Health Cover
Pre-authorisation, not the invoice, decides whether treatment is paid
A health policy that covers a procedure will still decline it if nobody asked first. The call before treatment is a condition of cover.
This is less a set of instructions about pre-authorisation than an argument, and it is worth saying so at the start.
The argument in brief
- Most private health policies require authorisation before treatment begins.
- Authorisation confirms eligibility, benefit limits and the fee basis in one step.
- Treatment started without it can be reduced or declined even when the condition is covered.
What the call actually does
Pre-authorisation is the insurer confirming, before money is spent, that the condition is eligible, the facility is acceptable and the benefit is available. It also fixes the fee basis, meaning how much of the consultant and hospital charge the insurer will meet. Getting that agreement in advance converts an open question into a documented commitment.
Doing it afterwards leaves every one of those questions live at exactly the point you have already been billed.
It is a condition, not a courtesy
Most wordings make prior authorisation a condition precedent to payment for planned treatment. A condition precedent is not an administrative preference; failing it can defeat an otherwise valid claim.
On an ordinary week, some insurers will pay anyway as a discretion, and discretion is not something to plan around. The safe assumption is that unauthorised planned treatment is uninsured treatment.
What the insurer asks for
Typically a referral, a provisional diagnosis, the proposed procedure code, the consultant and the facility. The consultant's secretary can usually supply these in a single email, and asking for them is routine. The insurer then issues an authorisation number that the hospital quotes on its invoice.
For most people, without that number the hospital will often ask you to guarantee the cost personally.
Shortfalls appear at this stage
Authorisation frequently reveals that the consultant charges above the insurer's fee schedule. The gap is yours to pay, and it is far easier to discuss with the consultant before treatment than after. Asking directly whether a consultant charges within your insurer's schedule is a normal question and is rarely asked.
That single question prevents a large proportion of unexpected medical bills under private cover.
Emergencies are handled differently
Emergency admissions cannot be pre-authorised, and wordings normally require notification as soon as reasonably possible instead. That period is often defined in days and is a condition in its own right.
Telling the insurer while you are still in hospital is generally better than explaining afterwards. Ask a relative to make the call if you cannot.
Some of this will suit you and some will not, and that is the point.
Keep the paper trail
Record the authorisation number, the date, the name of the person you spoke to and exactly what was authorised. Authorisation covers the specific treatment described, so a change of procedure usually needs a fresh approval. If a consultant proposes something different once you are admitted, the insurer needs to know before it happens where that is possible.
A five-minute call at that point is worth more than a long complaint later.
The takeaway
Never let planned treatment start without an authorisation number written down.
The version you keep doing is the version that works.
Questions readers ask
Does pre-authorisation guarantee payment?
It confirms eligibility on the information given, which is most of the battle. It can still be revisited if the disclosed information turns out to be incomplete, so give a full picture.
Who is responsible for getting authorisation, me or the hospital?
Ultimately you, as the policyholder. Many hospitals will do it, but the contractual obligation sits with you, so confirm it has been done rather than assuming.
