TL;DR
A serious illness diagnosis is a life-altering event. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we understand the stress involved. This guide demystifies using your private medical insurance (PMI) in the UK, ensuring you can focus on what truly matters: your health.
Key takeaways
- The NHS GP Referral Letter: Your PMI journey almost always starts with a referral from your GP to a specialist. This letter is the cornerstone of your claim, as it demonstrates the medical necessity for specialist consultation.
- The Diagnosis: You will need clear details of your diagnosis from the specialist. This includes the specific condition you have been diagnosed with.
- The Proposed Treatment Plan: The specialist will recommend a course of action. This could involve surgery, a course of chemotherapy, diagnostic scans, or specialist therapy. Get a copy of this plan, as your insurer needs to know what they are being asked to cover.
- An acute condition is a disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery, returning you to your previous state of health. Most cancers, hernias, joint replacements, and cataracts are treated as acute.
- A chronic condition is a disease, illness, or injury that has one or more of the following characteristics: it needs ongoing or long-term monitoring, it has no known cure, it is likely to recur, or it requires palliative care. Examples include diabetes, asthma, hypertension, and multiple sclerosis.
A serious illness diagnosis is a life-altering event. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we understand the stress involved. This guide demystifies using your private medical insurance (PMI) in the UK, ensuring you can focus on what truly matters: your health.
Notification, claims, and cover continuation best practices
Receiving a diagnosis for a serious condition like cancer, a heart condition, or a neurological disorder is overwhelming. Amid the emotional turmoil, you also have to navigate the practicalities of treatment. If you have private medical insurance, understanding how to use your policy effectively is crucial.
This comprehensive guide will walk you through the entire process, from the moment of diagnosis to notifying your insurer, making a claim, and understanding the future of your cover. We'll provide best practices to ensure your journey is as smooth as possible, helping you access the high-quality private care you're covered for without unnecessary delays or stress.
The Moment of Diagnosis: Your First Steps
Your health and wellbeing are the absolute priority. Before you even think about insurance paperwork, take a moment to process the news and lean on your support network. Your GP and NHS specialist are your primary medical guides.
Once you feel ready, the key is to get organised. Your PMI provider will need specific information to authorise your claim.
Key documents and information to gather:
- The NHS GP Referral Letter: Your PMI journey almost always starts with a referral from your GP to a specialist. This letter is the cornerstone of your claim, as it demonstrates the medical necessity for specialist consultation.
- The Diagnosis: You will need clear details of your diagnosis from the specialist. This includes the specific condition you have been diagnosed with.
- The Proposed Treatment Plan: The specialist will recommend a course of action. This could involve surgery, a course of chemotherapy, diagnostic scans, or specialist therapy. Get a copy of this plan, as your insurer needs to know what they are being asked to cover.
Keep these documents in a safe, accessible place. Creating a digital folder on your computer or a physical file can help you stay organised during a stressful time.
Understanding Your PMI Policy: What's Actually Covered?
This is the most important—and often misunderstood—aspect of private medical insurance. UK PMI is designed for a specific purpose, and knowing its boundaries is vital to avoid disappointment.
The Golden Rule: Acute vs. Chronic Conditions
Standard UK private health cover is designed to treat acute conditions that arise after your policy has started.
- An acute condition is a disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery, returning you to your previous state of health. Most cancers, hernias, joint replacements, and cataracts are treated as acute.
- A chronic condition is a disease, illness, or injury that has one or more of the following characteristics: it needs ongoing or long-term monitoring, it has no known cure, it is likely to recur, or it requires palliative care. Examples include diabetes, asthma, hypertension, and multiple sclerosis.
Crucially, standard PMI does not cover chronic or pre-existing conditions.
- Pre-existing Conditions: Any medical condition for which you have experienced symptoms, sought advice, or received treatment in the five years before your policy began will be excluded.
- Chronic Conditions: Once a condition is diagnosed and deemed chronic, PMI cover for it will typically cease. The day-to-day management of that condition will then be handled by the NHS. PMI may cover the initial diagnostic phase, but not the long-term management.
| Condition Type | Is it Covered by Standard PMI? | Example |
|---|---|---|
| Acute | Yes (if it starts after the policy begins) | A cancerous tumour that can be surgically removed, a broken bone needing surgery, gallstones. |
| Chronic | No (long-term management is not covered) | Type 2 Diabetes, Asthma, High Blood Pressure, Crohn's Disease. |
| Pre-existing | No | Knee pain you saw a doctor for 2 years before buying your policy, which is later diagnosed as arthritis. |
To be certain of your cover, locate these three key documents from your insurer:
- Policy Schedule: This summarises your specific cover level, outpatient limits, excess amount, and any special conditions.
