How to Make a Private Health Insurance Claim
Navigating a private medical insurance claim for the first time can feel daunting. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we believe that understanding your policy is the key to a smooth and successful claim. This guide provides expert, step-by-step advice for anyone with private health cover in the UK.
WeCovr's step-by-step guide to claiming on your PMI policy successfully
Private Medical Insurance (PMI) is designed to give you peace of mind and fast access to high-quality medical care when you need it most. But a policy is only as good as your ability to use it. Knowing the claims process inside and out means you can focus on what truly matters: your health.
This guide will walk you through every stage, from your first GP visit to the final bill being settled, ensuring you avoid common pitfalls and get the full benefit of your private health cover.
Before You Claim: Understanding Your Policy is Crucial
The single biggest cause of claim-related stress is a misunderstanding of what a policy covers. Before you even think about making a claim, take some time to familiarise yourself with your policy documents.
The Golden Rule of UK PMI: Acute vs. Chronic Conditions
This is the most important concept to grasp. Standard private medical insurance in the UK is designed to cover 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. Think of things like joint injuries, hernias, gallstones, or cataracts.
- A chronic condition is an illness that is long-lasting, often with no known cure. It can be managed but not resolved. Examples include diabetes, asthma, high blood pressure, and Crohn's disease.
Crucially, standard UK PMI policies do not cover the treatment of chronic conditions. They may cover the initial diagnosis of a condition that turns out to be chronic, but ongoing management will be handed back to the NHS.
Similarly, PMI does not cover pre-existing conditions—any illness or symptom you had before your policy began.
Reading Your Policy Documents: What to Look For
When you receive your policy pack, don't just file it away. Look for these key documents and terms:
- Policy Schedule/Certificate of Insurance: This is your personalised summary. It will show your name, the level of cover you've chosen, your policy start date, and your excess.
- Policy Wording: This is the detailed rulebook. It contains the full terms and conditions, including what is and isn't covered (your 'exclusions').
- Hospital List: This shows which private hospitals and facilities you are covered to use. Using a hospital not on your list can result in your claim being rejected or only partially paid.
Here are some key terms you'll encounter:
| Term | What it Means in Plain English | Why It's Important |
|---|---|---|
| Excess | The fixed amount you agree to pay towards the cost of a claim each policy year. For example, if your excess is £250 and your treatment costs £3,000, you pay the first £250, and your insurer pays the remaining £2,750. | Choosing a higher excess can lower your monthly premium, but you need to be able to afford it if you make a claim. |
| Pre-authorisation | Getting your insurer's approval and a unique authorisation number before you have any consultations, tests, or treatment. | This is a non-negotiable step. Without pre-authorisation, your insurer can refuse to pay for your treatment. |
| Out-patient Cover | Cover for consultations, tests, and diagnostics where you don't need to be admitted to a hospital bed. | This is often an optional add-on. Check your policy to see your annual limit for out-patient cover. |
| In-patient Cover | Cover for treatment that requires you to be admitted to a hospital and stay overnight. | This is a core benefit of most PMI policies. |
| Open Referral | When your GP refers you to a type of specialist (e.g., a cardiologist) rather than a named specialist. | Most insurers require an open referral so they can guide you to a specialist within their approved network. |
The 5-Step Claiming Process: From Symptom to Treatment
Once you're familiar with your policy, the actual claims process is usually very straightforward. Follow these steps for a hassle-free experience.
Step 1: Visit Your GP
For almost all conditions, your journey starts with your NHS or private GP. They are the gatekeeper to specialist care.
- Discuss your symptoms: Be clear and honest with your GP about your health concerns.
- Get a referral: If your GP believes you need to see a specialist, they will write a referral letter.
- Request an 'Open Referral': As mentioned, this is crucial. Ask your GP to refer you to a type of specialist (e.g., "an ENT surgeon") rather than a specific person. This gives your insurer the flexibility to guide you to a fee-assured consultant in their network, which helps avoid shortfalls.
Step 2: Contact Your Insurer for Pre-authorisation
This is the most important phone call you will make. As soon as you have your GP referral letter, call your insurer's claims line. Do not book any appointments before you do this.
Have this information ready:
- Your policy number
- Your full name and date of birth
- The details of your symptoms and when they started
- Your GP's details and a copy of the referral letter
During the call, the claims assessor will:
- Confirm your identity and policy details.
