TL;DR
At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we believe clarity is key when choosing private medical insurance in the UK. Understanding what your policy excludes is just as important as knowing what it covers, ensuring you have the right protection when you need it most. Latest breakdown of standard exclusions—including chronic conditions, pregnancy, cosmetic treatments, mental health caps—in November 2026 policies Private Medical Insurance (PMI) is designed to give you peace of mind, fast access to specialists, and comfortable private hospital care.
Key takeaways
- A disease, illness, or injury that is likely to respond quickly to treatment.
- It is expected to return you to your previous state of health.
- It's generally short-lived and unforeseen.
- Examples: A broken arm, appendicitis, gallstones, cataracts, or a joint replacement.
- A disease, illness, or injury that has one or more of the following characteristics:
At WeCovr, an FCA-authorised broker that has helped arrange over 900,000 policies, we believe clarity is key when choosing private medical insurance in the UK. Understanding what your policy excludes is just as important as knowing what it covers, ensuring you have the right protection when you need it most.
Latest breakdown of standard exclusions—including chronic conditions, pregnancy, cosmetic treatments, mental health caps—in November 2026 policies
Private Medical Insurance (PMI) is designed to give you peace of mind, fast access to specialists, and comfortable private hospital care. But it isn't a replacement for the NHS, and it doesn't cover everything. Every policy has a list of exclusions—things it simply won't pay for.
Navigating these exclusions can feel like reading the small print on a complex legal document. This guide is here to change that. We'll break down the most common PMI exclusions for 2025 in plain English, so you can make an informed decision about your private health cover.
The Golden Rule of PMI: Acute vs. Chronic Conditions
If you remember only one thing from this guide, make it this: UK private medical insurance is designed to cover acute conditions, not chronic ones. This is the fundamental principle that underpins the entire market.
But what does that actually mean?
An Acute Condition is:
- A disease, illness, or injury that is likely to respond quickly to treatment.
- It is expected to return you to your previous state of health.
- It's generally short-lived and unforeseen.
- Examples: A broken arm, appendicitis, gallstones, cataracts, or a joint replacement.
A Chronic Condition is:
- A disease, illness, or injury that has one or more of the following characteristics:
- It needs ongoing or long-term monitoring.
- It requires management through check-ups, medication, or special diets.
- It has no known "cure."
- It is likely to recur.
- Examples: Diabetes, asthma, high blood pressure (hypertension), arthritis, Crohn's disease, or eczema.
Your PMI policy is your partner for the unexpected, acute health scares. For the day-to-day management of long-term conditions, you will continue to rely on the excellent care provided by the NHS.
The Big One: Pre-existing Conditions Explained
Alongside chronic conditions, the other major hurdle for PMI coverage is "pre-existing conditions."
What is a pre-existing condition? It's any illness, injury, or symptom for which you have sought advice, received treatment, or experienced symptoms before the start date of your policy. This applies whether you received a formal diagnosis or not.
Insurers handle pre-existing conditions in two main ways, known as underwriting:
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Moratorium Underwriting: This is the most common method for individual policies because it's simple. You don't have to declare your full medical history upfront. Instead, the insurer automatically applies a "waiting period." They will not cover any condition you've had symptoms of or treatment for in the five years before your policy began.
- The good news: If you then go for a continuous two-year period after your policy starts without any treatment, advice, or symptoms for that condition, it may become eligible for cover.
-
Full Medical Underwriting (FMU): With FMU, you complete a detailed health questionnaire, declaring your entire medical history. The insurance company's underwriters review this information and then offer you a policy with specific, named exclusions.
- The benefit: You know from day one exactly what is and isn't covered. This clarity can be invaluable, but the application process is longer.
An expert PMI broker like WeCovr can help you decide which underwriting method is best for your personal circumstances.
A Detailed Look at Standard PMI Exclusions in 2026
While every policy is different, most UK PMI plans share a common set of exclusions. Let's explore them in detail.
Chronic Conditions
As we've established, this is the number one exclusion. PMI will not cover the long-term management of conditions like diabetes, asthma, or hypertension. However, it may cover an unexpected acute flare-up of a chronic condition, but this depends entirely on your insurer and policy wording. Always check.
