Key takeaways
- In-patient and Day-patient Treatment: This is the absolute cornerstone of PMI.
- In-patient: Covers costs when you are admitted to a hospital and stay overnight for treatment, such as for surgery. This includes hospital accommodation, nursing care, surgeon and anaesthetist fees, and medication.
- Day-patient: Covers treatment where you are admitted to a hospital for a procedure but do not need to stay overnight. Examples include cataract surgery or an endoscopy.
- Comprehensive Cancer Cover: This is a major reason many people invest in PMI. Standard policies usually offer extensive cancer cover, including diagnosis, surgery, chemotherapy, and radiotherapy. Some policies also include access to cutting-edge drugs and treatments not yet available on the NHS.
- Diagnostic Scans and Tests: When you have a policy, costs for tests like MRI, CT, and PET scans are usually covered when related to in-patient or day-patient treatment. This allows you to get a swift diagnosis.
Navigating the world of private medical insurance in the UK can feel complex, but understanding what’s covered is the first step to making an informed decision. As experienced brokers who have arranged policies for over 900,000 individuals and businesses, WeCovr is here to provide clarity.
What private health care plans and private healthcare plans typically include, with common add-ons and exclusions
A private health care plan, also known as Private Medical Insurance (PMI), is designed to cover the costs of diagnosis and treatment for new, acute medical conditions. An acute condition is a disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery.
The fundamental principle of UK private medical insurance is to complement, not replace, the NHS. It offers faster access to specialists, diagnostic tests, and treatment in private hospitals, helping you bypass NHS waiting lists.
Crucially, standard UK PMI does not cover chronic conditions (long-term illnesses like diabetes or asthma that require ongoing management) or pre-existing conditions that you had before your policy started.
This guide breaks down exactly what you can expect from a typical policy, what you can add, and what is almost always left out.
Core Inclusions: The Bedrock of Every PMI Policy
Nearly every private medical insurance policy in the UK is built on a foundation of 'core' cover. This is the essential protection that handles the most significant medical costs. Think of it as the non-negotiable part of your plan.
Here’s what is typically included as standard:
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In-patient and Day-patient Treatment: This is the absolute cornerstone of PMI.
- In-patient: Covers costs when you are admitted to a hospital and stay overnight for treatment, such as for surgery. This includes hospital accommodation, nursing care, surgeon and anaesthetist fees, and medication.
- Day-patient: Covers treatment where you are admitted to a hospital for a procedure but do not need to stay overnight. Examples include cataract surgery or an endoscopy.
-
Comprehensive Cancer Cover: This is a major reason many people invest in PMI. Standard policies usually offer extensive cancer cover, including diagnosis, surgery, chemotherapy, and radiotherapy. Some policies also include access to cutting-edge drugs and treatments not yet available on the NHS.
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Diagnostic Scans and Tests: When you have a policy, costs for tests like MRI, CT, and PET scans are usually covered when related to in-patient or day-patient treatment. This allows you to get a swift diagnosis.
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Specialist and Surgeon Fees: Your policy will cover the fees for the specialists and surgeons who treat you within the private sector.
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Hospital Charges: This covers the cost of the hospital room, operating theatre, and other related facility fees.
Summary of Core PMI Cover
| Benefit | What It Covers | Real-Life Example |
|---|---|---|
| In-Patient Care | Hospital admission for one or more nights. Includes bed, nursing, and surgical fees. | Admitted for a hip replacement operation and staying in hospital for three nights. |
| Day-Patient Care | Hospital admission for a procedure, but you go home the same day. | Having a colonoscopy or minor knee surgery (arthroscopy). |
| Cancer Cover | Diagnosis, surgery, chemotherapy, radiotherapy, and specialist consultations for cancer. | Following a diagnosis, your policy covers the full course of treatment at a private cancer centre. |
| Specialist Fees | Fees charged by the consultant or surgeon who oversees your treatment. | The cost of the orthopaedic surgeon who performs your hip replacement. |
Common Optional Add-Ons: Tailoring Your Cover
While core cover is powerful, most people choose to enhance their policy with optional extras. These add-ons provide more comprehensive protection and convenience, but they also increase your monthly premium. A key part of our role at WeCovr is helping you find the right balance between cost and coverage.
