How to Read Your PMI Policy Smallprint
TL;DR
As an FCA-authorised expert broker that has helped arrange over 900,000 policies of various kinds, WeCovr understands that navigating the world of private medical insurance in the UK can feel daunting. This guide is designed to demystify your policy documents, helping you make informed decisions about your health cover. Martin Lewis recommends scanning insurer key facts sheets for exclusions and claim limits.
Key takeaways
- Acute Condition: As we've discussed, a disease or injury that is short-lived and expected to be cured with treatment. This is what PMI covers.
- Chronic Condition: A condition that is long-term, has no definitive cure, and needs ongoing management. This is not covered.
- Pre-existing Condition: Any illness, injury, or symptom you had (or sought advice for) in a set period (usually 5 years) before your policy started. This is also not covered, subject to underwriting rules.
- In-patient: When you are admitted to a hospital bed overnight for treatment.
- Day-patient: When you are admitted to a hospital bed for a planned procedure but do not stay overnight.
As an FCA-authorised expert broker that has helped arrange over 900,000 policies of various kinds, WeCovr understands that navigating the world of private medical insurance in the UK can feel daunting. This guide is designed to demystify your policy documents, helping you make informed decisions about your health cover.
Martin Lewis recommends scanning insurer key facts sheets for exclusions and claim limits. Dont skim the paperwork—smallprint matters with PMI. — MoneySavingExpert
The advice from Martin Lewis and MoneySavingExpert hits the nail on the head. When you buy private medical insurance (PMI), you are not just buying peace of mind; you are entering into a contract. The 'small print'—your policy's terms and conditions—is the rulebook for that contract.
Skimming this document is like agreeing to play a game without knowing the rules. You might assume you're covered for a particular treatment, only to face a rejected claim and a significant medical bill when you need support the most. The details matter because they define exactly what your insurer will and will not pay for. Understanding these details upfront prevents nasty surprises later.
Why the Small Print is So Important with Private Health Cover
Private medical insurance is designed for a specific purpose: to cover the costs of diagnosis and treatment for acute conditions that arise after you take out your policy.
An acute condition is a disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Think of conditions like a cataract requiring surgery, a hernia repair, or treatment for a joint injury.
This is the single most important concept to grasp:
Critical Information: Standard UK private medical insurance does not cover pre-existing conditions or chronic conditions. A chronic condition is one that has no known cure and requires long-term management, such as diabetes, asthma, or high blood pressure. PMI is for new, curable health issues, not for managing long-term illnesses. Your ongoing care for chronic conditions will remain with our excellent NHS.
Ignoring the small print can lead to misunderstandings about this core principle, causing frustration and disappointment during the claims process.
Your PMI Policy Documents Explained
When you purchase a private health cover plan, you'll receive a pack of documents. They might seem intimidating, but they each have a specific job.
| Document Name | What It Is | Why It's Important |
|---|---|---|
| Key Facts / IPID | A short, standardised summary of your policy. The IPID (Insurance Product Information Document) is a legal requirement. | This is your starting point. It gives you a high-level overview of your cover, key benefits, major exclusions, and your cancellation rights. |
| Policy Wording | The complete rulebook. This is the detailed contract between you and the insurer, explaining everything in full. | This is the "small print" in its entirety. It contains the definitions, benefit limits, exclusions, and claims process you must follow. |
| Policy Schedule/Certificate | A personalised, one-page document confirming your specific cover details. | It lists the names of the people covered, your policy start date, the level of cover you chose, your excess, and the underwriting terms. |
| Hospital List | A directory of the private hospitals, clinics, and scanning centres your policy gives you access to. | It shows you where you can receive treatment. Using a hospital outside this list may mean your insurer won't cover the costs. |
Think of it like this: The Key Facts (IPID) is the trailer for a film, the Policy Wording is the full movie, and the Policy Schedule is your cinema ticket with your name and seat number on it.
Decoding the Key Sections of Your Policy Wording
To truly understand your cover, you need to dive into the main Policy Wording document. Let’s break down the key sections you absolutely must read.
Definitions
This section is your glossary. Insurers use specific language, and the meaning of a word here might be different from its everyday use. Pay close attention to these terms:
- Acute Condition: As we've discussed, a disease or injury that is short-lived and expected to be cured with treatment. This is what PMI covers.
- Chronic Condition: A condition that is long-term, has no definitive cure, and needs ongoing management. This is not covered.
- Pre-existing Condition: Any illness, injury, or symptom you had (or sought advice for) in a set period (usually 5 years) before your policy started. This is also not covered, subject to underwriting rules.
- In-patient: When you are admitted to a hospital bed overnight for treatment.
- Day-patient: When you are admitted to a hospital bed for a planned procedure but do not stay overnight.
- Out-patient: When you visit a hospital or clinic for a consultation or test but are not admitted to a bed.
What's Covered (The Benefits)
This is the exciting part—it tells you what your insurance will pay for. Most policies are built with a core foundation and optional extras.
