Common Policy Exclusions (and How to Spot Them)
As an FCA-authorised expert broker that has helped arrange over 900,000 policies, WeCovr understands that navigating the world of private medical insurance (PMI) in the UK can feel complex. This guide demystifies one of the most crucial aspects of any policy: the exclusions. Understanding what isn't covered is just as important as knowing what is.
Finance bloggers warn that all PMI excludes chronic, cosmetic, and many pre-existing conditions. Always read the exclusions before you buy. — Mrs MummypennyNimbleFins
This advice from leading finance bloggers is the single most important principle to grasp when considering private health cover. It cuts to the heart of what private medical insurance is designed for. Unlike the comprehensive, cradle-to-grave service provided by our cherished NHS, PMI is a specific tool designed for a specific purpose: to cover the diagnosis and treatment of new, acute medical conditions that arise after your policy begins.
Insurers include exclusions for a simple reason: to keep policies affordable and the system viable. If every condition, past and present, were covered, the cost of premiums would be astronomically high for everyone. Exclusions allow insurers to manage risk and offer a valuable service that complements, rather than replaces, the NHS.
Think of it this way:
- The NHS is your safety net for everything.
- PMI is your express lane for eligible, acute conditions.
Getting to grips with exclusions prevents nasty surprises down the line and ensures you are buying a policy that truly meets your expectations.
The "Big Three" Exclusions Explained
Nearly every standard private medical insurance policy in the UK will have exclusions related to pre-existing conditions, chronic conditions, and cosmetic treatments. Let's break down exactly what these mean for you.
1. Pre-existing Conditions
This is perhaps the most significant and misunderstood exclusion.
What is a pre-existing condition? It's any disease, illness, or injury for which you have experienced symptoms, received medication, advice, or treatment before the start date of your policy. This applies whether you have received a formal diagnosis or not.
Insurers handle pre-existing conditions in two main ways, known as "underwriting."
Moratorium Underwriting This is the most common method offered. You don't need to complete a detailed medical questionnaire upfront. Instead, the insurer applies a "waiting period," typically two years from your policy start date.
- How it works: For the first two years of your policy, any condition you had in the five years prior to joining will be excluded.
- The "rolling" part: If you go for two continuous years on the policy without needing any treatment, advice, or medication for that specific pre-existing condition, it may then become eligible for cover.
- Pros: Quick and easy to set up. You don't have to recall your entire medical history.
- Cons: There can be uncertainty. A claim may be delayed while the insurer investigates your medical history to see if the condition is pre-existing.
Full Medical Underwriting (FMU) With FMU, you complete a comprehensive health questionnaire when you apply. You must declare your full medical history.
- How it works: Based on your answers, the insurer gives you a definitive list of what is and isn't covered from day one. These exclusions are written onto your policy certificate and are usually permanent.
- Pros: You have complete clarity from the start. You know exactly where you stand, and claims can often be processed faster as the groundwork has already been done.
- Cons: The application process is longer. It requires you to be thorough and honest about your medical past. Forgetting to declare something can invalidate your policy.
Moratorium vs. Full Medical Underwriting: A Comparison
| Feature | Moratorium Underwriting | Full Medical Underwriting (FMU) |
|---|---|---|
| Application Process | Simple, no health forms | Detailed health questionnaire required |
| Clarity on Cover | Can be uncertain for the first 2 years | Clear list of exclusions from day one |
| Premiums | Often slightly higher due to insurer risk | Can be lower if you are in good health |
| Claims Process | May require medical history checks, potentially slower | Generally faster as cover is pre-agreed |
| Best For... | People who want a quick start and haven't had recent medical issues. | People who want certainty and have a clear medical history to declare. |
Real-Life Example: Imagine you suffered from intermittent back pain three years ago.
- With moratorium, you join a policy. A year later, your back pain returns. This would be excluded as it relates to a pre-existing condition. However, if you went two full years on the policy with no back symptoms or treatment, it might be covered if it flared up in year three.
- With FMU, you would declare the back pain. The insurer would likely place a permanent exclusion on your policy for any spinal conditions. You know from the outset that your back is not covered.
