TL;DR
Navigating the world of private medical insurance in the UK can feel complex. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we believe in clarity. This guide demystifies the key terms you'll encounter, making your journey to the right health cover simple.
Key takeaways
- Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Think of conditions like cataracts, joint replacements, or hernias. PMI is designed to cover these.
- Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics:
- It needs ongoing or long-term monitoring.
- It has no known cure.
- It is likely to come back.
Navigating the world of private medical insurance in the UK can feel complex. At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we believe in clarity. This guide demystifies the key terms you'll encounter, making your journey to the right health cover simple.
PMI terms explained in plain English — from excess to underwriting
Private Medical Insurance (PMI) is designed to give you more choice and control over your healthcare. It runs alongside the NHS, offering prompt access to eligible diagnosis and treatment in private facilities. But to find the best policy, you need to understand the language insurers use.
This glossary breaks down the jargon into simple, everyday terms, empowering you to make an informed decision about your health.
The Absolute Basics: What is Private Medical Insurance?
Private Medical Insurance, also known as private health cover, is an insurance policy that covers the cost of private healthcare for specific medical conditions. Its primary purpose is to cover the diagnosis and treatment of acute conditions.
The Critical Distinction: Acute vs. Chronic Conditions
This is the most important concept to understand in UK private health insurance.
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Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Think of conditions like cataracts, joint replacements, or hernias. PMI is designed to cover these.
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Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics:
- It needs ongoing or long-term monitoring.
- It has no known cure.
- It is likely to come back.
- It requires palliative care.
Examples include diabetes, asthma, high blood pressure, and arthritis. Standard UK private medical insurance does not cover the routine management of chronic conditions. You will continue to rely on the NHS for this long-term care.
Key Takeaway: PMI is for new, curable health problems that arise after you take out your policy. It is not a replacement for the NHS, but a partner to it.
Core Policy Terms: The Building Blocks of Your Cover
These are the fundamental terms that define what your policy includes, how much it costs, and how it works.
Premiums, Excess, and Policy Limits
| Term | Plain English Explanation | Real-Life Example |
|---|---|---|
| Premium | The fixed amount you pay to the insurer to keep your policy active. This is usually paid monthly or annually. | You agree to pay a premium of £60 per month. As long as you keep paying, your insurance remains in place. |
| Excess | The amount you agree to pay towards a claim. You can often choose your excess level; a higher excess usually means a lower premium. | Your policy has a £250 excess. You need a procedure costing £3,000. You pay the first £250, and your insurer pays the remaining £2,750. |
| Policy Limits | The maximum amount your insurer will pay out for a particular treatment or per year. Some policies have an overall annual limit, while others have limits on specific benefits (e.g., £1,000 for out-patient diagnostics). | A mid-range policy might offer "up to £1,500 for out-patient scans," while a comprehensive policy might offer "unlimited" cover. |
In-patient, Day-patient, and Out-patient Cover
Understanding these three levels of care is crucial as they form the core of every policy.
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In-patient Cover: This is for treatment that requires you to be admitted to a hospital and stay overnight in a bed. This is the most basic level of cover included in almost all PMI policies.
- Example: You have a hip replacement and need to stay in the hospital for three nights to recover.
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Day-patient Cover: This covers treatment where you are admitted to a hospital and occupy a bed, but you are discharged on the same day.
- Example: You undergo keyhole surgery to repair a cartilage tear in your knee and go home that afternoon.
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Out-patient Cover: This is for consultations, diagnostic tests, and therapies that do not require a hospital bed. This is often an optional add-on or is limited on cheaper policies.
- Example: You see a specialist for back pain, have an MRI scan, and then attend a course of physiotherapy. All of these are out-patient services.
Here's a simple breakdown:
| Type of Care | Do you need a hospital bed? | Do you stay overnight? | Example |
|---|---|---|---|
| In-patient | Yes | Yes | A major operation requiring a multi-day hospital stay. |
| Day-patient | Yes | No | A cataract removal surgery. |
| Out-patient | No | No | A consultation with a dermatologist or an X-ray. |
Hospital Lists and Networks
Insurers don't just let you go to any hospital. They have pre-agreed lists or "networks" of facilities where you can receive treatment.
- Hospital List: A directory of hospitals and clinics your policy gives you access to.
- Tiered Lists: Insurers often offer different tiers of hospital lists. A standard list might include good quality local private hospitals, while a premium list might add prime central London hospitals (like The London Clinic or The Cromwell). Choosing a more restricted list can significantly lower your premium.
