Mastering the Private Health Insurance Claim Process
As an FCA-authorised expert with over 900,000 policies arranged, WeCovr understands that navigating the UK private medical insurance (PMI) claims process can seem complex. This guide demystifies the steps, empowering you to get your treatment approved and bills paid swiftly, so you can focus on what matters most: your health.
WeCovr's step-by-step guide to ensuring your PMI claim is paid quickly
Private medical insurance is your key to unlocking fast access to high-quality diagnosis and treatment. However, knowing how to use your policy effectively is just as important as choosing the right one. A missed step or a simple misunderstanding can lead to delays or, in some cases, a rejected claim.
This guide breaks down the entire journey, from the first GP visit to the final payment, into clear, manageable steps. By following this process, you can ensure a smooth and stress-free experience.
First, Understand What Your PMI Policy Actually Covers
Before you even think about making a claim, it's vital to understand the fundamentals of your private health cover. The single most important concept to grasp is the difference between acute and chronic conditions.
UK private medical insurance is designed to cover acute conditions that arise after your policy has started.
- Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Examples include a hernia, cataracts, joint pain requiring a replacement, or infections.
- Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics: it needs ongoing or long-term monitoring, requires palliative care, has no known 'cure', or is likely to come back. Examples include diabetes, asthma, high blood pressure, and arthritis.
- Pre-existing Condition: Any health issue you had symptoms of, received medication for, or sought advice about before you took out your policy.
Crucial Point: Standard private medical insurance in the UK does not cover chronic or pre-existing conditions. It is for new, eligible medical problems that crop up unexpectedly. Attempting to claim for these will result in rejection.
What's Typically Covered vs. What's Not
While every policy is different, this table provides a general overview of what you can usually expect.
| Typically Covered (In-patient & Day-patient) | Typically Excluded |
|---|---|
| Hospital accommodation and nursing care | Pre-existing conditions |
| Specialist and surgeon fees | Chronic conditions (e.g., diabetes, asthma) |
| Diagnostic tests (MRI, CT, PET scans) | Normal pregnancy and childbirth |
| Cancer treatment (often a core benefit) | Cosmetic surgery (unless medically necessary) |
| Out-patient consultations and tests (up to a limit) | Self-inflicted injuries and substance abuse |
| Mental health support (varies by policy) | Professional sports injuries |
| Physiotherapy and complementary therapies | Emergency services (A&E) |
Always read your policy documents carefully. Understanding your benefit limits (the maximum amount the insurer will pay for a certain treatment) and your excess (the amount you pay towards a claim) is key to avoiding surprises.
Step 1: The First Sign of a Health Concern – Visit Your GP
For almost every condition, your journey into the private healthcare system begins at your local NHS GP surgery. Your GP is the gatekeeper for specialist referrals.
- Book an Appointment: When you develop a new symptom—be it a painful knee, persistent headaches, or a concerning lump—your first action should be to see your GP.
- Get a Diagnosis: The GP will assess your condition. They might be able to treat it themselves, but if you need to see a specialist, they will provide a referral.
- Request an 'Open Referral': This is a key tip for flexibility. An open referral is a letter that recommends you see a certain type of specialist (e.g., "an orthopaedic surgeon" or "a gastroenterologist") rather than a specifically named doctor. This gives you and your insurer more choice in finding a specialist who is available quickly and is on your insurer's approved list.
Real-Life Example: David, a 45-year-old architect, starts experiencing sharp pain in his shoulder. He visits his NHS GP, who suspects a rotator cuff tear. The GP writes David an open referral letter to see an orthopaedic consultant specialising in shoulder injuries.
The GP referral is the essential document that unlocks the next stage of your claim.
Step 2: Contact Your Insurer to Pre-Authorise Treatment
This is the most critical step in the entire process. You must contact your insurance provider before you book any appointments or undergo any tests. Failure to get pre-authorisation is the number one reason for claim rejections.
