Private health insurance

Making a claim

If your employees need to make a claim, then we’ll do everything we can to make things go smoothly. We understand that they may not be feeling 100% when they call. Most claims can be approved over the phone, with no need for paperwork at all.

Our claims follow two different paths depending on what type of condition your employees are claiming for. Don't worry though, they're both really easy to follow and only have small differences.

BacktoBetter claims

If your employees are claiming for pain in their back, neck, muscles or joints (musculoskeletal (MSK)) then they should use the BacktoBetter service. These claims follow a simple three step process and they don't need to see their GP.

Step 1

If an employee has consulted their GP before contacting us, their condition must still be assessed by our clinical case management providers and we will only cover treatment if it is managed by them unless:

  • the employee's GP has recommended osteopathy or chiropractic treatment or
  • the employee's condition does not relate to their back or neck, and
  • the employee's GP has recommended radiology, pathology, or referral to a specialist.

Step 2

Providing it's a valid claim, the claims adviser will arrange for a clinical case manager from one of our independent clinical providers to contact the employee to assess their symptoms.

We always aim to provide this assessment at a time that is convenient for your employee.

Step 3

The clinical case manager will determine whether treatment is necessary. If treatment is not necessary, the member will be taught how to self manage their condition. If clinically appropriate, this will include being referred to a physiotherapist on our clinical providers network for treatment within two working days and/or onward referral to a specialist.

Standard claims

For all other claims (any non-back, neck, muscle or joint pain) it's also a simple three step process. Your employees need to call the customer service helpline and we'll explain what needs to happen at each stage of their claim:

Step 1

If an employee is unwell they will need to see a GP, where they may be referred for further assessment or treatment. This could be an open referral or a named referral. A named referral is where the GP recommends a particular specialist. An open referral is where the GP just states which type of specialist they need to see or the type of treatment needed.

Step 2

After your employee has been referred by their GP they’ll need to call us to set up their claim. If they’ve been given a named referral, we’ll check to make sure the specialist is recognised by us. If we have a network of facilities, specialists or other practitioners for the treatment your employee needs they'll need to use this network and we’ll tell them where they can have their treatment. This may or may not be at a hospital included on your chosen list.

When we don't have a network, if it’s an open referral, we’ll use our specialist finder database to select an appropriate specialist and/or hospital.

NB - It’s really important that your employees get in touch with us before attending any appointments so we can make sure their claim is covered under the terms and conditions of the policy before they incur any costs.

Step 3

After an employee attends an appointment, their specialist may recommend hospital treatment – this is where they need to ask for a procedure code.

Once they’ve called us with these details, we can confirm whether or not their treatment is covered, and we will then provide information about hospitals either from our networks or recognised by us, where your employee can receive treatment.

Whatever route your employees' claim has taken, as soon as treatment has finished, we'll settle all eligible bills directly with the treatment provider. If your employee receives a bill for their treatment, they will need to forward it to us (taking a photocopy for their records), so we can arrange direct payment with the provider.

Claims can be approved over the phone

In the vast majority of cases our experienced claims consultants will be able to approve the claim over the phone with no need for further information.

If we need more information, we’ll do our best to make sure that paperwork doesn’t hold things up. If we can’t approve your employee’s claim because it’s not covered by your policy, we’ll explain the details to you – although we can't divulge any confidential medical details.

We’re here to help you

We have claims teams that have been trained in specialist areas. For example, our oncology claims department is trained to deal with the circumstances surrounding a claim for cancer treatment. And our psychiatric team understands that dealing with an insurance claim may be difficult at this time.

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