The NHS England waiting list reached 7.3 million in December 2025, with 2.8 million people waiting over 18 weeks for treatment. This backlog has made private medical insurance (PMI) a more frequent topic in broker-client conversations.
This guide covers what PMI is, what it covers, and how providers underwrite and price policies. It also sets out what brokers should ask clients before recommending a policy. You can also find useful ways to explain how private medical insurance works alongside the NHS.
“Private medical insurance is a policy that pays for some or all healthcare services delivered in a private setting rather than through the NHS,” explains Tom Woolgrove, chief executive of Benenden Health, a not-for-profit healthcare membership organisation that works with more than 128 UK intermediaries.
Also called private health insurance, PMI works with the client paying a monthly or annual premium. The insurer then picks up the bill for treatment of any condition the policy covers.
The British Medical Association (BMA) defines it more tightly: Private medical insurance helps pay for treatment of short-term, curable conditions, with self-pay treatment the main alternative for clients who choose not to take out cover.
Policies run alongside the NHS, rather than a replacement. Most clients still use the NHS for GP services and emergency care.
There are two ways clients usually get cover. Some clients buy it themselves, often after a long NHS wait or a change in their personal circumstances. Many get cover through work, where it counts as a taxable benefit in kind.
Cover varies between providers. As a general rule, most UK policies cover treatment of acute conditions that start after the policy begins.
Here’s what tends to be included:
As for the exclusions, you should make sure clients understand these are often out of scope:
Here’s a walkthrough of how UK policies typically split included and excluded treatments. This short explainer is a good companion to the lists above.
Brokers should walk clients through the difference between acute and chronic conditions. Private medical insurance pays for acute conditions, which are illnesses that come on suddenly and respond to treatment. It doesn’t pay for chronic conditions that need ongoing management.
Type 2 diabetes is an example, according to the BMA. If a client develops symptoms, the insurer will often pay for the diagnostic referral. Once diabetes is confirmed, the ongoing treatment and monitoring pass back to the NHS.
How an insurer reviews a client’s medical history shapes the whole policy. The UK market uses three main structures. The choice between them determines both the premiums and claims experience.
Age is the biggest driver of private medical insurance premiums, followed by:
Three policy decisions give brokers the most room to bring premiums down:
Woolgrove notes that cost is a long-running concern with traditional cover, with premiums under pressure from medical inflation on top.
“Traditional PMI often excludes pre-existing conditions, requires members to pay excesses depending on their situation, and may increase monthly premiums after a claim,” he says. “It’s also generally quite a costly option.”
Premiums vary widely by age and cover level. A healthy 30-year-old non-smoker can find entry-level cover for less than £20 a month. Comprehensive cover for an older client with full outpatient and cancer benefits can run well over £100 a month.
How can brokers find the right cover for clients?
Start with the client’s circumstances before looking at any policy. Without good fact-finding, you risk recommending cover that’s either too thin or paying for benefits the client will never use.
“Brokers can ensure they recommend the right type of cover by using data and research to understand client needs,” Woolgrove says. “Internal data such as employee age, family size and sickness absence trends can help build a picture of healthcare priorities.
“Understanding the client’s industry and the nature of employee roles is also valuable. For example, a construction company may have a more physically active workforce and therefore a greater need for physiotherapy services than an office-based organisation.”
Woolgrove adds that brokers can also gather insight directly from employees by issuing a simple questionnaire asking what they value most from a healthcare provider.
For more on how UK advisers approach private medical insurance selection, this video gives a useful broker-led perspective:
Once the client picture is clear, four conversations should shape your recommendation:
For more on broker excellence in advisory practice, check out our special report on the world’s top insurance professionals and brokers.
Brokers should be able to walk a client through what happens from the first symptom to the final invoice, and what their options are if things go wrong.
Most claims follow a similar path, regardless of insurer:
Two points come up often at renewal. The BMA notes that a claim can push premiums up by 20 to 30 percent at renewal. This is why you should check whether the client’s policy has a no claims discount and whether that discount is protected.
For clients moving insurers, you should also confirm that the new policy offers “no worse terms” than the existing one.
If a client can’t resolve a dispute with their insurer, the Financial Ombudsman Service is the free and independent escalation route. The service mediates between consumers and financial services firms, including private medical insurers.
For broker research on consultants and hospitals, the Private Healthcare Information Network (PHIN) holds verified UK data on private healthcare quality and outcomes.
For more information on the carriers delivering the strongest claims service to UK brokers, check out this special report.
The best broker conversations treat private medical insurance as something that works with the NHS rather than replaces it. The NHS still handles GP services, emergencies, chronic conditions, and most of the everyday healthcare clients will use across their lives.
“Private medical insurance plays a key role in improving access to healthcare services, supporting better health outcomes, and helping people stay healthier and happier both at home and at work,” Woolgrove says. “For people waiting for diagnosis or elective treatments, it can also reduce waiting times, which can be significant in the NHS.”
He adds that “private healthcare also works in partnership with the NHS to improve outcomes.” A fast private diagnostic or specialist consultation can move a client into the right NHS treatment pathway sooner than they would have reached it otherwise.
The six-week option is the most concrete way clients can blend the two. If NHS wait times fall under six weeks, the client uses the NHS. If they exceed six weeks, private cover kicks in. The premium is lower than full private cover. Clients still get faster access when it matters most.
This shifts broker conversations away from “do you need private healthcare” toward “what part of healthcare do you want to take private”. With NHS waiting lists now above seven million and private medical insurance admissions running well above pre-pandemic levels, this conversation is one most brokers will have more often.
