Private medical insurance (PMI) is an insurance policy designed to meet some or all of the costs of private medical treatment. It is also known as private health insurance.
There are two main types of private medical insurance policy:
Both “indemnity” and “cash-plan” policies can have additional benefits. For example:
Another variation is a "six week plan", which covers the costs of private medical treatment when NHS waiting times for that treatment are likely to be more than six weeks.
International private medical insurance policies (IPMI) provide medical treatment costs cover to expatriates living overseas.
Although individual consumers can and do take out private medical insurance, it is often taken out by an employer – who is the policyholder – for the benefit of their employees. This arrangement is known as a “group” policy.
There are specific rules about who can refer a complaint about a group policy to the ombudsman DISP 2.7.6(5), 2.7.6(6) and 2.7.7G, whether individual employees are able to complain to the ombudsman depends on whether the policy was taken out for their benefit or for the benefit of the employer (the policyholder), and/or whether they have a right to benefit from the claim.
There is more information about this and a full explanation of our approach to complaints involving group insurance schemes on issue 7 of ombudsman news.
We often see complaints where the insurer has rejected a claim for the costs of a medical treatment – or will not meet the full costs. This could be because:
As with other types of insurance, consumers also make complaints about administration – for example:
When deciding a complaint about a PMI policy, we will look at:
We will take into account the circumstances of each individual case when considering this information.
The following sections look at how we deal with the particular issues we see in complaints about private medical insurance.
Under the terms of a private medical insurance policy, the consumer must get the insurer’s authorisation for the medical or surgical treatment to be carried out before the treatment takes place. In practice, this means that:
Pre-authorisation can be arranged in a variety of ways, including over the phone. It wouldn’t be required for an emergency admission.
We know that consumers don’t always have much time to get the insurer’s approval before they receive the treatment in question. The consumer usually has to get a specialist to confirm the type and duration of the treatment – which can take some time.
If the consumer doesn’t have enough time to arrange pre-authorisation, they might decide to:
Even if the consumer arranges pre-authorisation in time, the insurer may refuse to meet all or some of the treatment costs because of some aspect of the policy’s terms and conditions. This may involve a disagreement about whether a condition is “acute” or “chronic”.
Private medical insurance policies are designed to pay out when the policy conditions are satisfied. But there may be policy conditions and exclusion clauses that limit the amount payable when the consumer makes a claim – or mean nothing is payable at all.
In some cases, the consumer tells us that they weren’t aware of these exclusions and conditions – and their effect on the availability of treatment – until they made a claim.
In this situation, we consider whether any conditions and exclusion clauses are clear in the policy. If we think a particular exclusion or restriction is significant or unusual, we will check whether the business brought it to the consumer’s attention before the consumer bought the policy.
The policy terms, exclusion and restrictions are particularly relevant to complaints involving claims relating to acute and chronic conditions.
Generally, private medical insurance policies cover acute conditions – but not chronic conditions.
Many complaints we receive about private medical insurance involve a disagreement about whether a condition is acute or chronic. Often, the insurer is refusing to pay for treatment on the basis that the condition is chronic – while the consumer says it is acute.
In general conversation, the words “acute” and “chronic” are often used interchangeably when talking about certain types and natures of illness – and medical staff may also not always use these terms precisely. This may mean that an exclusion for chronic conditions in a policy is misunderstood – leading to problems when the consumer makes a claim.
The exact wording of definitions of acute and chronic conditions will vary from policy to policy. But generally, policy definitions reflect that:
To decide how the insurer should deal with the claim, we will review medical evidence from the treating doctor to see if there are clear statements made by the consultant that indicate – on balance – whether the condition is acute or chronic.
We will also look for evidence suggesting that the condition is an acute flare-up of a chronic condition – or an acute condition that has become chronic.
Following a referral from their GP, a consumer will be covered by the PMI policy for treatment by specialists for surgical and other treatments of acute illness or injury – on a short-term basis.
