TL;DR
Navigating the world of private medical insurance (PMI) claims can feel daunting, but it doesn't have to be. As an FCA-authorised UK broker that has helped arrange over 900,000 policies, WeCovr is here to demystify the process, ensuring you get the fast, high-quality care you deserve. WeCovr's step-by-step guide to making claims quickly and successfully Making a claim on your private health cover should be a smooth and stress-free experience.
Key takeaways
- An Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Examples include joint replacements, cataract surgery, or treatment for hernias.
- A Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics: it needs ongoing monitoring, has no known cure, is likely to recur, or requires long-term management. Examples include diabetes, asthma, arthritis, and high blood pressure.
- What the symptom is.
- When it started.
- How often it occurs.
Navigating the world of private medical insurance (PMI) claims can feel daunting, but it doesn't have to be. As an FCA-authorised UK broker that has helped arrange over 900,000 policies, WeCovr is here to demystify the process, ensuring you get the fast, high-quality care you deserve.
WeCovr's step-by-step guide to making claims quickly and successfully
Making a claim on your private health cover should be a smooth and stress-free experience. After all, you've invested in your health to bypass potential delays and receive prompt treatment. This guide breaks down the entire journey, from the first symptom to the final invoice, into simple, manageable steps.
Our goal is to empower you with the knowledge to handle your claim with confidence, ensuring no administrative hurdles stand between you and your recovery.
The Golden Rule of UK PMI: Understanding Acute vs. Chronic Conditions
Before we delve into the claims process, it is absolutely essential to understand the fundamental principle of private medical insurance in the UK.
PMI is designed to cover acute conditions that arise after your policy has started.
- An Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Examples include joint replacements, cataract surgery, or treatment for hernias.
- A Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics: it needs ongoing monitoring, has no known cure, is likely to recur, or requires long-term management. Examples include diabetes, asthma, arthritis, and high blood pressure.
Crucially, standard UK private health insurance does not cover pre-existing conditions or chronic conditions. This is the single most important concept to grasp. Your policy is there for new, treatable health issues, not for managing long-term illnesses you already have.
| Condition Type | Covered by Standard PMI? | Examples |
|---|---|---|
| Acute | Yes | Broken bones, appendicitis, cataracts, hernia |
| Chronic | No | Diabetes, asthma, multiple sclerosis, Crohn's |
| Pre-existing | No (unless specified) | An ankle injury you had before taking the policy |
Understanding this distinction from the outset prevents disappointment and ensures you have realistic expectations of your private health cover.
Step 1: You Notice a Symptom – The Starting Point
Every health journey begins with you. You might notice a persistent pain, a new lump, or a change in your body that doesn't feel right. This is the trigger for the entire claims process.
At this stage, your priority is not to self-diagnose but to listen to your body. Keeping a brief diary of your symptoms can be incredibly helpful for your doctor. Note down:
- What the symptom is.
- When it started.
- How often it occurs.
- Anything that makes it better or worse.
This simple act can make your GP consultation more effective and speed up the diagnostic process.
Wellness Corner: Can You Prevent the Need to Claim?
While not all health issues are preventable, a proactive approach to your well-being can significantly reduce your risk of developing certain acute conditions.
- Diet: A balanced diet rich in fruits, vegetables, and whole grains supports your immune system and overall health. As a WeCovr customer, you get complimentary access to our AI-powered nutrition app, CalorieHero, to help you track your intake and make healthier choices.
- Exercise: The NHS recommends at least 150 minutes of moderate-intensity activity a week. Regular exercise strengthens your heart, bones, and muscles, reducing the risk of conditions that might otherwise require a PMI claim.
- Sleep: Aim for 7-9 hours of quality sleep per night. Good sleep is vital for physical and mental recovery, helping your body repair itself and fight off illness.
By focusing on preventative health, you take control. And for those moments when you do need medical support, your PMI is there as your safety net.
Step 2: Visit Your GP – The Gateway to Private Care
In the vast majority of UK private medical insurance plans, your General Practitioner (GP) is the gatekeeper to specialist care. You cannot simply decide you need to see a cardiologist and book an appointment; you need a referral from your GP first.
Why is a GP referral necessary?
- Clinical Triage: Your GP is a highly trained generalist who can assess your symptoms, rule out common issues, and determine the right type of specialist for you. This prevents unnecessary appointments and ensures you see the right expert from the start.
- Insurance Requirement: Insurers need a formal medical opinion to confirm that specialist treatment is necessary. A GP referral provides this clinical justification.
- Continuity of Care: Your GP holds your complete medical history. They can provide the specialist with crucial context, ensuring your private treatment works in harmony with any ongoing NHS care.
During your GP appointment, explain your symptoms clearly and mention that you have private medical insurance. If your GP agrees that you need to see a specialist, they will write you an open referral letter.
An open referral is usually best. This means your GP recommends a type of specialist (e.g., a dermatologist) rather than a specific named consultant. This gives you and your insurer the flexibility to choose from any specialist within their approved network, which can speed up appointment times.
