TL;DR
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 of various kinds, we believe accessing your private healthcare should be simple and stress-free. This expert guide demystifies the entire UK claims process.
Key takeaways
- Pre-authorisation: Getting approval from your insurer before you have any tests or treatment.
- Claim Submission: The formal process of providing the insurer with the details of your treatment and costs.
- Settlement/Reimbursement: The insurer paying the hospital and specialists directly or reimbursing you for costs you've paid upfront.
- Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Examples include joint replacements, cataract surgery, hernia repair, or treatment for an infection. PMI is designed to cover acute conditions.
- Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics: it needs ongoing or long-term monitoring, has no known cure, requires palliative care, or is likely to recur. Examples include diabetes, asthma, hypertension, and multiple sclerosis. Standard UK PMI policies do not cover the management of chronic conditions.
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 of various kinds, we believe accessing your private healthcare should be simple and stress-free. This expert guide demystifies the entire UK claims process.
The process of getting pre-authorisation, submitting claims, and receiving reimbursements
Making a claim on your private medical insurance (PMI) policy is the moment you truly see its value. It’s the reason you have the cover in the first place: to get fast access to high-quality diagnosis and treatment when you need it most.
However, the process isn't automatic. It follows a clear sequence of steps designed to ensure the treatment is necessary and covered by your policy. The three core pillars of any PMI claim are:
- Pre-authorisation: Getting approval from your insurer before you have any tests or treatment.
- Claim Submission: The formal process of providing the insurer with the details of your treatment and costs.
- Settlement/Reimbursement: The insurer paying the hospital and specialists directly or reimbursing you for costs you've paid upfront.
This guide will walk you through each stage in detail, giving you the confidence to navigate your healthcare journey smoothly.
First, Understand Your PMI Policy: The Foundation of a Successful Claim
Before you even think about making a claim, the single most important thing you can do is understand what your policy does—and does not—cover. Misunderstanding your cover is the number one reason for claim-related stress.
The Golden Rule: Acute vs. Chronic Conditions
This is the most critical concept in UK private medical insurance.
- Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Examples include joint replacements, cataract surgery, hernia repair, or treatment for an infection. PMI is designed to cover acute conditions.
- Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics: it needs ongoing or long-term monitoring, has no known cure, requires palliative care, or is likely to recur. Examples include diabetes, asthma, hypertension, and multiple sclerosis. Standard UK PMI policies do not cover the management of chronic conditions.
Your policy will pay for the initial diagnosis of a condition. If it's diagnosed as chronic, the insurer will cover the diagnosis but then return you to the care of the NHS for ongoing management.
Pre-existing Conditions: What's Excluded?
Alongside chronic conditions, PMI generally excludes treatment for any medical conditions you had symptoms of, received advice for, or were treated for in the years leading up to your policy start date. The exact period (usually the last 5 years) depends on your underwriting type.
Key Terms to Know in Your Policy Documents
Familiarise yourself with these terms in your policy booklet:
| Term | Plain English Explanation | Example |
|---|---|---|
| Excess | The amount you agree to pay towards the cost of a claim each policy year. You choose this amount when you buy the policy. | If your excess is £250 and your knee surgery costs £6,000, you pay the first £250 and your insurer pays the remaining £5,750. |
| Outpatient Cover | This covers diagnostic tests, consultations, and therapies that don't require a hospital bed. Cover can be limited or unlimited. | A consultation with a cardiologist or an MRI scan on your back would be outpatient treatments. |
| Inpatient/Day-patient | This covers treatment where you are admitted to a hospital and require a bed, either overnight (inpatient) or just for the day (day-patient). | A hip replacement (inpatient) or a colonoscopy (day-patient). |
| Hospital List | The list of private hospitals and clinics your insurer has approved for treatment. Using a non-listed hospital may result in your claim not being fully paid. | Your policy might have a "Nationwide" list but exclude premium central London hospitals unless you paid for an extended list. |
| Fee Guidelines | Insurers have limits on how much they will pay specialists for certain procedures. A "fee-assured" specialist agrees not to charge more than the insurer's limit. | An anaesthetist might charge £600, but your insurer's guideline is £500. If they are not fee-assured, you may have to pay the £100 shortfall. |
Taking 30 minutes to read your policy documents when you first receive them can save you hours of confusion later. If you're ever unsure, an expert broker like WeCovr can help you understand the fine print before you buy and support you during a claim.
A Step-by-Step Guide to the UK PMI Claims Journey
Let's follow a real-life example. Meet David, a 45-year-old architect with a PMI policy. He's been experiencing persistent knee pain after a hiking trip.
Step 1: Visit Your GP for an Initial Diagnosis and Referral
Your journey almost always begins with your NHS or a private GP. Insurers do not typically cover GP visits themselves, but this step is essential to kickstart a claim.
