TL;DR
As an FCA-authorised expert broker that has helped arrange over 900,000 policies, WeCovr knows that navigating a private medical insurance (PMI) policy in the UK can feel like learning a new language. This guide demystifies the jargon, helping you understand exactly what you are covered for. Plain-English explanations of terms, conditions, exclusions, and technical jargon Your private health insurance documents are your contract with the insurer.
Key takeaways
- Policy Schedule (or Certificate of Insurance): This is your personalised summary. It's usually a shorter document that lists the specifics of your individual policy.
- Your name and personal details.
- The names of anyone else covered on the policy.
- Your policy number.
- The start and end date of your cover (the policy year).
As an FCA-authorised expert broker that has helped arrange over 900,000 policies, WeCovr knows that navigating a private medical insurance (PMI) policy in the UK can feel like learning a new language. This guide demystifies the jargon, helping you understand exactly what you are covered for.
Plain-English explanations of terms, conditions, exclusions, and technical jargon
Your private health insurance documents are your contract with the insurer. They contain everything you need to know about your cover, but are often filled with technical terms. Think of this article as your personal translator, turning confusing jargon into clear, straightforward advice. We’ll break down every key term, so you can feel confident about your health protection.
The Core Components of Your PMI Policy Document
When you take out a private medical insurance policy, you will typically receive two main documents. Understanding the purpose of each is the first step to mastering your cover.
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Policy Schedule (or Certificate of Insurance): This is your personalised summary. It's usually a shorter document that lists the specifics of your individual policy.
- Your name and personal details.
- The names of anyone else covered on the policy.
- Your policy number.
- The start and end date of your cover (the policy year).
- Your chosen level of cover (e.g., 'Comprehensive', 'Intermediate').
- Your selected excess amount.
- The annual benefit limits for your policy.
- Any specific exclusions that apply only to you (known as personal exclusions).
- Your monthly or annual premium.
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Policy Wording (or Policy Handbook): This is the detailed rulebook. It's a longer, more generic document that explains all the terms and conditions of the insurance product itself. It applies to everyone who has bought that specific plan. Here you will find detailed definitions, the claims process, and a full list of general exclusions.
Top Tip: Always read your Policy Schedule and the Policy Wording together. The Schedule tells you what you've chosen, and the Wording tells you what that choice means in detail.
Key PMI Terms from A-Z: Your Glossary to Health Insurance Jargon
Let's dive into the most common terms you'll encounter. We've explained them in plain English to remove any confusion.
Acute Condition
An acute condition is a disease, illness, or injury that is likely to respond quickly to treatment and lead to your full recovery. Think of things like a joint replacement, cataract surgery, or treatment for a curable infection. Private medical insurance in the UK is specifically designed to cover acute conditions that arise after you take out your policy.
Annual Benefit Limit
This is the maximum amount of money your insurer will pay out for all your claims combined within a single policy year. Limits can range from tens of thousands of pounds to 'unlimited', depending on the policy. A higher limit usually means a higher premium.
Chronic Condition
This is one of the most important terms to understand. A chronic condition is an illness that cannot be cured and needs long-term monitoring and management. Examples include:
- Diabetes
- Asthma
- High blood pressure (hypertension)
- Arthritis
- Crohn's disease
Crucially, standard private medical insurance policies in the UK do not cover the treatment or management of chronic conditions. PMI is for short-term, curable problems. The NHS provides excellent care for long-term chronic conditions.
Cooling-Off Period
By law, you have a 14-day 'cooling-off' period starting from the day you receive your policy documents. During this time, you can cancel your policy for any reason and receive a full refund, provided you haven't made a claim.
Day-Patient, In-Patient, and Out-Patient
Understanding these three categories is key to knowing how your treatment is covered.
| Treatment Type | Description | Real-Life Example |
|---|---|---|
| In-Patient | You are formally admitted to a hospital and stay overnight for treatment. | Having a hip replacement and staying in a hospital bed for several nights to recover. |
| Day-Patient | You are formally admitted to a hospital for a planned procedure but do not stay overnight. | Undergoing keyhole surgery on your knee in the morning and going home the same evening. |
| Out-Patient | You visit a hospital or clinic for a consultation, test, or scan but are not admitted. | Seeing a specialist for an initial diagnosis, having an MRI scan, or attending a physiotherapy session. |
Most core PMI policies cover in-patient and day-patient treatment as standard. Out-patient cover is often an optional add-on or has a specific financial limit (e.g., up to £1,000 per year). (illustrative estimate)
Excess (or Deductible)
An excess is the amount you agree to pay towards the cost of your treatment when you make a claim. For example, if your excess is £250 and your treatment costs £3,000, you pay the first £250, and your insurer pays the remaining £2,750.
- Illustrative estimate: You can often choose your excess level (e.g., £0, £100, £250, £500).
