How to Make a Health Insurance Claim in the UK: Step-by-Step Guide

Making a private health insurance claim in the UK can feel confusing the first time you do it. You may have symptoms, a GP referral, a consultant recommendation, a scan request or a planned operation — but before you book anything privately, you need to know how your insurer wants the claim handled.

Private health insurance, also called private medical insurance or PMI, does not work like simply showing a card at a hospital and having everything paid automatically. Most insurers expect you to contact them before treatment, check whether the condition is covered, get authorisation, use approved consultants or hospitals, and understand any excess, benefit limits or shortfalls.

This guide explains how to make a health insurance claim in the UK step by step, from first symptoms to referral, pre-authorisation, treatment, invoices and what to do if your claim is refused.

Important: This article is general information, not financial advice, medical advice or insurance advice. Claim rules vary between insurers and policies. Always check your policy documents and contact your insurer before arranging private treatment.

1. Before you claim: understand what private health insurance is designed to cover

Most UK private health insurance policies are designed to cover eligible private diagnosis and treatment for new acute medical conditions. An acute condition is usually a disease, illness or injury that is likely to respond to treatment and return you to your previous state of health.

This means PMI may help with things like a new joint injury, hernia, cataract, suspected cancer symptoms, private scans, specialist consultations, physiotherapy or planned surgery, depending on your policy.

However, it may not cover:

pre-existing conditions;
routine management of chronic illnesses;
emergency care or A&E treatment;
normal pregnancy and childbirth;
routine GP care;
routine dental or optical treatment;
cosmetic treatment;
fertility treatment;
treatment that was not authorised by the insurer.

For a wider explanation, see What does private health insurance actually cover? and Pre-existing conditions and health insurance.

2. The golden rule: contact your insurer before booking private treatment

The most important rule is simple: contact your insurer before you book a private consultation, scan, procedure or hospital treatment.

Many claims problems happen because someone books private care first and asks the insurer to pay later. Your insurer may refuse the claim if you did not get authorisation, used the wrong hospital, saw a non-approved consultant, exceeded policy limits or arranged treatment that is excluded.

Even if a GP or consultant says you need treatment, that does not automatically mean your insurer will pay for it. The insurer must check the claim against your policy terms.

If your consultant recommends further tests, surgery, extra appointments or a different treatment after the first consultation, contact your insurer again before arranging the next step. Authorisation for one appointment does not always mean authorisation for everything that follows.

3. Check urgency, policy wording and referral requirements

Check whether the situation is urgent or an emergency

If you have urgent or life-threatening symptoms, use NHS urgent or emergency services. Private health insurance is usually not the right route for emergencies.

Use emergency services if you have symptoms such as:

chest pain or suspected heart attack;
stroke symptoms, such as face drooping, arm weakness or speech problems;
severe breathing difficulty;
heavy bleeding;
major injury;
loss of consciousness;
severe allergic reaction;
signs of sepsis;
suicidal thoughts or immediate risk of harm.

Private hospitals in the UK are usually focused on planned care, diagnostics and elective treatment. The NHS remains the main route for emergency care, ambulance services, A&E and intensive care.

Read the relevant parts of your policy

Before contacting your insurer, it helps to look at your policy documents. You do not need to understand every line, but you should check the areas most likely to affect your claim.

Look for:

what conditions are covered;
what exclusions apply;
how pre-existing conditions are treated;
whether outpatient consultations are covered;
whether scans and diagnostic tests are covered;
whether mental health treatment is included;
whether physiotherapy is included;
your hospital list;
whether you need a GP referral;
whether you need pre-authorisation;
your excess;
annual benefit limits;
rules around consultant fees and shortfalls.

If you are not sure what your policy includes, do not guess. Ask the insurer directly.

Get the right referral if your policy needs one

Many private health insurance claims start with a GP referral. This may be from your NHS GP, a private GP or a digital GP service included with your policy.

The referral usually explains:

your symptoms;
when the problem started;
why specialist assessment is needed;
which specialty you need, such as orthopaedics, cardiology, dermatology or gastroenterology;
whether tests or scans may be needed.

Some insurers allow direct access for certain services, such as physiotherapy, mental health support, menopause care or cancer pathways. Others require a GP referral before most claims.

Check your policy before arranging the referral. If you need help understanding referrals more generally, see How hospital referrals work in the UK.

4. Start the claim and ask whether the condition is covered

Contact your insurer’s claims team

Once you know you may need private care, contact your insurer. Most insurers let you start a claim by phone, online portal or app.

