BUPA BY YOU YOUR MEMBERSHIP GUIDE

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1 BUPA BY YOU YOUR MEMBERSHIP GUIDE bupa.co.uk

2 ABOUT THIS GUIDE Welcome to your Bupa By You guide. We know that insurance can be hard to follow. That s why we ve made this guide as simple as possible. You ll find individual chapters that deal with each aspect of your cover, including a step-by-step guide to making a claim. Please make sure that you keep this guide somewhere safe. You may need it when you come to claim. If any of the terms or language used leaves you confused don t worry. There is a glossary on page 41 you can refer to, where you ll find clear definitions of words that are in bold and italics in the text. Of course you can always call our helpline on or if you need help to understand your cover. HOW DO I KNOW WHAT I M COVERED FOR? This guide includes details of all of the options available with Bupa By You, not all of which will be relevant to you. The precise details of the individual cover options you have chosen are listed in your membership certificate. Please read this membership guide together with your membership certificate, as together they set out full details of how your health insurance works. HOW DOES THE MEMBERSHIP GUIDE WORK WITH MY MEMBERSHIP CERTIFICATE? Your certificate explains the benefits available to you and also provides a series of notes that correspond to the relevant section of the membership guide (where you will find a more detailed explanation of the benefit in your individual policy). CONTACT US We re always on hand to help. For queries about your cover call our dedicated helpline on or For those with hearing or speech difficulties who use a textphone, call us on Or write to us at Bupa, Salford Quays, Manchester, M50 3XL. BUPA ANYTIME HEALTHLINE If you have any questions or worries about your health call our confidential Bupa Anytime HealthLine on or Our qualified nursing team is on hand 24 hours a day, so whatever your health question or concern, they have the skills and practical, professional experience to help. If further advice is required, a GP will aim to call you back within the hour. Calls may be recorded and may be monitored. Calls may be recorded and to maintain the quality of our Bupa Anytime HealthLine service a nursing manager may monitor some calls always respecting the confidentiality of the call. TIP: CROSS-CHECK THE BENEFITS LISTED IN YOUR MEMBERSHIP CERTIFICATE WITH THE RELEVANT PARAGRAPHS IN THE GUIDE TO MAKE SURE THAT YOU HAVE THE COVER THAT YOU WANT.

3 CONTENTS AT A GLANCE Bupa By You Effective from January How your membership works p3 1.1 The agreement and your membership documents p4 1.2 Payment of benefits p4 1.3 When your membership starts, renews and ends p5 1.4 Making changes p8 1.5 General information p9 1.6 Making a complaint p9 2. Claiming p Making a claim p How we will deal with your claim p If you want to withdraw a claim p Ex-gratia payments p If you have an excess p17 3. Benefits: what you are covered for p18 Prompt Diagnosis p21 Treatment and Care p23 Comprehensive p25 Add ons p33 4. What you are not covered for p36 5. Glossary p45 6. Bupa Privacy Notice p54 1

4 Bupa By You: Your rules and benefits This membership guide sets out the general terms and conditions of your Bupa By You cover effective from January o o For anyone joining Bupa By You after the effective from date, the membership guide applies from their start date. For anyone whose membership of Bupa By You is renewed on or after the effective from date, it applies from their renewal date. Words and phrases in bold and italics in this membership guide are defined terms which have a specific meaning. You should check their meaning in the glossary. Please note that Bupa By You is shown throughout in italics. This is not a defined term but is in italics to show that it is the official name of the cover you have bought. Important note please read this section before you read the rest of this membership guide as it explains how this membership guide and your membership certificate work together. This Bupa By You membership guide and your membership certificate together set out full details of your benefits. They should not be read as separate documents. If you have Travel and Emergency Medical Cover as part of your Bupa By You scheme the details of that cover are not included in this membership guide. You will have a separate Bupa By You Travel and Emergency Medical Cover membership guide, which explains those benefits. This membership guide is a generic guide. It contains the general membership terms that apply to all Bupa By You members. You may not have all the cover set out in this membership guide. It is your membership certificate that shows the cover that is specific to your benefits. Any elements of cover in this membership guide that are either: o o shown in your membership certificate as not covered or do not appear in your membership certificate you are not covered for and you should therefore ignore them when reading this membership guide. If you are covered, the benefits and the amounts we pay are shown on your membership certificate. Your membership certificate could also show some changes to the terms of cover set out in this membership guide particularly in the further details section of your membership certificate. When reading this membership guide and your membership certificate, it is your membership certificate which is personal to you. This means that if your membership certificate contradicts this membership guide it is your membership certificate that will take priority. Always call the helpline if you are unsure of your cover. TIP: IF YOU DO FIND ANY TERMS OR PHRASES THAT YOU RE UNSURE OF, WHY NOT CHECK THE GLOSSARY ON PAGE 41. 2

