TL;DR
Navigating the world of private medical insurance (PMI) in the UK can feel complex. As an FCA-authorised expert broker that has helped arrange over 900,000 policies, WeCovr understands you want clear answers. This guide explains exactly what treatments and services private health insurance typically covers, what it excludes, and how you can tailor a policy to your needs.
Key takeaways
- Hospital Accommodation: A private, en-suite room, offering comfort and privacy during your recovery.
- Nursing Care: Round-the-clock care from the hospital's nursing team.
- Specialist Fees: The fees charged by the surgeon, anaesthetist, and any other specialists involved in your care.
- Operating Theatre Costs: All charges associated with the use of the surgical facilities.
- Diagnostic Tests: Any scans (like MRI or CT), X-rays, or blood tests you need while you are admitted to hospital.
Navigating the world of private medical insurance (PMI) in the UK can feel complex. As an FCA-authorised expert broker that has helped arrange over 900,000 policies, WeCovr understands you want clear answers. This guide explains exactly what treatments and services private health insurance typically covers, what it excludes, and how you can tailor a policy to your needs.
Common treatments included in PMI policies explained
Private Medical Insurance, often called PMI or private health cover, is designed to work alongside the NHS, not replace it. Its primary purpose is to cover the cost of treatment for acute conditions that arise after you’ve taken out your policy.
So, what’s an acute condition? Think of it as a disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. A broken bone, a hernia, or a cataract are all classic examples.
This is the most important distinction to understand: PMI does not cover chronic conditions. A chronic condition is one that is long-lasting, has no known cure, and needs ongoing management. Examples include diabetes, asthma, high blood pressure, and arthritis.
Likewise, PMI generally excludes pre-existing conditions – any medical issue you had symptoms of, or received treatment, medication, or advice for, in the years before your policy began.
Let's break down this crucial difference:
| Condition Type | Is it Covered by Standard PMI? | Examples |
|---|---|---|
| Acute Condition | Yes | Joint replacement, cataract surgery, gallbladder removal, appendicitis, treatment for a sports injury. |
| Chronic Condition | No | Diabetes, asthma, hypertension, Crohn's disease, multiple sclerosis. |
| Pre-existing Condition | No | Treatment for a knee injury you had surgery on two years before your policy started. |
The core benefit of PMI is speed of access and choice. While the NHS provides excellent care, waiting lists for certain procedures can be long. According to NHS England data, the referral-to-treatment waiting list stood at approximately 7.54 million in early 2024. Private medical insurance allows you to bypass these queues for eligible conditions, giving you access to specialist consultations, diagnostic tests, and treatment when you need it most.
In-patient and Day-patient Cover: The Core of Your Policy
Every private medical insurance policy in the UK is built around cover for in-patient and day-patient treatment. This is the fundamental component, and it's rare to find a policy without it.
What is In-patient Treatment?
In-patient treatment is when you are admitted to a hospital and require an overnight stay for treatment or monitoring. This could be for a single night or for several weeks, depending on the medical need.
Cover for in-patient care typically includes:
- Hospital Accommodation: A private, en-suite room, offering comfort and privacy during your recovery.
- Nursing Care: Round-the-clock care from the hospital's nursing team.
- Specialist Fees: The fees charged by the surgeon, anaesthetist, and any other specialists involved in your care.
- Operating Theatre Costs: All charges associated with the use of the surgical facilities.
- Diagnostic Tests: Any scans (like MRI or CT), X-rays, or blood tests you need while you are admitted to hospital.
- Medication and Dressings: All prescribed drugs and medical supplies used during your hospital stay.
- Prostheses and Implants: The cost of items like an artificial hip joint or a pacemaker.
Real-life example: David, 58, develops severe hip pain. His GP refers him to an orthopaedic surgeon. His PMI policy covers the private consultation and subsequent MRI scan. The scan confirms he needs a total hip replacement. David is admitted to a private hospital as an in-patient, has the surgery, and stays for three nights to recover. His PMI policy covers the entire cost, from the surgeon's fees to his private room and post-op physiotherapy.
