WeCovr's simple guide to understanding different types of private healthcare cover
Navigating the world of private medical insurance (PMI) in the UK can feel complex. As an FCA-authorised broker that has helped arrange over 800,000 policies, WeCovr understands that demystifying the jargon is the first step towards finding the right protection for you and your family. The most fundamental choice you’ll make is between inpatient and outpatient cover.
Understanding this single distinction is the key to tailoring a policy that fits your needs and your budget. This guide will walk you through everything you need to know, from basic definitions and real-world examples to how your choices impact your monthly premiums.
What Exactly is Private Medical Insurance (PMI)?
At its heart, private medical insurance is a policy you pay for that covers the cost of private healthcare for specific medical conditions. Its primary purpose is to help you bypass potential NHS waiting lists and gain faster access to specialists, diagnostic tests, and treatment in a comfortable, private setting.
The latest figures from NHS England show that the waiting list for consultant-led elective care stands at several million, with many patients waiting over 18 weeks for treatment. PMI is designed to provide a reassuring alternative for treatable, short-term conditions.
The Golden Rule of UK PMI: Acute vs. Chronic Conditions
Before we dive deeper, it's vital to understand one non-negotiable principle of standard UK private health cover:
- PMI is for acute conditions. An acute condition is a disease, illness, or injury that is likely to respond quickly to treatment and lead to your return to normal health. Think of things like joint replacements, cataract surgery, or hernia repairs.
- PMI does NOT cover chronic conditions. A chronic condition is an illness that requires long-term monitoring and management, often for life. Examples include diabetes, asthma, high blood pressure, and Crohn's disease. The management of these conditions remains the responsibility of our excellent National Health Service (NHS).
- PMI also does NOT cover pre-existing conditions. This refers to any ailment for which you have experienced symptoms, sought advice, or received treatment before your policy began.
The Foundation of Your Policy: Understanding Inpatient and Day-Patient Cover
Nearly every private medical insurance policy in the UK starts with inpatient cover as its foundation. It's the core component of any plan.
What is Inpatient Treatment?
In simple terms, an inpatient is a person who is admitted to a hospital and requires a bed for at least one night. This is typically for more serious procedures, surgeries, or medical monitoring.
What's generally included in standard inpatient cover:
- Hospital Accommodation & Nursing Care: The cost of your private room and the care you receive from hospital staff.
- Surgeon and Anaesthetist Fees: The fees charged by the specialists performing your procedure.
- Specialist Consultations: Consultations that take place while you are admitted to hospital.
- Diagnostic Tests: Any tests like MRI scans, CT scans, or blood tests that are required during your hospital stay.
- Operating Theatre Costs: The charges for using the surgical facilities.
- Medications and Dressings: Drugs and supplies administered during your inpatient stay.
Real-Life Example: David's Hip Replacement
David, 65, has been suffering from severe arthritis in his hip. His GP refers him to an NHS specialist, but he faces a potential 12-month wait for surgery. David has a PMI policy with standard inpatient cover.
- He uses his policy to see a private consultant (this may require outpatient cover, which we'll discuss next).
- The consultant confirms he needs a total hip replacement.
- His insurer authorises the procedure.
- David is admitted to a private hospital, has the surgery, and stays for three nights to recover.
- His PMI policy covers the entire cost of the surgery, the hospital stay, the surgeon's fees, and the post-operative care he receives in the hospital, totalling over £13,000.
What is Day-Patient Treatment?
A day-patient (or day-case) is someone who is admitted to a hospital or clinic for a planned medical procedure but does not need to stay overnight. You'll have your own bed for the day whilst you recover before being discharged.
This type of care is almost always included as standard alongside inpatient cover.
Common examples of day-patient procedures:
- Cataract surgery
- Endoscopies or colonoscopies
- Minor orthopaedic surgery (e.g., arthroscopy)
- Some chemotherapy sessions
- Removal of skin lesions
Think of day-patient cover as a vital part of the core policy, covering planned procedures that are significant enough for a hospital admission, but not an overnight stay.
Expanding Your Shield: The Role of Outpatient Cover
This is where you begin to customise your policy. Outpatient cover is usually offered as an optional add-on, and it significantly enhances your level of protection by covering the diagnostic journey before you are admitted to hospital.
What is Outpatient Treatment?
An outpatient is a person who receives medical care at a hospital or clinic but is not admitted and does not require a bed. This covers the crucial early stages of diagnosis.
What's typically included in outpatient cover:
- Specialist Consultations: The initial meetings with a consultant after a GP referral to diagnose your condition.
- Diagnostic Tests and Scans: Scans like MRI, CT, PET, and X-rays, as well as blood tests, that are performed to find out what's wrong.
