
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 800,000 policies, we believe everyone deserves to understand exactly what they're buying. This guide will demystify policy documents, turning complexity into clarity.
Private health cover is a significant investment in your wellbeing. Yet, the true value of a policy is only revealed when you understand its details—the terms, the benefits, and, most importantly, the exclusions. A policy document is more than just paperwork; it's a contract that defines your access to private healthcare. Getting it wrong can lead to unexpected bills and disappointment when you need support the most.
With NHS waiting lists for consultant-led elective care in England hovering around 7.5 million in late 2024, more people are turning to private options. Understanding your policy is the first step to ensuring you get the fast, high-quality care you're paying for.
When your policy documents arrive, they can seem intimidating. They are typically made up of several key parts. Here’s how to break them down and what to look for in each.
This is your essential starting point. The IPID is a standardised, plain-English summary of the policy, usually just two or three pages long. Mandated by regulators, its purpose is to give you a clear, at-a-glance overview.
What to check on the IPID:
Think of the IPID as the "blurb" on the back of a book. It gives you the main plot points but not the full story.
This document personalises the policy to you. It confirms the specific choices you have made and links them to the main policy wording.
Key information on the Policy Schedule:
This is the detailed rulebook—the "terms and conditions" of your health insurance. While dense, it's vital to know where to find information within it. It contains comprehensive definitions and explanations for everything mentioned in the IPID and Schedule.
Use the table of contents to navigate to sections you're particularly interested in, such as:
Nearly all UK PMI providers use a tiered hospital list. This list dictates which private hospitals and facilities you can use for treatment. Using a hospital outside your chosen list may result in you not being covered or having to pay a shortfall.
Common Hospital List Tiers:
When comparing policies, always check that your preferred local private hospital is on the list you choose. An expert PMI broker can help you check this quickly.
Health insurance is full of industry-specific terms. Understanding them is the key to unlocking your policy document.
| Term | Plain English Explanation | Real-Life Example |
|---|---|---|
| Acute Condition | A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. This is what PMI is designed to cover. | A broken bone, appendicitis, cataracts, a hernia, or a joint replacement. |
| Chronic Condition | An illness that is long-lasting, has no known cure, and needs ongoing management. Standard PMI does not cover chronic conditions. | Diabetes, asthma, high blood pressure, Crohn's disease, or rheumatoid arthritis. |
| Underwriting | The process the insurer uses to assess your medical history and decide what they will and will not cover. | See detailed explanation below. |
| Moratorium | The most common type of underwriting. It automatically excludes any condition you've had symptoms, advice or treatment for in the 5 years before joining. Cover for that condition may be added later if you complete a 2-year period without any issues. | You had knee pain 3 years ago. Your new policy won't cover knee problems for the first 2 years. If your knees are trouble-free for those 2 years, the exclusion is lifted. |
| Full Medical Underwriting (FMU) | You complete a detailed health questionnaire. The insurer reviews your medical history and may apply permanent exclusions for specific conditions. It provides certainty from day one. | You declare a history of migraines on your form. The insurer may add a permanent exclusion for "investigation and treatment of headaches and migraines." |
| Excess (or Deductible) | A fixed amount you agree to pay towards the cost of your claim each policy year. A higher excess reduces your premium. | Your excess is £250. Your knee surgery costs £6,000. You pay the first £250, and the insurer pays the remaining £5,750. |
| In-patient | Treatment that requires you to be admitted to a hospital bed overnight. | Recovering in hospital for two nights after a hip replacement. |
| Day-patient | Treatment that requires a hospital bed for the day but you do not stay overnight. | A colonoscopy or cataract surgery where you are admitted and discharged the same day. |
| Out-patient | Consultations, tests, or diagnostics that do not require a hospital bed. | Seeing a specialist for an initial consultation, followed by an MRI scan and physiotherapy sessions. |
| Benefit Limit | The maximum amount the insurer will pay for a specific type of treatment or across the whole policy year. | Your policy might have a £1,000 limit for out-patient diagnostics, or an overall annual limit of £1 million. |
| Pre-authorisation | The process of getting your insurer's approval for treatment before it takes place. This is a mandatory step for almost all planned procedures. | Your GP refers you to a specialist. The specialist recommends surgery. You call your insurer with the details and the procedure code to get it approved. |
| No Claims Discount (NCD) | A discount on your premium that increases each year you don't make a claim, up to a maximum level. Making a claim will usually reduce your NCD. | You start with a 0% NCD. After one year with no claims, you might get a 10% discount. If you then claim, your NCD might drop back to 0%. |
| Guided Consultant List | Some insurers offer a "guided" option where they give you a small panel of 3-5 pre-approved specialists to choose from for your condition. This usually results in a lower premium. | You need to see a cardiologist. Instead of choosing any cardiologist, your insurer provides a list of three they recommend in your area. |
This is the most misunderstood area of private medical insurance in the UK. Getting this right is fundamental to having a good experience with your provider.
