You’re not just buying benefits; you’re buying a claims process, a support model and a long-term relationship. Here’s how expats, retired expats and digital nomads can compare insurers without being swayed by marketing.
- You’re not buying a brochure, you’re buying a claims process
- Insurer vs plan: what you’re really choosing
- The short list: the 7–10 factors that matter most
- Networks and hospitals: access vs marketing
- Claims, pre-authorisation, and direct billing: the “moment of truth”
- Underwriting and pre-existing conditions: where insurer differences show up
- Exclusions, sub-limits, and wording traps: how to read like a sceptic
- Renewals and premium increases: the long game
- Financial strength and stability: what it means (and what it doesn’t)
- Service and support: time zones, language, response times
- Where a broker helps (without changing what the insurer decides)
- The insurer checklist: 25 questions to answer before you buy
- A scoring rubric you can actually use
- What people get wrong when choosing an insurer
- Red flags and sales tactics to watch for
- Case study #1
- Case study #2
- Case study #3
- Bottom line
You’re not buying a brochure, you’re buying a claims process
International Private Medical Insurance (IPMI) is rarely the exciting part of moving abroad. It’s not aspirational like choosing a neighbourhood or planning weekend travel. It’s admin—until it isn’t.
The moment a child spikes a high fever at midnight in a new country, you need an urgent specialist scan, or a hospital asks for a deposit before admitting you, your “insurance choice” stops being a brochure and becomes a workflow: who answers the phone, what evidence is needed, do they issue a guarantee of payment, and will they pay the hospital directly?
That’s why this guide is deliberately insurer-first. The plan’s benefit table matters, but the insurer’s claims handling and pre-authorisation capability is what determines whether your cover feels straightforward or exhausting. Many insurers emphasise that pre-authorisation exists precisely to organise care and make direct payment easier where possible.[1]
- Network: the list of providers (hospitals/clinics/doctors) the insurer has arrangements with, often enabling direct billing.
- Direct billing / direct settlement: the insurer pays the provider directly, rather than you paying first and claiming back.[2]
- Reimbursement: you pay first, then submit a claim and are reimbursed (subject to any deductible/excess and the policy terms).
- Pre-authorisation (pre-approval): insurer confirmation in advance for certain treatments, commonly inpatient or high-cost care.[1]
- Exclusions: treatments/situations not covered at all (for example cosmetic procedures or experimental treatment).
- Sub-limits: smaller caps within your overall annual limit (for example an outpatient cap, or a limit on physiotherapy sessions).
- Waiting period: a period before a benefit becomes payable (often maternity, or certain optional add-ons).
- Underwriting: how the insurer assesses risk and sets terms (medical questionnaire, exclusions, premium loadings).
- Moratorium vs full medical underwriting: a moratorium approach typically excludes pre-existing conditions for a defined period; full medical underwriting assesses your history upfront and confirms terms before cover starts.
- Continuity of cover: your ability to keep cover year after year without being medically re-underwritten (key for long-term predictability).
- Complaints/appeals: the formal steps to challenge a decision; in some UK-related cases, external escalation may be available via the Financial Ombudsman Service once the firm’s internal process is complete (and eligibility criteria are met).[12]
Insurer vs plan: what you’re really choosing
A plan tells you what is covered in theory. The insurer determines how that cover works in real life: the systems, speed, friction points, and the customer support model.
