What does Private Medical Insurance cover?

The pressures on the NHS in recent years are widely known; the COVID-19 pandemic put the NHS under significant strain, the effects of which are still being dealt with. Statistics show that as of December 2022, 7.2 million people were waiting to start NHS treatment, which has been steadily climbing since June 2020, when it stood at 3.96 million.

Given this context, it comes as no surprise that interest in private health insurance has spiked. Data from Statista Consumer Insights has revealed that, by December 2022, some 22% of adults were paying for private medical insurance. As recently as 2019, that figure was around the 12% mark. This growth is against a backdrop of a rising cost of living in recent years.

Illness rates predicted to rise

For many people, taking out health insurance could be a smart move for the future. One study supported by the National Institute for Health and Care Research (NIHR) found that, in 2015, 54% of people over 65 had two or more medical conditions. By 2035, this is predicted to rise to 67.8%. In this age group, 62.6% will be affected by arthritis, 55.9% by high blood pressure, 24.4% by respiratory disease, 23.7% by cancer, and 21.6% by diabetes.

One survey found that 53% of people would prefer to invest in health insurance, whether for themselves, their families, or their employees. It is, therefore, highly likely that many people will take out private health insurance for the first time over the next few years. If you are considering investing in this kind of cover, in this article, we look at how private medical insurance works and what it covers.

What is private medical insurance?

In the UK, you can receive medical treatment privately instead of through the NHS. If you do go privately, you will normally be able to get treated quicker, and you may also enjoy other benefits, such as access to private hospitals and drugs and treatment not available on the NHS.

The big drawback is that private medical treatment is expensive. If you need to see a psychiatrist, it costs in the region of £400-500 per hour. If you have cancer, you can pay £30,000 for a single round of chemotherapy.

For this reason, people invest in private medical insurance. These policies will pay some or all your medical bills to receive treatment privately.

What does private medical insurance cover?

Different policies offer different levels of cover. Generally, policies pay out for new, acute, short-term conditions.

This means that if you have a pre-existing condition, your insurance won’t typically cover it. For example, if you take out a policy and declare that you have suffered from heart disease or high blood pressure in recent years, these conditions are unlikely to be covered by the plan. However, most insurers will consider insuring you for such conditions if you have been symptom-free for a specified period.

The good news is that most policies will cover you for new conditions if they are acute and short-term. Acute means a significant condition with an identifiable cause and predictable prognosis, and a short-term condition is one that responds well to treatment. This generally excludes ‘chronic’ conditions that last a long time, but there are exceptions. We’ll look at these later in this article.

In terms of treatment types, most policies will pay for treatments such as:

Private consultations with medical specialists
Treatment in private hospitals
Physiotherapy
Outpatient care
Access to private GP consultations (sometimes online)

You can also choose to add additional cover for conditions such as mental health issues.

In the next section, we look in more detail at what policies can cover. However, it’s also worth remembering that illness can also affect your ability to earn a living. For this reason, it’s worth separately considering income protection insurance so that illness doesn’t result in money worries.

Can you use the NHS if you have private health insurance?

Yes, you can use the NHS if you have private health insurance. The NHS cannot withdraw care simply because you have your own insurance. You are entitled to all the care – free of charge – that you would have been entitled to if you had not chosen to have additional private care.

Can you mix NHS and private treatment?

Yes, you can mix NHS and private treatment. However, there are rules that determine how certain treatments can be mixed. The NHS gives the example of someone who needs a cataract operation. If you are in this position, you can either have the operation on the NHS and receive standard NHS lens implants, or you can have the operation privately and opt for special lens implants that are not available on the NHS. What you cannot do is have the operation on the NHS and pay privately for the special lens implants.

If you are unsure whether you can mix certain NHS and private treatments, talk to your insurer. The NHS has also published a helpful guide.

Does private health insurance cover specialist appointments?

Yes, private health insurance does cover specialist appointments. You will normally need a referral from the relevant professional, such as a GP (whether NHS or private), an osteopath, nurse practitioner, chiropractor, psychologist, or even a speech therapist. Talk to your insurer to find out which referrals they accept.

Some insurers will give you direct access to specialist appointments without a referral if your policy covers the suspected condition. For example, if you have potential cancer symptoms, mental health problems, or musculoskeletal issues, you may be able to contact your insurer direct and get a referral to a specialist.

Does private health insurance cover cancer treatment?

Yes, private health insurance can cover cancer treatment. Some policies offer cancer cover as standard, while others offer it as an optional extra. If you have had cancer in the previous five years, it’s unlikely you will be able to get cover. However, even if there’s a history of cancer in your family, this shouldn’t prevent you from getting a policy. Insurers can’t ask you about any genetic testing you’ve had in relation to cancer in your family, but if you get negative results, you may wish to tell your insurer.

If you choose a policy with cancer cover, check carefully what it includes. Some will pay out for radiotherapy and chemotherapy, while others can give you access to pioneering treatments. If you decide to have cancer treatment with the NHS as an inpatient, some of these policies will pay out a daily rate in place of private treatment.

Does my private health insurance cover me overseas?

Some policies will cover you when you’re abroad if you have international cover included. PMI generally provides you with UK cover, so normally the best solution is to buy travel insurance that covers you for medically necessary healthcare while you’re overseas. You can then use your PMI once you are back in the UK.

If you are travelling in the EU or Switzerland, you can also apply for a UK Global Health Insurance Card (UK GHIC) or (if you have rights under the Withdrawal Agreement) a UK European Health Insurance Card (UK EHIC). If you have an existing EHIC from before the UK left the EU, it remains valid until the expiry date and works in the same way as a UK GHIC. Both cards cover you for things like emergency treatment, treatment for long-term or pre-existing conditions, routine medical or maternity care, oxygen therapy, or kidney dialysis. You can find out more about these cards here, but it’s always a good idea to supplement them with appropriate travel insurance cover.

If you require further treatment once back in the UK, you can either receive this through the NHS or use your private medical insurance to access private treatment.

Does private healthcare cover A&E?

No, accident and emergency services are only offered by the NHS. If you have an accident or emergency, you should use NHS services.

Getting a private healthcare insurance quote

If you decide to invest in private cover, it’s always a good idea to shop around to find a policy that best meets your needs and offers a level of health insurance excess that you’re comfortable with.

If you’d like help tailoring your cover, talk to one of our private healthcare insurance specialists. They are experts at understanding your needs before searching the market to find the best policy for you.

Speak to us: 01603 967955