TL;DR
Navigating health concerns can be stressful, but your private medical insurance (PMI) is designed to make it smoother. As an FCA-authorised expert that has helped arrange over 900,000 policies, WeCovr knows the UK private medical insurance market inside out. This guide demystifies the process of booking a private specialist.
Key takeaways
- GP Referral: You visit your NHS or private GP to discuss your symptoms. They provide a medical referral if they believe you need specialist care.
- Insurer Pre-authorisation: You contact your PMI provider with your referral details. They check your cover and, if approved, issue an authorisation number for your consultation.
- Booking the Specialist: You use the authorisation number to book an appointment with a specialist from your insurer's approved list.
- Out-patient (illustrative): Treatment or consultation where you are not admitted to a hospital bed. This includes initial specialist consultations, diagnostic tests like blood tests or scans, and physiotherapy. Many policies have an annual financial limit for out-patient cover (e.g., £1,000 per year).
- Day-patient: A planned medical procedure where you are admitted to hospital and discharged on the same day, such as a minor surgical procedure.
Navigating health concerns can be stressful, but your private medical insurance (PMI) is designed to make it smoother. As an FCA-authorised expert that has helped arrange over 900,000 policies, WeCovr knows the UK private medical insurance market inside out. This guide demystifies the process of booking a private specialist.
Booking steps, paperwork, and how to make sure your claim is approved
Using your private health cover to see a specialist is a structured process designed to ensure your treatment is both appropriate and covered. While it might seem daunting at first, it typically follows three core stages:
- GP Referral: You visit your NHS or private GP to discuss your symptoms. They provide a medical referral if they believe you need specialist care.
- Insurer Pre-authorisation: You contact your PMI provider with your referral details. They check your cover and, if approved, issue an authorisation number for your consultation.
- Booking the Specialist: You use the authorisation number to book an appointment with a specialist from your insurer's approved list.
Mastering these steps, understanding your policy's fine print, and knowing what information to have ready will transform your PMI from a simple policy document into a powerful tool for your health. This article will walk you through every detail, ensuring your journey to see a specialist is fast, clear, and successful.
Understanding Your PMI Policy: What's Actually Covered?
Before you even think about booking an appointment, it's vital to understand the fundamentals of your policy. Not all private medical insurance in the UK is the same, and cover can vary significantly. The most important distinction to grasp is between acute and chronic conditions.
Critical Point: Standard UK private medical insurance is designed to cover acute conditions that arise after you take out your policy. It does not cover pre-existing conditions (any illness or symptom you had before your policy started) or chronic conditions.
| Condition Type | Is it Covered by Standard PMI? | Description & Examples |
|---|---|---|
| Acute Condition | Yes | A condition that comes on suddenly and is expected to be resolved with treatment. Your health returns to its previous state. Examples: Appendicitis, cataracts, a broken bone, a joint injury requiring surgery. |
| Chronic Condition | No | A long-term condition that cannot be cured, only managed. Requires ongoing monitoring and management. Examples: Diabetes, asthma, high blood pressure, Crohn's disease, eczema. |
| Pre-existing Condition | No | Any disease, illness, or injury for which you have experienced symptoms, received medication, advice, or treatment before your policy began. |
In-patient, Day-patient, and Out-patient Cover
Your policy will define three types of care. Seeing a specialist for an initial consultation falls under 'out-patient' cover.
- Out-patient (illustrative): Treatment or consultation where you are not admitted to a hospital bed. This includes initial specialist consultations, diagnostic tests like blood tests or scans, and physiotherapy. Many policies have an annual financial limit for out-patient cover (e.g., £1,000 per year).
- Day-patient: A planned medical procedure where you are admitted to hospital and discharged on the same day, such as a minor surgical procedure.
- In-patient: Treatment that requires you to be admitted to a hospital bed overnight or for a longer period, such as for major surgery.
Check your policy documents to see what your out-patient cover limit is. This will determine how much you can claim for consultations and initial tests.
