Find out how your medical insurance claim will be assessed

When you’re making a new claim on your medical insurance policy it will need to go through the claims assessment process. You’d be surprised how many people miss this step and go ahead with treatment without contacting their insurer. It’s vital for you get in touch with your insurer first and seek their approval. Although you may think you’re covered, there could be other circumstances surrounding your policy that you haven’t considered. If you go ahead without authorisation you will still be covered if your claim is eligible, but if not you could be left with a costly bill.

When your insurers claims team are assessing whether your claim is eligible, they consider a variety of factors. Whether some of these elements come into play or not will depend on the level of cover you’ve chosen, and your type of underwriting. As a rough guide you can expect a new claim to be assessed on the following basis.

  • Your medical condition

    • Your insurer will ask for a full disclosure of your medical information surrounding the claim.

    • Some medical conditions are not covered by any private medical insurance policy, this is usually due to cosmetic reasons, such as with warts.

    • In some cases your condition will only be covered in prescribed circumstances. Take for example claims regarding varicose veins. You may be covered for treatment if your symptoms are severe, such as if they are bleeding and inflamed, but a new vein may not be deemed serious enough to qualify for treatment.

  • Acute/chronic

    • As your insurance is designed only to cover you for acute conditions, your claims assessor will need to establish whether your claim is acute or chronic.

    • If you’re going through an acute stage of a chronic condition you could also be covered, but it’s up to your assessor to establish if this is the case.

    • Although chronic conditions are not covered as standard, if you have routine benefit on your policy this could cover you for consultations and check-ups.

  • Your medical history

    • If you have fully medically underwritten or moratorium underwriting then your assessor will need to look at your medical history.

    • If you’re fully medically underwritten they will want to check if you suffered from any symptoms before you took out the policy, that you declared this on your application form. Failure to have done so could lead to a non-disclosure investigation taking place.

    • For policyholders with moratorium underwriting your assessor will need to establish whether you’ve gone a 2 year clear period from the start of the policy without any advice, medication or treatment.

  • Your specialist

    • Your insurer will need to check the specialist you are using is registered with them. If they’re not registered your assessor will get in touch with the specialists secretary to start the registration process.

    • If your specialist works outside your insurers fee guidelines your assessor will find out their prices and advise you of any shortfalls. This gives you the chance to know the facts upfront so you can make an informed decision whether or not to change specialists.

    • If your specialist doesn’t satisfy the necessary requirements you’ll need to choose an approved specialist.

  • Your hospital

    • All policies have a hospital list attached to them. You can only use the hospitals on your list for in and day patient treatment

    • You can have outpatient treatment at any hospital.

    • If you use a hospital that is not on your list there could be additional charges, your claims assessor will have to look into this for you and get back to you with the details of any shortfalls.

  • Any policy restrictions

    • If you have a 6 week rule on your policy your insurer will need to check the NHS waiting list times for any in or day patient treatment before they approve your claim.

    • Your assessor will also check your outpatient limit and see how much you have used so far this policy year so they can advise you.

  • Primary or secondary care

    • Your assessor may need to check with your GP as to whether or not you’ve been referred on to a specialist, or remain under the care of your GP.

    • Unless you have a primary care option you will not be covered for treatment under the care of your GP.

Your claims assessor has a variety of factors to consider when assessing the eligibility your claim. They usually have a surprising degree of discretion in their decision making, so don’t just dismiss them as the people who fill in the paper work, they can be a great help in getting your claim approved.

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