You will usually need to provide:

your policy number;
your name, date of birth and contact details;
the symptoms or condition you are claiming for;
when symptoms first started;
whether you have had this problem before;
whether you have seen a GP or specialist;
the referral letter, if required;
the type of specialist you need;
your preferred hospital or consultant, if you have one;
any tests or treatment already recommended.

Be accurate about dates. If symptoms started before the policy began, the insurer may treat the condition as pre-existing. If you are unsure, say so rather than guessing.

Ask whether the condition is covered

The insurer will check whether the claim appears eligible under your policy. This may include checking whether the condition is:

new or pre-existing;
acute or chronic;
covered under your policy level;
excluded by your underwriting terms;
within your benefit limits;
covered for outpatient care, diagnostics or hospital treatment;
something that needs GP records before authorisation.

The insurer may ask for medical evidence before deciding. This is especially likely if the claim could relate to a previous condition, recurring symptoms, mental health history, back or joint problems, digestive symptoms or a condition already being investigated.

5. Get authorisation, check providers and ask about shortfalls

Get pre-authorisation before treatment

If the insurer agrees the claim can proceed, it may give you a pre-authorisation number, also called an authorisation code or claim number. This is very important.

Pre-authorisation usually confirms that the insurer has agreed to pay for a specific stage of care, such as:

an initial specialist consultation;
a set number of physiotherapy sessions;
a diagnostic test;
an MRI, CT or ultrasound scan;
a day-case procedure;
planned surgery;
a course of treatment.

Pre-authorisation does not always mean unlimited cover for everything that follows. If the consultant recommends further tests, surgery, extra appointments or a different treatment, you may need to contact the insurer again for further approval.

Check which consultants and hospitals you can use

Your insurer may have rules about which consultants, hospitals and clinics are covered. This depends on your hospital list, consultant choice rules and policy type.

Before booking, ask:

Is this consultant recognised by my insurer?
Is this hospital included on my hospital list?
Do I need to use a guided consultant list?
Can I choose my own consultant?
Will there be any shortfall?
Will the provider bill the insurer directly?
Do I need a new authorisation number for scans or treatment?

If you use a consultant or hospital outside your insurer’s approved network, you may need to pay some or all of the cost yourself.

Ask about fees and possible shortfalls

Even when a claim is approved, you can sometimes still receive a bill. This is called a shortfall.

A shortfall happens when a consultant, anaesthetist, hospital or clinic charges more than the insurer agrees to pay. You may then need to pay the difference.

Before treatment, ask both the insurer and the provider:

Are all fees covered in full?
Does the consultant charge within insurer limits?
Are anaesthetist fees covered?
Are hospital fees covered?
Are follow-up appointments covered?
Are scans and tests covered separately?
Will I have any out-of-pocket costs?

Do not assume that an approved claim means every cost is fully covered.

6. Book appointments, attend consultations and manage payment

Book the appointment and give the provider your authorisation details

Once you have authorisation and know which provider you can use, you can book the appointment.

When booking, give the consultant’s secretary, hospital or clinic:

your insurer name;
your policy number;
your claim or authorisation number;
what has been authorised;
any referral letter;
your contact details.

Ask whether the provider will invoice the insurer directly. In many cases they will, but not always. Some smaller clinics or therapists may ask you to pay and reclaim the cost later.

Attend the consultation

At your first private consultation, the specialist will review your symptoms, medical history and referral. They may recommend tests, scans, treatment, physiotherapy, surgery or follow-up.

Important: if the specialist recommends anything beyond the original authorisation, contact your insurer again before booking it.

For example, your insurer may authorise an initial orthopaedic consultation. If the consultant then recommends an MRI scan and possible surgery, you usually need further authorisation before arranging those next steps.

Get authorisation for tests, scans or treatment

Many claims happen in stages. Your insurer may approve one part first, then review the next part after the consultant reports back.

You may need separate authorisation for:

MRI scans;
CT scans;
ultrasound scans;
blood tests;
endoscopy or colonoscopy;
biopsies;
physiotherapy;
injections;
day-case procedures;
surgery;
hospital admission;
mental health treatment sessions.

For scan-related background, see MRI scan: what it shows, CT scan: what it shows and Ultrasound vs CT vs MRI.

Understand how payment works

There are two common ways payment works.

The provider bills the insurer directly. This is common for hospitals, larger private clinics and consultants recognised by the insurer. The provider sends the invoice to the insurer, and you pay only your excess or any shortfall.

You pay and reclaim the cost. Some providers may ask you to pay first. You then submit the invoice and receipt to your insurer for reimbursement, if the treatment is covered.

