What you need to know about who is watching
Who does what
Two separate regulators sit behind a UK health insurance policy, and they answer different questions. The Financial Conduct Authority asks whether the firm behaved properly: how the policy was sold, how it was explained, how claims and complaints are handled. The Prudential Regulation Authority, part of the Bank of England, asks whether the insurer is financially sound enough to pay the claims it has promised to pay. [1][6]
| Body | What it does | What it does not do |
|---|---|---|
| Financial Conduct Authority (FCA) | Authorises firms and sets conduct rules on selling, information and claims handling | Does not decide individual claims or set what a policy must cover |
| Prudential Regulation Authority (PRA) | Supervises insurers’ capital and financial resilience | Does not handle consumer complaints |
| Financial Ombudsman Service (FOS) | Decides individual complaints free of charge for consumers | Does not regulate firms or fine them |
| Financial Services Compensation Scheme (FSCS) | Protects policyholders if an authorised insurer fails | Does not help where a claim is simply declined |
| Competition and Markets Authority (CMA) | Investigates competition in the private healthcare market | Does not supervise insurance conduct |
How to check a firm
Every firm that sells, arranges or administers a UK health insurance policy must be authorised, and the Financial Conduct Authority publishes the Financial Services Register so anyone can check. [2] Search the firm name or reference number and you will see whether it is authorised, what it is permitted to do, its registered address and its trading names. A firm that cannot be found on the register, or whose permissions do not cover insurance, is a firm to walk away from.
Step 1: Ask for the firm’s registered name and reference number
Trading names are common in this market, so ask which legal entity you are dealing with.
Step 2: Look it up on the Financial Services Register
Check the permissions cover insurance distribution, and that the status is current.
Step 3: Check who the actual insurer is
A broker arranges the policy; a separate insurer underwrites it. Both should be authorised.
Step 4: Keep the documents you are given
The summary document and the full wording are the record of what you were told and sold.
What the rules actually require
Regulation shapes conduct rather than product design. There is no rule that says a policy must cover physiotherapy, or must apply an excess once a year rather than per claim. What the rules do require is that you are given appropriate information about the policy in good time before you commit, including a short standardised summary document alongside the full wording. [3]
Since the Consumer Duty came into force, firms also have to show that products deliver good outcomes for retail customers, that price represents fair value, that communications support understanding rather than merely disclose, and that customers get the support they need at claim and at renewal. [7] In practice this raises the standard a firm must meet when explaining something as consequential as an exclusion for a pre-existing condition.
What regulation does and does not give you
What works well
- A public register you can use to verify any firm before you buy
- A required summary of the policy in a standard format, before you commit
- A free, independent complaints service if the firm gets it wrong
- A compensation scheme if the insurer itself fails
What to watch
- No regulator decides what a policy must cover
- A declined claim is not automatically a regulatory failure
- The ombudsman looks at fairness on the facts, not at whether you like the outcome
- Employer-arranged schemes may route complaints differently
How to complain
Complaints follow a fixed order. You complain to the firm first — the insurer for a claims or policy decision, the broker for an advice or sales issue — and the firm must investigate and respond. If you are unhappy with the final response, or eight weeks pass without one, you can take the complaint to the Financial Ombudsman Service, which handles medical insurance complaints free of charge for consumers and can direct a firm to put things right. [4]
| Your situation | Where to go first |
|---|---|
| A claim has been declined or underpaid | The insurer’s complaints process, then the Financial Ombudsman Service |
| You were sold a policy that did not suit you | The firm that advised or arranged it, then the ombudsman |
| You cannot find the firm on the register | Stop, and check with the FCA before paying anything |
| Your insurer has gone out of business | The Financial Services Compensation Scheme |
| A private hospital or consultant bill is disputed | The provider, and check published provider information |
Complaints are most effective when they are specific. Say what you were told, what happened, which clause of the wording the firm has relied on and what outcome you want. Attach the authorisation reference, the invoices and the correspondence. The ombudsman decides on what is fair and reasonable in the circumstances, and a clear factual account is worth more than a strongly worded one.
Adviser insight
“The first thing to do when a claim is declined is to ask the insurer, in writing, which clause of the policy wording they are relying on. Nine times out of ten the answer tells you immediately whether there is an argument to make. What changes outcomes is evidence: the exact wording quoted back, the dates, the correspondence and the referral paperwork. A calm complaint with those attached gets further than an angry one, and if the firm still gets it wrong, the ombudsman looks at the same documents.”
