Will PMI Save Money on Private Surgery
As an FCA-authorised expert broker that has helped arrange over 900,000 policies, WeCovr understands the nuances of the UK private medical insurance market. When considering private surgery, the primary question is often about cost versus benefit. This guide breaks down exactly when PMI can save you a significant amount of money.
Martin Lewis and co say for major surgery, PMI can offer savings—but come prepared for policy admin and potential top-ups. Big operations can cost tens of thousands—PMI is often the only affordable route. — Martin Lewis
This statement from the UK's most trusted money expert hits the nail on the head. For many, the NHS is the cornerstone of healthcare. But with NHS waiting lists for routine treatment in England reaching 7.54 million cases at the start of 2024, many are looking for alternatives. When a major operation is on the horizon, the choice between waiting in discomfort or paying a hefty private bill becomes very real.
Private Medical Insurance (PMI) is designed to bridge this gap. It’s not about replacing the NHS, which remains exceptional for emergencies and complex care. Instead, it’s about giving you choice, speed, and comfort for planned, acute medical treatments.
But does it actually save you money? For minor issues, perhaps not. But for significant surgery, the maths becomes compelling. A new hip or a heart valve operation can cost more than a new car. PMI transforms this potentially ruinous one-off expense into a manageable monthly premium. Let's delve into the details.
The Staggering Cost of Private Surgery in the UK
To understand the value of PMI, you first need to appreciate the cost of going it alone. Paying for surgery yourself is known as 'self-funding' or 'self-pay'. While it offers the same speed and choice as using insurance, the invoices can be eye-watering.
Below are typical guide prices for common surgical procedures in the UK for 2025. These are estimates and can vary based on the hospital, the consultant's fees, and the complexity of your case.
| Surgical Procedure | Average Self-Pay Cost (2025 Estimate) | Potential NHS Waiting Time (Routine) |
|---|---|---|
| Hip Replacement | £13,000 - £18,000 | 18 - 52+ weeks |
| Knee Replacement | £14,000 - £19,000 | 18 - 52+ weeks |
| Cataract Surgery (per eye) | £2,500 - £4,000 | 12 - 40+ weeks |
| Hernia Repair | £3,000 - £5,000 | 12 - 36+ weeks |
| Heart Bypass (CABG) | £25,000 - £40,000+ | Varies (often prioritised) |
| Prostatectomy (Prostate Removal) | £18,000 - £25,000 | Varies based on urgency |
| Spinal Fusion (1-2 levels) | £20,000 - £30,000 | 20 - 60+ weeks |
Sources: NHS England waiting time statistics and guide prices from major UK private hospital groups.
Looking at this table, it's clear why Martin Lewis states that for major surgery, PMI is "often the only affordable route." Paying £15,000 for a knee replacement out-of-pocket is simply not an option for the vast majority of UK households.
How Does PMI Actually Pay for Your Surgery?
So, you need an operation. If you have the right private health cover, the process is generally straightforward, but it requires you to follow specific steps.
- GP Visit: Your journey almost always starts with your NHS GP. You discuss your symptoms, and they provide an 'open referral' letter recommending you see a specialist. PMI does not replace the need for a GP.
- Contact Your Insurer: You call your PMI provider's claims line with your referral details. This is a critical step. Do not book any appointments before your insurer authorises them.
- Pre-authorisation: The insurer will check your policy to confirm you are covered for the condition and the required treatment. They will give you a pre-authorisation number and a list of approved specialists and hospitals within your policy's network.
- Book Your Consultation: You can now book your initial consultation with a specialist from the approved list. The consultant will diagnose your issue and recommend a course of action, such as surgery.
- Authorise the Surgery: You or the consultant's secretary will provide the insurer with the details of the recommended surgery (using a specific medical procedure code). The insurer will then authorise the full treatment package, including hospital fees, surgeon fees, and anaesthetist fees.
- Undergo Treatment: You have your surgery in a private hospital, often in a private room, at a time that suits you.
- Direct Settlement: The hospital and specialists send their invoices directly to your insurance company. Apart from any excess you agreed to pay, you should have nothing else to handle financially.
This process removes the stress of dealing with large bills, allowing you to focus purely on your recovery.
The Catch: "Policy Admin and Potential Top-ups" Explained
Martin Lewis rightly adds a note of caution. While PMI is powerful, it's not a blank cheque. Understanding the limitations is key to avoiding surprise costs.
