Does health insurance cover you instantly?

Watch: How private health insurance works

Here's a short video explaining how private health insurance works:

What does health insurance cover?

When you choose your private health insurance coverage, you'll be offered different options to help you tailor your coverage. Health insurance policies provide different levels of coverage, both in the types of treatment they offer and the financial limits that apply.

Here's what you can expect from your private medical insurance.

Acute conditions

Private health insurance policies cover treatment for acute conditions. Acute conditions are any illness or injury that a single course of treatment can cure. Of course, if you've had a cancer diagnosis, your treatment may carry on over a long period. However, it's still classed as an acute condition.

If you have a condition you can manage but not cure, your private health insurance won't cover it. However, if you've had a sports injury or your GP has advised that you need a hip replacement, your health insurance should allow you to have private treatment as long as your policy covers it.

Core coverage

Every private health insurance policy includes some core coverage as a standard part of the policy. The details vary depending on your chosen provider. However, every insurance company provides inpatient, day-patient, and cancer care as part of their basic policy. You'll also have access to services such as a 24/7 virtual GP service that offers online appointments, telephone helplines and mental health support.

Health insurance companies also offer other perks and benefits, for example, discounts on products and services or rewards for healthy living.

Optional extras

If you want to enhance your private health insurance coverage, you can choose to add a range of optional extras to your policy. Standard policies don't typically cover consultant appointments and diagnostic tests, so you'll need outpatient coverage if you want to include them. Outpatient cover can also include things like physiotherapy.

Other optional extras can include optical and dental cover. You can also choose elements such as enhanced mental health insurance, additional therapies such as acupuncture or widen your choice of private hospitals.

What's excluded from health insurance coverage?

Private health insurance is designed to cover acute conditions so you can get back to full health after an illness or injury. This means that some conditions are excluded from coverage. Every insurance company has a list of standard exclusions that they don't cover under any circumstances. They'll also only cover treatment for new conditions that develop after you take out the policy.

Here's how exclusions work.

Pre-existing conditions

Private medical insurance only covers new illnesses, at least at the start of your policy. An insurance company excludes pre-existing medical conditions because there's an increased risk that you'll claim for something you've had before. That means the cost your insurance company pays for your treatment would be higher. They remove this risk by excluding any condition you've had advice or treatment for in the five years before you took out the policy.

If you remain symptom-free for the first two years after you take out private health insurance, your insurers can add the condition to your policy. However, if you've just had a medical diagnosis and are wondering whether you can take out health insurance to get private treatment, the answer is no.

Chronic conditions

Chronic illnesses include things like asthma, diabetes or high blood pressure that need ongoing management. Private health insurance doesn't cover these conditions because they'll likely need continued care and monitoring throughout your life. Generally speaking, private healthcare centres aren't set up to offer this type of care. With NHS treatment, you can get regular appointments with your GP or treating consultant to keep your condition under control.

Standard exclusions

Every private medical insurance company has some standard exclusions on their policies. These typically include cosmetic treatments, normal pregnancy and childbirth, fertility treatment and treatments for addiction.

Insurers vary in the exclusions they apply to their health insurance policies. Some have a longer list of exclusions but offer more comprehensive coverage in their standard health insurance plans. If a condition or type of treatment is particularly important to you, check the small print before you choose your policy.

Do you need treatment now?

If you've received a diagnosis from the NHS and are wondering whether you can take out private medical insurance to access treatment, you can't. Health insurance only covers conditions diagnosed after you take out the policy.

Of course, you can still take out private medical insurance. However, it will only pay private healthcare costs for conditions that develop in the future.

You have two options if you don't have health insurance and need to access treatment immediately. You can opt for NHS treatment or consider the self-pay option if you want to go private.

NHS treatment

If the NHS diagnosed you, you'll likely be on a waiting list for further NHS treatment. You'll be prioritised based on urgency but could still face a lengthy wait. The obvious advantage of staying with the NHS is its free healthcare. You'll also be treated by the same highly skilled and qualified doctors you'd see in a private setting. Many consultants have a private practice alongside their NHS work.

However, you may have to wait longer for treatment if your condition isn't life-threatening.

Self-pay treatment

If private medical insurance doesn't cover your treatment because you need treatment for a pre-existing condition, you can still access private healthcare. If your GP or NHS consultant has told you that you need surgery, for example, a hip or knee replacement, you can ask for a private referral letter, approach private healthcare providers and fund the treatment yourself.