5 1. HOW YOUR MEMBERSHIP WORKS The details of your Bupa By You cover are in this membership guide. In this first section you ll find explanations of how your benefits will be paid, along with information on how your policy works, how to make changes as well as how to cancel or renew your membership. As always, if there s anything that you don t understand or we can help you with, please don t hesitate to get in touch. 3

6 1.1 THE AGREEMENT AND YOUR MEMBERSHIP DOCUMENTS HOW YOUR MEMBERSHIP WORKS The agreement between you and us In return for you paying us subscriptions, we agree to provide you and your dependants (if any) with cover under the terms of our agreement. Only you and Bupa have legal rights under our agreement, although we will still allow anyone who is covered under your membership complete access to our complaints process (see Making a complaint in section 1.6). The documents that make up our agreement The following documents together make up the agreement. These documents must be read together as a whole, they should not be read as separate documents. 1. The Bupa By You membership guide: this sets out the general terms and conditions of membership (and any exclusions) and all the elements of cover that can be provided under your Bupa By You scheme. 2. Your membership certificate: this shows the cover that you have chosen, including the limits that apply, any variations to the benefits, terms or conditions explained in this membership guide and whether an excess applies to your cover and if it does the amount and how it applies. 3. Your application for cover: this includes any quote request, applications for cover for you and your dependants (if any) and the declarations that you made during the application process, including the answers you provided on your medical history and that of your dependants (if any). 4. Where you or your dependants (if any) have Travel and Emergency Medical Cover included in their benefits, the Bupa By You Travel and Emergency Medical Cover membership guide. 1.2 PAYMENT OF BENEFITS We only pay for treatment that you receive, or the benefits that you are entitled to, while you are covered under the agreement and we only pay in accordance with the agreement. We also only pay the benefits that applied to you on the date you received your treatment or the date that you became entitled to those benefits and only in relation to treatment you receive in the UK. When you receive private medical treatment you have a contract with the providers of your treatment. You are responsible for the costs you incur in having private treatment. However, if your treatment is eligible treatment we pay the costs that are covered under your benefits. Any costs, including eligible treatment costs, that are not covered under your benefits are your sole responsibility. In many cases we have arrangements with providers about how much they charge our members for treatment and how we pay them. For treatment costs covered under your benefits we will, in most cases, pay the provider of your treatment direct such as the recognised facility or consultant. We will write to tell the main member how we have dealt with any claim. Please also see the section Claiming. 4

