Utilising Your Policy – Outpatient Cover

If you have a private medical insurance (PMI) policy for yourself, your family, or your employees, understanding your cover is essential to ensure you get the most from it. One key area to focus on is outpatient cover, which can significantly impact your overall healthcare experience.

The aim of this article is to explain what outpatient is, the different levels available, how these levels vary between providers, and the costs associated with self-funding. By the end, you will hopefully have the knowledge to make an informed decision on outpatient cover during your next renewal, ensuring the best balance of cost and care for you or your team.

What is Outpatient Cover?

Outpatient cover is a vital component of private medical insurance that helps you manage the costs of consultations, tests, and follow-up appointments that don’t require you to be admitted to a hospital. It’s important to distinguish outpatient cover from primary care (usually GP visits) and inpatient/day patient care (treatment that is required in hospital).

Outpatient cover is generally divided into two parts: the diagnostic phase and the post-treatment phase.

• Diagnostic Phase: This occurs after seeing your GP (primary care) and receiving a referral letter to see a consultant. During this phase, the consultant typically carries out tests to diagnose the issue.

  
  

• Post-Treatment Phase: After receiving treatment—usually in the form of inpatient or day patient care—you attend follow-up appointments (e.g., consultations and tests) to ensure proper recovery. These visits are usually considered outpatient care since no further hospital stay is required.

Estimated Costs for Common Private Outpatient Treatments in 2025:

The following are approximate costs for common private outpatient treatments. These figures are based on industry experience and should be considered general estimates only. Actual costs can vary significantly depending on factors such as location, insurance provider, consultant, facility, and the specific treatment required. It is important to confirm prices with the relevant consultant, facility, or insurer before beginning any treatment or starting a claim.

Rough Estimates for Common Private Outpatient Treatments in 2025:

• Consultation with a specialist (Consultant) – £150 to £300

  
  

• MRI, CT, and PET scans – £400 to £2,000

  
  

• Blood tests – £50 to £250

  
  

• ECG (Electrocardiogram) – £75 to £400

  
  

• Ultrasound – £150 to £700

  
  

• Colonoscopy – £1,500 to £3,000

  
  

• X-ray – £100 to £300

  
  

• Mammogram – £200 to £400

  
  

These estimates are provided solely to offer a general understanding of the potential costs associated with self-funded outpatient treatments.

As you can see, the cost of outpatient care can quickly add up—especially for diagnostic tests. Therefore, it is essential to ensure your policy includes the appropriate level of cover to help manage these costs effectively.

Different Levels of Outpatient Cover

Each provider offers various levels of outpatient cover, and understanding these options can help you tailor your policy to meet your needs. Unlike inpatient or day patient care, which is generally included in most policies as part of the core cover, outpatient cover is usually an optional add-on.

Typical Outpatient Cover Options:

• No Outpatient Cover: If you opt not to include outpatient cover, you will need to self-fund consultations, tests, and follow-up visits or rely on NHS services.

  
  

• Monetary Limit on Outpatient Cover: For example, £500, £1,000, £1,500, or £2,000 limits per person per policy year. Once the limit is reached, you will either need to self-fund additional treatments or rely on NHS services.

  
  

• Full Outpatient Cover: This option provides unlimited cover for all eligible outpatient consultations and diagnostic tests, with no shortfalls (subject to the insurer’s policy terms and conditions).

  
  

Some insurers offer tailored outpatient cover options, such as full cover for diagnostic tests combined with a limit on consultations. This can be a great way to enhance your cover if you have a set monetary limit (e.g., £1,000), or to reduce from full cover in order to manage costs—while still maintaining a comprehensive level of protection.

How to Adjust Your Outpatient Cover

When reviewing your outpatient cover at renewal, you may have the option to adjust your level of cover. Below are some considerations for upgrading or downgrading your cover based on certain circumstances. For personalised advice, you can speak with your insurer or a regulated private medical insurance (PMI) broker.

Downgrading Your Cover:

• Full Outpatient Cover: If premiums have risen significantly, you may want to consider adjusting your outpatient cover to help manage costs. For example, reducing full outpatient cover to a level that still fully covers diagnostic tests, but limits the number of consultations, can help lower your premiums. Not all providers offer this option, so it’s important to double-check with your insurer or speak to a regulated broker to understand what’s available under your policy.

  
  

• Limited Outpatient Cover: If you have limited outpatient cover (e.g., a £1,000 limit) as part of your private medical insurance (PMI), you might consider reducing the limit further—or removing outpatient cover entirely. In this case, you would need to self-fund or rely on the NHS for outpatient consultations and tests. If your priority is to have private cover for inpatient and day-patient treatment, and you’re comfortable using the NHS or paying out of pocket for outpatient care, this can be a cost-effective option.

  
  

Upgrading Your Cover:

• No Outpatient Cover: If you currently have no outpatient cover, or only limited cover (e.g., a £1,000 limit), you may want to consider upgrading to a more comprehensive option. Doing so can help reduce or eliminate potential shortfalls when making a claim. For example, upgrading to full outpatient cover—where there are no restrictions on consultations or diagnostic tests for eligible claims—can provide greater peace of mind and financial protection.

  
  

• Limited Outpatient Cover: If you have limited outpatient cover that doesn’t include full diagnostics, you may want to consider adding it at renewal, assuming your insurer offers this option. The cost increase can be minimal, and this could help enhance your overall policy by ensuring all eligible diagnostic tests are covered.

  
  

Seeking Help from a Regulated Broker

If you’re considering changes to your outpatient cover or reviewing your policy, speaking with a regulated health insurance broker can be highly beneficial. A broker can help you assess the available options, ensure your policy suits your needs, and guide you through the different levels of cover offered by various insurers—helping you find the right balance between cost and protection.

In Summary

Understanding outpatient cover and how it fits into your private medical insurance (PMI) policy is crucial for managing both healthcare costs and your wellbeing. By familiarising yourself with the different cover options and costs, you can make an informed decision about whether to upgrade or adjust your cover at renewal. If you're unsure about what level of outpatient cover is right for you, consider consulting a regulated health insurance broker for impartial advice and guidance.

Disclaimers:

Disclaimer 1: The information provided in this article is accurate as of April 13, 2025. However, all details are subject to change in the future based on updates to insurer terms, market conditions, or regulatory changes. For the most up-to-date information, please contact a broker or your insurer directly.

Disclaimer 2: The information provided in this article is intended for educational purposes only and should not be used as specific advice for any individual insurer or policy. For details regarding your specific policy, always refer to your insurer’s policy documents or contact a broker or your insurer directly for personalised assistance.