How Does PMI Handle Claims for Pre-Existing Conditions
Navigating the world of private medical insurance (PMI) in the UK can feel complex, especially when it comes to past health issues. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we believe in clarity. This guide explains exactly how insurers handle pre-existing conditions.
Disclosure, exclusions, and moratorium options
Understanding how private health cover treats conditions you've had in the past is the single most important step in choosing the right policy. Get this wrong, and you could face the disappointment of a rejected claim just when you need support the most.
The entire system revolves around a fundamental principle: standard UK private medical insurance is designed to cover new, unforeseen, and acute medical conditions that arise after your policy begins. It is not designed to cover the ongoing management of long-term (chronic) illnesses or to treat conditions you already have.
This distinction shapes every aspect of your policy, from the questions you're asked when you apply to the way claims are assessed. The three key concepts you'll need to master are:
- Disclosure: Your duty to be honest about your medical history.
- Exclusions: The specific conditions your policy will not cover.
- Underwriting Options: The methods insurers use to decide on those exclusions, primarily 'Moratorium' and 'Full Medical Underwriting'.
Let's break down each of these pillars to give you the confidence to choose the right private medical insurance in the UK.
What Exactly is a Pre-Existing Condition in PMI?
In the simplest terms, a pre-existing condition is any illness, injury, or symptom for which you have sought medical advice, received treatment, or experienced symptoms before the start date of your PMI policy.
It doesn't matter if you received a formal diagnosis or not. If you went to your GP with persistent back pain six months before taking out cover, that back pain is a pre-existing condition.
Common Examples of Pre-Existing Conditions:
- A diagnosed condition: Asthma, eczema, high blood pressure, or a past cancer diagnosis.
- An ongoing injury: A recurring knee problem from a sports injury five years ago.
- Symptoms you've sought advice for: Seeing a doctor about migraines, joint stiffness, or digestive issues, even if no specific cause was found.
- Medication you've taken: Being prescribed tablets for anxiety or an inhaler for shortness of breath.
Insurers typically look back at your medical history over the last five years, but this can vary. The key takeaway is that if it happened before your policy started, it's "pre-existing."
Acute vs. Chronic Conditions: A Crucial Distinction
It's vital to understand the difference between acute and chronic conditions, as this is the bedrock of the UK PMI market.
| Condition Type | Definition | PMI Coverage | Example |
|---|---|---|---|
| Acute | A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. It has a sudden onset and is short-lived. | Covered (if it's a new condition that arises after your policy starts). | A broken bone, appendicitis, a cataract, or a hernia requiring surgery. |
| Chronic | A disease, illness, or injury that is long-term. It may have no known cure, requires ongoing management, and can involve periods of relapse and remission. | Not Covered | Diabetes, Crohn's disease, multiple sclerosis, rheumatoid arthritis, and most forms of hypertension. |
The NHS excels at managing chronic conditions, and this is its primary role. Private medical insurance complements the NHS by providing fast access to diagnosis and treatment for new, acute issues, helping you bypass NHS waiting lists. According to NHS data, the number of people in England waiting for routine hospital treatment remains in the millions, highlighting the value of PMI for acute care.
The Golden Rule: Full and Honest Disclosure is Non-Negotiable
When you apply for health insurance, you enter into a contract based on good faith. Under the Consumer Insurance (Disclosure and Representations) Act 2012, you have a legal duty to take "reasonable care" not to make a misrepresentation to your insurer.
In plain English: you must be completely honest.
Withholding information about a past health condition might seem tempting, perhaps to get a lower premium or avoid an exclusion. However, this is a high-risk strategy with serious consequences.
What Happens If You Don't Disclose a Condition?
If you make a claim and the insurer discovers a pre-existing condition that you failed to declare, they can:
- Reject Your Claim: The most immediate consequence. You will be left to fund the treatment yourself or rely on the NHS.
- Cancel Your Policy: The insurer can void your policy from the start, as if it never existed. You will not be covered for anything, and you will have to declare this cancellation when applying for any insurance in the future, making it harder and more expensive to get cover.
- Keep Your Premiums: In cases of deliberate or reckless non-disclosure, the insurer may be entitled to keep all the premiums you have paid.
- Investigate for Fraud: In serious cases, you could be investigated for insurance fraud, which has legal ramifications.
It is never worth the risk. A policy with a clear, upfront exclusion for a condition you know about is far more valuable than a policy that could be cancelled when you need it most.
