How to Appeal a Denied PMI Claim in 2026
Facing a denied claim on your private medical insurance (PMI) is incredibly stressful. As an FCA-authorised UK broker, WeCovr has assisted with over 900,000 policies of various types and understands how crucial it is to get the support you’ve paid for. This guide is here to help.
Guide for customers facing rejections, reform processes, and ombudsman help
Receiving a letter from your insurer stating your claim has been rejected can feel like a significant blow, especially when you are unwell. You might feel confused, angry, or helpless. But it's important to know that a "no" is not always the final answer.
The UK insurance industry is regulated by the Financial Conduct Authority (FCA), and there are established, fair processes for you to challenge a decision you believe is wrong. This guide will walk you through every step of the appeals process in 2026, from understanding the initial rejection to escalating your case to the Financial Ombudsman Service (FOS) if needed.
We will cover:
- Common reasons why claims are denied.
- How to build a strong case for your appeal.
- A step-by-step guide to the internal appeals process.
- When and how to take your complaint to the independent FOS.
- How to prevent claim denials in the first place.
Why Might a PMI Claim Be Denied in the UK?
Understanding why your insurer denied your claim is the first step to a successful appeal. Insurers don't reject claims lightly, and their decision is almost always based on specific clauses within your policy document.
The Golden Rule of UK PMI: It's absolutely critical to understand that standard UK private medical insurance is designed to cover acute conditions that arise after your policy begins. It is not designed to cover pre-existing conditions or chronic conditions that require long-term management. This is the single most common point of misunderstanding and a frequent reason for claim denials.
Here are the most common reasons for a rejected claim:
| Reason for Denial | Explanation |
|---|---|
| Pre-existing Condition | You received medical advice, treatment, or experienced symptoms for the condition before you took out the policy. This is true even if you didn't have a formal diagnosis at the time. |
| Chronic Condition | The condition is long-term and requires ongoing management rather than a short-term cure (e.g., diabetes, asthma, high blood pressure). PMI covers acute flare-ups of chronic conditions only in specific, limited circumstances. |
| Non-Disclosure | You failed to declare a previous medical condition or symptom on your application form when you took out the policy. Insurers rely on this information to assess your risk. |
| Policy Exclusion | The treatment or condition itself is specifically listed as an exclusion in your policy. Common exclusions include cosmetic surgery, experimental treatments, and normal pregnancy. |
| Exceeded Policy Limits | Your policy has annual financial limits for certain treatments (e.g., a £1,000 limit for outpatient therapies), and your claim has exceeded this cap. |
| Incorrect Claims Procedure | You did not follow the insurer's required process. For instance, you failed to get pre-authorisation before receiving treatment or you visited a hospital not on their approved list. |
Real-Life Examples
-
Scenario 1: The Pre-existing Knee Problem
- David buys a PMI policy in January 2026. In June, his knee starts to hurt, and he is diagnosed with a torn meniscus requiring surgery. His insurer denies the claim. Why? When investigating, they find a note from his GP from 2024 mentioning "intermittent knee pain after football". Even though it wasn't diagnosed then, the symptom was pre-existing, so the claim is rejected.
-
Scenario 2: The Chronic Back Pain
- Sarah has a long history of lower back pain, managed with painkillers from her GP. She takes out a health insurance policy. A year later, her pain worsens, and an MRI shows a degenerative disc disease. Her claim for private physiotherapy is denied because her back pain is a long-standing chronic issue, not a new, acute condition.
Your First Step: Understanding the Rejection Letter
When you receive the decision, take a deep breath and read the letter carefully. Do not discard it. This document is the foundation of your appeal.
Look for these key pieces of information:
- The Specific Reason for the Denial: The letter must clearly state why the claim was rejected. It shouldn't just say "not covered". It should reference the type of condition (e.g., "pre-existing") or the specific exclusion.
- The Policy Clause: The insurer should cite the exact section or clause number in your policy terms and conditions that justifies their decision. Find this clause in your policy document and read it yourself.
- The Evidence They Used: The letter may mention the information they based their decision on, such as a report from your GP or specialist.
- Information on Their Appeals Process: The letter is required to inform you of your right to appeal and provide instructions on how to start their internal complaints procedure.
Sometimes, a letter may not be an outright rejection but a request for more information. If your insurer needs more details from you or your GP to make a decision, provide it promptly to avoid delays.
