How Does Private Medical Insurance Work
As an FCA-authorised broker that has helped arrange over 800,000 policies, WeCovr provides expert, unbiased guidance on private medical insurance in the UK. This comprehensive guide explains exactly how it works, demystifying the process from choosing a policy to receiving fast, high-quality medical care when you need it most.
Step-by-step breakdown of policy design, claims process, typical exclusions, and the timeline from enrolling to receiving care in the UK
Private Medical Insurance (PMI), often called private health cover, is designed to work alongside the NHS, giving you more choice, control, and faster access to treatment for specific medical conditions. While the NHS provides an incredible service, particularly for emergencies and chronic care, waiting lists for routine procedures have become a significant concern for many.
According to the latest NHS England data, the referral to treatment (RTT) waiting list stands at over 7.5 million cases. For many, waiting months or even years for surgery or specialist consultations can impact their quality of life, ability to work, and overall wellbeing.
This is where PMI steps in. It's an insurance policy you pay for, typically through monthly or annual premiums, which covers the cost of private treatment for acute conditions that arise after your policy begins.
What is an 'Acute Condition'?
This is the single most important concept to understand.
- Acute Condition: A disease, illness, or injury that is likely to respond quickly to treatment and lead to a full recovery. Examples include cataracts, joint replacements, hernias, and most cancers. PMI is designed to cover these.
- Chronic Condition: A disease, illness, or injury that has one or more of the following characteristics: it needs ongoing or long-term monitoring, is incurable, has no known cure, or is likely to come back. Examples include diabetes, asthma, high blood pressure, and arthritis. Standard UK PMI does not cover the routine management of chronic conditions.
Think of PMI as a shortcut to diagnosis and treatment for new, curable health issues, allowing you to bypass NHS queues and get back on your feet sooner.
The Enrolment Journey: How to Choose and Buy a PMI Policy
Getting started with private health cover involves a few logical steps. Understanding this journey ensures you select a policy that genuinely fits your needs and budget.
Step 1: Assess Your Needs and Budget
Before looking at quotes, ask yourself a few key questions:
- Who needs cover? Are you looking for a policy for just yourself, you and a partner, or your whole family?
- What is your budget? Premiums can range from as little as £30 per month to over £150, depending on the level of cover, your age, and location. Be realistic about what you can comfortably afford long-term.
- What level of cover is important to you? Is your main priority to cover major surgery (inpatient), or do you also want cover for initial consultations and diagnostic tests (outpatient)?
Step 2: Understand Underwriting Options
'Underwriting' is how insurers assess the risk of insuring you. It determines what will and won't be covered, particularly concerning your past medical history. There are two main types in the UK.
| Underwriting Type | How It Works | Pros | Cons |
|---|---|---|---|
| Moratorium (Most Common) | You don't declare your full medical history upfront. Instead, the insurer automatically excludes treatment for any condition you've had symptoms, treatment, or advice for in the 5 years before your policy starts. | Simple and fast to set up. Pre-existing conditions may become eligible for cover after a 2-year continuous period on the policy, provided you've had no symptoms, treatment, or advice for it during that time. | Claims can be slower as the insurer may need to check your medical history at the point of a claim to see if it was pre-existing. There can be uncertainty about what's covered initially. |
| Full Medical Underwriting (FMU) | You complete a detailed health questionnaire, disclosing your entire medical history. The insurer then tells you upfront exactly what is excluded from your policy. | Complete clarity from day one. You know precisely what is and isn't covered. The claims process is often faster as the underwriting is already done. | The application process is longer and more intrusive. Exclusions are often permanent and won't be reviewed later. |
An expert broker, like WeCovr, can explain these options in detail and help you decide which is the best fit for your personal circumstances.
Step 3: Customise Your Policy
A modern private medical insurance UK policy is not a one-size-fits-all product. You start with a core foundation and add optional extras to build the plan you want.
Core Cover (Usually included as standard)
- In-patient treatment: Covers costs when you are admitted to a hospital bed overnight, including surgery, nursing care, and accommodation.
- Day-patient treatment: Covers procedures where you are admitted to hospital and discharged on the same day, like an endoscopy or minor surgery.
- Cancer Cover: Most policies offer extensive cancer cover as a core component, including chemotherapy, radiotherapy, and surgery. The level of cover can vary, so it's vital to check the details.
