHero, for all our clients.
- Regular Physical Activity: Aim for at least 150 minutes of moderate-intensity activity, like brisk walking or cycling, per week. Exercise is proven to reduce the risk of heart disease, type 2 diabetes, and some cancers.
- Prioritise Sleep: Most adults need 7-9 hours of quality sleep per night. Poor sleep can weaken your immune system and affect both your mental and physical health.
- Manage Stress: Chronic stress can contribute to a host of health problems. Incorporate stress-management techniques like mindfulness, yoga, or simply spending time in nature into your daily routine.
By purchasing PMI or Life Insurance through WeCovr, you may also be eligible for discounts on other types of cover, helping you build a comprehensive protection portfolio for you and your family. Our high customer satisfaction ratings reflect our commitment to providing holistic, client-focused advice.
What is the difference between an acute and a chronic condition in PMI?
Do I need to declare every single GP visit on my health insurance application?
Can my insurer cancel my policy if my claim is rejected?
How long does the Financial Ombudsman Service take to resolve a complaint?
A rejected claim doesn't have to be the final word. By understanding your policy, being organised, and presenting a clear, evidence-based appeal, you can successfully challenge your insurer's decision.
Take the first step towards peace of mind. Contact WeCovr today for a free, no-obligation quote and let our experts help you find the best private health cover for your needs.
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.
By tapping the button below, you can book a free call with them in less than 30 seconds right now:
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WeCovr is an insurance specialist for people valuing their peace of mind and a great service.👍 WeCovr will help you get your private medical insurance, life insurance, critical illness insurance and others in no time thanks to our wonderful super-friendly experts ready to assist you every step of the way.
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