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Last updated: 23/07/2020 | Estimated Reading Time: 4 minutes

Private medical insurance making a claim

If you have an active private medical insurance policy and you become acutely ill or injured, then it’s time to make a claim.

We’ll run you through the process of making a claim in this guide, as well as going over some of the things that you should be aware of when you do so.

In This Guide:

Policy exclusions

The first thing you should check is whether or not the illness or injury that you are suffering from is actually included in your cover.

Private medical insurance policies are, as a general rule, designed to cover acute medical conditions, that is, short term illnesses rather than long term or chronic conditions.

Chronic conditions include things like asthma or diabetes, where the treatment offered is more aimed at improving the overall quality of life of the sufferer, rather than actually curing the disease or illness in question.

You can refer to our article on cover and exclusions for more information, but if you are at all unsure about whether or not you will be covered for your health problem, then you should examine your initial policy paperwork which should include a list of excluded conditions. If you are still unsure, or if you can’t find the relevant paperwork then you should contact your insurance provider and they’ll be able to let you know whether or not you’ll be covered.

What you need to do to make a claim

When you come to make a claim, the first thing you should do is visit your GP for an examination and preliminary diagnosis.

You should ask your GP for a referral letter, either for a specific consultant or specialist, or what is known as an open referral letter. An open referral letter will detail exactly what kind of care or treatment that your GP believes you require, but it won’t be addressed to any consultant, specialist or other healthcare professional in particular.

Once you’ve seen your GP and have gotten hold of some kind of referral letter or documentation, then it’s time to get in touch with your insurer.

Once you’ve provided your insurer with all of the relevant information, including all of your policy details, they’ll be able to let you know if you’re going to be covered or not for the treatment you require.

Importantly, in order for your to guarantee that your treatment will be covered, your claim must be pre-approved by your insurer so it is imperative that you get in touch with them and follow the above steps before you actually begin treatment.

Voluntary excess

When you do come to undergo any treatment, you’ll have to pay a portion of it yourself before your insurer foots the rest of the bill. This is known as the voluntary excess. You will either pay this excess up front, with the insurer then dealing with the rest of the bill, or you will be billed retrospectively by your insurer. To find out exactly how you need to pay the excess, you should check your policy documentation or get in touch with your insurer directly.

You’ll have set up the level of excess that you’re required to pay at the opening of your policy.

As a general rule, once you’re claim has been approved, the insurance company will pay the hospital or clinic directly and so, aside from the voluntary excess, you won’t have to actually pay anything yourself and then get reimbursed in the future.

Moratorium delays

Sometimes, private medical insurance policies come with what is known as moratorium underwriting. This means that any health issues you have had within the last five years will be excluded from your policy for a period of around two years and will be included thereafter.

If this applies to you, then you may find that any claims you intend to make could be subject to delays while the insurance company goes over the relevant information to ensure that you are eligible to make a claim.