- Guided Consultants: Some policies offer a 'guided' option. Instead of choosing any specialist from their list, the insurer provides a shortlist of 3-5 approved consultants for you to choose from. This can also reduce your monthly premium.
Core Cover vs. Optional Extras
Most PMI policies are modular, allowing you to build a plan that suits your needs and budget.
- Core Cover: The standard, non-negotiable part of the policy. This almost always includes in-patient and day-patient treatment, as well as comprehensive cancer cover.
- Optional Extras: Benefits you can add to your policy for an additional premium. Common options include:
- Out-patient Cover (illustrative): As discussed above, this can be added with different limits (e.g., £500, £1,000, or unlimited).
- Therapies Cover: For treatments like physiotherapy, osteopathy, and chiropractic care.
- Mental Health Cover: Provides access to psychiatrists, psychologists, and therapy.
- Dental & Optical Cover: Contributes towards routine check-ups, glasses, and dental treatments.
An expert broker like WeCovr can help you navigate these options, ensuring you only pay for the cover you actually need, without charging you any fees for their service.
Understanding Underwriting: How Insurers Assess Your Health
Underwriting is the process an insurer uses to decide whether to offer you cover and on what terms. It specifically relates to how they handle your pre-existing medical conditions. There are two main types in the UK.
1. Moratorium Underwriting (MORI)
This is the most common and simplest type of underwriting.
- How it works: You don't declare your full medical history upfront. Instead, the insurer applies a general exclusion for any condition you've had symptoms, treatment, or advice for in the five years before your policy started.
- The "2-Year Rule": A pre-existing condition might become eligible for cover later on. If you go for two continuous years after your policy start date without experiencing symptoms, needing treatment, medication, or advice for that specific condition, it may be covered from that point onwards.
- Pros: Quick and easy application process.
- Cons: There can be uncertainty at the point of claim, as the insurer will investigate your medical history then to see if the condition is pre-existing.
Example of Moratorium: Sarah took out a PMI policy on 1st October 2025. In 2024, she saw her GP for shoulder pain. For the first two years of her policy, any treatment related to her shoulder is excluded. If she has no shoulder pain, consultations, or treatment until 1st October 2027, her shoulder may then become eligible for cover.
2. Full Medical Underwriting (FMU)
This is a more detailed process.
- How it works: You complete a full health questionnaire as part of your application, declaring your entire medical history. The insurer assesses this information and tells you from day one exactly what is and isn't covered. Any specific exclusions are written onto your policy certificate.
- Pros: Complete clarity from the start. You know precisely where you stand.
- Cons: The application process is longer and more intrusive. The exclusions applied are often permanent and won't be reviewed later.
Example of Full Medical Underwriting: David applies for a policy and declares he had surgery for a knee ligament tear in 2022. The insurer reviews this and issues his policy with a permanent exclusion stating, "No cover will be provided for the ligaments of the right knee." David knows from day one that he cannot claim for this issue.
Comparing Underwriting Types
| Feature | Moratorium (MORI) | Full Medical Underwriting (FMU) |
|---|---|---|
| Application Process | Quick and simple. No health forms. | Longer. Requires a detailed health questionnaire. |
| Clarity at Start | Less. Exclusions are general, not specific. | High. You receive a list of specific exclusions. |
| Claim Process | Can be slower as insurer investigates medical history then. | Often faster as underwriting is already done. |
| Cover for Pre-existing | Can be gained after a 2-year clear period. | Exclusions are usually permanent. |
| Best For | People with few recent medical issues who want a fast start. | People with a complex medical history who want certainty. |
Conditions & Treatments: What's Covered (and What Isn't)
Your policy document will list everything in detail, but here are the general principles.
The Big Exclusions: Pre-existing and Chronic Conditions
It's worth repeating: standard UK private medical insurance does not cover pre-existing or chronic conditions.
- Pre-existing Condition: Any illness or injury you had before your policy's start date. As explained under underwriting, these are either excluded for a set period (Moratorium) or permanently (FMU).
- Chronic Condition: Long-term conditions like diabetes, multiple sclerosis, or Crohn's disease. While PMI won't cover the day-to-day management of these, it may cover an acute flare-up if it's a new, unexpected event that is curable. This can be a grey area, so it's always best to check with your insurer.
