What isn’t covered by private medical insurance

When you buy private medical insurance, all insurers are keen to let you know what is covered, however, do they make it clear what isn’t covered by private medical insurance? Yes, you can look through the small print, but do you understand what it means in reality?

Personal medical exclusions on your private medical insurance

When you buy a policy with full medical underwriting, your insurance provider will issue a certificate. On this certificate, any personal medical exclusions will be shown. The underwriters will have made this decision based on the application form you completed. Your personal medical history and pre-existing medical conditions will be taken into consideration at this time.

If, however, you have a policy with moratorium underwriting, there is unlikely to be a specific exclusion applied. This is because you are underwritten at the point of claim, not at the start of your policy.

Large business policies might have Medical History Disregarded (MHD) underwriting, meaning no personal medical exclusions. The general exclusions and chronic conditions cover would affect what isn’t covered on your private medical insurance if you have MHD underwriting.

What isn’t covered by UK private medical insurance?

Your insurer will provide you with a membership handbook when you buy your policy. In your handbook you will find a list of general exclusions to the cover available. This is provider specific. Although, as a rule, all insurers have similar general exclusions, there will be minor differences.

The general exclusions for private medical insurance include (list not exhaustive!):

  • Alcohol, drug and substance abuse
  • Accident and Emergency treatment
  • Cosmetic treatment
  • Dialysis
  • Gender reassignment
  • Learning disorders
  • Natural ageing
  • Pregnancy and childbirth
  • Self-inflicted injury
  • Sleep disorders
  • Sports-related treatment
  • Varicose veins
  • Weight loss treatment

There will be exceptions to the general terms and conditions. As an example, Bupa will offer cover relating to drug and alcohol abuse and Vitality Health can offer help relating to weight loss, in certain circumstances. You can use the above as a guide; however, the best place to check for what isn’t covered is within your own policy wording. In truth, each provider has slightly different exclusions which is clearly confusing when you are new to PMI.

Seeing that pregnancy and childbirth are excluded from cover, what about complications of pregnancy? To clarify, health insurance will normally include cover for treatment when things go wrong. The reason that a normal and straightforward pregnancy is not covered is simply because it is not an illness. To emphasize for you, health insurance in the UK is primarily for the treatment of acute medical conditions.

Will private medical insurance cover chronic medical conditions?

The treatment of chronic medical conditions isn’t covered on a standard PMI policy. Insurers such as Aviva or AXA offer a policy add-on that will give you some cover; however, insurers all have a chronic conditions clause.

A chronic condition is a condition with different characteristics, including:

  • It needs long term monitoring.
  • You need control or symptom relief over a period of time.
  • The possibility of rehabilitation or training for you to be able to live with your condition.
  • There is no known cure.
  • The condition is likely to come back.
  • Your condition continues indefinitely.

Providing you had your policy in place prior to experiencing symptoms, your insurer will likely pay for diagnostic testing. Once you have a diagnosis, the NHS would look after the routine monitoring and medication for your chronic condition. If you then have an acute flare up, you will be able to access treatment from your insurer. This is subject to your policy offering you the benefits and cover necessary in your specific circumstances.

A medical condition can be classed as chronic at any time throughout your policy term.

Are preventative treatments covered on private medical insurance?

Although you may want to have a procedure “just in case”, your policy will not cover you for treatment if there are no symptoms. There are exceptions to this rule, but they are few and far between. Similarly, vaccinations are often a specific exclusion. Many insurers will offer you discounted health screening via a third-party provider, but they will not cover the cost of the screening in full. Genetic tests are also unlikely to be covered if you have no medical symptoms.

If you have a family history of a specific medical condition like cancer, you may need to self- fund any genetic testing, rather than claim on your PMI policy.

Natural ageing isn’t covered on health insurance

Natural ageing is not an illness. On this basis, UK private medical insurance will not cover you for claims of this type. Menopause and puberty are two examples to consider. Even though they may cause discomfort and physical symptoms, they are a natural process and not an acute medical condition. There are some excellent online reference sites and mobile Apps that can help with issues such as the menopause.

Below is just one of the many websites available here in the UK for menopause support.


Deafness isn’t covered if it is due to natural ageing or a congenital abnormality, nor is eyesight when the deterioration is part of the ageing process.

What about temporary relief of symptoms?

Some medical conditions can be kept at bay with a temporary fix. A steroid injection might stop pain for a while and save you having surgery, but your insurer will not pay for this on a long-term basis. If your consultant recommends surgery as your cure, you should opt for this treatment. An injection might work for a short time period, and you might prefer to avoid going under the knife, but this is not fixing the problem.

As you can see from the information above, there are a number of conditions and situations when you cannot claim on your private medical insurance. If you have a specialist health insurance broker, they will be able to guide you if you are unsure. Only your insurer, however, will be able to give you a definitive answer on whether you are covered for the claim you wish to make.

Please don’t let this information put you off health insurance as a whole! We want people to know the facts, but rest assured, there are far more medical conditions than not covered on a comprehensive PMI policy. Our team of experts can help you understand how health insurance works and, specifically, if you have exclusions on your policy – particularly if you are buying for the first time. Trust in our knowledge of the sector to help you find a policy that you can use if you need to!

You can contact us on 01245 929129 or by email:  lianne@smphealthcare.com