- Check that the condition you're claiming for is covered under your policy.
- Confirm you have a GP referral.
- Provide you with a pre-authorisation number. Keep this number safe!
- Give you a list of approved specialists and hospitals from your hospital list.
Step 3: Choose Your Specialist and Hospital
Your insurer will provide you with a choice of recognised consultants and medical facilities. Some policies have "guided pathways," where the insurer might offer a smaller, curated list to help control costs.
- Do your research: You can look up the specialists online to see their credentials and patient reviews.
- Book your appointment: Contact the specialist's secretary to book your initial consultation. You will need to provide your pre-authorisation number.
Step 4: Attend Your Consultation and Treatment
At your initial consultation, the specialist will assess you. They may decide you need further diagnostic tests (like an MRI or blood tests) or recommend a course of treatment or surgery.
- Further Authorisation: For every new stage of treatment (e.g., a scan, a surgical procedure, a course of physiotherapy), the specialist’s team will need to get a new authorisation from your insurer.
- Billing Codes: The hospital and specialist use specific codes (CCSD codes) for every procedure and consultation. They will use these to invoice your insurer. It's their responsibility to get these approved.
You can focus on your appointment, knowing the administrative side is being handled between the medical team and your insurer.
Step 5: Settling the Bill
In the vast majority of cases, you will never see a bill.
- Direct Settlement: The hospital and specialists will send their invoices directly to your insurance provider.
- Paying Your Excess: The only payment you typically make is your policy excess. The hospital will usually contact you to arrange payment of this amount after your treatment. You might pay it to the hospital directly or, in some cases, to the specialist. Your insurer will tell you who to pay.
The insurer then settles the remainder of the bill directly, leaving you free from financial paperwork and able to concentrate on your recovery.
A Real-Life Claim Example: Sarah's Knee Injury
To see how this works in practice, let's follow a typical claim.
- The Problem: Sarah, a 42-year-old amateur runner, develops persistent pain and swelling in her right knee after a long run. It doesn't get better with rest.
- Step 1 (GP Visit): She sees her NHS GP. The GP examines her knee, suspects a meniscal tear, and writes an open referral letter for an orthopaedic surgeon specialising in knees.
- Step 2 (Pre-authorisation): Sarah calls her insurer, WeCovr HealthPro. She provides her policy number and explains the situation, emailing a copy of the GP's letter. The claims handler confirms her policy covers musculoskeletal issues and provides a pre-authorisation number for an initial consultation.
- Step 3 (Choosing a Specialist): WeCovr HealthPro gives Sarah the names of three approved orthopaedic surgeons at a private hospital on her list, just 20 minutes from her home. She books an appointment for the following week.
- Step 4 (Consultation & Treatment): The surgeon examines Sarah and agrees an MRI scan is needed for a definitive diagnosis. His secretary calls the insurer with the MRI procedure code and gets immediate authorisation. Sarah has the scan the next day. The results confirm a torn meniscus requiring keyhole surgery (arthroscopy). The surgeon's team gets this procedure pre-authorised too.
- Step 5 (Settling the Bill): Sarah has the surgery two weeks later. The total cost is £4,800. The hospital bills her for her £250 policy excess. The insurer settles the remaining £4,550 directly with the hospital and surgeon. Sarah also gets six sessions of post-op physiotherapy, which are also pre-authorised and paid for by her insurer.
Within a month, Sarah has gone from diagnosis to treatment and is on the road to recovery, bypassing a lengthy NHS wait.
Common Pitfalls When Claiming and How to Avoid Them
While the process is designed to be simple, some common mistakes can lead to delays or rejected claims. Here’s how to steer clear of them.