When you call your insurer's claims line, they will start the claim process and confirm whether the treatment you need is covered under your policy.
Checklist: Information to Have Ready Before You Call
Being prepared makes the call quick and efficient. Have the following to hand:
- Your policy number
- Your full name, date of birth, and address
- The name of the patient (if claiming for a family member on your policy)
- Details of your symptoms and when they started
- Your GP's details and a copy of the referral letter
- A pen and paper to note down your authorisation code
The insurer will ask a series of questions to understand the nature of your condition and ensure it's not pre-existing. Be honest and clear in your answers.
If your treatment is approved, the insurer will give you an authorisation number (or code). This code is your golden ticket. It confirms to the hospital and specialist that your insurer has agreed to cover the costs. You will likely need a new authorisation number for each stage of treatment (e.g., one for the initial consultation, another for an MRI scan, and a third for any subsequent surgery).
Step 3: Choose a Specialist and Hospital
Once you have your authorisation code for an initial consultation, you need to find a specialist and a hospital. Your choice will be guided by your policy's "hospital list".
Most UK PMI providers use a tiered hospital list system:
| Hospital List Tier | Description | Who It's For |
|---|---|---|
| Local / Standard | A broad network of quality private hospitals across the UK, but may exclude some premium central London hospitals. | The most common and cost-effective option for most people. |
| Extended / National | Includes all the hospitals on the standard list plus some additional options, potentially including some central London facilities. | Those wanting a wider choice or living near a specific hospital on this list. |
| Premium / London | The most comprehensive list, including top private hospitals in central London like The London Clinic or The Cromwell Hospital. | People living or working in central London who want access to these premium facilities. This option significantly increases the policy premium. |
Your insurer will provide you with a list of recognised specialists who practise at the hospitals on your list. Many insurers have online portals where you can search for specialists by location and specialism.
How to find a specialist:
- Use your insurer's online specialist finder tool.
- Call your insurer's claims team and ask for recommendations based on your open referral.
- If your GP referred you to a named consultant, check if they are on your insurer's list.
Once you've chosen a specialist, you can contact their private secretary to book your initial consultation, providing them with your PMI policy details and your pre-authorisation code.
Step 4: Attend Your Consultation and Diagnostic Tests
At your initial consultation, the specialist will assess your condition. Often, they will need more information before they can recommend a course of treatment. This usually involves diagnostic tests.
- Common Diagnostic Tests: MRI scans, CT scans, X-rays, ultrasounds, and blood tests.
Important: The initial authorisation code for your consultation will likely not cover these tests. You must call your insurer again.
- The specialist's secretary will tell you which tests are needed and provide the associated medical procedure codes.
- Call your insurer with these codes to get a new pre-authorisation number specifically for the diagnostic tests.
- Once authorised, book the tests.
After the tests, you will have a follow-up consultation where the specialist will discuss the results and propose a treatment plan (e.g., physiotherapy, medication, or surgery). If surgery or another procedure is required, you will need to repeat the pre-authorisation process one more time for the treatment itself.
David's Journey Continues: David gets authorisation for a consultation. The orthopaedic specialist suspects a significant tear and recommends an MRI. David calls his insurer again, provides the details for the MRI scan, and gets a new authorisation code. The scan is booked. The results confirm a tear requiring keyhole surgery. David calls his insurer a third time to get authorisation for the surgical procedure.
Step 5: Receiving Treatment and Settling the Bill
With full authorisation in place, you can proceed with your treatment. The final step is settling the bill. In the vast majority of cases in the UK, this is handled directly between the provider and the insurer.
