What Does PMI Actually Cover Exclusions Explained
As an FCA-authorised broker that has helped arrange over 800,000 policies, WeCovr understands that navigating the world of private medical insurance in the UK can feel complex. This guide cuts through the confusion, explaining precisely what's covered, what's not, and the crucial details in between.
WeCovr details what's in, what's out, and what's a grey area
Private Medical Insurance (PMI) is designed to give you peace of mind. It's a contract between you and an insurer that says if you develop a new, eligible medical condition, they will pay for you to receive private diagnosis and treatment. This means faster access to specialists, comfortable private hospital facilities, and more choice over when and where you are treated.
However, no insurance policy covers everything. The key to making a smart decision is understanding the boundaries. This guide will walk you through:
- The Core Principle: Why PMI only covers 'acute' conditions, not 'chronic' ones.
- What's In: The standard treatments and services included in most policies.
- What's Out: The standard exclusions you need to be aware of.
- The Grey Areas: Optional extras and policy limits that let you tailor your cover.
Ultimately, PMI works alongside the brilliant but burdened NHS, providing a complementary route for non-emergency care. Let's dive into the specifics.
The Core Principle of PMI: Acute vs. Chronic Conditions
If you remember only one thing from this guide, let it be this: UK private medical insurance is designed to cover acute conditions that arise after you take out your policy. It is not designed to cover long-term, ongoing (chronic) conditions or issues you already have (pre-existing conditions).
Understanding this distinction is the foundation of understanding your cover.
- An Acute Condition is a disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Think of things that have a clear beginning and end, like a cataract operation, repairing a hernia, or setting a broken bone.
- A Chronic Condition is an illness that is long-lasting or recurring. It cannot be cured, only managed. Examples include diabetes, asthma, arthritis, high blood pressure, and Crohn's disease. The NHS is responsible for managing these long-term conditions.
This principle exists to keep insurance affordable. Covering the ongoing management of lifelong conditions for every policyholder would make premiums astronomically high. PMI focuses on providing rapid intervention for unexpected health problems, getting you diagnosed, treated, and back on your feet.
Acute vs. Chronic Conditions: A Clear Comparison
| Feature | Acute Condition (Generally Covered by PMI) | Chronic Condition (Generally Excluded by PMI) |
|---|---|---|
| Duration | Short-term and sudden onset. | Long-term, persistent, or recurring. |
| Outcome | Curable; treatment aims for a full recovery. | Incurable; treatment aims to manage symptoms. |
| Treatment | A defined course of treatment (e.g., surgery, a course of medication). | Ongoing monitoring and management. |
| Examples | Appendicitis, broken arm, gallstones, cataracts, joint replacement. | Diabetes, asthma, high blood pressure, arthritis, eczema. |
What Does Standard Private Health Cover Typically Include?
While every policy differs, most private health cover plans are built around a core set of benefits designed to cover the most significant costs associated with private treatment.
H3: In-patient and Day-patient Treatment
This is the foundation of almost every PMI policy. It covers treatment where you need to be admitted to a hospital and occupy a bed.
- In-patient: You are admitted and stay overnight (or longer).
- Day-patient: You are admitted for a procedure and occupy a bed for the day but do not stay overnight (e.g., for minor surgery like a colonoscopy or cataract removal).
What costs are typically covered?
- Hospital accommodation and nursing care fees.
- Surgeon, anaesthetist, and specialist fees.
- Diagnostic tests like CT, MRI, and PET scans while you're admitted.
- Operating theatre costs.
- Medication and dressings administered in the hospital.
- Prosthetics or joint implants (e.g., a new hip or knee).
H3: Out-patient Treatment
This is one of the most important areas to understand, as the level of cover can vary significantly and directly impacts your premium. Out-patient treatment is for diagnosis or care that does not require a hospital bed.
This includes:
- Initial consultations with a specialist after a GP referral.
- Diagnostic tests and scans to figure out the problem.