- Terms and Conditions: The detailed rulebook. It contains the definitions of what is and isn't covered.
- Hospital List: This tells you which private hospitals and treatment centres you are covered to use. Using a facility not on your list can result in you not being covered for the costs.
Notifying Your PMI Provider: The Claims Process Explained
With your medical information in hand, the next step is to contact your insurer. Do this before you book any private tests or treatment. All private care must be pre-authorised.
A Step-by-Step Guide to Making a Claim:
- Contact Your Insurer's Claims Team: Most providers have a dedicated claims helpline. Many also have online portals or apps for initiating a claim. Have your policy number ready.
- Provide Your Details: The claims assessor will ask for:
- Your name, date of birth, and policy number.
- The name and contact details of your referring GP.
- The name and contact details of the specialist you have seen (or wish to see).
- Details of your symptoms and the diagnosis you have received.
- Explain the Proposed Treatment: Tell the insurer what the specialist has recommended. They will check this against the terms of your policy to ensure it's a covered benefit.
- Receive Pre-Authorisation: If the treatment is covered, the insurer will give you an authorisation number. This is your green light. It confirms that they have agreed to cover the costs for the specified treatment with a particular specialist at an approved hospital.
- Share Authorisation with Your Specialist: Provide the specialist's clinic and the hospital with your PMI membership number and the pre-authorisation code. They will use this to bill your insurer directly. You will only be responsible for paying any excess on your policy.
Real-Life Example: Sarah's Breast Cancer Diagnosis
- Sarah, 45, finds a lump and her NHS GP refers her for a mammogram, which confirms a suspicious mass.
- She is on the NHS waiting list for a biopsy. Wanting to speed things up, she calls her private medical insurance provider.
- She gives them her policy number, her GP's details, and the referral information.
- The insurer pre-authorises a private consultation with an oncologist and a biopsy. She is given an authorisation code.
- Sarah sees the specialist within days. The biopsy confirms early-stage breast cancer. The oncologist recommends a lumpectomy followed by radiotherapy.
- Sarah calls her insurer again with the proposed treatment plan.
- The insurer pre-authorises the surgery and the full course of radiotherapy, as her comprehensive policy has full cancer cover.
- Sarah's treatment is carried out privately, and the insurer is billed directly. She can focus entirely on her recovery.
Common Pitfalls and How to Avoid Them During a Claim
Navigating a claim can feel complex, but avoiding these common mistakes will make the process much smoother.
- Assuming Cover Without Pre-Authorisation: Never book a private appointment or procedure without getting an authorisation code from your insurer first. If you do, you risk being liable for the full cost, which can run into thousands of pounds.
- Not Understanding Your Policy Limits: Many policies have an annual limit on outpatient cover (consultations, scans, and tests). For example, you might have a £1,000 limit. If your diagnostic scans cost £1,500, you would be responsible for the £500 shortfall. Check your policy schedule for these limits.
- Choosing a Non-Listed Consultant or Hospital: Insurers have networks of approved specialists and hospitals. Choosing someone outside this network may lead to your claim being denied or only partially paid. Always check your provider's approved list before booking.
- Delays in Providing Information: Insurers work on the information you provide. Delays in sending them your referral letter or treatment plan will delay the pre-authorisation, and in turn, your treatment. Act promptly to keep the process moving.
- Forgetting Your Excess (illustrative): Most policies have an excess, which is the amount you agree to pay towards a claim each year (e.g., £250). This will be deducted from the first claim payment or you'll be asked to pay it directly to the hospital.
What if My Serious Illness is Deemed Chronic?
This is a critical point to understand. If your condition, even a serious one, is diagnosed as chronic, your PMI cover for it will stop once the condition is stable.
For example, a condition like Multiple Sclerosis (MS) might be investigated and diagnosed privately under PMI. The policy would cover the initial consultations with a neurologist and diagnostic scans like an MRI. However, once a diagnosis of MS is confirmed and a long-term management plan is in place, the condition is considered chronic. At this point, PMI cover ceases, and the ongoing care (medication, routine check-ups, physiotherapy) reverts to the NHS.
This is a fundamental principle of how UK PMI is designed. It exists to complement the NHS by providing rapid access to diagnosis and acute treatment, not to replace the NHS's role in managing long-term, incurable conditions. This model helps keep private health cover affordable for millions.
Cancer Cover: A Special Case in Private Medical Insurance
Cancer is the single biggest reason people claim on their PMI. According to Cancer Research UK, there are around 393,000 new cancer cases in the UK every year (data from 2018-2020), highlighting the profound impact of the disease.
Because of this, most mid-range and comprehensive PMI policies offer extensive cancer cover, often as a core benefit with no financial limit.
