A Guide to Claiming for Private Medical Insurance

Navigating the claims process can be crucial for ensuring that employees receive the care they need without unnecessary delays or confusion. If you already have private medical insurance in place, the process of claiming can often seem daunting, but it doesn’t have to be.

In this article, we’ve created a simple step-by-step guide to help you understand how to claim for eligible private medical insurance treatments and make the process as smooth as possible during your time of need.

Step 1: Get a GP Referral Letter

The first step in making a claim is getting a referral letter from your GP. You can either visit your local GP in person or take advantage of your insurer’s telephone GP service. The referral letter is essential as it typically outlines the medical condition and the need for specialist treatment, which your insurer will need to assess and approve. Note, without a GP referral letter you will typically not be able to move forward with a claim.

Certain insurers now offer fast-track pathways for specific conditions, such as cancer or mental health. Under these pathways, you typically don't need a referral letter to start a claim. Instead, you can usually call the insurer’s dedicated team, go through a triage process, and be guided directly to the appropriate care or support service.

For more information on how to use your insurer’s telephone GP service, please refer to the article titled "Utilising Your Policy – Telephone GP Service," available on the blog page of our website.

Step 2: Call Your Insurer’s Claims Line

Once you have your referral letter, the next step is to call your insurer's claims number. Keep the referral letter on hand, as you’ll need to provide details about your condition and treatment needs. During this call, you will speak to a claims handler who will review your referral and ensure the treatment is eligible for cover.

Step 3: Speak to a Claims Handler

The claims handler will verify your eligibility for treatment under your policy. If the claim is eligible, they will provide you with an authorisation code. This is a critical step as you cannot proceed with your treatment without this approval. If your claim is not eligible, the claims handler will explain why it is not covered.

For more information on claiming eligibility, including underwriting terms and general exclusions, refer to our three-part series—"Understanding the Different Types of Underwriting Terms" and "Understanding General Exclusion Lists"—which can be found in the blog section of our website.

If you believe a claim is eligible but are being told otherwise, you should speak to a broker. A broker can usually investigate the eligibility of your claim and, where appropriate, build a case on your behalf.

Step 4: Receive an Authorisation Code

Assuming your claim is approved, you will be given an authorisation code. This code is essential for booking your treatment and ensuring that the insurer covers the costs up to the limits of your policy. Keep this code safe, as you’ll need to provide it to the healthcare consultant.

It is important to understand that you may have limits on your policy. In these instances eligible claims will only be covered up to the agreed limits. If you're unsure about your policy limits, refer to your policy documentation or contact your insurer or a broker.

Step 5: Book Your Treatment

Once you have your authorisation code, it’s time to book your treatment. If you’ve chosen an open referral hospital option, your insurer will provide you with a list of approved consultants. You then call your approved consultant and book a time and date that suits you. When making the appointment, ensure that you provide your authorisation code to confirm your coverage.

Step 6: Attend Treatment and Provide Your Authorisation Code

On the day of your treatment, make sure to bring your authorisation code with you. Your consultant will confirm the treatment plan, and the code will ensure that your insurer covers the costs of the treatment (up to the agreed limits of your policy). Bills are typically settled directly between the consultant and your insurer, so you won’t have to worry about paying upfront.

Step 7: Excess Payments

If you have an excess on your policy, your insurer will invoice you for the amount after your first claim. Typically, you’ll only pay the excess once per member per policy year. Once it’s paid, you won’t have to pay it again until the next policy year.

It’s important to note that some insurers offer an excess-per-claim option. If you’ve chosen this option, you may need to pay the excess multiple times within your policy year if you make multiple claims for different conditions.

Step 8: Additional Treatment and Further Pre-Approval

If you require additional treatment beyond what was initially authorised, you’ll need a new referral letter, typically provided by your specialist consultant. Your insurer must approve any further treatment and issue a new authorisation code before you can proceed with your claim. You can do this in the same way as before—by calling your insurer's claims number and having your new referral letter on hand. Always ensure you get pre-approval for new or further treatment to avoid unexpected costs.

Important Note on Dental and Optical Cashback Claims

Claims for eligible cashback treatments under this add-on benefit, whether at your dentist or optician, are handled separately from general medical claims. For more information, please refer to our article titled "How to Claim Money Back on Eligible Dental and Optical Treatments."

Online Claims

In addition to the traditional claims process outlined in this article, some insurers offer an online claims service. Through the insurer's portal or website, members can usually start, track, and monitor the progress of their claims. For more information and to find out if your insurer offers this service, refer to your policy documents or contact your insurer or a broker.

 Final Thoughts

Claiming can often feel daunting, but it doesn't have to be. By following these simple steps, you can ensure the claims process runs as smoothly as possible and that all eligible claims are pre-approved and authorised before starting treatment. For more information on claims, including eligibility, underwriting terms, and general exclusions, refer to our three-part series—"Understanding the Different Types of Underwriting Terms" and "Understanding General Exclusion Lists"—available in the blog section of our website.

A final note: A good broker is there to guide you through the claims process, allowing you and your employees to focus on what matters most—getting the care you need, when you need it. And remember, always obtain a referral letter and secure pre-approval for your treatment from your insurer before starting a claim!

Disclaimers:

Disclaimer 1: The information provided in this article is accurate as of April 13, 2025. However, all details are subject to change in the future based on updates to insurer terms, market conditions, or regulatory changes. For the most up-to-date information, please contact a broker or your insurer directly.

Disclaimer 2: The information provided in this article is intended for educational purposes only and should not be used as specific advice for any individual insurer or policy. For details regarding your specific policy, always refer to your insurer’s policy documents or contact a broker or your insurer directly for personalised assistance.

Disclaimer 3: The claims process outlined in this article is intended as a general guide to help readers better understand how to make a claim. Each insurer's claims process may vary, so for specific information regarding any individual insurer or policy, always refer to your insurer's policy documents or contact a broker for personalised assistance.