What is Day-patient Treatment?
Day-patient treatment is similar, but you are admitted to a hospital or clinic for a planned medical procedure and do not stay overnight. You arrive, have your treatment, recover for a few hours, and go home the same day.
This is increasingly common for many minor and intermediate surgical procedures.
Common day-patient procedures covered by PMI include:
- Endoscopies or colonoscopies
- Cataract removal
- Hernia repair
- Arthroscopy (keyhole surgery on a joint)
- Removal of skin lesions
The costs covered are largely the same as for in-patient care – surgeon fees, theatre costs, and medication – just without the expense of an overnight stay.
Out-patient Cover: A Crucial Optional Extra
While in-patient and day-patient cover form the core of a policy, out-patient cover is one of the most important and valuable optional extras you can choose.
Out-patient treatment refers to any consultation, test, or procedure where you are not formally admitted to a hospital bed.
This is the diagnostic stage of your treatment journey. It typically covers:
- Specialist Consultations: After a GP referral, this covers the cost of seeing a private specialist (like a cardiologist, dermatologist, or gastroenterologist) to diagnose your condition.
- Diagnostic Tests and Scans: This is a major benefit. It includes costs for MRI, CT, and PET scans, X-rays, ultrasounds, and blood tests needed to find out what's wrong. Accessing these scans privately can often reduce the wait time from months to just a few days.
- Follow-up Appointments: Consultations with your specialist after your treatment to check on your recovery.
Most insurers offer different levels of out-patient cover, allowing you to balance cost and benefits.
| Level of Out-patient Cover | Typical Annual Limit | What it Means for You |
|---|---|---|
| Basic / None | £0 | Your policy only starts paying once you are diagnosed and admitted for day-patient or in-patient treatment. You would need to pay for initial consultations and diagnostic scans yourself or use the NHS. |
| Standard | £500 - £1,500 | This is the most common choice. It provides a set financial limit per policy year for all out-patient services. This is usually enough to cover a few consultations and a key scan. |
| Comprehensive | Fully Covered | Your policy covers all eligible out-patient costs without an annual financial cap, offering complete peace of mind. This is the most expensive option. |
Choosing a mid-level limit (e.g., £1,000) is often a smart way to manage your premium while still having cover for the crucial diagnostic phase. An expert broker at WeCovr can help you model these different options to see what best fits your budget. (illustrative estimate)
What Specific Medical Treatments Does PMI Usually Cover?
Beyond the categories of care, it's helpful to know what specific treatments are most commonly claimed for on private medical insurance in the UK. While policies vary, comprehensive plans will typically cover the following:
Comprehensive Cancer Care
Cancer cover is one of the primary reasons people invest in private health insurance. The cover is usually extensive and one of the most valued benefits of any policy. It often includes:
- Prompt Diagnosis: Fast access to the scans and consultations needed to diagnose cancer.
- Treatment: No financial or time limits on treatments like surgery, chemotherapy, and radiotherapy.
- Advanced Therapies: Access to specialist drugs, targeted therapies, and treatments that may not be available on the NHS due to funding restrictions.
- Supportive Care: This can include services like home nursing, palliative care, and even contributions towards the cost of wigs and prostheses.
- Monitoring: Regular check-ups and scans after your treatment is complete.
Musculoskeletal (MSK) Conditions
Aches, pains, and injuries related to bones, joints, and muscles are a leading cause of PMI claims. Private treatment can help you get back on your feet faster.
- Joint Replacements: Hip, knee, and shoulder replacement surgery.
- Spinal Surgery: Procedures like discectomies for slipped discs or spinal fusion.
- Sports Injuries: Treatment for torn ligaments (e.g., ACL reconstruction), tendonitis, and fractures.
- Physiotherapy: Most policies offer access to a set number of physiotherapy sessions, either as standard or as part of a therapies add-on.
