How to claim on your private health insurance

How do I make a health insurance claim?

The exact process for making a health insurance claim varies by provider, but as a general rule, you'll need to follow these steps:

1. Book an appointment with your GP to assess your condition If they recommend that you see a specialist, ask the GP for a referral. Some health insurers require you to ask for an 'open referral', which specifies the type of treatment you need, but allows you to see any specialist in any location. 
2. Contact your health insurer You'll need to provide your membership information, and details of your condition and the GP's recommendations. Your insurer will confirm whether the recommended treatment is covered under your health insurance policy. 
3. Make an appointment with a specialist If your treatment is covered, your insurer will provide details of a suitable specialist (or specialists), so you can make an appointment. In most cases, your insurer will settle bills directly with the specialist. 

If the initial specialist recommends further tests or treatment, you'll need to contact your insurer again to keep them updated and make sure that the additional treatment is covered.

Please note that the information in this article is for information purposes only and doesn't constitute advice. Please refer to the particular T&Cs of an insurer before committing to any financial products.

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How do I claim in an emergency?

Private health insurance typically doesn't cover emergency medical treatment. If you experience a medical emergency, you should call 999 or go to your nearest A&E. 

However, you may be able to use your private health cover to get treatment more quickly if required once the initial emergency is dealt with, or to get you moved to a private room if you need to stay in hospital.

In these cases, you should contact your private health insurer as soon as possible, once you're feeling well enough, to advise them of the situation and check what your options are.  

Do you always need to see a GP to make a health insurance claim?

In most cases, you'll need to see a GP before you can initiate a claim. However, some insurers make exceptions to this rule for certain conditions. These may include:

• Muscle or joint conditions (which may require physiotherapy or osteopathy, for example)
• Mental health conditions (if your policy covers these)
• Cancer symptoms.

If your insurer offers this kind of 'direct access', contact it to initiate a claim. 

What's the difference between an open referral vs a named referral?

There are two types of referral that your GP can provide:

1. A named referral is where your GP refers you to see a specific consultant at a specific location. This kind of referral is more common when you're having NHS treatment. Remember that if you live in England, you have the right to choose where you receive non-urgent treatment, as we explain in our guide to patient choice. 
2. An open referral is where your GP outlines the treatment they recommend and the type of specialist you need to see, but doesn't specify a consultant or location. Many private health insurers recommend that you ask for an open referral, and some require it. This helps to ensure that you are seen by a consultant who is covered under your policy. 

Find out more: best private health insurance.

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How to find a healthcare provider

Each private health insurer will have a list of healthcare providers they work with as standard. These lists are usually fairly comprehensive, but they may not include the exact specialists or locations that you'd prefer. 

Some providers also offer more restricted lists (which will mean your policy costs less, but you have less choice) or more extensive lists (which will cost more, but give you wider choice). Some insurers have searchable online directories that let you check what's available in your area.

The provider list that you chose when you took out your policy will influence the hospitals and specialists that you can use for your private treatment. Once you've received an open referral from your GP, contact your insurer, as it will be able to provide you with information and guidance on the healthcare providers included under your policy. 

If you want to be treated by a healthcare provider that isn't included under your policy – perhaps because they've been recommended by a friend who has undergone similar treatment – discuss this with your insurer. If the specialist charges more than those who are covered under your scheme, you may still be able to see them if you're willing to pay a top-up fee. 

• Find out more: how to choose the right hospital and consultant.

How do I know if my claim will be covered?

If you're not sure whether your private health insurance will cover your claim, check the policy documents. These papers will outline what is and isn't covered under your scheme. 

If in doubt, contact your insurer to ask. It will be able to tell you whether or not specific conditions and treatments are covered, and any limits on your cover. 

In any case, you'll need to contact your insurer before you progress any private health insurance claim after seeing your GP. 

• Find out more: health insurance for over-60s.

Do I need to pay my healthcare provider and claim back?

In most cases, no. You shouldn't need to pay anything to your healthcare provider. 

Private health insurers typically have arrangements with the healthcare providers that are on their lists. This means that the healthcare provider you use will be able to invoice your insurer directly for your treatment, without involving you. 

It's important that you speak to your insurer before booking treatment, and agree with it which provider you'll use, so it can make sure everything is set up as needed. Some insurers may provide you with an authorisation code to give to the healthcare provider when you start treatment. 

If you do receive an invoice from your healthcare provider, check whether you should forward it the bill or pay the bill yourself and claim back. 

If there's an excess to pay on your policy, your insurer will usually contact you to settle this. 

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Are there any downsides to claiming on my health insurance?

Private health insurance can offer greater choice of treatments and specialists and, crucially, get you seen faster than might be possible on the NHS. So, if you have private health cover, it may seem like a no-brainer to claim on it if you develop a condition that needs medical attention. 

Be aware, though, that even if your treatment is completely or largely covered, making a claim may come with some financial strings attached, including:

• An excess This is a fixed amount you'll need to pay towards any claim you make. Excesses can vary between £0 to more than £1,000; typically, the lower the excess you choose, the higher your premium will be. Some insurers may charge one excess per year, no matter how many claims you make. Others may charge per claim. 
• Co-payments if you exceed your cover limits All but the most high-end policies place limits on how much treatment it will cover. These limits may be per-condition, per-year, or over the lifetime of your policy. If your treatment exceeds the limits in your policy, you'll be responsible for paying the extra yourself. 
• Increased premiums when you renew Claims history is one of the factors that insurers take into account when calculating premiums. If you claim, they may regard you as more likely to make further claims and this may push your premiums up the following year. You are also likely to lose any no-claims discount that you've built up by not claiming on your policy in previous years. 

Find out more: what does private health insurance cost and is it worth it?

What to do if a claim goes wrong

If you're unhappy with the way a private health insurance claim is handled or if you feel that a claim has been wrongly rejected (in part or in full), contact your insurer as soon as possible to express your concerns. 

If you're not satisfied with the insurer's initial response, escalate your concerns by following its complaints process, which should be clearly outlined on its website. 

If you're unhappy with its final response or it doesn't respond within eight weeks, you can contact the Financial Ombudsman Service (FOS). This is an independent service that investigates complaints from individuals about financial companies. It's free for consumers to use. If the FOS finds in your favour, it can require the insurer to put the situation right and/or pay you financial compensation. 

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