Your questions answered
How to claim on health insurance
Usually, we’ll be able to take all the information we need from you over the phone. However, there are times when we need more information from you, or from your doctor, and in these cases we’ll ask you to complete a claim form.
In most cases we’ll pay the healthcare provider direct. If you have an excess on your plan, you’ll have to pay this directly to the provider. We’ll let you know exactly when you need to pay this.
Our expert medical partners Alliance Surgical - an independent doctor-owned organisation – will choose the best consultant for you, based entirely on your medical needs. The consultant will then choose the most appropriate hospital for your treatment. We won’t pay for any treatment we have not authorised in advance.
However if you want to be treated at a particular hospital, you can also select a hospital list to add to your plan. Whichever hospital list you choose, you should only go to a hospital on that list.
Some consultants can send you for diagnostic tests and scans to a number of hospitals, so please always check that the hospital suggested by your consultant is available on your plan.
If you decide to go to a hospital that’s not on your hospital list, you’ll need to pay 40% of the cost of your treatment, excluding your consultants’ fees.
What is covered?
Private medical insurance is for curable (acute) conditions only. These respond quickly to treatment and return you to the state of health you were in before, or lead to a full recovery.
It doesn’t usually cover treatment of long-term (chronic) conditions, where the main aim is to keep the symptoms under control – that would make premiums much more expensive.
Private medical insurance also won’t cover any pre-existing conditions you may have when you take out a plan.
There are some standard treatments and conditions that we don't cover. These are:
- Any regular monitoring or treatment of long- term (chronic) conditions, like diabetes or allergies
- Any treatment you receive outside the UK
- Emergency treatment or visits to your NHS GP
- pregnancy, childbirth and most related conditions
- Cosmetic treatment
- Organ transplants
- Any treatments or practices that are experimental, unproven or unregistered
- Any treatment for learning difficulties, delayed speech disorders and other developmental problems
- Also, our plans are designed to cover new conditions that arise after your cover begins.
For full details on what’s covered in your plan, check your welcome pack or our terms and conditions (PDF).
How we deal with chronic conditions
A chronic condition is a disease, illness, or injury that has at least one or more of the following characteristics:
- it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and/or tests
- it needs ongoing or long-term control or relief of symptoms
- it requires your rehabilitation or for you to be specially trained to cope with it
- it continues indefinitely
- it has no known cure
- it comes back or is likely to come back.
However, cancer treatment is covered on our plans. See our terms and conditions.
We’ll pay for any consultations and diagnostic tests to find out the cause of your symptoms, providing your plan covers them. We’ll also pay for any initial hospital treatment you need to stabilise your condition. Later, if the treatment you’re receiving seems only to be monitoring your state of health or keeping the symptoms of your condition in check, rather than actively curing it, we’ll talk to you and your GP or consultant about your condition and treatment. In those circumstances, we’ll ask for your consent first. If we decide to withdraw cover, we’ll always take your current circumstances into account. We’ll never withdraw cover without giving you a reasonable amount of time to make alternative arrangements.
To give you an idea, here are four examples of how we deal with chronic conditions.
All these examples assume the chosen plan provides cover for the particular condition and treatment; that the plan premiums are being paid; and that the first symptoms of the condition arose after the start of cover.
Alan has been with VitalityHealth for many years. He develops chest pain and is referred by his GP to a consultant. He has a number of investigations and is diagnosed as suffering from angina. Alan is placed on medication to control his symptoms.
We cover Alan’s initial consultations and tests and advise him that we will cover further consultations with his consultant until his symptoms are well controlled.
Two years later, Alan’s chest pain recurs more severely and his consultant recommends that he has a heart bypass operation.
We confirm to Alan that we will cover this operation as it will substantially relieve his symptoms and stabilise the condition. We also advise him that we will cover his post-operative check-ups for one year to ensure that his condition has been stabilised.
Eve has been with VitalityHealth for five years when she develops breathing difficulties. Her GP refers her to a consultant who arranges for a number of tests. These reveal that Eve has asthma. Her consultant puts her on medication and recommends a follow-up consultation in three months to see if her condition has improved. At that consultation Eve states that her breathing has been much better, so the consultant suggests she have check-ups every four months.
We cover Eve’s consultations and tests and agree to pay for her next check-up. However, we advise her that we will not be able to cover her regular check-ups after this because her condition is now well controlled.
Eighteen months later, Eve has a bad asthma attack.
Due to the severity of the asthma attack, Eve needs an emergency admission to an NHS hospital which our plans are not designed to cover. However, once her condition has stabilised, we agree to cover the cost of one follow-up consultation with her consultant to make sure that her symptoms are well-controlled again.
Deirdre has been with VitalityHealth for two years when she develops symptoms that indicate she may have diabetes. Her GP refers her to an endocrinology consultant who organises a series of investigations to confirm the diagnosis, and she then starts on oral medication to control the diabetes. After several months of regular consultations and some adjustments to the medication regime, the consultant confirms that the condition is now well controlled and explains that he would like to see her every four months to review the condition.
We pay for the treatment of Deirdre’s condition up to this point. However, we advise her that because her condition is now stabilised we will not be able to continue to cover her regular four month check-ups. We tell Deirdre that we will cover one more check-up so that she has time to make alternative arrangements. We will not cover her medication at any time.
One year later, Deirdre’s diabetes becomes unstable and her GP arranges for her to go into hospital for treatment.
Assuming the admission is on an emergency basis, then this will usually be to a NHS hospital which our plans are not designed to cover. However, once she has been discharged we will pay for one further check-up to make sure that her condition is now stable.
Bob has been with VitalityHealth for three years when he develops hip pain. His GP refers him to an osteopath who treats him every other day for two weeks and then recommends that he return once a month for additional treatment to prevent a recurrence of his original symptoms.
As Bob’s plan includes cover for alternative therapies, we pay for two weeks of treatment as this helps stabilise his symptoms. We also tell him that we cannot cover his regular monthly treatments, as these are designed just to keep the symptoms in check but that if his symptoms worsen he should contact us again.
If Bob’s condition did deteriorate significantly and his consultant recommended a hip replacement, VitalityHealth would cover the cost of this. As the operation would replace the damaged hip and thereby cure Bob’s problem, we would pay for all the costs relating to this operation.
Even if we withdraw cover for a chronic condition, it doesn’t mean we’ll withdraw cover forever. If your condition gets worse and it’s not part of the normal progress of the illness or a recurring relapse, we may cover the treatment you need to return you to your state of health before your condition worsened.
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