TL;DR
As an FCA-authorised private medical insurance broker in the UK that has helped arrange over 900,000 policies, WeCovr understands the nuances of health cover. A common question we hear is whether private medical insurance (PMI) includes routine check-ups. The short answer is typically no, but the full story is more detailed.
Key takeaways
- The type of medical condition: Is it acute or chronic?
- The type of care: Is it inpatient, day-patient, or outpatient?
- Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Examples include a hernia, cataracts, joint pain requiring a replacement, or appendicitis. PMI is designed to cover these.
- Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics: it needs long-term monitoring, is incurable, has recurring symptoms, or requires ongoing management. Examples include diabetes, asthma, arthritis, and high blood pressure. Standard PMI does not cover the ongoing management of chronic conditions.
- The Principle of Insurance: PMI pools the premiums of many to pay for the unexpected, significant claims of a few. If it covered predictable, routine costs for everyone, the premiums would become unaffordable for the average person.
As an FCA-authorised private medical insurance broker in the UK that has helped arrange over 900,000 policies, WeCovr understands the nuances of health cover. A common question we hear is whether private medical insurance (PMI) includes routine check-ups. The short answer is typically no, but the full story is more detailed.
WeCovr clarifies what counts as outpatient cover in PMI policies
Private medical insurance is designed to provide cover for the diagnosis and treatment of new, acute medical conditions that arise after your policy begins. It is not a pre-payment plan for routine, preventative, or foreseeable healthcare. This is the single most important principle to grasp when considering private health cover.
Think of it like your car insurance: it covers the cost of repairs after an unexpected accident, but it doesn't pay for your annual MOT, servicing, or new tyres. PMI works in a similar way for your health.
The distinction boils down to two key areas:
- The type of medical condition: Is it acute or chronic?
- The type of care: Is it inpatient, day-patient, or outpatient?
Understanding these concepts is the key to unlocking the true value of your policy and knowing exactly what you are covered for.
Acute vs. Chronic Conditions: The Golden Rule of PMI
Every private medical insurance policy in the UK is built around this fundamental difference.
- Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Examples include a hernia, cataracts, joint pain requiring a replacement, or appendicitis. PMI is designed to cover these.
- Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics: it needs long-term monitoring, is incurable, has recurring symptoms, or requires ongoing management. Examples include diabetes, asthma, arthritis, and high blood pressure. Standard PMI does not cover the ongoing management of chronic conditions.
Similarly, pre-existing conditions—any medical issue for which you have experienced symptoms, sought advice, or received treatment before your policy started—are also excluded. PMI is for future, unforeseen health problems.
The Core of PMI: Inpatient vs. Outpatient Cover Explained
When you need medical care, it will fall into one of three categories. Your level of PMI cover for each will determine what your insurer pays for.
| Type of Care | Description | Common Examples |
|---|---|---|
| Inpatient | Treatment that requires you to be admitted to a hospital and stay overnight in a bed. | Major surgery (e.g., heart bypass, hip replacement), post-operative recovery, severe illness requiring overnight observation. |
| Day-Patient | Treatment that requires you to be admitted to a hospital or clinic for the day, with a bed allocated, but you do not stay overnight. | Minor surgical procedures (e.g., wisdom tooth removal, arthroscopy), some forms of chemotherapy, cataract surgery. |
| Outpatient | Medical care that does not require a hospital bed. You visit a hospital or clinic for a test or consultation and go home the same day. | Specialist consultations, diagnostic tests (MRI, CT scans, X-rays), physiotherapy, blood tests. |
All PMI policies cover inpatient and day-patient treatment as standard. Where policies differ most significantly—and where you can tailor your plan to your budget—is the level of outpatient cover.
So, Why Aren't Routine Check-Ups Covered by Standard PMI?
Now we can circle back to the original question. A routine check-up, such as an annual health screening with your GP or a private wellness clinic, is preventative care, not treatment for a specific, symptomatic, acute condition.
Here are the main reasons why it's excluded from core PMI policies:
- The Principle of Insurance: PMI pools the premiums of many to pay for the unexpected, significant claims of a few. If it covered predictable, routine costs for everyone, the premiums would become unaffordable for the average person.
