Outpatient Limits and Sub-Limits What to Look For
As an FCA-authorised broker that has helped arrange over 900,000 policies, WeCovr knows that understanding private medical insurance (PMI) in the UK can be a minefield of jargon. One of the most critical, yet often overlooked, areas is outpatient cover, where hidden limits and caps can lead to unexpected bills.
Analysis of annual and per-condition outpatient, therapy, and diagnostic caps—why reading the policy fine print could save £1000s
When you buy private health cover, you're buying peace of mind and fast access to medical care. The glossy brochures promise swift consultations and cutting-edge diagnostics. But what happens when you need a series of tests, specialist appointments, and physiotherapy?
This is where your policy's outpatient limits come into play. Many people are surprised to discover their "comprehensive" plan has a cap of just £500 or £1,000 for all the care they need before being admitted to hospital. A single MRI scan can wipe out most of that limit, leaving you to foot the bill for everything else.
In this guide, we will dissect the different types of outpatient limits, explain the impact of sub-limits for diagnostics and therapies, and show you, with real-world examples, how choosing the right level of cover can protect both your health and your finances.
What Are Outpatient Services in Private Medical Insurance?
Before we dive into the limits, let's clarify what "outpatient" means in the context of PMI. An outpatient is someone who receives treatment, tests, or consultations at a hospital or clinic but is not admitted overnight.
These services form the backbone of diagnosing and managing most health conditions. They typically include:
- Specialist Consultations: Appointments with consultants like cardiologists, dermatologists, or orthopaedic surgeons after a GP referral.
- Diagnostic Tests and Scans: Procedures needed to identify the cause of your symptoms. This includes blood tests, X-rays, ultrasounds, and more advanced imaging like CT, MRI, and PET scans.
- Therapies: Treatments provided by recognised therapists, such as physiotherapists, osteopaths, and chiropractors, to aid recovery.
- Minor Procedures: Small surgical procedures that don't require an overnight stay, sometimes performed in an outpatient setting.
Crucial Point: Standard UK private medical insurance is designed for acute conditions—illnesses or injuries that are new, unexpected, and likely to respond quickly to treatment. It does not cover chronic conditions (long-term illnesses like diabetes or asthma) or pre-existing conditions you had before taking out the policy.
Inpatient vs. Outpatient Care: A Clear Distinction
Understanding the difference between inpatient, day-patient, and outpatient care is fundamental to grasping your policy's structure. Insurers treat them very differently.
| Care Type | Description | Example | Typical PMI Cover |
|---|---|---|---|
| Inpatient | You are admitted to a hospital and stay overnight for one or more nights for treatment or surgery. | A hip replacement surgery requiring a few nights' hospital stay. | Core cover on virtually all PMI policies. |
| Day-Patient | You are admitted to a hospital or clinic for a planned procedure or treatment and are discharged on the same day. | Cataract surgery or an endoscopy. | Usually included as standard in core PMI cover. |
| Outpatient | You visit a hospital or clinic for a test, consultation, or therapy session and go home the same day without being formally admitted. | A consultation with a cardiologist, an MRI scan on your knee, or a physiotherapy session. | Often an optional add-on with various levels of cover and financial limits. |
While most policies provide comprehensive cover for inpatient and day-patient care, outpatient cover is where you have the most choice—and the most risk of being underinsured.
Demystifying Outpatient Limits: The Different Types of Caps
When you add outpatient cover to your PMI policy, it will almost always come with a limit. This is the maximum amount the insurer will pay out for outpatient services within a policy year. Understanding how this limit is applied is key.
1. Annual Monetary Limits
This is the most common type of cap. The insurer sets a total financial amount they will pay for all your outpatient claims in a single policy year.
- Common Levels: £500, £1,000, £1,500, or "Unlimited" (often called 'full cover').
- How it Works: Every outpatient claim, from a £250 consultant fee to a £600 MRI scan, is deducted from this annual pot of money. Once it's gone, you pay for any further outpatient care yourself until the policy renews and the limit resets.
Example: You have a £1,000 annual outpatient limit.
- You see a specialist for back pain: £250
- They refer you for an MRI scan: £700
- Total claimed: £950
- Remaining limit for the year: £50
If you then need physiotherapy at £60 per session, your policy will cover less than one full session. You would be responsible for the cost of the remaining physiotherapy course.
2. Per-Condition or Per-Claim Limits
Less common, but some policies may set limits based on the specific medical condition you are claiming for. This can be more generous if you have multiple, unrelated health issues in one year, but restrictive for a single, complex problem.