The most common and valuable add-on is:
1. Out-patient Cover
This is arguably the most important add-on. Without it, you would need to rely on the NHS for all your initial consultations and diagnostic tests before you could be referred for private in-patient treatment.
Out-patient cover includes:
- Specialist Consultations: The initial appointments with a consultant after a GP referral.
- Diagnostic Tests and Scans: MRI, CT scans, X-rays, and blood tests that are performed before a hospital admission is confirmed.
Broker Insight: We find that over 80% of our clients choose some level of out-patient cover. Without it, you remain subject to NHS waiting lists for diagnosis, which can defeat one of the primary purposes of having PMI. You can often choose a limit for this cover (e.g., £500, £1,000, or unlimited) to manage the cost.
2. Therapies Cover
This add-on covers treatments to help you recover from an injury or operation. It typically includes:
- Physiotherapy
- Osteopathy
- Chiropractic treatment
Most insurers provide a set number of sessions per year (e.g., up to 10 sessions) once referred by a specialist.
3. Mental Health Cover
Awareness of mental health has grown, and so has the demand for related cover. While some basic mental health support might be included in core plans (like a support helpline), a full mental health add-on provides access to:
- Consultations with psychiatrists and psychologists.
- In-patient and day-patient psychiatric treatment.
This cover can be invaluable for accessing talking therapies like CBT without the long waits often found in the public system.
4. Dental and Optical Cover
This is less common but available from some insurers. It typically functions more like a cashback plan, covering routine costs like check-ups, fillings, eye tests, and glasses up to an annual limit. It is not designed for major, unforeseen dental or optical surgery, which may be covered under the core policy if it's considered medical surgery (e.g., removing a wisdom tooth in hospital).
What's Almost Always Excluded? The Fine Print Explained
Understanding what your private medical insurance doesn't cover is just as important as knowing what it does. This prevents surprises during the claims process. The exclusions list is fairly standard across the UK private medical insurance market.
The Two Most Important Exclusions:
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Pre-existing Conditions: A private healthcare plan is designed for unforeseen medical issues that arise after you take out the policy. Any condition for which you have had symptoms, medication, or advice in the years leading up to your policy start date (typically the last 5 years) will be excluded. Insurers manage this through two types of underwriting:
- Moratorium: The insurer automatically excludes conditions you've had in the last 5 years. However, if you go for a continuous 2-year period after your policy starts without any symptoms, treatment, or advice for that condition, the insurer may reinstate cover for it.
- Full Medical Underwriting (FMU): You provide your full medical history upfront. The insurer then tells you exactly what is excluded from day one. This offers more certainty but can be more complex.
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Chronic Conditions: This is a fundamental principle of UK PMI. Private health insurance does not cover the routine management of long-term conditions that cannot be cured. This includes:
- Diabetes
- Asthma
- High blood pressure
- Arthritis
- Multiple Sclerosis
- Any condition requiring ongoing monitoring and management rather than a short-term cure.
PMI is for acute conditions (e.g., a cataract, a hernia, a joint injury). The NHS remains your provider for chronic care.
