The Claims Process How to Make a PMI Claim
Navigating the UK’s private medical insurance landscape can feel complex, but understanding the claims process is the key to unlocking fast, effective care. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies of various kinds, we believe in empowering you with clear, actionable knowledge.
Step-by-step claiming procedure, necessary GP referrals, documentation, and strategies to streamline approval with the leading UK insurers
Making a claim on your private health cover shouldn't be a source of stress. When you're unwell, the last thing you need is confusing paperwork and unclear procedures. This guide demystifies the entire process, from the initial GP visit to the final payment, ensuring you can access your private medical benefits smoothly and efficiently.
We will walk you through each stage, highlight the crucial role of a GP referral, list the essential documents you'll need, and offer insider strategies for dealing with the UK's top insurers.
Understanding Your PMI Policy: The Foundation of a Smooth Claim
Before you can make a claim, it's vital to understand what your policy is designed for. Think of your policy document as the instruction manual for your health cover. Taking 30 minutes to read it when you first take out the policy can save you hours of confusion later.
Critical Point: Acute vs. Chronic Conditions
This is the most important distinction 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 sprains, cataracts, hernias, or infections that require a short course of treatment. PMI is designed to cover acute conditions that arise after your policy begins.
- Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics: it needs ongoing monitoring, has no known cure, is likely to recur, or requires long-term management. Examples include diabetes, asthma, high blood pressure, and arthritis. Standard UK PMI policies do not cover the long-term management of chronic conditions.
A policy might cover an acute flare-up of a chronic condition, but it will not cover the day-to-day management.
The Impact of Underwriting on Your Claims
How your insurer assessed your medical history when you joined determines what is covered.
- Moratorium Underwriting: This is the most common type. The insurer does not ask for your full medical history upfront. Instead, they apply a "waiting period" (usually two years) for any condition you had symptoms of or sought advice for in the five years before your policy started. If you remain symptom-free and treatment-free for that condition for two continuous years after your policy starts, it may become eligible for cover.
- Full Medical Underwriting (FMU): With FMU, you complete a detailed health questionnaire when you apply. The insurer then analyses your medical history and explicitly lists any conditions that will be excluded from your cover from the outset. This provides more certainty but is a more intensive process.
Knowing your underwriting type helps you understand why an insurer might question a claim related to a condition you've had in the past.
The GP Referral: Your Gateway to Private Treatment
For almost all specialist consultations and diagnostic tests, you will need a referral from a General Practitioner (GP). This is a non-negotiable first step for the vast majority of PMI claims in the UK.
The referral serves a crucial purpose: it confirms to the insurer that your medical concern requires specialist investigation. It is the clinical justification for your claim.
How to Get a GP Referral
- Book an Appointment: See your regular NHS GP or, if your policy includes it, use a private or virtual GP service. Many modern private health cover policies offer 24/7 digital GP access, which can significantly speed up this step.
- Discuss Your Symptoms: Explain your health issue clearly to the GP. They will conduct an initial assessment.
- Receive the Referral: If the GP agrees that you need to see a specialist (like a cardiologist, dermatologist, or orthopaedic surgeon) or require a diagnostic test (like an MRI or CT scan), they will provide you with a referral.
This can be an 'open referral', where they recommend a type of specialist but not a specific person, or a 'named referral' to a particular consultant.
What should the referral letter include?
- Your full name and date of birth.
- A summary of your symptoms and medical history.
- The GP's provisional diagnosis or the reason for the referral.
- The type of specialist or investigation required.
- The GP's name, signature, and practice details.
Making the Claim: A Step-by-Step Guide
Once you have your GP referral, you are ready to formally start the claims process. It's essential to contact your insurer before you book any appointments or undergo any treatment.
Here is the standard procedure:
Step 1: Contact Your Insurer to Pre-Authorise Your Claim
This is the most critical step. Pre-authorisation is the insurer's green light, confirming that the proposed treatment is covered under your policy. Do not assume something is covered and try to claim for it later.
You can usually contact your insurer in one of three ways:
- By Phone: Speak to their claims department directly.
- Online Portal: Use the secure member area on their website (e.g., MyAviva, Bupa Touch).
- Mobile App: Many insurers now have dedicated apps for managing your policy and claims.
