Private GP membership or health insurance, what each covers

The difference between the two

Insurance and a GP membership answer different questions. Insurance asks whether a treatment is covered under the policy terms, and pays for it if it is. A membership gives you a doctor you can reach the same day, who knows your history and decides with you what you need next.

Most people who have both use them in sequence. The GP sees you first, examines you and refers you, and the insurer then pays for the specialist and any hospital treatment the policy covers.

What private medical insurance usually covers

Private medical insurance covers the cost of investigating and treating medical or dental conditions [1]. It comes in several forms, including individual policies paid for yourself, group policies offered by an employer, cash plans that pay a fixed sum in certain situations, and international policies for people living outside the country they were born in [1].

Insurers usually keep a list of recognised consultants and hospitals whose fees they will meet up to the policy limits [2]. Before you see a consultant, check that they are recognised by your insurer and ask whether the treatment needs authorisation first.

What private medical insurance usually excludes

The Financial Ombudsman Service, which settles complaints about insurance claims, describes the exclusions it sees most often. Policies usually cover acute conditions and not chronic ones, and most do not pay for experimental or unproven treatment, emergency treatment, routine care in pregnancy and childbirth, or cosmetic treatment [2]. Preventative tests or screening for someone in good health are usually excluded too [2].

A pre-existing condition is an illness or injury you had before the policy began or was renewed, such as diabetes, asthma, high cholesterol or a long-term back condition [3]. Some policies ask about your health when you apply and tell you what is covered, while others exclude every claim related to a pre-existing condition [3]. Read this part of any policy carefully before you rely on it.

What a private GP membership covers

A membership is private primary care and is not insurance. At The Wellness, Signature at £6,950 a year includes same day GP appointments in London, a doctor by phone or video wherever you are, a doctor on call overnight, a yearly blood test, the flu vaccine, two house calls and three guest passes [4]. Platinum at £17,450 a year adds a named physician and a personal concierge, the executive physical and your screening every year, a longevity plan reviewed every quarter, and six house calls and ten guest passes [4].

Hospital treatment, specialist fees, medicines, visits to doctors abroad, and scans or tests beyond those listed are not included, and are arranged at member rates with the price given first [4]. That is the part insurance is built for.

How people combine the two

The two fit together, because the membership covers the everyday care and the preventative checks that insurance usually leaves out, and the insurance covers the specialist and hospital care a membership does not. Your doctor writes the referral letter your insurer asks for, and can explain a consultant’s plan before you agree to it.

Before an outpatient consultation, a private consultant must tell you which insurers recognise them and that insured patients should check their policy, in particular the level and type of outpatient cover [5]. If your employer provides the cover, you are a beneficiary rather than the policyholder, and a complaint about how the policy was sold goes through your employer [1].

If your employer pays

When an employer provides medical treatment or insurance that is not exempt, it reports the benefit to HMRC on form P11D and pays Class 1A National Insurance on its value, or runs it through payroll if it reimburses you [6]. One periodic medical check or health screening a year is exempt [7]. Your employer’s payroll team can tell you how your own cover is treated.

Questions to ask before you decide

Ask your insurer and any membership these questions, and keep the answers in writing.

• Does the policy cover outpatient consultations, scans and tests, and up to what limit?
• How are pre-existing and chronic conditions treated?
• Which consultants and hospitals does the insurer recognise?
• Does treatment need authorisation before it starts?
• Does the membership include a named doctor and same day appointments?
• What does the membership leave out, and how is that priced?

How The Wellness can help

Our doctors see you the same day at our clinics on Baker Street in Marylebone and Eccleston Street in Belgravia, or at your home or hotel in London, and refer you to a named consultant when you need one. You pay us directly and receive a receipt and a doctor’s letter written for an insurer, since we do not bill insurers ourselves [8].

Every doctor is GMC registered, and regulated services are delivered through registered partner clinics and accredited laboratories.