TL;DR
As an FCA-authorised broker that has helped arrange over 900,000 policies, WeCovr understands that choosing private medical insurance in the UK can feel complex. One of the biggest questions we hear is: "What isn't covered?" Understanding the exclusions is just as important as knowing the benefits, ensuring you have peace of mind and no unwelcome surprises when you need to make a claim. WeCovr's guide to common exclusions and how to avoid surprises when claiming Private Medical Insurance (PMI) is designed to work alongside the fantastic care provided by our NHS.
Key takeaways
- 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 conditions like a hernia, cataracts, or a broken bone. The treatment has a clear beginning and end.
- 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 has no known "cure," it is likely to recur, or it requires palliative care. Examples include diabetes, asthma, high blood pressure, and arthritis.
- How it works: You don't declare your full medical history upfront. Instead, the insurer applies a "waiting period," typically two years. For any condition you had in the five years before your policy began, you will not be covered for it until you have gone two full, continuous years on the policy without any symptoms, treatment, medication, or advice for that condition.
- Example: You had physiotherapy for knee pain a year before buying your policy. For the first two years of your cover, any treatment related to that knee will be excluded. However, if you have no further pain, consultations, or treatment for your knee for two consecutive years, it may become eligible for cover thereafter.
- Pros: Quick and easy to set up.
As an FCA-authorised broker that has helped arrange over 900,000 policies, WeCovr understands that choosing private medical insurance in the UK can feel complex. One of the biggest questions we hear is: "What isn't covered?" Understanding the exclusions is just as important as knowing the benefits, ensuring you have peace of mind and no unwelcome surprises when you need to make a claim.
WeCovr's guide to common exclusions and how to avoid surprises when claiming
Private Medical Insurance (PMI) is designed to work alongside the fantastic care provided by our NHS. It offers you choice, speed, and comfort for specific types of medical needs. However, it is not a replacement for the NHS and has a clear purpose: to treat new, curable medical conditions that arise after your policy has started.
This guide will walk you through the standard exclusions found in most UK private health cover policies. By understanding these from the outset, you can choose the right level of cover and use your policy with confidence.
The Golden Rule of UK Private Health Insurance: Acute vs. Chronic Conditions
This is the single most important concept to grasp. UK private health insurance is built to cover acute conditions. It is not designed to cover chronic conditions.
- 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 conditions like a hernia, cataracts, or a broken bone. The treatment has a clear beginning and end.
- 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 has no known "cure," it is likely to recur, or it requires palliative care. Examples include diabetes, asthma, high blood pressure, and arthritis.
The NHS is structured to provide outstanding long-term management for chronic conditions. PMI's role is to step in for the short-term, curable issues, helping you bypass NHS waiting lists for eligible treatments.
| Feature | Acute Condition | Chronic Condition |
|---|---|---|
| Duration | Short-term | Long-term or lifelong |
| Outlook | Curable, full recovery expected | Incurable, requires ongoing management |
| PMI Cover | Generally Covered | Generally Excluded |
| Examples | Joint replacement, gallstone removal, appendicitis | Diabetes, Crohn's disease, asthma, epilepsy |
Key Takeaway: If a condition requires long-term management rather than a one-off treatment to cure it, it will be classified as chronic and therefore excluded from cover.
Pre-Existing Conditions: The Most Common Exclusion Explained
Alongside chronic conditions, pre-existing conditions are the other major exclusion you must understand.
A pre-existing condition is any disease, illness, or injury for which you have experienced symptoms, received medication, advice, or treatment before the start date of your PMI policy.
Insurers handle pre-existing conditions in one of two ways, known as "underwriting." The type of underwriting you choose determines how your past medical history affects your cover.
1. Moratorium Underwriting
This is the most common type of underwriting for personal policies.
- How it works: You don't declare your full medical history upfront. Instead, the insurer applies a "waiting period," typically two years. For any condition you had in the five years before your policy began, you will not be covered for it until you have gone two full, continuous years on the policy without any symptoms, treatment, medication, or advice for that condition.
