Health insurance gives you access to high-quality private medical care when you need it most. However, every policy has exclusions, which means it won’t cover everything. This guide examines the most common health insurance exclusions so you can consider whether health insurance is right for you.
How do health insurance exclusions work?
Health insurance pays for private health care for acute conditions that treatment can resolve and does not require long-term follow-up. However, there are exceptions.
Insurers have a list of standard exclusions detailing treatments that their health insurance policies do not cover. You will find some standard exclusions with most health insurance providers. The insurer may also decide to exclude some types of treatment in order to offer more coverage elsewhere.
Other health insurance exclusions depend on your medical history and will be unique to you.
Level of coverage
There is an important difference between health insurance exclusions and the level of coverage your policy provides. A health insurance policy includes basic coverage, usually hospital 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 coverage pays for private diagnostic tests and consultations with consultants. If it’s not on your policy, you’ll need an NHS diagnosis first. However, depending on your medical history or other policy exclusions, your outpatient insurance may exclude some treatments.
Health insurance policy exclusions
Exclusions from the health insurance policy refer to everything that is excluded by default. When your health insurance applies standard exclusions, their policies will not cover treatment for anyone, regardless of their medical history.
Each insurer has its own list of exclusions, so check the fine print before purchasing health insurance. However, here are some of the most common health insurance exclusions.
1. Cosmetic and weight loss treatments
Health insurance policies cover treatment costs for basic medical care. If your insurer considers the procedure you want to be a lifestyle choice rather than a medical necessity, they will usually exclude it. The NHS may offer cosmetic treatments or weight loss surgery in some circumstances if there is a medical or psychological benefit.
However, health insurance policies don’t usually cover cosmetic surgery, which means you’ll have to fund it yourself if you want this type of surgery.
2. Accident and emergency
Private hospitals do not have accident and emergency departments, so you must go to your local NHS A&E department or urgent care center or call 911 in an emergency. Health insurance provides planned care.
Some health insurance plans cover a private clinic, but it is not an emergency room. Provides transportation with planned private treatment. For example, you can order a private ambulance to take you home after surgery if you are unable to drive or travel by car for medical reasons.
3. Simple pregnancy and birth
Pregnancy and childbirth are considered lifestyle choices, which means your health insurance is unlikely to cover your routine checkups or childbirth. However, some policies include complications such as miscarriage, ectopic pregnancy or retained placenta.
Health insurance plans also exclude fertility treatments and family planning services.
4. Addiction treatment
Addiction therapies, whether for 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 rehabilitation in some of its health insurance plans.
Most health insurance plans include some mental health support and access to helplines. These services can help direct you to appropriate support services even if your health insurance does not cover your care.
5. Intensive care
Intensive care units (ICUs) provide highly specialized treatment and round-the-clock care when you are most vulnerable. Although private hospitals can treat complex medical conditions, such as cancer, they usually do not have adequate facilities, specialist equipment or highly trained doctors, nurses and healthcare assistants.
This may mean that if you experience complications during or after private surgery or other treatment, you are likely to need a transfer to an NHS hospital for continued care.
6. Learning difficulties, behavioral or developmental conditions
If you or your child has a suspected learning disability or behavioral or developmental condition, it can have a profound effect on your life and educational achievement. Your child may need professional help at school or your doctor may prescribe medication in some circumstances. Diagnosing a condition such as ADHD can take time. NHS guidelines advise a ‘watchful waiting’ period of around ten weeks to see if the child’s behavior improves. Keeping a diary detailing your child’s behavior can help. However, you may still face long wait times.
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 will not fund evaluations or treatment because learning disabilities usually require lifelong treatment, so they are not classified as acute conditions.
7. Chronic conditions
As mentioned, health insurance treats acute conditions, which means chronic conditions are not covered. Chronic conditions are all conditions that require lifelong management, monitoring and treatment. Private healthcare providers cannot offer long-term treatment, so you will need to see your NHS GP or consultant as needed.
Chronic conditions include:
- Diabetes
- Angina
- High blood pressure
- Cystic fibrosis
- Arthritis
- Epilepsy
- Chronic fatigue syndrome
If your policy includes outpatient coverage and your symptoms may indicate a chronic or acute condition, you can still use your health plan to make a diagnosis.
Pre-existing medical conditions
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 for which you sought medical advice or treatment during the five years before you took out the policy.
Health insurance only covers conditions that arise after the purchase of the policy. Pre-existing conditions are excluded as you are more likely to be looking for something you had before. However, if you remain symptom-free for the first two years of your policy, your insurance provider may remove the exclusion – be sure to read the fine print to see if this applies to you.
Your insurance options
The insurance on your chosen policy affects the information you must provide when you first purchase a policy and can also affect your overall claims experience. Individual health insurance policies exclude previous conditions during the first two years. However, there are differences between the two main types of risk taking.
Warranty moratorium
When you choose an insurance moratorium, your insurance company will not ask for any medical information when you purchase a policy. However, they will investigate when you claim to check if there are any pre-existing conditions that could mean your treatment is excluded from cover. This may mean that the process takes longer. Denied claims can also affect your renewal premium, even if they were only denied because you forgot about a call you made to your GP four years ago.
The moratorium guarantee is ideal for people with a simple medical history. It also means you’ll have less paperwork to fill out when buying a policy.
Full medical insurance
If your policy has comprehensive medical coverage, you will need to complete a medical questionnaire when you purchase health insurance. Filling in this information allows you to discover all relevant medical conditions. It gives you and your insurers certainty about what the policy covers from the start, which can give you a lower premium. Full health insurance is ideal for people with a complex medical history.
However, it would be best to be careful when filling out the questionnaire. Providing incorrect information can not only result in your claim being denied, but also void your policy and make it harder for you to get health insurance in the future.
Access to private treatment without health insurance
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, let’s say you already have a hip problem, which means your insurance plan doesn’t cover your hip replacement. If you have enough savings, you can contact a private hospital for a fixed fee offer and pay it yourself. Many hospitals also offer financing options that allow you to pay in installments.
You can also pay for private pregnancy care and delivery, with package prices depending on your choice of delivery.
