TL;DR
As an FCA-authorised broker that has helped arrange over 900,000 policies, WeCovr understands that navigating the world of private medical insurance in the UK can be complex. When things go wrong with your private healthcare, knowing the right steps to take is crucial. This guide explains the entire complaints process for private patients.
Key takeaways
- The Care Quality Commission (CQC): In England, the CQC inspects and regulates all hospitals, clinics, and care homes, both NHS and private. They ensure providers meet fundamental standards of quality and safety.
- Healthcare Inspectorate Wales (HIW): The equivalent body for Wales.
- Healthcare Improvement Scotland (HIS): The equivalent body for Scotland.
- The Regulation and Quality Improvement Authority (RQIA): The equivalent body for Northern Ireland.
- Dates and times of appointments, procedures, or conversations.
As an FCA-authorised broker that has helped arrange over 900,000 policies, WeCovr understands that navigating the world of private medical insurance in the UK can be complex. When things go wrong with your private healthcare, knowing the right steps to take is crucial. This guide explains the entire complaints process for private patients.
WeCovr explains the complaints process for private patients
Receiving private healthcare in the UK generally means a high standard of care, comfort, and choice. However, no system is perfect, and there may be times when the service you receive falls short of your expectations. Whether it's an issue with clinical care, a billing error, or poor communication, you have the right to complain and have your concerns addressed.
This comprehensive guide will walk you through every stage, from raising an issue informally to escalating it to an independent body. We’ll cover how to complain about a hospital, a specific consultant, and even your insurance provider, ensuring you feel empowered and informed.
Understanding Your Rights as a Private Patient in the UK
When you pay for private healthcare, you are protected by more than just the provider's promise of good service. You are entering into a contract, and your rights are enshrined in UK law.
The cornerstone of your protection is the Consumer Rights Act 2015. This legislation states that any service, including healthcare, must be carried out with "reasonable care and skill." If a provider fails to meet this standard, you are entitled to a remedy, which could be a repeat performance of the service or a price reduction (refund).
Beyond this, several regulatory bodies oversee the quality and safety of private healthcare:
- The Care Quality Commission (CQC): In England, the CQC inspects and regulates all hospitals, clinics, and care homes, both NHS and private. They ensure providers meet fundamental standards of quality and safety.
- Healthcare Inspectorate Wales (HIW): The equivalent body for Wales.
- Healthcare Improvement Scotland (HIS): The equivalent body for Scotland.
- The Regulation and Quality Improvement Authority (RQIA): The equivalent body for Northern Ireland.
These bodies don't typically handle individual complaints for compensation but can take action against a provider if they find evidence of widespread or serious failings.
Finally, your contract or Patient Terms and Conditions with the hospital or clinic is a key document. It outlines the specifics of the service you've agreed to, the costs, and usually, the provider's own complaints procedure.
Before You Make a Formal Complaint: Key First Steps
Often, issues can be resolved quickly and informally without needing to start a formal process. Taking these initial steps can save you time and stress.
Step 1: Gather Your Evidence
Before you do anything else, get your facts straight. Being organised is your greatest asset. Collect all relevant documents and information, such as:
- Dates and times of appointments, procedures, or conversations.
- Names of the staff involved (consultants, nurses, administrators).
- Copies of any letters or emails between you and the provider.
- Invoices and receipts.
- A copy of your medical records related to the incident. You have a legal right to request these.
- Photographs, if relevant to your complaint (e.g., related to facilities).
Make a clear, chronological timeline of events. Stick to the facts and avoid emotional language in your notes. This will form the backbone of your complaint if you need to take it further.
Step 2: Speak Directly to the Person Involved (If Appropriate)
If your issue is with a specific individual—a consultant, nurse, or administrative staff member—and you feel comfortable doing so, a direct and calm conversation can sometimes clear up a misunderstanding.
Real-life example: You felt your consultant rushed your follow-up appointment and didn't answer your questions properly. How to approach it: You could call their secretary and say, "I'm feeling a little unclear about a few things following my appointment with Dr. Smith on Tuesday. Would it be possible to have a brief five-minute call to clarify?"
This informal approach often resolves the issue immediately. However, if your complaint is of a serious clinical nature or you don't feel comfortable with a direct approach, it's best to proceed to the next step.
Step 3: Contact the Practice Manager or Patient Advisory Service
Every private hospital and most large clinics have a designated person or department to handle patient concerns. This could be a Practice Manager, a Patient Liaison Officer, or a Patient Advice and Liaison Service (PALS), similar to the one in the NHS.
