Key takeaways
- Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Your GP can usually manage it, but a specialist might be needed for a cure.
- Examples: Appendicitis, broken bones, hernias, cataracts, infections, or diagnosing the cause of new symptoms like joint pain.
- Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics:
- It needs long-term monitoring and management.
- It has no known cure.
As an FCA-authorised expert that has helped arrange over 900,000 policies, WeCovr knows that understanding what's not covered by private medical insurance in the UK is just as crucial as knowing what is. This guide demystifies the common exclusions so you can choose your policy with confidence.
WeCovr's guide to what isn't covered so you don't get caught out
Private Medical Insurance (PMI) is a fantastic tool for managing your health. It offers prompt access to specialists, comfortable private facilities, and greater choice over your treatment. However, it's not a replacement for the NHS and doesn't cover every eventuality.
The core purpose of private health cover in the UK is to treat acute conditions that arise after you take out your policy. Think of it as a plan for new, unexpected health issues that can be resolved, rather than ongoing management of existing or long-term problems. Understanding this single principle is the key to avoiding surprises.
This guide will walk you through the specifics, from the big "golden rules" to the finer details, ensuring you're fully informed.
The Golden Rule: Acute vs. Chronic Conditions
This is the most important concept in private health insurance. Insurers draw a clear line between two types of medical conditions.
- Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Your GP can usually manage it, but a specialist might be needed for a cure.
- Examples: Appendicitis, broken bones, hernias, cataracts, infections, or diagnosing the cause of new symptoms like joint pain.
- Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics:
- It needs long-term monitoring and management.
- It has no known cure.
- It is likely to recur.
- It requires ongoing medication or special diets.
- Examples: Diabetes, asthma, high blood pressure (hypertension), arthritis, Crohn's disease, eczema, and multiple sclerosis.
Key Takeaway: Standard UK private medical insurance is designed exclusively to cover the diagnosis and treatment of acute conditions. The management of chronic conditions is not covered and remains the responsibility of the NHS.
For example, if you develop sudden chest pains, your PMI would cover the consultations and tests to diagnose the problem. If it's an acute issue like a blocked artery needing a stent, that would be covered. If it's diagnosed as a chronic heart condition requiring long-term medication and monitoring, the initial diagnosis is covered, but the ongoing management will be handed back to your GP and the NHS.
Understanding Pre-existing Conditions
Alongside chronic conditions, pre-existing conditions are the other major category of exclusion.
A pre-existing condition is any illness, injury, or symptom for which you have sought advice, received treatment, or experienced symptoms before the start date of your policy. This applies whether you received a formal diagnosis or not.
Insurers handle pre-existing conditions in one of two ways, known as "underwriting".
1. Moratorium Underwriting
This is the most common and straightforward method. You don't need to complete a detailed health questionnaire. Instead, the insurer applies a simple rule:
- Any medical condition you (or anyone on your policy) have had symptoms, medication, tests, or advice for in the 5 years before your policy starts is automatically excluded.
- However, if you then complete 2 continuous years on the policy without needing any treatment, advice, or medication for that specific condition, the exclusion may be lifted, and it could become eligible for cover.
Example:
- Sarah's Knee Pain: Sarah had physiotherapy for knee pain in 2023. She takes out a PMI policy with a moratorium in January 2025. Her knee is excluded. If she remains symptom-free and needs no treatment for her knee until January 2027 (2 full years), it may become eligible for cover from that point on.
2. Full Medical Underwriting (FMU)
With FMU, you complete a detailed questionnaire about your medical history. The insurer's underwriting team assesses your health profile and provides a definitive list of what is and isn't covered from day one.
- This process takes longer, but it gives you absolute clarity.
- There's no ambiguity and no 2-year waiting period for conditions to become eligible. An exclusion on an FMU policy is typically permanent.
Moratorium vs. Full Medical Underwriting: Which is Right for You?
| Feature | Moratorium Underwriting | Full Medical Underwriting (FMU) |
|---|---|---|
| Application Process | Quick and simple. No health forms. | Longer. Requires a detailed health questionnaire. |
| Clarity on Cover | Exclusions are automatic based on a 5-year history. You may not be 100% sure what's covered at the point of a claim. | Completely clear from the start. You receive a policy certificate listing specific exclusions. |
| Cover for Pre-existing | Conditions can become eligible for cover after a 2-year symptom-free period. | Exclusions are generally permanent. |
| Best For | People with a clean bill of health or minor past issues who want a quick start. | People with a complex medical history who want certainty about their cover from day one. |
Navigating these options can be tricky. As an expert PMI broker, WeCovr can explain the pros and cons of each underwriting method based on your personal circumstances, ensuring you make the right choice.
Your A-Z of Common Private Health Insurance Exclusions
Beyond the two golden rules, most UK PMI policies exclude a standard set of treatments and services. Here is a detailed breakdown.
1. Chronic Conditions
As already explained, any condition that requires long-term management rather than a short-term cure is excluded. This is the bedrock of PMI in the UK.