A pre-existing condition is anything you have had symptoms, medication, advice, or treatment for in a set period (usually 5 years) before your policy starts.
With Moratorium Underwriting, these are automatically excluded for the first 2 years of your policy. This is often called the "2-5-2 rule":
With Full Medical Underwriting (FMU), you declare your history upfront. The insurer then decides whether to:
Private health cover is designed to return you to your previous state of health. It is not designed for the long-term management of incurable conditions.
While the initial diagnosis of a chronic condition might be covered (e.g., tests to determine you have diabetes), the ongoing management (e.g., insulin, check-ups, monitoring) will not be. This care remains with the NHS.
Commonly Excluded Chronic Conditions:
Every policy has a list of treatments and circumstances that are never covered. These are usually consistent across the market.
Standard PMI General Exclusions Table
| Exclusion Category | What It Typically Means |
|---|---|
| Emergencies | A&E visits, ambulance services, and any treatment needed for a medical emergency. You should always call 999 or go to A&E in an emergency. PMI is for planned, non-emergency care. |
| Normal Pregnancy & Childbirth | Routine antenatal care, delivery, and postnatal check-ups are not covered. However, complications of pregnancy may be covered by some comprehensive policies. |
| Cosmetic Surgery | Procedures for purely aesthetic reasons (e.g., a nose job, breast augmentation). Reconstructive surgery after an accident or for cancer treatment is often covered. |
| Substance Abuse | Treatment for addiction to alcohol, drugs, or other substances. |
| Self-inflicted Injuries | Any injury resulting from deliberate self-harm. |
| Experimental Treatment | Drugs or procedures that are not approved by the National Institute for Health and Care Excellence (NICE). |
| Professional Sports Injuries | Injuries sustained while playing a sport for which you are paid. |
| Mobility Aids | Items like wheelchairs, walking sticks, or hearing aids. |
Comparing policies can be overwhelming. Using a structured approach helps you focus on what matters. Working with an independent PMI broker like WeCovr makes this process simple, as we do the heavy lifting for you at no cost.
What is most important to you?
The core of every policy is in-patient and day-patient cover. This is usually unlimited. The main differentiator in basic policies is the out-patient limit.
This is one of the most valuable parts of any PMI policy. Cover varies significantly.
Typical Levels of Cancer Cover
| Feature | Basic Cancer Cover | Mid-Range Cancer Cover | Comprehensive Cancer Cover |
|---|---|---|---|
| Diagnosis | Yes | Yes | Yes |
| Surgery | Yes | Yes | Yes |
| Radiotherapy | Yes | Yes | Yes |
| Chemotherapy | Yes, but may have financial or time limits. May only cover drugs on a standard list. | Yes, usually with higher limits. | Yes, often unlimited. Includes access to some drugs not yet available on the NHS. |
| Targeted Therapies | Limited or not covered. | Often included, subject to limits. | Extensive cover, a key benefit. |
| Palliative Care | Limited | Yes, often with financial limits. | Yes, often with higher limits. |
| Follow-up Consultations | Limited | Yes | Yes |
Consider if you need extra protection for:
Use an online quote tool or speak to a broker to see how changing your excess affects your monthly premium. An excess of £500 can significantly reduce your premium compared to a £100 excess. Choose an amount you would be comfortable paying if you needed to claim.
Let's apply this knowledge to a few common situations.
Scenario 1: Sarah, 35, with old back pain. Sarah took out a PMI policy with moratorium underwriting. Four years ago, she visited her GP for back pain, which resolved after a few weeks.
Scenario 2: David, 55, needs a knee replacement. David has had comprehensive PMI for ten years. His knee has become painful due to osteoarthritis.
Modern private health cover is evolving. The best PMI providers now include benefits designed to keep you healthy, not just treat you when you're ill.
Look out for value-added benefits like:
When you purchase PMI or Life Insurance through WeCovr, you also get complimentary access to our cutting-edge AI calorie tracking app, CalorieHero, to support your health goals. Furthermore, our clients enjoy exclusive discounts on other types of insurance, helping you protect more for less.
Before signing on the dotted line, run through this final checklist:
Reading a PMI policy document doesn't have to be a chore. By breaking it down and focusing on the key areas, you can make an informed, confident choice that provides true peace of mind.
Ready to find the right private medical insurance for you? The friendly experts at WeCovr compare policies from across the UK market to find cover that fits your needs and budget.
Get your free, no-obligation PMI quote today and take control of your health.






