How does Private Medical Insurance work? Everything you need to know

People with private health insurance in the UK is on the rise as NHS waiting lists remain at a high. More people are looking for ways to protect their health and get peace of mind.

If you’re new to private healthcare, you may be wondering how does private medical insurance work?

We're exploring everything you need to know about cover and how health insurance can work for you.

If you already have health insurance and are looking for tips on comparing health insurance to find the best policy at the best price, we can help. 

How does private health insurance work?

Getting Started:

The process of obtaining private medical insurance can be simple when you follow the right steps and have expert advice to guide you.

A private health insurance policy will look different for each person and is designed to be bespoke to you and your needs. 

In simple terms, when you take out a policy, it's an agreement between you and the insurer that should you fall ill or suffer an injury, the policy will attempt to return you to the same level of health you had when you took it out.

You’ll usually make a monthly payment to your insurer which is known as your premium and your insurer will then cover your healthcare bills if you need to make a claim on your policy.

You may also have an excess which you agree to when taking out a policy, which is what you’ll pay towards the claim. Higher excess amounts normally mean a lower premium, and lower excess will mean you pay more on your premium, but it's about finding what works best for you.

Health insurance covers new conditions which begin after you’ve obtained your policy and pre-existing conditions are usually excluded. This doesn’t stop you getting a policy if you do have pre-existing conditions though, you’ll just have them excluded from your policy.

Coverage Options:

When it comes to PMI, it’s never a one-size-fits-all product. There are plenty of different coverage options to consider, which can make obtaining private medical insurance quite an overwhelming process without guidance.

This is why using an intermediary can help you to understand all coverage options available.

You can choose what you do and don’t want included in your policy and this will in turn affect your policy premium. This is one of the great benefits you get from talking with an expert adviser - you can understand each element of the cover and what would or wouldn’t work best for you.

We discuss coverage options in more detail in this blog here. 

Support finding a policy:

There are many options available to help you find a suitable policy. An effective way to do this is by using a free comparison service, like Usay Compare.

An expert adviser can guide you through the process of what options are available to you, their recommendations and important details of the policy that you need to know.

Once you’re happy with your policy and what’s involved, you have peace of mind that you’re covered if you fall ill or injured.

How does private health insurance work with the NHS?

One great benefit of private health insurance in the UK is how well it can work hand-in-hand with the NHS to deliver healthcare services to everyone.

When it comes to making a claim on a private health insurance policy, you’ll usually need an NHS referral (in some cases you can use your insurers online GP service to get a referral). So you'll still use the NHS services to some extent in the process.

There are certain situations where you may not need a GP referral, for example, with Bupa health insurance. If you have concerns about cancer, muscle bone and joint issues or mental health, you can speak to them about symptoms without a GP referral.

NHS or private medical?

There are certain things that private healthcare may be more suitable for, especially if you want to have treatment quicker and in a private facility.

There are also many things that you’ll always need to continue using the NHS for, such as accident and emergency, chronic conditions and pregnancy.

Private healthcare can be an option for potentially quicker access to treatment for things the NHS deem as non-urgent such as: hip and knee replacement surgery, cataract surgery, gallbladder removal surgery and colonoscopy.

Taking treatments private can also help to reduce the strain on the NHS, but it’s important to note even with health insurance, you will always have your access to the NHS and to use their services whenever you need.

The two work together to provide options for patients and ultimately provide the best care available to make sure everyone gets the healthcare that they need to continue living the lives they love, through a range of  options available.

Some of the key benefits of the NHS include:

• It's accessible to everyone in the UK.
• They offer a wide range of free medical services.
• No need for upfront payments and insurance premiums.

Some key benefits of private medical insurance include:

• Shorter waiting times for consultations, diagnostics, and treatments.
• Choice over preferred hospitals and specialists.
• Access to additional services and treatments not covered by the NHS.

Can I still use the NHS with private healthcare?

Yes, the NHS will always be there for you and you can choose to continue to use it whenever you need to.

As mentioned, there are some healthcare elements that the NHS will also need to be used for. For example, in an emergency you'll need to use the NHS, there are no private ambulances and no cover for emergencies so that will always be dealt with by the NHS.

Another key example is chronic/long term or pre-existing conditions. As these aren’t covered with a private health insurance policy, any pre-existing conditions you already have will have to be dealt with by the NHS, for example asthma or diabetes.

Private healthcare is about getting quicker access for consultations, diagnostics, and treatments than you usually would on an NHS waiting list, with benefits such as private rooms and breakthrough treatments not currently available on the NHS.

What types of cover is available and what do I need? 

There are a lot of different coverage options available that can be tailored to each individuals specific needs and requirements.

Some of the key elements typically included in core cover are:

• In-patient cover - Covers hospital accommodation charges, specialist fees such as consultants, surgeons and anaesthetists, and diagnostic tests and scans such as CT, PET and MRI scans, X-rays or physiological tests.
• Day-patient cover - Covers you when you’re admitted to hospital and discharged the same day and includes the same benefits as in-patient cover.
• Out-patient cover - Most private medical insurance policies will offer some out-patient cover within their core cover.
• Cancer cover - Most private medical insurance policies will offer cancer cover within their core cover.

