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How to stop health cover falling short

At VitalityHealth, when we say ‘Full Cover’ we mean it. Unlike other insurers, we settle consultant and anaesthetist’s fees in full, so your clients don’t have to pay any shortfalls.

Ask yourself, if they fell ill and needed treatment would your clients expect their consultant’s bill to be paid in full? Not all health insurers cover the full cost of consultants’ fees as standard, so at a time when their customers are already coping with poor health, they may also feel pressured to choose between their preferred consultant or the one whose costs will create the smallest shortfall on their insurance policy. With VitalityHealth, that’s one difficult conversation you won’t need to have with your clients.

There are currently more than 21,000 consultants in private practice. At VitalityHealth, we don’t believe the fear of a shortfall should influence which consultant our members can see. That’s why we cover consultant and anaesthetist’s fees in full. We know that’s the type of cover your clients want – two thirds of consumers agree that health insurers should pay consultant fees in full, no matter how much the consultant charges (1).


Access to a consultant at a convenient time and place is a key reason why clients purchase health insurance. Most also expect that, in return for their premium, their health insurance will cover the resulting fees in full. But despite the billions of pounds individuals and employers pay each year to ensure speedy access to a specialist when they need it, often there is no guarantee that the fee for this expertise will be covered in full. Most insurers use ‘fee maxima’ or ‘reasonable and customary guidelines’ to determine how much they allow toward consultant and anaesthetists’ services. On occasions where the fee is above the insurer’s maxima or guide, the customer is left to make up the difference. That’s a bitter pill for anyone to swallow.

The amounts and frequency of these shortfalls can vary significantly from insurer to insurer. Potential shortfalls can be in terms of hundreds of pounds and in some extreme cases can go into 4 figures (2). Similarly, the frequency at which shortfalls occur can vary anything from 5% of fees submitted with one insurer to 30% with another Surgery is just one part of the story. These ‘fee maxima’ and ‘reasonable and customary guidelines’ often apply to outpatient consultation fees, as well as advice and treatment for life-threatening conditions such as cancer. So even if a client has full outpatient cover and/or full cancer cover, shortfalls may occur if their specialist charges a fee more than their insurer allows.


The market has attempted to address the issue of shortfalls, through a combination of fee guaranteed specialist networks and open referral. But these measures can run the risk of restricting choice even further for your clients. In the case of fee guaranteed networks, a person may be influenced to choose a consultant from the approved list, rather than feeling free to select the specialist who can offer them the best treatment. With open referral, the number of consultants recommended varies from one to three, depending upon the insurer concerned.

VitalityHealth takes a different approach to rest of the market. Our Full Cover Promise means we settle consultant and anaesthetist’s fees in full so your clients don’t have to pay any shortfalls, as long as their condition is eligible for cover and their providers are recognised.


To ensure our Full Cover Promise remains cost effective for our business and our members, we set appropriate fee benchmarks for all of the hundreds of different procedures it covers. By employing this approach, we find only a small minority of consultants charge above these benchmarks. In these cases, VitalityHealth proactively engages with these consultants to understand what drives their charging patterns. Where appropriate, we will adjust payments upwards; on rare occasions, where a suitable outcome cannot be agree, VitalityHealth will derecognise the consultant.

The result is affordable premiums for your clients, and the confidence that any consultants’ fees will be covered at times of need. It’s why VitalityHealth’s Full Cover Promise makes sense for you and your clients.


  1. VitalityHealth’s Full Cover Promise allows your clients freedom to use the consultant of their choice.
  2. VitalityHealth’s Full Cover Promise gives your clients peace of mind that all consultant and anaesthetists bills are covered, as long as the treatment is eligible on their plan and their specialist recognised by us.
  3. VitalityHealth uses data to determine reasonable market charges as a benchmark. This benchmark helps VitalityHealth identify and work with those consultants and anaesthetists who charge outside of this benchmark; in the majority of cases reaching a solution that benefits all parties.
  4. VitalityHealth’s Full Cover Promise has a guiding principle to protect clients from fee discussions and the prospect of shortfalls.
  5. VitalityHealth’s Full Cover Promise protects you from uncomfortable conversations with your clients around fee-related shortfalls.

1. VitalityHealth / Immerse 2014
2. VitalityHealth analysis of health insurers’ fee guidelines

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