The Step-by-Step Guide to Booking Your Private Specialist
Follow these steps precisely to ensure a smooth and approved claims process.
Step 1: The GP Referral - Your Essential First Port of Call
With very few exceptions, all UK private medical insurers require a GP referral before you can see a specialist. This is not just red tape; it's a crucial medical safeguard. Your GP assesses your symptoms and determines if specialist care is clinically necessary.
What kind of referral do I need?
You will likely receive one of two types of referral from your GP:
- Named Referral: Your GP recommends a specific specialist by name. This is great if you have a preference, but you must check if that specialist is recognised and fee-assured by your insurer.
- Open Referral: Your GP refers you to a type of specialist (e.g., "a consultant dermatologist") without naming a specific individual. This is often the simplest and best route. It gives your insurer the flexibility to guide you to several approved, fee-assured specialists in your area, minimising the risk of you facing any payment shortfalls.
Top Tip: When you speak to your GP, tell them you have private medical insurance and ask for an 'open referral' letter. This will make the next step much easier.
Step 2: Contacting Your Insurer - Getting Pre-Authorisation
This is the most important step. Never book a specialist appointment before getting pre-authorisation from your insurer. If you do, your insurer is likely to reject the claim, leaving you to pay the entire bill yourself.
To get pre-authorisation, you'll need to call your insurer's claims line or use their online portal/app. Have the following information ready:
- Your PMI policy number
- Your full name and date of birth
- The details from your GP referral letter (the specialty you're being referred to and the symptoms/reason for referral)
- The date your symptoms first started
During the call, the insurer's claims handler will:
- Verify your identity and policy.
- Check that your policy is active and payments are up to date.
- Confirm the condition isn't a stated exclusion (e.g., a chronic or pre-existing condition).
- Issue a pre-authorisation number if the claim is approved.
This authorisation number is your golden ticket. It confirms that the insurer has agreed, in principle, to cover the cost of your initial consultation.
Step 3: Finding and Booking the Specialist
Once you have your authorisation number, you can find a specialist. Your insurer will provide you with a list of approved consultants. You can usually find this list via their website or by asking the claims handler on the phone.
Key Term: "Fee-Assured" Specialist Always choose a specialist who is "fee-assured." This means they have an agreement with your insurer to charge within a set pricing structure. If you choose a consultant who is not fee-assured, they may charge more than your insurer is willing to pay. This creates a "shortfall," which you will have to pay out of your own pocket.
When you call the specialist's private secretary to book the appointment, provide them with:
- Your name and contact details
- Your PMI provider's name (e.g., Bupa, Aviva, AXA Health)
- Your policy number
- Your pre-authorisation number
The secretary will handle the billing directly with your insurer, so you shouldn't have to pay anything upfront (unless you have an excess on your policy).
Step 4: The Consultation and Beyond
At your consultation, the specialist will assess your condition. What happens next depends on their findings.
- If you need diagnostic tests (e.g., MRI, CT scan, blood work): The specialist will recommend them. You must call your insurer again with these details to get a new pre-authorisation number specifically for those tests.
- If you need a follow-up consultation: You may need to get this pre-authorised as well, especially if it falls into a new policy year.
- If you need surgery or a procedure: This is a major step. The specialist will provide a "procedure code." You must contact your insurer with this code to get pre-authorisation for the in-patient or day-patient treatment. This will include the surgeon's fees, anaesthetist's fees, and hospital costs.
Never assume that authorisation for a consultation automatically covers subsequent tests or treatment. Always get separate pre-authorisation for each stage of your care.
