What Private Health Insurance Covers, and What It Doesn't

Last checked: 31 October 2026

Private health insurance, also called private medical insurance, usually pays for private diagnosis and treatment of acute conditions that start after the policy begins. It does not usually cover chronic conditions, pre-existing conditions or emergency care. What a policy pays for in practice depends on the cover chosen, such as how much outpatient care is included, and on how the policy is underwritten. The sections below explain the main things that are covered and the common things that are not.

Acute and chronic conditions

The most important line in private health insurance is between acute and chronic conditions.

• An acute condition is a disease, illness or injury that is expected to respond to treatment and lead to a full recovery, or a return to the state of health just before it started. A knee that needs surgery or a hernia that needs repair are typical examples. Acute conditions are what private health insurance is built to cover.
• A chronic condition is one that needs long-term management rather than a cure, such as one that continues indefinitely, comes back, or needs ongoing check-ups and medication. The long-term management of chronic conditions is usually not covered.

Some policies pay for the first diagnosis of a condition, or for treating an acute flare-up of a chronic condition, but not for its ongoing care. That ongoing care stays with the NHS. Private treatment works alongside the NHS: everyone keeps full access to NHS care, and the policy gives another route to be seen and treated.

Pre-existing conditions

A pre-existing condition is one a person had symptoms of, or treatment for, before the policy started. Pre-existing conditions are usually not covered. How this is handled depends on the type of underwriting.

Either way, a condition that started before the policy is not normally paid for at the start. The price effect of each type of underwriting is explained in the guide to how much private health insurance costs.

Inpatient and day-patient treatment

Most policies have a core part that pays for treatment when a person is admitted to hospital. This includes inpatient care, where a hospital bed is needed overnight, and day-patient care, where a bed is needed during the day but not overnight. Core cover typically pays for things such as:

• Surgery and the related hospital stay.
• Specialist and anaesthetist fees while in hospital.
• Tests and scans carried out as part of the hospital stay.

The hospitals that can be used are set by the hospital list on the policy.

Outpatient cover

Outpatient care is care that does not need a hospital bed, such as specialist consultations, diagnostic tests and scans. It is often the part that leads to a diagnosis in the first place.

Outpatient cover is usually an option rather than part of the core cover. It can be:

• Full, with no yearly limit on outpatient costs.
• Limited to a set amount each policy year.
• Left out, in which case consultations and scans before a hospital admission are paid for by the policyholder.

The level chosen has a large effect on what the policy pays for before treatment starts.

Cancer cover

Cancer cover is a common part of private health insurance, but how much is included varies between policies. In general terms, the options are:

• Full cancer cover, which pays for diagnosis, treatment such as surgery, chemotherapy and radiotherapy, and some follow-up care.
• Limited cancer cover, which caps the amount paid, the length of treatment, or which treatments are included.
• Cover linked to the NHS, where some or all treatment is expected to be given by the NHS.

Policies also differ on whether they pay for drugs and treatments that are not routinely available on the NHS. As with any condition, cancer that a person had before the policy started is usually not covered as a pre-existing condition.

Mental health and therapies

Some policies include cover for mental health treatment and for therapies such as physiotherapy. This is often an option or comes with limits, such as a set number of sessions or a cap on cost each year. What is included varies widely, so the policy wording sets out exactly what is paid for.

Common exclusions

Every policy has a list of things it does not pay for. The details differ, but common exclusions include:

• Emergency care. Emergency treatment, including accident and emergency (A&E), is usually not covered. Emergencies are handled by the NHS.
• Pre-existing conditions, as explained above.
• Long-term management of chronic conditions.
• Routine pregnancy and childbirth. Normal pregnancy and birth are not usually covered, although some complications may be.
• GP visits. Seeing a regular NHS GP is not part of the cover, and a GP referral is often needed before a claim. Some policies include access to a remote GP service.
• Self-inflicted injuries and injuries from dangerous sports or activities, on many policies.
• Treatment that has not been agreed with the insurer first, as most policies need a claim to be authorised before treatment starts.

Reading what a policy covers

What any one policy covers is set out in its policy wording and summary. The main points to look for are the type of underwriting, the level of outpatient cover, the cancer cover, the hospital list and the list of exclusions. As a guide to price, the average for a 35-year-old non-smoker is around £850 a year (about £71 a month), though the cover chosen changes this. A broker can explain how these features work on the policies available to you.