2. Pre-existing Conditions
Any health issue you had before your policy started is excluded, as defined by your underwriting choice (Moratorium or FMU).
3. Emergency Services (A&E)
Private hospitals in the UK are not equipped with Accident & Emergency departments. If you have a medical emergency—like a suspected heart attack, stroke, or a serious accident—you must call 999 or go to your local NHS A&E. Your PMI policy kicks in after you are stabilised and need further specialist treatment or surgery.
4. Routine Pregnancy and Childbirth
Standard, uncomplicated pregnancy and childbirth are not covered by private health insurance. This includes routine antenatal appointments, scans, and the delivery itself. However, many comprehensive policies will cover complications that arise during pregnancy or childbirth, such as:
- Miscarriage
- Ectopic pregnancy
- Post-partum haemorrhage
Check the policy wording carefully, as the definition of a "complication" can vary.
5. Cosmetic and Aesthetic Surgery
Surgery purely for aesthetic reasons is excluded. This includes procedures like rhinoplasty (nose jobs), breast augmentation, liposuction, and Botox.
However, reconstructive surgery following an accident, injury, or illness (like breast reconstruction after a mastectomy) is often covered under a comprehensive policy.
6. Mental Health
This is a nuanced area.
- Basic policies often have very limited or no mental health cover.
- Comprehensive policies typically offer some level of support, but it's usually capped. This might include:
- A set number of sessions with a therapist or psychologist.
- Outpatient consultations with a psychiatrist.
- Inpatient or day-patient treatment for acute psychiatric conditions, often limited to a certain number of days per year (e.g., 28 days).
Chronic mental health conditions like bipolar disorder or schizophrenia are generally not covered for long-term management.
7. Dental and Optical Care
Routine dental check-ups, fillings, crowns, and eye tests for glasses or contact lenses are not covered by standard private medical insurance. These can almost always be added as an optional extra for an additional premium. This add-on typically provides cashback for a portion of your routine dental and optical bills.
8. Organ Transplants
The assessment, surgery, and aftercare for organ transplants are highly complex and managed by specialist NHS centres of excellence. Therefore, they are excluded from PMI cover.
9. Fertility Treatments
Treatments to aid conception, including IVF, IUI, and related investigations, are not covered by standard policies. Some very high-end corporate schemes might offer limited benefits, but it's not a typical feature.
10. Experimental or Unproven Treatments
Insurers will only pay for treatments and drugs that are evidence-based and have been approved for use by the National Institute for Health and Care Excellence (NICE). Experimental, unproven, or "alternative" therapies without a strong clinical evidence base are excluded.
11. Self-inflicted Injuries and Reckless Pursuits
This category includes injuries resulting from:
- Drug or alcohol abuse
- Suicide attempts or intentional self-harm
- Participation in dangerous sports or hobbies (e.g., motorsports, mountaineering, boxing) unless you have declared them to your insurer and they have agreed to provide cover, often for a higher premium.
12. Geriatric & Long-Term Care
PMI is for acute medical treatment. It does not cover social care, such as help with daily living, nursing home fees, or long-term palliative care for the elderly.
Summary of Common Exclusions
| Exclusion Category | Is it Covered by Standard PMI? | Can it be Added or Covered in Some Cases? |
|---|---|---|
| Chronic Conditions | No | No |
| Pre-existing Conditions | No | Potentially, after a 2-year moratorium period. |
| Emergencies (A&E) | No | No, this is an NHS service. |
| Routine Pregnancy | No | Complications may be covered by comprehensive plans. |
| Cosmetic Surgery | No | Reconstructive surgery is often covered. |
| Mental Health | Limited / Often No | Yes, as a standard benefit in comprehensive plans or as an upgrade. |
| Dental & Optical | No | Yes, as a popular optional add-on. |
| Fertility Treatments | No | Very rarely, on top-tier corporate plans. |
| Experimental Drugs | No | Some top-tier cancer plans may cover drugs not yet available on the NHS. |
| Self-inflicted Injuries | No | No |
Navigating the Grey Areas: What Might Be Covered?
The line between covered and not covered can sometimes seem blurry. This is where choosing the right policy options becomes vital. A good broker can help you find a plan with the right level of cover for the things that matter most to you.
Enhanced Mental Health Cover
If mental health support is a priority, you can choose plans that go beyond the basic limits. These "enhanced" options might include more therapy sessions or broader cover for psychiatric conditions. This is becoming an increasingly important feature for many buyers of private medical insurance in the UK.
Therapies Cover (Physio, Osteo, Chiro)
Most policies include some cover for therapies like physiotherapy, but the number of sessions may be limited (e.g., 6-8 sessions per condition). If you are active or have a history of musculoskeletal issues, you might want a policy with a higher limit or even unlimited sessions when referred by a specialist.
Cancer Cover: The Most Important Variable
While cancer is an acute condition, the level of cover you receive is one of the biggest differentiators between policies.
- Basic Cover: May have financial limits on treatment, exclude certain types of aftercare, or not cover the latest, most expensive drugs.
