The purpose of PMI is to pay for the treatment of acute conditions outside of the NHS. It does not cover the treatment of accidents or emergencies or for the treatment of any conditions deemed as chronic. PMI will cover the costs of treatment up to the point of diagnosis of a chronic condition. It will also fund acute flare ups of a chronic condition.
Acute conditions are defined as:
A disease, illness or injury that is likely to respond quickly to treatment which aims to return you to the state of health you were in immediately before suffering the disease, injury or illness, or which leads to your full recovery.
Chronic condition‘s are defined as:
A disease, illness or injury that has one or more of the following characteristics:
- There will be ongoing or long-term monitoring through consultations, examinations, check-ups and/or tests.
- It needs ongoing or long-term control or relief of symptoms.
- You need rehabilitation you will need to be specially trained to cope with it.
- Currently there is no known cure.
- It continues indefinitely.
- The probability is that it will come back or is likely to come back.
Cancer is not classed as a chronic condition. All providers stipulate their full cancer cover separately within their policy literature.
Taking out PMI policies allows people more choice in hospitals, specialists and consultants. It enables people to arrange for treatment at a time convenient to them. Private treatment is usually accessed much quicker than waiting for treatment on the NHS.
Private medical insurance policies can be taken out as individual or family cover, SME or corporate. Policies can be purchased for people living in the UK or for ex-pat communities all over the world. Some countries do have their own healthcare rules and cover is only available if sourced locally to that country. International cover is available for purchase in the UK for the majority of countries/ regions.
General PMI information:
Private Medical Insurance pays for in-patient, day-patient and out-patient treatment. All treatments need to be referred by a GP (NHS or private).
On most policies you have cover enhancement options such as adding dental or optical cover to the core product. You can add cover for mental health treatment.
Applying an excess to the policy or reducing the out-patients treatment to £1000 is a way you can save money. Opting to remove cover for psychiatric care altogether is a good cost containment option.
Most policies available are flexible and can be tailored to suit the individual needs of all members.
Policies are often split into the following three levels:
- Comprehensive or Full refund
- Intermediate or Mid Range
- Budget or Core cover
Many insurers offer different hospital banding where the high charging hospitals will be on the most expensive option. Members should only go to hospitals within the list shown on their own membership.
There are many other products associated with private medical insurance such as Dental insurance, Health Screening, Occupational health, EAP’s and cash plans. They all offer different benefits and have values in their own right. Many groups and corporate schemes could have more than one product running at the same time.
When taking out PMI there are different underwriting methods.
Large group schemes can take MHD, medical history disregarded.
Group schemes and individual schemes can take FMU, full medical underwriting or MORI, moratorium underwriting. When switching insurer – members can also look at CPME, continued personal medical exclusions or CMORI, continued moratorium, therefore not losing any of their original underwriting.
Private medical insurance is an annual contract and cannot be cancelled mid-term. The insurer will issue renewal documents prior to renewal to allow the customer time to review the market options. You are encouraged to obtain PMI comparison options rather than just renewing you cover.
Private medical insurance claims are generally settled between the hospital and the insurer directly. It is essential that members obtain pre-authorisation from their insurer for any treatment. By doing this you ensure that there are no shortfalls in payment. A shortfall occurs when the specialist or hospital charge over and above the agreed rates of the insurer. The insurer will only pay the agreed percentage of the cost. When this happens the insured member would be liable to pay the difference.