What should I do if there is a shortfall on my private medical insurance?

Find out about your options when there is a difference between what a consultant charges for your treatment and what your private medical insurance company is prepared to pay.

woman on the floor making calculations
Simon PotterGetty Images

A shortfall is the difference between what a consultant charges for your treatment and what your medical insurance company is prepared to pay. In the last few years, some insurance companies have adopted a fee assured system or a capped payout scheme.

The companies set the fee for a named procedure and the total price is only covered if you choose a consultant who agrees to work for that set fee. If they don't, the extra has to be paid directly by you. But how can you avoid a shortfall and what can you do if you end up with a hefty medical bill you didn't expect?

Check your policy terms and conditions

Much confusion has arisen about whether companies make it clear enough that a shortfall is a possibility. Whenever you take out a new insurance policy, it is not good enough to just read the general information that comes to you as part of the sign up process. You need to go through all of the fine print in detail.

The terms and conditions can be written in language that is none too friendly, so consider going to a medical insurance broker for advice. This may involve a fee but it is likely to be much lower than a medical bill due to shortfall.

Insurance companies are under pressure to provide clearer information and to inform you, up front, if some treatments are at risk of generating a shortfall. They should also soon make it more obvious how much you are likely to pay.

Contact your private medical insurance provider

If you need treatment and you are then informed that there will be a shortfall, contact your insurance company. Explain the situation and see if they can offer any advice to resolve the problem. If you have chosen a named consultant that is not on the list provided by the insurance company, you could find out more about the consultants that the company has offered. If there is a doctor that you would be equally happy with, it may be possible to arrange the treatment with them.

Contact your consultant

One patient reported that her chosen consultant actually ended up doing her treatment for a fee lower than the one quoted by the consultants on her insurer's list. If you contact your chosen consultant and explain the situation, it may be that they are prepared to reduce their fees. This may save on your medical bills, even if it doesn't remove the shortfall completely.

If you feel that the shortfall has created a medical bill that is completely unexpected, you may have a case for complaint against your consultant for not making his or her fees clear enough. In once recent case, an anaesthetist lost a court case for claiming a fee for a patient's operation that was just short of that charged by the surgeons.

Contact the private medical insurance regulators

If you cannot resolve the issue of a shortfall and are unable or unwilling to pay the final bill because you feel you have been misled, contact the Financial Conduct Authority or the Financial Ombudsmen for further advice.

Want to know more?

Why should I buy private medical insurance?

What does private medical insurance cover?

What does private medical insurance not cover?

Why is private medical insurance so expensive?

What does private medical insurance cost?

What types of private medical insurance are available?

What type of scheme is right for me and my family?

Where do I go for a quote for private medical insurance?

Should I go to a private medical insurance broker?

How do I minimise the cost of private medical insurance?

What questions should I ask the insurer or broker?

What should I watch out for when buying private medical insurance?

Who are the biggest private medical insurance companies?

How do I compare private medical insurance providers?

How to choose the right private medical insurance policy

Does private medical insurance provide cancer cover?

What are the common restrictions on private medical insurance policies?

What are the alternatives to private medical insurance?

What is the best private medical insurance for elderly people?

Private medical insurance for people with pre-existing medical conditions

Can I get a no-claims discount for private medical insurance?

Will private medical insurance cover me if I fall ill abroad?

What does a moratorium on private medical insurance mean?

What does fee assured mean for patients with private medical insurance?

How to make a private medical insurance claim

What do I do if my claim is rejected?

How do I complain about my insurer or private medical insurance policy?

Last updated

Advertisement - Continue Reading Below
More From Private insurance