What Does Private Medical Insurance Cover?

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Health Insurance pays for the treatment of eligible, acute medical conditions in private hospitals and facilities. It provides you with faster access to healthcare, avoiding NHS waiting lists and getting you care exactly when you need it the most.

But what exactly does UK Private Health Insurance cover? If you take out a plan, your policy will pay for the treatment of certain conditions as standard. However, to get coverage for other conditions and medical needs, you may have to add extra options to your plan for an additional premium.

Importantly, Private Medical Insurance won’t cover every medical need — there are some exclusions. This means, even with a Health Insurance policy, the NHS will continue to provide some of your healthcare, for example emergency medicine and intensive care. The NHS is better resourced to offer these treatments than the private sector anyway.

Inpatient and Outpatient Private Medical Treatment

All medical treatment is split into two key parts:

  • Inpatient and day-patient treatment
    Health Insurance covers inpatient treatment as standard — it’s known as ‘core cover’. This involves overnight stays in hospital, for example for surgery. Day-patient cover, meanwhile, usually involves minor operations where you need a hospital bed but doctors discharge you the same day.
  • Outpatient treatment
    Outpatient treatment is an optional extra for an additional premium. It includes all medical care not needing a hospital bed, such as diagnostic tests and scans or physiotherapy. Depending on how comprehensive your Health Insurance is, your insurer may pay for outpatient treatment in full or up to a set limit per policy year.

Why Outpatient Cover?

You don’t have to add outpatient cover to your policy. Some people choose not to because they’re looking for a Low Cost Health Insurance. This still offers inpatient treatment such as surgery but means you’ll have to use the NHS for all your outpatient care.

While this does provide cheap Health Insurance, having no outpatient care at all could delay private inpatient treatment under your plan.

At the other end of the scale is Comprehensive Medical Insurance. This pays for all eligible inpatient and outpatient care in full. However, it’s the most expensive option to choose because of its wide coverage.

A happy medium for you may be a mid-range policy. This offers some outpatient treatment, but your insurer caps the amount of such care it will pay for at a fixed amount per policy year. This cap is typically around £1,000.

Health Insurance Coverage: Chronic vs Acute Healthcare

Private Health Insurance covers acute conditions. It’s not designed to pay for ongoing treatment of chronic conditions, which the NHS will continue to manage for you.

Broadly speaking, the difference between chronic and acute conditions is that acute conditions can pass with treatment, but chronic conditions remain with you for life.

Acute conditions include:

  • Joint pain treatable with a joint replacement
  • Appendicitis requiring removal of your appendix
  • Broken bones
  • Cataracts
  • Hernias.

Chronic conditions include:

  • Asthma
  • Arthritis
  • Heart failure
  • High blood pressure
  • Psoriasis.

Some people think the difference between chronic and acute conditions is their severity, but this isn’t the case. The actual different is the likely outlook for that condition with treatment.

For example, although one is far more severe than the other, both the common cold and a heart attack are acute conditions because, assuming you receive the necessary medical care, both can respond to treatment and then pass.

Acute Flare Ups of Chronic Conditions

In some cases, the boundaries are blurry between what insurers consider a chronic condition and what they consider an acute condition.

For example, although asthma is a chronic condition, an asthma attack is deemed an acute phase of the illness.

This is because with medical intervention / hospitalisation, such as inhalers, steroids, oxygen or nebuliser treatment, the asthma attack can be treatable. Once treated, you return to your previous state of health, although you’ll still have the underlying chronic condition.

In this instance, admittance to hospital to treat a severe asthma attack may be covered by Private Health Insurance, but it’s best to check with your provider or ask an expert.

Diagnosis of Chronic Conditions

If you develop symptoms of a chronic condition, Health Insurance will cover you to see specialists and consultants up to the point of diagnosis of your chronic health condition.

However, once doctors diagnose you, your insurance won’t cover ongoing care for that chronic illness.

So while your policy covers you to see a private consultant to get diagnosed with arthritis, if you require ongoing medication and GP reviews as a result, your insurance won’t pay for this.

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Cancer Cover

Private cancer care is one of the most valuable aspects of any Health Insurance policy. This is because private cancer treatment can include access to drugs, therapies, treatments and procedures the NHS may not yet pay for due to cost.

Almost all Health Insurance plans cover cancer treatment as standard, paying for:

  • Chemotherapy
  • Radiotherapy
  • Biological / hormone therapies
  • Cancer surgery / reconstruction.

Depending on your provider, your Private Medical Insurance may also cover:

  • Chemotherapy at home rather than in a clinical setting
  • Money towards wigs and prosthetics you require as a result of cancer treatment / surgery
  • Cash towards scalp cooling to reduce chemotherapy-related hair loss
  • Donations to a hospice if you require palliative care
  • Access to a set number of days of home nursing, where a private nurse will visit you at home to check on you during your treatment.

Private Medical Insurance Add-Ons and Additional Cover

Depending on your provider, you may be able to get extra cover with a selection of policy ‘add-ons’. This could increase your entitlement to medical care under the policy.

Does Medical Insurance Cover Mental Health Conditions?

While some Health Insurance plans cover mental health care as standard, for most insurers it’s an optional add-on to the policy.

It’s worth noting that how much treatment you’re entitled to under the psychiatric element of your policy will vary from provider to provider and on a case-by-case basis.

This is because insurers may consider some psychiatric conditions long-term and chronic. This could mean they’re not covered along with other chronic conditions.

Even if your insurer does decide your mental health condition is chronic, some providers may still pay for initial treatment but only up to a set limit.

This limit might be a cost limit, a cap on the number of days a patient can spend as an inpatient or on the number of outpatient consultant appointments available.

Dental and Optical Care

Most policies cover emergency dentistry. This pays out for treatment if you’ve had a tooth knocked out or severely damaged. Another common coverage is oral surgery, for example extraction of impacted wisdom teeth.

However, routine dental treatment — which pays for everyday dentistry such as checkups, filings and crowns — is an optional extra to Health Insurance.

The same is true for optical care. While surgery to remove cataracts would be covered by most policies, insurers won’t cover everyday eye care (checkups and glasses etc.) unless you choose an add-on.

This add-on usually takes the form of a cash payment towards your dental or optical healthcare needs.

Therapies Cover

The main four therapies Medical Insurance covers are:

  • Acupuncture
  • Chiropractic treatment
  • Osteopathy
  • Physiotherapy.

Only the best Health Insurance policies with a good level of outpatient cover will offer all four as standard. Alternatively, if it is not included by default, some insurers allow you to add therapies cover to your plan for an additional cost.

Exclusions: What Doesn’t Health Insurance Cover?

UK Health Insurance doesn’t provide all medical treatment. Some things it won’t cover include:

  • Emergency medicine
  • Intensive care
  • Ongoing management and treatment of chronic conditions
  • Kidney dialysis
  • Fertility treatment / IVF
  • Treatment required as a result of war, terrorism, contamination with radioactivity
  • Normal pregnancy and childbirth (you may have cover for complications)
  • Treatment for alcoholism / other substance abuse
  • Cosmetic surgery.

While this represents some of the most common exclusions on Health Insurance policies, it’s not an exhaustive list. Just what your plan covers will vary between providers and will depend the level of cover you buy.

Need Medical Insurance Advice?

There’s so much to consider when you’re buying PMI in terms of what exactly your policy will cover. That’s why, given the complexity that comes with arranging the best Health Insurance for your needs, it can be invaluable to speak to an expert who knows the market.

Why Speak to Us…

We started Drewberry™ because we were tired of being treated like a number.

We all deserve a first class service when it comes to issues as important as protecting our health. Below are just a few reasons why it makes sense to talk to us.

Pop us a call on 02074425880 or email help@drewberry.co.uk.

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