Our exclusions

Here’s what you need to know about our exclusions, including pre-existing conditions, cancer treatment, and chronic conditions.

1. Pre-existing conditions exclusion

At Equipsme, we don’t want your teams to have to fill out lengthy questionnaires about their detailed medical history, and we don’t want to make things more complicated by charging differently for different ages and risk profiles.

Instead, we have one price for all ages 16-69, and an exclusion of any conditions that the member has in the 3-years prior to joining.

What does a three-year pre-existing conditions exclusion mean?

It means members cannot make a claim for physiotherapy, diagnosis or treatment (all provided by AXA Health) for any condition they have had in the three years before their cover starts. This is a permanent exclusion.

We define a pre-existing condition as any disease, illness or injury that members:

• have received medication, advice or treatment for in the three years before the start of cover, or
• have experienced symptoms of in the three years before the start of cover; whether or not the condition was diagnosed.

Why do you have a three-year pre-existing conditions exclusion?

We believe insurance is really about covering the unexpected.

We think about it a bit like home insurance. You can’t insure your house while it’s actually on fire, so it seems reasonable you can’t take out health insurance against something that’s already happened or happening.

Excluding existing conditions from the three years before cover starts helps us keep with our commitment to responsible and sustainable pricing, meaning more businesses can potentially cover more people.

Why is that good for my workforce?

First and foremost we’re completely transparent about our exclusions, so people know exactly where they stand. Because it’s a fixed exclusion, there’s less confusion regarding whether or not something is covered.

It also means that NEW eligible conditions affecting your teams can be dealt with under their Equipsme plan.

By ‘eligible’ we mean that pre-existing isn’t the only exclusion that applies to cover under the plan, so do read on to understand more about the main exclusions.

As the UK workforce continues to age, more things go wrong with our health. Just because someone has had a long-term shoulder injury, doesn’t mean they’re not going to hurt their back, or develop a heart condition – or suffer from digestive problems in the future.

What benefits can people use for pre-existing conditions?

Members with pre-existing conditions can access health checks through Thriva, talk to our 24/7 Health Hero GP service, and talk to the nurses, pharmacists and midwives on our Nurse support line. They can also access our Online Outpatient service for support with pre-existing MSK conditions.

They can also use the Stress support line and Dental & Optical benefits, if these as part of your company plan.

How is this different to other private health insurance plans?

Other health insurance providers may operate other systems. One of them is known as a 522 Moratorium.

That means any condition someone has had symptoms or treatment for in the 5 years before they join is excluded.

After they join, if they’ve gone 2 consecutive years without any kind of symptoms, advice, medication or treatment intervention for the 5-year pre-existing condition, it may become eligible for cover. If they do have an intervention in the 2 year waiting-period, the 2 year clock resets.

How will people know if they’re covered or not?

With Equipsme, people need to contact the claims team AXA Health, who will assess if the claim is covered.  (This may require further medical information from their GP if the condition could be pre-existing. The GP may charge a fee for this, which the claimant will have to pay).

If the condition is then deemed eligible, AXA Health will help members arrange the next phase of private diagnosis or treatment. This reduces the risk of your employees facing bills that aren’t covered by their plan, because everything is agreed ahead of time.

2. Cancer treatment

At Equipsme, we don’t cover the private treatment of cancer once it has been diagnosed.

Instead, we focus on early diagnosis, to help people can get answers more quickly, and onto the right path of treatment under the NHS.

Our plans can help with faster cancer diagnosis, which is key to successful treatment. So we cover eligible scans and consultations up to diagnosis – including MRI and PET scans, and follow-up appointments to discuss the results.

Again, it’s a deliberate choice we’ve made to help control costs, and keep our prices accessible.

You can find out more about our approach to cancer treatment here.

3. Chronic (including long-term)conditions

At Equipsme, we don’t cover chronic conditions.

Most health insurance companies don’t do this either, which means it’s really important to know what counts as chronic and what doesn’t.

What is a chronic condition?

A chronic condition is a disease, illness or injury that:

• needs ongoing or long-term monitoring through consultations, examinations, check-ups or tests
• needs ongoing or long-term control or relief of symptomsr
• requires rehabilitation, or for you to be specially trained to cope with it
• continues indefinitely
• has no known cure
• reoccurs or is likely to come back in the future.

What sort of conditions are we talking about?

Chronic conditions can include things like Crohn’s Disease, diabetes or asthma, which require close management and ongoing monitoring; degenerative diseases like multiple sclerosis, muscular dystrophy or Parkinson’s; conditions like hyperthyroidism and other immune deficiency disorders; PCOS or endometriosis in women; plus numerous other long-term conditions.

Why don’t health insurance companies cover chronic conditions?

Chronic conditions are ongoing and often aren’t able to be treated and resolved. They require ongoing monitoring and medication to manage, so there’s no end point to how much they’re going to cost in terms of monitoring and treatment. Which means that they can become really expensive.

As with any kind of insurance, a few people claiming very large amounts means that in order to cover their losses, insurance companies are forced to put prices up for everyone.

By excluding chronic conditions, insurance firms can control costs more closely.

What happens if employees already have a chronic condition?

If employees already have a chronic condition, they won’t be able to claim for any treatment or consultations directly related to that condition.

They WILL be able to use their Equipsme plan for other health conditions, and those benefits will depend on what level of cover they have and any other terms, conditions or exclusions that may apply.

What if someone gets diagnosed with a chronic condition under the plan?

If in the course of medical investigations a member gets diagnosed with a chronic condition, eligible treatment will usually be covered up to the point at which it is deemed chronic by the claims team at AXA Health (if Diagnosis and treatment are part of their plan).

However, they will NOT get follow-up consultations or ongoing support. Instead, they go back to the NHS to manage the condition for the longer term.

For many people, however, it’s the early diagnosis bit they need private health insurance to help with. Often the most important step is being able to get quick access to a consultant to get that crucial diagnosis – especially if symptoms are confusing or debilitating.

4. Other exclusions

Health insurance is there to help you get better from unexpected health issues, therefore there are also some other exclusions that apply to our plans. Many of these are common across health insurance products. They include:

• Mental health conditions – if Stress support is part of your plan we can help employees over the age of 18 with telephone and face-to-face counselling, but we can’t provide other psychiatric treatment or support. However, all Equipsme members do have access to counsellors through the Nurse support line.
• Pregnancy and childbirth – but the plan will pay to treat certain medical conditions that arise during pregnancy (if it includes Diagnosis and Treatment). We do not cover investigation or treatment of infertility and assisted reproduction or treatment designed to increase fertility. However, all Equipsme members do have access to midwives through the Nurse support line.
• Development disorders and neurodiversity – the plan does not cover any treatment, investigations, assessment or grading to do with learning and development disorders or neurodivergent diagnosis.
• Gender re-assignment or gender conformation – or any connected treatments are not covered under this plan.
• Treatment received outside the UK.

Full details of our terms and conditions regarding what is and is not covered can be found in the Membership Handbook.