How to Make a Claim on Private Health Insurance

Private health insurance is designed to offer you protection in the event you unexpectedly become sick or injured and require medical treatment. If this does happen to either you or someone else named on your insurance policy, you may be able to claim back some or all of these costs through your health insurance provider, providing your claim is approved.

It's important to ensure you are familiar with the claims process not only because it can save time and effort on your part, but also because the last thing you need when seeking medical treatment is the extra stress! So we've put together this guide to ensure you know exactly what to expect from the claims process should you need to make a claim in the future.

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Before you claim

Before you go ahead and fill in your claims application, it's worth taking the time to read through your policy documents to see what conditions are not covered by your plan. This will help you avoid making a claim for something that isn't actually covered! Remember, private health insurance is typically designed to cover the costs associated with sudden, acute (short-term) medical conditions rather than pre-existing or chronic (long-term) conditions.

Reading the policy documents will also help you understand the claims process and the steps required. If you still have questions about your claim after you've read your policy documents we would recommend contacting your insurer. Their agents will be more than happy to assist you to ensure you get the information and support you need.

How to claim

The exact claims process may differ slightly from insurer to insurer, but broadly speaking the claims process usually consists of the following steps:

1. See your GP

If you're unwell or suffering from an injury, you should see your GP for advice. They may decide to refer you to a specialist, and if this is the case they will write you a referral letter. It's always best to ask for an open referral letter which means it does not name a hospital or doctor to carry out your treatment. This means you are less restricted when it comes to arranging the location of your treatment.

2. Contact your insurer

If your GP has referred you for private treatment, you should contact your insurer right away to let them know. They'll likely need to ask you a few questions so it's a good idea to have your policy documents and any other supporting information to hand. They will ask your name, policy number and some questions about your symptoms as well. You will also need to send a copy of your GP's referral letter. Your insurer will then assess your claim and determine whether this is covered by your plan. If it is, they may give you a pre-approved code to provide your specialist ahead of your appointment.

3. See your specialist

If your insurer accepts your claim you can then see your specialist. Depending on the insurer and plan you have opted for you may need to arrange your treatment directly through your provider. At your first appointment you'll need to give your specialist details such as your claims number and any other documents you have received from your insurer. It's good practice to keep your insurer updated throughout this process, and they will be on hand to give advice and answer any questions you may have.

4. Settling your bill

Your insurer will typically settle any bills directly with the hospital or specialist who has treated you though in some cases they may contact you for further information. If you chose to pay an excess when you took out your policy you will need to pay this (unless you have already contributed the total agreed amount during that policy year).

In any case, your insurer will always let you know whether there is an excess to pay. Once your provider has received the invoice for your treatment they will then cover this (minus any excess you are liable to pay) and will let you know how and when to pay your excess. You may need to pay any excesses upfront before you see your specialist, with your insurer settling the rest of the bill later on.

You can find out more about health insurance excesses here.

What can you make a claim for?

What you are and are not covered for will depend on your insurance provider and the specific policy you have taken out (plus any additional extras you might have paid for!). As we have stated, private health insurance is designed to cover the costs associated with sudden, acute conditions for which you have sought private medical assistance or treatment.

Here are some of the common costs that health insurance may cover as standard. Again, we must remind you that this list is to be used as a guide and we'd recommend you refer to your policy documents to determine what you are and are not covered for, as coverage varies from one company to the next and even one policy to the next from the same company.

  • Diagnostic tests
  • Consultations with a specialist
  • Surgery and other treatment
  • Overnight stays (or longer periods of time) in a private hospital
  • Outpatient consultations and treatment

Insurers may also offer you a range of optional extras that can be purchased at an additional premium and bolted on to your main policy. This may include cancer care, mental health and other more specialist types of cover. If you do opt for these, you can also make a claim for any treatment or consultations you require as long as it is approved and covered by your insurer.

Why might a claim be refused?

There are some common reasons why your insurance provider may reject your claim. In most cases it is simply because your policy does not cover what you thought or, whether intentionally or not, some information was left out of your claims application.

Here are the main reasons why your private health insurance claim may have been refused:

It is not covered by your policy

This may seem like common sense but any private health insurance plan will details very explicitly what it does and doesn't cover. More often than not customers will make a claim for something even though it is clearly listed as an exclusion in their documents and then get frustrated or disappointed when their claim isn't approved!

For example, whilst an inpatient stay following emergency treatment may be covered, the emergency care itself typically isn't. Or diagnostic tests might not be covered. Or you might claim for a condition that simply isn't covered by some providers, like acne.

This is why it is so important to read your policy documents carefully before signing an agreement.

Your condition may be pre-existing

Pre-existing conditions are those which you have been diagnosed (or awaiting diagnosis) and/or have received treated for (or awaiting treatment) prior to your policy start date. Whether or not these are covered by you insurer depends on a few things, such as the type of underwriting.

If you choose moratorium underwriting you'll typically find all pre-existing conditions you have experienced within a defined, set period of time prior to taking out cover (usually five years) will be excluded from your cover. The good news is that many insurers will eventually cover these if, after a set period of time, you have not received any treatment, diagnosis, medication or advice for your pre-existing condition(s).

If you choose full medical underwriting you will need to complete a full health questionnaire and let your insurer know of any pre-existing medical conditions you have. Your insurer may also request information from your GP, too. Your insurer will then review this information and detail what pre-existing conditions they will and will not cover.

Make sure to pay careful attention to the type of the underwriting used in your plan and if you know or think you have one or more pre-existing conditions, it is vital that you have absolute clarity about what is and isn't covered to save you making a claim that will ultimately be denied.

The details you have given are incorrect

Sometimes, whether intentional or not, information that should have been disclosed is not. With respect to making a claim, it is incredibly important that the information you give to you insurer is truthful and accurate to the best of your knowledge. If your insurer later finds out you did not disclose important information, or that some of the details you did give were incorrect, they can refuse your claim.

So, when you are submitting a claim make sure you sit down and proof read your application to ensure there are no mistakes or omissions.

Final thoughts

Taking some time to familiarize yourself with your insurer's claims process can save you a lot of time and stress in the eventually you actually need to make a claim on your private health insurance.

If you do make a claim, it's always worth having a quick read of your policy documents to ensure that it is covered by your insurer and you are aware of some of the reasons why your claim may be rejected—in some cases it may be a simple mistake that can quickly be rectified, but in other cases you may just have to come to terms with the fact it simply won't be approved.

If you're ahead of the curve and remember the information in this guide, hopefully any future claim process you embark on will be smooth sailing!