Core Cover: Almost all PMI policies include cover for:
- In-patient and Day-patient Treatment: This includes hospital accommodation, surgeons' and anaesthetists' fees, nursing care, and operating theatre costs.
- Cancer Cover: This is a major component of most policies, often providing access to specialist drugs and treatments not yet available on the NHS. Check the limits and extent of this cover carefully.
Optional Extras: You can add these to enhance your policy, usually for an extra premium:
- Out-patient Cover: This pays for specialist consultations and diagnostic tests (like MRI scans, CT scans, and blood tests) before you are admitted to hospital. This is one of the most valuable add-ons as it speeds up diagnosis.
- Mental Health Cover: Provides access to psychiatrists, psychologists, and therapists. Cover can range from limited out-patient sessions to full in-patient treatment.
- Therapies Cover: Pays for treatments like physiotherapy, osteopathy, and chiropractic care.
- Dental and Optical Cover: Provides money back towards routine check-ups, treatments, and eyewear.
A PMI broker like WeCovr can help you tailor a plan with the right balance of core cover and add-ons to fit your needs and budget.
| Feature | Basic "Core" Policy | Comprehensive Policy |
|---|---|---|
| In/Day-patient Care | ✅ Fully Covered | ✅ Fully Covered |
| Cancer Cover | ✅ Core Cover (check limits) | ✅ Enhanced Cover (higher limits, more options) |
| Out-patient Cover | ❌ Not included (or very limited) | ✅ Included (often with a limit, e.g. £1,500) |
| Mental Health Cover | ❌ Not included | ✅ Optional Add-on |
| Therapies Cover | ❌ Not included | ✅ Optional Add-on |
What's NOT Covered (The Exclusions)
This section is just as important as the benefits list. Every policy has a list of general exclusions. Knowing these will prevent rejected claims.
Standard UK PMI Exclusions Almost Always Include:
- Pre-existing conditions
- Chronic conditions (e.g., diabetes, hypertension, asthma management)
- A&E / Emergency services (these remain with the NHS)
- Normal pregnancy and childbirth (complications may be covered)
- Cosmetic surgery (unless for reconstructive purposes after an accident)
- Mobility aids, glasses, and hearing aids
- Self-inflicted injuries
- Treatment for addiction (e.g., alcohol or drug abuse)
- Experimental or unproven treatments
Read this list carefully. If cover for something is important to you, check if it's excluded.
Financial Limits and Excess
Your policy isn't a blank cheque. There are two key financial elements to understand:
- Excess: This is the amount you agree to pay towards a claim. For example, if you have a £250 excess and your eligible treatment costs £3,000, you pay the first £250 and your insurer pays the remaining £2,750. You can choose your excess level; a higher excess typically means a lower monthly premium. Check if your excess is per claim or per policy year.
- Benefit Limits: Your policy may have annual limits on certain benefits, especially for out-patient cover or therapies.
| Benefit | Typical Limit on a Mid-Range Policy | Implication |
|---|---|---|
| Out-patient Consultations & Tests | £1,000 per year | If your scans and appointments cost £1,200, you would need to self-fund the £200 shortfall. |
| Therapies (e.g., Physiotherapy) | £500 per year or 10 sessions | Once you reach this limit, any further sessions in that policy year will not be covered. |
| Mental Health (Out-patient) | £1,000 or 8-10 sessions | Provides initial support but may not cover extensive long-term therapy. |
Your Hospital List
Insurers negotiate rates with specific hospital groups. Your policy will come with a hospital list that dictates where you can have your treatment. These lists are often tiered:
- Local/Trust Network: A smaller list of hospitals, often excluding major city centres, leading to a lower premium.
- National Network: A comprehensive list of hospitals across the UK, usually excluding the most expensive central London hospitals.
- Premium/London Network: Includes everything in the national list plus the top private hospitals in central London (e.g., The Lister, The Cromwell). This is the most expensive option.
Check the list to ensure it includes high-quality hospitals that are convenient for you to travel to.
The Claims Process
Don't wait until you're unwell to figure out how to make a claim. The process is usually straightforward but must be followed correctly.
- Visit Your GP: You will almost always need a referral from your GP to see a specialist.
- Contact Your Insurer: Before booking any appointments or treatment, you must call your insurer to get the claim pre-authorised.
- Get a Pre-authorisation Number: The insurer will check your cover and confirm that the proposed treatment is eligible. They will give you a unique number.
- Receive Treatment: Go for your consultation or procedure, giving the hospital your policy details and pre-authorisation number.
- Settle the Bill: In most cases, the hospital will bill your insurer directly. You will only need to pay your excess if it applies.
Skipping the pre-authorisation step is a common reason for claims being rejected.
Understanding Underwriting: How Your Medical History Affects Your Cover
Underwriting is the process an insurer uses to assess your health and decide which conditions, if any, to exclude from your cover. There are two main types in the UK.
Moratorium Underwriting
This is the most common and simplest option. You don't have to complete a detailed medical questionnaire. Instead, the insurer automatically excludes any condition you've had symptoms, medication, or advice for in the 5 years before your policy starts.
