Private medical insurance and NHS waiting times: what the waiting list data says and what PMI does and does not cover

What the NHS waiting list data shows

NHS England data shows the Referral to Treatment (RTT) waiting list stood at around 7.4 million cases in 2025, with the 18-week standard met for roughly 60 percent of patients. The NHS Constitution standard is that 92 percent of patients should be treated within 18 weeks, a target not met since 2016. Longest waits are concentrated in orthopaedics, ear, nose and throat (ENT) and gynaecology.

The scale of the elective care backlog is the primary demand driver for households considering private medical insurance (PMI). According to NHS England's Referral to Treatment waiting times statistics, the total number of incomplete pathways has remained above seven million for an extended period. The monthly release tracks both the size of the list and the proportion of patients waiting longer than the constitutional maximum.

Specialty-level data reveals significant variation. Orthopaedic procedures, including hip and knee replacements, consistently show the highest volumes of long waits. ENT and gynaecology also feature prominently among the longest waits. For patients referred for these procedures, the gap between the 18-week standard and actual performance is most acute.

The 18-week clock starts when a hospital receives a referral from a GP or other clinician. It stops when treatment begins or when a clinical decision is made that treatment is not required. The data includes patients who have had their treatment suspended for clinical reasons or who have chosen to wait longer, which means the headline figure does not fully represent the number of people actively waiting for a first definitive treatment.

Waiting list data is published monthly and revised periodically. The figures cited here reflect the position in the most recent NHS England release. The trend since 2020 has been one of sustained pressure, with waiting times for elective care remaining substantially above pre-2020 levels.

What private medical insurance covers

PMI policies typically cover the cost of private consultations with specialists, diagnostic tests such as MRI and CT scans, and inpatient or day-case elective surgery. Cancer treatment is covered under most policies, including chemotherapy and radiotherapy. Cover is limited to treatment that is medically necessary and is accessed through the insurer's approved hospital list and network of consultants.

A standard PMI policy is designed to give policyholders faster access to planned care. The core components are outpatient consultations, diagnostics, and inpatient treatment. Outpatient cover is often subject to an annual limit, which can range from a few hundred to several thousand pounds, depending on the policy. Once that limit is reached, any further outpatient costs in that policy year are met by the policyholder.

Hospital cover is arranged through a network of private hospitals and private patient units within NHS hospitals. The insurer will specify which hospitals are covered under a given policy tier. Choosing a more restricted hospital list, sometimes called a 'value' list, reduces the premium but limits choice of where treatment takes place.

Cancer pathways are a significant part of modern PMI. Most comprehensive policies cover the full range of cancer treatments, including surgery, chemotherapy, radiotherapy and some newer drug treatments. Some policies also provide access to private cancer screening or genetic testing, although these are not universal and may be offered as add-ons.

Mental health cover is increasingly included, but it is often subject to separate limits on the number of therapy sessions or the duration of inpatient care. Policies vary in how they define eligible treatment, and the Association of British Insurers (ABI) notes that cover depends on the specific terms of each policy.

What it does not cover

PMI excludes chronic conditions such as diabetes, asthma and arthritis, which are managed rather than cured. Pre-existing conditions are excluded unless the insurer agrees to cover them under full medical underwriting. Emergency treatment, attendance at A&E, normal pregnancy and childbirth, cosmetic surgery and routine GP services are not covered by standard policies.

The distinction between acute and chronic conditions is central to understanding PMI. An acute condition is one that is curable or treatable to the point of recovery. A chronic condition is one that requires ongoing management, such as hypertension, COPD or inflammatory bowel disease. Insurers do not cover chronic conditions because the policy is designed for episodes of illness that resolve, not lifelong care.

Pre-existing conditions are those for which symptoms, diagnosis or treatment existed before the policy start date. Under moratorium underwriting, a condition is excluded if it occurred in the five years before the policy began. It becomes eligible for cover only after the policyholder has been symptom-free and received no treatment, medication or advice for that condition for two consecutive years on the policy.

Emergency care is excluded because PMI is not a substitute for accident and emergency services. If a policyholder is admitted to hospital as an emergency, the NHS provides that care. PMI covers planned treatment only. Normal pregnancy and childbirth are excluded, as are complications arising from them, unless the policy includes specific maternity cover, which is rare.

