TL;DR
Navigating the world of health protection can be confusing. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we believe in clarity. This guide demystifies two key products: private medical insurance (PMI) and critical illness cover, helping you make an informed choice for your UK protection needs.
Key takeaways
- Private Medical Insurance (PMI) is designed to pay for the cost of your treatment. Its goal is to get you diagnosed and treated quickly in a private facility, bypassing NHS waiting lists for eligible conditions.
- Critical Illness Cover (CI) is designed to pay you a tax-free cash lump sum. Its goal is to provide financial support if you are diagnosed with a specific, life-altering illness, allowing you to cover bills, lost income, or any other expenses you see fit.
- Visit Your GP: Your first port of call is usually your NHS General Practitioner. They cannot be bypassed.
- Get a Referral: If your GP believes you need to see a specialist, they will provide an open referral or a referral to a specific consultant.
- Contact Your Insurer: You contact your PMI provider to open a claim. They will check your policy to ensure the condition and proposed treatment are covered.
Navigating the world of health protection can be confusing. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we believe in clarity. This guide demystifies two key products: private medical insurance (PMI) and critical illness cover, helping you make an informed choice for your UK protection needs.
How PMI compares to CI policies for protection
Understanding the difference between Private Medical Insurance (PMI) and Critical Illness (CI) Cover is the first step toward building a robust financial and health safety net. While both are designed to protect you during times of illness, they function in fundamentally different ways.
- Private Medical Insurance (PMI) is designed to pay for the cost of your treatment. Its goal is to get you diagnosed and treated quickly in a private facility, bypassing NHS waiting lists for eligible conditions.
- Critical Illness Cover (CI) is designed to pay you a tax-free cash lump sum. Its goal is to provide financial support if you are diagnosed with a specific, life-altering illness, allowing you to cover bills, lost income, or any other expenses you see fit.
Think of it like this: PMI pays the hospital; Critical Illness Cover pays you. They solve different problems, and for many people, the most comprehensive protection comes from having both.
What is Private Medical Insurance (PMI)? A Deep Dive
Private Medical Insurance, often called private health cover, is a policy you buy to cover the costs of private healthcare for specific types of medical conditions. Its primary benefit is speed of access to specialists, diagnostic tests, and treatment.
With NHS waiting lists in England remaining a significant concern—the list for consultant-led elective care stood at 7.54 million in April 2024 according to NHS England data—PMI offers a valuable alternative for those who want to be seen sooner.
How Does Private Medical Insurance Work?
If you develop a new medical symptom, your journey with PMI typically follows these steps:
- Visit Your GP: Your first port of call is usually your NHS General Practitioner. They cannot be bypassed.
- Get a Referral: If your GP believes you need to see a specialist, they will provide an open referral or a referral to a specific consultant.
- Contact Your Insurer: You contact your PMI provider to open a claim. They will check your policy to ensure the condition and proposed treatment are covered.
- Authorisation: Once authorised, your insurer will approve the consultation, tests, or treatment at a private hospital from their approved network.
- Receive Treatment: You attend your appointments at a private hospital or clinic.
- Direct Settlement: The hospital bills your insurance provider directly. You are only responsible for paying any 'excess' you agreed to when you took out the policy.
What Does PMI Cover?
PMI is specifically designed to cover acute conditions. An acute condition is a disease, illness, or injury that is likely to respond quickly to treatment and return you to your previous state of health. Examples include cataracts, joint replacements, or removing cancerous tumours.
Crucial Point: Pre-existing and Chronic Conditions are NOT Covered It is vital to understand that standard UK private medical insurance does not cover pre-existing conditions (ailments you had before taking out the policy) or chronic conditions. A chronic condition is one that is long-lasting and cannot be cured, only managed—such as diabetes, asthma, arthritis, or high blood pressure. PMI is for new, curable medical problems that arise after your policy has started.