What comprehensive cancer cover typically includes:
- Full costs for diagnosis, including consultations and scans.
- Surgery, including reconstructive surgery.
- Chemotherapy and Radiotherapy.
- Targeted therapies and new generation drugs, sometimes including those not yet approved or funded by the NHS.
- Monitoring and follow-up consultations for a set period after your treatment ends.
- Palliative care and pain management.
When choosing a policy, it's worth asking a PMI broker like WeCovr to compare the cancer cover specifics between providers, as there can be subtle but important differences in what is offered as standard.
Managing Your Wellbeing During Treatment
A serious illness diagnosis takes a toll not just physically, but emotionally and mentally too. Prioritising your overall wellbeing can have a positive impact on your recovery.
- Nutrition: Treatment can affect your appetite and energy levels. Focus on small, nutrient-dense meals. Staying hydrated is also essential. As a WeCovr client, you get complimentary access to our AI-powered app, CalorieHero, which can help you track your intake and make healthier choices with ease.
- Mental Health: Don't be afraid to seek support. Many PMI providers include access to mental health support lines or even a set number of counselling sessions. Talking therapies can be invaluable for processing your diagnosis and managing anxiety.
- Gentle Activity: As cleared by your doctor, gentle movement like walking or stretching can boost your mood, improve sleep, and combat fatigue.
- Rest and Sleep: Your body is working hard to heal. Prioritise good sleep hygiene and allow yourself to rest whenever you feel tired.
Many of the best PMI providers now offer a suite of wellness tools, from digital GP apps to discounted gym memberships and mental health support, to help you stay healthy before, during, and after treatment.
After Treatment: Cover Continuation and Future Premiums
A common worry is what happens to your policy after you've made a large claim for a serious illness.
- Your Cover Continues: Your insurer cannot cancel your policy because you have claimed. You have the right to renew your cover.
- The Condition Becomes an Exclusion: The illness you claimed for will now be classed as a pre-existing condition. Any future treatment for that specific condition or any related conditions will be excluded from cover.
- Your Premiums Will Increase: At your next renewal, your premium is almost certain to rise. This increase is driven by three main factors:
- Age: Premiums increase each year as you get older.
- Medical Inflation: The cost of private healthcare rises each year, and this is passed on to policyholders.
- Your Claim: A significant claim will remove any no-claims discount you had and may result in an additional "claims-rated loading" being applied to your premium.
Should I Switch Insurers After a Claim?
Switching to a new provider after a serious illness claim is often not the best option. While you can get a new policy, the new insurer will exclude your major condition (and anything related to it) from day one. In most cases, it is better to stay with your current insurer, who will continue to cover you for any new, unrelated acute conditions that may arise in the future.
This is where an expert broker is invaluable. At renewal, WeCovr can review the market for you, assess whether a switch is viable, and even negotiate with your current provider on your behalf to ensure the renewal terms are fair.
UK Private Health Insurance Provider Overview
The UK PMI market is dominated by a few key players. While costs and specific benefits vary greatly depending on your age, location, and chosen cover level, here is a general overview.
| Provider | Typical Focus | Example Cancer Cover Feature | Digital Tools |
|---|---|---|---|
| Bupa | Comprehensive cover, large hospital network. | Often covers monitoring and follow-ups for years post-treatment. | Bupa Touch app, Digital GP, Mental Health support. |
| Aviva | Flexible options, often strong value. | 'Expert Select' option gives access to a curated network of specialists. | Aviva DigiCare+ app with health checks, nutrition, and mental health support. |
| AXA Health | Strong focus on wellness and mental health. | Access to specialist cancer nurses and dedicated support lines. | Doctor at Hand app, Mind Health service, discounted gym memberships. |
| Vitality | Unique model rewarding healthy living. | Full cancer cover is standard on most plans. | Rewards active lifestyles with discounts and perks through their app. |
Disclaimer: This table is for illustrative purposes only. Features and benefits are subject to change and depend on the specific policy chosen.
Do I need to declare a new serious illness to my PMI provider even if I use the NHS for treatment?
Will my private medical insurance premium go up after a cancer claim?
Can I get new PMI cover after being diagnosed with a serious illness?
What's the difference between moratorium and full medical underwriting?
Take the Next Step with Confidence
A serious illness diagnosis is a challenging journey, but you don't have to navigate your insurance alone. Working with an expert, independent PMI broker can save you time, money, and stress, ensuring you have the right cover in place when you need it most. We can also help you secure discounts on other policies like life or income protection insurance when you buy your PMI through us.
Ready to secure your peace of mind? Contact WeCovr today for a free, no-obligation quote and find the best private medical insurance UK policy for your needs.
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.
