When Does PMI Not Pay Common Exclusions to Be Aware Of
As an FCA-authorised broker that has helped arrange over 900,000 policies, WeCovr understands that choosing private medical insurance (PMI) in the UK is a significant decision. It offers peace of mind and fast access to high-quality healthcare. However, the value of a policy truly lies in understanding not just what it covers, but also what it doesn’t. This guide shines a light on the common exclusions to help you make an informed choice.
A practical look at the circumstances where claims are often declined
Private medical insurance is an exceptional tool for managing your health, offering a swift and comfortable alternative to potentially long NHS waits for eligible treatments. According to NHS England data, the waiting list for consultant-led elective care stood at around 7.54 million treatment pathways in early 2025, underscoring the value of private options.
However, a common source of frustration for policyholders is a declined claim. In most cases, this isn't due to the insurer being difficult; it's because the treatment falls outside the agreed terms of the policy. PMI is a specific product designed for a specific purpose: to treat new, curable medical conditions.
Understanding the framework of a PMI policy is the key to avoiding surprises. This article will walk you through the core principles, standard exclusions, and policy limits that every potential and current policyholder should be aware of.
The Golden Rule: Acute vs. Chronic Conditions
This is the single most important concept to grasp in UK private medical insurance. Your policy is designed to cover acute conditions, not chronic ones.
- 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 with a sudden onset and a foreseeable end, such as a joint replacement, cataract surgery, or removing a gallbladder.
- 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 and reviews, it has no known cure, or it is likely to come back. Examples include diabetes, asthma, arthritis, and high blood pressure.
The NHS is responsible for the management of chronic conditions. Your PMI policy is there to step in and restore you to your previous state of health when you develop a new, short-term illness or injury.
Acute vs. Chronic: A Clear Comparison
| Feature | Acute Condition | Chronic Condition |
|---|---|---|
| Onset | Usually sudden | Often gradual |
| Duration | Short-term | Long-term or lifelong |
| Treatment Goal | To cure the condition | To manage symptoms and slow progression |
| Outcome | Patient returns to their pre-illness state | Requires ongoing care and management |
| PMI Coverage | Generally Covered | Generally Excluded |
| Examples | Hernia repair, broken bones, appendicitis, infections requiring hospitalisation. | Diabetes, Crohn's disease, hypertension, asthma, multiple sclerosis. |
Real-Life Example: If you tear a knee ligament while playing football, your PMI would likely cover the consultation, MRI scan, and surgery to repair it (an acute event). However, if you have long-standing osteoarthritis in that same knee, the ongoing management, pain relief, and eventual joint replacement due to wear-and-tear would be considered chronic and therefore not covered.
The Big One: Pre-Existing Conditions Explained
Alongside chronic conditions, pre-existing conditions are the other major category universally excluded from new PMI policies.
A pre-existing condition is any illness, injury, or related symptom for which you have sought medical advice, received treatment, or been aware of before your policy start date. This applies whether you had a formal diagnosis or not.
Insurers handle pre-existing conditions in two main ways, through a process called underwriting.
1. Moratorium Underwriting
This is the most common type of underwriting for individual and small business policies in the UK.
- How it works: You don't have to complete a medical questionnaire when you apply. Instead, the insurer applies a temporary exclusion for any medical condition you've had symptoms, advice, or treatment for in the five years before the policy began.
- The "Two-Year Rule": This exclusion can be lifted. If you join a policy with moratorium underwriting and then go for a continuous two-year period without experiencing symptoms, seeking advice, or receiving treatment for that specific condition, it may become eligible for cover.
- Pros: Quick and easy to set up.
- Cons: There can be uncertainty. A claim may trigger a review of your medical history to see if the condition is pre-existing, which can sometimes cause delays.
2. 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 assesses this information and tells you from day one exactly what is and isn't covered. They will apply specific, named exclusions to your policy for any pre-existing conditions.
- Pros: Provides complete clarity and certainty from the outset. You know exactly where you stand.
- Cons: The application process is longer and more intrusive. The exclusions applied are often permanent.
An expert PMI broker, such as WeCovr, can help you decide which underwriting method is best for your personal circumstances.
