When you apply for health insurance, it is always important that you check the terms and conditions for any health exclusions. This refers to things that are not covered or are ‘excluded’ from your policy.
Whilst having private medical insurance covers you for a lot of things such as physiotherapy, diagnostic test and hospital treatment, there are exclusions that are unlikely to be covered for, such as:
- Pre-existing medical conditions
- Chronic conditions
- Dental work
- Prescription drugs
- Cosmetic surgeries
- Other exclusions e.g infertility, routine pregnancy, speech therapy
Pre-existing medical conditions
A pre-existing medical condition is one that you have had symptoms, medication or treatment for prior to the start date of a new health insurance policy and maybe are still getting treatment for.
This could affect conditions and treatment, from getting physio to treat a bad shoulder, treating bladder problems, middle-ear infections, lung, chest conditions and more.
Pre-existing health conditions and ailments are often excluded from your policy because health insurance is designed to treat new conditions that occur after your cover has started. Afterall, insurance is about unforeseen or unexpected risks rather than the insurer paying out immediately for something that happened before cover was in place.
To check for any pre-existing conditions, health insurers may require some medical history beforehand or apply a fixed exclusion.
Health insurance policies in the UK will not typically cover chronic conditions that are classed as ongoing, require long-term treatment, have no cure or likely to come back.
This could be recurring lung or heart problems, kidney dialysis or types of cancer.
Health insurance is designed to pay for treatment to nurse you back to original health – and if something is ongoing and likely to affect you long-term, they typically cannot cover you for it. But there may be circumstances where a chronic condition has a sudden, short-term deterioration, which can be treated to return you to your previous state of health that insurers can consider depending on the circumstances.
Routine dental treatment is usually covered by a separate dental insurance add-on or cash plan, rather than your health insurance.
However, this is not always the case. You may be eligible for cover in the event of certain specialist dental surgery, whereas a dental insurance add-on or health cash plan can allow you to claim back up to a certain cash amount each year for routine dental check-ups, appointments with a hygienist and fillings.
However, cosmetic dentistry such as braces, teeth whitening or veneers are not typically covered by your standard PMI.
Outpatient prescription drugs are not usually covered by your private medical insurance, but it may depend on whether you are receiving other private treatment at the time and drugs are prescribed by the specialist in charge of your treatment in hospital. In this case, it is worth checking the terms of your policy and what coverage you get as an outpatient.
Cosmetic surgeries are considered to be lifestyle choices or ‘elective treatments’, rather
than necessity and for this reason, they are not covered by health insurance policies. This includes cosmetic treatments such as nose jobs (rhinoplasty), breast implants, botox, face lifts and anything aesthetic.
However, some reconstructive surgeries may be covered by insurance following an accident and to treat a short-term curable condition that would otherwise be covered.
Always check the terms and conditions of your policy.
There are a number of general exclusions which are commonly found in the main UK health insurers policies – which may be because they meet some of the criteria discussed such as being chronic, long-term, cosmetic or if there are no cures available, this includes:
- Alcohol, drug or substance abuse
- Allergies or allergic disorders
- Birth control, infertility, sexual problems and gender re-assignment
- Treatment to correct eyesight (e.g. long or short)
- Genetic tests, health screenings or vaccinations
- Intensive care (other than in some specific circumstances)
- Learning difficulties, behavioural and developmental problems
- Overseas treatment and repatriation
- Routine pregnancy and childbirth (although certain complications of pregnancy may be covered)
- Professional sports injuries
- Puberty, menopause and ageing
- Self-inflicted injury or suicide
- Sleep problems and disorders
- Weight loss treatments
For more information, see our full range of health insurance plans and pricing.