Learn how the health insurance claims process works

If you’re about to make a claim, you’ll be interested to know how the process works. I’ve outlined the arrangement used by most large insurers during a typical claim. Obviously if you’re admitted straight into hospital this process will be slightly different, but you’ll still go through claims assessment in order to receive your decision.

1: Referral from your GP

As private medical insurance is primarily designed to cover you for secondary care, a referral from your GP is generally required. Your GP will note this on your medical records, so while you may not have to send the referral in to your insurer, they may check this in the future. Telling your insurer you have obtained a referral when this is not the case is fraudulent, and can lead to the discontinuation of your cover.

The referral from your GP has to be given out of genuine medical necessity, so it won’t be enough if you’ve asked to be referred just so you can claim on your policy.

2: Call your insurer

When you’ve received your referral its time to get in touch with your insurer and make a new claim. You’ll be put through the the claims department to speak with a claims assessor. After completing security checks make sure you’ve got the following details to hand:

  • Your policy number
  • The specialists name
  • The hospital you’d like to use
  • The procedure code, if you’ve been given one

3: Assessment of claim

After taking details of your condition and it’s history your claims assessor will need to go away and assess your claim. Sometimes this can be done while you’re on the phone, or you might be offered a call back.

Your claims assessor will be considering the terms and conditions of the policy to check this is a valid claim. In order to do this they’ll assess the requirements of your underwriting to see whether your symptoms or conditions are coverable.

4: Additional information may be requested

Sometimes your claims assessor may need additional information to make a decision. This is more usual in the case of policies with FMU or moratorium underwriting, where your medical history can depend on whether or not your claim is eligible.

You may be sent out a claim form that you will have to fill in with your GP. Unfortunately some GPs charge for this service, and it is non-refundable on your policy. After you’ve sent the relevant details in to your insurer it will take a few days for them to assess the claim. Any treatment you take in this time is at your own financial risk until a decision has been made.

5: Decision given

Once your claim has been properly assessed you’ll be given a decision – whether it be an authorisation for you to go ahead, or a denial.

If your treatment has been authorised you’ll be given an authorisation/assessment number which you can use at the hospital. Now you can go ahead and arrange your consultation or treatment.

6: Treatment

Once you’ve been given the go ahead you can book yourself in at an approved private hospital. Normally you’ll be seen the same week, at a time convenient for you. Just make sure you give the specialist’s secretary and the hospital your authorisation number, so they can send the invoices our to your insurer.

When you go to the hospital for treatment you may be asked to give your credit card information. This is completely standard across the industry so don’t worry. As long as your treatment has been approved by your insurer nothing will be deducted from your account.

If you need to stay in hospital longer than your insurer has authorised, don’t worry and concentrate on getting well. Hospital staff will be able to liaise with your insurer on your behalf, as long the extended stay is medically necessary there’s no reason it would be refused by your insurer.

Remember to only have the treatment the you’ve been authorised for, and always call your insurer to give them a full update if any new scans or treatment are needed.

7: Billing

The authorisation number you gave the hospital and specialise should ensure the bills are sent directly to your insurer. If you have an excess to pay your insurer will write to you and explain who you need to pay this to. Normally it won’t be paid directly to the insurer, but to either the hospital or the specialist.

Once your excess has been paid and your insurer pays out for your claim, any no claims discount you have will be affected. On the plus side remember that the no claims discount only applies once in any given policy year, so now you can make a many claims as you like for the rest of the year without being subject to any deductions.

I hope this overview has helped you to get your head around the claims process. It can seem complex, but when you’re given an overview it makes the whole process a lot easier to understand. If you’re in any doubt at which stage your claim is at just give your insurance company a call, they’ll be happy to talk through the procedure with you in more detail and put your mind at ease.

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