7 1.3 WHEN YOUR MEMBERSHIP STARTS, RENEWS AND ENDS Starting membership Your cover starts on your start date. Your dependants cover starts on their start date. Your start date and your dependants start date(s) may not be the same. Your right to cancel You may cancel your membership for any reason by calling us on or writing to us within 21 days of receiving the first membership certificate we send you each year confirming your cover. As long as you have not made any claims we will refund all of your subscriptions for that year and any sums you have paid for future years (if any). You may cancel any of your dependants membership for any reason by calling us on or writing to us within 21 days of receiving the first membership certificate we send you each year confirming their cover. As long as no claims have been made in respect of their cover we will refund all your subscriptions paid in respect of that dependant s cover for that year and any sums paid in respect of that dependant for future years (if any). Calls may be recorded and may be monitored. Renewing your membership Our agreement is an annual one and your membership must be renewed each year on your renewal date, subject to the Making changes section. Your membership will renew automatically as long as you continue to pay your subscriptions and any other charges unless: you decide to end your membership we decide to end the Bupa By You scheme, or o o if your cover is arranged by a group sponsor, we do not agree to your membership or the membership of any of your dependants renewing. If we decide to end the scheme or if your cover is arranged by a group sponsor and we do not agree to your membership or the membership of your dependants renewing, we will write to let you know at least 28 days before your renewal date. How membership can end You can end your membership or the membership of any of your dependants at any time. If you want to end your membership or that of your dependants at any time you may write to us or call us on We will refund any subscriptions you have paid which relate to a period after your or your dependants cover ends. +Calls may be monitored and may be recorded If your membership ends the membership of all your dependants will also end. Your membership and that of your dependants will automatically end if: you do not renew your membership o o you do not pay your subscriptions or any other payment you have to make in respect of the cover, on or before the date they are due o o you stop living in the UK (you must inform us if you stop living in the UK) you die, or we decide to end the scheme. Your dependants membership will automatically end if: your membership ends you do not renew their membership o o that dependant stops living in the UK (you must tell us if any dependant stops living in the UK) that dependant dies, or we decide to end the scheme. 5

8 In addition, if your dependants have the Health Expenses Cover Add on that cover will end automatically: if your membership ends o o when that dependant reaches 18 years of age (or 21 years of age if they are in full-time education) o o if that dependant is 18 years of age or over and ceases to be in full-time education (you must tell us if this happens) o o if that dependant stops living at your address (you must tell us if this happens). If your membership of the scheme is based on you being either: employed by the group sponsor, or a member of the group sponsor and the group sponsor has agreed with us that your membership and that of your dependants will end if: you cease to be employed by the group sponsor, or you cease to be a member of the group sponsor as applicable, we will end your membership of the scheme at the end of the month in which we are advised or determine that you are no longer employed by, or a member of, that group sponsor. You should call your helpline to confirm if your scheme is arranged by a group sponsor. We can end a person s membership if there is reasonable evidence that you or they misled us or attempted to do so. By this we mean, giving false information or keeping necessary information from us, either intentionally or carelessly, which may influence us when deciding: whether or not we will provide cover for them 6 whether we have to pay any claim. Joining another Bupa scheme If we decide to close the scheme, or if your cover is arranged by a group sponsor and we do not agree to your membership being renewed, we may offer you the opportunity to join another Bupa health insurance scheme on the basis of the terms and conditions of the new scheme that we offer you. If you are an underwritten member and transfer within one month we will not add any special conditions to your membership or that of any of your dependants, if they are underwritten members, under the new scheme other than those that apply under this scheme. If your membership ends for any other reason, or we don t offer you an opportunity to join another Bupa health insurance scheme on the basis explained above, you may apply to join another Bupa health insurance scheme. You may only do this as long as your membership didn t end because you misled or attempted to mislead us. We will consider your application at our sole discretion. Paying subscriptions and other charges You must pay subscriptions to us in advance for you and your dependants throughout your membership. The amount you must pay and your method of payment are shown on your payment schedule. If your cover is arranged by a group sponsor and you have agreed with your group sponsor that your subscriptions are collected by them and paid to us on your behalf (eg by payroll deduction) the group sponsor will pay us on your behalf. Refund of subscriptions if your membership ends If your membership ends for any reason we will refund any subscriptions you have paid which relate to a period after your cover ends. If your dependants membership ends for any reason we will refund any subscriptions you have paid in respect of that dependant which relate to a period after their cover ends. No claims discount (NCD) Your membership certificate will tell you if a no claims discount applies to your cover. In calculating the subscriptions payable next year we will apply a no claims discount to the core health insurance subscriptions based upon the value of the claims paid for you during

