Personal

Making claims clear

Common reasons why we can’t approve a claim

Our plans aren't designed to replace all NHS services so sometimes cover won't be available on your plan. This is usually because:

  • The condition or treatment you’re claiming for isn’t included as standard
    Not everything is covered under standard membership terms. As an example, cosmetic treatments aren’t included or the routine on-going monitoring of a long-term medical condition such as asthma or diabetes.
  • There might be a benefit limit on your plan
    You can choose private medical insurance with different levels of cover. That means you choose and pay for the cover you think you need, up to a certain amount of money. This is called a benefit limit. There’ll be a number of different benefit limits on your plan covering different types of treatment, such as outpatient benefit. If the cost of your treatment is more than its benefit limit, you will need to pay the difference. Take a look at Sally's story below.
  • You might have chosen a plan without cover for certain types of treatment 
    You might have chosen a plan where some conditions and treatments aren’t covered at all; some people just choose cover for in-patient care. That means they wouldn’t be covered for any out-patient treatments such as tests or consultations. You might also have chosen an increased excess or the 6 Week Option, both of which reduce the cost of your plan but will also reduce the cover available from your plan. View our short videos to help make sense of these options.
  • You might have a pre-existing condition
    Insurance is designed to cover new and unforeseen risks. Therefore, most private medical insurance doesn’t cover treatment for conditions you’re already suffering from until after a specified treatment free period. These are known as pre-existing conditions. View our short video on pre-existing conditions.

Choosing a non-approved specialist

We cover the costs in full for over 95% of the specialists we work with but we limit the amount we pay in order to keep premiums as low as possible.  If you choose a non-approved specialist who charges more than our agreed limits you may have to pay a contribution towards the cost of your initial and ongoing treatment. These costs could be considerable so we recommend you speak to us before agreeing to any treatment and we can discuss your options. 


Choosing to pay an excess

Agreeing an excess when you take out your plan is a good way to reduce your premiums.  When you call us to make a claim we’ll tell you whether there’s an excess on your plan. When we receive an invoice for your treatment we’ll reduce the amount we’ll pay by your excess. You’ll only have to pay your excess once in each membership year and not if you have more treatment throughout the year. 

We’ll let you know how to pay your excess when we send you a statement following a consultation or treatment. Take a look at our short video.

 

Where we approve treatment, but might not be able to cover the full cost

Sally needs minor surgery on her knee. She gives us a call to chat through her options. We let her know that this kind of operation is covered by her plan, so we approve it. We also let Sally know that tests and consultations before the surgery will take her up to her out-patient benefit limit for the year. Sally knows that she may need some more treatment on her knee this year, so she starts putting some money aside every week - just in case.

Sally's surgery goes really well, and we cover the cost of it in full. We even settle the bill directly with the provider that performed the surgery. It means that Sally doesn't have to pay a penny upfront, so she's not out of pocket.

After her surgery, Sally's specialist suggests a course of physiotherapy to speed up her recovery. Sally knows that she's reached her out-patient benefit limit for the year, and we won't be able to cover her physiotherapy bills. Sally needs to decide whether to cover the cost herself, or to get her physiotherapy through the NHS. Even though she's saved up enough money to cover the treatment herself, Sally decides to go through the NHS. She uses the money she's saved for a relaxing holiday instead.