An expert PMI broker like WeCovr can talk you through which underwriting option is best for your personal circumstances.
2. Chronic Conditions
This is the second pillar of PMI exclusions. It's vital to understand the difference between acute and chronic conditions.
- Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Examples include a broken arm, appendicitis, a hernia, or cataracts. PMI is designed to cover these.
- Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics: it needs ongoing or long-term monitoring, requires long-term management, has no known cure, or is likely to recur. Examples include diabetes, asthma, high blood pressure (hypertension), arthritis, and Crohn's disease. PMI does not cover the long-term management of these.
How PMI Interacts with Chronic Conditions While PMI won't cover the day-to-day management of a chronic illness, it will often cover the initial diagnosis.
Real-Life Example: You develop symptoms like joint pain and stiffness. You use your PMI to see a private consultant rheumatologist quickly. They run tests and diagnose you with rheumatoid arthritis, a chronic condition.
- What PMI covers: The initial consultation, diagnostic tests (like blood tests and X-rays), and the appointments to confirm the diagnosis and establish an initial treatment plan.
- What PMI does not cover: The ongoing prescriptions, regular monitoring, and long-term specialist check-ups required to manage the arthritis for the rest of your life. This care is then passed back to the NHS.
The value of PMI here is the speed of diagnosis, which can be critical in slowing the progression of many chronic diseases.
Acute vs. Chronic Conditions
| Characteristic | Acute Condition | Chronic Condition |
|---|---|---|
| Onset | Usually sudden | Can be gradual |
| Duration | Short-term | Long-term or lifelong |
| Outcome | Curable, leads to recovery | Incurable, requires management |
| PMI Cover | Yes (e.g., surgery for appendicitis) | No (for long-term management) |
| Examples | Broken bones, infections, cataracts | Diabetes, asthma, hypertension |
3. Cosmetic and Lifestyle Treatments
Private medical insurance is for medically necessary treatments. It does not cover procedures that you choose to have for aesthetic or lifestyle reasons.
What's generally excluded:
- Cosmetic Surgery: Nose reshaping (rhinoplasty), facelifts, liposuction, breast augmentation.
- Weight Loss Treatment: Bariatric surgery or programmes chosen purely for weight loss (unless it's deemed medically necessary to enable another eligible treatment, which is rare).
- Lifestyle Enhancements: Treatments for snoring, cosmetic dentistry like teeth whitening, or laser eye surgery to correct vision.
The Exception: Reconstructive Surgery There is a crucial difference between cosmetic and reconstructive surgery. If you need surgery to restore your appearance after an accident, or as part of a cancer treatment (e.g., breast reconstruction after a mastectomy), this is often covered by a comprehensive PMI policy as it is medically necessary. Always check your policy wording.
Other Common Exclusions to Watch Out For
Beyond the "big three," policies contain a list of other specific circumstances and treatments that are not covered. While they vary between insurers, these are some of the most common.
- Routine Pregnancy and Childbirth: A standard, uncomplicated pregnancy is not considered an "illness" and is therefore excluded. However, many policies will cover complications that arise during pregnancy or childbirth that require emergency medical intervention.
- Mental Health: This is a complex area. Historically, most mental health conditions were excluded. Today, the market has improved significantly. Most providers now offer some level of mental health cover, but it is often limited.
- Outpatient Cover: May be capped at a certain number of therapy sessions (e.g., 8-10 sessions of CBT).
- Inpatient Cover: May be limited to a set number of days (e.g., 28 days) per policy year.
- Some chronic mental health conditions may still be excluded. Comparing mental health benefits is a key area where a broker can add huge value.
- Dental and Optical: Routine dental check-ups, fillings, and eye tests are not covered as standard. These are usually available as an optional add-on for an extra premium. However, major surgical procedures like removing a wisdom tooth in a hospital or cataract surgery are typically covered under the core policy.
- Emergency Services: If you have a life-threatening emergency like a heart attack or stroke, you must call 999 and use the NHS A&E. PMI does not cover emergency room visits. It is for planned, non-emergency care.
