TL;DR
Welcome to your essential guide on claiming with private medical insurance in the UK. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we understand that making your first claim can feel daunting. This guide simplifies the entire process, ensuring you can access your private healthcare benefits smoothly and without stress.
Key takeaways
- 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 a hernia requiring surgery, cataracts, or a broken bone.
- A chronic condition is an illness that cannot be cured but can be managed through medication and ongoing monitoring. Examples include diabetes, asthma, high blood pressure, and arthritis.
- Moratorium Underwriting: You don't declare your medical history upfront. The insurer automatically excludes any condition you've had in the 5 years before joining. However, if you go 2 continuous years on the policy without any symptoms, advice, or treatment for that condition, it may become eligible for cover.
- Full Medical Underwriting (FMU): You complete a full health questionnaire when you apply. The insurer assesses your history and explicitly lists any conditions that will be permanently excluded from your policy.
- Excess: The amount you agree to pay towards a claim. For example, if your excess is £250 and your treatment costs £2,000, you pay the first £250, and the insurer pays the remaining £1,750.
Welcome to your essential guide on claiming with private medical insurance in the UK. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we understand that making your first claim can feel daunting. This guide simplifies the entire process, ensuring you can access your private healthcare benefits smoothly and without stress.
WeCovr's walkthrough for first-time PMI claimants
Navigating a health concern is challenging enough without the added worry of insurance paperwork. That's why we've created this step-by-step walkthrough. Think of it as your friendly co-pilot, guiding you from your initial GP visit to the final settlement of your medical bills.
Private medical insurance (PMI) is designed to give you peace of mind, faster access to treatment, and more choice over your care. But to unlock these benefits, you need to understand the claims process. Let's break it down.
Before You Claim: Understanding the Golden Rules of PMI
Before we dive into the 'how', it's crucial to understand the 'what'. Knowing the fundamental principles of your private health cover will prevent common pitfalls and ensure a smooth claims journey.
Rule 1: PMI Covers Acute Conditions, Not Chronic Ones
This is the single most important concept to grasp. UK private medical insurance is designed to treat acute conditions.
- 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 a hernia requiring surgery, cataracts, or a broken bone.
- A chronic condition is an illness that cannot be cured but can be managed through medication and ongoing monitoring. Examples include diabetes, asthma, high blood pressure, and arthritis.
Your PMI policy will cover the diagnosis and treatment to get you back to your previous state of health for an acute condition. It will not cover the day-to-day management of long-term, chronic illnesses. The NHS remains the cornerstone for managing these conditions in the UK.
Rule 2: Pre-existing Conditions Are Excluded
When you take out a PMI policy, any medical conditions you have had symptoms of, or received treatment for, in the years leading up to your policy start date (usually the last 5 years) are considered pre-existing. These are typically excluded from cover, at least initially.
There are two main ways insurers handle this:
- Moratorium Underwriting: You don't declare your medical history upfront. The insurer automatically excludes any condition you've had in the 5 years before joining. However, if you go 2 continuous years on the policy without any symptoms, advice, or treatment for that condition, it may become eligible for cover.
- Full Medical Underwriting (FMU): You complete a full health questionnaire when you apply. The insurer assesses your history and explicitly lists any conditions that will be permanently excluded from your policy.
Understanding your underwriting type is vital. If you're unsure, check your policy documents or speak to your broker.
Rule 3: Know Your Policy Inside and Out
Your policy is a contract between you and your insurer. The documents are your guide to what is and isn't covered. Before you need to claim, familiarise yourself with these key terms:
- Excess: The amount you agree to pay towards a claim. For example, if your excess is £250 and your treatment costs £2,000, you pay the first £250, and the insurer pays the remaining £1,750.
- Outpatient Limit (illustrative): This is the maximum amount your policy will pay for consultations, diagnostic tests, and therapies that don't require a hospital bed. Some policies have an unlimited outpatient limit, while others might cap it at, say, £1,000 per year.
- Hospital List: Your policy will have a list of approved hospitals where you can receive treatment. Using a hospital outside this list could result in your claim being rejected or only partially paid.
- Benefit Limits: Some treatments might have specific financial or time-based limits. For example, physiotherapy might be limited to 10 sessions per year.
A little time spent reading your policy documents now can save a lot of confusion later. If you arranged your policy through an expert broker like WeCovr, we can help you decipher the small print at no extra cost.
The 6-Step Guide to Making a PMI Claim
Now, let's get to the practical steps. Imagine you've developed a persistent pain in your knee that's stopping you from your daily activities. Here's how you would use your PMI to get it sorted.
Step 1: Visit Your GP
Your journey almost always begins with your General Practitioner (GP). The NHS is the gatekeeper to all specialist care in the UK, whether private or public.
- What to do: Book an appointment with your NHS GP. Explain your symptoms clearly and comprehensively.
- Why it's important: Your insurer will need a referral from your GP to a specialist. This confirms that the treatment is medically necessary. A claim without a GP referral is highly likely to be declined.