Here’s a simple breakdown of what is typically included and excluded:
| Typically Covered by PMI ✅ | Typically Not Covered by PMI ❌ |
|---|---|
| In-patient and day-patient treatment (e.g., surgery) | Chronic conditions (e.g., diabetes, asthma) |
| Out-patient consultations, tests, and diagnostics | Pre-existing conditions you had before the policy started |
| Advanced cancer treatment (drugs and therapies not on the NHS) | Emergency services (A&E visits) |
| Mental health support (varies by policy) | Routine pregnancy and childbirth |
| Physiotherapy and other therapies | Cosmetic surgery (unless medically necessary post-accident) |
| Private hospital room and nursing care | Organ transplants (often remain with the specialist NHS centres) |
Many modern PMI policies also come with valuable wellness benefits, such as discounted gym memberships, access to virtual GP services 24/7, and mental health helplines, encouraging a proactive approach to your wellbeing.
What is Critical Illness Cover (CI)? A Clear Explanation
Critical Illness Cover works very differently from PMI. It is a type of long-term protection policy that pays out a one-off, tax-free lump sum if you are diagnosed with one of the serious illnesses specified in your policy documents.
The payout is yours to use however you wish. There are no restrictions. People commonly use it for:
- Paying off a mortgage or rent
- Covering lost income while they are unable to work
- Paying for specialist private treatment not covered by PMI or the NHS
- Making adaptations to their home (e.g., installing a ramp)
- Reducing financial stress for their family during a difficult time
How Does Critical Illness Cover Work?
- Choose Your Cover: You decide on the amount of cover you need (the 'sum assured') and the length of the policy (the 'term'), often set to run until your mortgage is paid off or your children are financially independent.
- Diagnosis: You are diagnosed with one of the specific illnesses listed on your policy.
- Make a Claim: You and your doctor provide medical evidence to the insurance company to support your claim.
- Meet the Definition: The key part of a CI claim is that your condition must meet the exact definition stated in the policy document. For example, a policy's definition of a "heart attack" will have specific criteria regarding enzyme levels and ECG changes. A minor heart attack may not meet the definition for a payout.
- Receive the Lump Sum: If the claim is successful, the insurer pays the full sum assured directly into your bank account, tax-free. The policy then typically ends.
What Conditions Does Critical Illness Cover Include?
The number and type of conditions covered can vary significantly between providers. Basic policies might cover 40-50 conditions, while comprehensive ones can cover over 100. The core conditions almost always included are:
- Cancer: Specific types and severities are defined. Early-stage, non-invasive cancers may result in a smaller partial payment or may not be covered at all.
- Heart Attack: Must be of a specified severity.
- Stroke: Resulting in permanent neurological symptoms.
Other commonly covered conditions include:
- Multiple Sclerosis
- Kidney Failure
- Major Organ Transplant
- Parkinson's Disease
- Motor Neurone Disease
- Blindness or Deafness
- Loss of Limbs
Because the definitions are so specific and important, this is an area where an expert PMI broker like WeCovr can add huge value, helping you compare the small print between different insurers to find the policy with the most relevant and comprehensive definitions for your needs.
The Core Difference: Treatment vs. Cash
The most straightforward way to separate these two powerful protection products is by their fundamental purpose. One pays for treatment, the other provides financial aid.
| Feature | Private Medical Insurance (PMI) | Critical Illness Cover (CI) |
|---|---|---|
| Primary Purpose | To pay for the cost of private medical treatment. | To provide a cash lump sum for financial support. |
| Payout Method | Pays the hospital/clinic directly for eligible treatment costs. | Pays a tax-free lump sum directly to you. |
| What Triggers a Claim | Needing diagnosis or treatment for a new, acute medical condition. | Being diagnosed with a specific serious illness listed in the policy. |
| Main Benefit | Speed of access to private healthcare and choice of specialist. | Financial freedom and peace of mind during a major illness. |
PMI vs. Critical Illness Cover: A Detailed Comparison Table
This table provides a side-by-side look at the key features of each policy, helping you see where they differ and how they might work together.
