How to Make a PMI Claim UK
Navigating a health concern is stressful enough without worrying about the claims process. As FCA-authorised experts who have helped arrange over 900,000 policies, we at WeCovr know that understanding your private medical insurance in the UK is key. This guide demystifies the PMI claims journey, ensuring you can access treatment swiftly.
Step-by-step guide to getting treatment paid quickly
Making a claim on your private health insurance can feel daunting, but it's usually a straightforward process if you follow the correct steps. The golden rule is to always contact your insurer for pre-authorisation before you incur any costs. This ensures your treatment is covered and avoids any nasty surprises with unexpected bills.
Here's the typical journey from feeling unwell to receiving private treatment, broken down into simple, manageable steps.
First, a Crucial Note: What UK PMI Actually Covers
Before we dive into the claims process, it's vital to understand the fundamental purpose of private medical insurance in the UK.
PMI 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. Think of things like cataracts, joint replacements, or hernias.
Conversely, standard PMI policies do not cover:
- Chronic Conditions: These are long-term illnesses that have no known cure and need ongoing management, such as diabetes, asthma, or high blood pressure. These remain under the care of the NHS.
- Pre-existing Conditions: Any medical condition you had symptoms of, received advice for, or were treated for in the years before your policy began. Some policies may cover them after a set period (usually two years) if you remain symptom-free, a process known as moratorium underwriting.
Understanding this distinction is the single most important factor in a successful claims experience.
Step 1: Visit Your GP
For almost all non-emergency conditions, your first port of call is your NHS or private General Practitioner (GP).
- Why is this necessary? Your GP will assess your symptoms and determine if you need to see a specialist. The insurer needs this primary medical opinion to validate that specialist treatment is medically necessary.
- Virtual GP Services: Many modern PMI policies now include a 24/7 virtual GP service. This can be a much faster way to get an initial consultation, often via phone or video call, from the comfort of your own home. Check your policy documents to see if this is included.
- The Outcome: Your GP will provide a diagnosis or, more commonly, a referral to a specialist for further investigation.
Step 2: Get a GP Referral
Once your GP agrees you need specialist care, they will write you a referral letter. This is the key that unlocks your private treatment.
You will typically receive one of two types of referral:
- A Named Referral: Your GP recommends a specific specialist (e.g., "Dr. Smith, cardiologist at The Cromwell Hospital"). This can sometimes limit your options if Dr. Smith isn't on your insurer's approved list or their fees are higher than what your insurer will cover.
- An Open Referral: Your GP recommends a type of specialist without naming a specific person (e.g., "referral to a consultant cardiologist"). This is often the best option. It gives your insurer the flexibility to help you find a suitable, fee-assured specialist from their network, ensuring a smoother process with no payment shortfalls.
Pro-Tip: Always ask your GP for an open referral if possible. It simplifies the next step and minimises the risk of out-of-pocket expenses.
Step 3: Contact Your Insurer to Pre-authorise Your Claim
This is the most critical step. Do not book any appointments or tests before you have spoken to your insurer and received authorisation.
-
Gather Your Information: Before you call, have these details ready:
- Your policy number.
- The patient's full name and date of birth.
- The name of your GP and their practice.
- Details of your symptoms and the date they first started.
- A copy of the open referral letter from your GP.
-
Make the Call (or Go Online): Most major insurers have dedicated claims helplines. Many also have online portals or mobile apps where you can initiate a claim.
-
Explain Your Situation: The claims handler will ask about your condition and the referral. They will check your policy to confirm that the type of treatment you need is covered.
Step 4: Your Insurer Assesses the Claim
Behind the scenes, the insurer's team (which may include clinically trained staff) will review the information. They are checking for a few key things:
- Is the condition covered? Is it an acute condition, not a chronic or pre-existing one?
- Is the treatment covered? Does your policy level include this specific procedure or consultation?
- Are there any limits? Do you have an outpatient limit that might be exceeded? Is the chosen hospital on your approved list?
This is where having the right policy is crucial. A good PMI broker like WeCovr can help you compare policies from the outset, ensuring you have the appropriate level of cover for your needs and budget, preventing disappointment at the claims stage.
Step 5: Receive Your Authorisation Number
If your claim is approved, your insurer will provide you with an authorisation number or code. This code is your green light to proceed. It confirms to the hospital and specialist that the insurer has agreed to cover the costs.
Your insurer will also use this opportunity to:
- Guide your choice of specialist: With an open referral, they will provide a list of 2-3 approved specialists in your area.
- Confirm any excess: They will remind you of any policy excess you need to pay directly to the hospital.
- Explain any benefit limits: They will clarify if there are any caps on your cover, for example, for outpatient diagnostics.
