
As an FCA-authorised broker that has helped arrange over 900,000 policies, WeCovr knows that navigating private medical insurance in the UK can be complex. This guide explains outpatient and specialist cover, a crucial part of any policy, to help you make an informed choice for your health and peace of mind.
When you invest in private medical insurance (PMI), you're primarily buying speed of access and choice. While many people think of surgery and hospital stays, the journey to treatment almost always begins with an outpatient visit: a consultation with a specialist and the diagnostic tests they recommend.
Understanding how your policy covers these initial steps is the key to unlocking the full value of your private health cover. Get it right, and you’ll have a seamless experience; get it wrong, and you could face unexpected bills. This guide will break down everything you need to know about outpatient cover, from financial limits to specialist networks.
Before we dive into the details, let's clarify the three main types of hospital treatment your policy might cover. Almost all UK PMI policies cover inpatient and day-patient care as standard. Outpatient cover is the most common and important optional extra.
| Treatment Type | Description | Real-Life Example |
|---|---|---|
| Inpatient | You are admitted to a hospital and stay overnight for one or more nights for treatment, such as surgery or monitoring. | Having a knee replacement and staying in the hospital for three nights to recover. |
| Day-Patient | You are admitted to a hospital or clinic for a scheduled procedure but do not stay overnight. | A colonoscopy or cataract surgery where you go home the same day. |
| Outpatient | You visit a hospital or clinic for a test or consultation but are not formally admitted. This is the diagnostic stage. | Seeing a cardiologist for chest pains, followed by an ECG and a blood test. |
A Critical Note on PMI Coverage: It is essential to remember that standard private medical insurance in the UK is designed to cover acute conditions that arise after your policy begins. It does not cover pre-existing conditions (illnesses you already had or had symptoms of before taking out the policy) or chronic conditions (long-term illnesses like diabetes, asthma, or high blood pressure that require ongoing management rather than a cure).
So, you have a health concern and you want to use your PMI. How does it work? The path from symptom to specialist is usually very structured.
Visit Your GP: Your first port of call is almost always your NHS or private General Practitioner (GP). You discuss your symptoms, and if they feel you need specialist advice, they will write you a GP referral letter. This is a crucial document for your insurer.
Contact Your Insurer: With your GP referral in hand, you call your insurance provider's claims or pre-authorisation line. You'll explain the situation and provide the details of the referral.
Get Pre-Authorisation: The insurer will check your policy details. They'll confirm that the speciality is covered, that you have sufficient outpatient benefit remaining, and that you haven't exceeded any limits. They will then give you an authorisation number for the consultation.
Choose Your Specialist: Depending on your policy type (more on this later), you'll either be given a choice of specialists from a broad network or a more "guided" list of 2-3 approved consultants.
Book Your Appointment: You can now book your appointment directly with the specialist's secretary, giving them your PMI membership number and the pre-authorisation code. The specialist's clinic will usually bill the insurer directly, so you don't have to handle payments, aside from any excess on your policy.
Example in Action:
This is where policies differ the most and where you have the biggest decision to make. Insurers offer different levels of outpatient cover to cater to various budgets. Choosing the right level is a balance between what you can afford in monthly premiums and what you'd be willing to pay out-of-pocket if needed.
Here are the typical options:
| Level of Outpatient Cover | Typical Financial Limit | Who It's Good For | Monthly Premium Impact |
|---|---|---|---|
| Comprehensive (Full Cover) | Unlimited | Those who want complete peace of mind and no financial worries about diagnostic costs. | Highest |
| Mid-Range Cover | £1,000 to £2,000 per year | A popular choice offering a good balance of cover and cost. Covers most typical diagnostic journeys. | Medium |
| Basic (Low-Limit) Cover | £500 per year | Those on a tighter budget who want some cover for an initial consultation and simple tests. | Lower |
| No Outpatient Cover | £0 | People who are happy to use the NHS for diagnostics and only want PMI for inpatient treatment. | Lowest |
Your outpatient limit is a pot of money you can use for consultations, tests, and scans for the entire policy year.
A £1,000 limit might cover an initial consultation, one follow-up, and a simple scan or a series of smaller tests. A more complex issue requiring multiple scans could easily exceed this limit, meaning you would have to pay the remaining balance yourself.
Working with an experienced PMI broker like WeCovr is invaluable here. Their experts can model different scenarios for you, explaining how various limits would apply and helping you find the sweet spot between comprehensive cover and an affordable premium.
It's not just about how much cover you have, but also where you can use it. Insurers build networks of hospitals and specialists to control costs and ensure quality. Using a provider outside this network can leave you with a significant "shortfall" – the difference between what the specialist charges and what your insurer will pay.
A "fee-assured" specialist is a consultant who has agreed with an insurer that they will not charge more than the insurer's published fee schedule. By seeing a fee-assured specialist, you guarantee there will be no shortfall for their time.
Before booking any appointment, you should always ask your insurer:
In recent years, to help manage premiums, many leading UK PMI providers have introduced "guided" consultant options.
| Feature | Guided Consultant List | Open / Un-guided List |
|---|---|---|
| Choice | The insurer provides a shortlist of 2-3 vetted specialists for you to choose from. | You can choose any specialist from the insurer's wider network, provided they are recognised. |
| Cost | Premiums are typically 15-20% lower. | Standard or higher premiums. |
| Providers | Common with providers like Aviva (Expert Select) and Vitality (Consultant Select). | The traditional model, offered by most insurers like Bupa, AXA Health, etc. |
| Best For | People who are happy to trade some choice for a lower price and trust the insurer's vetting process. | People who have a specific specialist in mind or want maximum flexibility. |
Outpatient cover isn't just for seeing a consultant. It's for the entire diagnostic process.
Commonly Covered Diagnostic Tests & Scans:
These are nearly always paid for from your single outpatient monetary limit.
What About Therapies? Therapies like physiotherapy, osteopathy, and chiropractic treatment are often included, but their cover can be structured differently.
This is a subtle but important difference, so always check the policy details.
The primary driver for the growth in the UK private medical insurance market is the pressure on NHS services. According to the latest NHS England data, the total waiting list for consultant-led elective care stands at around 7.54 million treatments.
While the NHS works tirelessly, these figures mean that the waiting time for a specialist appointment and subsequent diagnostic tests can be months long. For many, this uncertainty and delay can be agonising.
This is where outpatient cover demonstrates its true value. It allows you to bypass these queues, often seeing a specialist within days or weeks. A faster diagnosis means faster treatment, faster recovery, and crucially, faster peace of mind.
While private medical insurance is an excellent safety net for when things go wrong, the best strategy is always to stay as healthy as possible. Integrating simple, positive habits into your life can significantly reduce your risk of developing acute conditions.
By taking a proactive approach to your health, you can complement the reactive security that PMI provides. What's more, customers who purchase PMI or life insurance from WeCovr often receive discounts on other types of insurance, helping you protect your finances as well as your health.
Choosing the right level of outpatient cover is one of the most important decisions you'll make when buying private medical insurance. It directly impacts both your premium and your experience when you need to claim.
Don't navigate this complex market alone. The expert advisors at WeCovr provide independent, FCA-authorised advice at no cost to you. We'll listen to your needs, compare policies from across the UK's best PMI providers, and find the perfect plan for your budget and peace of mind.