9 the 12 month period (10 month period in your first year of cover) preceding our calculation. We apply your no claims discount to your net subscription rate excluding Insurance Premium Tax. The calculation period As we calculate your subscriptions prior to your renewal date, we will assess all eligible claims paid by us for you: in the first 10 months of your first year, and for subsequent years, in months 11 and 12 of the previous year plus months one to 10 of the current year. Please note that payment may take a few weeks from the date of your treatment, depending on how quickly invoices are submitted to us. The following table shows how any claims you make will affect your level of no claims discount. Value of claims paid during the calculation period Change in discount level applied at the next renewal date (subject to the minimum and maximum discount levels available) 0.00 Move up the scale by 1 level 0.01 to 250 Move down the scale by 1 level to 500 Move down the scale by 2 levels and above Move down the scale by 3 levels The following table shows the amount of no claims discount that applies for each no claims discount level. Discount level 14 is the maximum discount level available and your no claims discount will therefore never exceed 70%. Discount level you are on Discount you will receive 0% 10% 20% 27.5% 35% 40% 45% 50% 55% 59% 62% 65% 68% 70% Please note: We may change the no claims discount or withdraw it at any time in accordance with the Making changes section of this membership guide. Low claims bonus (LCB) Your membership certificate will tell you if a low claims bonus applies to your cover. In calculating the subscriptions payable next year we will apply a low claims bonus to the core health insurance subscriptions based upon the value of the claims paid for you by us during the 12-month period preceding our calculation. If we do not pay any claims within the calculation period you will receive a bonus to reduce any subscription adjustment that is otherwise applied to your subscriptions. If we do pay a claim for you, you will receive an increase in addition to any subscription adjustment that is otherwise applied. The calculation period As we calculate your subscriptions prior to your renewal date, we will assess all eligible claims paid by us for you: in the first 10 months of your first year, and for subsequent years, in months 11 and 12 of the previous year plus months one to 10 of the current year. Please note that payment may take a few weeks from the date of your treatment, depending on how quickly invoices are submitted to us. We may change the low claims bonus or withdraw it at any time in accordance with the Making changes section of this membership guide. No claims discount and low claims bonus Please note that claims you may make in relation to any of the following benefits do not count as claims in the assessment of the no claims discount or low claims bonus to be applied to your subscriptions: TIP: IF YOU RE UNSURE IF ANY CHANGES AFFECT YOUR COVER, JUST GIVE US A CALL AND WE LL BE HAPPY TO ADVISE. 7

10 Add ons (benefits A1 to A4) Fitness check (benefit PD3.1) NHS cash benefit (benefits C5.5 and C10); and Travel and Emergency Medical Cover. In addition, any claims we pay for you during the calculation period that fall entirely within your excess will not be counted. If you are unwell, you should not delay seeking treatment because of the impact it will have on your no claims discount or low claims bonus. 1.4 MAKING CHANGES Changes we can make We can change the terms and conditions of the membership at your renewal date. These changes could affect: o o how we calculate subscriptions, the amount you have to pay, how often you pay them and the method of payment (the cost of subscriptions has typically risen higher than the retail price index (RPI) over the same period, but this does not mean that they will increase by the same rate in the future), and the amount and type of cover provided under the scheme. If your cover is arranged by a group sponsor, at your renewal date we may also change or withdraw the amount of any discount or preferential rates. We can, at any time, change the amount you have to pay us in respect of Insurance Premium Tax (IPT) or any other taxes, levies or charges that may be introduced and which are payable in respect of your cover if there is a change in the rate of IPT or if any such taxes, levies or charges are introduced. We will not add any special conditions to someone s cover for medical conditions that started after their start date provided they gave us all the information we asked for before their start date. If we do make any changes to the terms and conditions of your membership we will write to tell you at least 28 days before the change takes effect. If your cover is arranged by a group sponsor, we may make changes to the terms and conditions of your membership on your renewal date and if you do not accept any of the changes you can end your membership either: within 28 days of the date on which the change takes effect, or within 28 days of us telling you about the change whichever is later, and if you do end your membership within the 28 days we will treat the changes as not having been made. Changes you can make At your renewal date you can apply to: add, remove or change an excess o o change any of the Bupa By You options you have chosen. We will consider your application at our sole discretion. If you apply to increase cover under the scheme we may ask you to agree to special conditions before we accept your application. These changes may also affect the subscriptions you have to pay. Other parties No other person is allowed to make or confirm any changes to your membership or your benefits on our behalf or decide not to enforce any of our rights. Equally, no change to your membership or your benefits will be valid unless it is specifically agreed between the main member and us and confirmed in writing. 8