There will be options within your cover to add-on or change the amount you're covered for to best suit your needs.

For example with out-patient cover you can choose to have a fully comprehensive option which includes out-patient cover in full or you can remove or limit it.

If you choose to limit your outpatient cover, there are a range of limits you can set, usually from £500 to £1,500.

Other optional extras available include:

• Dental cover
• Optical cover
• Mental health cover
• Therapies such as physiotherapy, osteopathy and chiropractic

In-patient and out-patient cover:

Understanding the difference of what's included with in-patient and out-patient care will allow you to identify what's important to include in your cover.

In-patient refers to medical treatment that requires admission to a hospital or healthcare facility. This includes a whole range of services from surgeries and intensive care to overnight stays for monitoring and observation.

In-patient cover is included as standard with most insurers.

Out-patient care is medical services you'll receive without the need for an overnight stay in hospital. This would typically include consultations, diagnostic tests, minor procedures or follow-up appointments. 

With out-patient cover, you'll have different options to choose from on your policy, you can have this as fully comprehensive cover or even choose to remove it. 

As you can see, there is a lot to cover and a wealth of different elements that make up a health insurance policy.

It can be invaluable to utilise an intermediary. They’ll get to know your individual needs and explain the options available. You’ll get real peace of mind knowing exactly what you’re covered for and what to expect if you do need to make a claim.

Who are the UK's best providers?

There are many UK health insurance providers, which can make looking for health insurance a bit of a minefield!

At Usay Compare, we work with the UK’s leading insurance providers to bring our customers the most suitable policy at the best price available. Some of the top health insurance providers we're proud to work with include: Aviva, AXA, Bupa, Freedom, The Exeter, Vitality and WPA.

Who pays the bill for private healthcare when you have insurance?

With private health insurance, you have the peace of mind that as long as your premium is paid, your private healthcare bills will be covered. There may be an excess you agree to pay when you take out the initial policy, but other than that your healthcare bills are covered by your insurance provider.

This makes health insurance an attractive option, as you don’t have to foot expensive bills and you’re prepared for the unexpected. Your insurance provider will pick up the bills and deal with the payment on your behalf.

How do you claim on your private healthcare?

Whilst claiming on your private healthcare is a different process with each insurer, the process is usually similar.

The claims process will be explained when you take out a policy or in your policy documents, but the usual claims process will look something like this:

1. Visit a GP – This can either be your GP or the digital GP service provided by your insurer. Let your GP know you have private health insurance.
2. Get an open referral – An open referral is when your GP doesn’t specify a particular consultant by name. Instead it will state what specialism is needed.
3. Contact your insurer – They will usually want to see a copy of the referral letter and details. They’ll be able to check the treatment is covered on your policy.
4. Have the treatment – You’ll have your treatment in your private healthcare facility. Your provider will get details from the facility following your appointment.
5. Settling the bills – Your insurance provide will settle the necessary bills on your behalf, whilst taking into account any excesses or benefit limits.

What happens if your claim is rejected?

In the unfortunate circumstances that your claim does get rejected or denied, there are some steps we recommend to follow.

It’s always good to be aware of exactly what your policy covers from the start, but if a claim does get denied, take a look back at your policy details and see if you can identify the reason why this has happened.

It may be that you’re not covered for a certain thing. Other common reasons could include not getting pre-authorisation for the claim or you went to an out-of-network provider.

If you see no issues or want further advice or support you should then contact your health insurer, who will be able to explain the reason or any next steps you need to take in full details.

What is excess and how does it work?

An excess is an amount you’ll agree to pay when taking out your policy, that you’ll pay towards the fee if you need to make a claim.

An excess is a way to reduce your private health insurance premium, by volunteering to pay the first part of any claim, up to a fixed amount of money. A policy excess is the pre-determined initial amount you agree to pay towards a claim, before the insurance covers the rest.

Increasing the excess you agree to pay will help to bring your policy premiums down, but it’s important to consider this option carefully and that paying a larger excess wouldn’t affect you financially.

Having a lower excess would mean you spend more on your premium, so again, its worth considering what’s more affordable and how likely you think you’d be to claim and if it would be harder to pay a larger premium or larger excess.

What are limits, and how do they work?

Limits refer to the amount your policy will pay out each year.

It is what you'd be covered for up to a certain amount, so if your bill was over that amount, the provider would only cover up to the limit that is in place. These are typically used on out-patient cover, and would affect your premiums (the lower your limit the lower your premium).

So when it comes to out-patient cover, you can opt for full cover which is comprehensive and with no limits, the benefit of this is that you’re covered no matter what for the cost of consultations, diagnostic scans/tests and some minor surgical procedures.

If you choose to limit it, you’ll only be covered up to a certain amount and will need to pay the rest. This option understandably will make premiums cheaper, but again, needs consideration of if you will be able to cover the rest of the bill out of pocket.

When it comes to private medical insurance, there are a lot of elements to take into consideration. 

This is why an intermediary service can help, with a non-biased and no obligation quote, you can know your options and exactly what you’re covered for.

Ultimately, its about making informed decisions based on your needs and what's best for you.

Whenever you’re ready to find your policy, our advisers will be ready to support you. You can fill out a quote and await a call from our team or get started now and give us a call on: 01285 864670