Outpatient cover in health insurance

Health insurance is often pictured as paying for an operation. Before any operation comes the first part of care, which is seeing a specialist and having tests. This page explains how that part of a policy works, so you can choose the level that suits you and use it well.

What it pays for

The Association of British Insurers (ABI) says private medical insurance usually covers consultant fees and diagnostic tests, such as MRI and CT scans. It also covers hospital admission and surgery. Some policies also include outpatient consultations, physiotherapy, mental health treatment and chiropody.

Policies come at different levels. You can often choose the treatments covered, the level of cover for each, where you are treated, and how much you pay towards a claim yourself. That last part is called the excess.

Choosing a limit that fits

Different policies have different money limits. The ABI suggests asking a few plain questions before you buy. Is there a limit on how much of a treatment, or a course of treatments, is covered? Does the excess apply to each claim or to each policy year?

Private medical insurance is mainly for acute conditions that start after the policy begins. Conditions that need long-term management are usually not covered.

Getting your treatment authorised

Treatment usually begins with your GP referring you to a specialist. The ABI says to call your insurer before you arrange any private treatment, to check you are covered. Stay in touch with them at each stage.

Authorisation for a first appointment may not cover treatment given during it. In one case the Financial Ombudsman Service looked at, a patient had approval to see a consultant. She had been told to ask again before any treatment. Her claim for an injection given at that appointment was turned down, and the ombudsman found the insurer had acted fairly.

Health cash plans

A cash plan is a different product. You pay a regular premium and claim money back on routine care, such as dental check-ups, eye care and physiotherapy. The ABI says many cash plans cover conditions you already have. Some plans also let you add your partner or children.

Cover through your work

Your employer may offer a group scheme. These usually do not ask about your medical history. A basic scheme may only cover some treatment, such as hospital admission and tests, so it is worth asking your employer what yours includes.

Your choices in the NHS

Insurance sits alongside the NHS. When a GP refers you, in most cases you have the legal right to choose the hospital or service you go to. That can include many private hospitals that provide NHS services.

If something goes wrong

Complain to the insurer first. If you get no final response within eight weeks, or you are unhappy with it, you can take the complaint to the Financial Ombudsman Service. It is free to use.

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