Step 3: Contact Your Insurer – The Pre-Authorisation Call
This is the most important step in the claims process. You must contact your insurer and get your claim pre-authorised before you book any appointments or undergo any tests.
Failing to get pre-authorisation can result in your insurer refusing to cover the costs, leaving you with a significant bill.
What to Have Ready for the Call
To make the call as smooth as possible, have the following information to hand:
| Information Needed | Why It's Important |
|---|---|
| Your Policy Number | To identify you and your specific level of cover. |
| Your Full Name & Date of Birth | For security and verification purposes. |
| Details of Your Symptoms | To understand the nature of the medical issue. |
| Your GP's Name & Practice | To confirm the source of the referral. |
| The GP Referral Letter | The insurer will need to know the type of specialist you have been referred to. |
| Date Symptoms First Occurred | To check this is a new condition that arose after your policy began. |
During the call, the insurer's claims team will ask you a series of questions to establish the validity of the claim. They will check:
- Is the condition covered under your policy?
- Did the symptoms start after your policy began?
- Are there any exclusions on your policy that apply?
Step 4: Receive Your Authorisation Code
If your claim is approved, the insurer will give you a pre-authorisation number or claims reference number. This code is your golden ticket. It confirms to the hospital and specialist that your insurer has agreed to cover the costs for the initial consultation and any approved diagnostic tests.
What happens if the claim is not authorised?
In some cases, an insurer might decline a claim or ask for more information. This could be because:
- They suspect it's a pre-existing condition.
- The treatment is listed as a standard exclusion (e.g., cosmetic surgery).
- They need a more detailed report from your GP.
If your claim is declined, you have the right to appeal the decision. This is where having an expert PMI broker like WeCovr on your side can be invaluable. While we don't manage claims directly, we ensure you choose a policy with clear terms from a reputable provider, reducing the chances of disputes. We also help you understand the insurer's decision-making process.
Step 5: Booking Your Specialist Appointment
Once you have your authorisation code, you can book your appointment. Your insurer will typically provide you with a list of approved specialists and hospitals in your area. Many leading UK PMI providers, such as Bupa, AXA Health, and Vitality, have extensive networks.
You have two main options:
- Insurer-led Booking: Some insurers have a dedicated team that can book the appointment for you, ensuring you see a fee-assured specialist within their network. This is often the simplest and fastest option.
- Self-Booking: You can choose a specialist from the insurer's list and contact their secretary directly to book. When you do, make sure you:
- State that you are a patient of [Your Insurer's Name].
- Provide your pre-authorisation code.
- Confirm that the specialist is 'fee-assured' with your insurer (meaning they won't charge more than the insurer is willing to pay).
According to NHS England performance data from 2025, the median wait for consultant-led elective care on the NHS can exceed 14 weeks. With private health cover, this waiting time can often be reduced to a matter of days or weeks, which is the primary benefit of the insurance.
Step 6: The Consultation, Diagnosis, and Treatment Plan
You'll attend your appointment with the private specialist. They will assess you, discuss your symptoms, and may recommend diagnostic tests like an MRI scan, CT scan, or blood tests to confirm a diagnosis.
Important: If the specialist recommends further tests or treatment (such as surgery), you will likely need to contact your insurer again to get this next stage of treatment authorised. Do not assume your initial authorisation code covers everything.
Always check with your insurer before proceeding with:
- Diagnostic scans (MRI, CT, PET)
- Inpatient procedures (surgery requiring an overnight stay)
- Day-patient procedures (like an endoscopy)
- A course of therapy (e.g., physiotherapy)
Each new stage requires a new layer of authorisation to ensure it is covered by your policy.
Real-Life Example: Sarah's Knee Injury
- Symptom: Sarah, a 45-year-old teacher, develops persistent knee pain after a hiking trip.
- GP Visit: Her GP suspects a torn meniscus and writes an open referral to an orthopaedic surgeon.
- Insurer Call: Sarah calls her private health insurer. She provides her policy number, GP details, and explains the problem. The insurer confirms this is a new, acute condition and gives her a pre-authorisation code for an initial consultation.
- Booking: The insurer provides a list of three approved surgeons. Sarah chooses one and books an appointment for the following week, providing the authorisation code.
- Consultation: The surgeon examines her knee and agrees an MRI scan is needed for a definitive diagnosis.
- Second Authorisation: Sarah calls her insurer again with the surgeon's recommendation. The insurer approves the MRI scan and provides an updated authorisation.
- Diagnosis & Treatment: The scan confirms a torn meniscus requiring keyhole surgery. The surgeon's office sends the treatment plan to the insurer.
- Final Authorisation: The insurer approves the surgery and hospital stay.
- Treatment: Sarah has the surgery two weeks later in a private hospital.
- Billing (illustrative): The hospital and surgeon send their invoices directly to the insurer. Sarah pays only her policy excess of £250.
This streamlined process took Sarah from GP visit to post-surgery recovery in under a month, a testament to the efficiency of private medical insurance UK when the process is followed correctly.
Step 7: Settling the Bill – How Invoices Are Paid
In the UK, the vast majority of private medical insurance claims are handled via direct settlement.
