5 Questions to ask BEFORE you buy private medical insurance

When you look at buying private medical insurance for the first time there are many questions you might have. The insurance policy you buy should be specific to your own requirements as there is not a “standard” policy option. It is much better to know everything you can find out before you buy a policy.

Whether you are looking at cover as an individual, family or for your business. What are the 5 questions you really should ask?

  1. Will the policy cover my pre-existing conditions?

If you are a new customer buying a policy for yourself or your family there are two types of underwriting widely available. Full medical underwriting (FMU) or moratorium (MORI).  Depending on your medical history, you may find that neither option will cover your pre-existing conditions.

The best way to be sure about whether a pre-existing condition would be covered is to disclose fully to your broker. They can liaise with the insurers’ underwriters on your behalf.

By taking time to do this before you buy your policy, you will know exactly what exclusions would apply.

If you are a business with 15 or more employees you may qualify for medical history disregarded (MHD) underwriting. This means that there is no exclusion of pre-existing conditions regardless of what they are. The premiums for MHD underwriting are more expensive than the alternative options. The higher premium is due to the insurer taking a greater risk.

  1. Can I self-refer to a specialist or consultant?

Private medical insurance in the UK does not in general allow people to refer themselves to a specialist. Private health insurance works alongside the NHS not instead of it. Almost all providers need a GP referral before they will consider authorising specialist appointments.

Many insurers will allow you to call them directly in relation to problems affecting joints, bones and muscles. These are known as musculoskeletal or MSK claims. The claims handler will assess your condition over the phone and refer you to a specialist if necessary. This saves you having to obtain a GP referral. This is proving to be successful and saves time for people needing treatment for this type of medical condition.

  1. Can I use any private hospital?

It is always best to check what hospitals are available from your insurer before you agree to buy a policy. Some providers offer cover for all hospitals. Others have their hospital options broken down into lists.

If you want to have cover for the higher charging central London hospitals then you may need to take a London upgrade. This would be more expensive than the standard option.

We would recommend that you discuss any hospital requirement with your broker before you make your final decision.

  1. Can I see any consultant or specialist that has been recommended to me?

If your policy requires you to obtain an open referral from your GP, this means that you would get a referral to a specialist who deals with that particular category of illness rather than naming a consultant directly.

You would then call the claims team from your insurer who would provide you with options of specialists from their approved list. They will offer consultants as close to your home as possible.

If your policy does not require an open referral, your GP can refer you to a specific consultant or you could request a referral from your GP based on a recommendation from a friend or your own online research.

When you then call for pre-authorisation you will be told whether your choice of consultant is fee approved by the insurer you are with.

Please be aware, if you choose to see a consultant or specialist who is not fee approved by your insurer then you may be liable for the shortfall in payment.


Insurance companies have a list of fee guidelines. If the fee guideline for your procedure is £500 and the consultant or specialist charges £750 for that procedure then there would be a £250 shortfall in payment. The shortfall in payment would not be paid by the insurer.

When you call for pre-authorisation of your procedure, the claims team would tell you at this point if your consultant charges over the standard fee guidelines and would offer you an alternative option. If you are happy with the alternative consultant then you would avoid any shortfall in payment.

  1. How long does a private medical insurance policy last?

Once you have passed the cooling off period, private medical insurance policies are a 12 month contract whether you buy as a consumer or a business. Therefore this is the minimum term of cover.

Once your policy is in place you will be offered an annual renewal by your insurance company regardless of whether you have made claims.  It is at this time you can request any changes to your cover levels, change your excess or hospital lists.

The renewal offer from your current insurer should arrive at least 4 weeks prior to the renewal date. This will give you enough time to ask your broker to provide you with a review of the market.

If you find a cheaper alternative from another insurance company or you prefer a different insurer because of the cover levels and benefits that they offer, you can cancel the policy with your current provider and switch across to another insurer.

You can find further information from the ABI guide as below:


The team at SMP Healthcare are experienced at helping clients navigate the private medical insurance sector. If you have more questions that have not been answered within the information above, please call or email and we will be happy to answer them for you.

Telephone 01245 929129 or Email : enquiries@smphealthcare.com