How to Make a Private Health Insurance Claim 2026 Step-by-Step
As an FCA-authorised broker that has helped arrange over 900,000 policies, WeCovr understands that navigating the UK private medical insurance claims process can feel daunting. This definitive 2026 guide demystifies the entire journey, ensuring you can access the high-quality private healthcare you're paying for, quickly and without stress.
WeCovr's step-by-step guide to claiming on your PMI policy successfully
Having private medical insurance (PMI) provides invaluable peace of mind. It’s your fast-track ticket to diagnosis and treatment, bypassing the often lengthy NHS waiting lists. In 2025, data from NHS England regularly showed millions of treatment pathways waiting to begin, highlighting the profound value of having a private alternative.
But a policy is only as good as your ability to use it. Understanding the claims process before you need it is the secret to a smooth, successful outcome. This guide will walk you through every stage, from the first GP visit to the final payment, so you feel confident and in control.
Before You Claim: Understanding Your Policy is Key
The single most common reason for claim-related issues is a misunderstanding of what a policy covers. Before you even think about making a claim, take 15 minutes to review your policy documents.
Pay close attention to these key areas:
- Your Policy Excess: This is the amount you agree to pay towards any claim. For example, if your excess is £250 and your treatment costs £2,000, you pay the first £250, and your insurer pays the remaining £1,750.
- Outpatient Limits: Your policy will specify a limit on the value or number of consultations and diagnostic tests you can have before being admitted to hospital. Some policies have no limit, while others might cap it at £500, £1,000, or £1,500.
- Hospital List: Insurers have different lists of hospitals where you can receive treatment. Check if your policy has a specific, restricted list or offers a nationwide choice. Choosing a hospital outside your list can result in your claim being rejected or only partially paid.
- Policy Exclusions: Every policy has specific exclusions. These are treatments or conditions that are not covered. Common exclusions include cosmetic surgery, normal pregnancy, and A&E visits.
The Golden Rule of PMI: Acute vs. Chronic Conditions
This is the most critical concept to grasp in UK private medical insurance.
Standard UK PMI is designed to cover acute conditions that arise after your policy begins. It does not cover chronic conditions or pre-existing conditions.
Understanding this distinction is fundamental.
| Term | Meaning | Examples |
|---|---|---|
| Acute Condition | A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. | A bone fracture, appendicitis, a cataract, a joint replacement, most infections. |
| Chronic Condition | An illness or disease that continues indefinitely. It has no known cure and is managed with ongoing monitoring and treatment. | Diabetes, asthma, high blood pressure, arthritis, Crohn's disease. |
| Pre-existing Condition | Any illness, injury, or symptom for which you sought advice, diagnosis, or treatment in the years before your policy started (typically the last 5 years). | Back pain you saw a GP for 3 years ago; anxiety you were prescribed medication for before taking out cover. |
Most policies will cover pre-existing conditions after a set period (usually two years) provided you have been completely symptom, treatment, and advice-free for that condition during that time. An expert PMI broker, like WeCovr, can help you find a policy with underwriting terms that best suit your medical history.
Step 1: See Your NHS GP
For almost all non-emergency claims, your journey will begin at your local GP surgery. This step is non-negotiable for most insurers.
Why is a GP visit necessary?
- Medical Gatekeeper: The GP's role is to assess your symptoms and determine if you need to see a specialist. Insurers rely on this professional medical opinion to validate that your claim is for a genuine medical need.
- Initial Diagnosis: Your GP will perform an initial examination and may even order basic tests (like blood tests) via the NHS to get a clearer picture of your condition.
- Referral Letter: If your GP agrees that you need specialist care, they will write a referral letter. This letter is the key that unlocks your private health cover.
What to do at the GP appointment:
- Clearly explain your symptoms, when they started, and how they are affecting your life.
- Inform your GP that you have private medical insurance and would like to use it.
- Request an "open referral".
What is an Open Referral?
An open referral is a letter from your GP that recommends you see a certain type of specialist (e.g., a "consultant cardiologist" or an "orthopaedic surgeon") without naming a specific doctor.
This is hugely beneficial because it gives your insurer the flexibility to help you find a specialist from their approved network who can see you quickly. A named referral (to a specific Dr. Smith) can cause delays if that doctor isn't recognised by your insurer or has a long waiting list.
Step 2: Contact Your Insurer to Start the Claim
As soon as you have your open referral letter, it's time to contact your insurer. Do not book any appointments or consultations before you have spoken to them and received authorisation.
Most insurers have dedicated claims lines or online portals/apps.