Pregnancy and Childbirth
Routine pregnancy and childbirth are considered a lifestyle choice rather than an unforeseen medical event. Therefore, standard PMI policies do not cover:
- Antenatal appointments
- Scans
- The delivery itself (whether natural or C-section)
- Postnatal care
The Exception: Complications during pregnancy or childbirth are often covered. These are acute, unexpected medical emergencies. Examples include ectopic pregnancy, miscarriage that requires surgical intervention, or severe postpartum haemorrhage. Some high-end plans may also offer a small cash benefit upon the birth of a child.
Cosmetic and Aesthetic Surgery
Surgery that is performed purely to change your appearance is never covered by PMI. This includes procedures like:
- Rhinoplasty (nose job)
- Breast augmentation
- Liposuction
- Facelifts
The Grey Area: Reconstructive surgery following an accident or for a medical condition (that is covered by your policy) is often included. For example, if you were to have a mastectomy to treat cancer, your policy would likely cover the subsequent breast reconstruction surgery.
Mental Health Cover: Understanding the Caps and Limits
Awareness of mental health has grown, and PMI providers have responded by improving their cover. However, it is rarely unlimited. In 2025, you can expect to see:
- Financial Caps (illustrative): Most standard policies will cap outpatient mental health support, such as therapy or counselling, at a set amount per year (e.g., £1,000 to £1,500).
- Session Limits: It's common to see a limit on the number of therapy sessions, often between 8 and 10 per condition.
- Inpatient vs. Outpatient: Cover for being admitted to a psychiatric hospital (inpatient) is often more limited than cover for physical health conditions.
- Chronic Exclusion: As with physical health, chronic, long-term mental health conditions like schizophrenia or personality disorders are typically excluded. Cover is focused on acute episodes of conditions like anxiety, depression, or stress.
Other Common Exclusions in 2026 Policies
This table summarises other treatments and scenarios that are almost always excluded from a standard private medical insurance UK plan.
| Exclusion Category | Explanation & Examples | Why is it Excluded? |
|---|---|---|
| Emergency Services | Visits to Accident & Emergency (A&E) or ambulance transport. | The NHS provides free, immediate emergency care. PMI is for planned, non-emergency treatment. |
| Substance Misuse | Treatment for drug, alcohol, or solvent abuse and addiction. | This is often viewed as a self-inflicted condition requiring specialist, long-term rehabilitation. |
| Self-Inflicted Injury | Any injuries resulting from deliberate self-harm. | This falls outside the scope of "unforeseen" illness or injury. |
| Fertility Treatment | IVF, IUI, and other investigations into or treatments for infertility. | This is generally considered a lifestyle choice or a non-acute condition. |
| HIV/AIDS | Treatment related to HIV or AIDS. | Due to its chronic nature, the NHS is the primary provider of care for HIV. |
| Professional Sports | Injuries sustained while participating in sport as a professional. | This carries a high and predictable level of risk that insurers are not willing to cover as standard. |
| Experimental Treatments | Drugs, treatments, or procedures that are not approved by NICE (the National Institute for Health and Care Excellence). | Insurers will only cover proven, established medical practices. |
| Mobility & Home Aids | Wheelchairs, mobility scooters, stairlifts, or modifications to your home. | These are considered social care or long-term management aids, not acute medical treatment. |
Understanding Policy Add-ons: Expanding Your Cover
While the list of exclusions might seem long, you can often bolster your policy by purchasing optional add-ons. This allows you to tailor your private health cover to your specific needs and budget.
Dental and Optical Cover
Standard PMI doesn't cover routine check-ups, fillings, new glasses, or contact lenses. However, for an extra monthly premium, you can add a dental and optical benefit that helps with these costs. This is often a good-value addition if you regularly visit the dentist or optician.
Enhanced Mental Health Cover
If mental health support is a priority, most major insurers offer an upgraded option. This might remove the financial or session caps on outpatient therapy, providing more extensive support for your well-being.
