Unrecognised specialist & uninsured hospital: What can you do

When you’ve successfully jumped through all your insurers hoops and made a claim for a valid condition, you may well feel relieved. However, even though your claim is eligible, your cover may still be denied if you fail to use an approved specialist or hospital.

Unrecognised Specialists

While your insurer is prohibited from telling you which specific specialist they would like you to use, they can ask you to select one who is registered with them.

The registration requirement ensures that your insurer is happy with the level of qualifications possessed by your specialist. Essentially it’s a vetting process to check they are fully qualified to carry out this kind of work.

Not all specialists may meet the strict requirements imposed by your insurer. In many cases sports injuries specialists may be regarded at the top of their field by the profession but are ineligible for insurance purposes.

Primary care practitioners such as physiotherapists, osteopaths, chiropractors and acupuncturists also need to be registered with your insurer.

Registration is beneficial for your treatment provider as it allows them to invoice your insurer directly and opens their services to a wider range of clients.

What can you do?

  • If you’ve been denied cover because your specialist isn’t registered with your insurer, then the first option you should ask your insurer about is how to get them registered.

    The registration process involves your provider applying to the insurance company with details of their medical qualifications, provided these are recognised and valid then approval should be fairly quick and straight forward.

  • If you proceed with any treatment before they are registered it’s at your own financial risk, although once they are successfully registered you should be able to retrospectively claim for any costs.

  • If your provider is declined registration then if you want to use them you’ll have to fund the treatment yourself. However, you’ll be given the option to continue your treatment with another specialist who is registered with your insurer.

  • Your insurer should be able to give you the names of a few suitable local specialists, you can then look into these further and choose your own specialist.

Uninsured Hospitals

All private medical insurance policies come with a hospital list attached to them. This means that not all your local hospitals will be covered by your policy. You can upgrade your hospital list to a more extensive one on your policy renewal date. Generally the more extensive your hospital list, the higher your premium will be.

You should check your hospital list before taking out the policy to ensure you can use your preferred hospital.

Before choosing your specialist you should check they have admission rights at a hospital on your policy list.

Your insurer is not obligated to cover the full cost of the procedure at a hospital not on your list, so you could be left with considerable shortfalls.

What can you do?

  • Distance – If the closest hospital on your hospital list is over 40 miles away from your home, this could be regarded as unreasonable and unfair by the Financial Services Authority. Your insurer won’t expect you to undertake a mammoth journey to your hospital, so if it’s a long way to travel and there are facilities closer, you can always ask to use them based on these grounds.

  • Lack of suitable facilities – Some specialised procedures require expensive equipment that simply isn’t available at all hospitals. If the hospitals on your list in your area don’t provide the necessary facilities your insurer will cover you to have the treatment elsewhere.

  • Human error – The people who match hospital lists up with policies are human just like the rest of us and from time to time make mistakes. I’ve seen a policy for a family in Devon with a Scottish policy list attached to it. If you don’t think things add up with your hospital list then question it. it could be your insurer has made an error which is easily correctable.

  • Average price – If you refuse to use a facility on your list and instead opt for another hospital you may be subject to payment on an “average price” basis. This works whereby your insurer contributes the average cost of the hospital procedure towards your stay. This could cover your stay in full or you could find yourself with a shortfall that you need to make up.

You may find yourself under pressure to meet the requirements of your insurer by choosing the specialist and hospital that they recommend. However, don’t be put off from making your own treatment decisions, it’s your health at stake so remember you always have the final say. Just be aware of any financial implications that may arise so you don’t get any nasty surprises later.

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