- What to do: Book an appointment with your GP to discuss your symptoms.
- What the GP does: The GP will examine you and provide an initial assessment. If they believe you need to see a specialist, they will write you a referral letter.
- Crucial Tip: Ask for an 'Open Referral'. An open referral is a letter addressed to a type of specialist (e.g., "Dear Orthopaedic Surgeon") rather than a named individual. This gives you and your insurer the maximum flexibility to find a suitable, fee-assured specialist from their approved list. A named referral can limit your choices.
David's Experience: David visits his GP, who suspects a torn meniscus. The GP provides an open referral letter for an orthopaedic surgeon specialising in knees.
Step 2: Contact Your Insurer to Get Pre-Authorisation
This is the most important step in the claims process. Do not book any appointments or procedures before getting pre-authorisation. Failure to do so could leave you liable for the full cost of your treatment.
Pre-authorisation is your insurer's green light. It confirms that: a) Your symptoms are covered under your policy. b) The proposed diagnostic test or treatment is eligible.
How to get pre-authorisation:
- Call your insurer's claims line. The number will be on your policy documents, membership card, or their app.
- Have your information ready. This will speed up the call significantly.
| Information Needed for Pre-authorisation |
|---|
| Your policy number or membership number |
| Your full name, date of birth, and address |
| The symptoms you are experiencing |
| The type of specialist you have been referred to (e.g., cardiologist, dermatologist) |
| A copy of your GP's open referral letter (you may need to email it) |
- Explain your situation clearly. The claims handler will ask questions to understand the issue and check it against your policy's terms and exclusions.
- Receive your pre-authorisation number. If the claim is approved, you will be given a unique authorisation number. This is your proof of cover for this specific course of treatment. Keep it safe!
David's Experience: David calls his insurer. He provides his policy number and explains his knee pain. He tells them his GP has given him an open referral for an orthopaedic surgeon. The claims handler confirms this is a new, acute condition and provides him with a pre-authorisation number for an initial consultation and a potential follow-up MRI scan.
Step 3: Find a Specialist and Book Your Appointment
With your pre-authorisation number in hand, you can now find a specialist. Your insurer will guide you.
- Using the Insurer's List: Most insurers have an online portal or can provide a list of approved specialists and hospitals in your area over the phone. It is vital to choose from this list to ensure your costs are covered.
- Checking for "Fee-Assured" Status: When selecting a specialist, always confirm they are "fee-assured." This means they will not charge more than your insurer is prepared to pay, protecting you from unexpected bills (a "shortfall").
- Booking the Appointment: Contact the specialist's private secretary to book a consultation. You will need to provide:
- Your name and personal details.
- Your PMI provider's name (e.g., Bupa, Aviva).
- Your pre-authorisation number.
This tells the specialist's office how to bill for their services.
David's Experience: David's insurer gives him a list of three fee-assured orthopaedic surgeons near his home. He researches their profiles online, chooses one, and calls their secretary. He provides his pre-authorisation number and books an appointment for the following week.
Step 4: Attend Treatment and Manage the Invoicing
This is where your PMI policy springs into action.
- At the Appointment: Attend your consultation. The specialist may recommend diagnostic tests (like an MRI or X-ray) or a course of treatment (like physiotherapy or surgery).
- Further Authorisation: Crucial point: If surgery or another significant procedure is recommended, you or the specialist's secretary must go back to the insurer with the details (the procedure code, or "CCSD" code) to get a new pre-authorisation for that specific treatment. Do not assume your initial authorisation covers surgery.
- Paying for Treatment: In most cases, you won't handle any money yourself.
Direct Settlement vs. Pay and Claim
| Method | How It Works | Best For |
|---|---|---|
| Direct Settlement | This is the standard and most convenient method. The hospital and specialist send their invoices directly to your insurer. You only need to pay your policy excess (if applicable). | The vast majority of inpatient, day-patient, and specialist claims. It's hassle-free. |
| Pay and Claim | You pay the bill for your treatment upfront and then submit the receipt to your insurer for reimbursement. | Less common. Sometimes used for therapies like physiotherapy or for overseas treatment, depending on the policy. |
David's Experience: The surgeon confirms David has a torn meniscus requiring keyhole surgery (arthroscopy). The surgeon's secretary contacts the insurer with the procedure code and gets pre-authorisation for the operation. The hospital and surgeon bill the insurer directly. The total cost is £4,500. David's policy has a £250 excess, so the hospital sends him a separate invoice for this amount, which he pays. The insurer pays the remaining £4,250. (illustrative estimate)
Step 5: Post-Treatment Care and Finalising the Claim
Your care doesn't necessarily end after surgery.
