Using PMI for Specialist Consultations What to Expect
At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we know that navigating private medical insurance in the UK can feel complex. This guide demystifies using your PMI for specialist consultations, explaining the entire process from getting a referral to understanding what your policy covers.
Referral rules, appointment booking, and diagnosis coverage
When a health concern arises, the journey from your GP's office to a specialist's clinic is a critical pathway. With private medical insurance (PMI), this journey can be significantly faster and more flexible than relying solely on the NHS. However, it's a process governed by specific rules and procedures set by your insurer.
Understanding these steps—the referral, the authorisation, the booking, and what's covered—is key to a smooth and stress-free experience. This article will walk you through everything you need to know, ensuring you can make the most of your private health cover.
What is a Specialist Consultation and Why Might You Need One?
A specialist, or consultant, is a doctor who has completed advanced education and clinical training in a specific area of medicine. While your General Practitioner (GP) has a broad knowledge of many health conditions, a specialist has a deep, focused expertise.
You might be referred to a specialist for several reasons:
- Diagnosis: If you have symptoms that your GP can't definitively diagnose.
- Expert Opinion: To get a second opinion on a diagnosis or treatment plan.
- Specialised Treatment: For conditions that require specific procedures or management, like cardiology (heart), dermatology (skin), or orthopaedics (bones and joints).
- Ongoing Management: For complex conditions that need monitoring by an expert.
In the UK, the need for specialist care is growing. With NHS waiting lists for consultant-led elective care remaining a significant challenge—affecting millions of people according to NHS England data—private medical insurance offers a vital alternative for timely access.
A Critical Note on PMI Coverage
Before we go further, it's essential to understand a fundamental principle of private medical insurance in the UK:
Standard PMI policies are designed to cover acute conditions that arise after you take out the policy. They do not cover pre-existing conditions or chronic conditions.
- Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Examples include a hernia, cataracts, or a joint injury requiring surgery.
- Chronic Condition: A condition that is long-lasting, has no known cure, and needs ongoing management. Examples include diabetes, asthma, high blood pressure, and arthritis.
- Pre-existing Condition: Any illness or injury you had symptoms of, received advice for, or were treated for in the years before your policy began (typically the last 5 years).
Understanding this distinction is crucial, as it dictates what your insurer will and won't pay for.
The GP Referral: Your Gateway to Specialist Care
For the vast majority of PMI policies in the UK, the first step to seeing a specialist is visiting your GP. Your GP acts as the gatekeeper, assessing your symptoms and determining if a referral to a specialist is medically necessary.
There are two main types of referrals your GP can provide:
- Named Referral: Your GP refers you to a specific, named consultant. This might be a specialist they know and trust, or one you have requested.
- Open Referral: Your GP provides a referral letter for a type of specialist (e.g., a "consultant dermatologist") without naming a specific individual. This gives you and your insurer more flexibility to choose a consultant from their approved network.
Most insurers favour an open referral. It allows them to guide you towards a consultant within their network who they have fee agreements with, which can help control costs and streamline the process.
Can I Self-Refer with my PMI?
While the GP referral route is standard, some modern private health cover policies are introducing more flexible options, such as:
- Digital GP Services: Most insurers now include access to a virtual GP service, often available 24/7. You can use this service for an initial consultation and get a referral, which is often quicker than waiting for an appointment at your local NHS surgery.
- Direct Access Services: Some providers offer direct access for specific conditions, like musculoskeletal issues (e.g., back pain) or mental health support, allowing you to bypass the GP referral for these specific pathways.
Always check your policy documents or speak to your insurer to confirm the referral process required for your plan. An expert PMI broker like WeCovr can help you compare policies based on the flexibility of their referral options.
Navigating the Pre-Authorisation Process with Your PMI Provider
Once you have your GP referral, you must not simply book an appointment with a specialist. The next critical step is to contact your insurance provider to get pre-authorisation for the consultation.
Pre-authorisation is the process where your insurer confirms that the consultation is covered under your policy and provides you with a unique authorisation number. Without this, your insurer will almost certainly refuse to pay for the appointment.
