The Health Guide — clear answers, healthier tomorrows

    Health insurance

    What does private health insurance cover?

    Written by Stuart Hendy, PMI Expert and Head of Publishing, PremierPMI
    Reviewed by Parvoz Haydarov, Founder, PremierPMI

    Published 14 September 2026 · Last reviewed 14 September 2026 · Next review 14 March 2027 · 11 min read

    The short answer

    Private health insurance pays for eligible private treatment of new conditions that begin after your policy starts. Most policies cover diagnostic tests, specialist consultations and inpatient treatment; many exclude chronic conditions, pre-existing conditions, accident and emergency care, and routine pregnancy. Cover, limits and excesses vary by insurer, so the policy wording decides what is paid.

    PremierPMI is an insurance broker, authorised and regulated by the FCA (FRN 1029667). We may receive commission if you take out a policy. How we are funded.

    In this guide8 sections
    People covered, 2024
    6.5 million[1]
    Claims paid, 2024
    £4 billion[1]
    Covered by an employer
    4.7 million[1]
    NHS cases within 18 weeks
    65.4%[8]

    What you need to know before you rely on a policy

    1. Cover is built around acute conditions that start after the policy does, not long-term condition management. Read more
    2. The standard exclusions — pre-existing and chronic conditions, emergencies and routine maternity — do most of the work. Read more
    3. Two policies with the same description can pay very differently once outpatient limits and hospital lists are compared. Read more
    4. Nearly every claim needs authorisation before treatment, and a GP referral before that. Read more
    5. The policy wording is the contract, and the regulator requires a short standardised summary alongside it. Read more

    What the cover is for

    Private medical insurance is designed for an acute condition — a problem that starts after the policy begins and that treatment is expected to put right. That single idea explains most of what follows. If a condition is expected to need ongoing management rather than a course of treatment with an end point, insurers treat it as a chronic condition and fund little or nothing. If it existed before you applied, underwriting decides whether it is covered at all.

    It is not a replacement for the NHS, and it does not remove any NHS right. Emergency care, most long-term condition management and routine maternity care stay with the NHS, and the NHS Constitution sets out the rights you keep whether or not you hold a policy. [7] What private cover buys is speed, choice of consultant and choice of facility for planned treatment that falls inside the policy terms.

    What most policies include

    Almost every UK policy is assembled from the same building blocks. The core is inpatient and day-patient treatment: the surgery, the hospital stay, the surgeon, the anaesthetist and the associated hospital charges. Around that core sit optional modules that buyers switch on or off, and those modules are where the price and the payout both move.

    • Specialist consultations after a GP referral
    • Diagnostic tests and scans, once the insurer has authorised them
    • Inpatient and day-patient treatment in a private hospital
    • Surgeons’, anaesthetists’ and hospital fees for eligible treatment
    • Cancer cover, which in many policies is a separate module with its own terms
    • Mental health and therapies cover, usually capped in sessions or money
    • A hospital cash benefit when you have eligible treatment on the NHS instead of claiming

    The building blocks are consistent; the small print is not. One insurer may pay for a scan on an outpatient basis without limit, while the next counts the same scan against a £1,000 annual outpatient allowance. Neither is wrong — they are different products at different prices, and the only reliable way to compare them is to read the two policy wordings side by side.

    What is usually excluded

    Common exclusions on UK private medical insurance policies — scroll sideways to see all columns
    ExclusionWhy it applies
    Pre-existing conditionsUnderwriting decides which past conditions are covered; see how medical underwriting works.
    Chronic conditionsPolicies fund treatment that cures or stabilises, not ongoing management of a long-term condition.
    Accident and emergencyEmergency care is an NHS service; private hospitals rarely run emergency departments.
    Routine pregnancy and childbirthNormally excluded, though some policies cover specified complications.
    Cosmetic treatmentExcluded unless it follows an eligible accident or covered surgery.
    Treatment outside the hospital listCover usually applies only at facilities the insurer recognises for your plan.