1. Policy Administration
Navigating the pre-authorisation process, understanding policy terms, and dealing with paperwork can feel daunting, especially when you're unwell. This "policy admin" involves phone calls and ensuring every step of your treatment journey is pre-approved.
This is where an expert PMI broker like WeCovr provides immense value, not just at the point of sale but throughout the life of your policy. A good broker can help you understand your policy's rules and can often provide guidance if you hit a snag in the claims process.
2. Potential Top-ups (Shortfalls)
A 'shortfall' is any cost that your insurer does not cover, leaving you to pay the difference. These can occur for several reasons:
- Consultant Fee Shortfalls: Some top consultants charge more than the maximum fee set by an insurer. Most insurers have fee schedules or fee-sharing arrangements, but if you choose a consultant outside this agreement, you may have to pay the difference.
- Policy Excess: This is the most common top-up. An excess is a fixed amount (£100, £250, £500) you agree to pay towards the cost of your first claim each year. A higher excess lowers your monthly premium.
- Outpatient Limits: Your policy may have a limit on how much it will pay for diagnostic tests and consultations before you are admitted to hospital. If the cost of MRI scans, blood tests, and specialist appointments exceeds this limit, you pay the rest.
- Hospital List Restrictions: Cheaper policies often restrict you to a smaller network of hospitals. If you choose to be treated in a hospital outside your list (for example, a prime central London hospital), your insurer won't cover it.
- Exclusions: All policies have exclusions. These might include experimental treatments, cosmetic surgery, or specific high-cost drugs or prosthetics. Always read your policy documents carefully.
Example of a Shortfall on a £15,000 Knee Replacement:
| Cost Component | Total Bill | Amount Covered by PMI | Shortfall (Your Cost) | Explanation |
|---|---|---|---|---|
| Hospital Fees | £11,000 | £11,000 | £0 | Hospital was on the insurer's approved list. |
| Surgeon & Anaesthetist | £3,500 | £3,200 | £300 | The surgeon's fee was £300 above the insurer's maximum limit. |
| Prosthesis | £2,500 | £2,500 | £0 | Standard prosthesis was fully covered. |
| Policy Excess | N/A | N/A | £250 | You chose a £250 excess when you bought the policy. |
| Total Bill | £17,000 | £16,700 | £550 | Your total out-of-pocket cost is a manageable £550. |
In this scenario, PMI saved the patient £16,450. The £550 top-up, while not ideal, is vastly preferable to the full £17,000 bill.
The Golden Rule: PMI Does Not Cover Pre-existing or Chronic Conditions
This is the most important concept to understand about private medical insurance in the UK. Standard PMI is designed for acute conditions that arise after you take out your policy.
- What is an Acute Condition? A disease, illness, or injury that is likely to respond quickly to treatment and where a return to your previous state of health is expected. Examples include a hernia, cataracts, or a joint injury requiring replacement.
- What is a Chronic Condition? A condition that is long-term and often has no known cure. It requires ongoing management rather than a one-off fix. Examples include diabetes, asthma, high blood pressure, and Crohn's disease. PMI will not cover the routine management of these conditions.
- What is a Pre-existing Condition? Any medical condition for which you have experienced symptoms, received medication, or sought advice or treatment in the years leading up to your policy start date (typically the last 5 years). You cannot buy a policy today to cover surgery for a bad knee you've been seeing a doctor about for the last two years.
Insurers use two main methods for dealing with pre-existing conditions:
- Moratorium Underwriting: You don't declare your medical history upfront. Instead, the insurer automatically excludes any condition you've had in the 5 years before joining. However, if you go for a set period (usually 2 years) without any symptoms, treatment, or advice for that condition, it may become eligible for cover.
- Full Medical Underwriting (FMU): You declare your full medical history on an application form. The insurer then tells you exactly what is and isn't covered from day one. This provides certainty but means any declared pre-existing conditions will be permanently excluded.
Weighing the Costs: PMI Premiums vs. Saving for Surgery
A common question is: "Should I just put money aside in a savings account instead?"
Let's compare.
The monthly cost of a private medical insurance UK policy varies widely based on:
- Age: Premiums increase as you get older.
- Location: Living in or near London is typically more expensive.
- Level of Cover: Comprehensive plans cost more than basic ones.
- Excess: A higher excess leads to a lower premium.