- Focus on Acute Care: The primary value of private medical insurance in the UK is to bypass NHS waiting lists for diagnosis and treatment of acute conditions. According to NHS England data, the waiting list for consultant-led elective care stood at around 7.54 million treatments in spring 2024. PMI gives you a path to get seen and treated faster for eligible conditions.
- Moral Hazard: If check-ups were fully covered, there would be no limit to their use, driving up costs for the insurer and, subsequently, premiums for all policyholders.
Essentially, PMI is your safety net for when things go wrong, not a maintenance plan for when things are going right.
What Outpatient Services Are Typically Covered by PMI?
This is where the value of outpatient cover becomes clear. While a routine check-up isn't covered, the diagnostic process to investigate new symptoms absolutely is, provided you have the right level of cover.
Let's walk through a real-life example:
Scenario: David, a 45-year-old office worker.
- The Symptom: David develops persistent and worsening pain in his right knee after a weekend of gardening. It's not getting better with rest.
- The GP Visit: He visits his NHS GP, who examines the knee and suspects a possible meniscal tear. The GP says an MRI scan is needed, but the NHS waiting time is currently 8-10 weeks in his area.
- Using PMI: David calls his PMI provider. Because he has outpatient cover, they approve a referral to a private orthopaedic consultant.
- The Consultation (Outpatient): David sees the private consultant within a week. The consultant agrees an MRI is necessary. This consultation fee is covered by his outpatient limit.
- The Scan (Outpatient): David has his MRI scan two days later. The cost of the scan is covered.
- The Diagnosis: The scan confirms a significant meniscal tear requiring surgery (arthroscopy).
- The Treatment (Day-Patient): David has the surgery in a private hospital a fortnight later. As this is day-patient care, it is covered by his policy.
- The Recovery (Outpatient): His policy also includes post-operative physiotherapy to help him recover fully. The six sessions of physio are covered under his outpatient benefit.
In this scenario, David used his PMI to go from symptom to treatment in under a month, bypassing a potentially long wait and getting back on his feet quickly. Every step of his diagnosis and treatment for this new, acute condition was covered.
Navigating Different Levels of Outpatient Cover
Choosing the right level of outpatient cover is one of the most important decisions you'll make when buying private medical insurance in the UK. This is where an expert PMI broker like WeCovr can provide invaluable guidance.
Here are the typical options offered by providers:
| Level of Outpatient Cover | What It Typically Includes | Best For... |
|---|---|---|
| Full Cover | No annual financial limit on eligible consultations, diagnostic scans, and therapies. | Those who want the most comprehensive cover and peace of mind, and for whom budget is less of a concern. |
| Capped Cover | A set financial limit per policy year (e.g., £500, £1,000, or £1,500) for all outpatient services combined. | A great middle-ground. Provides cover for initial diagnosis while keeping premiums more affordable. The most popular choice. |
| Diagnostics Only | Cover for diagnostic scans and tests (like MRI, CT, PET scans) only. Does not cover specialist consultations or therapies. | People on a tighter budget who mainly want to speed up the diagnostic process, but are happy to use the NHS for consultations. |
| Inpatient Only | No outpatient cover at all. The policy only pays for treatment once you are admitted to hospital as an inpatient or day-patient. | Those on the strictest budget whose main priority is covering the high cost of surgery and hospital stays. |
Your choice depends on your personal attitude to risk and your budget. A higher outpatient limit will result in a higher premium, whereas a lower limit or no outpatient cover will significantly reduce your monthly cost.
The Rise of Wellness Benefits: A Modern Exception to the Rule
While standard PMI doesn't cover routine check-ups, the industry has evolved. Insurers recognise that a healthy client is less likely to make a large claim. Consequently, many of the best PMI providers now include a range of wellness and preventative benefits, either as standard or as an optional add-on.
These are not the same as core medical cover, but they are a fantastic value-add that can help you stay on top of your health.
Common wellness benefits can include:
- Health Screenings: Some insurers offer a basic health check (e.g., blood pressure, cholesterol, BMI) once every year or two. This is the closest you'll get to a "covered check-up".
- Digital GP Services: 24/7 access to a virtual GP via phone or video call. This is incredibly convenient for getting quick advice, prescriptions, and referrals.
- Mental Health Support: Access to counselling or therapy sessions, often without needing a GP referral. This is a hugely valuable benefit, addressing issues like stress, anxiety, and depression early on.
