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Understanding The Health Insurance Claims Process

Understanding the health insurance claims process involves knowing the right order of steps, who is involved in signing off permission for the claim and submitting paperwork on time.

But with all the technical jargon and lengthy policy details, many individuals find the process confusing and overwhelming. Throw in the added confusion of what is and isn’t covered by health insurance policies and you’re often left feeling helpless.

This guide will walk you through the process of health insurance claims and understanding your private health care policies.

How Does The Claims Process Work With Health Insurance?

The health insurance claims process varies between medical plans. The NHS offers free care, but some things might not be covered (or partially subsidised) - like eye exams and dentistry.  “Cash plan” policies allow you to claim back from your private health provider for certain NHS services such as dentist or optician appointments.

Private medical insurance may also provide quicker access to NHS health professionals, a choice of specialists and/or having a private room in a hospital.

This is how it's done:

1. Eligibility check

Before starting the claims process, it's important to confirm with your provider if the specific treatment and associated costs are covered by your private medical insurance (PMI) policy.

Here's how:

Review Policy Documents: Go through your policy with a fine-tooth comb to fully understand your medical insurance benefits and which healthcare expenses are covered.

Contact your insurance provider: If any information is unclear, contact your insurer to confirm any compensation claims and queries you may have.

Once you’ve confirmed your eligibility, visit your local GP and gather the necessary documentation.

2. Visit your GP

Visit your private doctor or NHS GP when feeling unwell, as you’ll need to speak with a GP before making a claim. They will provide the necessary referral letter needed to claim. If you use an NHS GP for your referral letter, you won’t need to pay but you can claim back on private doctor appointments via your PMI.

Include the following documentation:

Completed claims form: Most PMI providers offer downloadable claim forms on their website, or you can fill these in electronically via the online portal. With this, you'll need to provide your PMI policy number.

Medical Report: Copies of your medical records and referral letter are essential. These documents explain what your diagnosis is and if you're receiving treatment. If you haven't got these to hand, your insurer will likely write to you for permission to contact your GP for access.

Invoices/Receipts: Keep any invoices or receipts related to the treatment you claim, such as private consultant fees or out-of-pocket expenses.

When all your paperwork is collected, you can contact your insurer and begin the pre-authorisation process.

3. Start Your Claim

By this stage, you have everything you need to make a claim.

Submit your documents - claims form, medical letter, private healthcare invoices - to your PMI provider. As mentioned, this is generally done via an online portal but alternative communication channels, such as postage service, email or in-person drop-ins are also available.

Pre-authorisation: If all is in order, your insurer will give you a pre-authorisation number. This confirms your treatment has been authorised at private facilities.

Note: Any pre-existing illnesses or injuries (before taking out a PMI policy) won’t be covered, unless expressly agreed in writing from your insurer. You may have a blanket Moratorium period from the start of your policy, which is there to simplify the on-boarding process. This rule largely covers new medical conditions developed after cover has been put in place, and historical issues (if) they met the terms of the moratorium.

4. Find Health Professionals

Many insurance providers cover a wide range of health professionals, consultants and specialists. However, depending on your policy, you may encounter a few limitations such as shortfalls in their consultation fees. To avoid any hiccups, opt for consultants and hospitals on the “approved” list to avoid insufficient cover or payment problems.

Here are a few additional tips:

Hospital list: Generally, insurance companies will provide a list of approved hospitals you can choose from. Select the one most relevant to you. Note that hospitals in busy cities like London may charge higher medical fees than in quieter villages like Taunton.

Guided consultants: These healthcare professionals have agreed to keep their fees below a specific price, saving you money in the long run. If your insurer has suggested this option, they'll provide a shortlist of consultants/hospitals for you to choose from.

5. Payment

Once you’ve been treated, the hospital or consultant will invoice your PMI provider directly.

If, for whatever reason, you are required to pay for the medical expenses, your insurer will reimburse you.

Additionally, you are liable for excess payments. Usually, these excess amounts are added to your insurance payment – or automatically deducted on the next debit order.

Understanding these steps will help streamline your experience with the NHS health insurance claims process, ensuring you receive the necessary treatment and reimbursement.

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Final Thoughts

This guide has covered key areas of understanding the health insurance claims process.

The key lies in understanding your PMI policy, gathering the relevant medical reports and paperwork and submitting your claim on time.

Don't hesitate to contact your insurer if you need further clarification. Alternatively, contact the friendly MyHealthPal team - your trusted partner in navigating the complexities of health insurance.

Frequently Asked Questions

Get Answers to Common Queries About Health Insurance Coverage

  • What does private healthcare insurance cover?

    What is covered by private health insurance depends on the medical plan you’re on and what is stated in your policy documents. Generally, the following health services are covered:

    • Outpatient consultations (if covered on your policy, up to a claim limit)
    • Physiotherapy treatment following surgery
    • Alternative therapies (e.g. chiropractor or podiatrist)
    • In-patient treatment
    • Day-patient treatment
    • Outpatient diagnostics (either in full, or up to a policy limit)
    • Private GP
  • What is not covered by private healthcare insurance?

    • Pre-existing conditions, illnesses or injuries (unless agreed in writing by the insurer)
    • Chronic illnesses which require long-term treatment and have no known cure
    • Cosmetic surgery
    • Fertility treatment
    • Pregnancy and childbirth
    • Accident and emergency
Note: These details form part of the medical underwriting section of your policy. Medical underwriting is a process used by health insurance companies to evaluate an applicant's health history and current health status - including certain pre-existing condition exclusions.

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