Getting Private Healthcare – UK patients with private medical insurance

If you need medical attention you should in the first instance consult your GP (General Practitioner). Your GP will advise you whether or not referral to a consultant is necessary and if so, he (or she) should give you a letter of referral. Your GP will normally recommend an appropriate consultant for your condition but sometimes you may be aware of a particular specialist that you wish to consult. This is your choice but always listen to your GP’s opinion.

You should then contact your private medical insurance company and explain the nature of the problem and to whom you have been referred. You should take note of several points at this stage.

  • Your insurance policy may have specific exclusions (i.e. it will not pay for certain conditions)
  • Your insurance policy may exclude some aspects of treatment (i.e. out-patient care)
  • Your insurance policy may require you to pay an initial excess i.e. you pay some of the cost

Apart from these types of exclusions your insurance company should authorise your treatment. In some cases they may only agree to an initial consultation and investigation by the consultant and will then ask for more information. You may be given an authorisation number.

You should note that just occasionally some insurance companies might make comments about the consultant to whom you have been referred, sometimes implying that they are expensive or that they are not on one or other of their “Partnership” lists.

You should not be deterred from your choice by any such comments and you should expect an explanation of whether or not your treatment will be paid.

On some occasions your insurer will send you a Claims Form that will need completion by you, your consultant and sometimes by your GP.

When you see your consultant you should take your letter of referral, a claims form if requested and all your insurance information and numbers. You should also take any previous medical records or X-rays in your possession. Your consultant will then recommend the appropriate treatment and this might involve either in-patient or outpatient care. Some simple tests are often done in or just before or after the consultation, such as urine or blood pressure testing. Check with the Clinic or consultant’s secretary in case you need to bring a sample or to come prepared.

At this stage, particularly if hospitalisation is planned you should be able to get some idea of the costs from your consultant. This type of estimate will only cover the medical costs and not the hospital charges. Sometimes it is difficult for your initial consultant to estimate all the fees, as there may be no precise diagnosis made as yet. Sometimes complications can occur and other specialists may be called to see and treat you and this is difficult to know in advance. You should also note that consultants from some “service” specialties (pathology and radiology) may be involved in your care and even though you may not meet all of these specialists face to face, you are still ultimately responsible for their fees.

Sometimes the insurance company will settle directly with the consultants and sometimes they will reimburse you for these fees. Usually, all or most of your consultant’s fees will be covered by your insurance policy but if there is a shortfall then this becomes your responsibility. Insurance companies vary in what they will reimburse you even for the same condition or operation.

If your consultant recommends hospital treatment you will be able to discuss which hospital to go to. Your consultant will advise you and this decision will be based on your clinical requirements and the facilities available to treat you. Sometimes you will find that your particular insurance company or policy does not cover the hospital that you choose. This is because there are so-called “network hospitals” with which your insurer has a financial contract. This may not affect your care and the hospital may be perfectly satisfactory but occasionally you may need to go to an alternative hospital that has the necessary expertise and facilities for your condition. If there is any doubt then you should make a special appeal to the insurer with the assistance of your consultant.

Urgent or emergency care in the independent sector will also require a GP referral and insurance preauthorisation although sometimes this may be very difficult to obtain. You should note that the independent hospitals are not always the best places to go if you have an accident and then you should go to the nearest NHS Accident and Emergency Department. If you have another type of medical emergency then you should only go in to the private sector if a suitable consultant has been contacted and has accepted you under his care. Some private hospitals will have an emergency consultant rota and so may be able to organise a consultant to see you urgently.