Moratorium vs. Full Medical Underwriting
| Feature | Moratorium (MORI) | Full Medical Underwriting (FMU) |
|---|---|---|
| Application Process | No initial health questions. | Detailed health questionnaire required. |
| Speed | Very fast to set up. | Slower due to medical assessment. |
| Clarity on Cover | Less certainty; depends on 2-year rule. | Full certainty; exclusions are listed upfront. |
| Pre-existing Conditions | Automatically excluded for a period. | Explicitly excluded, usually permanently. |
| Best For | People with a clean bill of health or those wanting a quick start. | People with a complex medical history who want absolute clarity. |
Common General Exclusions Across Most UK PMI Policies
While every policy is different, a set of "standard exclusions" appears in almost every private medical insurance plan in the UK. It’s vital to be aware of them.
1. Emergency Treatment
PMI is not for blue-light emergencies. If you have a heart attack, a stroke, or are in a serious accident, you must call 999 and go to an NHS A&E department. Private hospitals are not equipped for major trauma or life-threatening emergencies. Your PMI policy is designed for the diagnosis and treatment that may follow after you have been stabilised by the NHS.
2. Routine Pregnancy and Childbirth
Standard, uncomplicated pregnancy and childbirth are not covered by PMI. The journey of pregnancy is seen as a natural life event rather than an unexpected illness. However, some comprehensive policies may offer cover for specific complications that arise during pregnancy, but this is an exception rather than the rule.
3. Cosmetic and Aesthetic Surgery
Procedures done purely for aesthetic reasons, such as a nose job, facelift, or liposuction, are excluded. The exception is often reconstructive surgery required after an accident or to restore appearance after an eligible procedure (e.g., breast reconstruction following a mastectomy for cancer covered by the policy).
4. Mental Health Conditions
This is a rapidly evolving area. Historically, almost all mental health issues were excluded. Today, many policies offer some level of cover, though often with limitations:
- Limited Sessions: Cover may be restricted to a set number of therapy or psychiatry sessions per year.
- Outpatient Only: Some policies cover outpatient therapy but not inpatient stays in a psychiatric hospital.
- Chronic vs. Acute: As with physical health, chronic mental health conditions like bipolar disorder or schizophrenia are typically excluded. Cover is aimed at acute episodes of conditions like anxiety or depression.
5. Infertility Treatment
The investigation and treatment of infertility, including procedures like IVF, are almost universally excluded from standard PMI.
6. Addictions and Self-Inflicted Injuries
Treatment for drug or alcohol abuse and rehabilitation is not covered. Likewise, any injuries sustained as a result of substance abuse, dangerous hobbies, or attempted suicide are also standard exclusions.
7. Unproven or Experimental Treatments
Insurers will only fund treatments and drugs that are evidence-based and approved by bodies like the National Institute for Health and Care Excellence (NICE). Access to clinical trials or unlicensed drugs may be available on some top-tier cancer plans but is otherwise excluded.
8. Ageing, Menopause, and Puberty
Normal physiological processes are not considered illnesses. Therefore, issues related to uncomplicated menopause, puberty, or general signs of ageing are not covered.
9. Sexual Health, HIV/AIDS, and Contraception
Treatment for STIs, management of HIV/AIDS, and any form of contraception are standard exclusions.
Navigating Policy-Specific Exclusions and Limits
Beyond the general exclusions, your ability to claim successfully depends on the specific limits and choices you made when you bought your policy. Cheaper policies invariably come with more restrictions.
Outpatient Limits
This is a critical area to check. "Outpatient" refers to any consultation, test, or treatment where you don't need to be admitted to a hospital bed.
- Consultations: Seeing a specialist.
- Diagnostics: MRI, CT, PET scans, X-rays, and blood tests.
- Therapies: Physiotherapy, osteopathy, etc.
Many policies place a financial cap on outpatient services.
| Policy Tier | Typical Outpatient Limit | What it Means |
|---|---|---|
| Basic | £0 - £500 | Very limited cover. You might get a consultation covered, but would likely pay for scans yourself. |
| Mid-Range | £1,000 - £1,500 | Covers the typical diagnostic journey for most common conditions. |
| Comprehensive | Full Cover | No financial limit on eligible outpatient diagnostics and consultations. |
If your policy has a £1,000 outpatient limit and you need a consultation (£250) followed by an MRI scan (£800), you will have exhausted your limit and will need to pay for any further outpatient needs yourself that year.
Hospital Lists
Insurers negotiate rates with specific hospital groups. Your policy will come with a "hospital list" that dictates where you can be treated.