Cosmetic surgery is excluded unless it is reconstructive surgery following an accident, injury or disease, and is deemed medically necessary. GP services are not covered; PMI does not pay for consultations with a general practitioner. Routine vaccinations, health screenings and dental treatment are also outside the scope of standard policies.

Underwriting: moratorium vs full medical underwriting

Moratorium underwriting excludes any condition that occurred in the five years before the policy started, until the policyholder has been symptom-free for two consecutive years on the policy. Full medical underwriting requires the applicant to declare their full medical history, and the insurer decides which conditions are excluded. Employer schemes often carry continued personal medical exclusions that do not clear over time.

When applying for PMI, the applicant chooses between moratorium and full medical underwriting. Under moratorium, no medical questions are asked at application. Instead, the policy contains a blanket exclusion for pre-existing conditions from the last five years. If a condition recurs or requires treatment within the first two policy years, it is not covered. After two symptom-free years, cover begins for that condition.

Full medical underwriting involves a detailed medical questionnaire. The insurer reviews the applicant's history and sets specific exclusions for conditions it considers pre-existing. This approach gives certainty at the point of claim, because the policyholder knows in advance what is and is not covered. The trade-off is that the application process is longer and requires accurate disclosure.

Employer-provided schemes operate differently. Group PMI policies are often issued with continued personal medical exclusions (CPMEs). These are conditions that existed before the employee joined the scheme and are permanently excluded from cover. Unlike moratorium underwriting, CPMEs do not clear after a symptom-free period. An employee moving from one employer scheme to another may find that new exclusions are applied based on their medical history.

Switching insurers is a significant decision. If a policyholder cancels their policy and later takes out a new one, the underwriting clock restarts. Any conditions that were covered under the previous policy may become excluded under the new one, depending on the underwriting method used. This loss of continuity is a key consideration for anyone thinking of changing provider.

Cost drivers and tax

Premiums for PMI are driven by the age of the policyholder, the level of excess chosen, the hospital list selected and the outpatient limit. Insurance Premium Tax (IPT) is charged at 12 percent on PMI premiums. Employer-provided PMI is a taxable benefit in kind, reported on a P11D form and subject to income tax and National Insurance.

Age is the single largest factor in premium calculation. Premiums rise with each age band, reflecting the higher likelihood of claims among older policyholders. A policy taken out at age 30 will cost substantially less than the same policy taken out at age 60. Insurers apply age-related pricing at each renewal, so premiums increase over time regardless of claims history.

The excess is the amount the policyholder pays towards each claim. Choosing a higher excess reduces the premium, because the insurer's exposure to small claims is reduced. Some policies offer a voluntary excess that applies per claim, while others apply an annual excess. The structure of the excess affects both the premium and the out-of-pocket cost at claim time.

Hospital lists are tiered. A policy that covers any hospital in the insurer's full network costs more than one restricted to a smaller list of approved hospitals. The outpatient limit also affects price: a higher annual limit for consultations and diagnostics increases the premium. Policyholders can adjust these parameters to balance cost against the breadth of cover.

Tax adds to the cost. HMRC sets Insurance Premium Tax at 12 percent for PMI, which is added to the premium. For employer-provided schemes, the value of the benefit is taxed through the P11D process. The employee pays income tax on the premium amount, and the employer pays National Insurance. This makes employer PMI less tax-efficient than other benefits such as pension contributions.

Alternatives and complaints

Alternatives to PMI include self-pay fixed-price surgery, where the patient pays a set price for a procedure at a private hospital, and the NHS Right to Choose scheme, which allows patients to select a different provider for certain treatments. Complaints about PMI policies can be referred to the Financial Ombudsman Service (FOS) if they are not resolved by the insurer.

Self-pay is an option for patients who want faster access to a specific procedure without taking out ongoing insurance. Many private hospitals publish fixed prices for common operations such as cataract surgery, hernia repair or hip replacement. The price typically includes the surgeon's fee, anaesthetist's fee, hospital stay and aftercare. Self-pay avoids the ongoing cost of premiums but requires the patient to fund the full cost at the point of treatment.

