TL;DR
WeCovr's clear guide to PMI — what it covers, how its priced, and how to make the most of it As an FCA-authorised 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 comprehensive guide will demystify how it works, what it covers, and how you can get the best value for your money. What Exactly is Private Medical Insurance (PMI)?
Key takeaways
- Speed: To bypass long NHS waiting lists for consultations, diagnostic scans, and elective surgery.
- Choice: To choose their specialist or consultant and select a hospital that is convenient for them.
- Comfort: Access to private hospital rooms, often with en-suite facilities, more flexible visiting hours, and other amenities.
- Access: To certain drugs or treatments that may not be available on the NHS due to funding constraints.
- Examples of Acute Conditions:
WeCovr's clear guide to PMI — what it covers, how its priced, and how to make the most of it
As an FCA-authorised 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 comprehensive guide will demystify how it works, what it covers, and how you can get the best value for your money.
What Exactly is Private Medical Insurance (PMI)?
Private Medical Insurance, often called private health cover, is an insurance policy designed to cover the costs of private healthcare for specific medical conditions. Its primary purpose is to work alongside the NHS, not to replace it.
In the UK, we are incredibly fortunate to have the National Health Service (NHS), which provides excellent care to everyone, free at the point of use. However, with increasing demand, waiting lists for non-urgent procedures have grown significantly. According to recent NHS England data (2025), millions of people are waiting for routine treatments.
This is where PMI steps in. It offers a solution for individuals and families who want:
- Speed: To bypass long NHS waiting lists for consultations, diagnostic scans, and elective surgery.
- Choice: To choose their specialist or consultant and select a hospital that is convenient for them.
- Comfort: Access to private hospital rooms, often with en-suite facilities, more flexible visiting hours, and other amenities.
- Access: To certain drugs or treatments that may not be available on the NHS due to funding constraints.
It's crucial to understand that PMI does not cover everything. It is specifically designed for acute conditions that arise after you take out your policy.
The Most Important Rule: Acute vs. Chronic Conditions
Understanding the difference between acute and chronic conditions is the single most important concept in UK private health insurance. Standard policies are built around this distinction.
Acute Conditions An acute condition is a disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. The goal of the treatment is to return you to your previous state of health.
- Examples of Acute Conditions:
- Cataracts
- Hernias
- Joint problems requiring replacement (e.g., hip or knee replacement)
- Bone fractures
- Appendicitis
- Gallstones
Chronic Conditions A chronic condition is an illness that cannot be cured and requires long-term monitoring and management. These conditions are lifelong.
- Examples of Chronic Conditions:
- Diabetes
- Asthma
- Hypertension (high blood pressure)
- Crohn's disease
- Arthritis
- Multiple sclerosis
Key Takeaway: Standard UK private medical insurance is designed to cover the diagnosis and treatment of acute conditions. It does not cover the ongoing management of chronic conditions. The NHS remains the primary provider for chronic care management.
What Does Private Health Insurance Typically Cover?
A PMI policy is usually structured with a core level of cover, to which you can add optional extras to tailor it to your needs and budget.
Core Cover (Usually Included as Standard)
This is the foundation of every PMI policy and primarily focuses on treatment you receive while admitted to a hospital.
| Feature | Description | Real-Life Example |
|---|---|---|
| In-patient Treatment | Covers costs when you are admitted to a hospital bed overnight. This includes surgery, accommodation, and nursing care. | You need a hip replacement. Your policy covers the surgeon's fees, anaesthetist's fees, the cost of the prosthetic joint, and your stay in a private hospital room. |
| Day-patient Treatment | Covers costs when you are admitted to a hospital for a procedure but do not stay overnight. | You require cataract surgery. Your policy covers the procedure in a day-patient unit. |
| Cancer Cover | This is a cornerstone of most policies, covering diagnosis, surgery, and treatments like chemotherapy and radiotherapy. Levels of cover can vary significantly. | After a diagnosis, your policy funds your chemotherapy sessions at a private cancer centre, as specified in your policy terms. |
| Diagnostics | Scans and tests (e.g., MRI, CT, PET scans) related to your in-patient or day-patient treatment. | Your consultant suspects a torn ligament. The MRI scan to confirm the diagnosis before surgery is covered. |
Optional Extras (Customise Your Policy)
These add-ons provide more comprehensive cover but will increase your monthly premium.