Step 2: Provide the Necessary Information
Have the following details ready when you call:
- Your policy number or membership number.
- The name of the patient (you or a family member on the policy).
- Details from your GP referral letter (the symptom, the recommended specialty).
- The name of the specialist you wish to see and the hospital, if you know it.
The claims handler will check your cover and confirm if the condition and proposed specialist/hospital are eligible.
Step 3: Receive Your Authorisation Code
If the claim is approved, the insurer will give you a pre-authorisation number or code. This code is vital. You will need to give it to the hospital and the specialist's secretary when you book your appointment. It's the key that links your treatment directly to your insurance policy for billing.
Step 4: Book Your Appointment and Treatment
With your authorisation code in hand, you can now contact the specialist's secretary or the private hospital's booking team.
- Give them your name, details, and the pre-authorisation code.
- They will arrange a convenient time for your consultation or procedure.
Important: Ensure the specialist and hospital are on your insurer's approved list or network. Using a non-recognised provider could leave you liable for the entire bill.
Step 5: Attend Your Treatment
Focus on your health. The financial side should now be largely handled between the provider and your insurer.
Step 6: Invoicing and Payment
In nearly all cases, the hospital and specialist will send their invoices directly to your private medical insurance provider, quoting your pre-authorisation code.
- Your Excess: If your policy has an excess (e.g., £100 or £250), you will need to pay this amount directly to the hospital. The insurer will pay the rest. The hospital will typically contact you to settle this after your treatment.
- Shortfalls: If you have used a provider who charges more than your insurer's approved rates, or if you have exceeded a benefit limit on your policy (e.g., for outpatient therapies), you will be responsible for paying the difference. This is known as a shortfall.
Essential Documentation for a Successful Claim
Keeping your paperwork organised will make the process seamless. While insurers are increasingly digital, it's wise to have these items accessible.
| Document | Why It's Important |
|---|---|
| GP Referral Letter | The clinical justification for your claim. Insurers often ask to see a copy. |
| Policy Number | Your unique identifier. Always have it ready when contacting your insurer. |
| Pre-Authorisation Code | The proof that your insurer has approved the treatment. Essential for booking. |
| Specialist & Hospital Details | Ensures you are using providers recognised by your insurer. |
| Invoices/Receipts | Only needed if you pay for treatment yourself and claim it back (uncommon). |
Streamlining Your Claim with Leading UK Insurers
While the core process is similar, each of the leading UK PMI providers has unique features and digital tools designed to make claiming easier.
Bupa
Bupa has invested heavily in digital tools to speed up the claims journey.
- Bupa Touch App: This app is a central hub for managing your policy. You can start a new claim, check your cover details, and find Bupa-recognised specialists and hospitals.
- Direct Access: For some conditions like muscle, bone, and joint problems, Bupa may offer 'Direct Access', allowing you to bypass the GP referral and speak directly to a specialist triage team.
- Open Referrals: Bupa's 'Open Referral' network can be a fast and cost-effective route. Your GP gives you an open referral, and Bupa helps you find a pre-approved specialist, often securing an appointment within days.
AXA Health
AXA Health focuses on guided support and digital convenience.
- Fast Track Appointments: For certain muscle, bone, and joint conditions, their 'Fast Track Appointments' service can get you booked with a physiotherapist often without needing to see a GP first.
- Online Claim Submission: AXA's online member portal allows you to submit claim information quickly without needing to call.
- Guided Option: If you choose a policy with a guided consultant list, AXA will provide you with a choice of 3-5 pre-approved specialists, simplifying the decision-making and ensuring there are no fee shortfalls.
Aviva
Aviva combines digital tools with flexible options to control costs.
- MyAviva Portal: This comprehensive online portal is where you can check your policy documents, start a claim, and track its progress.
- Specialist finders: Aviva's online tools help you locate consultants and hospitals from their approved network, ensuring your treatment is covered.
- Expert Select (Guided Option): Similar to AXA's guided option, this directs you to a curated list of specialists, which can help streamline the process and often comes with a premium discount.
Vitality
Vitality's unique approach links health insurance with a wellness programme.
- Vitality GP App: This is a key feature. It provides fast access to a video consultation with a private GP, who can provide referrals and prescriptions, massively accelerating the first step of a claim.