- Example: You had physiotherapy for knee pain a year before buying your policy. For the first two years of your cover, any treatment related to that knee will be excluded. However, if you have no further pain, consultations, or treatment for your knee for two consecutive years, it may become eligible for cover thereafter.
- Pros: Quick and easy to set up.
- Cons: There can be uncertainty about what is covered until you make a claim.
2. Full Medical Underwriting (FMU)
This method is more detailed from the start.
- How it works: You complete a full health questionnaire, declaring your entire medical history. The insurer assesses this information and then offers you a policy with specific, named exclusions listed in your documents.
- Example: You declare on your application that you have a history of acid reflux. The insurer will likely add a permanent exclusion to your policy for any investigations or treatments related to your stomach or oesophagus.
- Pros: You know exactly what is and isn't covered from day one.
- Cons: The application process takes longer.
Choosing the right underwriting is a crucial step. A specialist PMI broker like WeCovr can talk you through the options and help you decide which path is best for your personal circumstances.
| Feature | Moratorium Underwriting | Full Medical Underwriting (FMU) |
|---|---|---|
| Application | No medical questionnaire | Full health questionnaire required |
| Clarity | Exclusions are determined at the point of claim | Exclusions are listed on your policy from the start |
| Speed | Fast to set up | Slower to set up due to medical assessment |
| Best For | People with a clean bill of health or those wanting a quick start. | People who want absolute certainty about their cover from day one. |
A Detailed Breakdown of Standard PMI Exclusions
Beyond the overarching rules for chronic and pre-existing conditions, all policies contain a list of standard exclusions. Whilst the specifics can vary slightly between the best PMI providers, the following are almost universally excluded from core private medical insurance UK plans.
A&E and Emergency Services
Private hospitals are not equipped to handle life-threatening emergencies. If you have a heart attack, stroke, or are involved in a serious accident, you must call 999 and go to an NHS A&E. PMI is for planned, non-emergency treatments.
Normal Pregnancy and Childbirth
Routine antenatal care, delivery, and postnatal check-ups are not covered by PMI. The NHS provides comprehensive maternity services. However, some high-end policies may offer cover for complications of pregnancy and childbirth, but this is a specific, often optional, benefit.
Cosmetic and Aesthetic Surgery
Procedures done purely for aesthetic reasons, such as a nose job, facelift, or breast augmentation, are never covered. The exception can be reconstructive surgery required after an accident or for a medical reason (e.g., breast reconstruction following a mastectomy for cancer), which may be covered depending on your policy.
Mental Health Conditions (On Standard Policies)
Historically, mental health was a common exclusion. Today, the landscape is changing. Whilst basic policies may still exclude it or offer very limited cover (e.g., for initial diagnosis), most insurers now offer mental health support as a comprehensive add-on. This is a vital option to consider, as it can provide access to psychiatrists, psychologists, and therapy sessions far quicker than waiting for public services.
Dental and Optical Care (On Standard Policies)
Much like mental health, routine dental check-ups, fillings, and eye tests are not part of a standard PMI policy. They are typically offered as optional add-ons that you can purchase for an additional premium.
Conditions Related to Alcohol or Substance Abuse
Illnesses and injuries that are a direct result of alcohol, drug, or other substance misuse are excluded.
Fertility Treatment, IVF, and Contraception
The investigation and treatment of infertility, including procedures like IVF, are not covered. Contraception is also excluded.
Experimental or Unproven Treatments
For a treatment to be covered, it must be evidence-based and recognised by the mainstream medical profession in the UK. Experimental, unproven, or unlicensed drugs and treatments are excluded.
Self-Inflicted Injuries
Any injury or illness resulting from a deliberate act of self-harm is not covered.
Professional Sports Injuries
If you are a professional sportsperson, you will need specialist insurance. Injuries sustained whilst playing sport professionally are excluded from standard private health cover due to the high level of risk involved. Amateur sports are usually covered.
Understanding Policy Limits and 'Internal' Exclusions
Exclusions aren't just about what's never covered. They also relate to the financial and practical limits built into your specific plan. These are crucial to understand as they can also lead to surprises at the point of a claim.
- Annual Financial Limits: Most policies have an overall annual limit on the value of claims you can make, for example, £1 million or "unlimited". Some more basic policies might have lower limits or per-condition limits.
