Before You Buy Simplyhealth: Underwriting, Outpatient Cover and What to Interrogate

Moratorium vs FMU: the underwriting decision that determines what you can claim

Moratorium underwriting does not require a medical questionnaire at application. It automatically excludes any condition you have had symptoms, treatment, medication, or medical advice for in the preceding 5 years (3 years at AXA Health and Saga). After 2 continuous years on the policy without symptoms or treatment for an excluded condition, it may become eligible for cover. Moratorium is fast and requires no upfront disclosure. The trade-off: you do not know exactly what is excluded until you claim.

Full medical underwriting (FMU) requires a detailed health questionnaire at application. The insurer reviews your history and lists specific excluded conditions before cover begins. You know from day one what is and is not covered. FMU takes longer but provides certainty. For applicants with historical conditions -- a back injury 4 years ago, a mental health episode 3 years ago -- FMU provides a specific answer rather than moratorium uncertainty.

Continued Personal Medical Exclusions (CPME) applies when switching insurers. It carries over your existing exclusions from the prior insurer rather than triggering fresh underwriting, protecting against losing coverage for conditions already in your moratorium history.

The chronic condition exclusion: the most misunderstood PMI limitation

Private health insurance covers acute, treatable conditions -- those with a beginning, a treatment pathway, and an expected resolution. Chronic conditions requiring ongoing management are not covered as a standard PMI exclusion: this means diabetes, asthma, high blood pressure, rheumatoid arthritis, Crohn's disease, and epilepsy are all excluded from standard PMI cover for their ongoing management.

If you develop a new condition during the policy period that subsequently becomes chronic (for example, diagnosed with Type 2 diabetes), PMI typically covers the acute investigation and initial treatment. Ongoing monitoring and repeat prescriptions revert to the NHS. Understand this clearly before purchasing -- PMI is a supplement to the NHS for acute conditions, not a replacement for chronic disease management.

Outpatient cover: the decision most buyers get wrong

Outpatient cover -- specialist consultations, MRI and CT scans, physiotherapy, blood tests outside hospital -- is not standard on most UK PMI policies. It is an add-on. Without outpatient cover, you pay the specialist consultation fee (£150 to £400) and any diagnostic imaging (MRI: £400 to £800) out of pocket before your PMI policy contributes anything for that episode.

Outpatient limits typically range from zero to unlimited. A single MRI plus two specialist appointments can exhaust a £500 outpatient limit in one episode. Set your limit against realistic expected usage: if you expect to use private healthcare primarily for surgical procedures with predictable pathways, a lower limit may suffice. If you want private access to diagnostics for new symptoms, an unlimited or high outpatient limit is more appropriate.

Hospital list tiers: why this matters more than the headline premium

Every PMI insurer restricts you to hospitals on an approved list. The tier you choose determines which private hospitals you can access. Standard/local lists are the cheapest tier and typically cover private hospitals nearest to you. Extended/national lists add wider UK coverage. Comprehensive/London lists add major London private hospitals (The London Clinic, Harley Street, King Edward VII) and carry the highest premium.

Always use the insurer's hospital list tool before purchasing to confirm that your nearest private hospital and any specialist hospitals you might specifically need are on the standard list tier. A policy that does not include your local private hospital requires you to travel for all non-emergency private treatment.

Five things to check before you buy Simplyhealth

1. Hospital list: Use Simplyhealth's hospital list tool to verify your nearest private hospital and any specialist hospitals you specifically need are on the standard tier for your chosen plan.
2. Outpatient limit: Model your realistic expected usage -- a single MRI costs £400 to £800; a specialist consultation costs £150 to £400. Set the limit against actual expected usage, not just cost minimisation.
3. Moratorium or FMU: For a clean health history, moratorium is simpler and appropriate. For historical conditions you want certainty on, FMU provides a specific exclusion list from day one.
4. Chronic condition exclusion: PMI covers acute, treatable conditions. Ongoing management of established chronic conditions (diabetes, asthma, arthritis) is excluded as standard across all UK PMI providers.
5. Cancer cover continuity: Verify what happens to cancer cover after initial treatment -- specifically whether post-treatment surveillance is covered and for how long, as this varies between providers.

