Understanding Why Health Insurance Doesn't Cover Pending Treatments or Existing Illnesses

If you're currently awaiting treatment or having a condition investigated, you may wonder whether private health insurance is the solution. In this guide, we explain why health insurance won't cover existing illnesses and offer other options to consider.

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This article was written by:
Chris Steele
Founder and Editor

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.

The Challenge of Awaiting Treatment in the UK

If you are currently awaiting medical treatment in the UK or perhaps are in the early stages of having investigations and tests carried out, you'll know that waiting times via the NHS are currently at some of their longest, with a record-breaking backlog of both non-urgent and urgent treatments ahead of you in the queue. 

Add to this the doctors' strikes, with June's three-day walkout set to have an "enormous impact", according to Prof Stephen Powis, NHS England's national medical director, it's entirely understandable that you're worried, potentially in pain, and looking for solutions.

Unfortunately, insurance can't provide the solution you're hoping for if your treatment or illness was present before you took out a health policy. 

In this article, we explain why that is and discuss some other routes you might consider to get the care you need.

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Why Health Insurance Doesn't Cover Pre-Existing Conditions

This section explains what a pre-existing medical condition is and why most health insurance policies don't cover them. 

Definition of Pre-Existing Conditions

Pre-existing conditions are any illnesses or injuries you have before starting a health insurance policy. They range from chronic conditions like diabetes to recent injuries or pending treatments.

The Insurance Perspective: Risk Management

From an insurance point of view, covering pre-existing conditions is a high risk. Since these are known issues, you're very likely to claim, and that's a cost risk for insurers. Therefore, nearly all policies exclude them to keep premiums affordable for a broader range of people. The only exception is policies for large businesses that opt for a type of underwriting called "Medical History Disregarded"; however, it has to be said that comes at a high cost. 

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Your Health Insurance Policy: Reading the Fine Print

Here we explain more about what is and isn't covered by a health insurance policy. Remember, this is all general information, and you should refer to your policy documentation for precise detail.

What Most Health Insurance Policies Cover

Health insurance typically covers treatment for acute conditions that develop after you take out the policy. This can include surgeries, therapies, and sometimes even specialist consultations, but usually not chronic conditions management.

When Pre-Existing Conditions Become Eligible for Coverage

Now, there are instances when pre-existing conditions might eventually be covered. Some policies have moratorium periods. After a certain period without symptoms or treatment for a pre-existing condition, usually around two years, the insurer might cover the condition. However, this varies from policy to policy, and the underwriting is opted for at inception.

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Getting Around the Waiting Lists: Alternative Solutions

We know many of you will still be looking for options, and we want to provide some solutions that could help, albeit they all require having the means to pay for treatment.

1. Self-Pay for Consultations and Treatments

If you find yourself waiting for treatment, one option is to self-fund some aspects of your care. This could include consultations, diagnostics, or even treatments. Yes, it can be costly, but it may help to reduce your waiting time.

2. Privately Paid Services with Return to NHS Treatment

Another approach to consider is a mix-and-match method, combining private and NHS care. For example, you could choose to pay for an initial consultation or diagnostic test privately and then return to the NHS for the actual treatment. This approach could expedite the diagnosis process without the full cost of private treatment.

How to get quotes for treatments

If you want to find out what a specific test or treatment might cost privately, you will need to contact a private hospital and request a quote or engage directly with a consultant to find out about their charges.

Links to private hospital groups in the UK:

Please note that there are also numerous independent private hospitals, which may be closer to where you live.

Find a private medical consultant.

You can find a private medical consultant in several ways, but a good starting place is the PHIN website.

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The Importance of Understanding Your Insurance Policy

We can't stress enough how vital it is to thoroughly understand the ins and outs of your insurance policy. Knowing what is covered and what is not can help you make informed decisions about your healthcare options.

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Strategising Your Healthcare: Combining Private and NHS Services

Remember, combining NHS and private healthcare services could be a strategic way to manage costs while reducing waiting times. It's about finding the best balance for your specific needs and circumstances.

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.

Frequently Asked Questions

Can I get any kind of health insurance coverage for my pre-existing condition?

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Depending on your policy and the specific condition, you might be eligible for coverage after a certain moratorium period. Usually, this period is about two years without symptoms, advice, or treatment for the condition, but the specifics vary from policy to policy.

Can I get any kind of health insurance coverage for my pre-existing condition?

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Depending on your policy and the specific condition, you might be eligible for coverage after a certain moratorium period. Usually, this period is about two years without symptoms, advice, or treatment for the condition, but the specifics vary from policy to policy.

What if my condition worsens while I'm on a waiting list?

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If your health deteriorates significantly while waiting for treatment, get in touch with your doctor immediately. They can reassess your situation and potentially expedite your treatment, subject to NHS guidelines and capacities.

What if my condition worsens while I'm on a waiting list?

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If your health deteriorates significantly while waiting for treatment, get in touch with your doctor immediately. They can reassess your situation and potentially expedite your treatment, subject to NHS guidelines and capacities.

Is it worth paying for private healthcare if I'm on an NHS waiting list?

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There's no one-size-fits-all answer to this, as it really depends on your personal circumstances – such as the severity of your condition, your financial situation, and how long you've been waiting. In some cases, paying for certain services privately can speed up the process.

Will my health insurance cover treatment for a condition I develop after taking out the policy?

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Yes, most health insurance policies are designed to cover acute conditions that you develop after the policy starts. However, they may not cover the management of chronic conditions, so it's always important to read the fine print.

Can I switch insurance providers if I have a pre-existing condition?

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While switching providers is possible, you may find that your new insurer excludes pre-existing conditions you've had in the past five years. The best bet is to speak with a broker, who will be able to assist you in the decision-making process.

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