Guide
How do health insurance claims work?
When you're not feeling well, it could be stressful trying to get answers about your symptoms on time. Private health insurance can be a big help here. With private health insurance you can get a GP referral quickly and fast-track your treatment, which means you could get better sooner. And when you need care, you can easily check with your insurance company to see what services are covered in your plan.
Making a health insurance claim is part of the process to get the treatment you need.
In this informational guide, we’ll explain how health insurance claims work and how to make the most of your insurance to get the care you deserve. This guide does not detail the Vitality claiming process specifically but provides a general overview of how the claiming process works.
Understanding the health insurance claims process
How you start your health insurance claim will vary depending on your provider. Some insurance companies need you to complete a form. Others prefer that you contact them online or via an app.
At Vitality we make it easy to keep track of your claims through the Vitality Care Hub.
However you make your claim, you’ll probably go through the following four steps.
Get a referral from your doctor
The first place to seek help when you’re injured or unwell is with your GP. This can be your NHS GP or through a GP service provided by your private health insurance. The GP will assess you and decide if you need any treatment.
If you're seeing your NHS GP, let them know that you have private health insurance. They will need to provide you with an ‘open referral’ letter. You can show this letter to your insurer, and they’ll let you know if your treatment can be covered by your insurance.
An open referral means that you can choose where to have your treatment rather than letting the GP decide. You’ll have access to all the consultants and hospitals on the list of treatment centres supported by your health insurance.
For some conditions, you could get treatment without seeing a GP first. Such as physiotherapy and mental health support. And if your health insurance covers it, you can claim back the costs of seeing a private dentist, optician or hearing specialist. At Vitality you can self-refer for Talking Therapies and physiotherapy and claim back for certain treatments through the Care hub.
Check your treatment is covered
When you have your open referral letter or if you’re self-referring, contact your health insurer. This can often be done online or through an app. If you call your insurer, have your policy number and referral letter to hand.
Your insurer will usually be able to tell you there and then whether your treatment is covered by your health insurance. If it is, you can go ahead and choose your consultant and book an appointment with them.
Book your treatment
Most providers offer a list of consultants who are specialists in their field. You can look at their profiles and choose the consultant who best suits your needs.
Your insurer will usually provide a pre-authorisation code or number for your health insurance claim. This code lets your consultant know that your treatment is approved for payment. You’ll need to pass this code on to the specialist dealing with your treatment.
You can often book your appointment using the same online portal or app you used to start your claim. Or you can call the team dealing with your claim. They’ll let you know what to expect at the appointment.
Request next stage of treatment
If, after seeing the specialist, they think you may need follow up treatment, you’ll need to get back in touch with your insurer. Follow up treatment could include tests, scans, an operation or drug treatment.
In-patient treatment is often included in your cover. This means any treatment where you need to stay in hospital should be paid for. But some out-patient treatments aren’t covered as standard, so it’s best to check.
Learn more: In-patient and out-patient cover explained
Paying for treatment
When your insurer approves your treatment, they’ll usually pay the consultant or the hospital directly. If you get sent an invoice, check with your insurer before paying it. You may be able to send it on to your insurer for payment.
If there’s an excess on your policy, the insurance company will let you know how much to pay when you make your claim. Some insurance companies will ask you to pay it straightaway, others when they settle the bill for treatment.
Information you’ll need during your health insurance claim
As you go through making your health insurance claim, you’ll probably accumulate key pieces of information. It’s a good idea to keep track of this information as you may need to refer to it during the claims process. For example:
Username and password. If you’ve made a claim via an app or online, make sure you know your username and password. This way you’ll be able to track your claim quickly and easily.
Policy number. This should be on any correspondence from your insurer you’ve had about your claim. It will also be in your online account or app. Your insurer may need this number if they speak to you.
Pre-authorisation code or number. This shows the healthcare provider that the insurer has agreed to cover the cost of your treatment.
GP referral letter. This explains what treatment the GP feels is appropriate. It will help your insurer decide which specialists are best for your treatment.
Receipts and invoices. If any part of your treatment is paid for by you, such as dental treatment, keep all your invoices and receipts. You’ll need evidence that you’ve paid for the treatment when you claim back the cost.
Doctor’s correspondence. If you need to claim for further treatment, make sure you keep all correspondence from your specialist. It will help your insurer decide if they can continue funding the cost.
Will my health insurance premium increase after making a claim?
Health insurance premiums will usually rise each year due to several factors. This includes whether you’ve made a claim or not.
It’s quite common for insurers to increase your premium when you renew if you’ve made a claim that year. It depends what the claim was for. But if an insurer thinks you may make other claims then they may increase your premium to compensate.
If you don’t make a claim from one year to the next, some insurers allow you to build up a no-claims bonus – like you can with your car insurance. This can help manage your premium for the following year.
With Vitality, you can control the cost of your insurance by doing healthy things and earning Vitality points. The more points you earn the lower your premiums can be. Also, not all types of claim with us will affect your premiums in the following year. For example, optical, dental and hearing cover claims won’t affect premiums. However, even if you don't make a claim, premiums can still increase due to factors such as your age and rising medical costs.
How soon can you claim on private health insurance?
Many policies will allow you to make a claim as soon as you start paying your premiums. It's always a good idea to check the details of your specific policy to understand any waiting periods or specific requirements for making a claim. Some providers don’t allow you to make certain types of claims until you’ve had your policy for a few weeks or months.
Any condition you had before taking out the policy usually won't be covered. And you may need to pay an excess when making your claim.
Learn more: Health insurance and pre-existing conditions explained
Why choose Vitality health insurance?
Want to know more about private health insurance or thinking about taking out a policy? Here are some of the benefits of taking out health insurance with Vitality:
- Get video GP appointment within 48 hours
- Avoid lengthy hospital waiting lists
- Get specialist drugs and treatments
- See a consultant fast
- Refer yourself for physiotherapy
- Get mental health support fast and without a GP referral
- Get menopause support
- Get discounts from top brands. And rewards for getting healthy.
Health insurance claim FAQs
Can I make a claim for someone else?
You can make a health insurance claim for anyone who’s named on your policy. For example, your partner or your children. Just go through the same process as if you were making a claim for yourself.
What can I claim for?
Generally speaking, insurance companies will cover you for any illness or injury that you’ve not had before. This includes cover for cancer treatment, physiotherapy and mental health support.
What happens if my claim is denied?
Double check your cover. It could be that the condition you're claiming for isn't covered. Or that it’s linked to a condition you had before taking out this insurance. Your insurance company should explain exactly why they’ve denied your claim. If you disagree, you can ask them to reconsider. They may need more medical evidence before making a final decision.
If you’re not satisfied with your insurer’s explanation, you can make a formal complaint. Contact them about their complaints procedure or speak to the Financial Ombudsman Service.
Are there limits on what I can claim?
Some insurance companies put a limit on how much they’ll pay out over time, or for particular treatments. These are known as cover limits.
- Annual limit. This is the maximum amount that the insurance company will pay out in one policy year. This annual limit can apply to the total amount paid out over 12 months, or to the total amount paid for one type of treatment in a year.
- Lifetime limit. This is the maximum amount that your provider will pay out over the lifetime of the policy.
- Per-condition limit. Insurers sometimes put limits on the amount they’ll pay out for each condition.
How long does it take to process a claim?
Claims are often agreed the same day you contact your insurer. A referral from your GP is usually enough to get you booked in with a specialist. This can be done online or by calling your insurer. They’ll let you know if they need more details about your condition before making a decision about paying for your treatment.
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