- Follow-up Consultations & Physiotherapy: Your policy may include cover for post-operative care, such as a follow-up visit to your surgeon or a course of physiotherapy. Just like the initial treatment, you must get pre-authorisation for these sessions.
- Claim Finalisation: Once all bills have been received and paid, the insurer will close the claim. You will usually receive a statement summarising the costs paid on your behalf. Review this to ensure it's accurate.
David's Experience: The surgeon recommends a course of six physiotherapy sessions. David calls his insurer, provides his claim number, and gets authorisation for the physio. He completes the sessions, and the claim is finalised. Within a few months, he is back to hiking pain-free.
Common PMI Claim Issues and How to Solve Them
| Issue | Common Reason | Solution |
|---|---|---|
| Claim Rejected | The condition is chronic, pre-existing, or a specific policy exclusion (e.g., cosmetic surgery). | Review your policy documents. If you believe the decision is wrong, you have the right to appeal. Provide supporting evidence from your GP or specialist. |
| Shortfall on Fees | You used a consultant or anaesthetist who was not "fee-assured" and charged more than the insurer's guidelines. | This is why it's vital to use insurer-approved specialists. You will likely be responsible for paying the difference. |
| Treatment Not Authorised | You forgot to get pre-authorisation before undergoing a test or procedure. | Contact your insurer immediately. They may retrospectively approve it, but this is not guaranteed. You may have to pay the full cost. |
Having a trusted PMI broker like WeCovr can be invaluable here. While we help you find the best private health cover, our service can also extend to providing guidance if you encounter a complex claims issue, acting as an experienced advocate on your behalf.
Beyond Claims: Proactive Health and Wellness Benefits
Modern private health cover is about more than just reacting to illness. Top UK providers now include a wealth of benefits designed to keep you healthy.
- Digital GPs: Get a GP appointment via video call within hours, often 24/7. This can speed up the referral process significantly.
- Mental Health Support: Access to helplines, counselling sessions, and therapy apps without needing a GP referral. Recent NHS data for England (2023) shows a record 1.8 million people were in contact with mental health services, highlighting the need for fast access to support.
- Wellness Programmes: Many insurers, notably Vitality, offer rewards like cinema tickets and coffee for tracking your activity, promoting a healthier lifestyle.
- Nutrition and Diet Support: Some policies provide access to nutritionists or diet-planning tools.
At WeCovr, we enhance this further. When you arrange a PMI or Life Insurance policy through us, you get:
- Complimentary access to CalorieHero, our AI-powered calorie and nutrition tracking app to help you stay on top of your health goals.
- Exclusive discounts on other insurance products, such as travel or home insurance, helping you save money across the board.
Taking a proactive approach to your health—through regular exercise, a balanced diet, and sufficient sleep—is the best way to reduce your chances of needing to claim in the first place.
How Major UK PMI Providers Compare on Claims
While the core process is similar, providers differentiate themselves through technology and service.
| Provider | Key Claims Features & Technology | Customer Service Reputation |
|---|---|---|
| Bupa | Strong digital focus with the Bupa Touch app for claims tracking. Extensive network of hospitals and consultants. Well-regarded for cancer care pathways. | Generally very high, with dedicated support teams for complex claims. |
| AXA Health | "Fast Track" options for certain conditions. Doctor@Hand digital GP service. Well-structured online member portal for managing claims. | Strong reputation for efficient claims processing and clear communication. |
| Aviva | "Expert Select" guided consultant choice to ensure no shortfalls. Strong digital tools and a well-rated app. Good mental health support pathways. | High customer satisfaction ratings, often praised for its straightforward digital claims journey. |
| Vitality | Unique model rewarding healthy living. Claims process is integrated with their wellness programme. Guided care pathways are common. | Generally positive, though the model can be complex for new users. The rewards are a major incentive. |
This table provides a general overview. Features and service levels can vary by policy.
Choosing the right provider depends on your priorities—be it digital convenience, a guided healthcare journey, or wellness rewards. WeCovr's experts can compare the best PMI providers in the market to find a policy whose claims philosophy and benefits align perfectly with your needs.
What is the most common reason for a PMI claim being denied in the UK?
Do I have to pay anything when I make a PMI claim?
Can I go to any private hospital I want with my PMI?
Ready to secure your peace of mind with private medical insurance? The claims process is straightforward when you have the right cover and the right support.
Sources
- Office for National Statistics (ONS): Mortality, earnings, and household statistics.
- Financial Conduct Authority (FCA): Insurance and consumer protection guidance.
- Association of British Insurers (ABI): Life insurance and protection market publications.
- HMRC: Tax treatment guidance for relevant protection and benefits products.