Their role is to resolve problems quickly. Contact them by phone or email, briefly explain your issue, and state that you'd like their help in resolving it. They are often empowered to sort out administrative errors, communication problems, and minor service issues on the spot.
The Formal Complaints Process: A Step-by-Step Guide
If informal steps haven't worked or your complaint is more serious, it's time to begin the formal process. All private healthcare providers are required to have a clear, written complaints procedure.
Step 1: Find the Provider's Official Complaints Procedure
This is your roadmap. You can almost always find it on the provider's website, often in the "Contact Us," "Patient Information," or "About Us" sections. If you can't find it, call their main reception and ask for a copy to be emailed or posted to you.
The procedure will tell you:
- Who to address your complaint to (e.g., the Complaints Manager or Hospital Director).
- The expected timescales for a response.
- The different stages of the complaints process.
Step 2: Write a Formal Complaint Letter or Email
A written complaint is essential. It creates a formal record and ensures your concerns are documented precisely. Your letter or email should be clear, concise, and professional.
Structure of a Complaint Letter:
- Your Details: Start with your full name, address, date of birth, and patient number if you have one.
- Clear Subject Line: For example, "Formal Complaint regarding care received on [Date]".
- Introduction: State clearly that you are writing to make a formal complaint.
- Chronological Account: Using your evidence, explain what happened in the order it occurred. Be factual and specific.
- Explain What Went Wrong: Clearly state how the provider's actions (or lack of action) fell short of the standard you expected. Reference your rights under the Consumer Rights Act if appropriate (e.g., "The care I received was not of a reasonable standard...").
- State Your Desired Outcome: Be realistic. What do you want to achieve?
- An apology?
- A full explanation of what happened?
- A refund or partial refund?
- A commitment that procedures will be changed to prevent it from happening again?
- List Your Evidence: Mention the documents you have to support your complaint (e.g., "I have enclosed copies of the relevant correspondence and invoices.").
- Closing: End politely, stating that you look forward to their response within the timescale set out in their complaints procedure.
Do's and Don'ts of Writing a Complaint
| Do's ✔️ | Don'ts ❌ |
|---|---|
| Be factual and specific. Use dates, times, and names. | Don't be vague. "The service was bad" is not helpful. |
| Stay calm and professional. Avoid angry or emotional language. | Don't use abusive or threatening language. This will undermine your case. |
| Keep it concise. Use bullet points to break up text. | Don't write an overly long, rambling letter. Stick to the key points. |
| State your desired outcome clearly. | Don't make unrealistic demands. |
| Keep copies of everything. Your letter and any response. | Don't send original documents. Always send copies. |
Step 3: Await the Provider's Response
Once you've sent your complaint, the provider's own procedure kicks in. Typically, you should expect:
- An acknowledgement: Usually within 2 to 5 working days, confirming they have received your complaint.
- A full response: This takes longer, as they need to investigate. Most providers aim to respond fully within 20 to 25 working days. If it's a complex case, they should write to you to explain the delay.
A good response will:
- Address all the points you raised.
- Show that a proper investigation has taken place.
- Offer a clear explanation and, if appropriate, an apology.
- Outline the actions they will take.
- Inform you of your right to escalate the complaint if you remain unsatisfied.
Unhappy with the Response? How to Escalate Your Complaint
If you receive a final response from the provider (often called a "deadlock letter") and you're not happy with the outcome, you haven't reached the end of the road. Your next step is to seek independent review.
Introducing the Independent Sector Complaints Adjudication Service (ISCAS)
For the majority of private healthcare complaints, the next stage is ISCAS. It's an independent body that reviews complaints about its members.
Crucially, you can only use ISCAS if your healthcare provider is a subscriber. Most of the UK's major private hospital groups (like Nuffield Health, Spire Healthcare, HCA, and Circle Health Group) are members. You can check the full list on the ISCAS website.
The ISCAS process, known as the "Code of Practice for Complaints Management," has three stages:
| Stage | Who is Involved | Purpose | Timescale (Typical) |
|---|---|---|---|
| Stage 1: Local Resolution | You and the local hospital/clinic. | To resolve the complaint directly with the provider where you received care. | 25 working days |
| Stage 2: Corporate Review | You and the provider's head office/CEO. | An internal appeal where a senior manager who was not involved in Stage 1 reviews the complaint. | 20 working days |
| Stage 3: Independent Adjudication | You and an ISCAS Adjudicator. | An impartial, independent review of your complaint. The adjudicator's findings are binding on the provider. | 4-6 months |
To start a Stage 3 complaint, you must have completed the provider's internal process (Stages 1 and 2). You then have 6 months from the date of the final Stage 2 letter to apply to ISCAS. The service is free for patients. An adjudicator will review all the evidence from both you and the provider and make a final decision.