If you are asked to pay upfront, check with your insurer before paying. Make sure the treatment has been authorised and ask exactly what evidence you need to reclaim the cost.

Pay your excess if it applies

An excess is the amount you agree to pay towards a claim. For example, if your policy has a £250 excess, you may need to pay the first £250 of eligible costs.

Check whether your excess applies:

once per policy year;
once per claim;
once per condition;
per person on a family policy;
to outpatient care;
only to hospital treatment.

If you chose a higher excess to reduce your monthly premium, you should be prepared to pay it when claiming.

Keep copies and follow ongoing treatment rules

Keep a record of all documents and conversations. This can help if there is a billing issue, claim query or dispute later.

Keep copies of:

policy documents;
referral letters;
consultant letters;
test and scan reports;
authorisation numbers;
appointment confirmations;
invoices;
receipts;
emails from the insurer;
notes from phone calls;
names of people you spoke to;
dates and times of calls.

If your treatment continues over weeks or months, your insurer may need updates. This is common for physiotherapy, mental health treatment, cancer care, follow-up consultations and rehabilitation.

You may need:

new authorisation after a set number of sessions;
a consultant update;
a treatment plan;
evidence that treatment is still medically necessary;
approval before changing provider;
approval before moving from outpatient care to surgery.

Do not assume that once a claim is opened, everything connected to it will be covered indefinitely.

7. How to claim for physiotherapy, mental health, cancer and diagnostic tests

How to claim for physiotherapy

Physiotherapy claims vary between insurers. Some policies allow direct access, meaning you can contact the insurer and speak to a musculoskeletal triage team without seeing a GP first. Others require a GP or consultant referral.

Before booking physiotherapy, ask:

Do I need a GP referral?
Can I self-refer?
Do I need to use an approved physiotherapist?
How many sessions are covered?
Is there a session limit or monetary limit?
Do I need further authorisation after the first few sessions?
Are scans covered if physiotherapy does not help?

If the physiotherapist recommends scans or consultant review, contact your insurer again before booking.

How to claim for mental health treatment

Mental health claims can have different rules from physical health claims. Some insurers offer direct mental health access, while others need a GP referral or triage assessment.

Before arranging therapy or psychiatry, ask:

Is mental health cover included in my policy?
Is this condition treated as pre-existing?
How many therapy sessions are covered?
Are psychologist, psychotherapist and counsellor appointments covered?
Are psychiatrist appointments covered?
Is inpatient mental health treatment covered?
Do I need to use an approved therapist or clinic?
Is neurodevelopmental assessment included or excluded?

How to claim for cancer diagnosis or treatment

Cancer claims can be more complex because they may involve urgent diagnostics, surgery, chemotherapy, radiotherapy, drug treatments, follow-up scans and long-term monitoring.

If cancer is suspected, contact your insurer as early as possible and ask about their cancer pathway.

Ask:

Is suspected cancer investigation covered?
Do I need a GP referral?
Which hospitals or cancer centres can I use?
Are scans and biopsies covered?
Are surgery, chemotherapy and radiotherapy covered?
Are targeted therapies and immunotherapy covered?
Are follow-up scans covered?
Are there drug limits or treatment limits?
Is palliative care covered?
Will I need authorisation at each stage?

Cancer cover varies significantly, so check the policy wording carefully. Do not rely only on a headline phrase such as “comprehensive cancer cover”.

How to claim for scans and diagnostic tests

Private scans and diagnostic tests often require pre-authorisation. This includes MRI, CT, ultrasound, endoscopy, colonoscopy, cardiac tests and some blood tests.

Before booking a scan, ask:

Has the scan been authorised?
Is the scan covered under outpatient benefits?
Do I need a consultant referral?
Can my GP refer me directly?
Which imaging centres can I use?
Will contrast dye be covered if needed?
Will the radiologist report be covered?
Will follow-up with the consultant be covered?

If you arrange a scan yourself without authorisation, your insurer may not reimburse the cost.

8. Common reasons claims are refused and what to do next

A private health insurance claim may be refused for many reasons. Common examples include:

the condition is pre-existing;
the condition is chronic and needs routine management;
the policy does not include the type of cover needed;
outpatient cover is limited or missing;
the benefit limit has been reached;
the treatment is excluded;
the treatment is considered experimental;
the provider is not approved by the insurer;
the hospital is not on your hospital list;
the treatment was not pre-authorised;
the insurer does not consider the treatment medically necessary;
medical information was not disclosed correctly when applying;
the claim is for emergency, routine, cosmetic, dental or maternity care that is excluded.

