TL;DR
A clear guide to private health cover and private health insurance cover – inpatient, outpatient, diagnostics and more Navigating the world of private medical insurance in the UK can feel complex. What’s really covered? As experienced brokers who have arranged cover for thousands of clients, the team at WeCovr is here to demystify Private Medical Insurance (PMI), explaining precisely what you can expect from your policy.
Key takeaways
- Inpatient Care: This is when you are admitted to a hospital and stay overnight for treatment, such as for a hip replacement or major heart surgery.
- Day-Patient Care: This involves being admitted to a hospital for a procedure or treatment but not staying overnight. Examples include cataract surgery or an endoscopy.
- Hospital Charges: The cost of your private room, nursing care, and meals.
- Specialist Fees: Fees for the surgeon and anaesthetist performing your procedure.
- Diagnostics during your stay: Any tests like X-rays, blood tests, or scans you need while admitted to the hospital.
A clear guide to private health cover and private health insurance cover – inpatient, outpatient, diagnostics and more
Navigating the world of private medical insurance in the UK can feel complex. What’s really covered? As experienced brokers who have arranged cover for thousands of clients, the team at WeCovr is here to demystify Private Medical Insurance (PMI), explaining precisely what you can expect from your policy.
This comprehensive guide breaks down the different levels of cover—from core inpatient care to comprehensive outpatient benefits, diagnostics, and specialist treatments. Our goal is to give you the clarity and confidence to choose the right protection for you and your family.
What is Private Health Insurance (PMI)?
Private health insurance is a policy you buy to cover the cost of private medical care for acute conditions. An acute condition is a disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery.
Crucially, UK private health insurance is designed to work alongside the NHS, not replace it. The NHS remains the cornerstone of UK healthcare, especially for accidents, emergencies (A&E), and the management of long-term, chronic conditions.
PMI offers a parallel route, providing you with more choice, faster access to specialists, and a more comfortable care experience when you need eligible treatment. Think of it as a way to bypass NHS waiting lists for planned procedures and diagnostics.
Key Fact: Standard UK private medical insurance does not cover chronic conditions or pre-existing conditions that you had before taking out your policy. It is for new, curable medical issues that arise after your cover begins.
The Core of Every Policy: Inpatient and Day-Patient Cover
Every private health insurance policy is built on a foundation of core cover. This is the most basic level of protection and almost always includes cover for inpatient and day-patient treatment.
- Inpatient Care: This is when you are admitted to a hospital and stay overnight for treatment, such as for a hip replacement or major heart surgery.
- Day-Patient Care: This involves being admitted to a hospital for a procedure or treatment but not staying overnight. Examples include cataract surgery or an endoscopy.
What does core inpatient and day-patient cover typically include?
- Hospital Charges: The cost of your private room, nursing care, and meals.
- Specialist Fees: Fees for the surgeon and anaesthetist performing your procedure.
- Diagnostics during your stay: Any tests like X-rays, blood tests, or scans you need while admitted to the hospital.
- Post-operative Care: A limited number of follow-up consultations and physiotherapy sessions after your surgery to aid recovery.
- Cancer Care: Most core policies include extensive cancer cover, covering surgery, chemotherapy, and radiotherapy (more on this later).
A "core cover" or "inpatient-only" policy is the most affordable type of private health insurance. It provides a safety net for significant medical events that require a hospital stay, which are often the most expensive.
Expanding Your Protection: Outpatient Cover Explained
While core cover handles the big procedures, what about the journey to get there? This is where outpatient cover comes in. It’s the most common and valuable addition to a PMI policy.
Outpatient treatment is any consultation, test, or procedure where you are not admitted to a hospital bed. This includes:
- Initial consultations with a specialist.
- Diagnostic tests and scans (MRI, CT, PET scans).
- Minor procedures performed in an outpatient clinic.
- Therapy sessions like physiotherapy.
Without outpatient cover, you would rely on the NHS for your diagnosis. With it, you can see a private specialist and get a diagnosis in days or weeks, rather than months.