Generally, the insurer will pay for the treatment of an acute condition if it is likely to lead to a full recovery or restore the consumer to their previous state of health and activity – without receiving prolonged treatment.
Conditions resulting from chronic illness but which can be cured or substantially cured – for example, with hip replacement or heart bypass surgery – may also be referred to as acute.
“Chronic” is used to describe long-term conditions which current medical treatment can alleviate but not cure – for example, asthma, epilepsy or some heart conditions. Generally, these conditions are not covered by PMI policies – even if they first arise after the policy is taken out.
Because of the significance of an exclusion for chronic conditions, we will look for evidence that the insurer explained it fully to the consumer before they took out the PMI policy. If we decide this was not the case, we are unlikely to support an insurer’s decision to reject a claim if it is relying on its own interpretation of the exclusion.
When an insurer excludes a claim on the grounds that it relates to a chronic condition, we will ask it for evidence to show why it thinks the condition is chronic rather than acute.
A private medical insurance policy might also cover an acute episode of a chronic condition – if the condition can be treated by surgery and isn’t specifically excluded by the policy. Although the cover will depend on the terms of the particular policy, examples could include an operation for surgical implants to give long-term relief from pain caused by a chronic condition.
We see cases where the insurer has previously paid for treatment of a critically-ill consumer – who is then advised to have further treatment which could stabilise the condition and help them lead a more normal life. If an insurer has turned down a claim for this further treatment, we carefully consider whether the insurer’s decision to apply the chronic condition exclusion is reasonable.
The distinction between acute and chronic can become significant where the consumer has a serious medical condition like cancer.
The insurer might initially accept the condition as acute – but later reassess it as chronic if various treatments or operations haven’t been effective or the consumer’s condition deteriorates. The insurer may consider that further treatment can only relieve the symptoms rather than cure the condition – and decide not to cover any further treatment.
It is not always clear when this point has been reached – and the decision is often a matter of judgement. It could be seen as suggesting that the consumer is not expected to recover – when their own doctor may not yet have reached a potentially terminal diagnosis, or not yet had a conversation about this with the consumer and their relatives. So we would look for evidence that the insurer communicated its decision sensitively.
We sometimes receive complaints about an insurer’s decision to terminate cover a short time before the consumer undergoes a major operation – or at the time of a claim.
Here, we will ask the insurer for evidence that they told the consumer as soon as they decided that the condition had become chronic and further treatment wouldn’t be covered.
There is more information in ombudsman news case study 77/07.
A pre-existing medical condition is a physical or mental medical condition that the consumer had before the policy started.
Claims relating to pre-existing medical conditions are usually excluded if the consumer was treated for the condition within a particular time period before the policy started. Once a certain time has passed after the start of the policy, the exclusion may not apply.
There is more information about our approach to complaints involving pre-existing medical conditions in our online technical resource.
Many complaints we see involve an insurer refusing to meet the costs of treatment for a pre-existing medical condition because it falls into these exclusion periods – or because the insurer has excluded the cost of any treatment related to the medical condition in a “moratorium” clause. This might restrict benefits being payable for treatment for a pre-existing condition until – for example – two consecutive years after the start of the policy, so long as no treatment has been given for the condition.
A private medical insurance policy with a moratorium clause won’t usually be individually “underwritten” (or at least not fully underwritten). But policies without a moratorium clause may be underwritten – for example, using answers the consumer provides on a medical questionnaire – and contain specific exclusions for particular conditions.
If the consumer was asked to disclose their full medical history and the policy has been specifically underwritten on that basis, the insurer has had the opportunity to assess the risk. So we are unlikely to agree that it is fair for the insurer to rely on a general exclusion when rejecting a claim.
Sometimes, a consumer will have attended an investigation or test relating to a particular medical condition before taking out private medical insurance. If the consumer later makes a claim for that condition (or a related condition), the insurer may reject the claim on the grounds that the condition was pre-existing.