First, confirm you’re comparing the right product type
| Product | Designed for | What it usually does well | What it often doesn’t do |
|---|---|---|---|
| International health insurance / IPMI | Long-term living abroad; multi-country lifestyles | Comprehensive care (inpatient and often outpatient), continuity at renewal, and established pre-authorisation/direct payment workflows | Automatically cover every pre-existing condition; remove all paperwork; guarantee every provider is in-network |
| Travel medical insurance | Short trips (weeks/months) | Emergency treatment while travelling; may bundle travel-related benefits | Ongoing chronic management; routine care and long-term follow-up as a “resident abroad” |
| Local private insurance | Residents settled in one country | Fits one healthcare system well; may be cost-effective if you stay put | Portability across borders; seamless multi-country living; continuity if you move countries |
Insurers themselves draw a clear distinction: travel insurance is typically best for short-term trips, while longer stays are better suited to international expat health insurance.[5] Now Health similarly notes that travel and international health insurance “differ significantly” and that suitability depends on whether you’re travelling short-term or relocating.[6]
The short list: the 7–10 factors that matter most
If you want a practical way to compare insurers (Allianz, Cigna, Bupa, Now Health, and others), focus on these high-impact categories. Everything else is detail.
Not just “how big is the network?”, but “will they settle directly where I actually live and travel?”
Digital claims tools, typical turnaround times, documentation requirements, and how disputes are handled.
Which treatments need approval, how quickly it happens, and what the consequences are if you don’t obtain it.
Where cover is narrowed: mental health, outpatient caps, rehabilitation limits, “medical necessity” wording.
Full medical underwriting vs moratorium, how conditions are treated, and what “future-proofing” looks like once insured.
Predictability matters: age bands, geography, medical inflation, and the insurer’s pricing approach.
Ratings and what they do (and don’t) indicate about an insurer’s ability to meet claims over time.
Time zones and language are not “nice-to-haves” when you’re dealing with hospital treatment abroad.
Clear internal complaint routes and, where applicable, external escalation options.
Networks and hospitals: access vs marketing
“Network access” is one of the most overused phrases in international insurance. In practice, networks matter for one main reason: direct billing (also called direct settlement).
Allianz Care’s member guidance explains a common pattern: for private hospitals, members are advised to contact the insurer for pre-approval and confirmation of direct billing. Where arrangements exist, the insurer can help organise care and settle bills directly; where they don’t, you may receive an invoice to submit for reimbursement.[2] That “where possible” wording matters: direct billing is not guaranteed everywhere, even with major insurers.
How networks actually work (plain English)
- In-network + pre-authorised: the insurer will often settle directly with the provider, reducing the amount you may need to pay upfront.[3]
- Out-of-network: you may still be covered (depending on the plan), but often on a reimbursement basis.
- Emergency care: you get treated first; notification requirements usually apply afterwards.
What to check (instead of trusting “big network” claims)
- Can you access a provider directory? (Use it. Search your city and a “gold standard” hospital.)
- Do they explain how direct settlement works, and what you need to do to activate it? (Often: pre-authorisation.)[1]
- How do they handle out-of-network billing: do you need to pay deposits, do they issue guarantees of payment, and how quickly do they reimburse?
A strong network isn’t just a “nice perk”. It’s a cash-flow risk reducer. The more the insurer can settle directly, the less you need to self-fund large hospital bills while you wait for reimbursement.
Claims, pre-authorisation, and direct billing: the “moment of truth”
Claims is where insurer quality becomes obvious. A plan can look generous, but if the insurer’s process is slow, unclear, or difficult to navigate, it can add stress at the worst possible time.
Pre-authorisation: what it is and why insurers insist on it
Allianz describes pre-authorisation as a requirement for some treatments, mostly inpatient and high-cost, and explains that the process helps the insurer assess the case, organise matters with the hospital, and make direct payment easier where possible.[1] Bupa similarly says that if you’re treated by a provider in its network, pre-authorisation allows Bupa to settle directly with the provider, helping to avoid shortfalls and surprises.[3]
The key friction points to compare
- What requires pre-authorisation? (Typically inpatient care, surgery, some imaging, and certain high-cost outpatient treatment.)