3. Number of Session Limits (Primarily for Therapies)
For treatments like physiotherapy, osteopathy, or chiropractic care, insurers often impose a limit on the number of sessions they will fund, either per condition or per year. This might be, for example, "up to 8 sessions". This limit can exist even on a policy with a high overall monetary cap.
4. 'Full Cover' vs. Capped Cover
Many insurers offer a "full cover" or "unlimited" outpatient option. This is the gold standard, as it removes the worry of exhausting a financial limit during diagnosis. However, "full" doesn't always mean everything is limitless. It's vital to check for sub-limits, which we'll explore next.
Choosing between these options is a balancing act. A lower limit significantly reduces your monthly premium, while full cover provides the most comprehensive protection. An expert PMI broker can help you compare the cost-benefit of each level across different providers.
Deep Dive into Sub-Limits: The Devil in the Detail
This is where many policyholders get caught out. A sub-limit is a cap placed on a specific type of outpatient service, which sits within your main outpatient limit. Even if you have a "full cover" outpatient option, it might still have sub-limits for therapies or mental health.
Diagnostics Sub-Limits (MRI, CT, PET Scans)
Advanced diagnostic scans are expensive, with costs often running from £400 to over £1,500. Because of this, some policies place specific restrictions on them.
- What to Look For: Check if your policy has a separate, lower cap for diagnostics. For example, your policy might have a £1,500 overall outpatient limit, but a sub-limit of £1,000 for scans.
- Why it Matters: A single complex issue requiring a CT scan (£700) and a PET-CT scan (£1,500) could easily breach a sub-limit, even if you haven't used your main outpatient allowance.
According to NHS England data, the median waiting time for certain diagnostic tests can be several weeks. Accessing these tests privately in a matter of days is a primary driver for taking out PMI, making robust diagnostic cover essential.
Therapies Sub-Limits (Physiotherapy, Osteopathy, etc.)
This is one of the most common sub-limits. It's a major area of saving for insurers, as musculoskeletal issues are a frequent source of claims.
- What to Look For:
- Monetary Caps: A specific financial limit for all therapies (e.g., "up to £500 for therapies").
- Session Caps: A limit on the number of sessions (e.g., "up to 6 physiotherapy sessions per condition").
- Combined Limits: Some policies apply both.
- Why it Matters: Recovering from a sports injury or surgery can require a lengthy course of physiotherapy. If your policy only covers 6-8 sessions, but your specialist recommends 12, you will be paying for the extra sessions out-of-pocket, which could cost hundreds of pounds.
Mental Health Support Sub-Limits
As awareness of mental health grows, more PMI policies are offering cover. However, this is almost always tightly controlled with sub-limits.
- What to Look For: Outpatient mental health cover is often capped at a specific financial amount (e.g., £1,000 per year) or a set number of sessions with a psychiatrist or therapist. This is usually separate from your main outpatient limit for physical health.
- Why it Matters: A course of therapy can be expensive. Knowing the exact limit helps you plan for your care. If you believe mental health support is a priority, you must scrutinise this section of any policy.
Real-Life Scenarios: How Outpatient Limits Impact Your Wallet
Let's illustrate the financial impact with two common scenarios. Costs are indicative and can vary by hospital and location.
Scenario 1: Investigating a Knee Injury
Sarah, a keen runner, develops persistent knee pain. Her GP refers her to a private orthopaedic specialist.
Breakdown of Potential Outpatient Costs:
| Service | Average Private Cost | Cumulative Cost |
|---|---|---|
| Initial Orthopaedic Consultation | £250 | £250 |
| MRI Scan of the Knee | £650 | £900 |
| Follow-up Consultation (to discuss results) | £175 | £1,075 |
| Physiotherapy Course (8 sessions @ £65/session) | £520 | £1,595 |
| Total Outpatient Cost | £1,595 |
How Different Outpatient Limits Would Perform:
- With a £500 Limit: The policy would cover the initial consultation and part of the MRI scan. Sarah would have a shortfall of £1,095 to pay herself.
- With a £1,000 Limit: The policy would cover the consultations and the MRI scan. Sarah would have a shortfall of £595 for the physiotherapy.
- With a £1,500 Limit: The policy would cover most of the costs, but Sarah would still face a small shortfall of £95.
- With a "Full Cover" Limit (with no therapy sub-limit): The policy would cover all £1,595, leaving Sarah with no outpatient bills to pay (subject to her policy excess).
This example clearly shows how a low outpatient limit, chosen to save on premiums, can result in significant out-of-pocket expenses for a relatively common medical issue.
Scenario 2: Investigating Persistent Headaches
David has been suffering from chronic headaches and dizziness. His GP refers him to a private neurologist.
