What happens when you claim on Business Health Insurance?

Your employee needs to use their cover. Maybe a GP has suggested a referral, or they want to see a specialist without waiting on the NHS. Whatever the situation, knowing what to expect from the claims process makes a real difference, for you as an employer, and for the employee who needs support.

Here is a clear walkthrough of exactly what happens when a claim is made on a business health insurance policy, from the first phone call through to treatment and payment.

Step 1: The employee contacts the insurer directly

Most private medical insurance (PMI) claims are handled directly between your employee and the insurer. As an employer you do not typically need to get involved in the medical details, which is good for employee privacy and your own workload.

Your employee calls the insurer’s dedicated claims line. Most major UK insurers including Bupa, AXA Health, Vitality and Aviva have extended-hours lines for this purpose, though opening hours vary by provider so it is worth checking the specific details for your policy.

Charlie Cousins, Founding Director at Hooray: One of the most common mistakes I see is employees going ahead and booking treatment without speaking to the insurer first. I have seen it happen multiple times where someone has started seeing a therapist, only to find out later that the therapist is not registered with the insurer as a verified consultant. The claim gets rejected and the employee ends up out of pocket. Always speak to your insurer or broker before booking any treatment or appointments. It takes one phone call and can save a lot of stress.

Step 2: The insurer verifies eligibility and issues a referral code

The insurer confirms the employee is an active, covered member of your policy. They then ask about the medical issue, including:

• What symptoms the employee is experiencing
• When the symptoms started
• Whether they have seen their GP
• Whether any pre-existing conditions are involved

Based on the answers, the insurer either approves the claim straightaway or requests a GP referral letter first. Many insurers offer what is known as open referral, where no GP letter is required, but this varies by policy and insurer so check your specific terms rather than assuming it applies.

The level of cover available depends on the type of business health insurance policy you have purchased.

Step 3: The employee chooses a consultant or hospital

Once a referral code has been issued, your employee can choose from a list of approved consultants or hospitals within the policy’s network. The insurer will suggest options based on location and specialism.

The breadth of this network depends on the cover level. Budget policies may have a shorter approved list, while comprehensive plans typically cover a wider range of consultants and private hospitals across the UK.

If your employee books treatment without pre-authorisation or a valid referral code, the claim may not be covered. Always confirm with the insurer before any appointment is booked.

Step 4: Treatment takes place

Your employee attends the appointment, consultation or procedure. The consultant or hospital will usually bill the insurer directly, so your employee should not face upfront costs provided the treatment has been pre-authorised and stays within the policy terms.

Standard group health insurance policies typically cover outpatient consultations, diagnostics, inpatient and day-patient treatment, and depending on the policy, mental health support and physiotherapy. See our guide to what business health insurance covers for a full breakdown.

Step 5: The insurer pays the provider

Once treatment is complete, the healthcare provider submits the bill to the insurer. The insurer processes the claim and pays the provider directly. In most cases, your employee will receive a statement showing what was claimed and what the insurer paid.

If any element of the treatment falls outside the policy, for example a treatment that is excluded, or a consultant outside the approved network, your employee may receive notification of any shortfall they need to cover personally.

What about excess payments?

Some business health insurance policies include an excess, a fixed amount the employee contributes to each claim before the insurer pays out. This is often used to keep the overall premium lower.

If an excess applies, your employee will usually receive a bill from the provider for that amount. As an employer you can choose whether to cover this cost or leave it with the employee. It is worth clarifying this in your employee benefits communications so there are no surprises.

What happens to your premium after a claim?

Individual claims rarely trigger an immediate premium increase. However, group health insurance renews annually, and if your group’s overall claims experience has been high, the insurer may increase the renewal premium to reflect that.

This is one of the reasons working with an experienced broker matters at renewal time. At Hooray, we review your claims data, challenge unjustified increases, and shop the market on your behalf to make sure you are always on competitive terms.

What if a claim is declined?

Claims can be declined if the treatment relates to an excluded pre-existing condition, if the referral process was not followed correctly, or if the consultant was not on the approved list. If this happens, the employee has the right to appeal.

As your broker, Hooray can help with this. We will work with you and the insurer to understand the reason for the decline and, where appropriate, support an appeal on your behalf.

How Hooray can help

At Hooray, we make sure you and your team understand how to use your cover before you ever need to make a claim. From clear employee guides to being on hand when questions come up, we act as an extension of your HR function.

If you are considering business health insurance for your team, or want to review your existing cover, speak to our team today.

Related reading: What is the best health insurance broker for SMEs? | 7 best group health insurance providers for SMEs | Employee benefits for small businesses