- Addiction: Treatment for alcohol, drug, or substance abuse is often a standard exclusion.
- Experimental Treatments: Insurers will only pay for treatments and drugs that are evidence-based and have been approved by bodies like the National Institute for Health and Care Excellence (NICE).
- Professional Sports Injuries: If you're a professional athlete, you may find injuries related to your sport are excluded. You might need a specialist policy. For amateur sports, injuries are usually covered.
- Self-Inflicted Injuries: Any injury resulting from a deliberate act of self-harm is excluded.
How to Spot Exclusions in Your Policy Documents
Being an informed consumer is your best defence. You must know where to look for the small print.
-
The Insurance Product Information Document (IPID): This is a legally required, standardised summary of the policy. It's usually just two or three pages long and written in plain English. Look for the section titled "What is not covered?" with a red 'X' next to it. This is your first port of call.
-
The Policy Wording / Guide: This is the full, detailed contract. It will have a comprehensive section, often called "General Exclusions" or "What Isn't Covered," listing everything the policy excludes. Yes, it's long, but it's essential reading. Pay close attention to definitions, especially for terms like "chronic condition."
-
Your Personal Policy Certificate: If you chose Full Medical Underwriting, this document will list any specific, personal exclusions that apply only to you (e.g., "Exclusion: All conditions related to the right knee").
Quick Guide: Finding Your Exclusions
| Document Name | What It Is | Where to Look |
|---|---|---|
| IPID | A short, standardised summary | The "What is not covered?" section |
| Policy Wording | The full, detailed contract | The "General Exclusions" section |
| Policy Certificate | Your personal cover summary | The list of personal/named exclusions (FMU only) |
The Value of an Expert Broker
Trying to compare the subtle differences in exclusion clauses between providers like Bupa, AXA, Aviva, and Vitality can be overwhelming. This is where an independent, expert PMI broker adds enormous value.
A specialist broker like WeCovr works for you, not the insurer. Our role is to:
- Listen to your needs: We take the time to understand your health, your family's needs, and your budget.
- Explain the jargon: We translate complex policy wording into simple English, ensuring you understand concepts like moratorium underwriting and outpatient limits.
- Compare the market: We have access to policies from a wide range of leading UK insurers and can quickly identify the ones that best match your requirements, paying special attention to areas like mental health or cancer cover.
- Highlight the differences: We can create a side-by-side comparison that clearly shows how the exclusions and benefits differ between your top choices.
Using a broker like WeCovr costs you nothing. We are paid a commission by the insurer you choose, so you get expert, impartial advice completely free of charge.
Beyond Illness: Tapping into PMI Wellness Benefits
Modern private medical insurance isn't just about what happens when you get sick. Leading providers now include a wealth of proactive health and wellness benefits designed to help you stay healthy in the first place. These are valuable extras that can often offset the cost of your premium.
Look for policies that include:
- Digital GP Services: Access to a GP via phone or video call 24/7, often with the ability to get prescriptions delivered.
- Mental Health Support: Beyond therapy, many offer access to mindfulness apps, support phone lines, and online stress-management resources.
- Gym and Fitness Discounts: Significant savings on memberships at major UK gym chains.
- Wearable Tech Deals: Discounts or rewards linked to devices like an Apple Watch or Fitbit for staying active.
- Health and Wellness Apps: Many insurers now have their own platforms offering everything from nutrition advice to tailored workout plans.
At WeCovr, we enhance this value further. When you arrange a policy through us, you also get:
- Complimentary access to CalorieHero: Our proprietary AI-powered calorie and nutrition tracking app to help you manage your diet and health goals.
- Discounts on other products: We can offer you preferential rates on other types of cover, such as life or income protection insurance, when you become a PMI client.
Frequently Asked Questions (FAQs)
Is cancer treatment covered by private medical insurance?
Do I need to declare a minor condition I had years ago?
What happens if I develop a chronic condition after my policy starts?