Step 6: Book Your Consultation and Treatment
With your authorisation number in hand, you can now book your appointment.
- Contact the specialist's secretary or the hospital's private patient unit.
- Provide your name, policy number, and the authorisation number from your insurer.
- They will arrange a convenient time for your initial consultation.
If further tests (like an MRI scan) or a procedure (like surgery) are needed, the specialist's office will usually handle the next round of authorisation with your insurer directly. You should always double-check this is happening to be safe.
Step 7: Settle the Bill (The Easy Part!)
One of the biggest benefits of PMI is the seamless payment process. In over 95% of cases, you will never see a bill.
- Direct Settlement: The hospital and the specialist will send their invoices directly to your insurance provider.
- Paying Your Excess: The only amount you are typically responsible for is your policy excess. The hospital will usually contact you to arrange payment for this amount after your treatment. For example, if your treatment cost £5,000 and you have a £250 excess, the insurer pays £4,750 and you pay £250.
And that's it. Your treatment is complete, the bills are handled, and you can focus on your recovery.
Understanding Key PMI Terms in the Claims Process
Your policy document can be full of jargon. Understanding these key terms is essential for a smooth claim.
| Term | What It Means in Plain English | Example |
|---|---|---|
| Pre-authorisation | Getting permission from your insurer before you have any treatment or consultations. | You call your insurer with your GP referral before booking an appointment with a cardiologist. |
| Excess | A fixed amount you agree to pay towards a claim each policy year. A higher excess lowers your premium. | You have a £500 excess. Your knee surgery costs £8,000. You pay the hospital £500, your insurer pays £7,500. |
| Outpatient Limit | A cap on the amount your policy will pay for treatments that don't require a hospital bed (e.g., consultations, scans, physio). | Your policy has a £1,000 outpatient limit. Your initial consultation is £250 and your MRI scan is £800. You are now over your limit. |
| Hospital List | The list of private hospitals and facilities your insurer has approved for treatment. Choosing a hospital not on your list will mean your claim is not covered. | Your policy has a "local" hospital list. You cannot choose to have treatment at a top London hospital unless it's on that list. |
| Shortfall | A gap between what a specialist charges and what your insurer is willing to pay. This is rare if you use a specialist from your insurer's approved list. | A consultant charges £300 for a follow-up, but your insurer's fee guidelines are £250. You may have to pay the £50 shortfall. |
| Open Referral | A referral from your GP to a type of specialist (e.g., dermatologist) rather than a named specialist. | Your GP refers you "to see an orthopaedic surgeon" for your hip pain. Your insurer then helps you find one from their network. |
Real-Life Example: Sarah's Knee Injury Claim
Let's walk through a fictional but typical scenario to see how the process works in practice.
- The Patient: Sarah, a 45-year-old marketing manager with a PMI policy from a major UK provider. Her policy has a £250 excess and a comprehensive hospital list.
- The Problem: Sarah injures her knee while hiking. After a week of pain and swelling, she decides to use her PMI.
- GP Visit: Sarah uses her insurer's 24/7 Virtual GP app. The GP suspects a meniscus tear and provides an open referral to an orthopaedic surgeon.
- Call to Insurer: Sarah calls her insurer's claims line. She provides her policy number, details of the injury, and uploads the open referral letter to the insurer's portal.
- Authorisation: The claims handler confirms her policy covers diagnostics and surgery for this type of injury. They give her a list of three approved orthopaedic surgeons in her area and a single authorisation number to cover the initial consultation and any subsequent scans.
- Booking: Sarah chooses a surgeon whose clinic is near her office. She calls the secretary, provides the authorisation number, and books an appointment for the following week.
- Consultation & Scans: The surgeon examines her and confirms an MRI is needed. The hospital's imaging department uses the same authorisation number. The MRI confirms a significant tear requiring arthroscopic surgery.
- Further Authorisation: The surgeon's secretary sends the treatment plan to Sarah's insurer. The insurer authorises the surgery and provides a new authorisation code specifically for the hospital stay and surgical procedure.
- Treatment: Sarah has her keyhole surgery two weeks later. She stays one night in the hospital.
- Payment: The hospital and surgeon bill the insurer directly. A few weeks later, the hospital finance team sends Sarah a link to pay her £250 excess. She never sees the main bill, which was over £6,000.
Total time from GP call to surgery: Just under four weeks. This contrasts sharply with potential NHS waiting times, which for trauma and orthopaedic treatment, could be many months. According to NHS England data from mid-2024, the overall waiting list remains above 7.5 million, with a median wait of over 14 weeks for admitted treatment.
Common Claims Pitfalls and How to Avoid Them
While most claims go smoothly, some common mistakes can lead to delays or rejection.
-
Mistake 1: Not Getting Pre-authorisation.