- Local Lists: Cheaper premiums, access to a network of hospitals in your region.
- National Lists: Wider choice, including hospitals across the UK.
- Premium/London Lists: The most expensive option, giving you access to high-end clinics in Central London (e.g., The Lister, The Cromwell).
If you choose to be treated in a hospital not on your list, your insurer will not pay.
Cancer Cover
This is one of the most valuable parts of a PMI policy, but the level of cover varies enormously.
- Core Cover: May only include the initial diagnosis and surgical removal of a tumour.
- Standard Cancer Cover: Usually includes surgery, chemotherapy, and radiotherapy.
- Comprehensive Cancer Cover: The best level. Often includes everything in standard cover plus monitoring, targeted therapies, and sometimes access to drugs not yet available on the NHS.
Always check the fine print on your cancer cover. Understanding its limits is crucial.
How to Avoid a Declined Claim: A Practical Checklist
You can significantly improve your chances of a smooth claims experience by being proactive and informed.
- Be Honest and Thorough: When applying (especially with FMU), declare everything. Hiding a past condition is a breach of contract and will invalidate your policy when you need it most. The principle of 'utmost good faith' applies.
- Read Your Policy Documents: When you receive your policy pack, take an hour to read it, paying close attention to the "What's not covered" section. It's better to know the limitations now than at the point of a claim.
- Follow the Correct Claims Process: Insurers have a required pathway. Deviating from it can lead to a declined claim.
- Step 1: Visit your NHS GP to discuss your symptoms.
- Step 2: If they recommend specialist treatment, ask for an 'open referral' letter (one that doesn't name a specific specialist).
- Step 3: Call your insurer's claims line. This is the most important step. Do this before you book any appointments.
- Step 4: The insurer will pre-authorise the treatment, confirm it's covered, and provide a list of approved specialists and hospitals from your plan.
- Step 5: You can now book your appointment with confidence, knowing it's covered.
- Work With an Expert Broker: The UK private health insurance market is complex. A specialist broker like WeCovr works for you, not the insurer. We can compare policies from the UK's leading providers, explain the nuances of each one in plain English, and ensure the cover you choose aligns perfectly with your expectations and budget—all at no cost to you.
A Word on Wellness and Prevention
While insurance is there for when things go wrong, the best strategy is always to maintain good health. Leading a healthy lifestyle can reduce your risk of developing many of the conditions that require medical intervention.
- Diet: A balanced diet rich in fruit, vegetables, and whole grains can help prevent conditions like heart disease and type 2 diabetes. To help our clients on their journey, WeCovr provides complimentary access to CalorieHero, our AI-powered nutrition and calorie tracking app.
- Exercise: The NHS recommends at least 150 minutes of moderate-intensity activity a week. Regular exercise is proven to reduce stress and lower the risk of numerous chronic illnesses.
- Sleep: Prioritising 7-9 hours of quality sleep per night is vital for physical and mental regeneration.
Furthermore, WeCovr believes in rewarding healthy choices. Clients who take out a PMI or Life Insurance policy with us can often benefit from discounts on other types of cover, creating a holistic and cost-effective protection plan.
The Role of the NHS
It's vital to remember that PMI works in partnership with the NHS; it does not replace it. The NHS remains your safety net for:
- Accidents and emergencies.
- Management of chronic conditions.
- Any treatment or condition excluded by your private policy.
This partnership allows PMI to focus on what it does best: providing rapid access to planned, specialist treatment for acute conditions.
Do I need to declare a minor illness I had years ago on my PMI application?
Is mental health ever covered by private medical insurance in the UK?
What happens if I need emergency treatment? Does my PMI cover A&E?
Can WeCovr help me find a policy that covers my specific concerns?
Understanding the boundaries of private medical insurance is the key to unlocking its true value. By being aware of the distinction between acute and chronic care, pre-existing conditions, and policy-specific limits, you can ensure your health cover works for you when you need it most.
Ready to navigate the world of private health cover with an expert by your side? Get a free, no-obligation quote from WeCovr today. Our friendly advisors will help you compare the best PMI providers in the UK and find a policy that truly protects you.
Related guides
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:
Our Group Is Proud To Have Issued 800,000+ Policies!
We've established collaboration agreements with leading insurance groups to create tailored coverage
How It Works
1. Complete a brief form
2. Our experts analyse your information and find you best quotes
3. Enjoy your protection!
Any questions?
Learn more
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!