Here’s a step-by-step guide to the pre-authorisation process:
| Step | Action | What You Need | Top Tip |
|---|---|---|---|
| 1. Gather Your Information | Before calling your insurer, have all necessary details ready. | Your policy number, GP's referral letter, details of your symptoms and when they started. | Keep a dedicated folder or digital file for all your PMI-related documents to save time. |
| 2. Contact Your Insurer | Call your provider's claims or pre-authorisation helpline. This number will be on your policy documents and membership card. | - | Have your phone fully charged and be prepared for a call that could take 10-20 minutes. The best time to call is often mid-morning on a weekday. |
| 3. Explain Your Situation | Clearly explain your symptoms and that your GP has referred you to a specialist. The claims handler will ask questions to determine if the condition is acute and eligible for cover. | - | Be honest and precise. Don't downplay or exaggerate symptoms. Vague information can delay the process. |
| 4. Choose a Specialist | If you have an open referral, the insurer will provide a list of approved specialists in your area. You can choose from this list. If you have a named referral, they will check if that consultant is on their approved list. | - | Ask the insurer if they have any "fee-assured" specialists. This guarantees the consultant won't charge you more than the insurer's agreed rate. |
| 5. Receive Your Authorisation Number | Once approved, the insurer will give you a pre-authorisation number. This number is your proof of cover for the initial consultation. They may also authorise a certain amount for diagnostic tests. | - | Write this number down immediately and keep it safe. You will need to give it to the specialist's secretary when you book. |
Choosing Your Specialist and Booking Your Appointment
With your pre-authorisation number in hand, you're ready to book your appointment.
Using Your Insurer's Hospital List
Every PMI policy comes with a "hospital list," which is a directory of the hospitals, clinics, and specialists your plan gives you access to. These lists are usually tiered:
- Comprehensive Lists: Include almost all private hospitals in the UK, including high-end central London facilities. These policies are typically more expensive.
- Standard Lists: Include a wide range of private hospitals nationwide but may exclude some premium central London hospitals.
- Local or Limited Lists: Offer access to a smaller, curated list of hospitals, often to keep premium costs down.
When your insurer gives you options for a specialist, they will be from within your policy's approved hospital list. If you have a specific hospital or consultant in mind, it's vital to check they are covered by your plan before you buy the policy.
Making the Call
- Contact the Specialist's Secretary: Call the hospital or clinic and ask to speak to the secretary of your chosen specialist.
- Provide Your Details: Explain that you are a private patient with a GP referral and have pre-authorisation from your insurer.
- Give Your Authorisation Number: The secretary will need your name, your insurer's name, your policy number, and your pre-authorisation number.
- Book the Appointment: You can then arrange a date and time for your consultation.
Privately, you can often secure an appointment within a matter of days or weeks, a stark contrast to the potentially long waits for many NHS specialisms.
What Happens During and After Your Consultation?
Your initial consultation is a chance for the specialist to understand your medical history, discuss your symptoms, and conduct a physical examination.
Diagnostic Tests and Scans
Following the initial assessment, the specialist will likely recommend one or more diagnostic tests to get a clearer picture. Common tests include:
- Blood tests
- X-rays
- Ultrasound scans
- MRI (Magnetic Resonance Imaging) scans
- CT (Computerised Tomography) scans
Crucially, you will need to get pre-authorisation for these tests as well. Sometimes, your insurer may pre-authorise a certain amount for diagnostics during your initial call. In other cases, the specialist's secretary will contact your insurer on your behalf to get the necessary authorisation. Always clarify this process to avoid any unexpected bills.
The Diagnosis and Treatment Plan
Once the test results are in, you'll typically have a follow-up consultation with the specialist. During this appointment, they will:
- Provide you with a diagnosis.
- Explain the diagnosis and answer your questions.
- Recommend a treatment plan.
If the diagnosis is for an acute condition (e.g., gallstones requiring surgery), your PMI policy will likely cover the subsequent treatment, subject to your policy limits. You will need to get separate pre-authorisation for any surgery or treatment course.
If the diagnosis is for a chronic condition (e.g., diabetes or Crohn's disease), your PMI provider will not cover the long-term management. They will cover the diagnosis part of the journey, but you will then be returned to the care of your GP and the NHS for ongoing treatment.
