As FCA-authorised expert brokers who have arranged over 800,000 policies, we at WeCovr know that navigating the world of private medical insurance in the UK can feel complex. This comprehensive guide explains everything you need to know, from the basics of how it works to the details of what is and isn't covered.
The basics of private medical insurance how it works, what it covers, and exclusions
Private Medical Insurance (PMI), also known as private health cover, is an insurance policy designed to cover the costs of private medical care for specific conditions. It runs alongside the NHS, acting as a valuable complement rather than a replacement. Its primary purpose is to give you faster access to diagnosis and treatment for eligible conditions, offering you choice, convenience, and comfort when you need it most.
Think of it as a way to bypass potential NHS waiting lists for non-emergency procedures, allowing you to be seen by a specialist and receive treatment more quickly.
How Does Private Health Insurance Work in Practice?
The process is typically straightforward and designed to get you the care you need with minimal fuss. Here's a real-life example of the journey:
- You feel unwell: Let's say you develop persistent knee pain. Your first port of call is your NHS GP, just as it would be for anyone. The NHS remains central to your initial healthcare.
- Get a GP referral: Your GP examines your knee and decides you need to see an orthopaedic specialist. They will write you a referral letter. This is a crucial step for most PMI policies.
- Contact your insurer: You call your private health insurance provider's claims line with your policy details and the GP referral.
- Claim authorisation: The insurer checks your policy to ensure that seeing a specialist for knee pain is covered. They will then authorise the consultation and provide you with a pre-authorisation number. They will also give you a choice of approved specialists and hospitals from your chosen hospital list.
- Receive private treatment: You book an appointment with the specialist at a private hospital. After your consultation, if you need a scan (like an MRI) or a procedure (like keyhole surgery), you contact your insurer again for authorisation.
- The insurer settles the bill: The private hospital and specialist send their invoices directly to your insurance company. Apart from any excess you've agreed to pay, the costs are settled for you.
This process gives you control over when and where you are treated, helping you get back on your feet sooner.
What Does Private Health Insurance Typically Cover?
Policies are built around a 'core' level of cover, with the option to add extra benefits to create a more comprehensive plan. Understanding this structure is key to tailoring a policy that fits your needs and budget.
Core Cover: In-patient and Day-patient Treatment
This is the foundation of every PMI policy. It covers treatment where you need to be admitted to a hospital bed.
- In-patient: Treatment that requires an overnight stay in a hospital (e.g., a hip replacement).
- Day-patient: Treatment where you are admitted to hospital for a procedure but do not stay overnight (e.g., cataract surgery or an endoscopy).
Your core cover will almost always include:
| Core Cover Benefit | Description |
|---|
| Hospital Fees | The cost of the hospital room, nursing care, and operating theatre charges. |
| Specialist Fees | Fees for the surgeon, anaesthetist, and physician involved in your care. |
| Diagnostic Tests | Scans like MRI, CT, and PET scans, and X-rays related to your in-patient or day-patient stay. |
| Cancer Cover | Comprehensive cover for cancer is a cornerstone of most policies, including surgery, chemotherapy, and radiotherapy. |
To create a more comprehensive policy, you can choose from a range of valuable add-ons.
1. Out-patient Cover
This is arguably the most important and popular add-on. It covers diagnostic tests and consultations that do not require a hospital bed. This is vital for getting a diagnosis quickly. Without it, you would rely on the NHS for your initial specialist consultation and tests before your PMI could cover any subsequent in-patient treatment.
Out-patient cover is usually offered in tiers, for example:
- Up to £500 per policy year
- Up to £1,000 per policy year
- Fully comprehensive (no financial limit)
2. Therapies Cover
This covers treatments to aid your recovery, such as:
- Physiotherapy
- Osteopathy
- Chiropractic treatment
- Acupuncture
It's usually limited to a set number of sessions per year following a GP or specialist referral.
3. Mental Health Cover
With a growing focus on mental wellbeing, this has become a crucial option. Cover can range from providing a limited number of therapy sessions (counselling, CBT) to comprehensive cover that includes consultations with psychiatrists and in-patient psychiatric care.
4. Dental and Optical Cover
This is less common and usually covers a percentage of the costs for routine care like dental check-ups, fillings, eye tests, and contributions towards glasses or contact lenses. It's designed for maintenance rather than major cosmetic work.
