Private Medical Insurance
What is Private Medical Insurance?
Private Medical Insurance (PMI) is designed to cover the cost of private medical treatment for ‘acute conditions’ that start after your policy begins.
PMI is available at a range of different levels of cover at various premiums designed to meet the needs of different customers. For example, you can have choices around the types of treatment covered, what level of cover will apply to those treatments, the location where your treatment is provided and the contribution you might be willing to make to the treatment cost (called ‘the excess’).
Cover usually includes:
- The cost of hospital admission
- Diagnostic tests, such as MRI and CT scans
- Surgery
- The costs of seeing a consultant
- Hospital accommodation and nursing care
- Cancer drugs - some polices will include drugs that are not available on the NHS
Cover may also include:
- Outpatient consultations
- Mental health treatment options
- Complimentary therapies
- Physiotherapy and chiropody
Timely access to healthcare:
- Prompt referral to a consultant
- Quick admission to a private hospital
- Treatment at a time to suit you
Choice of healthcare:
- Direct care by a consultant
- Advanced treatment options, such as access to some cancer drugs that are not available on the NHS
High-quality private clinic and hospital accommodation:
- Privacy of an en suite room
- Home amenities, such as TV
- Comfort and cleanliness
Private medical treatment is designed for ‘acute conditions’ which start after your policy begins. An acute condition is a disease, illness or injury that is likely to respond quickly to the treatment that aims to return you to the state of health you were in immediately before suffering the disease, illness or injury, or which leads to your full recovery.
Your insurer will typically not cover ‘chronic conditions’. These are diseases, illnesses or injuries that have one or more of the following characteristics: needs long-term monitoring, control or relief of symptoms, requires rehabilitation, continues indefinitely, and has no known cure or is likely to come back.
You will normally not be covered for any illnesses you are currently suffering from, or have already had. However, you may be able to get cover for some preexisting medical conditions by paying a supplementary premium, or if you meet certain criteria.
When choosing PMI, you might want to know:
- Are there monetary limits on the policy – how much of the cost of a treatment, or course of treatments, would you be covered for?
- How does an excess work – will it be applied per claim or per policy year?
- What cover is there for cancer – what treatments are covered and for which stages of the disease?
There can be limits on cover for cancer drug treatments which you may want to ask the insurer about. A drug treatment that your insurer has covered might not be available on the NHS when your insurance cover ends. Your insurer will contact you as you approach the end of cover about the options available to you so you can discuss it with your specialist.
These options could include:
- Return to the NHS and receive the treatment there, if available
- Return to the NHS and receive alternative treatment
- Pay for the treatment privately on a self-pay basis
Types of policy:
Individual Policy
If you are applying for an individual policy, you will need to provide some information to the insurer. You must answer all questions as fully and accurately as you can, to the best of your knowledge and belief. Insurers will only ask you for information that is relevant to the cover you are applying for. There are two mains methods that insurers use to underwrite your application for PMI cover.
These are:
Full medical underwriting
All PMI companies will offer the option of full medical underwriting where you will be asked to give details of your medical history. With your consent, the insurer may write to your doctor for more information, but they do not do so in every case. You must give all the information you are asked for. If you are unsure whether to mention something, it is best to do so. If you do not, your insurer may reduce your claim or refuse to pay and cancel your policy. If you have a medical condition that is likely to come back, the insurer will issue a policy, but that medical condition (and any related to it) might not be covered.
Moratorium underwriting
Some insurance providers may offer PMI policies that use moratorium underwriting. This means you do not need to tell the insurer about your medical history when you apply for the policy. If you claim, however, your insurer might ask for medical notes that are needed to decide if your claim can be covered, as the insurer will not cover treatment for any medical condition that you have received treatment for, taken medication for, asked advice on or had symptoms of which predates the starting date of the policy.
In other words, you will not be covered for any condition that existed in the past few years (usually, this is in the last five years but the period of time may vary). Each moratorium works slightly differently so you may want to check with the insurer or read your policy documents so you can understand what this means for you.
Group Policy
Your employer may offer you access to a group PMI scheme, which typically does not ask employees to declare their medical history. The scheme is underwritten based on the average age of the workforce, the location of the company and other nonpersonal factors. A basic group PMI scheme will only cover some treatments such as hospital admission and tests. More extensive schemes could provide additional cover. Check with your employer to see what cover is available to you as it may be funded as an employee benefit or the employer might help to facilitate you accessing individual cover.
Dental Insurance
Dental hygiene affects eating and speech, and impacts on social and psychological aspects of our lives. Having bad teeth can negatively affect people’s lives and poor dental health can lead to depression and other mental illnesses.
When you visit your dentist either on the NHS or through private care, you will have to pay for at least some of your dental care, which can be expensive. Given that everyone needs regular dental checks ups and that the need for treatment isn’t uncommon, managing costs can be particularly important.
Dental insurance is a type of cash plan that helps cover the cost of your dental treatment, seperate to private medical insurance. There is a range of dental insurance plans to suit different oral health needs and budgets.
Facilitating access to dental maintenance and treatment can play a crucial role in early detection and prevention and helps maintain good physical and mental health. In 2016, health insurers helped hundreds of thousands customers to manage their oral health through dental check-ups, hygienists’ appointments, treatments and accident cover.
Dental insurance typically covers:
- Check-ups including x-rays and other dental investigations
- Dental maintenance such as descaling and polishing
- Restorative treatment such as filings, bridges and crowns
- Dental accidents and emergencies
Which insurers offer cover?
There are many providers who offer health insurance products. You can contact insurers directly or use an adviser to find the product that best suits your needs.
Switching insurance provider
If you are thinking about switching insurance provider, there are a number of things you need to consider:
- It is best to consider switching provider when your current policy reaches its renewal date, otherwise you may incur a fee for switching provider before the insurance contract has come to an end.
- You should compare the benefits, policy terms and cover limits from different providers carefully, so that you get the cover that is right for you.
- Some insurers might not cover illnesses or injuries you have had in the recent past or any condition that you suffer from now, even if these are covered by your current insurer.
Making a Claim
Although policies can differ, medical treatment usually has to start with a referral by your GP for specialist treatment. Before you arrange any private treatment, you should call your insurer to check that you are covered for the treatment.
Stay in touch with your insurer at each stage of your treatment so they can confirm your cover. It is likely that treatments for some illnesses, including pre-existing conditions (conditions from which you are already suffering, or have already had before your policy started) will not be covered by an individual private medical insurance policy.
The ABI’s Are you buying private medical insurance? guide is for individuals who are thinking about buying private medical insurance (PMI) for themselves and their families. This guide has been designed to help individuals understand more about what PMI in the UK is, why people buy it and how it works. The aim is to help anyone thinking of buying PMI be able to make an informed choice before they buy a policy.