- How quickly can it be arranged? Bupa’s provider guidance notes treatment can be pre-authorised immediately by phone, and if submitted by fax/email they respond within 24 hours.[4]
- What happens if you don’t pre-authorise? Allianz’s “Claims Made Easy” guide notes that some treatments require pre-authorisation and that it facilitates direct settlement of eligible costs, which means skipping it can create delays and increase the risk of the claim being paid later (or not in full, depending on the terms).[8]
- Direct billing vs reimbursement: Bupa explicitly distinguishes in-network vs out-of-network: in-network treatment may be settled directly; out-of-network typically requires you to submit a claim (often with proof of payment).[3]
Direct billing vs reimbursement: what often surprises clients
Many people assume international health insurance means never paying anything upfront. In reality, it depends on: (1) whether the provider is in the insurer’s network, (2) whether the treatment is pre-authorised, and (3) local provider practices. Insurers themselves advise checking whether direct billing exists with your provider and contacting them first for confirmation.[2]
Before you buy, pick two hospitals you’d realistically use (one in your main country and one in a likely travel destination), and ask: “Is direct settlement available there, and what do I need to do to activate it?”
Underwriting and pre-existing conditions: where insurer differences show up
Underwriting is the insurer’s way of translating your medical history into policy terms: standard terms, exclusions, premium loadings, waiting periods, or (occasionally) a decline.
Pre-existing conditions (plain English)
A pre-existing condition is typically any condition you’ve had symptoms of, treatment for, medication for, or medical advice about before your policy start (inception) date. Insurers use this concept to avoid taking on “known” costs without pricing them.
Two common underwriting approaches you’ll encounter
- Full medical underwriting: you disclose your history upfront; the insurer confirms terms (including any specific exclusions) before cover starts.
- Moratorium underwriting: pre-existing conditions are usually excluded for a defined period and may become covered if they haven’t recurred within the moratorium window. (Always check the policy definition.)
What matters for long-term predictability
- Continuity of cover: once you’re in, can you renew without new medical underwriting?
- Clarity in writing: if a condition is excluded or covered with specific terms, get it confirmed in writing (for example as a policy endorsement).
- Definitions and evidence: “pre-existing” definitions can be broader than “diagnosed”; they can include symptoms and advice.
“Let’s not mention that old issue” isn’t clever. It’s a fast track to claim problems later. Clear, accurate disclosure protects you because it makes the cover terms explicit before you rely on them.
Exclusions, sub-limits, and wording traps: how to read like a sceptic
People don’t usually get caught out by the headline exclusions (cosmetic-only, experimental treatment, etc.). They get caught out by the definitions and sub-limits that quietly narrow cover in situations they assumed were “obviously covered”.
What to look for in the documents
- General exclusions: what is never covered (check the insurer’s policy wording / product documentation).
- Sub-limits: outpatient caps, limits on physiotherapy sessions, mental health visit caps, maternity limits.
- Medical necessity language: insurers use “medically necessary” as a key concept in claims and pre-authorisation decisions.[7]
- “Customary and reasonable” fees: how they handle unusually high charges (common in some markets).
How to read like a sceptic (without becoming cynical)
- Start with what you might realistically use: outpatient diagnostics, mental health support, maternity, chronic condition management, and high-cost drugs.
- Find the definitions section and read it—definitions are where meaning is narrowed.
- Cross-check the claims/pre-authorisation guide: it often explains how decisions are made and what evidence is required.[8]
Ask your insurer (or broker): “If I needed an MRI and a specialist consultation next month, what steps do I follow, what would I need to pay, and do you settle directly or reimburse?” If the answer is vague, the claims experience may be vague too.
Renewals and premium increases: the long game
IPMI is often a multi-year decision. That makes renewal predictability more important than people realise.
Premium increases typically reflect a mix of age band changes, geography, and medical inflation. On the medical inflation side, WTW’s Global Medical Trends Survey projected a global average medical cost trend of 10.4% in 2025—an important reminder that healthcare costs can rise faster than general inflation.[13]
What to compare between insurers
- Renewal terms: is the policy guaranteed renewable (subject to payment and policy terms), or can the insurer refuse renewal?
- Pricing approach: do they explain the drivers (age/medical trend/region) in a transparent way?