Breakdown of Potential Outpatient Costs:
| Service | Average Private Cost | Cumulative Cost |
|---|---|---|
| Initial Neurologist Consultation | £300 | £300 |
| CT Scan of the Head | £550 | £850 |
| MRA Scan (to check blood vessels) | £750 | £1,600 |
| Follow-up Consultation | £200 | £1,800 |
| Total Outpatient Cost | £1,800 |
In this diagnostic-heavy scenario, even a £1,500 outpatient limit would leave David with a £300 shortfall. Someone with a £1,000 limit would be facing an £800 bill. This highlights the importance of checking not just the overall limit, but also any specific sub-limits on diagnostic scans.
How UK Insurers Structure Their Outpatient Cover
Most major UK private health insurance providers—such as Bupa, AXA Health, Aviva, and Vitality—offer a tiered approach to outpatient cover. This allows you to tailor your policy to your budget and perceived needs.
| Typical Outpatient Tier | Description | Best Suited For |
|---|---|---|
| No Outpatient Cover | Your policy only covers inpatient and day-patient care. You pay for all consultations and diagnostics yourself. | Those on the tightest budget who want a "safety net" for major surgery only. Not generally recommended. |
| Low Limit (e.g., £500) | Provides basic cover for an initial consultation and perhaps one or two simple tests. | Young, healthy individuals mainly wanting fast access to a diagnosis, who are prepared to pay for subsequent treatment. |
| Medium Limit (e.g., £1,000-£1,500) | A good middle-ground that covers the diagnostic journey for most common conditions. | The majority of people and families looking for a balance between comprehensive cover and affordable premiums. |
| Full / Unlimited Cover | Covers all eligible outpatient costs without a financial cap (but may have therapy sub-limits). | Those who want maximum peace of mind and protection against the costs of complex diagnostic journeys or multiple conditions. |
Navigating the subtle differences between providers' "full cover" options can be challenging. This is where working with an independent PMI broker like WeCovr is invaluable. We can compare the fine print from across the market to find the policy that truly offers the comprehensive cover you need, at no extra cost to you.
Top Tips for Choosing the Right Outpatient Limit
- Don't Default to the Cheapest Option: A policy with a low premium and a £500 outpatient limit might seem like a bargain, but as our scenarios show, it can be a false economy.
- Assess Your Risk and Priorities: Are you a very active person prone to sports injuries? A comprehensive therapy limit might be important. Do you have a family history of a certain condition? Ensure diagnostic cover is robust.
- Consider the Cost of Diagnostics: A single MRI or CT scan can cost more than a low-level outpatient limit. We recommend a limit of at least £1,000-£1,500 to comfortably cover the diagnostic phase for most issues.
- Read the Fine Print on 'Full Cover': If you opt for an unlimited policy, check a) the policy excess you've chosen, and b) any sub-limits, especially for therapies and mental health.
- Review Your Cover Annually: Your needs may change. As you get older, you might want to increase your cover. Don't just let your policy auto-renew without checking if it's still right for you.
- Use an Expert Broker: A good broker will ask the right questions about your lifestyle, budget, and health concerns to recommend the perfect level of cover. They do the hard work of comparing policy documents for you.
A Note on Wellness and Prevention
The best way to manage healthcare costs is to stay healthy. While private medical insurance is there for when things go wrong, prioritising your wellbeing can reduce the likelihood of needing to claim.
- Balanced Diet: A diet rich in fruits, vegetables, and whole grains can lower your risk of many conditions.
- Regular Exercise: Aim for at least 150 minutes of moderate-intensity activity a week, as recommended by the NHS.
- Quality Sleep: Good sleep is crucial for physical and mental recovery.
- Stress Management: Chronic stress can contribute to a range of health problems.
At WeCovr, we believe in supporting our clients' overall wellbeing. That's why customers who purchase Private Medical or Life Insurance with us receive complimentary access to CalorieHero, our AI-powered calorie and nutrition tracking app. Furthermore, we're pleased to offer discounts on other types of insurance, such as home or travel cover, to our PMI clients as a thank you for trusting us with their health.
What happens if I exceed my outpatient limit?
Does "full cover" outpatient mean everything is paid for?
Are therapies like physiotherapy always included in the main outpatient limit?
Can I change my outpatient limit?
Choosing the right private medical insurance is one of the most important financial decisions you can make for your health. Don't let confusing jargon or hidden limits undermine your peace of mind.
At WeCovr, our team of experts is here to demystify the market for you. We provide independent, tailored advice to help you find the optimal balance of cover and cost, ensuring there are no nasty surprises when you come to claim. With high customer satisfaction ratings and a commitment to clarity, we make the process simple and stress-free.
Ready to find the right private health cover for your needs? Get a free, no-obligation quote today and let our experts guide you through your options.
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?
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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!
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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.
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