When deciding whether it is likely a condition was pre-existing, we consider whether any “negative” post-operative check-ups the consumer attended involved receiving treatment or advice about the condition. We take into account:
The consumer may have attended a routine "well-person" check sometime before making a claim. If we find that the check wasn’t arranged because the consumer was experiencing particular symptoms and that no abnormalities were found, we are unlikely to support an insurer rejecting a claim on the grounds of a pre-existing condition.
However, we will carefully consider whether a negative check-up was connected to a later claim.
After Mrs C had non-malignant lumps removed from her breasts, she was required to have annual mammograph tests. This involved her going to hospital to have x-rays.
We thought that the requirement to have mammograph tests reflected the fact Mrs C’s condition needed regular, careful monitoring as a follow-up procedure. We decided that attending a test amounted to receiving "advice" – even if no abnormality was found.
After Mr D was diagnosed with an irregular heartbeat, his consultant confirmed that he didn’t need any follow-up treatment. However, Mr D decided to go voluntarily for occasional check-ups with his GP to reassure himself of his overall health.
We concluded that attending voluntary appointments didn’t amount to receiving treatment or advice. We thought the situation was comparable to somebody regularly attending a full medical check-up, and nothing unusual being found.
We receive many complaints involving:
Generally, PMI policies state that the insurer will not pay for treatment or procedures which are experimental or unproven based on established medical practice in the United Kingdom.
Examples include uses of drugs outside the terms of their licence, or procedures that have not been approved by the National Institute for Health and Care Excellence (NICE).
In some policies, the exclusion may have a further provision such as:
We may pay for this type of treatment. However you will need our written agreement before treatment is received.
There may also be a reference in the policy to “ex-gratia payments”. These are claims payments made by the insurer in situations where there is no legal obligation for it to pay.
Because ex-gratia payments are made at the insurer’s discretion, we cannot require the insurer to make one – even if the option to do so is written into the policy.
But if the insurer has already exercised that discretion in a way we think is it unfair and unreasonable, we can tell it to put things right.
For example, we might decide that it is unfair for the insurer to refuse to pay for an “unproven” treatment where it would have been liable for the cost of traditional treatment – had the consumer had chosen that option.
We may also question the insurer’s decision if an appropriately qualified consultant has recommended the consumer should proceed with the particular experimental or unproven treatment on medical grounds.
In these circumstances, we may tell the insurer to consider contributing towards the cost of the unproven treatment. The amount of indemnity (the amount the insurer pays) would usually be limited to the lower of either:
Private medical insurance policies normally exclude cosmetic treatment such as nose or breast reconstruction.
But if evidence suggests the treatment is required on medical grounds to cure or relieve the symptoms of a medical condition, we may tell the insurer to meet the claim.
Some private medical insurance policies include dental or oral treatment as an additional benefit. But the following treatments are not usually covered:
When deciding a case involving a claim for dental treatment, we will consider how strictly the insurer has applied the relevant term.
Mr F had his jaw removed because of mouth cancer – and needed reconstructive surgery to rebuild his mouth. But his insurer wouldn’t pay the cost of replacing his teeth.
Mr F’s medical insurance policy covered surgical operations for acute conditions – including mouth cancer – and we saw evidence that the procedure required to reconstruct Mr F’s face and mouth included the need for teeth to be reinstated.
So we decided that the whole procedure should be covered as part of the insurer’s commitment to restore Mr F to his previous state of health without having to receive prolonged treatment. However, we didn’t think Mr F’s insurer should pay for ongoing treatment once the reconstructive procedures had been completed.
Generally, only the medical expenses incurred by consulting with a specialist will be covered by a private medical insurance policy.
A “specialist” is usually defined in the policy as a medical or dental practitioner registered under the medical acts (legislation relating to medical professionals) who has been given accreditation as a specialist in the treatment for which the patient has been referred.
Categories of specialist can vary between policies – depending on the insurance company and the level of cover provided. If this comes up as an issue in a complaint, we will check the definition of specialist in the policy wording to see whether the medical or dental practitioner comes within the definition.