Insurers offer different levels of outpatient cover, allowing you to balance your premium with your desired level of protection.
| Level of Outpatient Cover | What It Typically Covers | Best For |
|---|---|---|
| Full Outpatient Cover | Unlimited specialist consultations and diagnostic tests. | Those who want complete peace of mind and the fastest possible diagnostic journey, without worrying about costs. |
| Capped Outpatient Cover | A set monetary limit per policy year (e.g., £500, £1,000, or £1,500) for all outpatient services. | A good middle ground, providing significant cover for diagnostics while keeping premiums more affordable than a 'full' plan. |
| Limited/Diagnostic Cover | May cover only diagnostic scans up to a limit, or a very small number of consultations (e.g., 2-3 per year). | Those on a tight budget who primarily want to speed up the diagnostic process but are happy to use the NHS for consultations. |
Real-Life Scenario: The Power of Outpatient Cover
Imagine you develop persistent, painful knee problems.
- Without Outpatient Cover: You visit your GP. You are referred to an NHS orthopaedic specialist, with a potential waiting time of several months. After your consultation, you may face another long wait for an MRI scan.
- With Outpatient Cover: You visit your GP and get a referral. You call your insurer, who authorises a consultation with a private specialist within a week. The specialist recommends an MRI, which you have within a few days. Your policy covers the cost of the consultation and the scan, and you have a diagnosis and treatment plan in under two weeks.
Essential Add-ons: Therapies, Mental Health, and More
Beyond standard outpatient cover, you can further enhance your policy with several valuable options.
Therapies Cover
This add-on covers treatments designed to restore movement and function. It's often bundled with outpatient cover or available separately. It typically includes:
- Physiotherapy
- Osteopathy
- Chiropractic care
Cover is usually subject to a set number of sessions (e.g., 10 per condition) or a monetary limit per policy year.
Mental Health Cover
Awareness of mental wellbeing has grown, and so has the quality of mental health cover available through PMI. This is nearly always an optional add-on. Cover can range from basic to comprehensive:
- Outpatient Mental Health: Covers consultations with psychiatrists and therapy sessions with psychologists (e.g., Cognitive Behavioural Therapy - CBT). This is usually capped at a monetary limit (e.g., £1,000) or a number of sessions.
- Inpatient Mental Health: For more severe conditions requiring a stay in a private psychiatric facility. This is a less common and more expensive option.
Having this cover allows for prompt access to talking therapies, which can have long waiting lists on the NHS.
Dental and Optical Cover
This is not a standard feature of private medical insurance UK plans. It is usually offered as an optional cash-back benefit. You pay for your routine dental check-ups, hygienist visits, eye tests, and glasses, and then claim a portion of the cost back from the insurer, up to an annual limit. It rarely covers major or cosmetic dental work.
The Cornerstone of PMI: Comprehensive Cancer Cover
For many people, cancer cover is the single most important reason to have private health insurance. While the NHS provides excellent cancer care, PMI offers distinct advantages.
What is typically included in cancer cover?
- Prompt Diagnosis: Fast access to the scans and biopsies needed to confirm a diagnosis.
- Full Treatment: Surgery, radiotherapy, and chemotherapy are covered as standard.
- Specialist Consultations: Consultations with leading oncologists.
- Advanced Therapies: Access to targeted biological therapies and drugs that may not yet be approved or funded by the NHS due to cost.
- Palliative Care: End-of-life care and pain management.
- Monitoring: Follow-up checks and scans after your treatment is complete.
Most policies provide extensive cancer cover as a core benefit, but some may offer "enhanced" cancer options that include access to more experimental treatments or a wider range of drugs. Always check the specifics of the cancer promise in any policy you consider.
What is Not Covered by Private Health Insurance? The Exclusions
Understanding what your policy doesn't cover is just as important as knowing what it does. This prevents surprises at the point of claim.
The two most important exclusions are:
- Pre-existing Conditions: Any medical condition you had symptoms of, received advice for, or were treated for before your policy started. Most insurers use a 'moratorium' system, where a pre-existing condition may become eligible for cover if you remain symptom-free and treatment-free for it for a continuous two-year period after your policy begins.
