Making a claim on private medical insurance is not quite like other insurance: there are steps to follow before treatment, and getting them right matters. This guide explains how to claim on private medical insurance step by step, including the all-important pre-authorisation, what you need, and what to do if a claim is queried.
Start with your GP
Most private medical insurance claims begin with a visit to your GP. If you have a health concern, you see your GP, who assesses you and, if appropriate, refers you to a specialist. This referral is usually required before your insurer will cover private specialist treatment, so it is an important first step. Some insurers now offer remote GP services as part of the policy, but a referral of some kind is generally the starting point.
Contact your insurer before treatment
This is the step people most often get wrong: contact your insurer before you book or have treatment, not after. Most policies require pre-authorisation, where the insurer confirms that the proposed treatment is covered before it goes ahead. Booking treatment first and claiming afterwards risks the claim being declined or reduced. Always call your insurer once you have a referral, and let them authorise the treatment before it takes place.
Getting pre-authorisation
When you contact your insurer, they will ask for details such as your policy number, your referral, the specialist or hospital, and the diagnosis or proposed treatment. They check this against your cover and, if it is covered, give you authorisation, often a reference number. This confirms the treatment will be paid for, up to your policy limits and subject to your excess. Keep the authorisation details safe, as you may need them.
Having your treatment
Once authorised, you have your treatment at a hospital or with a consultant on your insurer's approved list. Using an approved provider matters, because treatment outside the list may not be covered. The whole point of the process so far is to ensure that, by the time you are treated, the insurer has agreed to cover it, so you can focus on your health rather than worrying about whether the bill will be paid.
How the bills are paid
In most cases, the hospital and consultants bill your insurer directly for authorised treatment, so you do not have to pay large sums upfront and reclaim them. You will usually need to pay your excess, the amount you agreed to contribute, and any costs above your policy limits. For some outpatient costs you might pay first and claim back. Checking how your insurer handles payment avoids surprises about what you need to pay and when.
Outpatient and ongoing claims
For outpatient treatment, such as consultations, tests and scans, the process is similar, though some insurers handle smaller outpatient claims by having you pay and reclaim. For ongoing treatment, the insurer may authorise a course of treatment or ask you to seek further authorisation as it continues. Staying in contact with your insurer through a longer course of treatment keeps everything authorised and avoids parts of it falling outside what was agreed.
Keep records
Throughout any claim, keep good records: your referral, authorisation reference, correspondence, invoices and receipts. If a question arises about what was agreed or paid, these make it far easier to resolve. Good record-keeping is especially useful for longer or more complex treatment, and it means that if you ever need to query a decision or escalate a complaint, you have the evidence to hand rather than trying to reconstruct events later.
If a claim is queried or declined
If your insurer queries or declines a claim, find out exactly why. It may be a question of cover, a missing referral or authorisation, or a pre-existing condition. If you believe the decision is wrong, you can complain to the insurer, and if you remain unhappy after their final response, you can take the complaint to the Financial Ombudsman Service, which resolves disputes for free. Understanding the reason is the first step to challenging it effectively.
Emergencies do not go through this process
It is worth stressing that the claims process described here is for planned, private treatment. In a medical emergency you do not seek pre-authorisation; you go to an NHS A&E or call an ambulance, and the NHS treats you. Private medical insurance is not for emergencies, so never delay urgent care to arrange a private claim. The pre-authorisation steps apply to planned treatment of acute conditions, which is what PMI is designed to cover.
Watch for shortfalls in fees
One thing to check is whether a consultant's fees are fully covered. Some consultants charge more than an insurer's standard rates, which can leave you with a shortfall to pay. Many insurers have lists of fee-assured consultants whose fees are fully covered, so using one avoids an unexpected bill. When arranging treatment, it is worth asking your insurer about this, so you are not surprised by a gap between what the consultant charges and what the policy pays.
Keeping a course of treatment authorised
For treatment that continues over time, authorisation may cover a set number of sessions or a period, after which you need to seek further approval. Keeping in touch with your insurer through a longer course of treatment ensures each stage remains authorised and covered. Letting authorisation lapse, or continuing beyond what was agreed without checking, risks part of the treatment falling outside cover, so it pays to stay in contact as treatment progresses.
Tips for a smooth claim
A few habits make claims go smoothly: always get a referral and pre-authorisation before treatment, use approved hospitals and fee-assured consultants, keep your policy details and authorisation references to hand, and ask questions if anything is unclear. Being organised and contacting your insurer early, rather than after the event, is the single biggest factor in a trouble-free claim, and it lets you focus on your treatment rather than on paperwork.
The golden rule, worth repeating, is to contact your insurer before treatment, not after. Get that one thing right and the rest of the process usually follows smoothly, leaving you free to concentrate on getting better rather than on whether the bill will be paid.
A little organisation at the outset is repaid many times over in a claim that proceeds without a hitch.
In short
To claim on private medical insurance: see your GP for a referral, then contact your insurer for pre-authorisation before having any treatment, as this is the step people most often miss. Have your treatment with an approved hospital or consultant, pay your excess, and let bills go to the insurer where possible. Keep records throughout, and if a claim is unfairly declined, complain and, if needed, go to the Financial Ombudsman.
Where to get help and next steps
Read private medical insurance explained and how PMI works alongside the NHS for context, and pre-existing conditions and PMI on a common reason for queries. This is general information, not medical advice.