- A higher excess will lower your monthly premium.
- The excess is usually applied once per policy year, per person, but check your policy wording as some apply it per claim.
Exclusions
Exclusions are specific conditions, treatments, or circumstances that your policy will not cover. These fall into two types:
- General Exclusions: These apply to everyone on that policy and are listed in the Policy Wording. Common examples include pre-existing conditions, chronic conditions, normal pregnancy, cosmetic surgery, and A&E visits.
- Personal Exclusions: These are specific to you and are based on your medical history. They will be listed on your Policy Schedule. This only applies if you have chosen 'Full Medical Underwriting'.
Guided Consultant List / Hospital List
To manage costs, many insurers have approved lists of hospitals and specialists.
- Hospital Lists: These are often tiered. A budget-friendly policy might give you access to a local network of hospitals, while a premium policy might offer a nationwide or even London-based list. Choosing a more restricted list can reduce your premium.
- Guided Consultant Lists: Some policies require you to choose from a small selection of specialists recommended by the insurer for your condition. This "guided" option typically results in a lower premium but offers less choice than being able to choose any specialist you wish.
Pre-authorisation (or Pre-approval)
This is the process of getting your insurer's approval before you have any tests or treatment. It is a mandatory step for almost all claims. To get pre-authorisation, you will need to call your insurer with the details from your GP's referral. The insurer will check that the condition and proposed treatment are covered by your policy and issue an authorisation number. Failing to get pre-authorisation can result in your claim being rejected.
Pre-existing Condition
This refers to any illness, injury, or symptom for which you have sought advice, diagnosis, or treatment before the start date of your policy. As a rule, private medical insurance UK policies do not cover pre-existing conditions. How they are excluded depends on your underwriting type.
Premium
Your premium is the regular payment you make to keep your insurance active. You can usually pay monthly or annually. Paying annually often comes with a small discount.
Understanding Your Underwriting Type: Moratorium vs. FMU
Underwriting is how insurers assess your medical history to decide what they will and won't cover. There are two main types in the UK. Choosing the right one is vital, and a specialist broker like WeCovr can provide expert guidance to help you decide.
Moratorium Underwriting (Mori)
This is the most common type of underwriting in the UK.
- How it works: You don't have to declare your full medical history when you apply. Instead, for the first two years of your policy, the insurer will automatically exclude any condition you've had symptoms of, or received advice or treatment for, in the five years prior to your policy start date.
- The "Two-Year Rule": A pre-existing condition may become eligible for cover if you complete a continuous two-year period on the policy without experiencing any symptoms, or seeking any treatment, tests, or advice for that condition.
| Moratorium Underwriting | |
|---|---|
| Pros | ✅ Quicker and less intrusive application process. ✅ Possibility for past conditions to become covered over time. |
| Cons | ❌ Lack of certainty. You may not know if a condition is covered until you try to claim. ❌ The "rolling" nature of the moratorium can be complex to understand. |
Full Medical Underwriting (FMU)
- How it works: You complete a detailed health questionnaire as part of your application, declaring your full medical history. The insurer's underwriting team reviews this and then issues your policy documents with a list of specific, permanent exclusions (personal exclusions).
| Full Medical Underwriting (FMU) | |
|---|---|
| Pros | ✅ Complete certainty from day one. You know exactly what is and isn't covered. ✅ May be better if you have a complex medical history you want clarity on. |
| Cons | ❌ A longer and more detailed application process. ❌ Exclusions applied are typically permanent and will not be reviewed. |
An expert adviser can discuss your personal health history and help determine whether the simplicity of a moratorium or the certainty of FMU is the better path for you.
What's Covered and What's Not? A Clear Guide to Inclusions & Exclusions
While every policy is different, most UK PMI plans are built around a core set of benefits, with common exclusions.
| ✅ Typically Included (Core or as an Add-on) | ❌ Typically Excluded |
|---|---|
| In-patient and day-patient treatment: Hospital fees, surgeon fees, anaesthetist fees. | Pre-existing and Chronic conditions: The two fundamental exclusions of PMI. |
| Cancer Cover: Extensive cover for diagnosis and treatment is a cornerstone of most policies. | Emergency Services: A&E visits and ambulance transport remain the domain of the NHS. |
| Out-patient diagnostics: MRI, CT, and PET scans (often up to an annual limit). | Normal Pregnancy and Childbirth: Complications of pregnancy may be covered, but routine care is not. |
| Out-patient consultations: Seeing a specialist before or after treatment. | Cosmetic Surgery: Procedures for purely aesthetic reasons are excluded. |
| Mental Health Cover: Support for acute mental health conditions (often as an add-on). | Routine Dental and Optical Care: Check-ups, fillings, and glasses are usually excluded. |
| Therapies: Physiotherapy, osteopathy, and chiropractic treatment (often a set number of sessions). | Self-inflicted injuries: Including those from dangerous hobbies or substance abuse. |
The Golden Rule: Private health cover is designed to work alongside the NHS, not replace it. For emergencies, life-threatening situations, and the management of long-term chronic conditions, the NHS is your first port of call. PMI gives you choice and speed for eligible, acute conditions.