- Chronic Conditions: Long-term conditions that cannot be cured, only managed. PMI is for acute, curable conditions. Examples of chronic conditions not covered include:
- Diabetes
- Asthma
- High blood pressure (Hypertension)
- Arthritis
- Most allergies
- Crohn's disease
Other standard exclusions typically include:
- Accidents & Emergencies (A&E): This is always handled by the NHS.
- Normal Pregnancy & Childbirth: Uncomplicated pregnancies are not covered, though some policies may cover certain complications.
- Cosmetic Surgery: Procedures for purely aesthetic reasons are excluded.
- Fertility Treatment (IVF).
- Self-inflicted Injuries.
- Drug and Alcohol Abuse.
How to Tailor Your Policy and Manage Costs
One of the best things about modern PMI is its flexibility. You can adjust several elements of your policy to find a price point that suits your budget.
| Feature | How It Works | Impact on Premium |
|---|---|---|
| Excess | The amount you agree to pay towards the first claim(s) in a policy year (e.g., £100, £250, £500). | A higher excess significantly lowers your premium. |
| Hospital List | Insurers have tiered lists of hospitals. You can choose a local list, a national list, or a premium list including central London hospitals. | A more restricted hospital list lowers your premium. |
| 6-Week Wait Option | If the NHS waiting list for an eligible inpatient procedure is less than 6 weeks, you use the NHS. If it's longer, your private cover kicks in. | Adding this option significantly lowers your premium. |
| No-Claims Discount (NCD) | Similar to car insurance. For every year you don't make a claim, you receive a discount on your renewal premium, up to a maximum level. | Not claiming lowers your future premiums. |
An expert broker like WeCovr can model these different options for you, showing you exactly how changing your excess or hospital list affects your monthly cost across different providers.
How a PMI Claim Works: A Simple Step-by-Step Guide
The claims process is designed to be straightforward.
- See Your GP: Your journey always starts with your NHS GP. If you need further investigation, ask for an 'open referral' to a specialist.
- Contact Your Insurer: Call your PMI provider's claims line before you book any appointments.
- Get Authorisation: Provide your policy details and referral information. The insurer will confirm your cover is active and that the condition is eligible. They will provide an authorisation number.
- Choose Your Specialist: Your insurer will give you a list of approved specialists and hospitals from your chosen hospital list.
- Book and Attend: Book your appointment or treatment.
- Direct Settlement: The hospital and specialist will bill your insurer directly. Apart from any excess you have, you won't have to handle any invoices.
More Than Just Treatment: Extra Policy Benefits
Modern private medical insurance UK providers often include a suite of valuable extra benefits designed to keep you healthy and provide convenient access to everyday healthcare.
- Digital/Virtual GP: 24/7 access to a GP via phone or video call, allowing you to get medical advice and prescriptions without leaving home.
- Wellness Programmes: Many insurers, like Vitality and Aviva, offer rewards and discounts for healthy living, such as reduced gym memberships or smart-watch deals.
- Second Medical Opinion Services: If you receive a life-changing diagnosis, you can get a second opinion from a world-leading expert.
- Member Discounts: At WeCovr, clients who take out PMI or life insurance can benefit from discounts on other types of cover and gain complimentary access to our AI-powered calorie and nutrition tracking app, CalorieHero.
Making the Right Choice with WeCovr
Choosing the right private health cover is a significant decision. The "best" policy is the one that is correctly tailored to your needs, priorities, and budget.
As an independent, unbiased broker, WeCovr provides impartial, expert advice. We compare policies from across the market, explaining the subtle but important differences in cover for things like mental health, cancer care, and outpatient limits. Our service costs you nothing, but our expertise can save you thousands and ensure you have the right protection when you need it most.
Is private health insurance worth it in the UK?
How much does private health insurance typically cost?
Can I get private health cover for a pre-existing condition?
Does private medical insurance cover A&E and emergencies?
Ready to explore your options? Get a free, no-obligation quote from WeCovr today and let our experts find the perfect private health cover for you.