The NHS Right to Choose scheme gives patients in England the right to choose a different hospital or provider for their first outpatient appointment and any subsequent treatment. This can include private providers that hold NHS contracts. Waiting times under Right to Choose can be shorter than at the local hospital, and the cost is met by the NHS. The scheme does not cover all procedures or all providers, and availability varies by region and clinical commissioning group.

Complaints about PMI arise from disputed claims, exclusions applied at claim time, or delays in authorisation. The first step is the insurer's internal complaints procedure. If the complaint is not resolved within eight weeks, or if the policyholder is unhappy with the outcome, the matter can be referred to the Financial Ombudsman Service. The FOS is free to use and can make binding decisions up to a financial limit.

The Financial Ombudsman Service publishes data on complaints about health insurance, including the proportion upheld. Policyholders should keep records of all correspondence and policy documents when pursuing a complaint. The ABI also provides guidance on how to complain about an insurer and signposts to the FOS for unresolved disputes.

Does private medical insurance cover pre-existing conditions?

Under moratorium underwriting, pre-existing conditions from the last five years are excluded until the policyholder has been symptom-free for two consecutive years on the policy. Under full medical underwriting, the insurer decides at application which pre-existing conditions are excluded, and those exclusions are permanent.

What is the current NHS waiting list in England?

NHS England data shows the Referral to Treatment waiting list at around 7.4 million cases in 2025. The 18-week standard is met for roughly 60 percent of patients, against the NHS Constitution target of 92 percent.

Is private medical insurance a taxable benefit from an employer?

Yes. Employer-provided PMI is a taxable benefit in kind. The premium is reported on a P11D form, and the employee pays income tax on the value. The employer also pays National Insurance on the benefit.

What is moratorium underwriting in health insurance?

Moratorium underwriting is a method where no medical questions are asked at application. Any condition that occurred in the five years before the policy start date is excluded. Cover for that condition begins only after the policyholder has been symptom-free and received no treatment for two consecutive years on the policy.

Does private health insurance cover A&E or emergencies?

No. PMI does not cover accident and emergency attendances or emergency admissions. Emergency care is provided by the NHS. PMI covers planned, elective treatment only.

Frequently asked questions

Does private medical insurance cover pre-existing conditions?

Generally, no. Private medical insurance (PMI) typically excludes pre-existing conditions, which are defined as any condition you had symptoms, treatment, or medication for before your policy start date. Insurers may offer cover with medical underwriting, where they assess your condition and may add exclusions or loadings. Some policies use moratorium underwriting, which excludes conditions from the last five years until you have been symptom-free for two years on the policy.

What is the current NHS waiting list in England?

As of 2025, the NHS England referral-to-treatment (RTT) waiting list is around 7.4 million cases. The NHS Constitution standard is that 92 percent of patients should be treated within 18 weeks, but this has not been met since 2016. In recent monthly releases, roughly 60 percent of patients were seen within this timeframe, reflecting ongoing pressures on elective care.

Is private medical insurance a taxable benefit from an employer?

Yes, if your employer provides private medical insurance (PMI) for you, it is a taxable benefit in kind. You must report it on a P11D form, and you will pay income tax on the value of the premium. However, if the policy covers only treatment that is also available on the NHS, it may be exempt, but most PMI policies are not exempt. National Insurance contributions are not usually payable on this benefit.

What is moratorium underwriting in health insurance?

Moratorium underwriting is a type of medical underwriting used by some private medical insurers. It means that any condition you have had symptoms, treatment, or medication for in the five years before your policy start date is excluded from cover. However, if you remain symptom-free and have no treatment or medication for that condition for two consecutive years after your policy starts, the exclusion is lifted and cover begins.

Does private health insurance cover A&E or emergencies?

No, private medical insurance (PMI) does not cover emergency treatment or A&E visits. The NHS provides emergency care free at the point of use, and PMI is designed for planned, non-emergency treatment. If you have a medical emergency, you should go to A&E or call 999. PMI also excludes normal pregnancy, cosmetic surgery, and most mental health treatment beyond set limits.