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Latest News What does Private Medical Insurance cover?

What does Private Medical Insurance cover?

What does Private Medical Insurance cover?

Private Medical Insurance is designed to pay for treatment of new, acute, short-term conditions. To truly understand that statement it is probably worth breaking down the language. Let’s start with ‘new’.


The reason why the word ‘new’ appears is that Private Medical Insurance (PMI) will not, usually, pay for pre-existing conditions. Quite simply, if you already have a hernia the insurer is not going to take up the liability of paying for your treatment.

When you take out a policy you will have to disclose any pre-existing conditions (in some cases this only needs to be disclosed at the time you make a claim) and these conditions will become exclusions on your policy. If the issue does not resurface for a couple of years you may find your insurer willing to remove the exclusion and commence cover.

There is an exception to this. Some larger group schemes will negotiate with the insurer and get your medical history disregarded. That means the insurer will take on the cost of treatment for pre-existing conditions. This is why Group Private Medical Insurance can be a valuable employee benefit.


Next up is ‘acute’. The dictionary definition for acute states ‘experienced to a severe or intense degree’. That is to say it is it the opposite of negligible – it has to be significant. You can’t have private medical cover for a common-cold or a grazed knee. Acute conditions will have an identifiable cause and a predictable prognosis. Musculoskeletal issues are the most common reason for claiming (bad backs etc.).

It’s really important at this point to flag up that emergency conditions, such as a heart attack or a broken leg, are dealt with through the emergency services. You still need to call 999 or visit A&E – you wouldn’t use your PMI in any emergency situation.


‘Short-term’ conditions are ones that respond well to treatment. As you can imagine no insurance company in the world is going to agree to cover a condition that you’ll struggle to recover from. That is why PMI won’t usually cover you for treatment of chronic conditions.

A chronic condition is an illness or disease which lasts a long time and does not respond well to treatment. Examples include arthritis, diabetes, asthma or hepatitis C. Cancer has always been considered a chronic disease, however treatments are becoming more effective and you’ll now find that most private medical insurers will offer Cancer cover as an extension to their main policy.

What will PMI cover?

As already mentioned, the most common claims are for musculoskeletal injuries. That’s joints, bones and muscles, autoimmune diseases and back pain. Viruses and infections are very common too. Mental health cover can often be included if you choose to increase your treatment. As can dental and optical cover.

Your policy will also provide cover for a wide-range of diagnostic tests, consultations, scans and specialised treatments. You should also receive a range of additional benefits such as cash benefits when you use the NHS instead of your policy, home nursing, choice of hospitals and parent accommodation. Many insurers are now adding some unique benefits, such as digital GP’s – so you can book and see a doctor from your phone, discounts on gyms and fitness equipment, wellbeing support and helplines as well as providing cover for young dependents for free.

Of course, as with any type of insurance you can include or exclude many elements and the costs will rise or fall accordingly.

Insurance Product Information Document

Once you have agreed the limits of your policy you will be provided with a summary document known as an Insurance Product Information Document, or IPID for short.

Your IPID presents in the clearest way possible was is and what isn’t included in your PMI policy. You should check this carefully to ensure you are happy with the contents. It will also include some important essentials such as where in the world your PMI is valid, any restrictions on the policy and any obligations you have.

So, is Private Medical Insurance worth it?

We’re fortunate enough, in the U.K. to have one of the most phenomenal national health services in the world. But there are limits to what the NHS can deliver. Non-emergency conditions will have long waiting lists and limited availability of treatments.

However, with PMI in place you can remove the time spent waiting for treatment, get access to treatments unavailable on the NHS, private rooms, faster diagnosis and a choice of surgeon or hospital. All leading to improved welfare and, potentially, faster recovery.

As detailed in our previous article ‘Should I pay for private healthcare?’ 53% of people would pay for PMI if they could afford it.

If you are considering PMI either for you or your employees get in touch with one of our specialists on 01603 967955 or click here.

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