| Aspect | Private Medical Insurance (PMI) | Critical Illness Cover (CI) |
|---|---|---|
| Primary Goal | Get you diagnosed and treated quickly in the private sector for acute conditions. | Provide a financial cushion to protect your lifestyle and cover costs if you suffer a severe, life-changing illness. |
| How It Pays Out | Directly to the medical provider (hospital, specialist). You may have a small excess to pay. | A single, tax-free lump sum is paid to your bank account. |
| Coverage Scope | Covers a wide range of acute conditions, from minor surgery to extensive cancer care (as defined by policy). | Covers only a specific list of serious conditions that meet the insurer's precise definitions. |
| Use of Funds | Strictly for approved medical treatment costs. | Completely flexible. Use it for your mortgage, bills, lost income, holidays, or private treatment. |
| Pre-existing Conditions | Not covered. PMI is for conditions that arise after the policy starts. | May be covered, but your policy is likely to have exclusions for any illness related to a pre-existing condition. |
| Chronic Conditions | Not covered. Management of long-term conditions like diabetes or arthritis is excluded. | A chronic condition could trigger a payout if it meets a listed definition (e.g., kidney failure due to diabetes). |
| Cost Factors | Age, location, level of cover (outpatient limits, hospital list), excess, underwriting type. | Age, health, smoker status, occupation, sum assured (payout amount), length of policy term. |
| Best For... | Individuals and families who want to avoid NHS waiting lists and have more choice over their medical care. | Individuals and families with financial commitments (e.g., mortgage, children) who would struggle if an earner fell ill. |
| Policy Type | An annual contract that you renew each year. Premiums are reviewed annually and typically increase with age. | A long-term contract, often for 20-30 years. Premiums can be guaranteed (fixed) or reviewable. |
Do I Need Both PMI and Critical Illness Cover?
This is a common and important question. Since they serve different needs, PMI and Critical Illness Cover are not mutually exclusive; in fact, they are highly complementary. Having both provides the most comprehensive level of protection.
Let's consider a few scenarios for a 45-year-old architect named David who is diagnosed with a treatable form of bowel cancer.
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Scenario 1: David has only PMI. His PMI policy kicks in immediately. He bypasses the NHS waiting list, sees a top consultant within days, and has surgery in a private hospital a week later. The treatment is a success. However, he needs to take six months off work to recover fully. Without an income, he struggles to pay his mortgage and household bills, causing immense stress during his recovery. The PMI solved the health problem, but not the financial one.
-
Scenario 2: David has only Critical Illness Cover. His cancer diagnosis meets the policy definition, and his insurer pays him a £75,000 lump sum. This is a huge relief. He can pay his mortgage for the next year and cover his bills without worry. However, he is on the NHS waiting list for his surgery, which is scheduled for three months' time. The wait is anxious and uncomfortable. The CI policy solved the financial problem, but not the health one.
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Scenario 3: David has both PMI and Critical Illness Cover. This is the ideal scenario. His PMI ensures he gets fast-tracked for private surgery and treatment, minimising his waiting time and anxiety. At the same time, his successful CI claim provides a £75,000 lump sum. He can now focus entirely on his recovery, knowing his treatment is taken care of and his finances are secure. Both the health and financial problems are solved.
For many, this combination offers ultimate peace of mind. An expert adviser at WeCovr can help you assess your budget and needs to find the right balance of cover, whether it's one policy or both.
Understanding the Costs: What Affects Your Premiums?
The price of both policies is highly personalised. Here are the key factors that influence your monthly premiums.
For Private Medical Insurance (PMI):
- Age: Premiums increase as you get older.
- Location: Treatment costs are higher in some areas, like Central London, so premiums are too.
- Level of Cover: Comprehensive policies with high or unlimited outpatient cover cost more than basic ones.
- Hospital List: A policy that gives you access to all UK hospitals will be more expensive than one with a limited local network.