This means the hospital, the specialist, and the anaesthetist will send their invoices directly to your insurance company for payment. You should not receive these bills yourself.
The only part of the bill you are responsible for is your policy excess.
Understanding Your Excess
An excess is a fixed amount you agree to pay towards the cost of any claim you make. For example, if your excess is £250 and the total cost of your treatment is £5,000, you will pay the first £250, and your insurer will pay the remaining £4,750.
- You typically pay the excess once per policy year, regardless of how many claims you make.
- A higher excess usually results in a lower monthly premium.
- You will usually pay your excess directly to the private hospital where you received your treatment.
What is a "Shortfall"?
A shortfall occurs if your specialist or hospital charges more than your insurer has agreed to pay for a specific procedure. This is why it is vital to use specialists and hospitals from your insurer's approved network and to confirm the consultant is 'fee-assured'. If you go outside the network, you may be liable for the difference in cost.
| Payment Type | Who Pays It? | When Is It Paid? | How to Avoid Surprises |
|---|---|---|---|
| Treatment Cost | Your Insurer | After treatment is complete | Use approved hospitals and get pre-authorisation for every stage of treatment. |
| Excess | You | Usually paid directly to the hospital during treatment. | Know your excess amount when you buy the policy. Choose a level you are comfortable with. |
| Shortfall | You | After the insurer has paid their part. | Only use 'fee-assured' specialists from your insurer's approved network. |
Making the Most of Your WeCovr Policy
When you arrange your private health insurance through WeCovr, you benefit from more than just cover. We believe in adding value to your health journey.
- Discounts on Other Insurance: Our PMI and life insurance customers often receive preferential rates on other types of cover, such as home or travel insurance, helping you consolidate and save.
- Complimentary CalorieHero Access: As mentioned, all our health and life policyholders get free access to our premium AI nutrition app, CalorieHero, empowering you to take proactive steps towards a healthier lifestyle.
- Expert Guidance: We are an independent PMI broker. Our job is to help you compare the market and find the best PMI provider for your needs and budget, at no extra cost to you. Our high customer satisfaction ratings reflect our commitment to clear, impartial advice.
Final Checklist for a Successful Claim
- Confirm it's an acute condition. Your policy is for new, treatable issues, not long-term management.
- See your GP first. Get that all-important referral letter. Ask for an 'open referral'.
- Call your insurer before you book anything. Get your claim pre-authorised.
- Write down your authorisation code. Keep it safe.
- Use your insurer's approved network. Stick to their list of hospitals and specialists.
- Confirm your specialist is 'fee-assured'. This prevents unexpected shortfalls.
- Get fresh authorisation for each stage. The initial code may only cover the consultation.
- Know your excess. Be prepared to pay this amount directly to the hospital.
Following these steps will make your claims experience as smooth as your recovery.
Frequently Asked Questions (FAQ)
1. What happens if I need treatment while I'm abroad?
Standard UK private health insurance is designed for treatment within the United Kingdom. It does not typically cover medical emergencies that occur while you are overseas. For this, you need separate travel insurance, which is designed to cover emergency medical costs in other countries. Some comprehensive PMI plans may offer a limited overseas travel element, but you must check your policy details carefully.
2. Can I claim for dental or optical treatment?
Most standard private medical insurance policies do not cover routine dental check-ups, fillings, or eye tests as standard. These are usually considered maintenance rather than treatment for acute conditions. However, you can often add optional dental and optical cover to your policy for an additional premium, which would then allow you to claim for a portion of these costs. Surgical procedures like cataract removal are typically covered under the core hospital cover.
3. How long does a claim take from start to finish?
The timeline for a private medical insurance claim can vary significantly depending on the condition. For a straightforward consultation and diagnostic scan, the process from GP visit to getting your results can take as little as one to two weeks. For a condition requiring surgery, the entire journey from initial symptom to completing the operation might take four to eight weeks. This is significantly faster than typical NHS waiting times, which is a key reason people invest in private health cover.
4. Do I need to tell my insurer about every minor illness like a cold?
No, you do not need to contact your insurer for minor, self-limiting illnesses like a common cold or flu that you would not typically see a specialist for. Private medical insurance is for conditions that require specialist diagnosis or treatment. You only need to start the claims process when your GP has referred you for further investigation or treatment of a specific medical condition.
5. What if I switch insurers? How are my conditions treated?
When switching your private health cover, it's crucial to do so on a 'Continued Medical Exclusions' (CME) or 'Continuing Personal Medical Exclusions' (CPME) basis. This means your new insurer agrees to cover all the conditions that your old insurer covered, without adding new exclusions for conditions that have developed while you were insured. If you switch on a 'new underwriting' basis, any health issues you've claimed for previously would be classed as pre-existing and therefore excluded by your new policy.
Ready to find a private medical insurance policy that puts you in control of your health? The expert team at WeCovr is here to help. We compare plans from the UK's leading insurers to find the right cover for you, at the right price, with no obligation.
Get your free, no-obligation quote today and take the first step towards faster healthcare.
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.
