Claiming follows five steps: get a GP referral, call your insurer for pre-authorisation, receive an authorisation number, book your appointment, and the hospital invoices your insurer directly. You typically pay nothing upfront except your excess. The single biggest cause of declined claims is skipping the pre-authorisation call.
- ✓Always get pre-authorisation before booking treatment — it's the step that makes or breaks a claim.
- ✓Hospitals and consultants usually invoice your insurer directly; you rarely pay and reclaim.
- ✓Your excess is typically collected once per policy year, often by the hospital or insurer at first claim.
The five steps, in order
Every insurer words it slightly differently, but the claims journey across Bupa, AXA Health, Aviva, Vitality, WPA and The Exeter follows the same shape. The order matters: authorisation comes before booking, not after.
- Get a referral. See your GP (NHS or your policy's digital GP) and ask for a referral letter. Most insurers prefer an open referral — one that names the specialty needed, not a specific consultant — because it lets them direct you to a recognised specialist. Some services, such as physiotherapy or mental health support, allow self-referral on many policies.
- Contact your insurer for pre-authorisation. Call the claims line or use the insurer's app before anything is booked. They'll check the treatment is covered, that your underwriting terms don't exclude it, and that your chosen hospital and consultant are on your list.
- Receive your authorisation number. This code confirms the insurer will pay for the specified treatment. Note what it covers — often the initial consultation and diagnostics first, with a further authorisation issued once a treatment plan exists.
- Book your appointment. Give the hospital or consultant's secretary your authorisation number and insurer details when booking. A consultation typically follows within days.
- Invoices go direct to your insurer. Recognised hospitals and consultants bill the insurer, not you. You only pay your excess and anything outside your cover, such as amounts above an outpatient limit.
When and how you pay your excess
Your excess is the amount you contribute before the insurer pays — commonly £100 to £500 on personal policies. On most UK policies it applies once per policy year, not per claim, so a year with several linked claims usually costs you one excess.
How it's collected varies. Some insurers deduct it from the first invoice and ask the hospital to bill you; others invoice you directly after the first claim is processed. Either way, expect to pay it around your first treatment of the policy year, and keep the receipt — if a claim later spans two policy years, you may be asked for a second year's excess.
| Stage | Who you deal with | What you pay |
|---|---|---|
| GP referral | Your GP or the policy's digital GP | Nothing (digital GP typically included) |
| Pre-authorisation | Insurer claims line or app | Nothing |
| Consultation and diagnostics | Hospital/consultant, billed to insurer | Excess, if not yet paid this year |
| Treatment or surgery | Hospital, billed to insurer | Anything above policy limits |
| Aftercare/physio | Provider, billed to insurer | Amounts above any outpatient limit |
Why claims get declined — the honest list
Most claims are paid: industry-wide, insurers pay the large majority of private medical insurance claims they receive. But declines happen, and they cluster around a few predictable causes — nearly all avoidable.
- No pre-authorisation. Booking treatment first and telling the insurer afterwards is the classic mistake. Insurers can and do refuse to pay for unauthorised treatment, even when it would have been covered if asked.
- Pre-existing conditions. If you're on a moratorium, conditions from the five years before you joined generally aren't covered until you've had two clear years without symptoms, treatment or advice. Claims that trace back to a pre-existing condition are the most common substantive decline.
- Chronic conditions. Private medical insurance covers acute conditions — ones that respond to treatment and get better. Long-term management of chronic conditions like diabetes or asthma is generally excluded, though acute flare-ups may be covered.
- Out-of-list hospitals or consultants. Treatment at a hospital outside your hospital list, or with an unrecognised consultant, can be declined or only partly paid.
- Exhausted limits. If your policy has a capped outpatient limit, claims above it fall to you.
- Non-disclosure. On fully medically underwritten policies, failing to disclose relevant history when you applied can void a claim — or the policy.
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If your claim is declined: how to appeal
Start with the insurer's own complaints process — every UK insurer must have one. Ask for the decline reason in writing, then address it directly: medical evidence from your GP or consultant if the dispute is about whether a condition is pre-existing or chronic, policy wording if it's about what's covered.
- Request written reasons and the specific policy clause relied on.
- Gather evidence. GP records showing no prior symptoms or advice are powerful in pre-existing disputes.
