1 Check your level of cover

Not all private medical insurance policies are as comprehensive as each other, and they're often graded by price.

The most important thing is to check the contract terms before making a commitment to ensure you're getting the right coverage for your needs.

If, at a later stage, you have a problem with the level of cover that your policy offers, revisit your contract and check the details.

You'll only be entitled to the cover stated in your contract.

Checklist

  • Ensure you inform your provider of all pre-existing medical conditions.
  • Always read the contract before making a commitment to ensure the cover meets your needs.
  • If you're unhappy with your cover or with a service, complain to your provider in the first instance.

Common exclusions

A common issue for policy holders is pre-existing conditions. When you take out a policy, you will be required to detail all pre-existing medical conditions and your provider may not cover you for illnesses relating to these.

Another common restriction is around treatment choices. Policies may only cover treatment from selected specialists, or surgical procedures and treatment considered to be 'proven', as opposed to 'experimental'.

If you disagree with your policy provider's decision and feel their exclusions were not made clear to you, complain to your insurer.

Should they be unable to solve your problem, the Financial Ombudsman Service (FOS) can review your case, and act if a service or administrative error has occurred.

If the insurance provider has failed to provide all that has been laid out in your contract, or if you feel the contract exclusions were not made clear to you, then your provider could be held in breach of contract and you may be able to challenge them.

2 Speak to the practice manager

If you're unhappy with a private medical provider’s service, the first step is to speak to the medical professional in question, or the practice manager. 

If necessary, go through their official complaints procedure.

Make sure you've collected as much evidence as possible, such as photographs and any other documentation, to support your complaint.

If you're unhappy with the way a medical professional has behaved, the practice should investigate the individual in questio.

Top tips

  • The first step is always to speak to your practice manager if you have a problem, following their complaints procedure if necessary.
  • If you are concerned about the standards or behaviour of a medical professional, you can report them to the General Medical Council.
  • There are ombudsmen who can help as a last resort.  

3 Independent Sector Complaints Adjudication

If you're unhappy with the response to your complaint, you may be able to contact the Independent Sector Complaints Adjudication (ISCAS).

ISCAS represents some independent healthcare providers. If your provider is represented, they must adhere to ISCAS’s Complaints Code.

They also offer an independent adjudication service that can help with negotiations.

4 Complain to the GMC

If a medical professional seeks an improper relationship, makes unsolicited visits, breaches your confidentiality, appears to canvas or simply displays bad manners, alarms bells should ring.

If you suspect serious or repeated mistakes have occurred during you treatment, that you have been poorly examined, or the practitioner has failed to respond to your needs, you should also seek help.

Notify your practice manager immediately, and follow their complaints procedure if necessary.

If your issue is not resolved, you may wish to take your complaint to The General Medical Council (GMC)

The GMC regulates registered doctors. They may not look into all complaints, but in cases of serious misconduct the GMC may investigate your issue.

5 Complain to your provider

If you have a problem with your private medical insurance company, for example, regarding the details of your policy, or the manner in which your policy was agreed, the first step is to make a complaint to the insurance company.

If you don't have the level of coverage that you expected or feel that the contract was misleading, you have a right under the Unfair Terms in Consumer Contracts Regulations to challenge any unfair terms. 

Take a look at our guide to challenging unfair contract terms.

6 Contact the FOS

The Parliamentary and Health Service Ombudsman cannot look into complaints about privately funded healthcare services.

However, you can refer issues about private healthcare insurers to the Financial Ombudsman Service (FOS)

The FOS will look at all claims, but can only take action on claims in which administrative or service errors have occurred.

7 Take the matter to court

If you suffer pain, injury, inconvenience or extra costs as a result of poor private medical treatment, you can file a personal injury claim. 

This could also include claiming for loss of earnings, if necessary.

If you wish to use the small claims court to do this, it's worth noting that you can only claim £1000 for personal injury. 

If you wish to claim more than this, you'll need to use the 'fast track' court procedure. Personal injury claims can be complicated, and will require expert legal help. 

In Scotland, small claims courts cannot be used to claim personal injury compensation at all.

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