Submitting a claim to your health insurer can feel daunting, but understanding what happens behind the scenes helps you prepare. Whether you have a UK PMI policy or an IPMI plan, insurers follow a similar process. The first step is to verify eligibility: they will check whether your policy covers the treatment you are seeking. UK PMI policies cover acute conditions and often require a referral from your GP; chronic conditions, pregnancy and routine check‑ups are excluded. When you contact your insurer after obtaining a referral, the claims team will ask for your policy number, details of your symptoms and a copy of the referral letter. They will then confirm that the proposed treatment is within the policy’s benefits, that it will be performed at a hospital on your plan’s approved list and that you have an appropriate level of outpatient cover.
The next question the insurer considers is when your symptoms started. Private medical insurance is designed for new, unforeseen health issues, not for conditions you had before the policy began. Under moratorium underwriting, insurers automatically exclude any condition for which you had symptoms, medication or treatment in the five years before your policy started. At the point of claim, the handler will ask when you first noticed symptoms and when you first saw a doctor. If the answers suggest the condition pre‑dates the policy, they may request your medical records (with your consent) to confirm. With full medical underwriting, your medical history is assessed upfront, but the insurer may still contact your doctor to clarify details if the condition is complex. Being honest in your application and at claim time is crucial; misrepresenting your medical history is one of the biggest reasons for claims being denied.
Once eligibility and medical history have been checked, the insurer will look at network and authorisation. Most policies restrict treatment to a list of approved hospitals and consultants; some use ‘guided consultant lists’ or require pre‑authorisation before each stage of treatment. The claims team will ensure your chosen consultant and hospital are on the policy’s network and provide a pre‑authorisation code. If your policy includes a 6‑week wait option or a limited hospital list, they will check NHS waiting times or restrict your choice accordingly. They will also confirm your excess and whether it applies per claim or per policy year.
Finally, insurers assess the financial aspects. They determine whether the claim falls within your benefit limits (e.g., outpatient cap, mental health allowance) and whether any co‑payment or excess applies. Once everything is approved, they issue confirmation and either pay the provider directly or reimburse you. Preparing accurate documentation, disclosing your medical history honestly and following the referral and pre‑authorisation process helps your claim go smoothly. If you are unsure, your broker can liaise with the insurer to clarify what information is needed.