Why is primary care commonly denied by health insurers?

While making a claim, many policyholders are disappointed to discover they aren’t covered for everything they envisaged. To some extent this is understandable as often when taking out a new policy you are presented with reams of paperwork to read and sign. Many people simply expect that primary care is included in their medical insurance policy, but this isn’t usually the case. If you want this option then most insurers ask you to pay an additional premium.

What is primary care?

  • Primary care covers basic first line healthcare services such as those covered by your GP. Your medical insurance policy is designed to cover secondary care and as a rule will not generally include primary case services.

  • Primary care includes cover for physiotherapy, osteopathy, acupuncture.

  • Scans that go back to your GP for analysis such as CT, MRI and PET scans.

In what circumstances might claims not be covered?

  • Often before your GP refers you on to a consultant they will want to exhaust all other alternatives. This could mean they request scans, blood tests or even physiotherapy to see if this resolves the problem. Unless you have these additional benefits on your policy you won’t be covered for these treatments privately when referred by a GP.

  • Your insurer will not cover you to see a private GP as this is classed as primary care.

In what circumstances will primary care be covered?

  • When you take out your policy many insurers will offer you the chance to take out primary care cover as an additional option. For an increase in premium you can benefit from private physiotherapy, osteopathy and acupuncture.

  • If you are referred by a consultant for primary care treatments you will be covered under your policy. This can be infuriating for policyholders who are denied cover for the same treatment when they are referred by a GP, but often if you explain the situation to your GP they may try and help you by offering a referral to the consultant first. However, they have no obligation to do this and while such a tactic is frowned on by your insurer it is a useful way to get around the provisions of the policy! It’ worth mentioning that if your insurer feels you are deliberately trying to get around the provisions of the policy they may request a GP referral letter, but as long as you are able to provide this your insurer will honour your treatment. Whatever you do, don’t be tempted to lie to your insurer as this will be regarded as fraud, and if discovered your policy could be terminated.

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