The Internal Appeals Process: A Step-by-Step Guide for 2026
Every insurer has a formal internal complaints or appeals process. You must complete this process before you can escalate your case to an external body.
Step 1: Gather Your Evidence
This is the most important part of your appeal. You need to build a logical, evidence-based case to counter the insurer's decision.
- The Rejection Letter: Your starting point.
- Your Policy Documents: The full terms and conditions, not just the summary.
- Your Original Application: If the issue is non-disclosure, you need to see what you originally declared.
- A Supporting Letter from Your Doctor: Ask your GP or specialist to write a letter. This is incredibly powerful. The letter should aim to:
- Clarify the nature of your condition (is it truly acute?).
- Provide a timeline of your symptoms and diagnosis.
- If the issue is 'pre-existing', the doctor might be able to state that your current condition is new and unrelated to a previous minor symptom.
- State that the recommended treatment is standard practice and not 'experimental'.
- Medical Records: You can request a copy of your medical records from your GP surgery. Look for any notes relevant to the insurer's decision.
Step 2: Draft Your Appeal Letter
Once you have your evidence, it's time to write to the insurer's complaints department.
- Be Professional and Factual: Keep your tone polite and business-like. Avoid angry or emotional language, as it can detract from your argument. Stick to the facts.
- Structure Your Letter Clearly:
- Start by stating your name, policy number, and claim number.
- Clearly state: "I am writing to formally appeal the decision to deny my claim..."
- Address the insurer's reason for denial head-on. For example: "Your letter states the claim was denied because the condition was pre-existing. I believe this is incorrect for the following reasons..."
- Present your counter-arguments one by one, referencing your evidence. For example: "As you can see from the enclosed letter from my consultant, Dr. Smith, the symptoms for this acute condition first appeared on [Date], which is after my policy inception date."
- List all the documents you have enclosed.
- State what you want to happen (e.g., "I request that you reconsider your decision and approve the claim for my treatment.").
- Send it Securely: Send your appeal by email (so you have a timestamp) and also consider sending a physical copy via Royal Mail Signed For delivery. This gives you proof they received it.
Step 3: Await the Response
The FCA gives financial services firms, including insurers, up to eight weeks to provide a final response to a complaint. Many will respond faster, but they have this full period if the case is complex.
You will receive one of two outcomes:
- Appeal Upheld: The insurer agrees with you, overturns their original decision, and approves the claim.
- Appeal Rejected (Final Response): The insurer maintains its position. They will send you a "final response" letter, which again explains their reasoning. Crucially, this letter must also inform you of your right to take your complaint to the Financial Ombudsman Service (FOS) and include a leaflet explaining how to do so.
What if Your Internal Appeal is Unsuccessful? The Financial Ombudsman Service (FOS)
If you have received a final response and are still unhappy, your next port of call is the Financial Ombudsman Service (FOS).
The FOS is a free, independent, and impartial service that settles disputes between consumers and financial businesses. Their decision is based on what is fair and reasonable in the circumstances of the case, taking into account the law, regulations, and good industry practice.
Key Facts about the FOS in 2026:
- It's Free: You do not have to pay to use the service.
- Time Limit: You must contact the FOS within six months of the date on your insurer's final response letter. This is a strict deadline.
- Their Power: The FOS can order an insurer to pay a claim, refund premiums, and even pay compensation for any distress or inconvenience caused.
- Binding Decision: If you accept the FOS's final decision, it is legally binding on the insurance company. They must comply. If you don't accept it, you can still take your case to court, but this is often costly and complex.
How to Take Your Case to the FOS
- Check You're Eligible: You must have completed the insurer's internal complaints process and received a final response. If eight weeks have passed and you've heard nothing, you can also go to the FOS.
- Fill in the Complaint Form: Go to the official Financial Ombudsman Service website and complete their online complaint form. It will ask for details about you, the insurer, and the nature of your complaint.
- Submit Your Evidence: Upload all the evidence you gathered for your internal appeal, including the final response letter from your insurer.
An adjudicator will be assigned to your case. They will review all the evidence from both you and the insurer and give their initial assessment. If you or the insurer disagree with the adjudicator's view, the case can be passed to an ombudsman for a final, binding decision.
Based on recent FOS annual reports, around 30-35% of complaints about health and medical insurance are upheld in favour of the consumer. This shows that a significant number of initial insurer decisions are overturned, making an appeal a worthwhile endeavour if you have a strong case.