However, if you then go 2 continuous years on the policy without any symptoms, medication, or advice for that condition, the insurer may add it back into your cover. It’s a "wait and see" approach.
Full Medical Underwriting (FMU)
With FMU, you complete a detailed health questionnaire when you apply. You must declare your full medical history. The insurer assesses your answers and provides a policy with specific, named exclusions from the outset. For example, it might state, "Cover excludes any treatment related to knee pain or associated conditions."
The benefit of FMU is clarity. You know exactly what is and isn't covered from day one.
| Feature | Moratorium Underwriting | Full Medical Underwriting (FMU) |
|---|---|---|
| Application Process | No medical forms; quick and easy. | Requires a full health questionnaire. |
| Exclusions | Automatic exclusion of anything from the last 5 years. | Specific, named exclusions based on your declared history. |
| Clarity | Can be uncertain what is covered, especially for older issues. | Total clarity from the start. You know exactly where you stand. |
| Claims Process | Can be slower as the insurer may need to investigate your medical history at the point of claim. | Generally faster, as the underwriting was done upfront. |
An expert adviser at WeCovr can discuss your personal circumstances and help you decide which underwriting option is best for you.
Real-Life Scenarios: Putting Policy Wording to the Test
Let's see how these rules apply in practice.
-
Scenario 1: The New Knee Injury
- Situation: Sarah takes out a PMI policy. Six months later, she twists her knee playing tennis. Her GP refers her to a specialist.
- Outcome: This is a new, acute condition that arose after her policy began. Her PMI will cover the consultations, MRI scan (subject to out-patient limits), and any required surgery. Claim Paid.
-
Scenario 2: The Old Knee Injury
- Situation: David has a new PMI policy with moratorium underwriting. He wants a consultation for a grumbling pain in his right knee, which he last saw his GP about 3 years ago.
- Outcome: Because he sought advice for this condition within the 5 years prior to his policy starting, it is classed as a pre-existing condition. Claim Rejected.
-
Scenario 3: The Chronic Condition Diagnosis
- Situation: Mark develops symptoms and, after a series of tests arranged via his PMI, is diagnosed with Crohn's disease, a chronic condition.
- Outcome: His PMI policy will pay for the initial diagnostic process (the consultations and tests that led to the diagnosis), as this is an acute phase. However, the long-term management of his Crohn's disease (ongoing medication, regular check-ups) is chronic and will not be covered. He will transition back to the NHS for this ongoing care.
WeCovr: Your Expert Guide Through the Small Print
Feeling overwhelmed? You're not alone. The complexities of private medical insurance UK are why working with an independent, FCA-authorised broker is so valuable.
At WeCovr, our job is to be your expert guide. We work for you, not the insurers.
- We decipher the jargon: We translate the complex policy wording into plain English.
- We compare the market: We compare policies from the UK's leading insurers to find the one that best fits your needs and budget.
- We highlight the differences: We point out the crucial differences in cancer cover, hospital lists, and benefit limits that you might otherwise miss.
- Our service is at no cost to you: We are paid by the insurer, so you get expert, impartial advice for free.
Furthermore, when you purchase a policy through WeCovr, you get complimentary access to our AI-powered calorie and nutrition tracking app, CalorieHero, to support your health goals. We also offer discounts on other types of insurance, helping you protect more for less.
Top Tips for Reviewing Your PMI Policy
- Start with the IPID: Read the one-page Key Facts Document first for a clear summary.
- Check Exclusions Twice: This is the most important section. Read it, then read it again. If you're unsure, ask.
- Know Your Numbers: Memorise your excess amount and the main annual benefit limits (e.g., for out-patient cover).
- Locate Your Hospitals: Check the hospital list. Are there good, convenient options near your home and work?
- Be 100% Honest: When applying, especially with Full Medical Underwriting, be completely truthful. Non-disclosure can invalidate your entire policy.
- Don't Be Afraid to Ask: If a single word or sentence is unclear, call your insurer or, better yet, your expert broker for clarification. There are no silly questions when it comes to your health.
A Note on Wellness and Prevention
Health insurance is there for when things go wrong, but the best policy is to stay healthy in the first place. Many modern PMI providers recognise this and now include a range of wellness benefits designed to support a healthy lifestyle, such as:
- Discounted gym memberships
- Digital GP services (24/7 access)
- Health and wellbeing apps
- Rewards for hitting activity goals
This proactive approach to health is something we champion at WeCovr. By providing tools like the CalorieHero app, we empower our clients to take control of their wellbeing. A balanced diet, regular physical activity (aim for 150 minutes of moderate-intensity exercise per week), and sufficient sleep (7-9 hours per night for adults) are the cornerstones of good health and can reduce your long-term reliance on medical care.
What happens if a condition starts as acute but becomes chronic?
Why are pre-existing and chronic conditions not covered by standard PMI?
Do I need to declare every single cold or minor illness I've had on my application?
Ready to find the right private health cover without the headache of decoding the small print alone?
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.
By tapping the button below, you can book a free call with them in less than 30 seconds right now:
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