Illustrative Monthly PMI Premiums (2025 Estimates)
| Age | Mid-Range Cover (e.g., £250 excess) | Comprehensive Cover (e.g., £100 excess) |
|---|---|---|
| 30s | £45 - £65 | £70 - £95 |
| 40s | £60 - £85 | £90 - £120 |
| 50s | £80 - £120 | £130 - £180 |
| 60s | £130 - £200 | £200 - £300+ |
Now, let's say a 45-year-old takes out a mid-range policy for £70 per month. That's £840 per year. If, after three years, they need a £15,000 hip replacement, they will have paid £2,520 in premiums. Add a £250 excess, and their total outlay is £2,770.
The Saving: £15,000 (Surgery Cost) - £2,770 (Premiums + Excess) = £12,230
The financial benefit is enormous. Furthermore, it's nearly impossible to predict when you might need surgery. It could be in year one of your policy or year ten. PMI provides a safety net against this uncertainty, which a savings account cannot.
Choosing the Right PMI Policy: Key Features for Surgical Cover
Not all private health cover is created equal. When your main goal is to cover potential surgery, focus on these policy features:
- Inpatient and Day-Patient Cover: This is the absolute core of any policy. It covers the costs when you are admitted to a hospital bed, including surgery, accommodation, and nursing care. Ensure this is 'unlimited' or has a very high annual limit.
- Outpatient Cover: This covers the diagnostic phase before surgery. Better policies offer unlimited outpatient cover, ensuring all your consultations, MRI/CT scans, and tests are paid for. Cheaper policies may limit this to £500 or £1,000, which can be used up quickly with a single MRI scan.
- Hospital List: Insurers offer tiered hospital lists. A 'National' list gives you a wide choice, while a more restricted 'Local' or 'Trust' network will lower your premium but limit your options. Ensure the hospitals you would want to use are on the list.
- Cancer Cover: This is one of the most valuable parts of a PMI policy. Good cancer cover will pay for access to the latest chemotherapy, radiotherapy, and biological therapies, some of which may not be available on the NHS.
Comparing these options across multiple providers can be complex. Using an independent PMI broker like WeCovr simplifies the process. We can compare the market for you, explain the differences in plain English, and find a policy that matches your needs and budget, all at no cost to you.
More Than Just Surgery: The Added Value of Modern PMI
Today's best PMI providers offer far more than just surgical cover. These wellness benefits can help you stay healthy and potentially avoid the need for surgery in the first place.
- Digital GP: Get a GP appointment via video call within hours, 24/7. This is incredibly convenient for getting quick advice and referrals.
- Mental Health Support: Most policies now include access to a set number of therapy or counselling sessions, helping you manage stress, anxiety, and other conditions.
- Physiotherapy: Many plans provide fast access to physiotherapy without needing a GP referral, helping you tackle musculoskeletal issues before they become severe.
- Wellness Programmes: Insurers often have apps and programmes that reward you for healthy living (e.g., tracking your steps, going to the gym) with perks like free coffee or cinema tickets.
As a WeCovr client, you also get complimentary access to CalorieHero, our AI-powered calorie and nutrition tracking app, to support your health goals. Furthermore, customers who purchase PMI or Life Insurance through us can often benefit from discounts on other types of cover, adding even more value.
In Conclusion: Is PMI a Smart Financial Move for Surgery?
For major surgery, the answer is a resounding yes. Private medical insurance acts as a financial shield, transforming a potentially catastrophic five-figure bill into a predictable monthly payment. It buys you peace of mind, speed of access, and choice over where and by whom you are treated.
While you must be prepared for the administrative steps and the possibility of small shortfalls, these are minor compared to the financial devastation of self-funding a major operation. The key is to choose the right policy from the outset, ensuring it has robust cover for diagnostics and inpatient treatment.
Remember the crucial rule: PMI is for future, unknown acute conditions. It is not a solution for health problems you already have. By planning ahead and securing cover while you are in good health, you ensure the safety net is there when you need it most.
Does PMI cover all costs of private surgery?
Can I get private medical insurance for a condition I already have?
How quickly can I have surgery with private health cover?
Do I have to use a specific hospital for my surgery with PMI?
Ready to see how affordable your peace of mind could be? Get a free, no-obligation quote from WeCovr today. Our expert team will compare the UK's leading insurers to find the perfect private medical insurance for your needs and budget.
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.
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