Comparing PMI Provider Approaches to Diagnosis
| Provider | Typical Approach to Consultations & Diagnosis | Key Feature |
|---|---|---|
| Aviva | Strong focus on their "Expert Select" hospital list and guided consultant choice to manage costs. Open referrals are preferred. | Often provides a cash benefit if you opt for NHS treatment instead of private. |
| AXA Health | Flexible options, including self-referral for certain conditions like muscle, bone, and joint problems through their "Working Body" service. | Strong emphasis on digital tools and a "Doctor at Hand" virtual GP service. |
| Bupa | Well-established network. Consultants must be Bupa-recognised. Open referrals are strongly encouraged for their "Open Referral" network. | Comprehensive mental health cover is often a standout feature, with direct access for some therapies. |
| Vitality | Unique approach that integrates wellness and rewards. A GP referral is standard, but they offer extensive digital support via the Vitality GP app. | The "Consultant Select" option can reduce premiums, but it means Vitality chooses the specialist for you. |
An independent broker like WeCovr can provide a detailed comparison of the best PMI providers and help you find a policy that aligns with your preferences for choice and flexibility.
The Financial Side: Understanding Excesses and Policy Limits
While PMI covers the bulk of the costs, you will likely have some financial contribution to make.
- Excess: This is a fixed amount you agree to pay towards a claim each policy year. For example, if you have a £250 excess and your specialist consultation and tests cost £1,500, you would pay the first £250, and your insurer would pay the remaining £1,250. Choosing a higher excess can significantly lower your monthly premium.
- Outpatient Limits: Your policy will have a limit on how much it will pay for outpatient services (like consultations and diagnostic tests) per year. This can range from £0 to £500, £1,000, £1,500, or even be fully comprehensive ("unlimited"). If your outpatient costs exceed this limit, you will have to pay the difference.
It's vital to choose an outpatient limit that you are comfortable with. While a lower limit reduces your premium, a single MRI scan can cost upwards of £500-£1,000, quickly using up a modest allowance.
A Real-Life Example: David's Journey to a Specialist
To illustrate the process, let's follow a fictional example:
- The Problem: David, a 45-year-old architect, starts experiencing persistent knee pain after a hiking trip. It's affecting his ability to work and enjoy his hobbies.
- GP Visit: He books an appointment with his NHS GP, who examines his knee and suspects a meniscal tear. The GP provides an open referral for an orthopaedic consultant.
- Pre-authorisation: David calls his private medical insurance provider. He gives them his policy number and the referral details. The claims handler confirms the condition is acute and gives him an authorisation number for an initial consultation and up to £750 for diagnostics. They provide a list of three approved orthopaedic surgeons in his area.
- Booking: David researches the three surgeons and chooses one based at a private hospital near his home. He calls the surgeon's secretary, provides the authorisation number, and books a consultation for the following week.
- Consultation & MRI: The consultant examines David and agrees that an MRI scan is needed. The secretary confirms the cost of the MRI is within the pre-authorised limit. David has the scan the next day in the same hospital.
- Diagnosis & Treatment: A few days later, David has a follow-up appointment. The MRI confirms a meniscal tear. The consultant recommends keyhole surgery (arthroscopy).
- Treatment Authorisation: The consultant's office sends the treatment plan and costs to David's insurer. David calls his insurer again to get a new pre-authorisation number for the surgical procedure.
- The Outcome: Two weeks later, David has his surgery. His policy has a £200 excess, which he pays directly to the hospital. His insurer covers the rest of the costs, totalling over £4,000. Within six weeks of his initial GP visit, he is on the road to recovery.
Without PMI, David might have faced a wait of many months for the consultation, MRI, and surgery on the NHS.
Maximising Your Health with WeCovr's Added Benefits
Choosing the right private medical insurance in the UK is about more than just hospital lists and excess levels. At WeCovr, we believe in providing holistic value that supports your overall wellbeing.
When you arrange your PMI policy through us, you gain access to a suite of benefits designed to empower your health journey:
- Complimentary Access to CalorieHero: All our PMI and life insurance clients receive free access to our AI-powered calorie and nutrition tracking app, CalorieHero. Maintaining a healthy weight is one of the most effective ways to prevent a range of health issues, from joint problems to heart disease.
- Discounts on Other Insurance: We value our clients' loyalty. When you take out a PMI or life insurance policy, we offer attractive discounts on other types of cover you may need, such as home or travel insurance.
- Expert, Unbiased Advice: With high customer satisfaction ratings, our team is dedicated to providing clear, jargon-free advice. We're here to answer your questions and act as your advocate, ensuring you get the most from your private health cover, at no extra cost to you.