Popular Optional Extras
- Out-patient Cover: This is one of the most valuable add-ons. It covers diagnostic tests (like MRI and CT scans), specialist consultations, and other procedures that don't require a hospital bed. Without this, you would rely on the NHS for diagnosis and then use your PMI for treatment.
- Therapies Cover: Pays for a set number of sessions with specialists like physiotherapists, osteopaths, and chiropractors.
- Mental Health Cover: Provides cover for consultations with psychiatrists and psychologists, and treatment at specialist mental health facilities.
- Dental & Optical Cover: Contributes towards routine check-ups, dental treatments, and the cost of glasses or contact lenses.
Step 4: Control Your Premium
Several levers allow you to adjust your monthly premium to fit your budget.
| Cost-Control Option | What It Is | Impact on Premium |
|---|---|---|
| Excess | The amount you agree to pay towards a claim, either per claim or per policy year. A typical excess is £100, £250, or £500. | A higher excess will lower your premium. |
| Hospital List | A tiered list of private hospitals where you can receive treatment. Options might include a local list, a national list, or a premium list including central London hospitals. | Choosing a more restricted hospital list will lower your premium. |
| Six-Week Option | A popular choice where your PMI will only cover your treatment if the waiting time for that treatment on the NHS is longer than six weeks. | Significantly lowers your premium, as you agree to use the NHS for quicker procedures. |
| No Claims Discount (NCD) | Similar to car insurance, your premium is discounted for every year you don't make a claim, often up to a cap of 60-70%. | Rewards you for not claiming, lowering your premium over time. |
The Claims Process: A Step-by-Step Guide from GP to Treatment
So, you have your policy and you start to feel unwell. What happens next? The process is refreshingly straightforward.
- See Your NHS GP: Your journey almost always starts here. PMI does not replace your GP. You visit them to discuss your symptoms as you normally would.
- Get an 'Open Referral': If your GP feels you need to see a specialist, they will write you a referral letter. For PMI purposes, it's best to ask for an 'open referral'. This means they refer you to a type of specialist (e.g., "an orthopaedic surgeon") rather than a specific named doctor. This gives your insurer the flexibility to recommend a specialist from their approved network.
- Contact Your Insurer: Before you book any appointments, call your insurer's claims helpline. Have your policy number and referral letter handy. Explain the situation and what your GP has recommended.
- Receive Claim Authorisation: The insurer will check that your policy covers the condition and the recommended treatment. If approved, they will give you a pre-authorisation number and a list of approved specialists and hospitals you can use.
- Book Your Appointment & Treatment: You can now book your initial consultation with a specialist from the approved list. If they recommend a scan or procedure, you simply call your insurer again with the details to get it authorised.
- Receive Treatment: You attend your appointments, scans, and have your procedure in a private hospital. You'll often benefit from a private room, flexible visiting hours, and à la carte food menus.
- Bills are Settled Directly: The hospital and specialist will send their bills directly to your insurance company. You don't have to handle any invoices, apart from paying your agreed excess directly to the hospital if applicable.
Example Timeline: PMI vs. NHS
Let's imagine a scenario for a common procedure like a knee arthroscopy (keyhole surgery for a cartilage tear).
-
With PMI:
- Week 1: Visit GP, get an open referral. Call insurer and get authorisation.
- Week 2: See a private specialist consultant. MRI scan in the same week.
- Week 4: Undergo keyhole surgery in a private hospital.
- Week 5 onwards: Begin post-op physiotherapy.
- Total Time from GP to Treatment: Approx. 3-4 weeks.
-
With the NHS (based on median waiting times):
- Week 1: Visit GP.
- Weeks 2-18: Wait for a routine referral to an NHS specialist.
- Weeks 19-24: Wait for an MRI scan.
- Weeks 25-45+: Wait for the surgery itself. The NHS target is 18 weeks from referral to treatment, but the median wait for orthopaedics can be significantly longer in many trusts.
- Total Time from GP to Treatment: Approx. 6-12+ months.
This demonstrates the core value of PMI: speed of access.
What's Not Covered? Understanding Typical PMI Exclusions
No insurance policy covers everything, and PMI is no different. Being aware of the standard exclusions is crucial to avoid surprises.
You are generally NOT covered for:
- Pre-existing Conditions: Any medical condition you had symptoms, advice, or treatment for before your policy start date (subject to your underwriting terms).