The Role of a PMI Broker Like WeCovr in Preventing Denied Claims
The best way to handle a denied claim is to prevent it from happening in the first place. This is where an expert private medical insurance broker plays a vital role.
Using a broker like WeCovr costs you nothing extra – our fee is paid by the insurer you choose. Our value lies in providing independent, expert guidance to help you find the right cover and navigate the complexities of the application.
Here's how we help:
- Understanding Your Needs: We take the time to understand your medical history and what you want from a policy.
- Explaining the Jargon: We cut through the confusing terminology to explain exactly what is and isn't covered, especially around the crucial topics of pre-existing and chronic conditions.
- Ensuring Full Disclosure: We guide you through the application questions to ensure your medical history is declared accurately and fully. This is the single most effective way to prevent future "non-disclosure" rejections.
- Comparing the Market: We compare policies from a wide range of the best PMI providers in the UK, helping you find the one with the right benefits, hospital lists, and underwriting for your situation.
While a broker cannot formally represent you in a FOS dispute, a good advisory firm like ours can provide invaluable guidance on understanding your policy wording and the insurer's decision, empowering you during the appeals process.
Understanding Key PMI Terminology: Acute vs. Chronic vs. Pre-existing
These three terms are the bedrock of UK private health cover. Misunderstanding them is the root cause of many disputes.
| Term | Definition | PMI Coverage? | Example |
|---|---|---|---|
| Acute Condition | A disease, illness, or injury that is likely to respond quickly to treatment which aims to return you to the state of health you were in before, or which leads to your full recovery. | Yes - This is what PMI is for. | Appendicitis, a broken leg, a cataract, a hernia. |
| Chronic Condition | A disease, illness, or injury that has one or more of the following characteristics: it needs ongoing or long-term monitoring, it has no known cure, it is likely to come back, or it requires palliative care. | No - Standard PMI does not cover the long-term management of chronic conditions. | Diabetes, asthma, arthritis, Crohn's disease, high blood pressure. |
| Pre-existing Condition | Any ailment, illness, or injury for which you have experienced symptoms, received medication, advice, or treatment before your policy start date. | No - Not at first. With 'moratorium' underwriting, it may become eligible for cover after a set period (usually two years) if you remain symptom- and advice-free for that condition. | Knee pain you saw a GP about three years ago; anxiety for which you took medication before the policy started. |
Proactive Health Management & Your PMI Policy
While PMI is there for when you get sick, taking proactive steps to manage your health can improve your overall wellbeing and potentially reduce the need to claim. Insurers are increasingly rewarding healthy behaviours.
- Balanced Diet: A diet rich in fruits, vegetables, lean proteins, and whole grains can lower your risk of developing many chronic conditions.
- Regular Exercise: Aim for at least 150 minutes of moderate-intensity activity a week, as recommended by the NHS. This could be brisk walking, cycling, or swimming.
- Quality Sleep: Good sleep is vital for both physical and mental health. Aim for 7-9 hours per night and maintain a regular sleep schedule.
- Stress Management: Chronic stress can impact your health. Techniques like mindfulness, yoga, or simply spending time in nature can make a big difference.
To support our clients on their health journey, WeCovr provides complimentary access to our AI-powered calorie and nutrition tracking app, CalorieHero. It's a simple, effective tool to help you make more informed choices about your diet. Furthermore, clients who purchase PMI or life insurance through us can often benefit from discounts on other types of cover, adding even more value.
Final Thoughts: Be Prepared and Persistent
Facing a denied PMI claim is disheartening, but you have clear rights and a well-defined path to challenge the decision. The key is to be methodical, factual, and persistent.
- Understand the reason for the denial.
- Gather your evidence, especially a supporting letter from your doctor.
- Follow the insurer's internal appeals process first.
- Escalate to the Financial Ombudsman Service if you're still not satisfied.
To give yourself the best chance of a smooth claims experience from the outset, partner with an expert. The team at WeCovr has a strong track record of high customer satisfaction because we put in the work upfront to ensure our clients understand their policies and choose the cover that's right for them.
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Don't let the fear of a denied claim put you off securing the peace of mind that private medical insurance offers. Get expert advice from the start.
Contact WeCovr today for a free, no-obligation quote and let our experts help you navigate the world of private health cover with confidence.
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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