How Invoices Are Paid
| Payment Method | How It Works | Patient Responsibility |
|---|---|---|
| Direct Settlement | The hospital, specialist, and anaesthetist send their invoices directly to your insurance provider for payment. This is the standard for in-patient and day-patient care. | You are only responsible for paying your policy excess. You usually pay this directly to the hospital before or on the day of treatment. |
| Pay and Claim | You pay the provider's invoice yourself and then submit the receipt to your insurer for reimbursement. This is sometimes used for out-patient consultations or therapies like physiotherapy. | You pay the full amount upfront. The insurer reimburses you, minus your excess if it applies to that part of your cover. |
Always keep a record of your authorisation codes and any correspondence with your insurer. If you receive any unexpected bills, contact your insurer immediately to clarify the situation.
Common Reasons for Claim Delays or Rejections (and How to Avoid Them)
A smooth claims process is the goal, but pitfalls exist. Understanding them is the best way to steer clear.
| Issue | Why It Happens | How to Avoid It |
|---|---|---|
| No Pre-authorisation | You booked a consultation or had a test without telling your insurer first. | Always call your insurer first. Get an authorisation code for every single step of your treatment journey. |
| Condition Is Excluded | The claim is for a chronic condition, a pre-existing condition, or something specifically excluded in your policy (e.g., cosmetic surgery). | Read your policy documents thoroughly when you buy. Be honest about your medical history during the application. A broker like WeCovr can help you understand these exclusions before you commit. |
| Non-Disclosure | You didn't declare a previous condition or symptoms when you applied for the policy. The insurer later discovers this during the claim investigation. | Be 100% truthful on your application form. It's better to have an exclusion on your policy from the start than to have a claim denied later. |
| Exceeding Benefit Limits | Your policy has a financial cap on certain treatments (e.g., £1,000 for out-patient cover), and your claim exceeds this limit. | Check your policy schedule for benefit limits. Your insurer should warn you if you are approaching a limit when you call to pre-authorise. |
| Using a Non-Recognised Provider | You received treatment from a hospital or specialist not on your insurer's approved list. | Only use hospitals and specialists from your insurer's approved list. Check their online directory or ask the claims team for confirmation. |
Beyond the Claim: Maximise Your PMI Policy's Value
Modern private medical insurance is about more than just surgery. Many policies now include a suite of wellness benefits designed to keep you healthy and address issues before they escalate. Best of all, using them often doesn't count as a claim and won't impact your No Claims Discount.
- Digital GP: Get a GP appointment via video call within hours, often 24/7. This is perfect for getting quick advice, prescriptions, or a referral without waiting for an in-person NHS appointment.
- Mental Health Support: Most top-tier policies include access to telephone counselling or a set number of face-to-face therapy sessions without needing a GP referral.
- Wellness Programmes: Many insurers offer discounts on gym memberships, fitness trackers, and health screenings to encourage a proactive approach to your health.
- Expert Medical Opinion: Get a second opinion on a diagnosis or treatment plan from a leading global expert, all arranged by your insurer.
WeCovr Member Benefits
At WeCovr, we believe in adding value beyond just finding you the right policy. When you arrange your PMI through us, you also get:
- Complimentary access to CalorieHero: Our proprietary AI-powered calorie and nutrition tracking app to help you manage your diet and fitness goals.
- Exclusive discounts: You'll receive preferential rates on other insurance products, such as life insurance or income protection, helping you build a comprehensive financial safety net.
An expert PMI broker like WeCovr can help you compare these value-added benefits across different providers, ensuring you get a policy that supports your overall wellbeing, not just when you're unwell.
What is the difference between an acute and a chronic condition for PMI?
Do I have to pay anything when I make a private health insurance claim?
Can I claim for a condition I had before I took out my policy?
How long does a PMI claim take from start to finish?
Take Control of Your Health Journey Today
Mastering the claims process transforms your private medical insurance from a simple policy into a powerful tool for managing your health. By understanding the rules and following the steps, you can ensure fast, stress-free access to the care you need, when you need it.
Ready to find a private medical insurance UK policy that puts you in control?
The expert team at WeCovr is here to help. We compare policies from the UK's leading insurers to find the perfect fit for your needs and budget, all at no extra cost to you.
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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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.
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