Claim correctly on your Private Medical Insurance

It is surprising how many people actually do not know how to make a claim on their Private Medical Insurance and many call us to find out whether they can claim and how to do it. As a specialist broker we offer you this help as part of our service. We also thought it may be a good idea to provide a helpful guideline to enable you to claim correctly on your policy.

The claims procedure is always confirmed within your renewal or inception documents and we would recommend that you refer to these for clarification of the terms and conditions of your policy.

If you do not follow the claims procedure you could find yourself with a shortfall in payment. In order to avoid a shortfall,  we recommend you follow the correct claims procedure every time.

As a rule all UK domestic insurers will require you to pre-authorise your treatment prior to having it done.

6 Pointers that will help you to Claim Correctly on your Health Insurance

Find your certificate of insurance.

On here you will find confirmation of your cover, your membership number and the contact number you need to call to register your claim. It will also confirm any specific exclusion that apply to your membership. If you have Medical History Disregarded underwriting there will be no specific exclusions on your policy. You will be able to access these documents online in most cases.

Go to your GP.

Almost all claims, whether on a company or individual policy will need a GP referral.  There are exceptions such as muskuloskeletal claims where you can often call your insurer directly. Remote private GP appointments are available from many insurers. This will save you time waiting for an NHS GP appointment.

Check that your condition is not excluded.

Make sure it is not listed in the “general policy exclusions”. Chronic conditions, HIV/Aids, Alcoholism, sleep disorders and professional sports injuries are just a few of the types of conditions that may be excluded. Check your specific terms and conditions for confirmation of what exclusions apply with your insurer. If you have any specific personal medical exclusions on your policy, these will be shown on your certificate of insurance.

Check your hospital list.

Some providers offer different levels of hospital list. You need to make sure that the referral you have is at a facility that your level of cover allows. As an example, if you had your policy with Vitality Health on the Local hospital list and your GP referred you to The Royal Marsden hospital in Chelsea, the fees would not be covered in full as this hospital is not on the Local Hospital List.  In fact in this example, you would be expected to contribute 40% (excluding consultant fees) towards the cost of your treatment.

Check the excess you have in place.

If you have an excess on your policy then it could be either per year or per claim. You will be expected to pay this amount and your insurance provider will pay the balance where applicable.


Accident and Emergency situations are not covered under Private Medical Insurance and should be dealt with via the NHS. They have the equipment and expertise to deal with emergency situations.

To clarify, in order to Claim Correctly on your Health Insurance you will need to:

Once you have checked your cover levels, have your certificate to hand and have your GP referral in place and then you need to call your Insurer and register your claim. They will provide you with a pre-authorisation number that will be linked to your claim. At this stage your insurer will confirm if there is any issue with your claim, the consultant or specialist you have been referred to or the treatment that has been recommended and where appropriate will advise you of the alternative options available to you. The claims handler will confirm what they are pre-authorising. As an example they authorise your initial consultation, diagnostic tests and follow-up consultation. If you needed to have further treatment or surgery, it is essential to pre-authorise before you have anything else done.

The team at SMP Healthcare can help you understand the claiming process. As a client you can call us to discuss your claim prior to contacting your insurer. We cannot make claims on your behalf but we can help you navigate through the right procedures.

Please contact us on either 0800 047 0127/ 01245 929129 or