PMI Policy Documents How to Read the Fine Print
Navigating the world of private medical insurance in the UK can feel complex, but understanding your policy is crucial for peace of mind. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies of various types, we believe in empowering you with clear, expert knowledge. This guide will demystify your PMI policy documents, ensuring you know exactly what you're covered for.
A guide to decoding exclusions, limits, and hospital lists
A Private Medical Insurance (PMI) policy is your passport to faster access to high-quality private healthcare. However, like any contract, its value lies in the details. The policy document is a comprehensive guide to your cover, but it can be filled with industry-specific terms.
This article will act as your translator. We'll break down the three most critical components—exclusions, limits, and hospital lists—so you can read your policy with confidence and make the most of your private health cover.
Why Reading Your PMI Policy Document is Non-Negotiable
Imagine buying a ticket for a round-the-world trip but never looking at the itinerary. You wouldn't know which destinations are included, what the baggage allowance is, or if flights are direct. Your PMI policy is no different. It’s your healthcare itinerary.
Reading it thoroughly ensures there are no surprises when you need to make a claim. It empowers you to:
- Understand Your Cover: Know precisely which conditions and treatments are included.
- Avoid Rejected Claims: Prevent the frustration and distress of a claim being denied because it falls under an exclusion.
- Budget Effectively: Be aware of any excess payments or financial limits, so you can plan accordingly.
- Maximise Value: Discover all the added benefits your policy might offer, such as virtual GP services or wellness discounts.
The Financial Conduct Authority (FCA) requires UK insurers to provide a clear and fair Insurance Product Information Document (IPID), but the detailed terms are in the main policy wording. Taking the time to read it is the single best investment you can make in your health security.
The Core Components of a PMI Policy Document
Your PMI documentation isn't a single booklet but a collection of documents that work together. Here are the key parts you'll receive.
| Document | Purpose | What to Look For |
|---|---|---|
| Policy Schedule | Your personal summary. A one-page overview of your specific cover. | Your name, address, policy number, start date, premium amount, chosen excess, and level of cover (e.g., outpatient limit). |
| Policy Wording / Guide | The main rulebook. This is the detailed contract explaining all terms, conditions, benefits, and exclusions. | The definitions section, claims process, general exclusions, and details on specific benefits like cancer care or mental health. |
| Hospital List | Your treatment network. The list of private hospitals, clinics, and day-patient units you are eligible to use. | The different tiers (e.g., Local, National, London). Check that hospitals convenient for you are included. |
| IPID (Key Facts) | A standardised summary. The Insurance Product Information Document gives a simple, at-a-glance overview of the policy's main features and limitations. | What is insured? What is not insured? Are there any restrictions on cover? Where am I covered? |
Always start with the Policy Schedule and IPID for a quick overview, then dive into the main Policy Wording for the complete picture.
Decoding General Exclusions: What Most PMI Policies Won't Cover
This is the most critical section to understand. UK private medical insurance is designed to cover acute conditions that arise after you take out the policy. It is not designed to replace the NHS, especially for emergencies or long-term conditions.
The Golden Rule: No Cover for Pre-existing or Chronic Conditions
- Pre-existing Conditions: These are any diseases, illnesses, or injuries for which you have experienced symptoms, received medication, or sought advice from a medical professional before your policy start date. For most policies, this look-back period is five years.
- Chronic Conditions: These are conditions that are long-lasting, have no known cure, and require ongoing management. PMI is not designed to cover the routine management of chronic illnesses.
Here are some common examples to clarify the difference:
- Acute Condition (Covered): You develop sudden knee pain, are diagnosed with a torn meniscus, and require surgery. This is a treatable, short-term condition.
- Chronic Condition (Not Covered): You have been diagnosed with Type 1 diabetes. The ongoing management, including insulin, regular check-ups, and blood sugar monitoring, would not be covered.
- Pre-existing Condition (Not Covered): You received physiotherapy for a bad back two years before buying your policy. If the back pain returns, it would likely be excluded as a pre-existing condition.
