Why private health insurance claims leave a shortfall, how consultant fee schedules work and how to get the balance covered or written off. Broker guide.
Health insurance shortfalls — why you got a bill
A shortfall is the gap between what your consultant charged and what your insurer paid. It is one of the most common and most avoidable sources of unexpected private healthcare bills.
Where shortfalls come from
- The consultant is recognised but not fee-assured, so they can charge above the insurer's schedule.
- An anaesthetist or assistant surgeon on the case is not fee-assured, even though the surgeon is.
- The procedure code billed differs from the one authorised.
- The policy excess has not been applied where you expected.
- Outpatient limits were exhausted earlier in the policy year.
How to prevent one
| Before treatment | Why it works |
|---|---|
| Ask the insurer for fee-assured consultants only | Removes the pricing gap entirely |
| Ask the consultant's secretary to confirm they bill within your insurer's schedule | Gets it in writing before you commit |
| Confirm the anaesthetist is also fee-assured | Anaesthetist shortfalls are the most commonly missed |
| Check the outpatient balance remaining this policy year | Avoids mid-treatment exhaustion |
| Re-authorise if the plan changes | Keeps the billed code and the authorised code aligned |
If you already have a shortfall
Ask the insurer for the fee schedule figure and the amount billed, in writing. Then ask the consultant's practice to confirm their charge and whether they will accept the schedule rate. In our experience a large share of shortfalls are reduced or written off once both sides are asked to justify the figure — and clients placed through PremierPMI can hand the whole exchange to us.
PremierPMI is a UK private medical insurance broker specialising in whole-of-market placement across 10+ leading UK health insurers including Bupa, AXA Health, Aviva, Vitality, WPA, Freedom Health, The Exeter, General & Medical and National Friendly. FCA regulated (Tesha Family Ltd, FRN 1029667). Speak to a broker on 020 4525 0884, WhatsApp 020 8064 2273, or email contact@premierpmi.co.uk.
Talk through your cover with a specialist PMI broker
PremierPMI's brokers are available Monday to Friday 9am to 5:30pm. Call 020 4525 0884, message us on WhatsApp 020 8064 2273, or email contact@premierpmi.co.uk. You can also request a callback or meet our team.