Cardiovascular (Heart) Conditions
For acute heart conditions, PMI provides access to leading cardiologists and surgeons.
- Coronary artery bypass surgery
- Angioplasty and stent insertion
- Pacemaker and defibrillator implantation
- Heart valve repair or replacement
Common Surgical Procedures
PMI covers a vast range of planned surgical procedures to resolve acute conditions.
- Gastrointestinal: Hernia repair, gallbladder removal, appendix removal.
- Gynaecological: Hysterectomy, removal of ovarian cysts.
- ENT (Ear, Nose, and Throat): Tonsillectomy, sinus surgery.
- Ophthalmology: Cataract surgery.
Mental Health Support
Insurers have significantly improved their mental health offerings in recent years, recognising the growing need for support. Cover varies widely between providers, but can include:
- Out-patient Therapies: Access to a number of sessions with a psychologist or psychiatrist.
- In-patient Treatment: Cover for admission to a psychiatric hospital for intensive treatment of acute mental health conditions.
- Digital Mental Health Platforms: Many insurers now include access to apps and online services offering talking therapies, mindfulness resources, and self-help programmes.
What's Generally Not Covered by Standard PMI Policies?
Understanding the exclusions is just as important as knowing what's covered. It helps set clear expectations and avoids disappointment at the point of claim.
| Typically Covered by PMI | Typically Excluded from PMI |
|---|---|
| Acute Conditions (e.g., hernia, cataracts) | Chronic Conditions (e.g., diabetes, asthma) |
| In-patient & Day-patient Surgery | Pre-existing Conditions (diagnosed before policy start) |
| Specialist Consultations (with out-patient cover) | A&E and Emergency Services (you must use the NHS) |
| MRI, CT, and PET Scans (with out-patient cover) | Routine Maternity & Childbirth |
| Comprehensive Cancer Care | Cosmetic Surgery (unless medically necessary) |
| Mental Health Treatment (to varying levels) | Fertility Treatment (IVF) |
| Therapies (Physio, Osteo - often as an add-on) | Routine Dental & Optical Care (unless an add-on is bought) |
Let's look at these key exclusions in more detail.
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Pre-existing Conditions: This is the golden rule of PMI. Any condition for which you have experienced symptoms, sought advice, or received treatment before your policy start date is not covered. Insurers manage this through underwriting, either by asking for your full medical history upfront or by applying a "moratorium," where any condition you've had in the last five years is excluded for the first two years of your policy.
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Chronic Conditions: As explained earlier, PMI is for conditions that can be cured. Long-term management of incurable conditions like diabetes or high blood pressure remains with the NHS.
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Emergencies: If you have a heart attack, a stroke, or are in a serious accident, you should call 999 and go to A&E. The NHS is set up for emergency response. Your PMI policy may kick in for follow-up elective surgery or rehabilitation once your condition is stable.
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Routine Pregnancy and Childbirth: Standard, uncomplicated pregnancies are not covered. However, some comprehensive policies may offer cover for complications that arise during pregnancy or childbirth.
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Cosmetic Surgery: Procedures done purely for aesthetic reasons, like a nose job or breast augmentation, are excluded. The exception is reconstructive surgery needed after an accident or for a medical reason (e.g., breast reconstruction after a mastectomy).
Understanding Policy Add-ons and Optional Benefits
One of the great things about modern private medical insurance UK policies is that you can tailor them to your specific needs and budget by adding optional benefits.
Therapies Cover
This is a very popular add-on. It provides cover for a set number of sessions with practitioners like:
- Physiotherapists
- Osteopaths
- Chiropractors
- Acupuncturists
This is ideal for sorting out back pain, sports injuries, and other musculoskeletal issues without a long wait.
Dental and Optical Cover
Standard PMI doesn't cover routine dental check-ups or eye tests. However, you can buy a dental and optical add-on that provides cashback for:
- Routine check-ups, hygienist visits, and fillings.
- Accidental dental injury.