- Chronic Conditions: Long-term illnesses that require ongoing management, such as diabetes, asthma, Crohn's disease, and high blood pressure. Your NHS GP and specialist will continue to manage these.
- Emergencies: If you have a heart attack, stroke, or are in a serious accident, you should go to A&E. The NHS is the best place for emergency care.
- Normal Pregnancy & Childbirth: Routine maternity care is not covered, though some policies will cover complications.
- Cosmetic Surgery: Procedures done for purely aesthetic reasons are excluded. However, reconstructive surgery following an accident or eligible cancer treatment may be covered.
- Self-Inflicted Injuries: Including those related to substance abuse or dangerous sports not declared to your insurer.
- Infertility Treatment: IVF and other fertility procedures are typically excluded.
- Experimental or Unproven Treatments: Insurers only cover treatments that are evidence-based and widely recognised in the UK.
Beyond Treatment: Added Value and Wellness Benefits
The best private medical insurance providers today offer more than just treatment. They actively help you stay healthy.
- Digital GP Services: Most policies now include 24/7 access to a private GP via phone or video call. This is incredibly convenient for getting quick advice, prescriptions, or referrals without waiting for an NHS GP appointment.
- Mental Health Support: Many insurers provide access to telephone counselling or support lines as a standard benefit, helping you manage stress, anxiety, or other mental health concerns early on.
- Wellness Programmes: Some providers, like Vitality, have built their entire model around rewarding healthy behaviour. By tracking your activity, eating well, and having health checks, you can earn points to reduce your premium and get discounts on things like gym memberships, smartwatches, and healthy food.
- WeCovr's Exclusive Benefits: When you arrange your policy through an expert broker like WeCovr, you get more. We provide our PMI and Life Insurance clients with complimentary access to our AI-powered nutrition app, CalorieHero, to help you manage your diet and health goals. Furthermore, our clients often receive discounts on other insurance products, such as life or income protection cover, creating a holistic and cost-effective approach to your personal protection.
Why Use a Specialist PMI Broker?
The UK private health insurance market is complex, with dozens of providers and hundreds of policy combinations. Trying to navigate this alone can be overwhelming. A specialist broker like WeCovr acts as your expert guide.
- Independent Advice: We are not tied to any single insurer. Our loyalty is to you, our client. We provide impartial advice focused on finding the right cover for your specific needs.
- Market Comparison: We compare policies from across the market, including leading providers like Aviva, AXA Health, Bupa, and Vitality, saving you hours of research.
- No Extra Cost: Our service is free to you. We are paid a commission by the insurer you choose, which is already built into the premium, so you don't pay a penny more than going direct.
- Expertise on Hand: We demystify the jargon, explain the small print, and help you with the application process. We are also there to offer support if you ever need to make a claim. Our high customer satisfaction ratings reflect our commitment to clear, helpful, and professional service.
Private medical insurance is a powerful tool for taking control of your health. By understanding how it works, you can make an informed decision and invest in peace of mind for you and your family.
Can I get private health insurance for a condition I already have?
Generally, no. Standard UK private medical insurance is designed to cover new, acute medical conditions that arise after your policy begins. Conditions you had before you took out the policy are known as 'pre-existing' and are typically excluded from cover. However, with Moratorium underwriting, a pre-existing condition may become eligible for cover after you have been on the policy for two years without any symptoms, treatment, or advice for that condition.
Do I still need the NHS if I have private medical insurance?
Absolutely, yes. Private medical insurance (PMI) is a complement to the NHS, not a replacement for it. You will still rely on the NHS for emergency services (A&E), management of long-term chronic conditions, and in most cases, your initial GP consultations. You must also continue to pay your National Insurance contributions. PMI simply provides an alternative route for eligible, non-emergency treatment.
How much does private medical insurance cost in the UK?
The cost of private medical insurance varies significantly based on several factors: your age, location, smoking status, the level of cover you choose (e.g., adding out-patient or dental), your excess, and your chosen hospital list. A basic policy for a young, healthy individual might start from £30-£40 per month, while a comprehensive policy for an older person or a family could be £150 per month or more. The best way to find out the cost for you is to get a personalised quote from a broker like WeCovr, who can compare the market to find the best value.
Ready to take control of your health and explore your options?
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!
There is no need to wait until the renewal of your current policy.
We can look at a more suitable option mid-term!
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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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!