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Out-patient Cover: This is one of the most valuable and common add-ons. It covers diagnostic tests and consultations with a specialist that do not require a hospital admission. Without this, you would rely on the NHS for your initial diagnosis before you could use your PMI for treatment. Cover is often capped at a certain amount per year (e.g., £500, £1,000, or unlimited).
-
Mental Health Cover: While some basic mental health support might be included in core plans, comprehensive cover for therapies like counselling or psychiatric treatment is usually an optional extra.
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Therapies Cover: This provides cover for treatments like physiotherapy, osteopathy, and chiropractic care, often up to a set number of sessions per year. This is particularly useful for musculoskeletal issues.
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Dental and Optical Cover: This is less common but can be added to some policies. It typically covers a percentage of routine dental check-ups, restorative work, and the cost of glasses or contact lenses, separate from major oral surgery which might be covered under the core policy.
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Alternative Therapies: Some insurers offer cover for treatments like acupuncture or homeopathy.
What is Generally Not Covered by UK PMI?
It's just as important to know what isn't covered to avoid any surprises when you need to make a claim.
- Pre-existing Conditions: Any medical condition for which you have experienced symptoms, received medication, or sought advice for in the 5 years before your policy start date. We explain how this works in the underwriting section below.
- Chronic Conditions: As explained earlier, long-term conditions like diabetes or asthma are not covered.
- Emergency Services: A&E visits, ambulance services, and any immediate, life-threatening emergencies are handled by the NHS.
- Routine Pregnancy & Childbirth: Normal pregnancy and delivery are not covered, although some complications may be.
- Cosmetic Surgery: Procedures done purely for aesthetic reasons are excluded. Surgery that is medically necessary (e.g., reconstruction after an accident) may be covered.
- Organ Transplants: These are highly complex and typically handled by specialist NHS centres.
- Drug & Alcohol Abuse: Treatment for addiction and related issues is excluded.
- Self-inflicted Injuries: Any injuries resulting from deliberate self-harm are not covered.
How Insurers Assess Your Health: Underwriting Explained
Underwriting is the process an insurer uses to assess your health and medical history to decide on the terms of your policy. For PMI in the UK, there are two main types.
1. Moratorium (MORI) Underwriting
This is the most common and straightforward option.
- How it works: You don't need to complete a detailed medical questionnaire. Instead, the insurer automatically excludes treatment for any medical condition you've had symptoms of, sought advice for, or received treatment for in the five years before your policy began.
- The "Two-Year Rule": The clever part of a moratorium is that these exclusions can be lifted. If you go for a continuous two-year period after your policy starts without having any symptoms, treatment, or advice for that specific condition, it may become eligible for cover.
- Pros: Quick and easy to set up. No need for lengthy medical forms.
- Cons: There can be uncertainty about what is covered until you make a claim. The insurer will investigate your medical history at the point of a claim, which can sometimes cause delays.
2. Full Medical Underwriting (FMU)
This method is more detailed and provides more certainty from the outset.
- How it works: You complete a full health questionnaire, providing details of your medical history. The insurer's underwriting team assesses your information and may contact your GP (with your permission). They then issue a policy with specific, clearly stated exclusions for any pre-existing conditions. These exclusions are usually permanent.
- Pros: You know exactly what is and isn't covered from day one. The claims process can be faster as the underwriting is done upfront.
- Cons: The application process is longer. It requires you to disclose your full medical history.
Moratorium vs. Full Medical Underwriting: A Comparison
| Feature | Moratorium (MORI) | Full Medical Underwriting (FMU) |
|---|---|---|
| Application Process | Fast and simple. No medical forms. | Slower. Requires a full health questionnaire. |
| Exclusions | General exclusion on conditions from the last 5 years. | Specific, named exclusions listed on your policy. |
| Clarity of Cover | Less certainty upfront; assessed at claim time. | Full certainty from the start. |
| Lifting Exclusions | Possible after a 2-year trouble-free period. | Exclusions are typically permanent. |
| Best For | People with a clean bill of health or those wanting a quick start. | People with a complex medical history who want clarity. |
How Your Private Health Insurance Premium is Calculated
The price you pay for your private health cover is influenced by a range of personal and policy-related factors.