Common General Exclusions Table
Almost every standard private medical insurance UK policy will exclude the following:
| Exclusion Category | Examples | Why is it excluded? |
|---|---|---|
| Chronic Conditions | Diabetes, asthma, hypertension, Crohn's disease, arthritis. | PMI is for short-term, curable conditions. The NHS is structured to provide long-term care pathways. |
| Pre-existing Conditions | A condition you had symptoms of or treatment for in the 5 years before your policy started. | Insurance is designed to cover unforeseen future events, not known existing problems. |
| Emergencies & A&E | Heart attacks, strokes, major trauma from accidents. | Emergency services (999, A&E) are the domain of the NHS, which is expertly equipped for immediate, life-saving care. |
| Normal Pregnancy | Routine check-ups, normal delivery. | Childbirth is considered a natural life event, not an unexpected illness. Complications may be covered by some policies. |
| Cosmetic Surgery | Facelifts, rhinoplasty, breast augmentation. | Treatments that are for aesthetic preference rather than medical necessity are excluded. Reconstructive surgery after an accident or illness (e.g., cancer) may be covered. |
| Self-inflicted Injury | Injuries resulting from deliberate self-harm or illegal activities. | These are not considered insurable risks. |
| Addiction Treatment | Rehabilitation for drug or alcohol dependency. | This requires specialist, long-term management often outside the scope of standard PMI. |
| Fertility Treatment | IVF, IUI, and related investigations. | These are elective treatments rather than for an acute medical condition. |
Understanding Policy Limits: The 'How Much' and 'How Often'
Your policy won't offer a blank cheque. Insurers use limits to manage risk and keep premiums affordable. These limits can be financial or based on the number of treatment sessions.
Financial Limits
This is the maximum amount the insurer will pay out.
- Overall Annual Limit: Most policies today offer a high overall limit (e.g., £1 million) or are described as having 'unlimited' cover for eligible treatment. This means you are very unlikely to run out of cover in a single year.
- Outpatient Limits: This is a crucial area of variation. Outpatient treatment is any consultation, test, or diagnostic scan that doesn't require a hospital bed.
- Basic Cover: May have a low limit, such as £500 per year.
- Mid-Range Cover: Typically offers £1,000 to £1,500.
- Comprehensive Cover: Provides unlimited outpatient cover. This choice significantly impacts your premium. A lower outpatient limit means you might have to pay for some initial diagnostic tests yourself before the policy covers any resulting inpatient surgery.
- Per-Treatment Limits: Less common now, but some policies may have caps on specific procedures. Always check the small print for this.
Time & Session Limits
Many policies limit the number of therapy sessions you can have per year.
- Physiotherapy/Osteopathy: A common limit is 8-10 sessions per condition per year.
- Mental Health Therapy: Cover for talking therapies (e.g., CBT) might be limited to a set number of sessions, such as 8 or 12.
Your Policy Excess
An excess is the amount you agree to pay towards the cost of a claim. It’s a way of sharing the cost with the insurer, which in turn lowers your premium.
- How it works: If you have a £250 excess and receive eligible treatment costing £3,000, you pay the first £250. Your insurer pays the remaining £2,750.
- Per Claim vs. Per Year: Most policies apply the excess per person, per policy year. This is more favourable, as you only pay it once per year, no matter how many separate claims you make. Some older or cheaper policies might apply it per claim.
- Choosing an Excess: You can typically choose an excess from £0 to £1,000. A higher excess means a lower monthly premium.
Example: Impact of Excess on Premiums (Illustrative)
| Excess Option | Approximate Monthly Premium | Your Contribution per Year |
|---|---|---|
| £0 | £80 | £0 |
| £250 | £65 | £250 |
| £500 | £55 | £500 |
| £1,000 | £45 | £1,000 |
Navigating Hospital Lists: Where You Can Be Treated
Your choice of hospital list directly impacts your premium and your access to care. Insurers negotiate rates with hospital groups, creating networks or 'lists' for their policyholders.