- Minor procedures that don't need a full day-patient unit.
Most insurers offer different levels of out-patient cover, from a basic option that might only cover consultations up to a set financial limit (e.g., £1,000 per year), to a comprehensive option with unlimited cover. Choosing a lower level of out-patient cover is a common way to make a policy more affordable.
H3: Cancer Cover
For many people, this is the single most important reason to have private medical insurance. NHS cancer care is excellent, but PMI can offer access to treatments, drugs, and specialists that may not be available on the NHS due to funding or licensing restrictions.
Cancer cover is often a core benefit but can sometimes be an optional add-on or have different levels. A comprehensive cancer plan will typically cover:
- Surgery to remove tumours.
- Radiotherapy and chemotherapy sessions.
- Access to specialist cancer centres.
- Monitoring, consultations, and scans.
- The cost of expensive, cutting-edge drugs that NICE (the National Institute for Health and Care Excellence) may not have approved for widespread NHS use yet.
H3: Mental Health Support
Awareness of mental health has grown, and insurers have responded by improving their support. While cover for chronic mental health conditions is excluded, policies increasingly offer valuable benefits for acute issues like anxiety, depression, and stress.
Cover often includes:
- A set number of therapy or counselling sessions (e.g., Cognitive Behavioural Therapy).
- Access to psychiatric consultations for diagnosis and treatment planning.
- In-patient or day-patient treatment for acute mental health episodes.
Limits often apply, such as a cap on the number of sessions or an annual financial limit.
H3: Other Valuable Benefits
Modern PMI policies come with a suite of additional perks designed to support your day-to-day wellbeing.
- Digital GP Services: 24/7 access to a GP via phone or video call, often with the ability to get prescriptions or referrals.
- Health and Wellness Support: Telephone helplines for advice on stress, diet, and lifestyle, as well as second opinion services.
- Exclusive Member Perks: As a WeCovr client, you get complimentary access to our AI-powered calorie and nutrition tracking app, CalorieHero, to help you stay on top of your health goals. You can also benefit from discounts on other insurance products, like life or income protection cover, when you take out a PMI policy with us.
The Big Question: What Does PMI Not Cover? (Standard Exclusions)
Understanding exclusions is just as important as knowing what's included. Insurers apply these to manage risk and keep premiums viable. Here are the most common things you'll find are not covered by standard UK private medical insurance.
H3: Pre-existing Conditions
This is the most significant exclusion. A pre-existing condition is any disease, illness, or injury for which you have experienced symptoms, received medication, or sought advice from a medical professional before the start date of your policy.
Insurers handle this in one of two ways:
- Moratorium (Mori) Underwriting: This is the most common method. You don't complete a medical questionnaire. Instead, the policy automatically excludes any condition you've had in the 5 years before joining. However, if you then go for 2 continuous years on the policy without any symptoms, treatment, or advice for that condition, it may become eligible for cover. It's a "serve your time" approach.
- Full Medical Underwriting (FMU): You complete a detailed health questionnaire. The insurer assesses your medical history and may place specific, named exclusions on your policy certificate. This provides certainty from day one about what is and isn't covered, but those exclusions are often permanent.
Moratorium vs. Full Medical Underwriting
| Feature | Moratorium Underwriting | Full Medical Underwriting |
|---|---|---|
| Application Process | Quick and simple, no health forms. | Requires a detailed health questionnaire. |
| How Exclusions Work | A blanket exclusion on conditions from the last 5 years. | Specific conditions are named as exclusions. |
| Clarity | Less certainty at the point of claim. | Complete clarity from day one. |
| Can Exclusions Be Lifted? | Yes, after a 2-year trouble-free period. | Usually not, exclusions are permanent. |
| Best For | People with a clean bill of health or minor past issues. | People who want absolute certainty about their cover. |
H3: Chronic Conditions (Reiterated)
As explained earlier, PMI does not cover the management of long-term, incurable conditions like diabetes, asthma, or multiple sclerosis. Your PMI policy might pay for the initial diagnosis of a chronic condition, but once confirmed, the long-term care and management will be passed back to the NHS.