How Insurers Underwrite Pre-Existing Conditions: The Two Main Paths
"Underwriting" is the process an insurer uses to assess your health and risk profile to decide the terms of your policy. For pre-existing conditions, there are two main methods in the UK.
- Moratorium Underwriting
- Full Medical Underwriting (FMU)
Choosing between them is one of the biggest decisions you'll make. An expert PMI broker, like the team at WeCovr, can provide personalised guidance on which path is best for your unique circumstances.
Moratorium Underwriting: The "Wait and See" Approach
This is the most common type of underwriting for individual and family policies because it's quick and simple.
How it works: With a moratorium policy, you do not complete a health questionnaire upfront. Instead, the policy automatically excludes any medical condition you've had symptoms, treatment, or advice for in the 5 years before the policy began.
This exclusion isn't necessarily permanent. The condition may become eligible for cover later on if you meet two criteria:
- You serve a continuous two-year period after your policy start date.
- During that two-year period, you have remained completely free of any symptoms, treatment, medication, or medical advice for that specific condition (and any related conditions).
Example in Practice:
- Meet Ben: Ben had physiotherapy for a shoulder injury 3 years before taking out a moratorium PMI policy.
- The Exclusion: His shoulder is automatically excluded for the first two years of his policy.
- Scenario A - No Flare-Up: Ben's shoulder causes him no trouble at all for two full years. He doesn't see a doctor about it or take any medication for it. After this two-year "moratorium period," his shoulder condition is no longer considered pre-existing, and he can now claim for new issues with it.
- Scenario B - A Flare-Up: One year into his policy, Ben's shoulder starts aching again, and he visits his GP. This visit breaks the two-year continuous period. His claim for the shoulder will be rejected, and the two-year "wait" clock for that condition resets from the date of this latest consultation.
Pros and Cons of Moratorium Underwriting
| Pros | Cons |
|---|---|
| Fast & Simple Application: No lengthy health forms to fill out. | Lack of Certainty: You don't know for sure what's covered until you claim. |
| Less Intrusive: You don't have to recall and list your entire medical history. | Potential for Claim Delays: Insurers will need to investigate your medical history when you make a claim, which can slow things down. |
| Exclusions Can Be Overturned: Conditions can automatically become eligible for cover after the 2-year period. | The "Reset" Clock: A minor symptom or GP visit can restart the 2-year waiting period for that condition. |
Full Medical Underwriting (FMU): The "Lay Your Cards on the Table" Approach
This is a more traditional method of underwriting.
How it works: With FMU, you complete a detailed health questionnaire as part of your application. You must declare all of your past medical conditions, treatments, and consultations. The insurer's underwriting team will then review your medical history.
Based on your answers, they will issue policy documents that explicitly state any specific exclusions that will apply to your cover. These exclusions are usually permanent.
Example in Practice:
- Meet Chloe: Chloe has a history of mild asthma and suffered from sciatica two years ago.
- The Application: She fills out the FMU health declaration form, detailing both conditions.
- The Insurer's Decision: The insurer reviews her application. They issue her a policy certificate that clearly states: "This policy excludes any treatment, consultations, or diagnostics related to any respiratory condition (including but not limited to asthma) and any condition of the lumbar spine (including but not limited to sciatica)."
- The Outcome: Chloe knows from day one, with 100% certainty, that she cannot claim for her asthma or back problems. However, she also knows she is fully covered for any new, unrelated acute conditions, like a gallbladder issue or a broken wrist.
Pros and Cons of Full Medical Underwriting
| Pros | Cons |
|---|---|
| Total Certainty: You know exactly what is and isn't covered from day one. | Lengthy Application Process: The health questionnaire can be long and detailed. |
| Faster Claims Process: As exclusions are pre-agreed, claims for eligible conditions are often processed more quickly. | More Intrusive: Requires you to provide detailed personal health information upfront. |
| No "Grey Areas": Avoids the uncertainty of a moratorium investigation at the point of claim. | Exclusions are Often Permanent: It is harder to get an FMU exclusion removed than to pass a moratorium period. |
Comparison Table: Moratorium vs. Full Medical Underwriting
| Feature | Moratorium Underwriting | Full Medical Underwriting (FMU) |
|---|---|---|
| Application Process | Quick and simple, no health forms. | Requires a detailed health questionnaire. |
| Upfront Certainty | Low. You only find out if a condition is covered when you claim. | High. Exclusions are clearly stated on your policy certificate from the start. |
| Speed of Policy Setup | Very fast, often instant. | Slower, as it requires assessment by an underwriter. |
| Claim Process | Potentially slower, as insurer may need to request medical records to check for pre-existing history. | Generally faster for eligible conditions, as exclusions are already defined. |
| Exclusions | Automatically applied to conditions from the last 5 years. Can "drop off" after a 2-year clear period. | Specifically listed on your policy. Usually permanent, but can sometimes be reviewed. |
| Best For... | People with a clean bill of health or very minor past issues who prefer a quick start. | People with a complex medical history who want absolute clarity on what is and isn't covered. |
Switching Insurers? How Pre-Existing Conditions Are Handled
Many people with existing PMI policies worry about switching providers, fearing they will lose cover for conditions that have developed while they were insured. This is a valid concern, but there is a specific underwriting method to handle it.