Common Pitfalls and How to Avoid Them
Even with the best intentions, it's easy to make a mistake that could lead to a rejected claim or an unexpected bill. Here are the most common errors and how to steer clear of them.
| Pitfall | Why It's a Problem | How to Avoid It |
|---|---|---|
| Booking before getting pre-authorisation | Your insurer can refuse to pay, leaving you with the full bill. | Always call your insurer and get an authorisation number before you book any appointment, test, or procedure. |
| Choosing a non-fee-assured specialist | The specialist may charge more than the insurer's limit, creating a "shortfall" that you must pay. | Use your insurer's approved list and specifically ask the claims handler for "fee-assured" specialists. |
| Forgetting about your excess | You receive an unexpected bill for your policy excess after treatment. | Know your excess amount. The first part of any claim in a policy year is usually paid by you. This is often paid directly to the hospital. |
| Not authorising diagnostic tests | You assume your initial authorisation covers scans and tests. It doesn't. | If your specialist recommends a test, call your insurer immediately to get a separate authorisation number for that specific test. |
| Trying to claim for an excluded condition | Your claim is rejected because the condition is pre-existing, chronic, or a general exclusion (e.g., cosmetic). | Be honest and upfront with your insurer from the start about your medical history. Read your policy documents to understand what is not covered. |
Making the Most of Your Private Health Cover
A modern private medical insurance policy often comes with a host of extra benefits designed to keep you healthy and provide faster access to care.
- Digital GP Services: Most major insurers now offer a 24/7 virtual GP service via an app. This allows you to get medical advice and an open referral without waiting for an in-person NHS appointment, significantly speeding up Step 1 of the process.
- Mental Health Support: While comprehensive psychiatric treatment is often excluded or available on higher-tier plans, many policies now include access to a limited number of therapy or counselling sessions (e.g., CBT) without needing a GP referral.
- Wellness Programmes: Insurers are increasingly focused on prevention. Look out for discounts on gym memberships, fitness trackers, and health screenings.
- WeCovr Client Benefits: When you arrange your policy through an expert broker like WeCovr, you can also gain extra advantages. We provide our PMI clients with complimentary access to CalorieHero, our AI-powered calorie and nutrition tracking app, to support your health goals. We also offer discounts on other insurance products, such as life or home insurance, when you hold a policy with us.
UK Private Healthcare: A Look at the Numbers
The demand for private healthcare is growing, largely driven by pressures on the NHS. Understanding the landscape helps explain why PMI is so valuable.
According to the latest data from NHS England, the challenge of waiting lists remains significant. In mid-2024, the total number of unique patients on the referral to treatment (RTT) waiting list was over 6 million, with the total number of care pathways waiting to start treatment exceeding 7.5 million. For many, waiting over 18 weeks for routine treatment has become common.
This is where PMI steps in. Industry data shows that around 12% of the UK population has some form of private health cover, using it to bypass these queues for eligible acute conditions. It provides peace of mind and, most importantly, faster access to diagnosis and treatment.
How a PMI Broker Like WeCovr Can Help
Choosing the right private medical insurance UK policy is the foundation of a good claims experience. This is where an independent broker is invaluable.
An expert broker like WeCovr works for you, not the insurer. Our role is to:
- Understand Your Needs: We take the time to learn about your budget, your health priorities, and what you want from a policy.
- Compare the Market: We use our expertise to compare dozens of policies from the UK's best PMI providers, explaining the differences in out-patient limits, hospital lists, and excess options.
- Find the Best Value: We find the most suitable cover for your circumstances at a competitive price, at no cost to you. Our service is paid for by the insurer.
- Provide Ongoing Support: We are here to offer guidance and clarity throughout the life of your policy.
By ensuring you have the right policy from day one, we help you avoid the nasty surprise of discovering your cover is inadequate when you need it most. Our high customer satisfaction ratings reflect our commitment to clear, expert, and friendly advice.
What happens if my PMI claim is rejected?
Can I use my PMI for a condition I had symptoms for before I bought the policy?
Do I have to pay anything when I use my private health cover?
Can I go to any specialist or hospital I want?
Ready to find a private medical insurance policy that gives you peace of mind and a smooth claims process?
Sources
- Office for National Statistics (ONS): Inflation, earnings, and household statistics.
- HM Treasury / HMRC: Policy and tax guidance referenced in this topic.
- Financial Conduct Authority (FCA): Consumer financial guidance and regulatory publications.