- The Problem: You book and attend a specialist appointment, then try to claim the cost back. The insurer may refuse to pay as they weren't given the chance to approve the treatment or guide you to a fee-assured specialist.
- The Fix: Always call your insurer first. It is the single most important rule.
-
Mistake 2: Using a Non-Listed Hospital or Specialist.
- The Problem: You go to a hospital your friend recommended, only to find it's not on your policy's hospital list. Your claim will be rejected.
- The Fix: Use the specialists and hospitals recommended by your insurer. They have pre-agreed fee schedules, which prevents shortfalls.
-
Mistake 3: Exceeding Your Benefit Limits.
- The Problem: Your policy has a £1,000 outpatient limit. You have a consultation (£250), an MRI (£750), and then blood tests (£200). You are now £200 over your limit and must pay this yourself.
- The Fix: Be aware of your limits. The insurer will state them when you get authorisation. Keep a running total if you're having multiple tests.
-
Mistake 4: Assuming Everything is Covered.
- The Problem: You assume your policy covers dental, optical, or mental health, but you have a basic policy that excludes them.
- The Fix: Read and understand your policy documents before you need to claim. An expert broker like WeCovr provides a free service to help you compare the 'small print' of different policies and find one that truly matches your needs.
What If My Private Medical Insurance Claim Is Rejected?
It's disheartening to have a claim denied, but it's important to understand why it might have happened and what your options are.
Common Reasons for Rejection:
- Policy Exclusion: The treatment is for a condition specifically excluded in your policy terms (e.g., cosmetic surgery, normal pregnancy, chronic conditions).
- Pre-existing Condition: The insurer believes the condition, or its underlying cause, existed before your policy began.
- Chronic Condition: The condition is deemed long-term and requiring ongoing management rather than a short-term cure.
- Failure to Pre-authorise: You sought treatment without getting prior approval.
Your Right to Appeal:
If you believe your claim was unfairly rejected, you have a clear path for appeal.
- Contact Your Insurer: Your first step is to speak to the insurer's claims department. Ask for a detailed written explanation for the rejection. If you have new information (e.g., a letter from your GP clarifying when symptoms first started), provide it to them.
- Make a Formal Complaint: If you're still not satisfied, ask for details of their official complaints procedure. This will escalate your case to a senior manager or a dedicated complaints team. They have up to eight weeks to provide a 'final response'.
- Go to the Financial Ombudsman Service (FOS): If you are unhappy with the insurer's final response, or if they fail to provide one within eight weeks, you can take your case to the FOS. This is a free, independent service that settles disputes between consumers and financial services firms. Their decision is binding on the insurer.
Maximising Your Health Cover: Beyond Just Claims
Modern private health cover is about more than just paying for surgery. The best PMI providers offer a wealth of proactive health and wellness benefits designed to keep you healthy and out of hospital.
Make sure you're using everything your policy offers:
- 24/7 Virtual GP: As mentioned, this is often the fastest way to get medical advice.
- Mental Health Support: Many policies now include access to a set number of counselling or therapy sessions without needing a GP referral.
- Physiotherapy: Some insurers provide direct access to physiotherapy networks for muscle and joint issues, bypassing the need for a GP visit.
- Wellness Programmes: Providers like Vitality are famous for rewarding healthy behaviour. You can get discounts on gym memberships, fitness trackers, and even healthy food, all designed to improve your long-term wellbeing.
- Digital Health Tools: When you buy a policy with WeCovr, you get complimentary access to our AI-powered nutrition app, CalorieHero, helping you manage your diet and health goals. We also offer discounts on other types of insurance when you take out a PMI or life policy with us, helping you protect your entire lifestyle.
Taking a proactive approach to your health doesn't just improve your quality of life—it can help reduce your long-term medical costs and the likelihood of needing to make a major claim.
Do I always need a GP referral to make a PMI claim?
What is the difference between a policy excess and a shortfall?
Can I use my private medical insurance for an A&E emergency?
Finding the right private medical insurance UK policy is the best way to ensure a simple, stress-free claims process when you need it most. At WeCovr, our expert advisors provide free, impartial advice, comparing leading providers to find the perfect cover for your needs and budget.
Ready to secure your peace of mind? Get your free, no-obligation PMI quote from WeCovr today.
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:
Our Group Is Proud To Have Issued 900,000+ Policies!
We've established collaboration agreements with leading insurance groups to create tailored coverage
How It Works
1. Complete a brief form
2. Our experts analyse your information and find you best quotes
3. Enjoy your protection!
Any questions?
Learn more
Who Are WeCovr?
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.
Just a quick and simple form and an easy conversation with one of our experts and your valuable insurance policy is in place for that needed peace of mind!