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Last updated: 02/05/2024 | Estimated Reading Time: 6 minutes

Private Health Insurance Exclusions

Choosing private health insurance can be a smart choice for those looking for a little extra peace of mind when it comes to healthcare. Many people decide to take out a private medical insurance policy to avoid the long wait times associated with the NHS and to access high-quality care when it's needed most.

However, it's really important to remember that not all private health insurance policies cover everything. Each plan is different, and you don't want to find yourself in a situation where you think you're covered for something, only to find out later that you're not. That's why it's essential to take a close look at what your policy covers before you sign up. You wouldn't want any surprises, especially when it comes to your health.

In this guide, we're going to walk through some common health insurance exclusions, as well as what you can expect to have covered in your plan. We're here to help make sure you've got as much information as possible to make the best choice for your healthcare journey.

In This Guide:

What is Not Covered by Private Health Insurance?

Every private health insurance policy is different, but many share the same types of exclusions. Some common health insurance policy exclusions include:

Pre-Existing Medical Conditions

These are health issues you've already been diagnosed with, treated for, or have shown symptoms of before your insurance policy starts. This can range from receiving physiotherapy for joint issues to treatments for more complex conditions like lung or ear infections. Since health insurance aims to cover unforeseen illnesses that arise after your policy begins, pre-existing conditions are generally not covered. Insurers might require a medical history review or set specific exclusions for these cases.

Dental Treatments

Routine dental care often falls outside standard private medical insurance (PMI) and might require a separate dental plan. While emergency or specific specialist dental treatments could be covered under health insurance, routine procedures like check-ups, fillings, or cosmetic dentistry usually are not.

Chronic Conditions

Conditions that are ongoing, incurable, or require long-term management, such as certain heart diseases, chronic kidney conditions, or some cancers, are usually not covered by private health insurance in the UK. The essence of health insurance is to provide financial support for treatments that can restore your health to its previous state, not to manage long-standing health issues.

Cosmetic Treatments

Elective cosmetic surgeries and procedures are not covered because they are considered lifestyle choices rather than medical necessities. This includes surgeries like rhinoplasty, breast augmentation, and face lifts. However, reconstructive surgery following an accident might be covered if it treats a condition normally covered by your policy.

Prescription Medications

Outpatient prescription medications typically aren't covered by PMI. Cover might be available if the drugs are part of an in-hospital treatment and prescribed by the attending specialist, but this varies by policy.

Other Common Exclusions

Health insurance policies also often exclude treatments for conditions such as:

  • Visiting a GPs clinic
  • Visiting Accident and Emergency
  • Drug or substance abuse
  • 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”).
  • Self-inflicted injuries - deliberately caused
  • Fertility treatment
  • Trial or experimental drugs or treatments
  • Kidney Dialysis
  • War hazards

What Exclusions Apply to My Medical Insurance Policy?

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 Health Insurance Policies have Exclusions?

The private healthcare sector in the UK primarily focuses on treating conditions that have a clear path to recovery. Unfortunately, this means there's limited capacity for dealing with long-term or incurable illnesses. If insurers promised cover for treatments not readily available in private facilities, you might end up paying for benefits you can't use, which is neither fair nor practical. Covering long-term or lifetime treatments would also necessitate significantly higher premiums, making such policies financially impractical for most. 

For chronic illnesses and long-term care, the NHS is often the more appropriate choice. With its extensive resources and funding aimed at supporting these conditions, the NHS is equipped to offer comprehensive care that private insurers simply can't match. 

Can You Get Private Healthcare with Pre-Existing Conditions?

Health insurance policies often exclude pre-existing conditions, especially those for which you have received treatment, medication, or had symptoms before the start of the policy. However, the approach insurers take for these conditions can vary:

  • Moratorium Underwriting: Some policies operate on a moratorium basis, which means they might start covering pre-existing conditions after you've been symptom-, treatment-, and medication-free for a specified period, commonly two to five years, under the policy. This doesn't necessarily reduce your premiums but can eventually lead to coverage of conditions that were initially excluded.
  • Full Medical Underwriting (FMU): Choosing full medical underwriting involves disclosing your full medical history when you apply for insurance. The insurer may then decide to cover some pre-existing conditions from the start of the policy, possibly at a higher premium or with specific exclusions. The idea here is not always to reduce premiums but to accurately assess and price the risk of covering you, including for any pre-existing conditions.

What Treatments Are Covered By a Private Health Insurance Policy?

As a general rule, private health or medical insurance is designed to pay for the 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.

Most health insurance plans 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 plans will also cover:

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

Understanding Health Insurance Exclusions and Cover

Understanding what your health plan covers and excludes is key to avoiding surprises and making the most out of your private health insurance. Designed to support acute conditions with quick access to private treatment, these policies are a safety net for unexpected health issues. However, being aware of exclusions like chronic illnesses and pre-existing conditions ensures you’re fully informed, helping you navigate your healthcare journey with confidence and peace of mind.