Information you will need to have ready:
| Information Required | Why it's needed | Where to find it |
|---|---|---|
| Policy Number | To identify you and your specific level of cover. | On your policy documents, membership card, or insurer's app. |
| Personal Details | Your full name, date of birth, and address. | From memory. |
| GP's Details | Name and address of your GP surgery. | From memory or a quick search. |
| Details of Symptoms | A brief explanation of your condition. | What you discussed with your GP. |
| Referral Details | The type of specialist your GP has referred you to. | On the GP's referral letter. |
During this call, the claims handler will:
- Confirm your cover is active.
- Check that your condition is not a stated exclusion.
- Ask about when your symptoms first started to assess if it's a pre-existing condition.
- Confirm your outpatient limits and policy excess.
If everything is in order, they will give you a pre-authorisation number. This number is vital—it’s the insurer’s green light for your claim. Keep it safe!
Step 3: Choosing Your Specialist and Hospital
With your pre-authorisation number in hand, the next step is to find the right specialist. How this works depends on your policy type.
- Guided Option (or "Expert Select"): If your policy has a "guided" option, your insurer will typically provide you with a shortlist of 2-3 specialists from their network who they have confirmed can treat your condition. This is often a cheaper policy option and simplifies the choice for you.
- Standard/Unguided Option: If you have a standard policy, your insurer will direct you to their full list of approved specialists. You can then research and choose who you want to see from that list.
WeCovr's Tip: When choosing, don't just look at the first name on the list. Consider their special interests, patient reviews, and the location of their practice. Your insurer's online portal often provides detailed profiles for each consultant.
Once you've chosen a specialist, either you or your insurer will book the initial consultation.
Step 4: Attending Your Consultation and Diagnostics
You will attend your initial consultation with the private specialist. They will discuss your symptoms, review your GP's letter, and conduct an examination.
Almost certainly, the specialist will recommend further diagnostic tests to confirm a diagnosis. This could include:
- An MRI scan
- A CT scan
- An ultrasound
- An X-ray
- Endoscopy
Crucial Point: You must contact your insurer again to get pre-authorisation for these diagnostic tests. The specialist's secretary will often provide you with a cost estimate or "procedure code" for the scan. Pass this to your insurer to get it approved before you book the test.
Once the tests are authorised, you can proceed. The results will be sent back to your specialist, who will then see you for a follow-up appointment to discuss the diagnosis and recommend a treatment plan.
Step 5: Authorisation for Treatment
If the specialist recommends treatment, such as surgery or a course of therapy, you guessed it—you need to get pre-authorisation for that too.
The specialist's secretary will provide the procedure code(s) and cost for the proposed treatment. You will need to pass this information to your insurer. The insurer will check that:
- The treatment is for a covered condition.
- The costs are within their "reasonable and customary" charges.
- The hospital is on your approved list.
Once approved, you will be given the go-ahead to book your treatment.
A Real-Life Example: David's Knee Injury
Let's walk through a typical claim to see how it works in practice.
- The Problem: David, a 45-year-old with a PMI policy, injures his knee playing football. It's swollen and painful.
- GP Visit (Step 1): He sees his NHS GP, who suspects a meniscus tear. The GP gives him an open referral to an orthopaedic surgeon.
- Call Insurer (Step 2): David calls his insurer. He provides his policy number and referral details. They confirm his cover, note it's a new condition, and give him a pre-authorisation number for an initial consultation.
- Choose Specialist (Step 3): His insurer gives him a list of three approved surgeons near his home. He chooses one and books an appointment.
- Consultation & Diagnostics (Step 4): The surgeon examines David and agrees it's likely a meniscus tear, recommending an MRI scan to confirm. The surgeon's secretary gives David the procedure code for the MRI. David calls his insurer, gives them the code, and gets authorisation for the scan. He has the MRI the following week.
- Treatment Plan (Step 5): The MRI confirms a significant tear. The surgeon recommends keyhole surgery (arthroscopy). David gets the codes and costs for the surgery and hospital stay. He calls his insurer one last time to get full pre-authorisation for the entire treatment package.
- Treatment & Payment (Step 6): David has the surgery two weeks later. The hospital and surgeon send their invoices directly to the insurer. The insurer pays them in full. David receives a letter asking him to pay his £200 policy excess, which he pays directly to the hospital.
From injury to surgery, David's entire journey took just over four weeks—a process that could have taken many months on the NHS.
Step 6: Settling the Bill (The Easy Part!)
One of the best things about private health insurance is that you rarely have to handle large sums of money or complex invoices yourself.
The process is simple:
- Direct Settlement: The hospital, specialist, and anaesthetist will send their bills directly to your insurance provider, quoting your policy number and pre-authorisation code.
