Pre-Existing Conditions
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Pre-Existing Conditions

The purpose of Private Medical Insurance
Insurance policies provide cover against an unexpected event happening after the start of the policy. In health insurance this means cover for the cost of private medical treatment for unforeseen medical conditions arising after your policy starts.

Your policy is not intended to cover conditions that you already have before your policy starts - these are called "pre-existing conditions". Conditions that are related to pre-existing conditions are also not usually covered. A related condition is one that is caused by, or could be the cause of, another condition.

Your policy will not cover all medical treatments. You should check your policy carefully to see which treatments are covered and which are not.

Your PMI underwriting options
Underwriting is the process by which an insurer decides on what terms it will accept a person for cover based on the information they supply. This section is designed to explain the two most common methods by which you can apply for cover, so that you can decide which one best suits your requirements.

Your choices
You have a choice between two ways of applying for the cover Choices provides.

1. Full medical underwriting
This is based on your completing a health questionnaire (also called a Medical History Declaration).

If you choose this option, you will be asked a number of questions about your health. These will enable us to understand your medical history (and that of any member of your family whom you wish to insure). It is important that you consider the questions carefully, for each person to be covered, and answer them fully. We will review your details and decide the basis on which we can accept you for cover. If necessary, we may need to ask your doctor for any further information we need to help us to do this.

If you have a pre-existing condition that may need treatment in the future, we will usually exclude it from the cover along with any conditions related to it. We will show any exclusions on the policy schedule you receive form us when we have processed your application. (The same process will also apply for any members of your family included in your application.)

If we exclude treatment for a pre-existing condition at the time when your policy starts we will, in some cases, review the exclusion in future should you wish us to do so.

Of course, any new medical conditions arising after the start of your policy will be covered immediately subject to the policy terms and conditions.

Note: You must ensure that you provide full and accurate information in answer to the questionnaire. Failure to do so may mean that we cannot cover a claim or even that your policy is void. If you are unsure whether we would want to know about a particular condition, you should tell us about it.

What is the advantage of full medical underwriting?
Although this option involves more of your time when completing your application it does mean that, when you receive your policy documentation, you will know which conditions are excluded from cover.

2. Moratorium
With this option you do not need to fill in a health statement. Instead, we automatically exclude any pre-existing medical conditions for which you (and any family member included in your application) have received treatment and/or medication or asked advice on, or had symptoms of (whether or not diagnosed), during the five years immediately before your PMI cover started.

However, if you do not have any treatment, medication or advice for those pre-existing conditions, and any directly related conditions, for two continuous years after your policy starts, then we will reinstate cover for those conditions.

You should understand that long-term medical conditions, which are likely to continue to need regular or periodic treatment, medication or medical advice, will never be covered by your policy.

You should not delay seeking medical advice or treatment for a pre-existing condition simply to obtain cover under your policy.

Of course, as with full medical underwriting, new medical conditions arising after the start of your policy will be covered immediately subject to the policy terms and conditions.

What is the advantage of moratorium underwriting?
If you choose this option you will only be asked to provide basic information about you and any members of your family you wish to insure. You will not be asked to disclose details of your medical history, but it relies on you to understand that if you have any medical conditions these will be excluded from cover. Also if you can satisfy the criteria (two years) outlined in the above section, for a pre-existing condition then treatment for that condition will automatically be covered should it later recur, subject to the policy terms and conditions.

Examples of how both options work:

Example 1 - I had an operation on my right knee recently. Will I be covered for any further treatment to it after my policy starts?

Full medical underwriting
Having disclosed this operation (and the reason it was necessary) a suitable exclusion would be placed on your policy. As such no cover would apply to the condition, and related conditions. You could, in the future, ask us to review the exclusion if the operation was successful and you have suffered no further problems in this respect since the operation.

Moratorium
Under the terms of the moratorium the condition (and related conditions) would be excluded. If, after the start of your cover, you went two continuous years without further treatment or medication for, or advice on the condition, the condition would be covered should it recur later.

Example 2 - Some time after my cover begins, I go to the doctor for a routine visit. A heart condition is diagnosed and must have started to develop before my policy began. What is the position?

Full medical underwriting
At the time you completed your health questionnaire you were unaware that you had any condition and you could not therefore be expected to disclose anything. As such, cover would be provided for the condition.

Moratorium
At the time you applied for cover you were not displaying any symptoms, nor had you had any treatment, medication or advice for the condition - you were unaware that you had a condition. As such the condition would not be classed as pre-existing and cover would apply under your policy.

Example 3 - What if I suspect I am suffering from a condition (for example, I have a lump) but have not seen a doctor about it, nor received any firm diagnosis before my cover starts? Will I be covered if I need to have any investigations or treatment for the condition once my policy has started?

Full medical underwriting
Part of the health questionnaire will ask whether you have any condition that may need treatment in the future. You should therefore disclose such conditions even though you may not yet have had any treatment or even sought advice. Once you have disclosed the condition we will apply a suitable exclusion and thus, cover will not apply to any treatment or medication required in the future.

Moratorium
The moratorium applies to any pre-existing whether or not there has been any treatment, medication or advice relating to it and whether or not it has been diagnosed. As such, the condition will be excluded under the terms of the moratorium.

For moratorium only - Example 4 - How do regular check-ups affect the moratorium?

If you suffer from a pre-existing condition that requires you to have regular check-ups, you will not be able to go for two continuous years without treatment, medication or advice, as long as the check-ups continue. Consequently the pre-existing condition will be excluded under the terms of the moratorium, until the check-ups cease and you are able to go for two continuous years without treatment, medication or advice.

For any claim under the policy you should always phone our helpline on 0844 873 0900 before you incur any medical costs.

They will be able to discuss professionally and confidently your concerns regarding your claim and the cover provided by your policy, in the strictest confidence.