Some modern policies now offer a digital GP service as a benefit. This can be a faster way to get an initial consultation and a referral, often from the comfort of your home. Check if your policy includes this feature.
Step 2: Get an 'Open Referral'
Once your GP agrees that you need to see a specialist (in our example, an orthopaedic consultant), they will write you a referral letter.
- Ask for an 'Open Referral': This is a crucial tip. An open referral doesn't name a specific specialist. It simply states the type of specialist you need to see (e.g., "orthopaedic consultant").
- Why it's better: An open referral gives your insurer the flexibility to recommend a specialist from their approved network who they have fee agreements with. This often makes the claims process faster and ensures the specialist's fees will be covered in full. If your GP refers you to a specific named consultant, that person may not be recognised by your insurer or may charge fees above what your insurer will cover, leaving you with a shortfall to pay.
Step 3: Contact Your Insurer to Start the Claim
With your open referral letter in hand, it's time to contact your private medical insurance provider. Do not book any appointments or tests before you do this.
You must get pre-authorisation for every stage of your treatment.
You can usually start a claim in one of three ways:
- By Phone: This is often the quickest way. Have your policy number ready.
- Online Portal: Most major insurers have sophisticated online portals or apps where you can upload your referral and initiate a claim.
- By Post: This is the slowest method and not recommended if you need prompt treatment.
Below are the typical contact points for major UK insurers.
| Insurer | Typical Claims Method | Key Information Needed |
|---|---|---|
| Aviva | Phone or online via MyAviva | Policy number, GP referral details |
| AXA Health | Phone or online via Customer Online | Membership number, GP referral |
| Bupa | Phone or online via Bupa Touch | Membership number, symptoms, referral |
| Vitality | Online via Member Zone or phone | Membership number, referral details |
| WPA | Phone or via their app | Policy number, GP details |
During this call or online process, the claims assessor will:
- Confirm your identity and policy details.
- Ask about your symptoms and the reason for the claim.
- Check that the condition is covered under your policy terms (i.e., it's not a pre-existing or chronic condition).
- Take the details from your GP referral letter.
Step 4: Receive Your Pre-Authorisation
If the claim is approved, the insurer will give you a pre-authorisation number. This is your golden ticket. It's the insurer's formal agreement to cover the costs of the next stage of your treatment.
The insurer will then typically provide you with a list of 2-3 approved specialists in your area.
- What to do: You can now choose a specialist from this list and book your initial consultation. When you book, give the hospital or clinic your name, your insurer's name, your policy number, and your pre-authorisation number.
- What happens next? The specialist will assess you. They will likely recommend further diagnostic tests, such as an MRI scan in our knee pain example.
Crucially, you must get separate pre-authorisation for each step.
- Initial Consultation: Pre-authorisation required.
- Diagnostic Tests (MRI, CT, X-ray): A new pre-authorisation is needed. The specialist's secretary will often handle this for you, but it's your responsibility to ensure it's in place before the test.
- Surgery or Procedure: If surgery is needed, you will need a third pre-authorisation. The specialist will provide your insurer with a procedure code (CCSD code), and the insurer will confirm cover.
Step 5: Receive Your Treatment
Once all the necessary authorisations are in place, you can proceed with your treatment. This could be your surgery, a course of physiotherapy, or another medical procedure.
One of the main benefits of PMI is the improved environment. You can expect a private room, often with an en-suite bathroom, better food choices, and more flexible visiting hours. This comfort can play a significant role in your recovery.
A WeCovr Wellness Tip: Preparing for Treatment
A positive mindset and a healthy body can improve recovery outcomes. In the lead-up to any planned procedure:
- Nourish Your Body: Focus on a balanced diet rich in vitamins and protein to support tissue repair. Our clients get complimentary access to the CalorieHero AI app to help track nutrition and make healthy choices.
- Stay Gently Active: If cleared by your doctor, gentle movement like walking or stretching can maintain muscle tone and improve circulation.
- Prioritise Sleep: Aim for 7-9 hours of quality sleep per night. Sleep is when your body does most of its healing.
Step 6: Settling the Bill (The Easy Part!)
This is the part you generally don't have to worry about. Because you got pre-authorisation, the hospital and the specialists will invoice your insurer directly. The payments happen in the background without your involvement.
The only part of the bill you will need to handle is your excess.
- How it works: The insurer will pay the bill minus your excess amount. For example, if the total cost was £4,500 and your excess is £500, the insurer pays £4,000.
- How you pay (illustrative): The hospital will usually contact you directly to collect the £500 excess payment. This might be before your treatment or shortly after.
What if there's a shortfall?
A shortfall occurs if a specialist's fee is higher than the limit your insurer will pay. This is rare if you use a specialist from the insurer's approved list but can happen if you choose your own. If there is a shortfall, you will be responsible for paying the difference. This is another reason why using an 'open referral' is so beneficial.