Personal Factors
- Age: This is the single biggest determinant of your premium. The likelihood of needing medical treatment increases with age, so premiums rise accordingly.
- Location: Healthcare costs, particularly for private hospitals and consultants, vary across the UK. Premiums are typically highest in Central London and other major cities.
- Smoker Status: Smokers are considered higher risk and will pay more than non-smokers.
Policy and Cover Factors
- Level of Cover: A basic, in-patient-only policy will be much cheaper than a comprehensive policy with unlimited out-patient cover, therapies, and mental health support.
- Excess: This is the amount you agree to pay towards the cost of a claim. For example, if you have a £250 excess and your treatment costs £3,000, you pay the first £250 and the insurer pays the remaining £2,750. Choosing a higher excess will lower your monthly premium.
- Hospital List: Insurers have different tiers of hospitals. A policy that gives you access to a limited local network will be cheaper than one that provides access to all private hospitals nationwide, including premium London facilities.
- The Six-Week Option: This is a popular way to reduce costs. If the NHS waiting list for the in-patient treatment you need is less than six weeks, you agree to use the NHS. If the wait is longer than six weeks, your private cover kicks in. This can reduce your premium by 20-30%.
Example Monthly Premiums (Illustrative)
These are guide prices to show how factors can influence cost. For an accurate price, it's essential to get a personalised quote.
| Profile | Basic Cover (In-patient, £500 excess) | Comprehensive Cover (Out-patient, Therapies, £100 excess) |
|---|---|---|
| 30-year-old, Non-smoker, Midlands | ~£45 per month | ~£80 per month |
| 45-year-old, Non-smoker, Midlands | ~£70 per month | ~£125 per month |
| 60-year-old, Non-smoker, Midlands | ~£130 per month | ~£220 per month |
| 45-year-old, Non-smoker, London | ~£85 per month | ~£150 per month |
How to Make a Claim: The Patient Journey Step-by-Step
The claims process is generally very straightforward. Here’s a typical journey:
- Visit Your GP: Your journey always starts with your NHS GP. You discuss your symptoms, and if they feel you need to see a specialist, they will provide you with a referral letter. This can be an 'open referral', which means they recommend a type of specialist (e.g., a dermatologist) rather than a named individual.
- Contact Your Insurer: With your GP referral letter in hand, you call your PMI provider's claims line. You will need your policy number.
- Get Pre-authorisation: You explain your situation and provide the details of the referral. The insurer will check your policy to confirm that the consultation and any potential treatment are covered. They will give you a pre-authorisation number. This is a crucial step – never proceed with a private appointment without pre-authorisation.
- Choose Your Specialist: Your insurer will provide a list of approved specialists and hospitals in your area. You can then book your appointment.
- Receive Treatment: You attend your consultation and any subsequent tests or treatment. You provide your pre-authorisation number to the hospital or clinic.
- Direct Settlement: The hospital and specialist will send their invoices directly to your insurance provider for payment. You only need to pay your excess (if applicable).
How to Choose the Best PMI Provider for You
With several major providers in the UK, including Bupa, AXA Health, Aviva, and Vitality, choosing the "best" one depends entirely on your personal circumstances and priorities. This is where using an independent PMI broker like WeCovr becomes invaluable.
A specialist broker can:
- Save You Time and Hassle: Instead of gathering quotes from multiple insurers, we do the legwork for you.
- Provide Expert Advice: We understand the nuances of different policies and can explain the jargon, helping you compare apples with apples.
- Tailor the Policy to You: We listen to your needs—whether it's comprehensive cancer cover, access to a specific hospital, or keeping costs down—and find the policy that fits.
- Offer the Service at No Cost: Our advice and service are free to you. We are paid a commission by the insurer you choose, which is already built into the premium, so you don't pay more by using our expertise.