What if the Provider Isn't an ISCAS Member?
If your provider is not subscribed to ISCAS, you have other options, though they can be more complex:
- Alternative Dispute Resolution (ADR) / Mediation: You could suggest using a neutral third-party mediator to help you and the provider reach an agreement. Both parties must agree to this.
- Contacting Regulators: You can report your concerns to the CQC (in England) or the relevant national body. They won't resolve your individual complaint but may launch an inspection if they believe patient safety is at risk. If your complaint is about the professional conduct of a doctor or nurse, you can report them to the General Medical Council (GMC) or Nursing and Midwifery Council (NMC) respectively.
- Legal Action: This is the last resort. If you believe you have suffered harm due to clinical negligence, you should seek advice from a specialist medical negligence solicitor. This is a formal legal process and is separate from the complaints system.
How to Complain About Your Private Health Insurance Provider
Sometimes, your issue isn't with the hospital but with your insurance company. As an expert PMI broker, WeCovr helps clients understand their policies to avoid these issues, but disputes can still arise.
Common reasons for complaining about an insurer include:
- A claim being unfairly rejected.
- Disputes over what your policy covers.
- Poor customer service or administrative delays.
- Disagreement over the amount paid towards a claim.
The process is different from complaining about a healthcare provider:
- Formal Complaint to the Insurer: First, you must make a formal complaint directly to the insurance company. Like healthcare providers, they have a formal, regulated complaints procedure you must follow.
- The Financial Ombudsman Service (FOS): If you are unhappy with the insurer's final response, or if they haven't responded within 8 weeks, you can take your complaint to the FOS.
The FOS is a free, independent service that settles disputes between consumers and financial services businesses, including insurance companies. They will look at the facts from both sides and decide what is fair and reasonable. Their decisions are binding on the insurer.
A Crucial Reminder: What Private Medical Insurance Covers
Many complaints stem from a misunderstanding of what a private medical insurance UK policy is for. It's vital to remember this key point:
Standard UK private health insurance is designed to cover acute conditions that arise after you take 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 (e.g., joint replacement, cataract surgery, hernia repair).
- A chronic condition is an illness that cannot be cured, only managed. This includes conditions like diabetes, asthma, high blood pressure, and arthritis.
- Pre-existing conditions are any illnesses or injuries you had before your policy began.
Standard private health cover does not pay for the management of chronic conditions or treatment for pre-existing conditions. This is the single most important principle of UK PMI. Understanding this from the outset can prevent disappointment and disputes later on. At WeCovr, we make this crystal clear to all our clients when helping them compare and choose the best PMI provider for their needs.
Beyond Treatment: Focusing on Your Health and Wellbeing
While it's important to know how to act when things go wrong, the best scenario is staying healthy. Modern private health cover is increasingly focused on prevention and wellness, offering benefits that help you maintain a healthy lifestyle.
Many top-tier policies include:
- Discounted gym memberships.
- Access to virtual GP services.
- Mental health support and therapy sessions.
- Rewards for healthy habits.
At WeCovr, we support this holistic approach. That's why all our clients gain complimentary access to CalorieHero, our AI-powered calorie and nutrition tracking app, to help them manage their diet and health goals. Furthermore, customers who purchase private medical or life insurance through us are often eligible for discounts on other types of cover, from home to travel insurance.
A few simple tips can go a long way in protecting your health:
- Balanced Diet: Focus on whole foods, fruits, vegetables, and lean proteins.
- Regular Activity: Aim for at least 150 minutes of moderate-intensity exercise per week, as recommended by the NHS.
- Quality Sleep: Prioritise 7-9 hours of sleep per night to allow your body to repair and recharge.
- Stress Management: Incorporate mindfulness, meditation, or hobbies to manage daily stress.
Frequently Asked Questions About Private Healthcare Complaints
Can I get compensation for a private healthcare complaint?
How long do I have to make a complaint about a private provider?
What is the difference between a complaint and a medical negligence claim?
Does making a complaint affect my future care from that provider?
Navigating the healthcare landscape can be daunting, but you are not alone. Whether you're considering your options for private health cover or need help understanding the system, having an expert on your side makes all the difference.
Ready to find the right private medical insurance for you? The team at WeCovr compares policies from the UK's leading insurers to find cover that fits your needs and budget, all at no cost to you.
Get your free, no-obligation quote from WeCovr today and take the first step towards peace of mind.
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.