- Minor Procedures: Small procedures that can be carried out in a consultant’s consulting room.
- Therapies: In some comprehensive plans, this can include post-diagnostic physiotherapy or other therapies.
Real-Life Example: Sarah's Knee Pain
Sarah, 42, a keen runner, develops persistent knee pain. Her GP suspects a cartilage tear but isn't sure.
- Without Outpatient Cover: Sarah would join the NHS waiting list to see an orthopaedic specialist and then another list for an MRI scan. This could take many months.
- With Outpatient Cover: Sarah gets an open referral from her GP. She calls her insurer, who approves a consultation with a private orthopaedic specialist within a week. The specialist recommends an MRI scan, which Sarah has two days later. Her outpatient cover pays for the initial £250 consultation and the £600 MRI scan. The results confirm a torn meniscus requiring surgery. Her day-patient cover then kicks in to pay for the keyhole surgery.
Without outpatient cover, Sarah's access to the private surgery would have been delayed by the NHS diagnostic bottleneck.
Inpatient vs. Outpatient Cover: A Head-to-Head Comparison
To make it crystal clear, let's compare the two types of cover side-by-side.
| Feature | Inpatient & Day-Patient Cover | Outpatient Cover |
|---|
| Definition | Covers treatment when you are admitted to a hospital and occupy a bed, either overnight (inpatient) or for the day (day-patient). | Covers diagnostic tests and consultations that do not require a hospital bed. It's the "finding out what's wrong" stage. |
| When is it used? | For planned surgeries, major medical treatments, and post-operative recovery that requires a hospital stay. | For initial consultations with specialists and diagnostic scans/tests following a GP referral. |
| Common Examples | Hip/knee replacements, heart surgery, cancer surgery, gallbladder removal, arthroscopy, cataract surgery. | Specialist consultations, MRI/CT/X-ray scans, blood tests, pre-operative assessments. |
| Is it Standard? | Yes, this is the core component of virtually all UK PMI policies. You cannot have a policy without it. | No, this is typically an optional add-on that you choose to include, often with varying levels of financial cover. |
| Cost Impact | Forms the base cost of your premium. | Adding this cover will increase your monthly premium. The higher the level of outpatient cover, the higher the cost. |
How Your Choice Affects Your Private Health Insurance Premiums
The level of cover you choose is the biggest factor, after your age and medical history, in determining the cost of your policy.
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Core Cover (Inpatient & Day-Patient Only): This is the most basic and affordable type of PMI. It provides a crucial safety net for significant medical events that require hospitalisation. It ensures that if you need major surgery, you can have it done privately without a long wait. However, you would rely on the NHS for the initial diagnosis.
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Mid-Level Cover (Limited Outpatient): This is a popular and balanced option. It includes full inpatient and day-patient cover, plus a set financial limit for outpatient services each year. This limit could be £500, £1,000, or £1,500. It's enough to cover a few consultations and key diagnostic scans, giving you the best of both worlds: speedy diagnosis and comprehensive treatment cover, all at a manageable cost.
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Comprehensive Cover (Full Outpatient): This is the most extensive and expensive option. It provides unlimited (or very high limits for) outpatient consultations and diagnostics, in addition to full inpatient and day-patient cover. This is for individuals who want complete peace of mind, knowing that their entire private healthcare journey, from the first symptom to full recovery, is covered.
Here's a simplified look at how these levels can impact cost:
| Policy Level | Key Inclusions | Typical Customer Profile | Estimated Monthly Premium Impact |
|---|
| Basic / Core | Full Inpatient & Day-Patient | Someone on a budget, happy to use the NHS for diagnostics but wants private treatment for major issues. | £ |
| Mid-Range | Core Cover + Limited Outpatient (e.g., £1,000) | The most common choice. Wants fast diagnosis and full treatment cover, balancing cost and benefits. | ££ |
| Comprehensive | Core Cover + Full Outpatient Cover | Someone wanting maximum peace of mind, with every stage of private care covered without financial limits. | £££ |
As expert PMI brokers, the team at WeCovr can provide detailed quotes across all these levels from the UK's leading insurers, helping you find the perfect balance for your personal circumstances and budget.
Other Important Options to Tailor Your Cover
Beyond the inpatient/outpatient choice, you can further customise your policy with other add-ons.
- Therapies Cover: This covers treatments like physiotherapy, osteopathy, and chiropractic care. It's often bundled with outpatient cover or available as a separate add-on. Given the long waits for NHS physio, this is a highly valued benefit.
- Mental Health Cover: Standard policies may offer limited mental health support, but a dedicated add-on provides more extensive cover. This can include access to psychiatrists and psychologists, and cover for inpatient psychiatric treatment.