Tiers of Hospital Lists
- Local / Trust Lists: These are the most restrictive and cheapest options. They might limit you to a specific list of private hospitals in your region or even just the private patient units within local NHS Trusts.
- National Lists: This is the most common option. It provides access to a wide network of several hundred private hospitals across the UK. However, it often excludes the most expensive hospitals in Central London.
- Premium / London Upgrade: This is the top-tier list. It includes the major national hospitals plus the prestigious, high-cost private hospitals in Central London (e.g., The Harley Street Clinic, The London Clinic, The Lister Hospital). This option carries the highest premium and is typically chosen by those who live or work in London and want maximum choice.
Top Tip: Before choosing, check the list on the insurer's website. Ensure there are good, convenient hospital options near both your home and your workplace. There’s little point in saving money on a policy if your nearest approved hospital is a two-hour drive away.
The Crucial Role of Underwriting: Moratorium vs. Full Medical Underwriting
Underwriting is how an insurer assesses your medical history to decide which pre-existing conditions to exclude. There are two main methods.
| Feature | Moratorium (Mori) Underwriting | Full Medical Underwriting (FMU) |
|---|---|---|
| Process | No initial health questionnaire. Fast and simple to set up. | You complete a detailed health questionnaire. |
| Exclusions | Automatically excludes any condition you've had symptoms of or treatment for in the last 5 years. | The insurer assesses your form and issues a policy with specific, named exclusions from day one. |
| Clarity | "Wait and see." You only find out if a condition is covered when you claim. The insurer will check your medical history at that point. | "Certainty from the start." You have a document listing exactly what is and isn't covered. |
| Lifting Exclusions | An exclusion can be lifted if you remain treatment-free and symptom-free for that condition for a continuous 2-year period after your policy starts. | Exclusions are typically permanent, though you can sometimes ask for a review after several years. |
| Best For | People with a clean bill of health who want a quick start. | People with a complex medical history who want absolute clarity on their cover. |
An expert PMI broker, such as WeCovr, can help you decide which underwriting method is best for your personal circumstances, ensuring there are no grey areas.
Added Value Benefits: More Than Just Medical Treatment
Modern PMI is evolving from a reactive "sickness" product to a proactive "wellness" partner. Insurers now include a host of valuable benefits designed to keep you healthy.
- 24/7 Virtual GP: Get a video or phone consultation with a GP at any time, day or night, often with same-day appointments. This is perfect for getting quick advice, prescriptions, or referrals.
- Mental Health Support: Most policies now include access to mental health support lines or a set number of therapy sessions without needing a GP referral. Given that the Office for National Statistics (ONS) reports rates of depression in Great Britain remain higher than pre-pandemic levels, this is an incredibly valuable benefit.
- Wellness Programmes: Many providers offer discounts on gym memberships, fitness trackers, and health screenings to encourage a healthy lifestyle.
- Exclusive WeCovr Benefits: When you arrange a policy through us, we go a step further. Our clients receive complimentary access to CalorieHero, our AI-powered calorie and nutrition tracking app, to support their health goals. Furthermore, customers who purchase PMI or Life Insurance often receive discounts on other types of cover, adding even more value.
A Practical Checklist: How to Review Your PMI Quote and Documents
Use this step-by-step guide to analyse any policy document like a pro.
- Start with the IPID: Read the one-page summary first. Does it align with your expectations?
- Check the Policy Schedule: Confirm all personal details are correct. Is the excess what you chose? Is the outpatient limit correct?
- Scan General Exclusions: Read this section carefully. Are you clear that chronic and pre-existing conditions are not covered?
- Review Financial & Time Limits: What is your outpatient limit? Are there any limits on therapies like physiotherapy?
- Examine the Hospital List: Does it include hospitals that are convenient for you? Is it a local, national, or premium list?
- Understand Your Underwriting: Is your policy on a Moratorium or FMU basis? If FMU, review your personal exclusions certificate carefully.
- Note the 'Extras': What digital GP, mental health, or wellness benefits are included?
- Clarify the Claims Process: How do you start a claim? Do you always need a GP referral first? (Most policies require one).
