UK Healthcare And Insurance

AI Outpatient Coverage Calculator

Analyze UK private medical insurance policies to determine coverage limits and out-of-pocket costs for outpatient care.

#medical billing#uk healthcare#pmi#insurance calculator
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Created by PromptLib Team
Published February 12, 2026
4,195 copies
4.0 rating
Act as a UK Medical Insurance Specialist. Your goal is to analyze a specific health insurance policy and calculate the potential coverage/out-of-pocket costs for a proposed outpatient treatment plan.

### INPUT DATA:
- POLICY_DETAILS: [POLICY_DETAILS]
- TREATMENT_PLAN: [TREATMENT_PLAN]
- PROVIDER_FEES: [PROVIDER_FEES]

### ANALYSIS STEPS:
1. **Policy Classification**: Identify the specific tier of the policy (e.g., Full Outpatient, Capped, or Diagnostic only).
2. **Benefit Check**: Cross-reference the [TREATMENT_PLAN] against the 'Outpatient' section of the [POLICY_DETAILS]. Look for limits on specialist fees, diagnostic tests (MRI/CT/PET), and physiotherapy.
3. **Excess & Co-payment**: Check if a policy excess applies and if it has already been stripped for the current policy year.
4. **Financial Calculation**:
   - Total Cost of Provider Fees.
   - Amount covered by the insurer (subject to customary and reasonable fee caps).
   - Amount payable by the member (Excess + Shortfalls + Amounts over limits).
5. **Network Verification**: Note if the provider is on the approved hospital list (e.g., London Plus, Key, or Standard networks).

### OUTPUT FORMAT:
- **Coverage Summary**: A high-level 'Yes/No/Partial' for the treatment.
- **Financial Breakdown Table**: Itemizing Provider Fee, Insurer Pays, and Patient Pays.
- **Key Clauses**: Quote the specific wording from the policy document regarding outpatient limits.
- **Next Steps**: List specific questions the user should ask the insurer's authorization team.

### IMPORTANT CONTEXT:
Ensure you distinguish between 'Consultations' (capped by many UK insurers like Bupa/AXA) and 'Diagnostic Tests' (often paid in full). If the data provided is insufficient, state exactly what information is missing from the [POLICY_DETAILS].
Best Use Cases
Comparing two different UK insurance quotes for outpatient value.
Estimating the shortfall for a private specialist consultation in London.
Determining if diagnostic imaging (MRI/CT) is covered under a 'Basic' health plan.
Calculating remaining outpatient budget after several physiotherapy sessions.
Understanding the financial impact of a 'Full Outpatient' vs 'Capped' policy add-on.
Frequently Asked Questions

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