Cancer Cover: A Closer Look
Cancer cover is a cornerstone of most PMI policies and is often cited as a key reason for taking out a policy. It typically includes:
- Costs of surgery, radiotherapy, and chemotherapy.
- Access to new and expensive cancer drugs and treatments that may not be available on the NHS due to funding restrictions.
- Palliative care and end-of-life support.
- Wigs, prostheses, and monitoring.
Always check the level of cancer cover, as some basic policies may have limits.
Mental Health Cover
Awareness around mental wellbeing has grown, and so has the cover offered by insurers. A good policy may include:
- Access to a network of psychiatrists and psychologists.
- Cover for in-patient, day-patient, and out-patient psychiatric treatment.
- Cover for talking therapies like CBT (Cognitive Behavioural Therapy).
This is often an optional add-on, so if it's important to you, make sure you select it.
Common Standard Exclusions
Besides chronic and pre-existing conditions, most policies will also exclude:
- Normal pregnancy and childbirth
- Cosmetic surgery (unless it's reconstructive after an accident or eligible surgery)
- Treatment for addiction (e.g., alcohol or drugs)
- Emergency treatment (this is always handled by NHS A&E)
- Self-inflicted injuries
The Claims Process: From GP Referral to Treatment
So, you have a policy and a new health concern. What happens next?
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GP Referral: Your journey almost always starts with your NHS or private GP. If they believe you need to see a specialist, they will write you a referral letter. Some policies offer a Digital GP service, allowing you to get a referral quickly via video call.
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Pre-authorisation: Before you book any consultation or treatment, you must contact your insurer to start a claim. You'll give them the details from your GP referral. They will check your policy and confirm if the condition and treatment are covered. This is called pre-authorisation. They will give you a claim number.
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Booking Treatment: Once your claim is authorised, you can book your appointment with a specialist or hospital from your insurer's approved list.
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Direct Settlement: In most cases, you won't see a bill. The hospital or specialist will send their invoice directly to your insurer for payment. This is known as direct settlement. If you have an excess, you will usually pay this directly to the hospital.
Added Value: More Than Just Medical Cover
The modern private health cover market is competitive, and insurers offer a range of perks to attract and retain customers.
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Wellness Programmes: Many providers, such as Vitality and Aviva, have programmes that reward you for healthy living. By tracking your activity, getting health checks, or eating well, you can earn points towards rewards like cinema tickets, coffee, and discounts on gym memberships or travel.
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Digital GP Services: 24/7 access to a GP via your smartphone is now a common feature. This is incredibly convenient for getting quick advice, prescriptions, or a referral without waiting for an NHS appointment.
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WeCovr's Exclusive Benefits: When you arrange a policy through us, you get more than just expert advice. Our clients receive complimentary lifetime access to CalorieHero, our AI-powered calorie and nutrition tracking app, to support their health goals. Furthermore, customers who purchase PMI or life insurance through WeCovr are eligible for discounts on other insurance products, such as home or travel cover.
Understanding the UK Health Landscape: Why Consider PMI?
PMI exists because, while the NHS is a world-class service, it is under significant pressure.
According to NHS England data for mid-2025, the elective care waiting list remains substantial, with several million treatment pathways outstanding. For patients, this can mean long waits for diagnosis and non-urgent surgery.
For example, the 18-week Referral to Treatment (RTT) standard, which states that over 92% of patients should wait no more than 18 weeks from GP referral to treatment, has not been met nationally for several years.
PMI offers a solution by providing:
- Speed: Bypassing long NHS waiting lists for eligible conditions.
- Choice: Selecting your specialist and the hospital where you'll be treated.
- Comfort: Access to a private room, flexible visiting hours, and other amenities.
It is a complementary service, not a replacement. You will still use the NHS for emergencies, chronic care, and GP services.
Frequently Asked Questions (FAQ) about PMI
Is private medical insurance worth it in the UK?
Can I get health insurance if I have a pre-existing medical condition?
What is the main difference between Moratorium and Full Medical Underwriting?
Get Your Personalised PMI Quote Today
Understanding these terms is the first step towards finding the right protection for you and your family. The UK private medical insurance market offers a vast range of choices, and navigating them alone can be daunting.
As an independent, FCA-authorised broker, WeCovr compares policies from leading UK insurers to find the best fit for your needs and budget. Our expert advice is completely free.
Contact us today for a no-obligation quote and discover how affordable peace of mind can be.
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.