Reading the Fine Print: Conditions That Can Invalidate Your Cover
An insurance policy is a contract based on good faith. There are a few key responsibilities on your part to ensure your cover remains valid.
- Duty of Fair Presentation: You must be honest and disclose all relevant information during your application (especially with Full Medical Underwriting) and when making a claim. Hiding a pre-existing condition is known as 'non-disclosure' and can lead to your policy being cancelled and claims being denied.
- Claiming for Excluded Items: Attempting to claim for a treatment you know is excluded is not permitted.
- Failing to Get Pre-authorisation: As mentioned, this is a crucial step. Insurers need to approve the cost and medical necessity of treatment before it happens. Proceeding without this approval can leave you liable for the full cost.
Making a Claim: A Step-by-Step Guide
The claims process is designed to be straightforward, provided you follow the steps.
- See Your GP: Your journey almost always starts with your NHS GP. You experience a symptom, and your GP assesses you. If they believe you need to see a specialist, they will provide you with an 'open referral' letter.
- Contact Your Insurer for Pre-authorisation: Call your insurer's claims line. Have your policy number and GP referral details ready. They will confirm your cover, discuss your choice of hospital/specialist (depending on your policy), and give you a pre-authorisation number.
- Book Your Appointment: Contact the specialist's secretary or hospital to book your consultation or treatment. Provide them with your policy details and pre-authorisation number.
- Attend Your Treatment: Go to your appointment, scan, or procedure.
- Billing is Handled Directly: In most cases, the hospital or specialist will send the bill directly to your insurance company. You don't need to handle invoices.
- Pay Your Excess: If your policy has an excess, the hospital will usually ask you to pay it directly. Alternatively, your insurer may pay the full bill and then ask you to reimburse them for the excess amount.
Beyond the Basics: Added Value and Wellness Benefits
Modern private medical insurance is about more than just paying for treatment. Insurers are increasingly focused on keeping you healthy. Many policies now include a fantastic range of wellness benefits at no extra cost, such as:
- Digital GP Services: 24/7 access to a GP via phone or video call, often with the ability to get prescriptions delivered to your door. This is incredibly convenient and helps you get advice quickly.
- Mental Health Support: Access to telephone helplines with trained counsellors, or a set number of therapy sessions, even without a GP referral.
- Wellness and Lifestyle Discounts: Many providers partner with popular brands to offer discounts on gym memberships, fitness trackers, and healthy food services.
- Health Information Hubs: Access to online portals and apps with reliable health information, articles, and tools.
At WeCovr, we enhance this further. All our private medical insurance clients receive complimentary access to CalorieHero, our AI-powered calorie and nutrition tracking app, to support their health goals. Furthermore, clients who purchase PMI or life insurance through us are eligible for exclusive discounts on other types of cover, from home to travel insurance.
Why You Need an Expert PMI Broker Like WeCovr
The UK private medical insurance market is complex, with dozens of providers and hundreds of policy combinations. Trying to compare them yourself can be overwhelming. This is where an independent, expert broker is invaluable.
- Expertise and Simplicity: A broker does the hard work for you. We use our deep knowledge of the market to filter the options and present you with the most suitable choices for your needs and budget.
- Personalised Advice: We take the time to understand your personal circumstances, health, and what you value most in a policy, ensuring you don't pay for benefits you don't need.
- No Cost to You: Our service is free. We are paid a commission by the insurer you choose, so you get expert, impartial advice without any extra fees.
- Advocacy: We work for you, not the insurance company. We can help you with the application and are here to offer support if you ever need to make a claim.
As an FCA-authorised broker with high customer satisfaction ratings, WeCovr provides a trusted, human touch to help you secure the right protection for you and your family.
What is the difference between a chronic and an acute condition for PMI?
Will my private medical insurance premium go up every year?
Do I still need the NHS if I have private medical insurance?
Can I switch my private health insurance provider?
Ready to cut through the jargon and find the perfect private health cover for your needs? The friendly experts at WeCovr are here to help. Get a free, no-obligation quote today and let us compare the UK's leading insurers to find a policy that gives you peace of mind at the right price.
Sources
- NHS England: Waiting times and referral-to-treatment statistics.
- Office for National Statistics (ONS): Health, mortality, and workforce data.
- NICE: Clinical guidance and technology appraisals.
- Care Quality Commission (CQC): Provider quality and inspection reports.
- UK Health Security Agency (UKHSA): Public health surveillance reports.
- Association of British Insurers (ABI): Health and protection market publications.