| Common Pitfall | The Consequence | How to Avoid It |
|---|---|---|
| Forgetting Pre-authorisation | Your insurer can refuse to pay for your treatment, leaving you with the entire bill. This is the most serious mistake you can make. | Always call your insurer after seeing your GP and before booking any appointments. Make it a non-negotiable step. |
| Not Understanding Exclusions | You begin a claim for something your policy explicitly doesn't cover (e.g., cosmetic surgery, a chronic condition). | Read your policy wording carefully. If in doubt, call your insurer or a broker like WeCovr to clarify your cover before you start. |
| Using a Non-Approved Provider | You see a specialist or use a hospital that is not on your insurer's approved list. | Only use the list of specialists and hospitals your insurer provides. Don't be tempted to go "off-piste," even if a friend recommends someone. |
| Unexpected Shortfalls | Your specialist charges more than the insurer's approved rate, leaving you to pay the difference (the 'shortfall'). | Always use a specialist from your insurer's list. They are 'fee-assured,' meaning they've agreed not to charge more than the insurer will pay. |
| Claiming for a Pre-existing Condition | You try to claim for a condition or symptoms you had before your policy started. | Be completely honest during your application. Trying to hide a pre-existing condition will invalidate your policy and your claim. |
The Power of a Good PMI Broker
Choosing the right private medical insurance UK policy is the first step to a successful claim. This is where an independent broker like WeCovr provides invaluable help.
- Expert Guidance: We don't work for one insurer; we work for you. We compare policies from across the market to find the one that best suits your needs and budget. We explain the differences in hospital lists, out-patient limits, and excess options in plain English.
- No Cost to You: Our service is free. We receive a commission from the insurer you choose, but the price you pay is the same as going direct.
- Claim Advocacy: While you will deal directly with the insurer for your claim, having a good broker in your corner can be helpful if any disputes or complex issues arise. We can act as an advocate on your behalf.
- Exclusive Benefits: When you arrange a policy through WeCovr, you also get complimentary access to our AI-powered nutrition app, CalorieHero, to support your health goals. Furthermore, our clients often receive discounts on other types of cover, like life or travel insurance.
UK Private Healthcare: A Snapshot in 2025
The demand for private medical insurance is closely linked to the pressures on the NHS. Understanding the current landscape helps show why PMI is becoming an increasingly popular choice for families and individuals across the UK.
According to the latest NHS England data from early 2025, the number of people on the waiting list for routine hospital treatment remains a significant concern, with millions waiting for procedures.
| NHS Performance Indicator (England, early 2025 data) | Statistic | Implication for Patients |
|---|---|---|
| Total Waiting List | Over 7.5 million treatment pathways | A significant backlog for elective care. |
| Median Waiting Time | Approx. 14-15 weeks | This is the average wait; many wait much longer for specific specialities like orthopaedics or ophthalmology. |
| Patients Waiting Over 52 Weeks | Over 300,000 | A substantial number of people are facing waits of a year or more for treatment. |
Source: NHS England Consultant-led Referral to Treatment (RTT) waiting times data.
This data highlights the core benefit of PMI: speed. The ability to bypass these queues for eligible acute conditions is the primary reason people invest in private health cover. The UK private healthcare market, valued in the billions, exists to provide this alternative route to swift diagnosis and treatment.
Your Health is Your Wealth: Proactive Wellness
Many leading PMI providers now actively encourage a healthier lifestyle by offering a range of wellness benefits. They understand that prevention is better than cure. These can include:
- Discounted gym memberships
- Access to digital GP services
- Mental health support lines and apps
- Online health assessments
- Discounts on wearable tech like fitness trackers
Embracing these benefits can help you stay healthier and reduce your chances of needing to claim. Simple lifestyle changes can have a huge impact:
- Balanced Diet: Focus on whole foods, fruits, vegetables, and lean proteins. A healthy diet can reduce the risk of many conditions that could lead to a claim. Our CalorieHero app can be a fantastic tool to help you with this.
- Regular Activity: Aim for at least 150 minutes of moderate-intensity exercise per week, as recommended by the NHS. This could be brisk walking, cycling, or swimming.
- Quality Sleep: Prioritise 7-9 hours of sleep per night. Good sleep is essential for physical and mental recovery and a strong immune system.
By taking a proactive approach to your health, you not only improve your quality of life but also get the maximum value from your health insurance investment.
What happens if my private health insurance claim is rejected?
Can I claim for a medical condition that started before I took out my PMI policy?
Do I need a GP referral every time I want to make a claim?
Ready to find the right private health cover? The claims process is simple when you have the right policy in place.
Contact WeCovr today for a free, no-obligation quote. Our expert advisors will compare the UK's leading insurers to find the perfect cover for your needs and budget, ensuring you're fully prepared if you ever need to make a claim.
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!