- Complain formally. The insurer has 8 weeks to give a final response.
- Escalate to the Financial Ombudsman Service if you're unhappy with the final response — it's free, independent, and you have six months from the final response letter to refer your case.
The Ombudsman upholds a meaningful share of PMI complaints in the customer's favour, particularly where policy wording was ambiguous or the insurer's evidence for 'pre-existing' was thin. It costs you nothing to ask.
Making the process smoother
A few habits make claiming almost frictionless. Use the insurer's app where one exists — Bupa, AXA Health, Aviva and Vitality all let you start claims, upload referrals and track authorisations digitally, which is faster than phone queues. Keep your membership number, underwriting certificate and any authorisation numbers in one place. And if your policy includes a digital GP, starting there can compress referral-to-authorisation into a day or two.
Finally, ask the insurer up front what your authorisation actually covers. 'Consultation and initial diagnostics' is not the same as 'surgery' — a second authorisation before treatment is normal, not a warning sign, and knowing that saves an anxious phone call later. If you're comparing policies partly on claims experience, it's a fair question to put to a broker: claims handling differs between insurers more than their brochures suggest.
Frequently asked questions
Do I need to see a GP before claiming on my health insurance?
Usually, yes. Most insurers require a GP referral before they'll authorise a claim, though many accept referrals from their own digital GP service, which is often faster. Some benefits — commonly physiotherapy and mental health support — allow self-referral without a GP letter on many policies. Check your policy's claims section for exceptions.
What is pre-authorisation on a health insurance claim?
Pre-authorisation is your insurer's confirmation, before treatment, that a claim will be paid. You contact the claims line or app with your referral details; the insurer checks cover, underwriting terms and your hospital list, then issues an authorisation number. Treatment booked without pre-authorisation can be declined even if it would otherwise have been covered.
What is a health insurance authorisation number?
It's the reference code your insurer issues once a claim is approved, confirming it will pay for the specified treatment. You quote it when booking so the hospital and consultant can invoice the insurer directly. Check what it covers — insurers often authorise the consultation and diagnostics first, then issue a further authorisation for treatment.
Do I pay upfront and claim the money back on health insurance?
Rarely. For authorised claims at recognised hospitals, invoices go straight from the provider to your insurer — you typically pay only your excess and anything above policy limits. Paying and reclaiming mainly happens for cash benefits or out-of-network care, where you submit invoices through the insurer's app or claims form.
When do I pay my excess on a health insurance claim?
Typically once per policy year, at your first claim. Depending on the insurer, the hospital bills you the excess directly or the insurer invoices you after processing the first claim. Later claims in the same policy year usually carry no further excess, though a claim spanning two policy years can trigger a second one.
Why would a health insurance claim be declined?
The common causes: no pre-authorisation, the condition being pre-existing under your underwriting terms, the condition being chronic rather than acute, treatment at a hospital or consultant outside your list, exhausted benefit limits, or non-disclosure at application. Most are avoidable — pre-authorising every claim removes the single biggest risk.
Can I appeal a declined health insurance claim?
Yes. Ask for the decline reason and policy clause in writing, gather medical evidence — GP records are decisive in pre-existing disputes — and use the insurer's formal complaints process, which must conclude within 8 weeks. If you're unhappy with the final response, the Financial Ombudsman Service will review it free of charge.
How long does health insurance claim authorisation take?
Often minutes to a couple of days. Straightforward claims made via an insurer's app or claims line are frequently authorised on the spot; ones needing medical information from your GP or consultant take longer. Once authorised, a private consultation typically follows within days and routine surgery within 2–6 weeks.
Do I need a new authorisation for each stage of treatment?
Often, yes. Insurers commonly authorise in stages — consultation and diagnostics first, then treatment once a plan exists. That's normal practice, not a sign your claim is in trouble. Quote your existing authorisation number when requesting the next stage, and confirm each new authorisation before anything further is booked.
Can I choose my own consultant when claiming on health insurance?
It depends on your policy. Open-referral or guided policies mean the insurer directs you to a consultant from its approved panel, usually in exchange for a lower premium. Policies with free choice let you name any recognised consultant on your hospital list. Either way, confirm the consultant is recognised before booking.