    Exclusions are not there to catch people out; they are what keeps the product priced for the risk it actually carries. The practical consequence is that a policy is best judged on its exclusions rather than its inclusions. Two questions answer most of it: what has happened to me medically in the past, and what does this insurer do with that history?

    Judging a policy on cover alone

    What works well

    • Fast access to a specialist and to diagnostics for a new, eligible problem
    • A named hospital list, so you know in advance where you can be treated
    • A cash benefit in many policies if you choose NHS treatment instead
    • Clear, written terms that the regulator requires to be summarised in a short document

    What to watch

    • Chronic and pre-existing conditions sit outside almost every policy
    • Outpatient allowances are where two similar-looking policies diverge most
    • Nothing is normally payable without authorisation before treatment
    • The premium is reviewed every year, and claims history feeds into it

    How limits and hospital lists change what you get

    Two policies with the same headline description can pay very differently. Outpatient cover may be unlimited, capped at a money amount, or excluded altogether. Therapies, mental health cover and cancer cover are often modular. The hospital list attached to your policy also decides where you can be treated, and lists in central London are routinely narrower — and more expensive to widen — than lists elsewhere. [3]

    Information about private providers is more public than it used to be. The Private Healthcare Information Network publishes data on private hospitals and consultants, including the procedures they perform, which is a useful way to sanity-check a hospital list before you buy. [4] It is also worth knowing that the private market has been examined in detail by the competition regulator, whose investigation led to ongoing obligations on private hospitals and consultants about the information they must disclose. [3]

    How much the market pays out

    Cover is now widely held. Association of British Insurers data published in January 2026 shows 6.5 million people in the UK were covered by private medical insurance in 2024, up about 4% on the year, and that insurers processed a record £4 billion of individual and workplace claims — roughly £11 million a day. Around 4.7 million of those people were covered through an employer scheme rather than an individual policy. [1]

    Private medical insurance claims paid, UK
    • 20233.57 bn£3.57bn
    • 20244 bn£4bn

    Source: Association of British Insurers, 21 January 2026

    6.5 million
    People in the UK covered by private medical insurance in 2024, according to the ABIAssociation of British Insurers · 21 January 2026

    Those numbers matter to a buyer for one reason: they show that claims are routinely paid, at scale, and that the growth in cover is being driven substantially by employers. If you are weighing a policy up, it is worth checking whether you already have cover through work before buying your own.

    Adviser insight

    “The misunderstanding I see most often is that people expect a policy to behave like the NHS with shorter queues. It does not. It is built around acute conditions that respond to treatment, so a new knee problem is usually in and a long-term condition you already live with usually is not. Read the outpatient limit before you read anything else — that single line decides whether the scans and consultations that lead up to treatment are paid for, and it is where most disappointment starts.”
    Stuart Hendy, PMI Expert and Head of Publishing, PremierPMI

    How a claim actually runs

    Cover only becomes real at the point of claim, and the sequence is almost always the same. You see your GP; the GP refers you; you tell the insurer before anything is booked; the insurer confirms the treatment is eligible and issues an authorisation number; treatment goes ahead at a facility on your list; the hospital invoices the insurer directly; you pay only your excess and anything the policy does not cover.

    1. Step 1: See your GP and get a referral

      Self-referral is accepted by some insurers for some services, but the default route is a GP referral.

    2. Step 2: Call the insurer before booking

      This is pre-authorisation. Booking first is the most common reason a claim runs into trouble.

    3. Step 3: Check the facility is on your list

      Treatment at a hospital outside your list may be refused or only part-paid.

    4. Step 4: Let the hospital invoice the insurer

      Most bills are settled directly; you are billed separately for the excess.

    5. Step 5: Keep the paperwork

      If you later need to complain, the authorisation record and the wording are what the case turns on.