We may also consider whether the insurer should have drawn its definition of a specialist to the consumer's attention. If we think the definition is restrictive, we will decide what we think is fair and reasonable interpretation in the circumstances of the complaint.
Usually, an insurer will have a preferred list of specialists that it recommends to consumers. There is more about this under “choice of consultant or hospital”.
Insurers often limit the amount they will pay in specialists’ fees to a specific amount, based on a scale of fees that they set. These may not be the same fees charged by the specialists – although insurers try to keep them in line with what is generally charged by specialists.
A typical policy wording might be:
"We pay specialists' fees in full when they are at a level which is customarily charged by specialists generally for providing that service. This principle applies to charges for treatment, consultations and diagnostic procedures."
Consumers aren’t always aware of the limits of cover. And they may not be aware that the specialist they’re due to be treated by charges higher fees than is usual for that procedure. In these situations, the consumer could be liable for the difference between the amount the insurer will pay out and the specialist’s charges in full.
When deciding a case, we would consider how the insurer highlighted the terms relating to fees to the consumer – before the consumer agreed to go ahead with the treatment with that specialist.
We would also consider whether the consumer checked if the proposed specialist's charges would be greater than the benefit limit when they got pre-authorisation for the procedure.
The insurer has no control over the charges made by the specialists. If we are satisfied that the insurer sufficiently drew the consumer's attention to the benefit limits, we are unlikely to tell the insurer to pay difference – even if the consumer needs treatment at short notice.
In addition to taking into account the opinions of the consumer's treating doctors, an insurer may decide to commission its own report on the consumer’s health or treatment from a different doctor or specialist.
If these specialists' reports express differing views, we will consider which specialist has the most experience of treating the condition.
Private medical insurers have a list of consultants and hospitals – usually called “partnership” consultants and hospitals – whose fees they are prepared to meet up to the policy benefit limit. If the consumer incurs consultants' fees for day-care or inpatient treatment in a non-partnership network hospital, these won’t normally be met by the insurer.
Partnership consultants are specialists who appear on the insurer’s list of consultants whose fees they will meet. The consumer can check with an insurer if the consultant is on their list.
The insurer lists its partnership network hospitals in the policy documentation. These are hospitals it recognises as treating the medical condition the consumer is suffering from and carrying out the specific type of treatment that the consumer needs.
Problems may arise if the insurer has no partnership consultant or hospital near to where the consumer lives, meaning they have to be referred to a specialist or hospital in another area whose fees are higher than those in the insurer's tariff table. In this situation, we may ask the insurer to meet the full fees of the specialist or hospital the consumer was actually referred to.
Many private medical insurance policies have an exclusion clause meaning that the consumer would have to meet the cost of receiving treatment outside of the UK.
If the treatment is carried out by a consultant approved in the UK, the insurer could be liable for part of the cost. So some cases we see involves the insurer’s decision about whether to exercise its discretion and pay something towards the costs.
Mr G’s consultant advised him not to undergo the particular medical treatment he needed in the UK. So he received the treatment in France and asked his insurer to exercise its discretion to pay part of the cost. The insurer refused.
Mr G had been told by his consultant that the surgeon in France had more experience and expertise than any in the United Kingdom. So Mr G thought that the right decision was to go to France for the treatment – a technique which had only just started being carried out in the UK.
In the circumstances, we decided that it wasn’t fair or reasonable for the insurer to refuse to pay the amount it would have paid for the treatment to be carried out in the UK by a partnership consultant in a partnership hospital. We told the insurer to pay this amount to Mr G.
See ombudsman news case study 77/05 for more information.
If a consumer needs emergency treatment while they’re abroad, the costs of the treatment may be covered by their travel insurance policy or by their private medical insurance policy – depending on the scope of each policy’s cover.
The cost of rehabilitation – for example, after a stroke – may be covered by a PMI policy where it is essential to restoring health and/or mobility, or allowing the consumer to live an independent life. But insurers will not usually cover private hospital accommodation costs for recovery or rehabilitation.
