If you have private medical insurance (PMI), but aren’t sure where to start, take a look through our guide below. It covers what PMI is, the key things you need to check with your insurer and three simple steps to become a private patient at Circle Reading Hospital.
Have a question? Give our friendly team a call on 0118 922 0026 or email firstname.lastname@example.org
Private medical insurance (PMI) is an insurance policy designed to meet some or all of the costs of private medical treatment. Private medical insurance is often referred to as PMI, private health insurance, private health cover and health insurance.
PMI is designed to ensure that if you need medical treatment in the future, you won’t need to worry about NHS waiting lists or for self-funding the costs of your treatment. If you are treated privately, health insurance will pay all or some of your bills.
Health insurance covers many things including hospital scans, surgical procedures, inpatient treatment (staying overnight in a hospital bed) and medicines. However not all costs are covered in every situation, so it’s best to check with your insurer about any exclusions in your policy. For instance, insurers will not usually cover the costs of treating chronic or on-going conditions that you were aware of before you were insured.
There are many different insurance companies who offer various types of insurance cover. These can include specialist policies for over-55s, ones that focus on particular medical conditions or international policies aimed at expatriates living overseas. For information on other insurance terminology such as ‘indemnity’ or ‘cash plan’ policies, visit the Financial Ombudsman Service website here.
By paying an insurance company a regular amount, known as a premium, this prepares you for unexpected healthcare costs in the future. Insurance is designed to cover the costs surrounding unexpected illnesses, including most costs for private treatment.
Important reasons why patients choose to take out private medical insurance include: fast access to treatment, flexibility to choose the consultant you want to see and having the choice of a particular hospital which is convenient for you. There are many other advantages too, so find out more about accessing private treatment without the wait here.
Step 1 – get a GP referral
To make a claim through your private medical insurer, you will usually need to provide a referral letter from your GP.
For certain treatments such as physiotherapy, your insurer may allow you to self-refer (which means you would not need a GP referral letter). Your insurer will tell you which conditions and treatments require a referral letter.
Step 2 – contact your insurer
Before booking an appointment at Circle, you should always contact your insurer so they can approve (or “pre-authorise”) your treatment. Your insurer will check that your policy covers you to see a specific consultant at Circle.
If your GP has not referred you to a specific named consultant, but you know you want to have treatment at a Circle Hospital, simply let your insurer know. They can then provide a list of consultants who practice at Circle, so you can choose who you see for your treatment. You can also call our Private Patient Enquiry line on 0118 922 0026 or email email@example.com if you have any questions about our consultants.
Step 3 – book your private consultation
Contact our Private Patient Enquiry line on 0118 922 0026 or email firstname.lastname@example.org to book with us directly. To book in your appointment, you will need:
- Insurer details (name of insurer and membership number)
- Your pre-authorisation code for your first outpatient appointment
- The name of the consultant you would like to see (don’t worry if you’re not sure, we can recommend a specialist for you)
- Your diary to arrange the best time to book your appointment
Booked your appointment and looking for directions to the hospital? Visit our FAQs page here for details.
- Participating hospital/registered provider
A registered provider or participating hospital has an agreement with an insurance provider. This means they can be offered as a choice to members with insurance policies. Circle Health hospitals are registered providers, which means we’re authorised to see patients with private health insurance. See the section below for a full listing of which insurance companies recognise Circle Hospitals.
Your insurance policy is a document detailing the terms and conditions of your contract with your health insurance company. This usually details the duration of coverage, your premium amount and any exclusions. Your policy serves as legal evidence of your insurance agreement.
An insurance premium is the amount of money that you pay for your insurance cover – this is usually paid as a monthly instalment or as a lump sum for the duration of your policy. The amount of coverage that is included for the premium will vary by the type of insurance product among other factors.
An excess payment is a contribution you are required to pay towards a claim you make on your insurance policy.
The exact process and amount depends on your policy but most insurance companies will ask you to pay for the care that is under your excess amount directly to the healthcare provider.
- Pre-authorisation code
You are likely to need pre-authorisation (approval) from your insurer at different stages of your treatment. For example, for an appointment(s), surgical treatment(s), test(s) and scan(s) etc. This is often to check they are medically necessary and covered in your policy. Sometimes this is also referred to as prior authorisation, prior approval or pre-certification. If you need access to a phone to call your insurer to get pre-authorisation for your treatment, test or appointment while you are visiting Circle, please ask a member of staff and one can be provided for you.
Depending on your policy, you may have approval from your insurer for just your first outpatient appointment only. Alternatively, this may include approval for any tests or scans your consultant refers you for. You can check your policy document for details or call your insurer to confirm.
Similarly, if you need surgery you will usually have to get additional approval from your insurer before your treatment is booked in. Don’t worry though, your insurance company will be able to talk you through the process and our team are on hand if you have any questions.
A shortfall is the difference between what a consultant charges for your treatment and what your medical insurance company is prepared to pay.
Some insurance companies have adopted a fee assured system or a capped pay-out scheme. This means the insurance companies set the fee for a named procedure or appointment. The price is only covered if the consultant you chose has agreed with the insurance company to work for this set fee. If the consultant you have been referred to, or you have chosen to see, has not agreed to work for the fee(s) the insurance company has set, you will have to pay the difference (known as a shortfall).
- What do we mean by “inpatient”, “outpatient” and “day case”?
These three terms are determined by how long you’re staying in hospital for. As an “inpatient” you will stay in hospital overnight while you have your treatment. Your consultant will discuss this with you and let you know how many nights you should expect to stay in hospital.
As an “outpatient” you will simply visit hospital for your appointment and then head home afterwards. When you have your first appointment with a consultant, this is often referred to as an “outpatient appointment”.
“Day case” refers to when you need to stay in hospital following a procedure, but only for a short time during the day. You will then usually be discharged (sent home) on the same day as your procedure. However, sometimes a patient may have come into hospital for their treatment as a “Day case” but for clinical reasons will need to stay overnight, therefore becoming an inpatient. Quite often, your insurance company will need to be notified to approve the unplanned overnight stay.
- What should I do before my first appointment?
You will need to gather the following before your appointment (even if you have attended a Circle Hospital before):
- your policy documentation (usually a booklet or email sent from your provider)
- the name of your insurance company
- your membership or policy number (this is usually listed on documents sent from your insurer)
- your preauthorisation or claim reference number (this confirms that you are eligible for this treatment)
- you may also be asked for your NHS number, so please have this to hand if possible
- What is included under my insurance cover?
In general, health insurance covers short-term treatment designed to help you recover from illness or injury. Insurance usually only covers conditions that develop after you first took out your policy.
- What is not covered under my insurance cover?
If you are aware of any medical condition you have before taking out insurance, this will not usually be covered by insurance companies. For instance, if you’ve previously had an injury, treatment or medical advice for a condition before taking out insurance, you may not be covered. This is sometimes referred to as a “pre-existing condition”. It’s always best to check directly with your insurer if you’re not sure.
Most medical insurance companies won’t cover treatment costs for chronic or on-going conditions. There will also be a list of “exclusions” to look out for on your policy, which are specific treatments not covered by your insurance. Examples include cosmetic surgery and A&E care.
You should check your policy and contact your insurer if you have any questions.