Maximising the Value of Your Private Health Cover
Your PMI policy can offer much more than just treatment for when you're unwell. Many providers now focus heavily on proactive health and wellbeing.
- Wellness and Reward Programmes: Insurers like Vitality are famous for this, rewarding you with discounts on gym memberships, smartwatches, and healthy food for staying active. Other providers offer similar perks, including health screenings and online fitness resources.
- Digital GP Services: Most policies now include 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 an NHS GP appointment.
- WeCovr Member Benefits: At WeCovr, we believe in adding extra value for our clients. When you arrange your PMI through us, you get complimentary access to our AI-powered nutrition app, CalorieHero, to help you manage your diet and health goals. Furthermore, our clients often receive discounts on other policies, such as life or critical illness cover.
- Annual Policy Review: Don't just "set and forget" your policy. Your circumstances can change, and insurers frequently update their products. An annual review with your broker can ensure your cover remains appropriate and cost-effective.
The UK Health Landscape: Why More People are Choosing PMI
The decision to take out private medical insurance is often driven by the current state of public healthcare. While the NHS remains a world-class institution, particularly for emergency and critical care, the pressures it faces are undeniable.
Data from the Office for National Statistics (ONS) and the Association of British Insurers (ABI) show a steady rise in the uptake of private medical insurance in the UK. The ABI reported that over 4.2 million people were covered by a PMI policy at the end of 2022, a figure that has likely grown. This trend is largely a response to record-high waiting lists for elective care, with many people seeking faster access to diagnosis and treatment to maintain their quality of life and ability to work.
For those who can afford it, private health cover offers peace of mind and control over their healthcare journey.
Frequently Asked Questions (FAQ)
1. Can I get private health insurance if I have pre-existing conditions?
Yes, you can still get private health insurance. However, the pre-existing conditions themselves, along with any related conditions, will be excluded from your cover. You will be covered for new, independent acute conditions that arise after your policy begins. The two main underwriting methods, Moratorium and Full Medical Underwriting, determine how these exclusions are applied.
2. Is private medical insurance worth the cost in the UK?
This is a personal decision based on your priorities and financial situation. If your primary concerns are fast access to specialists, bypassing NHS waiting lists for non-urgent surgery, and having more choice over your hospital and consultant, then PMI can be very worthwhile. It provides peace of mind and control. However, the NHS provides comprehensive care for emergencies, chronic conditions, and general health, so PMI should be seen as a complement to it, not a replacement.
3. How much does private health insurance cost per month?
The cost varies significantly based on age, location, and the level of cover chosen. A basic policy for a healthy 30-year-old might start from around £40-£50 per month, while a comprehensive plan for a 60-year-old could be £200 or more. The best way to get an accurate figure is to get a personalised quote from a broker who can compare the market for you.
4. Can I add my family to my private health insurance policy?
Yes, most insurers allow you to add your partner and children to your policy. Family policies can sometimes be more cost-effective than individual policies for each person. Insurers often have specific benefits for families, such as cover for child-specific conditions or accommodation for a parent if a child is in hospital.
5. What is the difference between private health insurance and a cash plan?
Private health insurance (PMI) is designed to cover the high costs of private surgery, specialist consultations, and major treatments for acute conditions. A health cash plan is different; it helps you cover routine, everyday healthcare costs. You pay a monthly fee, and in return, you can claim back a set amount of money for things like dental check-ups, eye tests, physiotherapy, and prescriptions, up to an annual limit. Cash plans are much cheaper than PMI and cover different things.
Ready to take the next step and see what private medical insurance could look like for you?
The expert, friendly team at WeCovr is here to help. We compare policies from the UK's leading insurers to find cover that's perfectly tailored to your needs and budget. Our advice is FCA-regulated, independent, and comes at no cost to you.
Get your free, no-obligation PMI quote today and gain peace of mind and control over your health.
Sources
- Office for National Statistics (ONS): Mortality, earnings, and household statistics.
- Financial Conduct Authority (FCA): Insurance and consumer protection guidance.
- Association of British Insurers (ABI): Life insurance and protection market publications.
- HMRC: Tax treatment guidance for relevant protection and benefits products.