- Lifestyle Discounts: Money off gym memberships, fitness trackers (like Fitbit or Garmin), and healthy food services.
- Nutrition and Health Coaching: Access to experts who can provide personalised advice on diet and lifestyle.
At WeCovr, we believe in promoting this proactive approach to health. That's why clients who purchase PMI or Life Insurance through us receive complimentary access to CalorieHero, our proprietary AI-powered calorie and nutrition tracking app, to help them achieve their health goals.
A Critical Reminder: Pre-existing and Chronic Conditions
It is vital to be absolutely clear on this point: standard private medical insurance in the UK is for new, acute medical conditions that occur after your policy starts.
It does not cover:
- Pre-existing conditions: Any illness or injury you had before taking out the policy.
- Chronic conditions: Long-term illnesses like diabetes, Crohn's disease, asthma, or epilepsy that require ongoing management rather than a curative treatment.
Your policy will be underwritten in one of two ways to exclude these:
- Moratorium Underwriting: This is the most common method. Your policy automatically excludes any condition you've had in the 5 years before joining. However, if you go for a continuous 2-year period after your policy starts without any symptoms, treatment, or advice for that condition, it may become eligible for cover.
- Full Medical Underwriting (FMU): You provide a full medical history questionnaire upfront. The insurer then manually assesses your health and lists specific, permanent exclusions on your policy from the start.
Understanding this ensures there are no surprises when you need to make a claim.
How WeCovr Helps You Find the Right Balance of Cover
Navigating the complexities of outpatient limits, wellness benefits, and underwriting can be daunting. As an independent PMI broker, WeCovr's job is to make it simple.
- We Listen: We take the time to understand your priorities, your health concerns, and your budget.
- We Compare: We use our expertise to compare policies from across the UK's leading insurers, including Bupa, AXA Health, Aviva, and Vitality, to find the perfect match.
- We Explain: We break down the jargon and clearly explain the differences between policies, so you know exactly what you're buying.
- We Add Value: On top of finding you the best price, we offer extra benefits like our CalorieHero app and discounts on other insurance products, such as life or income protection cover, when you buy through us. Our high customer satisfaction ratings reflect our commitment to providing exceptional service.
Practical Health & Wellness Tips from the WeCovr Team
While insurance is crucial for when things go wrong, preventing illness in the first place is always the best strategy. Here are some simple, evidence-based tips to support your wellbeing.
1. Nourish Your Body
A balanced diet is the foundation of good health. Focus on whole foods: fruits, vegetables, lean proteins, and whole grains. Try to limit processed foods, sugary drinks, and saturated fats. Using an app like CalorieHero, which WeCovr provides to its clients, can make it easy to track your intake and understand the nutritional content of your food.
2. Prioritise Sleep
Sleep is not a luxury; it's a biological necessity. Aim for 7-9 hours of quality sleep per night. To improve sleep hygiene, create a relaxing bedtime routine, avoid screens before bed, and ensure your bedroom is dark, quiet, and cool.
3. Move Every Day
The NHS recommends at least 150 minutes of moderate-intensity activity (like a brisk walk, cycling, or swimming) or 75 minutes of vigorous-intensity activity (like running or HIIT) a week. Find an activity you enjoy, as you're more likely to stick with it.
4. Manage Your Stress
Chronic stress can have a significant negative impact on both your physical and mental health. Incorporate stress-management techniques into your day, such as mindfulness, deep breathing exercises, spending time in nature, or connecting with loved ones. Many PMI policies now offer excellent resources for mental health support.
Does private medical insurance cover dental or optical check-ups?
Can I add a health screening benefit to my PMI policy?
What is the difference between an outpatient limit and a policy excess?
Why doesn't my PMI policy cover my long-term diabetes management?
Ready to find a private health cover plan that perfectly balances comprehensive protection with your budget? The expert team at WeCovr is here to help. We provide free, impartial advice and can generate personalised quotes from the UK's top insurers in minutes.
Get your free, no-obligation PMI quote today and take control of your health.
Sources
- Department for Transport (DfT): Road safety and transport statistics.
- DVLA / DVSA: UK vehicle and driving regulatory guidance.
- Association of British Insurers (ABI): Motor insurance market and claims publications.
- Financial Conduct Authority (FCA): Insurance conduct and consumer information guidance.