The Critical Part: What Private Health Insurance Does NOT Cover
Understanding the exclusions is just as important as knowing what's covered. It prevents surprises and helps you manage your expectations. UK private medical insurance is designed for a specific purpose, and some things will always fall outside its scope.
The Golden Rule: Acute vs. Chronic Conditions
This is the most important distinction in private health insurance.
- Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Examples include a hernia, cataracts, or a joint injury. PMI is designed to cover acute conditions.
- Chronic Condition: A disease, illness, or injury 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. Examples include diabetes, asthma, high blood pressure, and arthritis. PMI does not cover the routine management of chronic conditions.
While PMI won't cover the day-to-day management of a chronic condition, it may cover acute flare-ups if that treatment is expected to return you to your previous state of health.
Pre-existing Conditions
This is the second golden rule. A pre-existing condition is any disease, illness, or injury for which you have experienced symptoms, received medication, advice, or treatment before your policy start date.
Standard PMI policies will not cover pre-existing conditions from the outset. How they are excluded depends on the type of underwriting you choose.
Underwriting: How Insurers Assess Your Health History
There are two main methods insurers use to decide what they will and won't cover based on your medical history.
| Underwriting Type | How It Works | Pros | Cons |
|---|
| Moratorium | You don't declare your full medical history upfront. Instead, the policy automatically excludes any condition you've had in the 5 years before joining. If you then go 2 continuous years on the policy without any symptoms, treatment, or advice for that condition, it may become eligible for cover. | Quicker and simpler to set up. Potential for conditions to become covered over time. | Less certainty at the start. Claims process can be slower as the insurer investigates your history. |
| Full Medical Underwriting (FMU) | You complete a detailed health questionnaire when you apply. The insurer assesses your medical history and applies specific, permanent exclusions to your policy based on your answers. | You know exactly what is and isn't covered from day one. Claims process is often faster. | The application process is longer. Exclusions are usually permanent. |
An expert broker like WeCovr can help you decide which underwriting method is best for your personal circumstances.
Other Common Exclusions
Beyond chronic and pre-existing conditions, most UK PMI policies will not cover:
- Accident & Emergency (A&E) treatment: This is always handled by the NHS.
- Normal pregnancy and childbirth: However, complications of pregnancy may be covered by some comprehensive policies.
- Cosmetic surgery: Unless it's reconstructive surgery needed after an accident or eligible procedure (e.g., after a mastectomy).
- Self-inflicted injuries, drug or alcohol abuse.
- Experimental or unproven treatments.
- Mobility aids like wheelchairs or home adaptations.
How Much Does Private Health Insurance Cost in the UK?
The price of a policy is highly personal and depends on several key factors. While it's impossible to give a single figure, understanding these factors will help you see how your premium is calculated.
Key Factors Influencing Your Premium:
- Age: This is the most significant factor. Premiums increase as you get older because the statistical likelihood of needing medical treatment rises.
- Level of Cover: A basic, in-patient-only plan will be much cheaper than a fully comprehensive plan with no limits on out-patient cover, therapies, and mental health support.
- Excess: This is the amount you agree to pay towards a claim. A higher excess (e.g., £500 or £1,000) will significantly lower your monthly premium.
- Location: Medical costs vary across the UK, with treatment in Central London being the most expensive. Your home postcode will affect the price.
- Hospital List: Insurers offer different tiers of hospital lists. A policy covering only local hospitals will be cheaper than one that includes premium national hospitals and those in London.
- No-Claims Discount (NCD): Similar to car insurance, most providers offer an NCD that reduces your premium for every year you don't make a claim.
Illustrative Monthly Costs for Private Health Insurance
The table below provides an estimated monthly cost for a non-smoker with a £250 excess. These are for illustration only – your actual quote will depend on your specific choices.
| Age Group | Basic Cover (In-patient only) | Comprehensive Cover (Incl. Out-patient & Therapies) |
|---|
| 30-39 | £35 - £55 | £65 - £95 |
| 40-49 | £50 - £75 | £85 - £125 |
| 50-59 | £70 - £110 | £130 - £190 |
| 60-69 | £100 - £160 | £180 - £280+ |
Is Private Health Insurance Worth It? A Balanced View
The decision to buy PMI is personal. For many, the value lies in peace of mind and swift access to care, especially in light of current pressures on the health service.
According to NHS England data, the referral-to-treatment waiting list stood at approximately 7.54 million in early 2024. While the NHS provides excellent care, particularly for emergencies and critical illness, these figures highlight the potential for long waits for elective procedures.
