How to Make a Private Health Insurance Claim

Most claims on UK private medical insurance follow the same simple sequence. Understanding it before you need to claim makes the whole process noticeably less stressful.

The standard six-step claim process

1. See your NHS GP

For most claims, the first step is your NHS GP. They examine you, decide whether specialist input is needed, and write a referral letter.

Some insurers now offer a virtual GP service as part of the policy. Their virtual GP referral usually counts the same way for claim purposes; handy when your NHS GP has a long wait.

2. Call your insurer’s claims line

Before you book any private appointment, call the insurer (or use their app) to pre-authorise the claim. They’ll check:

• Is the condition covered under your policy?
• Are any benefit limits relevant?
• Is your chosen consultant on their recognised list?

You’ll get an authorisation number, which you give to the consultant or hospital when you book.

3. Choose a consultant

The insurer either gives you a list of suitable consultants or asks you to nominate one. Two key things to check:

• The consultant must be recognised by your insurer (most are; new private consultants may not yet be).
• The consultant should be fee-assured, which means their fees are agreed in advance with the insurer. If they aren’t, you may have to pay any shortfall yourself.

4. Attend the initial consultation

The consultant assesses you. They may recommend further investigation (scans, blood tests) or move straight to treatment recommendations.

5. Authorise diagnostics or treatment

For each next step; a scan, a procedure, surgery; call the insurer again to authorise. The insurer confirms cover and a recognised hospital. You don’t usually pay anything except your excess.

6. The insurer pays the hospital and consultant

You don’t see the bill in most cases. The insurer pays directly. You receive a claims summary so you know what was paid on your behalf.

Things people get caught out by

Going outside the recognised hospital list

Treatment at hospitals not on your policy’s list is usually not covered. Always confirm the hospital before you book.

Using a consultant who isn’t fee-assured

If the consultant’s fees are higher than the insurer’s agreed rate, you pay the difference. Always ask the consultant whether they’re fee-assured for your insurer.

Outpatient sub-limits

Some policies have a low outpatient limit (e.g. £1,500). Diagnostics on top of consultations can chew through this fast. Check the limit when you authorise.

Pre-existing condition flags

If the insurer reviews your medical records and finds a related symptom from before the policy started, they may classify the new claim as pre-existing and decline. The fix is usually to provide additional evidence or move to a different specialist.

Policy excess

You pay the excess once per claim or once per policy year; depending on the policy. Confirm before treatment so there’s no surprise.

Tips for a smooth claim

• Call to authorise before booking, not after.
• Keep your policy number, your claims helpline, and your authorisation reference together.
• Take notes during phone calls; names, times, what was authorised.
• If something is borderline (chronic vs acute, pre-existing vs new), ask for the decision in writing.

Frequently asked questions

Do I have to use my NHS GP? Usually yes for the initial referral. Some insurers’ virtual GP service can substitute. Going straight to a private specialist without a referral is rarely covered.

How long does authorisation take? For routine claims, minutes; most insurers can authorise on the call. Complex claims with pre-existing concerns can take days while medical records are checked.

Can I choose any private hospital? Only those on your policy’s recognised list. Premium hospital lists give wider choice; guided lists are more restrictive.

Will claiming affect my premium? Most policies have a no-claims discount. Claiming usually drops you down a step or two at the next renewal. We can model the long-term cost vs benefit before you decide whether to claim.

Need help with a tricky claim? Call 0800 131 0400 or email info@insuredhealth.co.uk.