TL;DR
Navigating the world of private medical insurance (PMI) in the UK can feel like learning a new language. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies of all types, we believe everyone deserves clarity. This jargon-buster simplifies the complex terms, helping you make confident health choices.
Key takeaways
- Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. PMI is designed to cover these.
- Examples: Appendicitis, broken bones, hernias, joint replacements, cataracts.
- Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics: it needs long-term monitoring, has no known cure, is likely to recur, or requires ongoing management. Standard PMI policies do not cover chronic conditions.
- Examples: Diabetes, asthma, high blood pressure, arthritis, Crohn's disease.
- Emergency Care: A&E visits should always be via the NHS.
Navigating the world of private medical insurance (PMI) in the UK can feel like learning a new language. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies of all types, we believe everyone deserves clarity. This jargon-buster simplifies the complex terms, helping you make confident health choices.
WeCovr's glossary of the most common PMI terms explained simply
Private Medical Insurance is designed to give you peace of mind and faster access to high-quality medical care when you need it most. However, the paperwork can be filled with terms that are confusing. Let's break them down one by one, so you can understand exactly what you're getting.
The Foundations: Core PMI Concepts
These are the absolute basics of any health insurance policy. Understanding them is the first step to choosing the right cover.
Private Medical Insurance (PMI)
Also known as 'private health insurance' or 'private health cover', PMI is an insurance policy that pays for the costs of private medical treatment for acute conditions. It works alongside the NHS, giving you more choice over your care, including when and where you are treated and by which specialist.
Key takeaway: PMI is for new, curable medical conditions that arise after you take out your policy.
Inpatient, Day-patient, and Outpatient Cover
Your treatment will fall into one of these three categories. Most basic policies cover the first two as standard, while outpatient cover is often an optional extra.
| Category | What it Means | Real-Life Example |
|---|---|---|
| Inpatient | You are admitted to a hospital and stay overnight for one or more nights for treatment. | Having a knee replacement surgery and staying in the hospital for recovery. |
| Day-patient | You are admitted to a hospital or clinic for a scheduled procedure but do not stay overnight. | Minor surgery like wisdom tooth removal under general anaesthetic or a cataract operation. |
| Outpatient | You visit a hospital or clinic for a consultation, diagnosis, or treatment but are not admitted. | Seeing a specialist for an initial consultation, having diagnostic tests like an MRI scan, or attending a physiotherapy session. |
Most entry-level policies focus on covering inpatient and day-patient treatment, which are typically the most expensive costs. Adding comprehensive outpatient cover will increase your premium, but provides end-to-end private care.
Understanding Your Cover: What's In and What's Out?
This is the most critical section to understand. A policy is defined as much by what it doesn't cover as by what it does.
Acute Condition vs. Chronic Condition
This is the single most important distinction in UK private medical insurance.
-
Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. PMI is designed to cover these.
- Examples: Appendicitis, broken bones, hernias, joint replacements, cataracts.
-
Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics: it needs long-term monitoring, has no known cure, is likely to recur, or requires ongoing management. Standard PMI policies do not cover chronic conditions.
- Examples: Diabetes, asthma, high blood pressure, arthritis, Crohn's disease.
While a PMI policy won't cover the long-term management of a chronic condition, it may sometimes cover an 'acute flare-up'. However, this depends heavily on the insurer and your policy wording. The NHS will always provide care for chronic conditions.
Pre-existing Conditions
A pre-existing condition is any disease, illness, or injury for which you have experienced symptoms, received medication, or sought advice from a medical professional before the start date of your policy.
Crucially, all standard private medical insurance UK policies exclude pre-existing conditions, at least for an initial period. How they do this depends on the type of underwriting you choose.
General Exclusions
Every policy has a list of standard exclusions. While they vary slightly between providers, they almost always include:
- Emergency Care: A&E visits should always be via the NHS.
- Normal Pregnancy & Childbirth: Uncomplicated pregnancies are not covered. Private cover may kick in for specific complications.
- Cosmetic Surgery: Procedures done purely for aesthetic reasons are excluded, unless required for reconstructive purposes after an accident or eligible surgery.
- Self-inflicted Injuries: Including those resulting from dangerous sports or substance abuse.
- Infertility Treatment: Such as IVF.