Therapies Cover
This covers treatments like physiotherapy, osteopathy, and chiropractic sessions. While some policies include a limited number of sessions as standard, an add-on can provide more comprehensive cover. This is particularly useful if you play sports or have a physically demanding job.
How WeCovr Helps You Navigate the Maze of Exclusions
Trying to compare policies, exclusions, and add-ons from providers like Bupa, AXA Health, Aviva, and Vitality can be overwhelming. This is where an independent, expert PMI broker is invaluable.
At WeCovr, our specialists live and breathe the private medical insurance market. We take the time to understand your needs, your budget, and your health concerns. We can then compare the whole market on your behalf, explaining the subtle but crucial differences in policy wording. Our service is completely free to you, and we are dedicated to finding you a policy with no hidden surprises.
Wellness & Lifestyle: Proactive Health is Your Best Policy
The best way to manage your health is to be proactive. A healthy lifestyle can reduce your risk of developing many conditions, keeping you out of hospital altogether. Many modern PMI policies actively encourage this.
- Balanced Diet: Following principles like the NHS Eatwell Guide can have a huge impact. Aim for five portions of fruit and veg a day, choose wholegrain carbohydrates, and opt for lean proteins and healthy fats. As a WeCovr customer, you get complimentary access to CalorieHero, our AI-powered calorie and nutrition tracking app, to make this easier.
- Regular Activity: The NHS recommends at least 150 minutes of moderate-intensity activity (like a brisk walk or cycling) or 75 minutes of vigorous-intensity activity (like running or swimming) per week.
- Quality Sleep: Aim for 7-9 hours of quality sleep per night. It's crucial for mental and physical recovery. Establish a routine, avoid screens before bed, and create a calm, dark sleeping environment.
- Stress Management: Chronic stress can impact your health. Make time for hobbies, practice mindfulness or meditation, and spend time in nature.
Insurers like Vitality have pioneered a model that rewards you for healthy living with perks like cinema tickets and coffee, and even discounts on your premium.
Private Medical Insurance UK Market in 2026: Key Statistics
The demand for private health cover continues to grow, largely driven by pressures on the NHS.
- NHS Waiting Lists: Based on trends from late 2024, NHS England's referral to treatment (RTT) waiting list is expected to remain a significant concern throughout 2025, with several million patients waiting for consultant-led treatment. This long wait is the primary driver for individuals and companies seeking PMI.
- PMI Growth: According to market analysis from sources like LaingBuisson, the number of people in the UK covered by private medical insurance is approximately 4 million, a figure that has shown steady growth as people seek faster access to care.
- Mental Health Demand: ONS data consistently shows that rates of depression and anxiety in the adult population remain elevated. This has fuelled demand for PMI policies with robust mental health support, making it more important than ever to understand the caps and limitations of any plan.
The WeCovr Advantage: More Than Just a Broker
Choosing a PMI policy is a big decision. At WeCovr, we go beyond just finding you a price.
- Expert, Authorised Advice: We are authorised and regulated by the Financial Conduct Authority (FCA). Our advice is professional, impartial, and tailored to you.
- Market-Wide Comparison: We work with all the leading UK insurers to find the best fit for your needs.
- High Customer Satisfaction: Our clients consistently give us high ratings on independent review websites for our friendly, clear, and efficient service.
- Added Value: When you arrange a PMI or Life Insurance policy through us, you not only get expert guidance but also complimentary access to our CalorieHero AI nutrition app. Plus, you can receive discounts on other types of insurance you may need, saving you money across the board.
We don't just sell policies; we build relationships and provide ongoing support to ensure your health and finances are protected.
Is cancer covered by private medical insurance?
Do I need to declare conditions I had years ago?
Why isn't A&E covered by PMI?
Can I get PMI if I already have a chronic condition?
Take the Next Step Towards Clarity and Peace of Mind
Ready to find a private health cover plan that truly works for you? Stop guessing and start knowing. Let our friendly experts at WeCovr demystify the options and find the perfect policy for your needs and budget.
Get your free, no-obligation PMI quote today and gain absolute clarity on your health protection.
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.