11 1.5 GENERAL INFORMATION Change of address You should call or write to tell us if you change your address. If you do not contact us to tell us you have changed your address and you pay your subscriptions by direct debit, your membership of the scheme will automatically end on your next renewal date if we cannot contact you. Correspondence and documents All correspondence and membership documents are sent to the main member. When you send documents to us, we cannot return original documents to you. However, we will send you copies if you ask us to do so at the time you give us the documents. Letters between us must be sent with the postage costs paid before posting. We can each assume that the letter will be received three days after posting. Applicable law The agreement is governed by English law. 1.6 MAKING A COMPLAINT We are committed to providing you with a first class service at all times and will make every effort to meet the high standards we have set. If you feel that we have not achieved the standard of service you would expect or if you are dissatisfied in any other way, then this is the procedure that you should follow. If Bupa, or any representative of Bupa, did not sell you this policy and your complaint is about the sale of your policy, please contact the party who sold the policy. Their details can be found on the status disclosure document or the terms of business document they provided to you. For any other complaints, our member services department is always the first number to call if you need help or support or if you have any comments or complaints. You can contact us in several ways: By phone: In writing: Customer Relations, Bupa, Salford Quays, Manchester, M50 3XL By Or via our website: bupa.co.uk/members/member-feedback How will we deal with your complaint and how long is this likely to take? If we cannot resolve your complaint immediately we will write to you, within five working days, to acknowledge receipt of your complaint. We will then continue to investigate your complaint and aim to send you our full written final decision within 15 working days. If we are unable to resolve your complaint within 15 working days we will write to you to confirm that we are still investigating your complaint. Within eight weeks of receiving your complaint we will either send you a full written final decision detailing the results of our investigation or send you a letter advising that we have been unable to complete the review of your complaint. If you remain dissatisfied after receiving our final decision, or after eight weeks you do not wish to wait for us to complete our review, you may refer your complaint to the Financial Ombudsman Service. You can write to them at: Exchange Tower, London, E14 9SR or call them on (free for fixed line users) or (free for mobile phone users who pay a monthly charge for calls to numbers starting 01 or 02). For more information you can visit Calls may be recorded and may be monitored. 9

12 Your complaint will be dealt with confidentially and will not affect how we treat you in the future. Whilst we are bound by the decision of the Financial Ombudsman Service, you are not. For members with special needs we can offer a choice of braille, large print or audio for correspondence and marketing literature. Please get in touch to let us know which you would prefer. The Financial Services Compensation Scheme (FSCS) In the unlikely event that we cannot meet our financial obligations, you may be entitled to compensation from the Financial Services Compensation Scheme. This will depend on the type of business and the circumstances of your claim. The FSCS may arrange to transfer your policy to another insurer, provide a new policy or, where appropriate, provide compensation. Further information about compensation scheme arrangements is available from the FSCS on or or on its website 10

13 2. CLAIMING This section of the guide explains how to claim on your Bupa policy. It is essential you understand this claiming process so that accessing your treatment runs smthly and you can ensure your costs are paid in full. 11