This is why it is important to check cover before arranging private care.

If your insurer refuses your claim, do not panic. Ask for the decision in writing and work through it carefully.

What to do if your claim is refused

Ask for a written explanation. The insurer should explain which policy term, exclusion or benefit limit it is relying on.
Ask what evidence was used. For example, the insurer may have used GP records, consultant letters, symptom dates or underwriting information.
Check your policy wording. Compare the refusal with your policy terms, especially exclusions, pre-existing condition wording, chronic condition wording, benefit limits and claims rules.
Check the timeline. Write down when symptoms started, when you first sought medical advice, when your policy started, when you received a diagnosis, when you contacted the insurer and when treatment was recommended.
Ask your doctor or consultant for clarification. If the insurer says the claim is linked to a pre-existing or chronic condition, your doctor may be able to explain whether the current problem is new, related or separate.
Use the insurer’s complaints process. If you disagree with the refusal, make a formal complaint. Explain clearly why you believe the claim should be covered and include supporting evidence.
Escalate if needed. If the complaint is not resolved, you may be able to take it to the Financial Ombudsman Service. The Ombudsman generally expects you to complain to the insurer first and give it a chance to respond.

9. How to avoid claim problems before treatment starts

You cannot avoid every issue, but you can reduce the risk of delays, refused claims and unexpected bills.

Read your policy before you need to claim.
Understand your underwriting method.
Be honest about your medical history.
Contact your insurer before booking private care.
Get authorisation numbers in writing where possible.
Check whether your consultant and hospital are approved.
Ask about shortfalls before treatment.
Check whether scans and tests need separate authorisation.
Keep all invoices and receipts.
Do not assume follow-up treatment is automatically covered.
Ask if you are unsure.

Questions to ask your insurer before treatment

Is this condition covered under my policy?
Could this be considered pre-existing?
Is it treated as acute or chronic?
Do you need my GP records?
Do I need a GP referral?
Do I have outpatient cover?
Are consultations covered?
Are scans and tests covered?
Is this consultant approved?
Is this hospital on my hospital list?
What authorisation number should I give the provider?
Does the authorisation cover only the consultation or also tests?
Will I need further authorisation for treatment?
What excess do I need to pay?
Are there any benefit limits?
Could there be a shortfall?
Will the provider bill you directly?
What documents do I need to keep?

What information should you have ready when calling the insurer?

Before calling the claims team, gather:

your policy number;
your date of birth and contact details;
your GP referral, if you have one;
details of your symptoms;
when symptoms started;
whether you have had the problem before;
any test results;
the name of the consultant or hospital, if known;
the recommended treatment or scan;
details of any previous related medical history.

Being prepared can make the claim call quicker and reduce delays.

10. Special situations: NHS waiting lists, paid treatment, second opinions and overseas care

Can you claim if you are already on an NHS waiting list?

Sometimes, but it depends on when symptoms started and what your policy covers.

If you already had the condition before buying the policy, the insurer may treat it as pre-existing. But if you already had a valid policy before symptoms started and you are now on an NHS waiting list, your insurer may consider a claim for private treatment if the condition is covered.

Do not remove yourself from an NHS waiting list until you know whether your insurer will cover the private route. It may be sensible to keep the NHS pathway active until private authorisation is clear.

Can you claim for treatment you already paid for?

Possibly, but only if the treatment was covered and your insurer agrees. Many policies require authorisation before treatment, so retrospective claims can be risky.

If you have already paid privately, contact the insurer and ask whether you can submit:

the referral letter;
consultant report;
invoice;
receipt;
test results;
proof the treatment was medically necessary.

However, the insurer may refuse reimbursement if the treatment was not authorised in advance.

Can you claim for a second opinion?

Some policies include second opinion services, but not all do. A second opinion may be covered if it is medically appropriate and authorised. Some insurers have their own second opinion pathway.

Ask your insurer:

Is a second opinion covered?
Do I need a referral?
Can I choose the consultant?
Will scans or tests be repeated?
Will you cover treatment recommended by the second consultant?

Can you claim for treatment abroad?

Standard UK private health insurance usually covers UK private treatment only, unless the policy includes international cover. It is not the same as travel insurance or international health insurance.

If you are considering overseas treatment, ask your insurer before arranging anything. Most UK PMI policies will not automatically cover surgery or hospital care abroad.

Can you claim for private GP appointments?

Some policies include digital GP or private GP access, but standard PMI does not always cover routine GP appointments. If your policy includes a virtual GP, you may need to use the insurer’s app or approved provider.