    If a claim is declined and you disagree, you complain to the insurer first, and then, if you are still unhappy, to the Financial Ombudsman Service, which handles medical insurance complaints and can direct a firm to put things right. [5]

    Where the rules come from

    Private medical insurance is a regulated product. Firms selling it must give you appropriate information about the policy in good time before you commit, including a short standardised summary document, so that you can make an informed decision. [2] Since the Consumer Duty came into force, firms also have to show that products deliver good outcomes for retail customers and that communications support understanding rather than merely disclose. [6]

    None of that changes the basic discipline for a buyer: the summary document tells you the shape of the cover, and the full wording tells you whether your particular situation is inside or outside it. Where the two appear to conflict, the wording governs.

    What to check before you rely on a policy

    1. Step 1: Read the policy wording, not the brochure

      The wording is the contract; the summary is not.

    2. Step 2: Check the exclusions and any personal exclusions

      Underwriting can add exclusions specific to you, on top of the standard list.

    3. Step 3: Check the hospital list

      Cover usually applies only at facilities the insurer recognises for your plan.

    4. Step 4: Check the outpatient limit

      This is where most policies differ most, and where most unexpected bills come from.

    5. Step 5: Check what happens at renewal

      Ask how claims affect the premium and whether any no-claims discount can be protected.

    If you want to go deeper, read how medical underwriting works, what an excess is and the NHS 18-week waiting time standard, which together explain most of what decides whether a policy is worth holding.

    Looking at cover with PremierPMI

    PremierPMI is a specialist private medical insurance broker and the publisher of The Health Guide. If you want to talk through what this means for your own cover, you can start there.

    Or, if you would rather start here, send an enquiry and PremierPMI will contact you.

    PremierPMI is an insurance broker, authorised and regulated by the FCA (FRN 1029667). We may receive commission if you take out a policy. How we are funded.

    Common questions

    Does private health insurance cover pre-existing conditions?
    Usually not, at least not at the start. Medical underwriting decides which past conditions are excluded, either automatically under a moratorium — which sets aside anything you have had symptoms of, advice about or treatment for in a defined recent period — or by listing the exclusions in writing before you buy. Under a moratorium, a past condition can come back into cover if you go a continuous qualifying period without symptoms, advice or treatment for it. Under full medical underwriting, the exclusion is fixed unless the insurer agrees to review it. Neither route pays for something you were already being treated for when you applied. Read how medical underwriting works for the detail, and check the wording for how your insurer defines the qualifying period.
    Does private health insurance cover A&E or emergencies?
    No. Emergency care in the UK is an NHS service and private hospitals rarely run emergency departments, so a policy is not something you call on when something goes badly wrong suddenly. If you need urgent help, call 999 or use NHS 111. Private cover is for planned, eligible treatment that follows a referral and has been authorised in advance. There is an indirect connection worth knowing: if you are admitted as an emergency and later need planned follow-up surgery, that follow-up may be claimable if the underlying condition is eligible and the insurer authorises it. Ask the insurer at the time rather than assuming either way.
    Can I use private health insurance instead of the NHS?
    You can use both, and most people do. Private cover does not remove any NHS right; the NHS Constitution sets out what you are entitled to regardless of any insurance you hold. [7] In practice people use the NHS for emergencies, for GP care and for long-term conditions, and use a policy for prompt diagnostics and planned treatment of new problems. Many policies also pay a cash benefit if you choose to have eligible treatment on the NHS instead of claiming, which can be worth more than it looks when the NHS wait for that particular procedure is short. See the NHS 18-week waiting time standard for what the NHS must offer you.
    How many people in the UK have private health insurance?
    The Association of British Insurers reported 6.5 million people covered by private medical insurance in 2024, an increase of about 4% on the previous year, with a record £4 billion of individual and workplace claims processed in that year — figures published in January 2026. [1] Around 4.7 million of those people were covered through a workplace scheme, so employer-funded cover is now the larger part of the market by some distance. If you are considering buying your own policy, check first whether your employer already provides cover, and whether family members can be added to it.
    What is the difference between outpatient and inpatient cover?
    Inpatient treatment means you occupy a hospital bed, either overnight or as a day case. Outpatient cover pays for consultations, tests and scans where you are not admitted. Almost every policy covers inpatient treatment in full for eligible conditions, because that is the expensive end and the part people cannot self-fund. Outpatient cover is where policies differ: it may be unlimited, limited to a set amount a year, limited to diagnostics only, or excluded entirely. A policy with no outpatient cover can still be useful, but you should expect to pay for the consultation and the scan that establish what is wrong before the policy starts paying.
    Do I need a GP referral to claim?
    Usually yes. The standard route is that your GP refers you to a named specialist or to a specialty, and you then contact the insurer for authorisation before the appointment is booked. Some insurers now accept self-referral for certain services, such as physiotherapy or mental health support, through their own digital services; others run a virtual GP service that can issue the referral. What is almost never optional is the authorisation step. Going ahead and asking afterwards is the most common way a perfectly eligible claim turns into a dispute, because the insurer has had no chance to confirm eligibility, the fee or the facility.
    Will my premium go up if I claim?
    It can. Most policies are annual contracts that are re-rated at each renewal, and the pricing takes account of your age, medical inflation, the claims made on the policy and the insurer’s overall experience. Some policies carry a no-claims discount scale that steps down when you claim and steps back up over subsequent claim-free years; others price on the group or the individual without a formal scale. None of this is a reason to avoid a valid claim on a policy you are paying for, but it is a reason to read how your insurer handles renewal before you buy, and to review the market at renewal rather than accepting the quoted increase automatically.
    What should I do if a claim is turned down?
    Ask the insurer, in writing, which clause of the policy wording the decision rests on. Most declines fall into a small number of categories: the condition is pre-existing or chronic, the treatment was not authorised in advance, the facility was not on your list, or an annual limit has been used up. If you believe the decision is wrong, complain to the insurer formally and give them the chance to review it. If you are still unhappy after their final response, or after eight weeks, you can take the complaint to the Financial Ombudsman Service, which handles medical insurance complaints free of charge for consumers. [5]