If an insurer fails
The Financial Services Compensation Scheme is the backstop if an authorised insurer becomes insolvent. It exists for firm failure, not for disagreements about a claim, and the level of protection depends on the type of policy and the circumstances. [5] It is one more reason to make sure the entity underwriting your policy is authorised in the UK, which the register will tell you in a few seconds. [2]
The wider market picture
Beyond financial regulation, the private healthcare market itself has been examined by the Competition and Markets Authority, whose investigation led to continuing obligations on private hospitals and consultants about the information they disclose. [8] The market is also substantial: insurers covered 6.5 million people in 2024 and paid a record £4 billion in claims. [9] For the practical consequences of all this, read what private health insurance covers, how medical underwriting works and what an excess is.
What good looks like when you are being sold to
Regulation is easier to use if you know what it should feel like from your side of the table. A firm meeting the standard tells you which entity it is and gives you its reference number without being pushed. It explains how it is paid, and by whom, before you decide anything. It gives you the summary document and the full wording in time to read them, rather than after you have agreed. It asks about your circumstances before recommending anything, and it writes down why the recommendation suits you. [3][7]
Certain things should stop a conversation. Pressure to decide today. A refusal to put the recommendation in writing. Vagueness about which insurer will underwrite the policy. An unwillingness to talk through exclusions, or a suggestion that you can leave a medical question blank. None of these are matters of taste: they cut across the rules on information and fair treatment, and they are worth reporting as well as walking away from. [1]
Keep everything. The quote, the summary document, the full wording, the emails, the name of the person you dealt with and the date. If a dispute ever arises, the outcome usually turns on what was said and supplied at the point of sale, and the party with the records is the party in the stronger position. Neither the regulator nor the ombudsman can reconstruct a conversation nobody wrote down. [4]
Looking at cover with PremierPMI
PremierPMI is a specialist private medical insurance broker and the publisher of The Health Guide. If you want to talk through what this means for your own cover, you can start there.
Or, if you would rather start here, send an enquiry and PremierPMI will contact you.
Common questions
Does the FCA decide whether my claim should be paid?
How do I check my insurer or broker is authorised?
What can the Financial Ombudsman Service actually do?
Is the ombudsman service free?
Who regulates private hospitals and consultants?
Does regulation set what a policy has to cover?
What protection do I have if my insurer goes bust?
Are employer-arranged schemes regulated differently?
Sources and methodology
- [1] Financial Conduct Authority. “About the FCA”. View source(opens in a new tab)Primary source
- [2] Financial Conduct Authority. “The Financial Services Register”. View source(opens in a new tab)Primary source
- [3] Financial Conduct Authority. “ICOBS 6: Product information (FCA Handbook)”. View source(opens in a new tab)Primary source
- [4] Financial Ombudsman Service. “Complaints about medical insurance”. View source(opens in a new tab)Primary source
- [5] Financial Services Compensation Scheme. “What we cover: insurance”. View source(opens in a new tab)Primary source
- [6] Bank of England. “Prudential Regulation Authority”. View source(opens in a new tab)Primary source
- [7] Financial Conduct Authority. “The Consumer Duty”. View source(opens in a new tab)Primary source
- [8] Competition and Markets Authority. “Private healthcare market investigation”. View source(opens in a new tab)Primary source
- [9] Association of British Insurers. “Insurers process record £4bn across individual and workplace health schemes (2024 data)”. View source(opens in a new tab)Primary source
We cite primary sources wherever possible. Read about our sourcing methodology.
Ilana Eldad
Corporate PMI Specialist, PremierPMI
- ACCA-qualified
- Corporate and SME scheme specialist
Ilana oversees business health insurance schemes for the corporate and SME team, guiding employers from initial quotes through claims and renewal. ACCA-qualified, she applies that financial background to reducing premiums and advising on tax-deductibility, and runs the largest corporate portfolio at PremierPMI.
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Andrew Buscu
PMI Specialist & Copywriter, PremierPMI
- Whole-of-market private medical insurance adviser
- Claims and renewal specialist
Andrew is a member of the private medical insurance advisory team. He gathers detailed client requirements and liaises with insurers to arrange tailored quotes across the whole UK market, guiding clients from first quote through to claims and renewal. In one case he reduced a client renewal premium from £36,000 to £11,520 without reducing cover.
Read full profile