H3: Emergency and A&E Treatment
If you have a heart attack, a stroke, or are in a serious accident, your first port of call is always 999 and the NHS A&E department. Private hospitals are not equipped to handle life-threatening emergencies. PMI is for planned, non-emergency (elective) treatment. Your policy may, however, cover follow-up treatment or reconstructive surgery after the initial emergency has been stabilised by the NHS.
H3: Routine and Preventative Care
Your day-to-day healthcare needs are generally not covered. This includes:
- Routine dental check-ups and treatment (unless you have a specific dental add-on).
- Routine eye tests and the cost of glasses or contact lenses (again, unless you have an optical add-on).
- Vaccinations.
- Preventative health screenings without symptoms.
H3: Maternity and Childbirth
Standard PMI policies do not cover routine pregnancy, childbirth, or post-natal care. These are managed by the NHS. Some high-end, premium policies may offer a cash benefit upon childbirth or cover certain complications of pregnancy, but this is not standard and must be checked carefully.
H3: Cosmetic Surgery
Procedures done purely for aesthetic reasons, such as a facelift, liposuction, or breast augmentation, are never covered. The exception is reconstructive surgery required after an accident or illness (like breast reconstruction after a mastectomy for cancer), which is often included.
H3: Other Common Exclusions
You can also expect the following to be excluded from your policy:
- Infertility treatments like IVF.
- Treatment for alcohol or drug addiction.
- Self-inflicted injuries.
- Treatment overseas (unless you have a specific international or travel plan).
- Experimental or unproven treatments and therapies.
Navigating the Grey Areas: Optional Extras and Policy Limits
What might seem like a 'grey area' is often just a choice. You can customise your policy by adding or removing benefits and setting limits to balance your level of cover with your monthly premium. Working with a PMI broker like WeCovr is invaluable here, as we can help you model different scenarios.
Customising Your PMI Policy: Common Add-ons
| Add-on | What It Covers | Is It Worth It? |
|---|---|---|
| Therapies Cover | Physiotherapy, osteopathy, and chiropractic treatment. | Highly recommended. These are some of the most frequently claimed benefits and can speed up recovery from injuries. |
| Full Out-patient Cover | Removes any financial limits on out-patient consultations and diagnostics. | Ideal for peace of mind, but significantly increases the premium. A mid-range limit (e.g., £1,500) is a good compromise for many. |
| Mental Health Cover | Extends the standard mental health support, offering more therapy sessions or higher financial limits. | A very popular choice, especially for those in high-stress jobs or with a family history of mental health challenges. |
| Dental & Optical Cover | Contributes towards the cost of routine check-ups, treatment, and eyewear. | Can be good value if you know you will use it, but check the benefit limits to see if it outweighs the extra premium. |
| Travel Cover | Provides medical cover when you are abroad. | Can be a convenient alternative to a separate travel insurance policy, but check it covers your specific destinations and activities. |
H3: Understanding Financial and Treatment Limits
These are the levers you can pull to control the cost of your premium:
- Excess: This is the amount you agree to pay towards the cost of any claim you make in a policy year. It could be £100, £250, £500, or more. A higher excess means a lower premium.
- Hospital List: Insurers have tiered lists of participating private hospitals. Choosing a policy that uses a more restricted local list instead of a nationwide list (which includes expensive central London hospitals) can result in significant savings.
- The 'Six-Pack' or Guided Option: Some insurers, like Aviva and Vitality, offer a discount if you agree to use a consultant from a small, pre-approved list for your treatment. This helps them control costs, and they pass the saving on to you. It reduces your choice of specialist but can be a very effective way to lower your premium.
How to Get the Right Cover: A Practical Checklist
- Assess Your Needs: What are your priorities? Are you most concerned about fast diagnosis, comprehensive cancer care, or access to therapies? Write down your 'must-haves' and 'nice-to-haves'.