Common Roadblocks and How to Navigate Them
Even with the best preparation, you might encounter a few bumps in the road. Here's how to handle common issues.
| Potential Problem | Solution |
|---|---|
| Claim is delayed | The most common reason is missing information. Call your insurer to check if they are waiting for anything from you or your GP. Be proactive. |
| Claim is declined | Politely ask for the reason in writing. It's often due to an exclusion (e.g., pre-existing condition). Review your policy documents. If you believe the decision is unfair, you have the right to complain. |
| Specialist fees are not fully covered | This happens when you use a non-network consultant. Always use a specialist recommended by your insurer to avoid this. If you're set on a specific person, ask them for their fee schedule and check it with your insurer first. |
| You're unsure about a term in your policy | Don't guess! This is where a good broker is invaluable. If you're a WeCovr client, you can call us, and we'll explain it in plain English. We work for you, not the insurer. |
The Formal Complaints Process
If you disagree with your insurer's decision, you can make a formal complaint.
- Complain to the Insurer: Follow their internal complaints procedure first. They have up to eight weeks to provide a final response.
- Escalate to the Financial Ombudsman Service (FOS): If you're unhappy with the final response, or if they don't provide one in eight weeks, you can take your case to the FOS. The FOS is an independent body that settles disputes between consumers and financial services firms. Their decision is binding on the insurer.
Why is UK Private Medical Insurance Growing in Popularity?
The demand for private health cover in the UK is on the rise. Recent data highlights the pressures on the NHS, which is a key driver for individuals and companies seeking private alternatives.
According to the most recent NHS England data, the waiting list for routine consultant-led hospital treatment stood at around 7.5 million in early 2024. Of those, several hundred thousand people have been waiting for over a year for treatment. These long waits can have a significant impact on quality of life, mental health, and the ability to work.
This is where PMI steps in, offering a valuable alternative for those who can afford it. It's not about replacing the NHS – which remains world-class for emergency and chronic care – but about complementing it.
Key Benefits of Having a PMI Policy:
- Speed of Access: Bypass long NHS waiting lists for diagnosis and treatment.
- Choice: Choose your specialist and hospital from an approved list.
- Comfort: Access to private rooms and more comfortable facilities.
- Advanced Treatments: Some policies offer access to new drugs or treatments not yet available on the NHS.
- Mental Health Support: Most comprehensive policies now include excellent cover for mental health, from therapy to psychiatric care.
Choosing the right private medical insurance UK policy is a big decision. A specialist PMI broker can compare the market for you, ensuring the policy you choose matches your needs and budget. At WeCovr, we provide this service at no cost to you and our clients benefit from high customer satisfaction ratings and access to exclusive perks.
WeCovr's Added Value: More Than Just Insurance
We believe in supporting our clients' overall health and wellbeing, not just when they need to make a claim. When you arrange your health or life insurance through us, you get more than just a policy.
- Complimentary CalorieHero App: All clients gain free access to our AI-powered nutrition app, CalorieHero. It's a fantastic tool for managing weight, understanding your diet, and supporting a healthy lifestyle, which can help prevent some health issues from arising in the first place.
- Discounts on Other Cover: We value your loyalty. Our PMI and life insurance clients are eligible for discounts on other types of insurance they might need, such as home or travel cover.
- Expert, Human Support: When you have a question, you can speak to a real person who understands the market and your policy. We are here to advocate for you.
Final Checklist Before Making a Claim
- Read your policy documents. Do you understand your excess, benefit limits, and hospital list?
- Visit your GP. This is your non-negotiable first step.
- Get an open referral. This gives you and your insurer maximum flexibility.
- Have your policy number ready. Keep it somewhere safe and accessible.
- Contact your insurer for pre-authorisation BEFORE booking anything. This is the most critical step.
- Get a pre-authorisation number for EACH stage of treatment. (Consultation, tests, procedure).
- Use specialists and hospitals from your insurer's approved list. This is the best way to ensure your bills are paid in full.
Following this checklist will put you in the best possible position for a hassle-free claim, allowing you to focus on what truly matters: your health and recovery.
Frequently Asked Questions (FAQs)
Do I need to tell my PMI provider about every GP visit?
What happens if I need treatment while I am abroad?
Can my private health cover premium go up after I make a claim?
What is the difference between an inpatient and an outpatient claim?
Ready to explore your options for private health cover? The world of private medical insurance can be complex, but you don't have to navigate it alone.
At WeCovr, our expert, friendly advisors can compare policies from all the UK's leading insurers to find the perfect fit for your needs and budget. Our advice is completely free and impartial.
[Get Your Free, No-Obligation PMI Quote Today]
Sources
- Office for National Statistics (ONS): Mortality, earnings, and household statistics.
- Financial Conduct Authority (FCA): Insurance and consumer protection guidance.
- Association of British Insurers (ABI): Life insurance and protection market publications.
- HMRC: Tax treatment guidance for relevant protection and benefits products.
