11 aspects your private medical insurance won’t cover

Misconceptions surrounding the extent of private medical insurance cover are more common than you might think. The last thing you want to do is make a claim, only to discover at the time that you won’t be covered. While sometimes this is unavoidable, in many cases it’s possible to know upfront what kinds of treatments fall outside the remit of your policy.

What isn’t covered?

I’ve listed below some aspects which are commonly not covered by your medical insurance, in some cases you can add these on to your policy at an additional cost, where this is possible I’ve highlighted the fact. As with most things, there are always some if’s and but’s, so it’s best to treat the below list as a general guide and contact your provider with any specific questions.

  • Cosmetic treatments – Currently no medical insurance provider in the UK offers cover for solely cosmetic procedures. Some insurers will look to cover you if a cosmetic procedure is deemed as a medical necessity, but these exceptions are few and far between. Some examples can include if you’ve had a mastectomy due to cancer treatment and need breast reconstruction. Similarly if you break your nose and suffer from breathing difficulties, you could be covered for a nose job to correct it.

  • Chronic conditions – Chronic conditions are primarily long term permanent conditions which need regular monitoring and treatment. While treatment will help maintain the condition and alleviate some symptoms, it will not offer a cure. Examples of chronic conditions include osteoporosis and asthma.

    However, it’s important to note that acute flare ups of chronic conditions will be covered. So while routine monitoring of illnesses such as asthma will not covered, if you have an asthma attack and need treatment, your insurer should be able to cover this.

  • Primary care – Primary care encompasses first line health services, such as initial healthcare advice and treatment under the care of a GP. While your policy won’t cover the cost of you seeing a private GP, for an additional fee many policies will include some primary care cover. This can cover you for GP referred physiotherapy and scans privately.

  • Experimental procedures – Your insurance policy will usually not provide any cover for experimental and unproven procedures.

  • Take home drugs and dressings – While any drugs and dressings used during your hospital stay will be covered, your insurer will not meet the cost of the drugs and dressings you’ll need at home. As you’re a private patient you can no longer take advantage of the subsidised NHS medication rates, and it’s worth noting that some medications can be considerably expensive.

  • Normal healthy pregnancy – As pregnancy isn’t a medical condition, your insurance won’t cover you to have any scans privately, or for the birth to take place in a private hospital. There’s limited benefit available for the complications that arise over the course of a normal pregnancy, such as pre-eclampsia and edema.

  • Professional or sponsored sports – Your policy won’t cover you for any symptoms or conditions arising from participation, or training, for professional or sponsored sports.

  • Any excluded conditions – Based on your medical history and the kind of underwriting you take out on your policy, some conditions can be excluded completely from your cover. Although you can request a review of these exclusions in time, while they remain on your policy you won’t be able to claim for them, or anything else which is medically related.

  • Dental work – While some policies can offer an additional dental benefit for routine check-ups at a local dentist, orthodontic and periodontic treatments won’t be covered under your policy.

  • Obesity surgery – Although obesity is regarded as a medical condition, to date private medical insurers have refused to fund any kind of bariatric surgery. Fortunately for sufferers with a high BMI, treatment can be accessed for free through the NHS, or alternatively funded privately.

  • Travel insurance – It important to know that private medical insurance isn’t the same as travel insurance. While some policies include an international element, usually for an additional charge, this will only cover you for emergency treatment abroad, in the nearest appropriate facility. Repatriation back to the UK won’t be covered under your policy, so PMI providers always recommend taking out an additional comprehensive travel insurance policy.

This isn’t an exhaustive list. Medical insurers are constantly reviewing and updating existing terms and conditions, both to reflect best practice and meet new industry standards. If you’re in any doubt as to whether a condition or treatment will be covered, you should contact your insurer directly. Medical insurers receive hundreds of similar queries everyday, and will be able to advise you details of the specifics, allowing you to put your mind at ease.

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