Pros of PMI:
- Peace of Mind: Knowing you can access care quickly if you fall ill.
- Speed of Access: Significantly shorter waiting times for consultations, diagnosis, and treatment.
- Choice and Control: Choose your specialist, hospital, and a time for treatment that suits you.
- Comfort and Privacy: Access to a private room during a hospital stay.
- Access to Specialist Drugs: Some policies provide cover for cancer drugs and treatments that may not be available on the NHS.
Cons of PMI:
- Cost: It's an ongoing financial commitment, and premiums increase with age.
- Exclusions: It does not cover everything, most notably chronic and pre-existing conditions.
- It's Not a Replacement for the NHS: You will still rely on the NHS for GP services, A&E, and management of long-term illnesses.
Ultimately, if your priority is to minimise time spent waiting for treatment and you value choice and comfort, PMI can be an excellent investment in your health and wellbeing.
Beyond Insurance: Wellness and Added Benefits
Modern health insurance is evolving. The best PMI providers now include a host of added-value benefits designed to keep you healthy, not just treat you when you're ill.
These often include:
- Digital GP Services: 24/7 access to a GP via phone or video call, allowing you to get medical advice and prescriptions without leaving your home.
- Mental Health Support: Access to telephone counselling or support lines, even if you don't have full mental health cover.
- Health and Wellness Apps: Tools to help you track your fitness, nutrition, and overall wellbeing.
- Discounts and Rewards: Many insurers partner with gyms, fitness tracker companies, and healthy food brands to offer discounts and reward you for living a healthy lifestyle.
At WeCovr, we enhance this further. Our clients not only get a policy perfectly matched to them but also receive complimentary access to CalorieHero, our advanced AI-powered calorie and nutrition tracking app. Furthermore, customers who purchase PMI or Life Insurance through us are eligible for exclusive discounts on other insurance products, providing even greater value.
How to Find the Best Private Health Cover
With so many providers, policy options, and variables, finding the right plan can be daunting. This is where an independent PMI broker is invaluable.
A specialist broker like WeCovr works for you, not the insurance companies. Our role is to:
- Understand Your Needs: We take the time to learn about your health priorities, lifestyle, and budget.
- Compare the Market: We use our expertise and industry knowledge to compare policies from the UK's leading insurers, including Bupa, AXA Health, Aviva, and Vitality.
- Explain the Jargon: We cut through the complex terminology to explain the pros and cons of each option in plain English.
- Find the Best Value: We ensure you get the most appropriate cover at the most competitive price, at no extra cost to you. Our service is free for our clients as we are paid a commission by the insurer you choose.
Our high customer satisfaction ratings are a testament to our commitment to providing clear, impartial advice tailored to each individual.
Frequently Asked Questions (FAQs)
Do I still need to pay National Insurance if I have private health insurance?
Yes, absolutely. Private Medical Insurance is a complement to the NHS, not a replacement for it. You will still need the NHS for GP services, Accident & Emergency, and the management of long-term chronic conditions. Your National Insurance contributions fund the NHS, which remains available to you at all times, regardless of whether you have private cover.
What is the difference between an acute and a chronic condition?
An acute condition is an illness or injury that is short-lived and expected to respond quickly to treatment, leading to a full recovery (e.g., a cataract, joint injury, or hernia). Private health insurance is specifically designed to cover these. A chronic condition is a long-term illness that cannot be cured, only managed (e.g., diabetes, asthma, or arthritis). The routine management of chronic conditions is not covered by private health insurance.
Can I get cover for a pre-existing medical condition?
Generally, standard UK private medical insurance policies exclude pre-existing conditions from cover. However, if you choose 'moratorium' underwriting, a condition you had in the five years prior to taking out the policy may become eligible for cover after you have been on the policy for two continuous years without any symptoms, treatment, or advice for it.
Is cancer treatment always covered by private medical insurance?
Comprehensive cancer cover is a key feature and a major reason many people take out private health insurance. Most policies offer extensive cover for diagnosis, surgery, radiotherapy, and chemotherapy. However, the level of cover can vary. Some policies may have limits on certain expensive drugs or experimental treatments. It's crucial to check the specific details of the cancer cover in any policy you are considering.
Ready to explore your options and secure your peace of mind? The expert, friendly team at WeCovr is here to help. We make the complex simple, comparing the market to find the perfect private health cover for you.
Get your free, no-obligation PMI quote today and take control of your health.