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Private Medical Insurance - Will you be covered?

Private medical insurance can be a great way to get yourself some peace of mind when you are in need of medical care and attention. Many people choose to sign up to a private medical insurance policy in order to avoid the long waiting lists on the NHS and to ensure that they have the highest quality of care if they require it.

Whilst this can be a very appealing option to many people, private medical insurance policies will not always cover you for every type of illness or condition that you may have. As a result of this it is very important to check what a policy does or does not cover before you go ahead and sign up to it. This is because you do not want to sign up to a health insurance plan only to find out that it does not actually cover you for the care that you may need.

This guide will explain some of the things that are and are not excluded from a typical private medical insurance plan.

What treatments are covered by private medical insurance?

As a general rule, private medical insurance is designed to pay for treatment of short term illnesses, curable diseases or injuries. The phrase that is often used to refer to these complaints is "acute conditions" and these are the types of conditions that health insurance plans are made to cover.

PMI will normally cover the following costs:

  • Inpatient tests
  • Surgery as either an inpatient or a day patient
  • Nursing care and hospital accommodation
  • Cash reimbursements for treatment provided by the NHS as an inpatient

Some PMI plans will also cover:

  • Tests for outpatients
  • Consultations or treatment with a specialist as an outpatient
  • Physiotherapy or other forms of therapy

The treatments listed below are NOT normally covered by private medical insurance plans:

  • Visiting a GPs clinic
  • Visiting Accident and Emergency
  • Drug or substance abuse
  • AIDS/HIV
  • Standard pregnancy - without complications
  • Sex changes
  • Wheelchairs or other mobility aids
  • Organ transplants
  • Injuries that are brought about as a result of dangerous pastimes (or “hazardous pursuits”).
  • Pre-existing conditions - illnesses that you had prior to the insurance commencing.
  • Chronic conditions that require long term treatment
  • Dental treatment
  • Prescribed drugs as an outpatient
  • Self-inflicted injuries - deliberately caused
  • Fertility treatment
  • Cosmetic surgery or treatments
  • Trial or experimental drugs or treatments
  • Kidney Dialysis
  • War hazards

Prior to the start of your medical insurance, your insurance provider will supply you with a comprehensive list of the things that they will and will not cover. It is extremely important that you read these terms and conditions in full before you complete your contract. This is because you should make sure that you are aware of what you are and are not covered for in the event of making a claim. Many insurers will also provide a list of the policy's "Key Facts", this factsheet is designed to inform you of any unusual or otherwise important features of the policy.

Why do private medical insurance policies have exclusions?

There are a few different reasons that health insurance plans have so many things that they do not cover. One of these reasons is the fact that the private sector is designed to help treat illnesses or conditions that can be cured and ideally done so fairly quickly. This means that there are not many private institutions in existence in the UK that actually cater for the needs of those with incurable or long term illnesses. As a result of this, there is no guarantee that you would be able to receive treatment from such a facility. Therefore if your insurer claimed to be able to cover you in this eventuality, you could end up paying for this cover and then find yourself unable to claim it even if your insurer was willing.

Another reason that private medical insurers have exclusions that apply to long term medical conditions or illnesses is the fact that a huge amount of the NHS' funding is aimed specifically at dealing with treating people in situations such as these. This means that the NHS would almost always be better equipped to meet your requirements than any private hospital due to the much larger scale and budget with which it operates. As a result of this it would be unwise to pay a private insurer to cover you for this, as you may end up receiving a lower quality of service than you would have for free on the NHS.

Another thing that insurers have to take into account when they are offering cover, is how much you would actually be willing to pay for the cover. If you found yourself in a position where you needed a high level of treatment for the long term or even the rest of your life, your insurers would have to charge you a premium that reflected that. What this would mean in reality is that you would have to pay astronomically high premiums for cover that you are not even necessarily going to need. This would be made all the more unnecessary when you take into consideration the fact that the NHS would most likely be able to provide you with that same treatment for free.

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