- Continuity of cover: do you face new underwriting at renewal? (Many IPMI models avoid this; verify in your terms.)
- Changes in circumstances: if you move countries, what happens to premium and terms at renewal?
“If I develop a chronic condition next year, what changes at renewal?” The best answer is: “Your cover continues; no new medical underwriting is applied at renewal, only premium adjustments based on age/portfolio/region.” (Always confirm in your actual policy terms.)
Financial strength and stability: what it means (and what it doesn’t)
Financial strength ratings are designed to answer a narrow but crucial question: how likely is an insurer to be able to pay claims over time? The Insurance Information Institute explains that multiple independent agencies rate insurers’ financial strength, each with its own scales and standards.[9] S&P describes an Insurer Financial Strength Rating as a forward-looking opinion of an insurer’s ability to pay its policies and contracts.[10]
What financial strength does mean
- More confidence the insurer can meet its obligations (especially on large, long-running claims).
- More confidence the insurer is stable enough to be a long-term partner.
What financial strength does not mean
- It does not guarantee fast claims handling or a smooth customer experience.
- It does not guarantee the insurer will interpret borderline claims in your favour.
- It does not replace reading the policy wording and understanding exclusions/sub-limits.
Practical due diligence: where available, check at least two reputable ratings sources and compare them, rather than relying on a single marketing claim.[9]
Service and support: time zones, language, response times
If you ever need hospital treatment abroad, customer support becomes part of your healthcare infrastructure. Strong service models usually include 24/7 access, multilingual support, and clear escalation routes.
Signals of an insurer designed for international life
- Clear 24/7 support model (not “call us during office hours”).
- Support in multiple languages where relevant to your household.
- Pre-authorisation processes that work in practice (phone + digital, reasonable turnaround times, helpful staff).
- Digital self-service: claims submission tools, provider search, documents in one place.
Escalation routes (what to do when something goes wrong)
You want an insurer with a transparent complaints process and, where applicable, an external route. In the UK context, the Financial Ombudsman Service explains that you typically complain to the financial business first. If unresolved, the complaint can be escalated and time limits may apply (including the “eight weeks” rule and “six months after the final response” rule).[11]
Where a broker helps (without changing what the insurer decides)
A specialist broker can materially improve the buying and claims experience, without pretending to “override” underwriting decisions or rewrite policy terms. Think of a broker’s value as process support, not “pull”.
What brokers can do (client-first, practical support)
- Clarify needs and trade-offs: inpatient-only vs inpatient+outpatient, deductible/excess strategy, geographic area, likely provider preferences.
- Translate policy wording into plain English: definitions, exclusions, sub-limits, and “what this means in real life”.
- Organise underwriting information: helping you disclose accurately and avoid accidental omissions.
- Support pre-authorisation paperwork: ensuring the insurer gets what it needs to issue approvals and guarantees of payment.
- Help with claims documentation: what invoices, proof of payment, and clinical notes are needed (especially for out-of-network claims).
- Support escalations and renewals: identifying the right internal team, documenting timelines, and escalating fairly when delays occur.
A good broker can help you navigate between insurer teams (claims, pre-authorisation, network, underwriting), and translate what the insurer is really asking for when documentation requests feel unclear. Insurers often use specialised terminology (“clinical notes”, “itemised invoice”, “proof of payment”, “medical necessity”), and that semantic gap is where delays and misunderstandings happen. A broker’s value is not “changing the decision”; it’s helping you submit the right evidence in the right format, first time.
The insurer checklist: 25 questions to answer before you buy
- Is this policy truly long-term international health insurance (IPMI), not travel medical cover?[5]
- Does the geographic area of cover match the countries I live in and travel to most?
- Can I access a provider directory and confirm hospitals I’d actually use are listed?
- Where does direct billing apply, and what triggers it (network + pre-authorisation)?[3]
- For inpatient care, do they typically issue guarantees of payment to hospitals?