- Consultant Select: Vitality uses a panel of approved consultants. When you make a claim, they will direct you to a specialist on this panel, guaranteeing their fees are covered in full.
- Care Hub: Vitality's online platform for managing your care pathway, from booking tests to authorising surgery.
| Provider | Key Claim Feature | How it Streamlines Your Claim |
|---|---|---|
| Bupa | Bupa Touch App & Direct Access | Manage claims digitally and bypass GP referral for some conditions. |
| AXA Health | Fast Track Appointments | Quick access to physiotherapy without a GP visit. |
| Aviva | MyAviva Portal & Guided Options | Easy online claim submission and simplified specialist choice. |
| Vitality | Vitality GP App & Consultant Select | Ultra-fast GP referrals and guaranteed cover for consultant fees. |
Common Pitfalls and How to Avoid Them
Most claim issues arise from a few common misunderstandings. Here’s how to avoid them.
- Forgetting to Pre-Authorise: This is the number one mistake. Always get approval before treatment. If you have a procedure and ask the insurer to pay afterwards, they are within their rights to refuse the claim.
- Using a Non-Recognised Provider: Every insurer has a network or list of approved hospitals and specialists. Going "off-piste" and choosing someone not on the list will likely result in your claim being rejected. Always check first.
- Claiming for an Exclusion: Remember, PMI doesn't cover everything. Common exclusions are pre-existing conditions (depending on underwriting), chronic conditions, cosmetic surgery, and routine pregnancy.
- Exceeding Benefit Limits: Your policy may have annual limits on certain treatments, such as outpatient physiotherapy or mental health support. A standard policy might offer, for example, up to £1,000 for outpatient diagnostics. Be aware of your limits to avoid a shortfall.
- Misunderstanding Your Excess: The excess is the part of the claim you pay. If your excess is £250 and your treatment costs £2,000, you pay the hospital £250, and your insurer pays £1,750. This is usually payable once per policy year, per person.
The Role of a PMI Broker in the Claims Process
While you deal directly with the insurer during a claim, an expert broker like WeCovr plays a vital role in two key areas:
- Before You Claim: A broker's primary job is to match you with the right policy in the first place. By understanding your needs and budget, they compare the market to find a policy with the benefits, hospital list, and claims philosophy that suits you best. This proactive step prevents issues down the line.
- During a Claim (Advocacy): If you run into a complex or disputed claim, a good broker can act as your advocate. They understand the policy wording and can speak to the insurer on your behalf to help resolve the issue fairly. This support can be invaluable when you are feeling unwell and vulnerable.
Choosing the best PMI provider is easier with impartial advice. WeCovr can help you compare policies from across the market at no extra cost to you.
Beyond the Claim: Leveraging Your PMI for Overall Wellness
Modern private health cover is about more than just claims; it's a tool for proactive health management. Make sure you use the value-added benefits that often come with your policy:
- Digital GP Services: 24/7 access to a GP via phone or video call is now a standard feature. Use it for quick advice, prescriptions, and referrals.
- Mental Health Support: Most policies include access to helplines or a set number of therapy sessions (e.g., CBT) without affecting your main policy benefits.
- Wellness Programmes: Many insurers offer discounts on gym memberships, fitness trackers, and health screenings to encourage a healthy lifestyle.
- WeCovr Client Benefits: As a WeCovr client, you also get complimentary access to our AI-powered calorie and nutrition tracking app, CalorieHero, to support your health goals. Furthermore, clients who purchase PMI or Life Insurance often receive discounts on other types of cover, such as home or travel insurance.
Staying active, eating a balanced diet, and getting enough sleep are fundamental pillars of good health that can reduce your need to claim in the first place. Your PMI policy is there as a safety net for when things go wrong, but its wellness benefits can help you stay healthy day-to-day.
Do I always need a GP referral to make a PMI claim?
What happens if my PMI claim is rejected?
Will making a claim increase my private medical insurance premiums?
What's the difference between an excess and a shortfall?
Ready to find a private medical insurance policy that puts you in control? The team of experts at WeCovr is here to help. We provide independent, no-obligation advice to help you compare the UK's leading insurers and find the perfect cover for your needs and budget.
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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.
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