If you pay for an independent private GP appointment yourself, check whether your insurer will reimburse it. Many policies will not, unless the GP service is part of the policy.

For more detail, see Private GP subscription services vs health insurance and Private GP services in the UK: costs.

Can you claim for dental or optical treatment?

Routine dental and optical care are usually not included in standard private medical insurance. Some policies include dental or optical add-ons, and some health cash plans reimburse part of the cost of dental check-ups, glasses or eye tests.

If you need dental or optical treatment, check whether you have:

standard PMI only;
a dental add-on;
an optical add-on;
a health cash plan;
separate dental insurance.

11. Claim checklist and final thoughts

Claim checklist

Use this checklist before arranging private treatment:

I have checked whether this is urgent or an emergency.
I have read the relevant policy section.
I know whether I need a GP referral.
I have contacted my insurer before booking treatment.
I have explained when symptoms started.
I have checked whether the condition may be pre-existing.
I have checked whether outpatient care is covered.
I have an authorisation number.
I know exactly what the authorisation covers.
I know whether scans need separate authorisation.
I know whether surgery needs separate authorisation.
I have checked the consultant is approved.
I have checked the hospital is on my list.
I have asked about shortfalls.
I know what excess I need to pay.
I know whether the provider bills directly.
I have kept copies of all documents.

Final thoughts

Making a private health insurance claim in the UK is usually straightforward when the condition is covered, the provider is approved and you get authorisation before treatment. Most problems happen when people assume cover without checking, book private care too early, overlook pre-existing condition rules, or do not realise that scans, surgery and follow-up may need separate approval.

The safest approach is to contact your insurer early, be clear about your symptoms and medical history, get authorisation in writing where possible, and ask direct questions about excesses, limits and shortfalls.

Private health insurance can be valuable, but it works best when you understand the claims process before you need it.

12. FAQ: Making a health insurance claim in the UK

Do I need to contact my insurer before seeing a private consultant?

Usually, yes. Most insurers expect you to contact them before arranging private consultations, tests or treatment. If you do not get authorisation, the claim may be refused.

What is a pre-authorisation number?

A pre-authorisation number is a claim or approval code from your insurer confirming that a specific stage of care has been authorised. You usually give this number to the consultant, clinic or hospital.

Does authorisation mean everything is covered?

Not always. Authorisation may cover only a specific consultation, test or treatment. Further scans, surgery or follow-up may need separate approval.

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

Often, but not always. Some policies allow direct access for physiotherapy, mental health support or digital GP pathways. Check your policy before booking.

Can I choose any private consultant?

It depends on your policy. Some policies allow broad consultant choice, while others use guided consultant lists or approved provider networks.

Can I use any private hospital?

No. Most policies have a hospital list. If you use a hospital outside your list, you may have to pay some or all of the cost yourself.

What information will the insurer ask for?

The insurer may ask about your symptoms, when they started, whether you have had the problem before, your referral, your medical history and the treatment being recommended.

Will the insurer check my GP records?

They may, especially if the claim could involve a pre-existing condition, recurring symptoms or unclear medical history.

Can I claim for a pre-existing condition?

Usually not under standard individual PMI, unless your policy specifically covers it or moratorium rules allow cover later. Employer schemes may sometimes be different.

Can I claim for a chronic condition?

Routine chronic condition management is usually not covered. Some acute flare-ups or investigations may be considered depending on the policy wording.

What is an excess?

An excess is the amount you pay towards a claim. For example, if your policy has a £250 excess, you may need to pay the first £250 of eligible costs.

What is a shortfall?

A shortfall is the difference between what a provider charges and what your insurer agrees to pay. You may need to pay the shortfall yourself.

Will the hospital bill my insurer directly?

Often, yes, especially for approved hospitals and consultants. But some providers may ask you to pay first and reclaim the cost, so check before treatment.

Can I claim for treatment I already paid for?

Possibly, but it can be risky if you did not get authorisation first. Ask your insurer what evidence is needed and whether retrospective reimbursement is allowed.

What should I do if my claim is refused?

Ask for the refusal in writing, check the policy wording, gather medical evidence, use the insurer’s complaints process and consider the Financial Ombudsman Service if the complaint remains unresolved.

Can I stay on the NHS waiting list while claiming privately?

Often, yes. It may be sensible not to cancel an NHS appointment or waiting list place until your private claim has been authorised and treatment is confirmed.

Does private health insurance cover emergency care?

Usually not. Emergency care is mainly provided by the NHS. Use 999, A&E or NHS urgent care services for emergency symptoms.