NHS waiting lists: the primary commercial driver for PMI demand

The UK private health insurance market grew 13.8% year on year to £8.64 billion in 2025 (LaingBuisson). 7.6 million UK adults now hold PMI (FCA Financial Lives Survey, 2024). UK private hospitals recorded 953,000 admissions in 2025 -- a record for the fourth consecutive year, with 670,000 funded by PMI (PHIN). These figures reflect a single underlying driver: NHS waiting times.

NHS England's waiting list for elective treatment has been at record levels. Average waits for orthopaedic procedures, cataracts, and other elective surgeries routinely exceed 12 to 18 months in many health trust areas. PMI's primary commercial proposition is bypassing this wait -- for conditions where private treatment is available and functionally equivalent to NHS treatment, PMI converts a 52-week NHS wait into a 2-week private pathway.

The value proposition is most clear for: elective surgical procedures with predictable NHS backlogs (hip replacement, cataract, hernia, joint replacement); specialist consultations for new symptoms where NHS diagnostic waiting times for imaging and specialist appointment are extended; and mental health treatment where NHS IAPT pathways have long waits. PMI is less relevant for: emergency care (NHS emergency departments remain the primary pathway); chronic disease management (excluded from standard PMI); and GP access (increasingly addressed by insurer Digital GP services as a standalone benefit).

What private health insurance does not cover: a practical checklist

Standard UK PMI exclusions across all major providers:

• Chronic conditions: Ongoing management of any established chronic condition -- diabetes, asthma, hypertension, Crohn's disease, arthritis. The policy covers initial diagnosis and acute episodes; ongoing management reverts to NHS.
• GP appointments: NHS GP consultations are free and PMI does not reimburse them. Digital GP services within PMI (Bupa, Aviva, AXA) are separate service benefits, not funded GP appointments.
• Routine dental and optical: Not covered by standard PMI. Dental insurance and optical add-ons are separate products; health cash plans (Simplyhealth) cover routine dental and optical costs on a cashback basis.
• Cosmetic procedures: Not covered unless cosmetic treatment is required following reconstructive surgery for a covered acute condition.
• Fertility treatment: IVF and fertility treatment are not standard PMI inclusions.
• Pregnancy and maternity: Normal pregnancy is not covered. Complications of pregnancy may be covered on some policies.
• Substance abuse treatment: Not covered under standard PMI on most policies.
• Pre-existing conditions: Excluded under moratorium for 2 years; may be permanently excluded under FMU.

When to consider PMI: the decision framework

Private medical insurance is worth considering for working-age adults who: have financial obligations that cannot be sustained during a prolonged NHS wait for treatment; want control over when and where they receive non-emergency treatment; have specialist healthcare needs where private access produces meaningfully better or faster outcomes; or have employer-provided PMI that is available at subsidised group rates.

PMI is less relevant for: adults without significant financial obligations where NHS treatment is functionally adequate and timing is not critical; retired adults covered by comprehensive NHS provision without working income at risk during treatment delays; and those whose financial position can absorb the cost of private treatment on a self-pay basis when needed.

The most practical PMI use case in the UK in 2025 is the elective surgical procedure with a predictable NHS backlog: hip replacement, cataract surgery, hernia repair, knee arthroscopy, varicose vein treatment. For a 45-year-old professional whose income depends on physical capacity (a builder, physio, or surgeon) facing a 14-month NHS wait for a hip replacement, the PMI case is clear. For a 30-year-old professional facing a 2-month wait for an ankle ligament repair, the PMI case is weaker. Match the product to your specific circumstances rather than buying it as generic health security.

Sources

FCA Financial Services Register (register.fca.org.uk) • ABI (abi.org.uk) • PHIN (phin.org.uk) • Financial Ombudsman Service (financial-ombudsman.org.uk)