- Which treatments require pre-authorisation (inpatient, surgery, MRI/CT, rehabilitation, etc.)?[1]
- How quickly do they handle pre-authorisation requests (phone/email/portal)?[4]
- In emergencies, what are the notification rules and timelines?
- How do I submit claims (app/portal/email), and what documents are required?
- Do they require proof of payment for reimbursement claims (and in what format)?[3]
- What is the typical claim turnaround time for complete submissions (and do they state a target)?
- What is the annual overall limit, and is it realistic for high-cost markets?
- What are the biggest sub-limits (outpatient, mental health, physio, maternity, drugs)?
- Are chronic conditions covered (once accepted), and are there maintenance/treatment restrictions?
- What underwriting approach is used (full medical vs moratorium) and how are pre-existing conditions handled?
- Are there waiting periods (maternity, dental/vision add-ons, etc.)?
- Do policy terms confirm renewal without new medical underwriting (continuity of cover)?
- How are premiums recalculated at renewal (age band, region, medical trend)?[13]
- If I move countries, what happens to premium and service (mid-term vs at renewal)?
- What is the service model: 24/7 helpline, multilingual support, regional teams?
- Do they offer care support services (second medical opinion, nurse line, telemedicine)?
- What is the formal complaints process (internal steps, timelines, documentation)?
- Where applicable, is there an external escalation route (e.g., an ombudsman) and what are the time limits?[11]
- What independent financial strength ratings exist and what do they mean?[9]
- What exclusions would actually affect my lifestyle (sports, mental health, pregnancy, high-cost drugs)?
A scoring rubric you can actually use
Adjust the weight of each criterion (sliders), then score each insurer 1–5 (sliders). The totals update instantly. If your weights don’t add up to 100%, totals still work (auto-normalised), and you can click “Normalise weights to 100%”.
Totals are shown as 0–100 (easiest to compare) and an equivalent 1–5 average.
If you’re a retired couple or managing chronic conditions, you might increase the weight of renewals and outpatient cover. If you’re a digital nomad, you might increase network/direct billing and service responsiveness.
What people get wrong when choosing an insurer
- “Travel insurance is basically the same.” It’s built for short trips; expat cover is designed for longer stays and ongoing needs.[5]
- “Big network = no upfront costs.” Direct billing depends on provider arrangements and pre-authorisation steps.[2]
- “If I skip pre-authorisation, it’ll be fine.” Pre-authorisation is the pathway to direct settlement for many inpatient/high-cost treatments.[8]
- “All insurers handle claims the same.” The workflow (tools, timescales, evidence) can differ dramatically.
- “The cheapest premium is best value.” A cheaper plan with tight outpatient sub-limits can cost more in practice.
- “I don’t need outpatient cover.” Diagnostics and specialist care often happen outpatient; it’s where expats commonly feel gaps.
- “Pre-existing conditions don’t matter if I feel OK now.” Underwriting is driven by history and definitions, not how you feel today.
- “I can just switch insurers later if I need to.” Switching often triggers new underwriting and new exclusions for conditions that develop in the meantime.
- “Financial strength ratings mean they’ll pay anything.” Ratings are about ability to pay, not whether a claim meets the policy terms.[10]
- “If a claim is rejected, I’m stuck.” There are complaint routes; in the UK context, firms must respond within timeframes and consumers may be able to escalate externally (where applicable).[14]
Red flags and sales tactics to watch for
- “Everything is covered.” Response: ask for exclusions and sub-limits in writing (policy wording / benefit guide).
- Pressure to buy today. Response: slow down; insurer quality stands up to scrutiny.
- Vague answers on pre-existing conditions. Response: ask what underwriting approach applies and get terms confirmed in writing.
- Hand-waving around pre-authorisation. Response: ask exactly what requires approval and what turnaround times apply.[1]
- “Direct billing everywhere.” Response: pick two hospitals and verify the reality of direct settlement.[2]
- No access to full documents pre-sale. Response: don’t buy without the policy wording.
