1. Ask your GP for a referral to a specialist if required

  2. Find your policy number and your insurer's contact details

  3. Contact your insurer's claims team or fill out a claim form online

  4. Get treatment from a health professional

  5. Your insurer pays the bill for you directly

What you can claim for

Health insurance can pay for medical treatment including:

  • Seeing a private GP

  • Diagnostic tests and consultations

  • Appointments with health specialists

  • Surgery and other treatment

  • Some medicines and equipment

  • Staying overnight or for longer in a private hospital

Each insurer has different rules on what they can pay out for and what treatments and conditions they exclude. Some also let you add cover for specific things like physiotherapy and dental treatment.

Here is what health insurance covers and how it works.

How to make a claim

Find the information you need

Check your policy documents to find:

  • Your insurer's contact details

  • Your policy or membership number

Note down the details you need to let your insurer know, such as:

  • Your illness or symptoms and when it began

  • If and when you spoke to your doctor

  • What treatment your doctor has recommended

Start your claim

You can book a medical appointment and start the process:

  • By phoning your insurer and asking them to refer you to a specialist.

  • Online, using your insurer's website. You need an online account set up, which lets you start a claim for some symptoms.

  • By visiting your GP, who can refer you to a specialist for treatment. Some insurers need an Open Referral letter from your GP, which describes what treatment you need.

If your GP refers you for treatment, you then need to contact your insurer by phone or online. You can check they can cover your treatment and start the claims process.

They will send you any paperwork you have to complete and ask you for all the details they need.

How long does it take?

Once your insurer agrees to cover your treatment, you can book the appointment immediately. You do not have to wait for payment first.

You can either:

  • Ask them to book an appointment for you

  • Book an appointment with a medical specialist yourself

Some insurers give you a pre-authorisation number if you book the appointment yourself. You need to give this to the private hospital, doctor or medical professional you use.

They should send the bill directly to your insurer, who will pay it for you.

Costs of claiming

Excess

Your insurer pays the bill for you directly to the treatment provider, but you may need to pay an excess. This amount is agreed when you take out your policy and is usually between 50 and 1,000.

You usually have to pay this amount directly to the treatment provider. For example, if your excess is 100 and you claim for a 300 appointment, you pay 100 to the medical facility and your insurer pays the other 200 to them.

Most policies only make you pay this excess once each year, so if you claimed for another 300 appointment that year, your insurer would pay the whole amount.

Higher premiums

Making a claim can make your premiums more expensive when you renew your policy it or take out a new one next year.

This is because when you take out health insurance, any symptoms or illnesses you have claimed for before are known as pre-existing conditions.

They can push up the cost of your premiums next year, and a policy from a new insurer could even exclude cover for pre-existing conditions.

What if your claim is rejected?

This can happen if your insurer decides your policy does not cover the treatment you requested.

If this happens, carefully check your policy documents to work out what your medical insurance covers.

If you think they should be able to pay for your treatment, ask them why they rejected your claim and complain if you think they are wrong.

If you need treatment for something your policy does not cover, you could: