Private Health Insurance Exclusions

Every private health insurance policy is different, but many share the same types of exclusions. Some common health insurance policy exclusions include:

Pre-Existing Medical Conditions

These are health issues you've already been diagnosed with, treated for, or have shown symptoms of before your insurance policy starts. This can range from receiving physiotherapy for joint issues to treatments for more complex conditions like lung or ear infections. Since health insurance aims to cover unforeseen illnesses that arise after your policy begins, pre-existing conditions are generally not covered. Insurers might require a medical history review or set specific exclusions for these cases.

Dental Treatments

Routine dental care often falls outside standard private medical insurance (PMI) and might require a separate dental plan. While emergency or specific specialist dental treatments could be covered under health insurance, routine procedures like check-ups, fillings, or cosmetic dentistry usually are not.

Chronic Conditions

Conditions that are ongoing, incurable, or require long-term management, such as certain heart diseases, chronic kidney conditions, or some cancers, are usually not covered by private health insurance in the UK. The essence of health insurance is to provide financial support for treatments that can restore your health to its previous state, not to manage long-standing health issues.

Cosmetic Treatments

Elective cosmetic surgeries and procedures are not covered because they are considered lifestyle choices rather than medical necessities. This includes surgeries like rhinoplasty, breast augmentation, and face lifts. However, reconstructive surgery following an accident might be covered if it treats a condition normally covered by your policy.

Prescription Medications

Outpatient prescription medications typically aren't covered by PMI. Cover might be available if the drugs are part of an in-hospital treatment and prescribed by the attending specialist, but this varies by policy.

Other Common Exclusions

Health insurance policies also often exclude treatments for conditions such as:

• Visiting a GPs clinic
• Visiting Accident and Emergency
• Drug or substance abuse
• AIDS/HIV
• Standard pregnancy - without complications
• Sex changes
• Wheelchairs or other mobility aids
• Organ transplants
• Injuries that are brought about as a result of dangerous pastimes (or “hazardous pursuits”).
• Self-inflicted injuries - deliberately caused
• Fertility treatment
• Trial or experimental drugs or treatments
• Kidney Dialysis
• War hazards

Prior to the start of your medical insurance, your insurance provider will supply you with a comprehensive list of the things that they will and will not cover. It is extremely important that you read these terms and conditions in full before you complete your contract. This is because you should make sure that you are aware of what you are and are not covered for in the event of making a claim. Many insurers will also provide a list of the policy's "Key Facts", this factsheet is designed to inform you of any unusual or otherwise important features of the policy.

The private healthcare sector in the UK primarily focuses on treating conditions that have a clear path to recovery. Unfortunately, this means there's limited capacity for dealing with long-term or incurable illnesses. If insurers promised cover for treatments not readily available in private facilities, you might end up paying for benefits you can't use, which is neither fair nor practical. Covering long-term or lifetime treatments would also necessitate significantly higher premiums, making such policies financially impractical for most. 

For chronic illnesses and long-term care, the NHS is often the more appropriate choice. With its extensive resources and funding aimed at supporting these conditions, the NHS is equipped to offer comprehensive care that private insurers simply can't match. 

Health insurance policies often exclude pre-existing conditions, especially those for which you have received treatment, medication, or had symptoms before the start of the policy. However, the approach insurers take for these conditions can vary:

• Moratorium Underwriting: Some policies operate on a moratorium basis, which means they might start covering pre-existing conditions after you've been symptom-, treatment-, and medication-free for a specified period, commonly two to five years, under the policy. This doesn't necessarily reduce your premiums but can eventually lead to coverage of conditions that were initially excluded.
• Full Medical Underwriting (FMU): Choosing full medical underwriting involves disclosing your full medical history when you apply for insurance. The insurer may then decide to cover some pre-existing conditions from the start of the policy, possibly at a higher premium or with specific exclusions. The idea here is not always to reduce premiums but to accurately assess and price the risk of covering you, including for any pre-existing conditions.

As a general rule, private health or medical insurance is designed to pay for the treatment of short-term illnesses, curable diseases or injuries. The phrase that is often used to refer to these complaints is "acute conditions" and these are the types of conditions that health insurance plans are made to cover.

Most health insurance plans will normally cover the following costs:

• Inpatient tests
• Surgery as either an inpatient or a day patient
• Nursing care and hospital accommodation

Cash reimbursements for treatment provided by the NHS as an inpatient

Some plans will also cover:

• Tests for outpatients
• Consultations or treatment with a specialist as an outpatient
• Physiotherapy or other forms of therapy