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Health insurance gives you access to high-quality private medical care when needed most. However, every policy has exclusions, meaning it won't cover everything. This guide examines the most common health insurance exclusions so you can consider whether health cover is right for you.
Chris is our resident private health insurance and healthcare expert. He has over a decade of experience writing about private medical insurance and treatment. He's Chartered Insurance Institute qualified and is regularly quoted by the national press.
Health insurance pays for private healthcare for acute conditions that treatment can resolve and don't need long-term monitoring. However, there are exceptions.
Insurers each have a list of standard exclusions detailing treatments their health insurance policies don't cover. You'll find some standard exclusions in health insurance from most providers. An insurer may also decide to exclude some types of treatment to offer more coverage elsewhere.
Other health insurance exclusions depend on your medical history and will be unique to you.
There's an essential difference between exclusions in health insurance and the level of cover your policy provides. A health insurance policy includes core cover, typically inpatient treatment, cancer care and other membership benefits. You can also add optional extras at an additional cost to provide more comprehensive coverage.
For example, outpatient cover pays for private diagnostic tests and consultant appointments. If your policy doesn't have it, you'll need an NHS diagnosis first. However, depending on your medical history or other policy exclusions, your outpatient cover may exclude some treatments.
Policy exclusions in health insurance relate to anything that's excluded as standard. When your health insurers apply standard exclusions, their policies won't cover treatment for anyone, regardless of their medical history.
Each insurer has its own exclusion list, so check the small print before you buy health insurance. However, here are some of the most common health insurance exclusions.
Health insurance policies cover treatment costs for essential medical care. If your insurer classes the procedure you want as a lifestyle choice rather than a medical necessity, they'll typically exclude it. The NHS may offer cosmetic treatments or weight loss surgery in some circumstances if there's a medical or psychological benefit.
However, health insurance policies typically don't cover cosmetic surgeries, meaning you'll need to self-fund if you want this type of surgery.
Private hospitals don't have accident and emergency departments, so you must head to your local NHS A&E department or urgent care centre or call an ambulance in an emergency. Health insurance provides planned care.
Some health insurance plans cover a private ambulance, but this isn't an emergency service. It provides transport in conjunction with planned private treatment. For example, you can book a private ambulance to take you home after an operation if you can't drive or travel in a car for medical reasons.
Pregnancy and childbirth are considered lifestyle choices, meaning your health insurance likely won't cover your routine checks or birth. However, some policies include complications such as miscarriage, ectopic pregnancy or retained placenta.
Health insurance plans also exclude fertility treatments and family planning services.
Therapies for addiction, whether to drugs, alcohol or anything else, are excluded from most plans. However, there are exceptions. Bupa treats addiction as a mental health condition and includes access to rehab on some of its health insurance plans.
Most health insurance plans include some mental health support and access to telephone helplines. These services may help signpost you to appropriate support services even if your health insurance doesn't cover your care.
Intensive care units (or ICUs) provide highly specialised treatment and around-the-clock care when you're most vulnerable. While private hospitals can treat complex medical conditions, such as cancer, they don't typically have the right facilities, specialist equipment or highly trained doctors, nurses and healthcare assistants.
It can mean that if you experience complications during or after private surgery or other treatment, you'll likely need a transfer to an NHS hospital for continuing care.
If you or your child have a suspected learning difficulty or behavioural or developmental condition, it can profoundly affect your life and educational attainment. A child may need specialist support at school, or your doctor may prescribe medication in some circumstances. Conditions such as ADHD can take time to diagnose. NHS guidelines advise a 'watchful waiting' period of around ten weeks to see if a child's behaviour improves. Keeping a journal detailing your child's behaviour can help. However, you may still face a lengthy waiting time.
You can pay for a private ADHD or autism diagnosis and report. Prices vary, but you can expect to pay around £1,200 to £1,600 on average. Unfortunately, health insurance plans won't fund assessments or treatment as learning difficulties typically need lifelong management, so they aren't classed as acute conditions.
As mentioned, health insurance treats acute conditions, meaning chronic conditions aren't covered. Chronic conditions are any conditions that need life-long management, monitoring and treatment. Private healthcare providers can't offer long-term treatment, so you'll need to see your NHS GP or consultant as appropriate.
Chronic conditions include:
If your policy has outpatient cover and your symptoms could indicate either a chronic or acute condition, you can still use your health plan to get a diagnosis.
We've already mentioned that some exclusions depend on your circumstances and history. All health insurance providers exclude pre-existing medical conditions, defined as conditions you sought medical advice or treatment about during the five years before you took out a policy.
Health insurance only covers conditions that arise after you buy the policy. Pre-existing conditions are excluded because you're more likely to claim for something you've had before. However, if you stay symptom-free for the first two years of your policy, your insurance provider can remove the exclusion.
The underwriting on your chosen policy impacts the information you must provide when you first buy the policy and can also affect your overall claims experience. Individual health insurance policies exclude pre-existing conditions for the first two years. However, there are differences between the two main types of underwriting.
When you choose moratorium underwriting, your insurance company won't ask for any medical information when you buy the policy. However, they'll investigate when you claim to check for any pre-existing conditions that might mean your treatment is excluded from cover. This can mean the process takes longer. Rejected claims can also impact your renewal premium, even if they are only rejected because you've forgotten about a call you made to your GP four years ago.
Moratorium underwriting is ideal for people with a straightforward medical history. It also means you'll have less paperwork to complete when buying the policy.
If your policy has full medical underwriting, you'll need to complete a medical questionnaire when you buy your health insurance. Filling out these details allows you to disclose any relevant medical conditions. It gives you and your insurers certainty about what the policy covers from the outset, which can give you a lower premium. Full medical underwriting is ideal for people with complex medical histories.
However, it would be best if you were careful when completing the questionnaire. If you provide inaccurate information, it can not only lead to rejected claims but also invalidate your policy and make it more difficult for you to get health insurance in the future.
If your health plan doesn't cover the treatment you need, you may still be able to access private care. Private providers offer some treatments on a self-pay basis. For example, say you have a pre-existing hip problem, meaning your insurance plan doesn't cover your hip replacement. If you have enough savings, you can contact a private hospital for a fixed-fee quote and pay for it yourself. Many hospitals also offer finance options that let you pay in installments.
You can also pay for private pregnancy care and birth, with packaged prices depending on your birth choices.
MyTribe guides offer general advice to help you learn more about health insurance. However, they aren't a replacement for specialist advice tailored to your circumstances. Speaking to a broker lets you choose the right health insurance policy for your needs and understand how health insurance exclusions could affect your coverage. Contact us for a comparison quote, and we'll put you in touch with a regulated broker for tailored advice.
Disclaimer: This information is general and what is best for you will depend on your personal circumstances. Please speak with a financial adviser or do your own research before making a decision.
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