Helping you understand our language
To help you understand what health care insurance and employee health benefit policies are about, we’ve included this helpful guide to private medical insurance. We have also created a Glossary of terms used in the health insurance industry for your reference.
What is private medical insurance?
An insurance policy designed to cover the cost of acute medical treatment required after the policy has started. It will pay for treatment of acute episodes of illness or injury.
How many people benefit from private medical insurance in the UK?
6.5 million people benefit through an individual healthcare policy or as an employee benefit via a company policy.
How do I make a claim?
Each private medical insurer has a different procedure for claiming, see our "How to claim guide" for more details.
What are the benefits of medical insurance?
What’s the difference between medical insurance, income replacement and cash plans?
Only medical insurance will pay for the treatment you require. Cash plans only pay a small amount of money if you are hospitalised. This may not be enough to cover private treatment. Income replacement will provide a monthly payment to replace your income if you can’t work through accident or illness. If you contract one of the named critical illnesses then you receive a lump sum.
What’s the difference between Budget and Comprehensive private medical cover?
The level of health cover provided by the different schemes will vary between insurance companies. Different policies also use different hospitals.
Is there a limit to my health cover?
All health policies have areas where cover is limited. This is to control claims costs and limit premiums from rising to unsustainable levels. The cost of hospital treatment and out-patient consultations is not generally limited. Limits for medical insurance usually apply to such services as alternative medicines, home nursing, private ambulances etc.
Can I save money by paying the Excess?
It’s possible to save as much as 20% on monthly premiums by adding an excess of £100 or £200 to a policy. Larger excesses (up to £5,000) and shared cost schemes are increasingly popular as the premiums are extremely competitive.
Is anything excluded from a policy?
All private medical cover excludes certain things to control costs and keep premiums down. This is a list of the most common exclusions you can expect:
What is underwriting?
Private medical insurance will not cover any conditions that exist or are known about. Insurance may still be offered but will exclude these existing conditions. Only unforeseen medical conditions can be covered.
To administer this, the insurance companies use one of the following:
A. Full Medical Underwriting
This is the most common form of risk management used by private medical insurance providers
Newly-insured individuals must provide information about their medical history – the questions vary from company to company. The answers reveal current or expected treatment, and these are then excluded from the cover. As a result, the insurer will not have to pay claims immediately as this will impact on the overall claims fund (how much you can claim as a policy holder). Past treatment from a GP or consultant will generally be excluded. It depends on the condition in question
This type of underwriting excludes all previous conditions for a continuous period of (usually) two years. If no symptoms occur, and no treatment or advice is sought during the two years, the condition is then covered. The moratorium is rolling so the two-year period could start again from the date of symptoms, advice or treatment
Note: the exact terms of a moratorium can vary from insurer to insurer. A full disclosure of the insurers’ moratorium should be obtained
How on earth do I choose which health policy to take?
With the proliferation of policies available, it’s become impossible to make an informed decision without the help of an expert
That expert should be a specialist healthcare intermediary, regulated by the General Insurance Standards Council and preferably a member of the Association of Medical Insurance Intermediaries (AMII). The AMII is an association dedicated to maintaining the high standards of service that specialist medical insurance intermediaries currently offer
Can I use any hospital?
Each scheme has its own defined hospital list which lists the hospitals that are available on the particular scheme you have chosen. This might also then be sub-divided into different scales – sometimes using a, b or c or other methods. So all hospitals are available to be used but consideration needs to be given at the point of purchase to ensure that any hospital you would particularly like is available on the list for the scheme you have chosen. If a scheme is chosen that has a network of hospitals, there would be an allowance for treatment to be received at the most appropriate hospital should the hospitals on the network not have the medical capability to treat any particular condition.
Will I need a medical?
Most of the schemes are joined without the need for a medical. However, there are some schemes where a medical may be necessary. This is almost always done at the expense of the insurer and should be seen as a positive benefit.
Does the company contact my GP for medical records?
Medical insurance is not designed to pay for conditions that are already present when you take out a policy. To do this, insurers use one of the forms of underwriting described in our fact sheet. Like all insurances, there needs to be checks built into the system. With medical insurance, the check will come from the GP records of the insured person. In most cases there is no need for the GP to be contacted, nor for the medical records to be disclosed when taking out a policy. The contact with the GP is usually done with any checks that may be required at the point of claim.
Do any of the companies operate at the specialist fee schedule system?
Most of the insurance companies offer a table of specialist fees that are payable in the event of a claim. The only company that is currently able to publish this is BUPA. This is due to an Office of Fair Trading ruling which prevents other companies that use these schedules to publish them. In fairness, most companys fee schedules are broadly the same, and, as altering is pre-authorised, you do have the opportunity to know if there will be any shortfall on your selected specialist prior to any treatment taking place. There are also schemes where there is no fee schedule and full-cover means full-cover. Here, the insurer will pay an eligible claim irrespective of the fees that the consultant may charge. If a consultant is extremely expensive on a persistent basis then this may lead to an insurer removing them from their approved panel. This means you would not be able to use them at all. This, however, is extremely rare. Most consultants will charge what is a reasonable and customary amount for the procedure performed. Further advice would need to be given on a scheme’s specific basis.
Can I claim compensation if they cannot treat me in my hospital of choice?
The objective of medical insurance is to cover the costs of treatment of acute medical condition within the terms and conditions of the policy. This enables you to have treatment at any of the hospitals on the schemes hospital list (see "can I use any hospital?”) and the insurer will indemnify the costs. Therefore, the issue of compensation would not arise as the only reason for not being treated in the hospital of your choice, and on your scheme’s hospital list, would be if that hospital was unable to treat you, either in the time frame that you require or indeed for the condition that you have.
If I have to make lots of claims will the premium increase drastically?
Almost all of the schemes are community-rated within the appropriate age banding. This means that premiums are set using the claims experience across the community (i.e. all people of your age) of insured individuals. This is the original principal of insurance and even if you have extremely high claims, your premium would still be at the community-rated premium. There are some schemes that use a no-claims-discount to reward those people that don’t claim by reducing the community rated premium. Just like car insurance, any no-claims-discount that you have will reduce should you make claims. Therefore, if you are on a scheme with a no-claims-discount, although the base rates are worked out on a community basis because of the no-claims-discount, you can see your premium rise as a direct result of claims that you make.
The above information does not constitute part of any contract, nor should it be relied upon as specific advice.