How private health insurance works

As the uptake in UK private health insurance is increasing, you may wonder how health insurance works? If you are new to health insurance, let us help you understand how it works in practical terms. It is important to remember that health insurance (also known as PMI) does not replace the NHS. Health insurance works alongside the NHS and the premium you pay will dictate the benefits and cover you receive. If you want to be able to have access to private treatment for everything, then you will need to buy a fully comprehensive policy. You may even need to look at an international policy if you want to include private maternity treatment. By the same token, if you are happy to have some treatment via the NHS, such as out-patient consultations and therapies, then you can look at a mid-range policy which will cost you less.

Making a claim on your health insurance

When you make a claim on your PMI, in general, you will need a GP referral. More often than not, your insurance provider will offer access to a remote GP service. This alleviates the need to visit your own NHS GP. Remote GP appointments can be arranged at a time to suit you. Some medical conditions do not need a GP referral.

When you have musculoskeletal (MSK) issues (aches and pains with bones, joints and muscles), you will be able to contact your insurer directly, in most cases. Aviva offer this via Back to Better and AXA via Working Body. These are two examples of UK insurance companies who accept self-referral for MSK claims. If you need an onward referral, the private GP will be able to provide this.

When your GP confirms you need to see a specialist, they will need to provide you with a referral. Your referral can either name a consultant or be an open referral. Please be aware that if your PMI policy has a guided hospital option then you will need an open referral. The cost for a policy with a guided hospital is less that the cost for a policy with a full hospital list. The guided option means that your insurer will direct you to a consultant or facility in their network for your treatment. You will have a choice, but only from the specialists that your insurer provides. If your policy has a hospital list, you can do your own research or accept a named referral, if the specialist and hospital facility is covered under the hospital list you have chosen.

Pre-authorise your treatment with your insurer

Before you attend your consultation, you must pre-authorise your claim with your insurer to make sure you have the appropriate cover in place and that there will be no *shortfalls in payment. Your health insurance works far better if you follow the claiming procedure.

*A shortfall will occur if your consultant or hospital charges over the fee guidelines for your treatment. All medical procedures have a code, and each code has an agreed cost. Your insurer will not pay over the agreed cost for treatment.

Your insurer will confirm what is covered on your policy. As an example, when you call, they will advise how many consultations are covered and whether diagnostic tests are included. If you need further treatment, you will need to call and make sure this is also covered by your policy.

Health insurance works well, providing you follow the guidelines for making a claim. If you have any doubt, talk to your broker who can help you navigate the claims process.

How health insurance works for mental health claims

The cover for mental health treatment is often an add-on benefit. You can therefore exclude cover for mental health or psychiatric conditions to save money on your annual premium. That said, it has become one of the most popular benefits available. Since Covid 19, more people are suffering with mental health conditions and cover via the NHS can have lengthy wait times. Being able to access rapid counselling and CBT can stop your mental health condition from getting worse. Knowing you have rapid access to mental health treatment can offer peace of mind regardless of your age, background or financial circumstances.

If you do not have health insurance, you can use the NHS. If the waiting time is too long, then websites such as MIND offer a wealth of information and support:

Many of the UK insurance providers also offer a number of easy self-help and quick access mental health guides.

What happens if you need accident and emergency treatment?

Health insurance works well for the treatment of acute medica conditions. It does not, however, cover you for accident and emergency treatment. In all A & E situations, the best route to treatment is via the NHS. They have excellent A & E facilities and are equipped to deal with medical treatment of this type. Very few private hospitals have A & E facilities available to their members. If you do have an accident and are admitted to an NHS hospital, then, until you are in a stable condition, it is unlikely you will be allowed to move to a private hospital for further treatment. Only when your consultant agrees it is an option can you then approach your insurer to see if you have cover for further treatment privately.

You might be eligible to claim cash back from your private medical insurance for treatment you have via the NHS. Cash back will be for in-patient treatment (sometimes day-patient) and you will need to provide proof of your hospital admission and discharge to be able to claim.

How health insurance works for claims relating to cancer

If you are diagnosed with cancer and already have a policy in place, your insurer will make sure you have rapid access to treatment. Having PMI in place will give you access to the latest medication, diagnostics and procedures. There is no “postcode lottery” for drugs and if you need chemotherapy, you may even be able to have this at home. Cancer cover is important to many people and insurers now specify clearly in their terms and conditions what cover they will offer you for cancer.

What happens if your consultant suggests a new treatment?

If your consultant recommends a procedure that is new or not normal for your condition, you may need written clarification for your insurer. There are instances where the common treatment for a condition would not work and therefore something different is needed. When this happens, your insurer may need further information from your consultant explaining why you need something different to the normal course of treatment.  Perhaps you take medication that would make surgery difficult. Maybe an anaesthetist has advised against being under for a long period of time. Sometimes new treatments become available that are not yet commonplace and therefore the insurer will need more details.

When you call to pre-authorise your treatment, the claims handler will let you know if there is an issue. If they decline the treatment, they will let you know why. If it is because the treatment is not recognised for that condition, there may be circumstances for them to re-consider. Ask your broker to speak to the claims’ team for you to find out why a claim has been declined. The insurer is likely to revisit their decision if your consultant can explain why your case is different.

As there are a number of different elements to PMI, explaining how health insurance works in relation to each and every benefit is somewhat challenging, but we hope the above information has given you a good insight. If you would like to speak to one of our team directly, we can be contacted on 01245 929129.