- Outpatient Cover Limits: This is one of the most significant variables in a policy. Outpatient care refers to consultations and diagnostics that don't require a hospital bed (e.g., seeing a specialist, MRI/CT scans).
- Illustrative estimate: Basic policies might have no outpatient cover or a very low limit (e.g., £500).
- Mid-range policies often have a limit of £1,000 - £1,500.
- Comprehensive policies will have full outpatient cover. If your outpatient costs exceed your chosen limit, you will need to pay the remainder yourself.
- Therapy Limits: Policies often limit the number of sessions for therapies like physiotherapy, osteopathy, and chiropody. For example, your plan might cover up to 8 physiotherapy sessions per condition per year.
- Hospital Lists: Insurers have networks of partner hospitals. Your choice of policy will determine which list of hospitals you can use. A cheaper policy might give you access to a more restricted local network, whilst a premium policy will offer a nationwide or even central London list. If you choose to use a hospital outside your approved list, your treatment won't be covered.
Here's how different levels of private health cover might structure these limits:
| Policy Level | Typical Outpatient Limit | Typical Therapy Cover | Hospital List |
|---|---|---|---|
| Comprehensive | Full cover | Generous (e.g., covered in full when referred) | Extensive national list, including central London |
| Mid-Range | £1,000 - £1,500 per year | Capped number of sessions (e.g., up to 10) | Good national list, may exclude prime central London |
| Basic / Budget | £0 - £500, or diagnostics only | Often excluded or a very low number of sessions | Restricted local network of hospitals |
How to Avoid Surprises: Your Checklist Before You Buy and Claim
Knowledge is power. By being proactive, you can ensure your PMI journey is smooth and stress-free.
- Read Your Policy Documents Thoroughly: Before you buy, review the Insurance Product Information Document (IPID). This is a simple, standardised summary of the key features and exclusions. Once you've bought the policy, read the full terms and conditions. Yes, it's long, but it's the contract between you and your insurer.
- Be 100% Honest and Accurate: When applying, especially for Full Medical Underwriting, disclose everything. Insurers can access your medical records, and failing to disclose a relevant condition (known as "non-disclosure") can lead to your policy being cancelled and claims being rejected.
- Understand Your Underwriting: Make sure you are clear on whether you have a Moratorium or FMU policy and what that means for any past conditions.
- Get Pre-Authorisation for ALL Treatment: This is the golden rule of claiming. Once your GP has referred you to a specialist, you must call your insurer before you book any appointments or procedures. They will confirm if the specialist and treatment are covered under your plan and will provide you with a pre-authorisation number. This simple phone call eliminates almost all potential surprises.
- Speak to an Expert PMI Broker: Navigating the maze of providers, policy levels, and underwriting options can be overwhelming. A specialist broker like WeCovr does the hard work for you. We compare the market to find a policy that matches your needs and budget, explain all the jargon, and help you with your application – all at no cost to you.
- Review Your Cover Annually: Your health needs and financial circumstances can change. At renewal, take the time to review your policy to ensure it still provides the right level of private health cover.
The WeCovr Advantage: Beyond Just Finding a Policy
At WeCovr, we believe in empowering our clients with knowledge and ongoing value. We are an FCA-authorised broker with high customer satisfaction ratings, dedicated to making insurance simple and effective.
When you arrange your PMI with us, you get more than just a policy.
- Expert, Unbiased Advice: We work for you, not the insurers. Our goal is to find you the best possible cover for your budget.
- Wellness on Us: All WeCovr PMI clients get complimentary access to CalorieHero, our AI-powered calorie and nutrition tracking app, helping you stay on top of your health goals.
- Loyalty Discounts: We value our clients. If you hold a PMI or Life Insurance policy with us, you'll be eligible for discounts on other types of cover you might need.
We are here to be your long-term partner in health and wellbeing.
Can I get private health insurance if I have a chronic condition like diabetes?
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Ready to find the right private health cover without the jargon and confusion? The team at WeCovr is here to help. We'll compare leading insurers and find a policy that fits you perfectly.
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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.