- Insurer Pays: Your insurer checks the invoices against the authorised treatment and pays the providers directly.
- You Pay the Excess: If your policy has an excess, your insurer will inform you of the amount you need to pay. You will usually pay this directly to the hospital where you received your main treatment.
It's a streamlined process designed to let you focus on what matters most: your recovery.
Maximising Your Policy's Value: It's More Than Just Claims
A modern private health insurance policy offers far more than just claims processing. To get the best value from your cover, make sure you're using all the added benefits.
- Digital GP Services: Most top-tier policies include access to a 24/7 virtual GP service. This is perfect for getting quick medical advice, prescriptions, or even a referral without waiting for an NHS GP appointment.
- Mental Health Support: Many insurers now offer dedicated phone lines or therapy sessions for mental health concerns, often without needing a GP referral. Check your policy for details on services like CBT (Cognitive Behavioural Therapy).
- Wellness Programmes and Discounts: Insurers are increasingly focused on preventative health. They may offer discounts on gym memberships, fitness trackers, and health screenings.
WeCovr's Unique Benefits: When you arrange a policy through us, you get even more. We provide complimentary access to our AI-powered calorie and nutrition tracking app, CalorieHero, to help you manage your health proactively. Furthermore, clients who purchase PMI or life insurance through WeCovr are often eligible for discounts on other types of cover, helping you protect your family and finances more affordably.
Staying Healthy: A WeCovr Guide
While insurance is there for when things go wrong, the best strategy is always prevention.
- Diet: A balanced diet rich in fruits, vegetables, and lean protein is fundamental. Use an app like CalorieHero to understand your nutritional intake and make healthier choices.
- Activity: The NHS recommends at least 150 minutes of moderate-intensity activity a week. This could be a brisk walk, cycling, or swimming. Find an activity you enjoy to make it a sustainable habit.
- Sleep: Aim for 7-9 hours of quality sleep per night. Poor sleep is linked to a host of health issues, from a weakened immune system to an increased risk of chronic disease.
- Stress Management: Chronic stress can have a significant physical impact. Incorporate mindfulness, yoga, or simple breathing exercises into your daily routine.
What If My Health Insurance Claim Is Rejected?
It's the scenario everyone fears, but if you've followed the steps above—particularly getting pre-authorisation at every stage—it is very rare.
However, claims can sometimes be delayed or rejected. Here are the most common reasons:
| Reason for Rejection | How to Avoid It |
|---|---|
| It's a Policy Exclusion | Read your policy documents carefully before you claim. Common exclusions are cosmetic surgery, addiction treatment, and normal pregnancy. |
| It's a Pre-existing Condition | Be completely honest about your medical history when you take out the policy. If unsure, declare it. |
| It's a Chronic Condition | Understand that PMI is for acute conditions. Ongoing management of chronic issues like diabetes is typically not covered. |
| You Didn't Get Pre-authorisation | Never book any appointment, test, or treatment without getting an authorisation number from your insurer first. |
| You Exceeded Your Policy Limits | Be aware of your outpatient and other benefit limits. Your insurer should warn you if you are approaching them. |
If your claim is rejected, don't panic.
- Ask for a Reason: Ask your insurer for a clear, written explanation of why the claim was denied, referencing the specific clause in your policy.
- Review and Appeal: If you believe the decision is unfair or based on incorrect information, you have the right to appeal. Collate your evidence (e.g., a letter from your specialist) and submit a formal complaint to the insurer.
- Financial Ombudsman Service: If you exhaust the insurer's internal complaints process and are still not satisfied, you can escalate your case to the Financial Ombudsman Service. This is an independent body that will review your case for free.
An experienced broker can be a valuable ally in these situations, helping you understand the insurer's reasoning and navigate the appeals process.
Frequently Asked Questions (FAQs) about PMI Claims
Do I have to pay anything when I make a private health insurance claim?
Can I claim for a condition I had before I bought the insurance?
What happens if my claim is rejected?
How long does a UK health insurance claim take from start to finish?
Take the Next Step with WeCovr
The UK private medical insurance market can be complex, but making a claim doesn't have to be. By understanding your policy and following this step-by-step guide, you can unlock the full potential of your health cover with confidence.
At WeCovr, our high customer satisfaction ratings are built on helping clients not just find the best PMI provider, but also understand how to use their policy effectively. We are independent, FCA-authorised experts who compare policies from across the market to find the right cover for your needs and budget, at no extra cost to you.
Ready to secure your peace of mind?
Get your free, no-obligation private medical insurance 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:
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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!