- HIV/AIDS: Treatment is typically provided by the NHS.
The Crucial Part: How Insurers Assess Your Health (Underwriting)
'Underwriting' is the process an insurer uses to assess your medical history and decide on the terms of your policy. In the UK, there are two main types.
1. Moratorium Underwriting (The "Wait and See" Approach)
This is the most common and simplest type of underwriting. You don't need to declare your full medical history upfront.
- How it works: The insurer applies a blanket exclusion for any medical conditions you've had in a set period before the policy started (usually the last 5 years).
- The "Moratorium Period": This exclusion can be lifted for a specific condition if you go for a continuous period after your policy starts (usually 2 years) without experiencing any symptoms, or seeking treatment, medication, or advice for it.
- The "5-Year Rule": If you have a condition that you last had treatment for more than 5 years ago, it might be covered from day one, but this can be complex.
Example: You had physiotherapy for shoulder pain 3 years before buying your policy. Under a moratorium, your shoulder is excluded. If you then go 2 full years on the policy with no shoulder pain or treatment, it may become eligible for cover in the future.
2. Full Medical Underwriting (FMU) (The "Declare Everything" Approach)
With FMU, you complete a detailed health questionnaire when you apply, disclosing your entire medical history.
- How it works: The insurer's underwriting team reviews your application and decides what they can and cannot cover. They will then issue policy terms with specific, named exclusions written into your contract from the start.
- Clarity from Day One: The main benefit of FMU is certainty. You know exactly what is excluded from the moment your policy begins. There are no grey areas.
Comparing moratorium and FMU can be tricky. At WeCovr, our expert advisors can walk you through the pros and cons of each underwriting option based on your personal circumstances, ensuring you choose the best path.
Comparison: Moratorium vs. Full Medical Underwriting
| Feature | Moratorium Underwriting | Full Medical Underwriting (FMU) |
|---|---|---|
| Application Process | Quick and simple. No health forms. | Longer. Requires a full health questionnaire. |
| Initial Exclusions | General exclusion for conditions from the last 5 years. | Specific, named exclusions listed on your policy. |
| Clarity | Can be uncertain. Cover for past issues depends on the "2-year rule". | Complete clarity from day one. You know what's not covered. |
| Claim Process | Can be slower as the insurer may investigate your medical history at the point of a claim. | Generally faster as underwriting was completed upfront. |
| Best For... | People with a clean bill of health or those who prefer a faster application. | People with a complex medical history who want certainty about their cover. |
Making a Claim: The Step-by-Step Process
When you need to use your insurance, the process is usually straightforward.
- Visit Your GP: Your journey almost always starts with your NHS or private GP. If they believe you need to see a specialist, they will provide a referral.
- Contact Your Insurer for Pre-authorisation: Before you book any consultations or treatment, you must call your insurer. You'll need your policy number and the details from your GP referral.
- Get Pre-authorisation: The insurer will check that the condition and proposed treatment are covered by your policy. They will provide you with a pre-authorisation number. This is your green light to proceed.
- Book Your Treatment: Your insurer will usually provide a list of approved specialists and hospitals from your chosen hospital list. You can then book your appointments.
- Invoices are Settled Directly: In most cases, the hospital and specialist will send their bills directly to your insurer for payment. You only need to pay your pre-agreed excess (if any).
Jargon Alert: What is 'Pre-authorisation'? Pre-authorisation is the formal approval from your insurance provider before you undergo treatment. Getting treatment without it can result in your claim being rejected, leaving you liable for the full cost.
Your Policy Costs: Premiums, Excess, and More
Understanding the costs involved is key to finding a policy that fits your budget.
Premium
This is the regular amount you pay to keep your insurance active, either monthly or annually. Your premium is calculated based on several factors:
- Age: Premiums increase as you get older.
- Location: Treatment costs vary across the UK, so living in London, for example, often means higher premiums.
- Cover Level: The more comprehensive your policy (e.g., unlimited outpatient cover, mental health), the higher the premium.
- Excess: Choosing a higher excess will lower your premium.
- Hospital List: Opting for a more restricted list of hospitals reduces the cost.
Excess
An excess is a fixed amount you agree to pay towards the cost of a claim each policy year. For example, if you have a £250 excess and your private surgery costs £5,000, you pay the first £250, and your insurer pays the remaining £4,750. A higher excess leads to a lower premium, but means you contribute more when you claim.
