Making claims clear

    • In 2015 we paid over £1,232.5m in claims for our members in the UK.

      There are some circumstances though, where a request for treatment may not be covered or a bill might not be paid in full. It’s important that you understand why this happens before you make a claim. To help you, we’ve listed some of the most common reasons below along with some links to how you can find out more information on what is and isn't covered on our individual plans.

    • Where private medical insurance fits in

      Private medical insurance is also known as personal health insurance, private healthcare insurance or PMI. It's designed to provide valuable cover which supplements what you receive on the NHS. People who have a private medical insurance plan choose how much cover they need. And if something’s not covered by their plan, they can still get treatment on the NHS.

      Understand your cover before you buy

    • Common reasons 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:

      1) 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. Nor is the routine on-going monitoring of a long-term medical condition such as asthma or diabetes.

      2) 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. If the cost of your treatment is more than its benefit limit, you won’t be covered for the cost above that benefit limit.

      3) 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.

      4) 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.

    • Example 1

      Where we can’t approve or pay for treatment because of a pre-existing condition

      Joe has had asthma since he was a child. It’s a chronic condition, and one he’s been managing for years - long before he decided to take out a private medical plan.

      Joe calls us to ask about treatment for his asthma. We explain that because it’s a pre-existing condition, it won’t be covered by his plan. We explain that private medical insurance typically only covers new conditions that develop after you’ve taken out a plan. We let him know that this is standard industry practice, and that there’s some more information about it in The Association of British Insurers Guide to Buying Private Medical Insurance.

      Joe does his research and decides to take out a plan with us. And now that he knows his asthma isn't covered, he can budget for any extra treatment he might need. He could decide to get treatment on the NHS, just like he's done in the past.

      Example 2

      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.

    • Understanding cover before you buy

      It’s always a good idea to understand what kind of cover you’re getting before you buy it.

      • Visit our What's covered page. You’ll be able to see summaries of what is and isn’t covered under our Personal Health plan for individuals and families. You can read the Personal Health membership handbook here too – this outlines the terms and conditions of the plan.
      • Read the Association of British Insurers Guide to Buying Private Medical Insurance. It’s helpful for understanding what private medical insurance is and isn’t. It also explains the kinds of things that are typically excluded from cover, no matter who provides your plan – things like routine pregnancy and childbirth.
      • Check your quote and accompanying documents. They’ll always outline any specific terms of your plan that are there because of your medical history.

      If you want to check whether a condition or treatment is covered before you join, you can give our helpful agents a call:

      To get a quote for a new private medical insurance membership – please call
      0800 111 4004

      Existing personal members – please call 0800 132 203

      For all other questions, please contact us here

    • Call us on 0800 111 4004* or get a quote online

    • *Lines open 09.00 - 20.00 Mon - Fri. Closed Sat - Sun. Telephone calls may be recorded and/or monitored for quality assurance, training and as a record of our conversation