    Sources and methodology

    1. [1] Association of British Insurers. “Insurers process record £4bn across individual and workplace health schemes (2024 data)”. Published 21 January 2026. View source(opens in a new tab)Primary source
    2. [2] Financial Conduct Authority. “ICOBS 6: Product information (FCA Handbook)”. Published Accessed 14 September 2026. View source(opens in a new tab)Primary source
    3. [3] Competition and Markets Authority. “Private healthcare market investigation”. Published 2 April 2014; case page updated 2 July 2026. View source(opens in a new tab)Primary source
    4. [4] Private Healthcare Information Network. “Information about private hospitals and consultants”. Published Accessed 14 September 2026. View source(opens in a new tab)Primary source
    5. [5] Financial Ombudsman Service. “Complaints about medical insurance”. Published Accessed 14 September 2026. View source(opens in a new tab)Primary source
    6. [6] Financial Conduct Authority. “The Consumer Duty”. Published Accessed 14 September 2026. View source(opens in a new tab)Primary source
    7. [7] Department of Health and Social Care. “The NHS Constitution for England”. Published Updated 17 August 2023. View source(opens in a new tab)Primary source
    8. [8] NHS England. “Referral to treatment (RTT) waiting times statistics, July 2026 data”. Published 10 September 2026. View source(opens in a new tab)Primary source

    We cite primary sources wherever possible. Read about our sourcing methodology.

    Written by

    Stuart Hendy

    PMI Expert and Head of Publishing, PremierPMI

    • 20 years in UK private medical insurance
    • Underwriting and corporate placement specialist

    Stuart brings over 20 years of experience advising on UK private medical insurance. He is a key member of the private medical insurance team and Head of the Publishing Team, gathering detailed client requirements, liaising with insurers on tailored quotes, and running training on insurer product changes and underwriting nuance.

    Read full profile

    Reviewed by

    Parvoz Haydarov

    Founder, PremierPMI

    • Founder of PremierPMI
    • Whole-of-market private medical insurance

    Parvoz founded PremierPMI as a specialist private medical insurance brokerage. He sets the direction of the firm — insurer relationships, service standards, compliance culture and the editorial bar for everything published under the PremierPMI name — and personally reviews the largest corporate and family cases before they go to market.

    Read full profile

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