- Understand Your Budget: Be realistic about what you can comfortably afford each month. A policy is only useful if you can continue to pay for it.
- Compare Underwriting Options: Think about your medical history. If it's clear, Moratorium is simple. If you have had issues in the past, Full Medical Underwriting might provide more clarity.
- Read the Small Print: Before you buy, always read the Key Facts and Policy Wording documents. Pay close attention to the list of exclusions.
- Use an Expert Broker: This is the simplest way to get it right. An independent broker like WeCovr does the hard work for you. We compare policies from the UK's best PMI providers, explain the complex terms in plain English, and find cover that is perfectly matched to your needs and budget. Our advice and service are completely free to you.
Real-Life Examples: How PMI Works in Practice
Scenario 1: Sarah's Knee Injury (Covered) Sarah, 45, is a keen runner. She develops persistent knee pain. Her NHS GP suspects a torn meniscus and refers her to a specialist. The NHS waiting list for an orthopaedic consultation is 9 months.
- Action: Sarah calls her PMI provider. They approve the consultation.
- Outcome: She sees a private consultant within a week, has an MRI scan a few days later, and undergoes keyhole surgery the following week. Her policy covers the consultant fees, scan, and all hospital and surgical costs, minus her £250 excess. She is back to gentle jogging in two months.
Scenario 2: David's Diabetes (Not Covered) David, 55, feels unusually tired and thirsty. His GP runs blood tests and diagnoses him with Type 2 diabetes.
- Action: David asks if his PMI can be used.
- Outcome: The insurer explains that while they might have covered the initial diagnostic tests (if he'd used his out-patient benefit), diabetes is a chronic condition. Its long-term management, including regular check-ups, medication, and lifestyle advice, will be handled by his NHS GP practice.
Scenario 3: Maria's Pre-existing Back Pain (Initially Excluded) Maria, 38, took out a moratorium policy in January 2024. She had seen a physiotherapist for back pain in 2022. In June 2024, her back pain returns.
- Action: Maria calls her insurer to see if she can get a private MRI.
- Outcome: The claim is declined. Because she had symptoms and sought advice for her back in the 5 years before her policy started, it is considered a pre-existing condition and is excluded. However, if Maria remains free of symptoms and needs no treatment or advice for her back until January 2026 (2 full years into her policy), the exclusion will automatically be lifted, and future back problems would be eligible for cover.
The UK Health Landscape in 2025: Why Consider PMI?
The NHS is one of our country's greatest assets, but it is under unprecedented strain. According to the latest NHS England data, the referral-to-treatment (RTT) waiting list remains stubbornly high, with millions of people waiting for routine procedures. As of early 2025, the total waiting list stood at approximately 7.5 million treatment pathways.
This isn't a criticism of the NHS; it's a reflection of rising demand, workforce challenges, and the after-effects of the pandemic.
Private medical insurance is not a replacement for the NHS. It's a parallel system that offers a solution for elective care, easing the burden on public services while giving you control, choice, and speed when you need it most. It ensures that for a new, treatable condition, you can bypass the queues and focus on getting better.
Do I need a GP referral to use my private medical insurance?
Can I get PMI if I have a pre-existing condition?
Is cancer treatment always included in PMI?
Does private health cover pay for my prescriptions?
Feeling clearer about what private medical insurance does and doesn't cover? The next step is to see how it fits your personal circumstances and budget.
At WeCovr, our expert advisors provide free, no-obligation quotes, comparing the UK's leading insurers to find the right policy for you. We'll help you navigate the options and build a plan that gives you true peace of mind.
Get your personalised quote today and take control of your health.
Why private medical insurance and how does it work?
What is Private Medical Insurance?
Private medical insurance (PMI) is a type of health insurance that provides access to private healthcare services in the UK. It covers the cost of private medical treatment, allowing you to bypass NHS waiting lists and receive faster, more convenient care.How does it work?