- Suspiciously low premium vs peers. Response: identify what’s missing (outpatient cover, sub-limits, geographic restrictions, underwriting exclusions).
- Encouraging non-disclosure. Response: walk away; it puts future claims at risk.
- Unclear complaints/appeals process. Response: ask for the documented process and timelines; understand external escalation rules where applicable.[11]
- Overreliance on a single rating/claim. Response: cross-check ratings and remember what they do and don’t measure.[9]
MoneyHelper’s guidance on rejected insurance claims recommends making a clear, formal complaint with supporting evidence, stating what you want put right, and noting escalation to the Financial Ombudsman Service if you remain unhappy (where applicable).[14] This isn’t about being aggressive; it’s about being organised.
Broker perspective: a specialist broker can also help you navigate the insurer’s internal teams (claims, pre-authorisation, network), and clarify exactly what documentation the insurer is requesting. Insurers’ terminology can create confusion; a broker can translate the “insurer language” into plain English and help you submit the right evidence, in the right format, first time.
Case study #1
Their priorities weren’t flashy add-ons; they wanted stability and low friction. They compared insurers by: (1) whether direct billing was realistic in Portugal, (2) whether they could use private care when visiting France, (3) how pre-authorisation works for inpatient care, and (4) renewal predictability as they age.
Their “insurer test” was simple: could the insurer explain, in plain language, how a hospital admission in Lisbon would be handled, and whether the hospital could be paid directly once pre-authorised?[1] They also wanted clarity on what happens if a private hospital does not have direct billing arrangements—would they be invoiced and then claim back?[2]
How their evaluation differs: retirees often weight renewal predictability and outpatient/chronic management more heavily than a younger nomad would.
Case study #2
The employer plan covers care only in the country of residence—fine for day-to-day needs—but it doesn’t solve the family’s real concern: the ability to seek elective specialist care in Switzerland if a complex condition requires it.
Their comparison focused on: (1) whether the insurer is set up for international treatment workflows, (2) whether out-of-country care can be pre-authorised and supported through direct settlement where possible, and (3) how out-of-network claims are handled if the Swiss specialist is not in the insurer’s network. Bupa’s published guidance makes the in-network vs out-of-network distinction explicit: in-network treatment can be settled directly with pre-authorisation; out-of-network typically requires claim submission through its portal.[3]
How their evaluation differs: they prioritise network quality and high-cost treatment logistics over “extras”.
Case study #3
This buyer’s biggest risk isn’t “one healthcare system”; it’s constant transition. They value: (1) multi-country suitability (IPMI over travel insurance for longer stays), (2) a predictable pre-authorisation process across borders, and (3) a service model that can respond across time zones.
They start by confirming they’re not mistakenly relying on travel insurance for an extended lifestyle: Cigna’s explainer frames the first decision as duration—short-term trips vs longer-term expat cover.[5] Now Health similarly highlights that the right product depends on whether you’re taking a short-term trip or relocating longer term.[6]
How their evaluation differs: nomads often weight service responsiveness and cross-border practicality more highly than local “comfort features”.
Bottom line
- Define your “care reality”. Write down where you’d want to be treated in a serious scenario (and why).
- Shortlist 2–3 insurers. Focus on operational quality: claims, pre-authorisation, direct billing, support model.
- Stress-test the network. Check two hospitals you’d use and confirm the direct settlement steps.[2]
- Run the 25-question checklist. If you can’t answer a question clearly, you haven’t finished your due diligence.
- Use the scoring rubric. A structured score helps you avoid over-weighting price or marketing.
- Plan for renewal reality. Remember medical costs can trend up sharply; medical inflation is a real driver of premiums.[13]
- Document everything. Keep policy wording, disclosures, and written confirmations together.
The goal isn’t to buy the “most expensive” plan. It’s to choose an insurer whose processes hold up when life gets messy— because that’s the point of insurance.