Self-pay is ideal if you have some savings, although most hospitals also offer finance options to help you spread the cost. You can choose a hospital and consultant that suits your needs. It's also worth asking your NHS consultant if they can see you as a private patient. You'll get a fixed fee quote that covers your pre-operative checks, surgery, some aftercare and the costs of your stay in hospital.

Self-pay may not be the best option if you've been diagnosed with cancer. Whilst the cost of private surgery is generally predictable, cancer treatment can be complex. Treatment costs can quickly become unaffordable.

How the claims process works

If you have private medical insurance and want to access treatment, start the process by claiming your health insurance. Your insurance company then considers your claim to decide whether the policy covers it before approving treatment. The process varies depending on your underwriting type but typically starts in the same way.

Submitting a new claim

When you take out private health insurance, your insurance company will send you information detailing how to make a claim. Many insurers offer an app or ask you to make a claim online. Others prefer you to phone and speak to an adviser.

Health insurance providers aim to decide claims as quickly as possible. However, the time this takes can depend on the underwriting your policy has.

Policy underwriting

Health insurance policies have two types of underwriting. Both exclude pre-existing medical conditions, as we've already discussed. However, they differ in the information you're asked to provide upfront, and the time it can take for a claim to be settled.

Moratorium underwriting

If your policy has moratorium underwriting, you won't have to provide details of your medical history when you take out the policy. However, your insurer will check whether your treatment is covered when you claim.

Your insurer will likely contact your GP to ask for information. Your GP will be mindful of your privacy and only provide relevant information. The BMA has issued guidance on requests from insurers to advise doctors on how to respond to these requests.

Full medical underwriting

When you choose full medical underwriting, you'll be asked to provide medical details when you take out the policy. Your insurer can then confirm what's covered from the start. The claims process is typically quicker because your insurance provider already has the information they need to decide.

Rejected claims

Insurers can reject claims for several reasons. You may claim for treatment without realising it's a standard policy exclusion. Policies have limits on the number of treatment sessions it covers or how much money is available for different therapies. If you have some treatment and hit the limit, your insurer may not be willing to approve more.

If your insurer asks your doctor for a report, they may decline your claim because of something in your medical history. Insurers define pre-existing conditions as anything related to your current claim. For example, your insurers could deny your claim to access physiotherapy for neck pain because you had a whiplash injury four years ago. Your earlier injury may have healed but could still be considered a related condition.

Fraud

A rejected health insurance claim could mean you must explore other treatment options. However, in some circumstances, it could be considered fraud.

The insurance market treats tackling fraud as a high-priority issue, as insurance fraud can potentially cost billions of pounds. Insurers identified fraudulent claims totalling £1.1 billion in 2021 and believe that a similar amount is paid each year thanks to undetected fraud. Some of these claims will be from ordinary people, but others will help to fund organised crime.

If you've already had a medical diagnosis and are wondering whether you can fudge your health insurance claim to access private healthcare, please don't. You may not view it as fraud, but your insurance company likely will, and it could have serious consequences.

Be honest

Deliberately withholding or falsifying the information you provide to your insurers can be classed as fraud. At the very least, it could mean they withdraw policy coverage. Even if you provided medical information when buying health insurance, your insurer may still contact your doctor to check on any claims you make when you first have the policy.

You could also claim, forgetting that you saw your doctor for a related condition four years ago. That could be regarded as an honest mistake. However, if your GP reports back saying that you had a new diagnosis a month ago, that could be treated as fraud too.

If you know you have had treatment for something before, you must be honest when you provide insurance information and make a claim.

Does it matter if I claim for a pre-existing condition?

Many people think of fraud as a victimless crime. You're claiming money from a huge insurance provider with lots of money. However, the reality is that all claims impact the cost of insurance premiums, and insurers pass price rises on to all their customers. It's one thing if that happens because of genuine claims, but if you make a fraudulent claim, you push the cost up for everyone, including yourself.

If you're caught, the penalties can be severe. Fraud can carry a prison sentence and impact your ability to find a job and get insurance in the future.

Getting professional advice

MyTribe guides provide general information to help you to understand your options when choosing health insurance and finding the right coverage for your needs.

When you contact us for a comparison quote we'll put you in touch with a regulated broker who'll give you tailored advice based on your circumstances. Get in touch today.