No private health cover for GP referred treatments? Think again

You may not know this but as standard private medical insurance policies don’t include any GP referred treatments or scans. This means unless you pay extra for extended cover you could find yourself with your claim being unexpectedly denied. Many policyholders don’t read the small print on their policies, and understandably think that all treatment is covered provided it’s been authorised by their GP. Sadly this isn’t the case. It’s a leading cause of dissatisfaction among customers, generating many complaints to major medical insurance providers.

However, there’s a way around the problem that your insurer won’t tell you. Knowing the system could mean your treatment gets that all important approval. This can save you money by avoiding the need to pay out yourself, and allow you speedy access private treatment, without a long wait on an NHS waiting list.

Primary care explained

Primary care falls outside the scope of private medical insurance policies, which are designed to cover secondary, or consultant led care. This can means the following GP referred treatments and diagnostics won’t be covered on a standard policy:

  • GP referred physiotherapy, chiropody, chiropractics, acupuncture and osteopathy.
  • GP referred scans such as MRI, CT, PET and ultrasounds.

So unless you’ve taken out extended primary care cover, which could add a hefty fee to your premium, your insurance won’t cover you for these commonly sought healthcare services.

Specialist referral

What your insurer won’t tell you is that all the above services are accessible to most customers with a standard policy, provided they have a referral from a hospital specialist. Although it sounds odd that you can’t access these treatments directly through your GP, it’s your insurers way of minimising the number of eligible claims. So all you need to do to obtain cover for these treatments under your policy is to ask your GP to refer you to a specialist first, it’s that simple. Okay, so you have to go through an additional stage in order to obtain cover, but on the plus side you’ll be seen by a top specialist who can confirm your GPs recommendations, or suggest alternative ways to help.

However, it’s worth bearing in mind that insurers don’t take kindly to policyholders trying to get around the terms and conditions of their policy. While they’ll happily tell you you’re not covered for GP referred services, they won’t advise that you that you can access these facilities via a specialist.

In order to get your claim approved it must satisfy the following requirements

  • Must be medically necessary – If your referral to a specialist isn’t medically necessary your insurer won’t cover you. However, you can argue that if your GP is willing to refer you then it must be medically necessary. Insurers can’t really argue with this as it could breach the requirement of ‘fairness’ imposed by the Financial Services Authority Financial Services Authority. It could be seen as them questioning your GPs recommendation, which is also a big no-no as claims assessors aren’t medically trained and always have to defer to the advice of the policyholders GP.

  • Must be able to supply a referral letter – Your insurer may want to see a referral letter at the outset of your claim. Your GP will be able to provide you with a copy. Whatever you do, don’t pretend to have a GP referral when you don’t. Your insurer can request a copy at any time, and if it later transpires that you lied whilst making a claim it could be classed as fraud.

It’s best not to cause suspicion from your insurer, so if you’ve not yet made a claim you’ll now know that GP referred services aren’t covered on standard policies. This means rather than calling your insurer and receiving a denial, which will be documented on your records, you can go back to your GP and obtain a referral to a specialist straight away. Often you won’t even need to make another surgery appointment, and will be able to do this over the phone. Most GPs will do all they can to help their patients get private treatment, and are be happy to refer you.

Once you’ve got your referral, give your insurer a call. As you’ve not tried to claim before the process will be relatively straight forward and your specialist appointment should be covered. After you’ve visited your specialist you can update your insurer with their recommendations, and they’ll put the necessary cover in place.

If you’ve made a claim previously which has resulted in a denial, this makes the process a little more tricky. But if you’re savvy and can provide a referral letter from your GP, you should still be able to obtain cover. Just don’t ring your insurer back straight away after a denial telling them about your new specialist referral. Claims assessors are not stupid and they know it’ll take time for you to see your GP, so it’ll only serve to set off warning bells.

Remember you’re not doing anything wrong by accessing treatment in this way, you’re simply using your knowledge of the policy to access your policy benefits. Don’t feel guilty, insurers make millions in profit every year, after years of paying into a policy you deserve access to private treatment when you need it.

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