- Comprehensive Cover: This is where PMI truly shines. Top-tier policies offer extensive cancer care that can include:
- Full cover for surgery, radiotherapy, and chemotherapy.
- Access to specialist cancer centres.
- Cover for new and experimental drugs not yet funded by the NHS.
- Prosthetics, wigs, and post-surgery therapies.
- Palliative care if required.
Understanding the nuances of a policy's cancer cover is critical.
Private Health Insurance Exclusions in Practice: Real-Life Scenarios
Let's see how these rules apply in practice.
Scenario 1: Mark's Chronic Asthma Mark has had asthma since he was a child. He takes out a new private health insurance policy. A few months later, he has a severe asthma attack.
- A&E Visit: Covered by the NHS.
- Follow-up with a Private Specialist: His PMI provider will not cover this, as asthma is a chronic and pre-existing condition. He will need to see his NHS GP for ongoing management.
Scenario 2: Chloe's Skiing Accident Chloe is on a skiing holiday in France and breaks her leg. Her travel insurance covers her immediate medical care and repatriation to the UK. Back home, she faces a long NHS wait for surgery to set the bone correctly.
- PMI Action: Chloe contacts her PMI provider. Because her policy covers sports injuries and this is a new, acute condition, they approve her for:
- An immediate consultation with a private orthopaedic surgeon.
- Surgery in a private hospital the following week.
- A full course of post-operative physiotherapy to get her back on her feet.
Scenario 3: David's New Heart Condition David, 55, has had no prior heart issues. He takes out a comprehensive PMI policy. Six months later, he starts experiencing chest pains.
- PMI Action: His GP refers him for urgent tests. His PMI covers:
- A consultation with a private cardiologist within days.
- All diagnostic tests (ECG, angiogram, MRI scan).
- The tests reveal a blocked artery. The subsequent angioplasty and stent procedure are fully covered by his policy.
- Because this was a new acute condition that arose after his policy started, all diagnosis and treatment were covered.
The UK Health Landscape in 2025: Why PMI Matters
Understanding exclusions is vital, but so is understanding the context in which PMI operates. Pressures on the NHS make private options more attractive than ever.
According to the latest NHS England data, the consultant-led elective care waiting list remains a significant challenge. As of late 2024, the number of unique patients waiting for treatment stood at over 6.3 million, with hundreds of thousands waiting over a year for planned procedures.
Furthermore, data from organisations like the Office for National Statistics (ONS) and health charities consistently shows that a large proportion of the UK population is living with long-term conditions. It is estimated that over 15 million people in England alone have at least one chronic condition. This places a huge, ongoing demand on NHS resources, which can impact its capacity to deliver prompt elective care for acute issues.
PMI works in partnership with the NHS. It helps you bypass waiting lists for eligible acute conditions, freeing up NHS resources for those who need them most for emergency, chronic, and complex care.
Beyond Insurance: Proactive Steps for Your Health
While insurance is a safety net, the best strategy is to stay healthy. Many PMI providers actively encourage this with wellness benefits. As a WeCovr client, you also get complimentary access to CalorieHero, our AI-powered nutrition app, to help you build healthy habits.
- Balanced Diet: Follow the NHS Eatwell Guide to ensure you get a good mix of fruit, vegetables, protein, dairy, and carbohydrates.
- Regular Activity: The UK Chief Medical Officers recommend at least 150 minutes of moderate-intensity activity (like brisk walking or cycling) or 75 minutes of vigorous activity (like running) per week.
- Prioritise Sleep: Aim for 7-9 hours of quality sleep per night. It's essential for physical and mental recovery.
- Stay Connected: Strong social ties and good mental wellbeing are linked to better long-term health outcomes.
By investing in your health, you reduce your risk of developing many conditions. And if you have PMI and purchase other policies like life insurance through WeCovr, you may be eligible for discounts on your cover.
Why You Need an Expert on Your Side
Policy documents can be long, complex, and filled with jargon. Trying to compare providers and their different rules on exclusions can be overwhelming. This is where an independent, expert broker like WeCovr adds immense value.
- We Explain the Jargon: We translate the complex terminology into plain English.
- We Compare the Market: We have access to policies from the UK's leading insurers and can compare their benefits, costs, and—crucially—their exclusions side-by-side.
- We Tailor to You: We listen to your needs, budget, and health priorities to find the best PMI provider and policy for you and your family.
- No Extra Cost: Our expert advice and support are completely free to you. We are paid by the insurer you choose, so you get the benefit of our expertise without paying a penny more.
With high customer satisfaction ratings and a commitment to clarity, WeCovr is your trusted partner in navigating the world of private health insurance.
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Take the Next Step with Confidence
Understanding what isn't covered is the first step to finding a policy that genuinely meets your expectations. Don't let the small print catch you out.
The team of experts at WeCovr is here to provide clear, independent advice. We'll help you compare the UK's best PMI providers and find a plan that protects you and your loved ones, with no hidden surprises.
Get your free, no-obligation quote today and let us find the right cover for you.