Do I always need a GP referral to see a specialist with PMI?
What happens if my PMI policy doesn't cover the full cost of the consultation or tests?
Can I choose any specialist or hospital I want?
My specialist diagnosed a chronic condition. What will my PMI cover now?
Ready to explore how private medical insurance can give you fast access to the specialist care you need?
The world of PMI can be complex, but you don't have to navigate it alone. Our expert advisors at WeCovr are here to provide friendly, no-obligation advice. We'll compare leading UK providers to find a policy that fits your needs and budget.
Related guides
Why private medical insurance and how does it work?
What is Private Medical Insurance?
Private medical insurance (PMI) is a type of health insurance that provides access to private healthcare services in the UK. It covers the cost of private medical treatment, allowing you to bypass NHS waiting lists and receive faster, more convenient care.How does it work?
Private medical insurance works by paying for your private healthcare costs. When you need treatment, you can choose to go private and your insurance will cover the costs, subject to your policy terms and conditions. This can include:• Private consultations with specialists
• Private hospital treatment and surgery
• Diagnostic tests and scans
• Physiotherapy and rehabilitation
• Mental health treatment
Your premium depends on factors like your age, health, occupation, and the level of cover you choose. Most policies offer different levels of cover, from basic to comprehensive, allowing you to tailor the policy to your needs and budget.
Questions to ask yourself regarding private medical insurance
Just ask yourself:👉 Are you concerned about NHS waiting times for treatment?
👉 Would you prefer to choose your own consultant and hospital?
👉 Do you want faster access to diagnostic tests and scans?
👉 Would you like private hospital accommodation and better food?
👉 Do you want to avoid the stress of NHS waiting lists?
Many people don't realise that private medical insurance is more affordable than they think, especially when you consider the value of faster treatment and better facilities. A great insurance policy can provide peace of mind and ensure you receive the care you need when you need it.
Benefits offered by private medical insurance
Private medical insurance provides numerous benefits that can significantly improve your healthcare experience and outcomes:Faster Access to Treatment
One of the biggest advantages is avoiding NHS waiting lists. While the NHS provides excellent care, waiting times can be lengthy. With private medical insurance, you can often receive treatment within days or weeks rather than months.
Choice of Consultant and Hospital
You can choose your preferred consultant and hospital, giving you more control over your healthcare journey. This is particularly important for complex treatments where you want a specific specialist.
Better Facilities and Accommodation
Private hospitals typically offer superior facilities, including private rooms, better food, and more comfortable surroundings. This can make your recovery more pleasant and potentially faster.
Advanced Treatments
Private medical insurance often covers treatments and medications not available on the NHS, giving you access to the latest medical advances and technologies.
Mental Health Support
Many policies include comprehensive mental health coverage, providing faster access to therapy and psychiatric care when needed.
Tax Benefits for Business Owners
If you're self-employed or a business owner, private medical insurance premiums can be tax-deductible, making it a cost-effective way to protect your health and your business.
Peace of Mind
Knowing you have access to private healthcare when you need it provides invaluable peace of mind, especially for those with ongoing health conditions or concerns about NHS capacity.
Private medical insurance is particularly valuable for those who want to take control of their healthcare journey and ensure they receive the best possible treatment when they need it most.
Important Fact!
We can look at a more suitable option mid-term!
Why is it important to get private medical insurance early?
👉 Many people are very thankful that they had their private medical insurance cover in place before running into some serious health issues. Private medical insurance is as important as life insurance for protecting your family's finances.👉 We insure our cars, houses, and even our phones! Yet our health is the most precious thing we have.
Easily one of the most important insurance purchases an individual or family can make in their lifetime, the decision to buy private medical insurance can be made much simpler with the help of FCA-authorised advisers. They are the specialists who do the searching and analysis helping people choose between various types of private medical insurance policies available in the market, including different levels of cover and policy types most suitable to the client's individual circumstances.
It certainly won't do any harm if you speak with one of our experienced insurance experts who are passionate about advising people on financial matters related to private medical insurance and are keen to provide you with a free consultation.
You can discuss with them in detail what affordable private medical insurance plan for the necessary peace of mind they would recommend! WeCovr works with some of the best advisers in the market.
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