Insurers generally cover rehabilitation as part of the treatment for an acute condition – if it takes place within a specified period from the date of inpatient treatment, and in a rehabilitation centre recognised by the insurer.
However, the consumer will usually need written agreement from the insurer for the rehabilitation and confirmation of the maximum number of days that costs will be paid for.
Mr H, 79, had a fall in his home and fractured his neck and humerus. He was admitted to hospital as an emergency, and then went home. But after a week, he was admitted as a matter of urgency to a private hospital for treatment for oedema of both legs, cardiac failure, a fractured arm and physiotherapy. The insurer refused to pay for his treatment in the private hospital, excluding it under the policy’s rehabilitation clauses.
We saw medical evidence suggesting that Mr H’s condition remained acute – and decided that his treatment fell within the policy’s terms. We didn’t think the insurer had acted reasonably in deciding his private hospital treatment was “rehabilitation”, and told them to pay the claim.
Mr J had a stroke while he was on holiday abroad, which left him debilitated and unable to speak. When his partner phoned to tell the insurer, they told her that Mr J should be admitted to an NHS hospital on his return to the UK – and that when his condition had stabilised, the insurer would consider transferring him to a private hospital. When Mr J was able to be moved with the help of a nurse, he was admitted to a private hospital.
However, the insurer considered that the acute phase of Mr J’s illness was over when he was admitted to the private hospital. It said that his stay there was for the purpose of rehabilitation only – which was specifically excluded under the terms of the policy as a chronic condition.
We took the view that the severe brain haemorrhage which left Mr J disabled and in need of specialist care could be classed as an acute illness – and the medical evidence we saw stated that the nursing care he received was for acute treatment. So we told the insurer to pay the claim.
Most private medical insurance policies don’t cover medical expenses for routine procedures during pregnancy or childbirth – but they do often cover treatment of an acute medical condition which arose during pregnancy or childbirth. However, caesareans, either elective or emergency, are generally not covered. If an insurer has rejected a claim relating to pregnancy or childbirth, we will carefully consider whether any relevant exclusions were made clear to the consumer.
When we uphold a complaint, we need to decide what would be fair compensation in the circumstances.
For example, if we decide poor administration on the insurer’s part meant the consumer had an operation on the NHS rather than privately – and the consumer would have had a valid claim under their private medical insurance policy – we would be likely to make an award.
When deciding the amount, we would consider the approximate cost of the private hospital accommodation, excluding the treatment.
In some cases, delays in pre-authorising treatment cause the consumer’s health to deteriorate – or mean that they need to be treated in an NHS hospital instead of a private hospital.
Generally, we would look for an insurer to have systems in place for dealing with urgent pre-authorisation applications which are not necessarily emergencies – particularly where uncertainty over pre-authorisation could cause the consumer’s condition to deteriorate.
Depending on the individual circumstances of the case, we might make an award for any inconvenience, distress, pain or suffering we think the consumer experienced as a result of the insurer’s actions.
Mr K needed an operation. He contacted the insurer for pre-authorisation, but the insurer delayed the pre-authorisation process. So Mr K – not wanting to risk going ahead with the treatment only for his claim to be refused – had the operation in an NHS hospital. The claim later turned out to be valid and Mr K complained that he’d been denied the comforts of private accommodation.
To calculate the award in this case, we looked at the daily rate for a private bed in the insurer’s partner hospital where Mr K could have had the operation. We multiplied this by the number of days Mr K stayed in an NHS bed. But we didn’t award the cost of the private treatment itself – because Mr K was still treated.
There is more information about our general approach to awards for non-financial loss on our online technical resource.
contact our technical advice desk on 020 7964 1400
This is part of our online technical resource which sets out our general approach to complaints about a wide range of financial products and issues. We would like your feedback on how helpful you found it. Please also use the feedback form below to tell us about anything you think we could clarify or explain better.