Take the Next Step to a Healthier Future
Understanding policy exclusions is the key to buying private medical insurance with confidence. You're not just buying a product; you're investing in peace of mind and fast access to healthcare when you need it most.
Don't navigate the complexities of the private health insurance UK market alone. The expert advisors at WeCovr are here to provide free, no-obligation advice tailored to your unique needs. We compare leading providers to find you the right cover at the right price.
Related guides
Why private medical insurance and how does it work?
What is Private Medical Insurance?
Private medical insurance (PMI) is a type of health insurance that provides access to private healthcare services in the UK. It covers the cost of private medical treatment, allowing you to bypass NHS waiting lists and receive faster, more convenient care.How does it work?
Private medical insurance works by paying for your private healthcare costs. When you need treatment, you can choose to go private and your insurance will cover the costs, subject to your policy terms and conditions. This can include:• Private consultations with specialists
• Private hospital treatment and surgery
• Diagnostic tests and scans
• Physiotherapy and rehabilitation
• Mental health treatment
Your premium depends on factors like your age, health, occupation, and the level of cover you choose. Most policies offer different levels of cover, from basic to comprehensive, allowing you to tailor the policy to your needs and budget.
Questions to ask yourself regarding private medical insurance
Just ask yourself:👉 Are you concerned about NHS waiting times for treatment?
👉 Would you prefer to choose your own consultant and hospital?
👉 Do you want faster access to diagnostic tests and scans?
👉 Would you like private hospital accommodation and better food?
👉 Do you want to avoid the stress of NHS waiting lists?
Many people don't realise that private medical insurance is more affordable than they think, especially when you consider the value of faster treatment and better facilities. A great insurance policy can provide peace of mind and ensure you receive the care you need when you need it.
Benefits offered by private medical insurance
Private medical insurance provides numerous benefits that can significantly improve your healthcare experience and outcomes:Faster Access to Treatment
One of the biggest advantages is avoiding NHS waiting lists. While the NHS provides excellent care, waiting times can be lengthy. With private medical insurance, you can often receive treatment within days or weeks rather than months.
Choice of Consultant and Hospital
You can choose your preferred consultant and hospital, giving you more control over your healthcare journey. This is particularly important for complex treatments where you want a specific specialist.
Better Facilities and Accommodation
Private hospitals typically offer superior facilities, including private rooms, better food, and more comfortable surroundings. This can make your recovery more pleasant and potentially faster.
Advanced Treatments
Private medical insurance often covers treatments and medications not available on the NHS, giving you access to the latest medical advances and technologies.
Mental Health Support
Many policies include comprehensive mental health coverage, providing faster access to therapy and psychiatric care when needed.
Tax Benefits for Business Owners
If you're self-employed or a business owner, private medical insurance premiums can be tax-deductible, making it a cost-effective way to protect your health and your business.
Peace of Mind
Knowing you have access to private healthcare when you need it provides invaluable peace of mind, especially for those with ongoing health conditions or concerns about NHS capacity.
Private medical insurance is particularly valuable for those who want to take control of their healthcare journey and ensure they receive the best possible treatment when they need it most.
Important Fact!
We can look at a more suitable option mid-term!
Why is it important to get private medical insurance early?
👉 Many people are very thankful that they had their private medical insurance cover in place before running into some serious health issues. Private medical insurance is as important as life insurance for protecting your family's finances.👉 We insure our cars, houses, and even our phones! Yet our health is the most precious thing we have.
Easily one of the most important insurance purchases an individual or family can make in their lifetime, the decision to buy private medical insurance can be made much simpler with the help of FCA-authorised advisers. They are the specialists who do the searching and analysis helping people choose between various types of private medical insurance policies available in the market, including different levels of cover and policy types most suitable to the client's individual circumstances.
It certainly won't do any harm if you speak with one of our experienced insurance experts who are passionate about advising people on financial matters related to private medical insurance and are keen to provide you with a free consultation.
You can discuss with them in detail what affordable private medical insurance plan for the necessary peace of mind they would recommend! WeCovr works with some of the best advisers in the market.
By tapping the button below, you can book a free call with them in less than 30 seconds right now:
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