Other Standard Exclusions:
| Exclusion Category | Examples | Reason for Exclusion |
|---|---|---|
| Emergencies | A&E visits, heart attacks, strokes. | The NHS is set up to handle life-threatening emergencies. You should always call 999 in an emergency. |
| Normal Pregnancy & Childbirth | Routine antenatal appointments, delivery. | PMI is for unforeseen illness, and pregnancy is a planned life event. Complications of pregnancy may be covered. |
| Cosmetic Surgery | Facelifts, nose jobs, liposuction. | These are considered lifestyle choices, not medically necessary treatments. |
| Self-inflicted Injuries | Injuries resulting from substance abuse, dangerous hobbies (unless declared and accepted). | The risk is considered self-imposed and not an insurable event in the standard sense. |
| Fertility Treatment | IVF and other assisted conception methods. | Generally considered a lifestyle choice by insurers. |
| Experimental Treatment | Treatments and drugs not approved by NICE (National Institute for Health and Care Excellence). | Insurers rely on established clinical evidence for effectiveness and safety. |
Understanding Key Policy Levers That Affect Your Cover & Cost
When you get a quote, you'll see several options that allow you to adjust your level of cover and, therefore, your monthly premium.
- Hospital List: Insurers group private hospitals into tiers. A policy covering only a local list of hospitals will be cheaper than one offering access to premium central London hospitals.
- Excess: This is the amount you agree to pay towards any claim. For example, if you have a £250 excess and your treatment costs £3,000, you pay the first £250, and the insurer pays the remaining £2,750. A higher excess leads to a lower premium.
- The 'Six-Week Option': This is a popular cost-saving feature. If you choose this, your policy will only pay for treatment if the NHS waiting list for that treatment is longer than six weeks. If you can be seen on the NHS within six weeks, you will use the NHS. This significantly reduces your premium.
An experienced PMI broker can model these different options for you, showing you precisely how each choice impacts your final price.
Beyond the Core Policy: Value-Added Benefits
In today's competitive market, insurers add extra perks to their policies to offer more day-to-day value. These often come at no extra cost.
- Digital GP Services: Most policies now include 24/7 access to a virtual GP via phone or video call. This is incredibly convenient for getting quick advice, prescriptions, and referrals.
- Wellness Programmes: Some providers, notably Vitality, have built their entire model around rewarding healthy living. By tracking your activity, you can earn discounts on your premium, cinema tickets, and coffee.
- Mental Health Support Lines: Confidential helplines staffed by trained counsellors are often included as standard.
- Exclusive WeCovr Benefits: When you arrange your policy through us, you also get complimentary access to our AI-powered calorie and nutrition tracking app, CalorieHero. Furthermore, our clients often receive discounts on other insurance products like life or income protection cover when they take out a PMI policy.
Do All UK Insurers Offer the Same Cover?
While the core principles are similar, there are important differences between the major private medical insurance UK providers.
| Insurer | Known For / Key Differentiator |
|---|---|
| Bupa | One of the most established names with a large network of its own facilities. Known for strong cancer cover. |
| AXA Health | Praised for excellent customer service and a clear, modular policy structure. Offers strong mental health options. |
| Aviva | The UK's largest insurer. Often very competitive on price and offers a "back to health" promise for muscular issues. |
| Vitality | Unique wellness-based model that rewards members for being active. Can be great value if you engage with the programme. |
| The Exeter | A friendly society known for its flexible underwriting, which can be beneficial for those with some medical history. |
This is why working with an independent, unbiased broker like WeCovr is so valuable. We compare the entire market to find the policy that not only fits your budget but also offers the specific benefits and terms that matter most to you. Our high customer satisfaction ratings are a testament to our commitment to finding the right fit for every client.
Is dental work included in private health care plans?
Does private medical insurance cover conditions I already have?
Can I use private health insurance for an emergency?
Take the Next Step Towards Peace of Mind
Understanding what's included in a private health care plan is the most important part of your research. The right policy offers invaluable peace of mind, ensuring you can access high-quality care quickly when you need it most.
The next step is to see how these options translate into a personalised plan. At WeCovr, our expert advisers provide a free, no-obligation service to compare quotes from all leading UK insurers. We'll help you navigate the add-ons, exclusions, and policy levers to build a plan that is perfect for your needs and budget.
Contact us today to get your free, personalised quote and discover how affordable peace of mind can be.