No-Claims Discount (NCD)
Similar to car insurance, most PMI providers offer a no-claims discount. For every year you don't make a claim on your policy, you earn a discount on your renewal premium, up to a maximum level (e.g., 65-75%). If you do make a claim, your NCD will typically be reduced.
Hospital Lists
Insurers group private hospitals into tiers or "lists", often based on cost. A typical structure might be:
- Local/Trust Hospitals: A limited list of private units within NHS hospitals. This is the cheapest option.
- National List: A broad range of private hospitals across the UK, excluding the most expensive ones in Central London.
- Premium/London List: Includes all hospitals, even the high-cost ones in Central London.
Choosing a more limited hospital list is a very effective way to manage your premium.
Enhancing Your Policy: Optional Extras and Benefits
A core policy provides a great safety net, but you can add optional benefits to tailor it to your needs.
Outpatient Cover
As discussed, this is the most common add-on. You can usually choose a set limit of cover per year (e.g., £500, £1,000, £1,500) or opt for fully comprehensive unlimited cover. This pays for specialist consultations and diagnostic tests. (illustrative estimate)
Mental Health Cover
With growing awareness of mental health, this is an increasingly popular and important option. It provides cover for consultations with psychiatrists and psychologists, and for treatment at private mental health facilities.
Therapies Cover
This add-on covers treatments like:
- Physiotherapy
- Osteopathy
- Chiropractic
- Acupuncture
It's particularly valuable for musculoskeletal issues, helping you recover from injuries faster.
Dental and Optical Cover
This provides a contribution towards routine check-ups, dental treatments (like fillings and crowns), and the cost of new glasses or contact lenses. It's often more like a cash plan benefit, paying a set amount back per year.
Beyond Insurance: Proactive Health and Wellness Tips
Having private medical insurance is an excellent way to prepare for ill health, but the best strategy is always to stay as healthy as possible. Many insurers now actively encourage this with wellness programmes and rewards.
The Power of a Balanced Diet
Following the NHS 'Eatwell Guide' is a great start. Aim for a diet rich in fruits, vegetables, and whole grains, with lean proteins and healthy fats. Reducing your intake of processed foods, sugar, and salt can significantly lower your risk of developing chronic conditions like heart disease and type 2 diabetes.
The Importance of Movement
The NHS recommends adults get at least 150 minutes of moderate-intensity activity a week, or 75 minutes of vigorous-intensity activity. This could be anything from a brisk walk or bike ride to a gym class. Regular exercise boosts your immune system, strengthens your bones, and is a powerful tool for managing stress and improving mental health.
Sleep: The Unsung Hero of Health
Aim for 7-9 hours of quality sleep per night. Good sleep hygiene—like having a regular bedtime, avoiding screens before bed, and creating a dark, quiet environment—can improve everything from your mood and concentration to your body's ability to fight off infection.
WeCovr Health & Wellness Bonus: We're passionate about proactive health. That's why when you purchase a private medical insurance policy through WeCovr, you receive complimentary access to CalorieHero, our AI-powered calorie and nutrition tracking app. Plus, our clients often enjoy exclusive discounts when bundling PMI with other policies like life insurance or income protection.
Why Consider PMI in 2025?
With the NHS facing sustained pressure, private health cover offers a valuable alternative for those who can afford it. As of early 2024, NHS England reported a waiting list of 7.54 million treatment pathways. Private medical insurance can help you bypass these queues for eligible conditions, allowing you to get diagnosed and treated faster.
While the NHS provides excellent emergency and chronic care, PMI gives you control over elective (planned) treatment, reducing worry and helping you get back to your life sooner.
Do I need to declare my full medical history for a PMI policy in the UK?
Can I get health insurance for a pre-existing or chronic condition?
What's the difference between private health insurance and a health cash plan?
Why should I use a PMI broker like WeCovr?
Ready to Find Your Perfect Health Cover?
Understanding the jargon is the first step. The next is finding a policy that gives you and your family security and peace of mind.
The expert, FCA-authorised team at WeCovr is here to help. We'll cut through the noise, compare the market for you, and provide a free, no-obligation quote tailored to your exact needs.
Get your personalised quote today and take control of your health journey.
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.
