Health Insurance Jargon Buster

Health insurance is complex. Whoever you’re with, we’re very happy to talk through your cover and explain the wordings in detail. We only recommend insurers who offer 5-star Defaqto-rated policies – we’re familiar with a wide range of policies. This health insurance jargon-buster might also help.

6-week option

You’ll often see 6-week options being offered in private medical insurance policies. Sometimes it’s a 4-week option. With this option in place, you have to use the NHS first if you can have in-patient or day-patient care for that treatment within 4- or 6-weeks. If the NHS can’t treat you within that time, and you have an eligible claim then you can make a claim on your policy in the usual way instead. Taking out a 6-week or 4-week option will usually bring your premiums down.

Acute flare up

This is a sudden or unexpected deterioration of a chronic condition, one that’s likely to respond to prompt treatment and bring you back to the state of health you were in before the flare-up.

Acute conditions

An acute condition is one that’s happens without warning and is curable. An acute condition responds quickly to treatment and return you to the state of health you were in before, or lead to a full recovery. By contrast, a chronic condition is one that’s developed over a long period of time – such as asthma and cannot be cured.

Chronic conditions

A chronic condition is one that’s developed over a long period, such as asthma. Insurers’ definitions vary, but most agree that a chronic condition has one or more of these characteristics:

  • It needs ongoing or long-term monitoring with examinations, check-ups, and/or tests
  • It needs ongoing or long-term control or relief of symptoms
  • It requires your rehabilitation or for you to be specially trained to cope with it
  • It continues indefinitely
  • It has no known cure
  • It comes back or is likely to come back

One example of a chronic condition is diabetes. Private medical insurance is unlikely to cover regular check-ups for diabetes, but if you had an acute flare-up and needed treatment, then some policies might cover the costs of those appointments. The aim would be to get you on the road back to the state of health you were in before the flare-up.

Continued Personal Medical Exclusions (CPME)

This is a type of underwriting. It lets you switch from one insurer to another by transferring all the exclusions you have in place already. Existing medical conditions are then covered by the new insurer, unless they put a personal exclusion into the terms. Private medical insurance companies will only allow you to switch if you meet certain eligibility criteria, such as whether or not you’re due to have medical treatment. If an insurer can’t offer Continued Personal Medical Exclusions, then the only alternatives are Full Medical Underwriting or a Moratorium.

Day-patient

If you’re a day-patient, then you need a bed in hospital for one day, but you’re not expected to have an overnight stay as well.

Eligible condition

If something’s an eligible condition, then it’s a condition that’s covered by your policy.

Fee schedule

Sometimes this is referred to as the insurer’s ‘fee guidelines’. Each insurer decides how much it will pay for a procedure, or for a consultant’s services etc. it can vary, depending on the hospital involved, the experience of the consultant and so on.

Full cover promise

This is a promise, made by the insurer, to cover any shortfalls on the agreed cover for eligible in or day patient treatment. It’s an option that’s offered on some policies, but not all.

Full Medical Underwriting

This is a type of underwriting. Quite often, an insurer wants to understand your lifestyle your medical history in detail before working out whether exclusions will apply on a health insurance policy. In that case, you’ll need to provide detailed information about any historical, current and pending medical conditions, along with any associated treatment and medication. Sometimes an insurer will ask to look at your medical records too, or want a report from your Doctor.

With Full Medical Underwriting, it’s very clear what you’re not covered for by your policy. The disadvantage is that an insurer might add medical exclusions. These may be hard to remove at a future date. The more serious the medical condition, the more likely it is to see a personal medical exclusion added.

In-patient

If you’re an in-patient, then you need an overnight stay in a hospital bed for one night or more.

Medical History Disregarded

This is a type of underwriting. If an insurer says they’ll underwrite your policy on a ‘Medical History Disregarded’ basis, it means they’re not going to take pre-existing conditions into account.

Moratorium Underwriting

This is a type of underwriting. It’s generally seen as the most straightforward approach. It works on the basis you’ll need to prove you’re eligible to make a claim, if or when you make that claim.

Generally speaking, you’re not covered for medical conditions or related conditions you’ve had (or been treated for, advised about or had symptoms of) in the previous five years, unless you’ve been treatment, advice, symptom and medication free for two continuous years.

The advantages of a Moratorium are that you don’t need to fill out medical forms. Also, a condition that you had over five years ago might be covered if it were to re-appear in the future. The main disadvantage is that you’re not sure what will be covered until you make a claim.

Continued Moratorium Underwriting

This is a type of underwriting – it’s similar to Continued Personal Medical Exclusions. If an insurer offers you Continued Moratorium Underwriting, then they’re offering to switch you from your existing policy to a new one whilst back dating the new Moratorium clause to the start date of your current policy.

The advantage is that the Moratorium clause runs from the date it was agreed with the previous insurer. The disadvantage is that each insurer may have slightly differing versions of the Moratorium, and the claim will always be assessed under the most recent terms and conditions.

Networks

If you need treatment, it helps to be as close to home as possible. There’s also a great deal of reassurance in being treated by specialists in a hospital that’s been recognised for its expertise in treating specific conditions.

Each insurer prefers their customers to use a defined group, or network, of hospitals and specialists. Usually, this is because the insurer has a pricing agreement in place with that network.

Some insurers might use the same facilities –whilst others prefer to use their own facilities. Your policy will show you clearly which hospitals would be included with your cover, and which ones aren’t.

NHS cash benefit

This is an option that’s offered by some insurers. Instead of claiming on your policy for an eligible condition, you accept a payment from the insurer and use the NHS instead. The amount of money is directly related to the number of days or nights you’d be in hospital. Each insurer has its own terms and conditions for NHS cash benefits and we’re happy to talk them through with you.

Outpatient

If you need to go to hospital, but don’t need a bed, then you’re what’s known as an outpatient. Outpatient cover is usually used to get an initial diagnosis. It often covers the costs of consultations and diagnostic tests, such as blood tests and physiotherapy. Outpatient cover is also likely to include visits after a treatment and diagnostic tests – like X-rays – in a follow-up consultation.

Personal Medical Exclusions

These are exclusions that are written into your policy, which only apply to the person named.

Pre-existing condition

This is a disease, illness or injury that you’ve had treatment, advice, or medication for or seen signs / symptoms of before you took out the policy, whether or not the condition has been diagnosed.

Private medical insurance vs. health insurance

These are two ways to describe the same kind of insurance policy. We usually call it health insurance. Different insurers prefer to use different descriptions.

Private medical insurance – ‘PMI’ – supplements the treatment offered by the National Health Service (NHS). Benefits often include ‘no waiting’ lists and access to treatments that aren’t always available on the NHS. Other perks might be private rooms and unrestricted visiting hours.

Qualifying period

A qualifying period is an agreed amount of time that needs to pass, after you’ve bought your health insurance policy, before the cover starts.

Shortfall

Insurers use fee guidelines to confirm how much they’re willing to pay for a treatment. If the cost of that treatment turns out to be higher, then you’ll be asked to cover the difference – which is known as the shortfall. For example, your insurer will probably not want to pay more than a certain amount for a knee replacement. If you prefer to use a consultant whose work costs more than that, then you’d have to pay the extra amount.

Pending medical conditions

If you have distinct symptoms but an associated medical condition hasn’t been diagnosed yet, then you have ‘pending medical conditions’.

Underwriting

Underwriting is the term that insurers use to describe assessing risks and then offering a policy, based on those risks. There are several different types of underwriting, and your medical history might affect which types are available to you from each insurer.

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