Continued Personal Medical Exclusions (CPME) Underwriting:
This is the best option for anyone looking to switch their private health cover. With CPME, your new insurer agrees to replicate the underwriting terms of your previous policy.
- What this means: Any exclusions on your old policy will be carried over to your new one. Crucially, any new conditions that developed while you were with your old insurer will continue to be covered by your new insurer, without being classed as pre-existing.
- The Catch: You must switch without any gap in cover. You cannot have cancelled your old policy months before applying for the new one.
Navigating a CPME switch can be complex. Insurers have different rules and appetites for taking on new members this way. This is where an independent PMI broker like WeCovr is invaluable. We can compare the market to find a provider who will offer you CPME terms, ensuring your continuity of cover is protected.
Beyond Exclusions: Enhancing Your Wellbeing with PMI
Even if you have pre-existing conditions that are excluded from treatment cover, a modern PMI policy offers a wealth of benefits to help you manage your overall health and wellbeing. These are often available to all members, regardless of their medical history.
- Digital GP Services: Get 24/7 access to a virtual GP via phone or video call. This is incredibly convenient for getting quick advice, prescriptions, or referrals without waiting for a face-to-face appointment.
- Mental Health Support: Most top PMI providers now include access to telephone counselling or support lines for issues like stress, anxiety, and depression, even if you have a pre-existing mental health exclusion for therapy.
- Wellness Programmes: Many policies come with discounts on gym memberships, fitness trackers, and preventative health screenings. This encourages a proactive approach to staying healthy.
- Nutrition and Lifestyle Tools: As a WeCovr client, you get complimentary access to CalorieHero, our AI-powered calorie and nutrition tracking app. This can be a fantastic tool for managing weight, improving your diet, and supporting your overall health goals.
- Exclusive Discounts: When you take out a PMI or Life Insurance policy through WeCovr, you can also benefit from discounts on other types of cover you may need, adding even more value.
By using these benefits, you can take control of your health, potentially reducing the impact of your pre-existing conditions and lowering your risk of developing new acute problems.
Why Expert Advice from a PMI Broker is Crucial
The information in this guide highlights the many variables involved in securing the right PMI policy. The decision between Moratorium and Full Medical Underwriting alone can have a huge impact on your future cover.
This is why partnering with an expert, independent broker is so important.
The team at WeCovr lives and breathes the private medical insurance UK market. We are authorised and regulated by the Financial Conduct Authority (FCA), and our high customer satisfaction ratings reflect our commitment to providing clear, impartial advice.
How a broker helps:
- Personalised Assessment: We take the time to understand your medical history and your priorities.
- Underwriting Guidance: We explain the pros and cons of Moratorium vs. FMU for your specific situation.
- Market Comparison: We compare policies from the UK's leading insurers to find the best fit and price.
- Switching Support: We manage the complex CPME process to ensure you don't lose valuable cover when you switch.
- No Extra Cost: Our service is free to you. We are paid by the insurer you choose, so you get expert advice without paying a penny more.
Don't navigate the complexities of pre-existing conditions alone. Let us do the heavy lifting for you.
Do I need to declare mental health conditions on my PMI application?
What happens if I forget to declare a minor condition from years ago?
Can I get private medical insurance if I have a chronic condition like diabetes?
Is pregnancy considered a pre-existing condition?
Take the Next Step with Confidence
Understanding how private health cover handles pre-existing conditions is your key to peace of mind. With the right advice, you can find a policy that gives you clarity, control, and fast access to healthcare when you need it.
Contact WeCovr today for a free, no-obligation quote. Our expert team will help you compare your options and find the perfect private medical insurance policy for you and your family.
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.
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