How to Claim on Health Insurance | Health Insurance Search

To claim on private medical insurance (PMI), check your policy, follow its referral route and contact your insurer before booking private tests or treatment. The insurer needs to confirm that the condition and proposed care are eligible and tell you which providers and services it has authorised. The exact process depends on your policy; some plans also allow direct access for particular symptoms or services.

This guide explains the usual steps. For a wider explanation of what policies may cover, read what private health insurance covers.

1. Check your policy and membership details

Before arranging care, find your policy schedule, membership handbook and any exclusions letter. Check:

when your cover started and who is insured
whether the benefit you need is included, and any annual or per-claim limit
your excess or other contribution
exclusions and underwriting terms that may apply to the condition
whether you need a GP referral or can use a direct-access service
which hospitals, consultants and other providers your policy recognises

Do not assume that a condition is covered simply because you have private health insurance. Policies commonly restrict cover for pre-existing conditions, ongoing chronic care and emergency treatment. The exact wording matters.

2. Follow the referral route in your policy

Many insurers expect you to see a GP and obtain a referral before a specialist consultation or diagnostic test. Some policies let you contact the insurer directly for certain symptoms or services, so check before booking.

If your GP refers you, ask whether the insurer needs an open referral. This describes the speciality you need without naming a particular consultant. For example, Aviva asks customers to tell their GP they have Aviva cover and request an open referral; Bupa says open referrals are required on some schemes. Other policies may give different instructions.

3. Contact the insurer before private care

Use the insurer’s app, online account or telephone service to open the claim. Give an accurate account of:

your symptoms and when they began
any GP advice, tests or treatment already received
the referral and speciality, if you have one
the provider or appointment you are considering

Ask for a claim or authorisation reference and write down what the insurer has agreed to cover. Aviva tells members to contact it before tests or treatment. AXA Health provides an online claim route, while Bupa sets out a claim process that can include checking symptoms and arranging a referral.

4. Confirm the consultant, hospital and approved care

The insurer may offer you a choice of eligible specialists or ask you to select from a particular network. Check that both the consultant and the treatment location are recognised under your policy, not just by the insurer generally.

Ask the insurer to confirm whether approval covers the initial consultation, diagnostic tests, scans, treatment and any follow-up. Approval for one appointment does not necessarily mean every later stage has been authorised.

5. Attend treatment and keep the paperwork

Bring your authorisation details to the appointment. Keep referral letters, invoices and any messages from the insurer or provider. Some insurers pay approved providers directly; Aviva says it pays agreed bills to the healthcare provider. Do not assume that every policy or provider uses direct payment, and ask before treatment if you might need to pay and claim reimbursement.

If the consultant recommends further tests or treatment, contact the insurer again before arranging them. The insurer can explain whether another authorisation is needed and whether any excess or benefit limit remains.

What if the insurer declines a claim?

Ask the insurer for its decision and the policy wording it relied on. If relevant, provide requested medical information or ask the provider to clarify the proposed treatment. If you still disagree, use the insurer’s formal complaints process. The Financial Ombudsman Service explains how it handles complaints about private medical insurance and says insurers should handle claims promptly and fairly.

Frequently asked questions

Do I need a GP referral to claim on private health insurance?

Often, but not always. Some insurers offer direct access for selected symptoms or services. Check your policy and ask the insurer before making a private appointment.

Should I book a private scan before contacting my insurer?

Usually, no. Contact the insurer first and get confirmation that the scan and provider are authorised under your policy. A GP referral alone is not the same as insurer approval.

Can I use any private hospital or consultant?

Not necessarily. Your policy may limit you to a hospital list or recognised consultants, and it may set limits on provider fees. Confirm the exact provider and treatment with the insurer before booking.

How to Claim on Private Health Insurance in the UK