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Private Medical Insurance Guide

Introduction

There are times in everyone’s life when a medical problem crops up that we need to deal with quickly and in our own time.

Unfortunately, the NHS does not work that way: it will attend to your needs in due course, but if it is not considered an emergency you may have to wait for treatment, sometimes for years.

Which is where private medical insurance (PMI) comes in. PMI is designed to cover the costs of private medical treatment for curable short-term illness or injury. These are commonly known as acute conditions.

However, PMI is not designed to replace all the services offered by the NHS. Some, such as accident and emergency, are beyond the scope of most private hospitals.

What cover does PMI provide?

PMI policies offer a range of benefits. These are usually divided into “budget”, “standard” and “comprehensive”. The sort of things that might be covered by PMI include:

• Accommodation and nursing in a private bed, in a hospital or registered nursing home while you receive treatment for illness or injury
• Home nursing benefits, payable when the services of a qualified nurse are required for full time nursing at home
• Surgeons’ and anaesthetists’ fees for an operation, including aftercare
• Specialist physicians’ fees for treatment in a hospital or registered nursing home
• Courses of radiotherapy
• Specialists’ fees for consultations, pathology and radiology investigations and physiotherapy, received on an in-patient or outpatient basis
• Fees charged by the hospital for the use of the operating theatre and for surgical dressings and drugs prescribed for use whilst an in-patient
• Cash benefit while treatment is being received free of charge under the NHS in an NHS hospital (either by choice or in an emergency). The amount may be fixed, or calculated as a percentage of the comparable private treatment.

Of the above:

• Standard plans will not normally cover outpatient, routine maternity or dental costs

• Comprehensive plans generally have higher budget limits and may also cover outpatient care specialists, complementary medicine, dental treatment, routine maternity care, travel cover and personal accident insurance

• Budget plans have a variety of limitations and exceptions. The most common of these is a six-week plan, which excludes cover for treatments available on the NHS within six weeks

Exclusions

It is not possible to be covered under any eventuality. Generally, “chronic” long-term illnesses, for example emphysema, are excluded from cover.

The other most common exclusions include: drug abuse, self-inflicted injuries, out-patient drugs and dressings, HIV/AIDS, infertility, normal pregnancy, cosmetic surgery, gender reassignment, sterilisation, kidney dialysis, mobility aids, experimental treatment, experimental drugs, organ transplant, war-related injuries (although some people may have this cover through their workplace), and injuries arising from dangerous hobbies (often called “hazardous pursuits”).

Pre-existing conditions

In addition, pre-existing conditions are generally excluded.

This is typically defined as a condition that has been diagnosed and required medical treatment in the past.

Or it is one which you have sought medical advice for, or where symptoms have occurred in a period immediately prior to you applying for the plan.

If the application form gives details of medical conditions which you have recently suffered from, sometimes going back as far as five years, an insurer will exclude those conditions from cover. Or the amount of cover you are offered may be reduced.

In addition, insurers may sometimes ask for a medical history questionnaire to be completed and signed. Or they may write to your GP, or ask you to undergo medical tests. It is essential that you provide all the information required by insurers to avoid future questions or worse, rejection of claims.

Moratorium cover

This is easier to obtain and you can get “on plan” much more quickly. You simply fill in a form, but you are not asked to give details of your medical history.

Instead, the insurance company simply does not cover any medical condition that existed in the last five years.

These conditions may automatically become eligible for cover, but only when you do not have symptoms, or receive treatment, medication, tests and advice from your GP or a specialist for that condition for a continuous period of at least two years after your policy has started.

Of course, the moment you claim for any of these illnesses, it then carries out checks.

So before taking out moratorium cover, ALWAYS make sure the salesperson explains its implications and how his or her company applies it.

More pages

Page 1: Introduction
Page 2: The cost of PMI
Page 3: Regulation of PMI cover

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