- Ask an Expert: If any part is unclear, don't guess. An independent PMI broker like WeCovr can translate the jargon and compare policy features across the market for you, at no extra cost.
The Connection Between Lifestyle and PMI
While PMI is there for when things go wrong, a healthy lifestyle can reduce your chances of needing to claim. It can also help you make the most of your policy's wellness benefits.
- Diet and Exercise: A balanced diet and regular physical activity are the cornerstones of good health, lowering your risk of developing many acute conditions. Tools like the CalorieHero app, which WeCovr provides to clients, make it easier to stay on track.
- Sleep and Mental Wellbeing: Prioritising 7-9 hours of quality sleep is vital for both physical and mental resilience. If you're struggling, don't hesitate to use the mental health support lines included in most PMI policies. Early intervention is key.
- A Note on Travel: Remember, your UK private medical insurance is for treatment within the UK. It is not a substitute for comprehensive travel insurance when you go abroad.
Common Pitfalls and How to Avoid Them
- The Assumption Pitfall: "I assumed my long-standing dodgy knee would be covered."
- Avoidance: Understand that pre-existing conditions are excluded. Be honest about your medical history during application.
- The Hospital List Pitfall: "I chose the cheapest policy but now my local private hospital isn't on the list."
- Avoidance: Always check the hospital list before you buy. Balance the premium cost with practical access to care.
- The Excess Pitfall: "I was surprised I had to pay £500 before the insurer paid anything."
- Avoidance: Check your Policy Schedule to confirm your chosen excess. Remember it when budgeting for potential treatment.
- The Auto-Renew Pitfall: "My premium went up, but I just let it renew without checking."
- Avoidance: Treat your renewal as an opportunity for a market review. Your needs may have changed, and a different provider might offer better value. A broker can do this annual review for you, saving you time and money.
Do I need to declare every minor illness I've ever had on a Full Medical Underwriting (FMU) application?
Generally, you should be honest and thorough, but focus on the time period the application asks about (usually the last 5 years). Insurers are interested in persistent or significant conditions, consultations, and treatments. A common cold or a one-off headache from five years ago is typically not relevant, but a recurring issue like back pain, even if minor, should be declared. When in doubt, it is always better to declare it.
Can I change my hospital list or excess level mid-way through the year?
Usually, you can only make changes to your core cover levels—such as your excess or hospital list—at your annual renewal date. This is why it's so important to get these choices right from the start. If your circumstances change significantly, you should speak to your insurer or broker to discuss your options.
What is the difference between an acute and a chronic condition in PMI terms?
This is a key distinction for private medical insurance. An acute condition is a disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery (e.g., a cataract, appendicitis, a bone fracture). A chronic condition is one that has one or more of the following characteristics: it needs long-term monitoring, has no known cure, is likely to recur, or requires ongoing management (e.g., diabetes, asthma, hypertension). UK PMI is designed to cover acute conditions only.
Is mental health treatment covered by private medical insurance in the UK?
Yes, increasingly so. Most modern PMI policies provide some level of cover for mental health. However, the extent of this cover varies widely. Some policies may only cover a limited number of outpatient therapy sessions (like CBT), while more comprehensive plans may include inpatient treatment for more severe conditions. It is essential to check the specific limits and terms for mental health in your policy document.
Feeling overwhelmed by the small print? You don't have to be. The experts at WeCovr are here to help.
As an FCA-authorised broker, we provide free, impartial advice to help you find the best private medical insurance UK has to offer. We'll decode the jargon, compare the market, and ensure you get a policy that truly fits your needs and budget.
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!
There is no need to wait until the renewal of your current policy.
We can look at a more suitable option mid-term!
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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WeCovr is an insurance specialist for people valuing their peace of mind and a great service.👍 WeCovr will help you get your private medical insurance, life insurance, critical illness insurance and others in no time thanks to our wonderful super-friendly experts ready to assist you every step of the way.
Just a quick and simple form and an easy conversation with one of our experts and your valuable insurance policy is in place for that needed peace of mind!