Private medical insurance works by paying for your private healthcare costs. When you need treatment, you can choose to go private and your insurance will cover the costs, subject to your policy terms and conditions. This can include:• Private consultations with specialists
• Private hospital treatment and surgery
• Diagnostic tests and scans
• Physiotherapy and rehabilitation
• Mental health treatment
Your premium depends on factors like your age, health, occupation, and the level of cover you choose. Most policies offer different levels of cover, from basic to comprehensive, allowing you to tailor the policy to your needs and budget.
Questions to ask yourself regarding private medical insurance
Just ask yourself:👉 Are you concerned about NHS waiting times for treatment?
👉 Would you prefer to choose your own consultant and hospital?
👉 Do you want faster access to diagnostic tests and scans?
👉 Would you like private hospital accommodation and better food?
👉 Do you want to avoid the stress of NHS waiting lists?
Many people don't realise that private medical insurance is more affordable than they think, especially when you consider the value of faster treatment and better facilities. A great insurance policy can provide peace of mind and ensure you receive the care you need when you need it.
Benefits offered by private medical insurance
Private medical insurance provides numerous benefits that can significantly improve your healthcare experience and outcomes:Faster Access to Treatment
One of the biggest advantages is avoiding NHS waiting lists. While the NHS provides excellent care, waiting times can be lengthy. With private medical insurance, you can often receive treatment within days or weeks rather than months.
Choice of Consultant and Hospital
You can choose your preferred consultant and hospital, giving you more control over your healthcare journey. This is particularly important for complex treatments where you want a specific specialist.
Better Facilities and Accommodation
Private hospitals typically offer superior facilities, including private rooms, better food, and more comfortable surroundings. This can make your recovery more pleasant and potentially faster.
Advanced Treatments
Private medical insurance often covers treatments and medications not available on the NHS, giving you access to the latest medical advances and technologies.
Mental Health Support
Many policies include comprehensive mental health coverage, providing faster access to therapy and psychiatric care when needed.
Tax Benefits for Business Owners
If you're self-employed or a business owner, private medical insurance premiums can be tax-deductible, making it a cost-effective way to protect your health and your business.
Peace of Mind
Knowing you have access to private healthcare when you need it provides invaluable peace of mind, especially for those with ongoing health conditions or concerns about NHS capacity.
Private medical insurance is particularly valuable for those who want to take control of their healthcare journey and ensure they receive the best possible treatment when they need it most.
Important Fact!
We can look at a more suitable option mid-term!
Why is it important to get private medical insurance early?
👉 Many people are very thankful that they had their private medical insurance cover in place before running into some serious health issues. Private medical insurance is as important as life insurance for protecting your family's finances.👉 We insure our cars, houses, and even our phones! Yet our health is the most precious thing we have.
Easily one of the most important insurance purchases an individual or family can make in their lifetime, the decision to buy private medical insurance can be made much simpler with the help of FCA-authorised advisers. They are the specialists who do the searching and analysis helping people choose between various types of private medical insurance policies available in the market, including different levels of cover and policy types most suitable to the client's individual circumstances.
It certainly won't do any harm if you speak with one of our experienced insurance experts who are passionate about advising people on financial matters related to private medical insurance and are keen to provide you with a free consultation.
You can discuss with them in detail what affordable private medical insurance plan for the necessary peace of mind they would recommend! WeCovr works with some of the best advisers in the market.
By tapping the button below, you can book a free call with them in less than 30 seconds right now:
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Who Are WeCovr?
WeCovr is an insurance specialist for people valuing their peace of mind and a great service.👍 WeCovr will help you get your private medical insurance, life insurance, critical illness insurance and others in no time thanks to our wonderful super-friendly experts ready to assist you every step of the way.
Just a quick and simple form and an easy conversation with one of our experts and your valuable insurance policy is in place for that needed peace of mind!