- Major restorative work like crowns or bridges.
- The cost of glasses and contact lenses.
Enhanced Mental Health Cover
While most policies offer some mental health support, you can often upgrade to a more comprehensive level of cover. This might increase your out-patient therapy limit or provide more extensive in-patient cover should you need it.
Wellness and Wellbeing Programmes
Leading PMI providers are increasingly focused on proactive health. Many policies now come with fantastic wellness benefits designed to keep you healthy, often at no extra cost. These can include:
- Discounted gym memberships.
- Wearable tech deals (e.g., Apple Watch, Fitbit).
- Online GP services for 24/7 access to a doctor.
- Health screenings and assessments.
- Smoking cessation programmes.
At WeCovr, we enhance this further. All our clients who purchase private medical or life insurance receive complimentary access to CalorieHero, our AI-powered calorie and nutrition tracking app, helping you stay on top of your health goals.
How to Control the Cost of Your Private Medical Insurance
A comprehensive PMI policy can be a significant investment, but there are several levers you can pull to make it more affordable without sacrificing essential cover.
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Choose a Higher Excess: An excess is the amount you agree to pay towards a claim. For example, if you have a £250 excess and your treatment costs £3,000, you pay the first £250 and the insurer pays the remaining £2,750. Choosing a higher excess (£500 or £1,000) will significantly reduce your monthly premium.
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Select a Hospital List: Insurers offer different tiers of hospitals. A comprehensive list including prime central London hospitals is the most expensive. Opting for a list that covers quality private hospitals in your local area but excludes the top-tier London ones can offer substantial savings.
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The 'Six-Week Option': This is a clever cost-saving feature. With this option, if the NHS waiting list for your in-patient treatment is less than six weeks, you agree to use the NHS. If the wait is longer than six weeks, your private policy kicks in. Because this reduces the likelihood of a claim, it lowers your premium.
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Limit Out-patient Cover: As discussed, opting for a financial limit on out-patient cover (e.g., £1,000) instead of a fully comprehensive option is a very effective way to manage costs.
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Build Your No Claims Discount (NCD): Just like with car insurance, you can build up a no claims discount on your PMI. The longer you go without claiming, the bigger your discount on renewal.
Navigating these options can be daunting. Working with an independent PMI broker is invaluable. We can compare policies from all the best PMI providers, explain the pros and cons of each cost-saving option, and tailor a solution that gives you the right cover at the best price.
The WeCovr Advantage: More Than Just a Policy
Choosing the right private health cover is a big decision. At WeCovr, we believe in making the process simple, transparent, and personal.
- Expert, Independent Advice: We are not tied to any single insurer. Our job is to understand your needs and search the entire market to find the best policy for you.
- No Cost to You: Our advisory service is completely free for you to use. We are paid a commission by the insurer you choose, which doesn't affect the price you pay.
- High Customer Satisfaction: Our clients consistently rate our service highly for its clarity, friendliness, and professionalism. We are here to be your long-term health insurance partner.
- Value-Added Benefits: On top of finding you the best policy, we provide our PMI and Life Insurance clients with complimentary access to our CalorieHero nutrition app and offer exclusive discounts when you take out other types of cover with us.
Private medical insurance is a powerful tool for taking control of your health. It offers the peace of mind that should you fall ill with an acute condition, you can get the high-quality treatment you need, right when you need it.
Does UK private health insurance cover pre-existing conditions?
Do I still need the NHS if I have private health insurance?
How does the claims process work with private medical insurance?
Can I add my family to my private health insurance policy?
Ready to explore your options? Get a free, no-obligation quote from WeCovr today and let our experts find the perfect private health cover for you.
Sources
- Department for Transport (DfT): Road safety and transport statistics.
- DVLA / DVSA: UK vehicle and driving regulatory guidance.
- Association of British Insurers (ABI): Motor insurance market and claims publications.
- Financial Conduct Authority (FCA): Insurance conduct and consumer information guidance.