- Excess: Choosing a higher voluntary excess (the amount you pay towards a claim) will lower your premium.
- Underwriting: The method used to assess your medical history (e.g., 'moratorium' or 'full medical underwriting') affects your cover and price.
For Critical Illness Cover (CI):
- Age: The younger and healthier you are when you take out the policy, the cheaper it will be.
- Sum Assured (illustrative): A £200,000 payout will cost more than a £50,000 one.
- Policy Term: A policy that runs for 30 years will cost more per month than one that runs for 15 years.
- Health & Lifestyle: Smokers pay significantly more than non-smokers. Your weight, alcohol intake, and family medical history are also considered.
- Occupation: A high-risk job (e.g., scaffolder) may lead to higher premiums than a low-risk office job.
- Guaranteed vs. Reviewable Premiums: Guaranteed premiums are fixed for the policy term, giving you certainty. Reviewable premiums may start cheaper but can increase over time.
Illustrative Monthly Premiums
To give you a rough idea, here are some example costs for a healthy, 35-year-old non-smoker. Please note these are for illustration only and are not a quote.
| Policy Type | Cover Level / Sum Assured | Estimated Monthly Premium |
|---|---|---|
| Private Medical Insurance | Mid-range cover with £250 excess | £45 – £70 |
| Critical Illness Cover | £100,000 sum assured over 25 years | £15 – £30 |
The only way to know the true cost for your circumstances is to get a personalised quote.
The Role of an Expert Broker Like WeCovr
Trying to compare dozens of policies, each with different benefits, exclusions, and definitions, can be overwhelming. This is where an independent broker shines.
- Whole-of-Market Comparison: WeCovr compares policies from a wide panel of leading UK insurers, ensuring you see the best options available, not just one company's products.
- Expert Guidance: Our advisers are specialists in private medical insurance UK. We can explain the jargon, highlight the crucial differences in Critical Illness definitions, and help you tailor a policy to your exact needs and budget.
- No Cost to You: Our service is free. We receive a commission from the insurer if you decide to proceed, but this does not affect the price you pay.
- Client-Focused: We work for you, not the insurance company. Our goal is to find you the best possible cover, and our high customer satisfaction ratings reflect this commitment.
- Added Value: As a WeCovr client who purchases PMI or Life Insurance, you'll receive complimentary access to our AI-powered nutrition app, CalorieHero, and may also benefit from discounts on other insurance products, helping you manage both your health and your finances more effectively.
Beyond Insurance: Proactive Steps for Better Health
While insurance provides a crucial safety net, the best strategy is always to invest in your health proactively. A healthier lifestyle not only reduces your risk of needing to claim but can also lead to lower insurance premiums over time.
- A Balanced Diet: Follow the principles of the NHS Eatwell Guide. Focus on a diet rich in fruits, vegetables, whole grains, and lean proteins while minimising processed foods, sugar, and saturated fats.
- Regular Physical Activity: The NHS recommends at least 150 minutes of moderate-intensity activity (like brisk walking or cycling) or 75 minutes of vigorous-intensity activity (like running or tennis) a week.
- Prioritise Sleep: Aim for 7-9 hours of quality sleep per night. Good sleep is essential for physical repair, mental clarity, and immune function.
- Manage Stress: Chronic stress can negatively impact your health. Explore techniques like mindfulness, meditation, yoga, or simply spending time in nature. Many PMI policies now include access to mental health support lines which can be a valuable first step.
Can I get private health insurance with a pre-existing condition?
Is the payout from Critical Illness Cover taxed?
Which is more important, PMI or Critical Illness Cover?
Do I have to use the NHS first before my PMI kicks in?
Ready to explore your options and find the right protection for your peace of mind?
The friendly, expert team at WeCovr is here to help. We'll compare the market for you, answer all your questions, and provide a free, no-obligation quote tailored to your needs. Take the first step towards securing your health and financial future today.
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.