- Dental & Optical Cover: This helps with the costs of routine check-ups, dental treatments, and prescription eyewear. It's less common but useful for those wanting to consolidate all their health-related insurance.
- Hospital Lists: Insurers use 'hospital lists' to manage costs. A basic policy might give you access to a limited list of local private hospitals, whilst a more comprehensive policy will offer a nationwide or even a central London list (which is the most expensive).
WeCovr's Added Value: More Than Just a Policy
We believe in providing holistic value to our clients. When you arrange your private medical insurance through WeCovr, you get more than just a policy document.
- Complimentary Access to CalorieHero: All our PMI and life insurance clients receive free access to our AI-powered calorie and nutrition tracking app, CalorieHero. Proactively managing your health is the best way to prevent future medical issues.
- Multi-Policy Discounts: We value your loyalty. Clients who take out PMI or life insurance with us are eligible for discounts on other insurance products we offer, helping you protect all aspects of your life for less.
- Unbiased Expert Advice: With high customer satisfaction ratings, our mission is to provide clear, impartial advice. We compare the market for you, explaining the pros and cons of each provider, ensuring you make an informed decision at no extra cost to you.
Proactive Health: Tips to Keep You Out of the Hospital
Whilst insurance is there for when things go wrong, the best strategy is to maintain good health. A healthy lifestyle can reduce your risk of developing many acute conditions that require surgery.
- A Balanced Diet: Focus on whole foods—fruits, vegetables, lean proteins, and whole grains. The NHS "Eatwell Guide" is an excellent resource for visualising a balanced plate. Reducing processed foods, sugar, and saturated fats can lower your risk of heart disease and certain cancers.
- Consistent Exercise: The UK Chief Medical Officers' guidelines recommend at least 150 minutes of moderate-intensity activity (like brisk walking or cycling) or 75 minutes of vigorous-intensity activity (like running or tennis) a week. Strength-building exercises are also crucial for bone and muscle health.
- Prioritise Sleep: Aim for 7-9 hours of quality sleep per night. Poor sleep is linked to a host of health problems, including a weakened immune system, high blood pressure, and difficulty concentrating.
- Manage Stress: Chronic stress can have a physical impact on your body. Practices like mindfulness, meditation, yoga, or simply spending time in nature can significantly improve your mental and physical wellbeing.
By investing in your health today, you reduce the likelihood of needing to make an inpatient or outpatient claim tomorrow.
Do I always need a GP referral for private medical insurance?
Generally, yes. Most UK private medical insurance providers require a referral from your NHS or private GP before you can see a specialist. This ensures your treatment path is medically appropriate. Some modern policies or integrated health apps from insurers are starting to offer "digital GP" services which can provide a faster referral, but the principle of a GP-led pathway remains the standard.
What is an 'excess' and how does it affect my inpatient and outpatient cover?
An excess is a fixed amount you agree to pay towards a claim before the insurer pays the rest. For example, if you have a £250 excess and your outpatient claim is £800, you would pay the first £250 and your insurer would pay the remaining £550. You typically pay the excess only once per policy year, per person. Choosing a higher excess is a common way to lower your monthly premium, as you are agreeing to share more of the initial cost. It applies to both inpatient and outpatient claims.
Can I choose any hospital for my inpatient treatment?
This depends on your policy's 'hospital list'. Insurers create different tiers of hospital lists to manage costs. A standard policy will include a broad national network of private hospitals. A more comprehensive (and expensive) policy might include premium hospitals in Central London, such as The London Clinic or The Cromwell. When getting a quote, it's important to check that the hospitals convenient for you are on the list included with your chosen plan. An expert broker like WeCovr can help you compare these lists.
Why doesn't private medical insurance in the UK cover chronic conditions like diabetes?
Private medical insurance is designed and priced to cover the risk of unforeseen, short-term (acute) conditions that can be treated and cured. Chronic conditions like diabetes or asthma are long-term, often lifelong, and require continuous management rather than a one-off cure. Covering these conditions would make premiums prohibitively expensive for everyone. The UK's healthcare system is structured so that the NHS provides excellent, comprehensive care for the ongoing management of all chronic conditions, free at the point of use.
Ready to Find Your Perfect Level of Cover?
Choosing between inpatient and outpatient cover is the most important step in building a private medical insurance policy that works for you. Whether you need a basic safety net for major surgery or a comprehensive plan for rapid diagnosis and treatment, the choice is yours.
The UK's private health cover market offers a wealth of options, and navigating them alone can be daunting. At WeCovr, our expert advisors are here to help. We'll listen to your needs, explain your options in plain English, and compare policies from the UK's leading insurers to find you the best cover at the right price.
Contact WeCovr today for a free, no-obligation quote and take the first step towards health peace of mind.