14 A STEP-BY-STEP GUIDE TO MAKING A CLAIM CLAIMING If you are unwell and your GP thinks you need to have some tests or see a consultant or other healthcare professional, just follow our simple step-by-step guide to claiming. It includes how to ask your GP for a referral to a healthcare professional and how to check that your treatment costs will be covered by Bupa. For all other schemes, please follow these steps: 1. Visit your GP Your GP will advise you if you need to see a consultant or healthcare professional for your health needs. There are some conditions where a GP referral is not required and you can find details at bupa.co.uk/policyinformation. These details may be updated from time to time. 2. Ask your GP for a referral to a consultant or healthcare professional for your consultations or treatments If you have a condition for which a GP referral to a consultant or healthcare professional is required, we recommend that you ask your GP for an Open Referral letter which will detail the care your GP would like you to have, but will not be addressed to a specific consultant, hospital or healthcare professional. An Open Referral letter needs to include your GP s assessment of your symptoms, the body area affected and the type of specialist your GP would like you to see. Alternatively, you can give your GP our simple Open Referral form to complete as an alternative to a standard referral letter. A copy of the form can be downloaded from bupa.co.uk/referral An Open Referral means that we can offer you greater flexibility and a choice of consultants, as well as help you to make sure you avoid any extra costs for the surgeon fees (some consultants charge fees which are outside our benefit limits and if they do, you may need to pay some of these fees yourself). You can, of course, ask your GP to suggest a suitable person for you to see. If your GP does want to give you a referral to a specific consultant, make sure you call us first to confirm with us that they charge within our limits to avoid you being liable for any unforeseen costs. 3. Call the Bupa Helpline before arranging a consultation or receiving treatment As sn as you have seen your GP, please call us so that we can discuss your options and explain which consultants and healthcare professionals are covered under your Bupa membership. We will let you know what you need to do next and send you any necessary pre-treatment forms you may need to complete. To help us to make the claims process as simple and swift as possible, please have the following information close to hand when you call to make a claim: your Bupa membership number the condition you are suffering from details of when your symptoms first began details of when you first consulted your GP about your condition details of the treatment that your GP has recommended 12

15 4. Get a pre-authorisation number When we have confirmed that your treatment is covered, we will discuss your claim with you and give you a pre-authorisation number. You can then contact your consultant or healthcare professional to arrange an appointment. We recommend you give your pre-authorisation number to the consultant or healthcare professional you see so that the invoice for any treatment costs can be sent to us directly. Please call us to authorise any further consultations or treatments to ensure that they are covered by your policy. If for any reason you are sent the invoice, simply send it on to: Claims Department, Bupa, Salford Quays, M50 3XL Once we have paid the invoice on your behalf, we will send you a summary of your claim and treatment details. Please note that payment may take a few weeks, depending on how quickly invoices are submitted to us. CLAIMS CHECKLIST WHAT YOU LL NEED TO MAKE A CLAIM To help us to make the claims process as simple and swift as possible, please have the following information close to hand when you call to make a claim: Your Bupa membership number The condition you are suffering from Details of when your symptoms first began Details of when you first consulted your GP about your condition Details of the treatment that has been recommended TIP: BEFORE YOU MAKE A CLAIM PLEASE REFER TO THE CLAIMS CHECKLIST OPPOSITE TO ENSURE YOU HAVE ALL THE INFORMATION YOU LL NEED. IF POSSIBLE, ALWAYS HAVE YOUR MEMBERSHIP CERTIFICATE TO HAND WHEN YOU CALL. 13

16 2.1 MAKING A CLAIM Claims other than cash benefit We recommend that you always contact us before arranging or receiving any treatment. This is the only way that we can confirm the benefits that are available to you before you incur any costs for your treatment. Any costs you incur that are not covered under your benefits are your responsibility. For underwritten members With full medical underwriting, your medical history is provided when you join the scheme. We then review your information and decide what cover we can offer you. Any pre-existing condition (and conditions related to it) will be excluded and listed as a special condition on your membership certificate. We can, in some cases, review your special conditions in future if you ask us to. When you call us we will: o o confirm whether your proposed treatment, medical provider or treatment facility will be eligible under your benefits the level of benefits available to you, and o o if you wish to make a claim, tell you whether you will need to complete a claim form. If you do not need to complete a claim form, we will treat your call to us as your claim once we are notified that you have received your treatment. In most cases we will be notified that you have received your treatment by your consultant or the provider of your treatment. If you do need to complete a claim form, you will need to return the fully completed claim form to us as sn as possible and in any event within six months of receiving the treatment for which you are claiming unless this was not reasonably possible. For moratorium members With moratorium underwriting, you are asked to provide details about your medical history if you make a claim and not when you join the scheme. Cover is automatically excluded for two years from the start of your scheme for any conditions which you: had symptoms of received medication for had treatment for, or received advice about in the five years before your start date. Cover is also excluded for any moratorium condition unless you do not: have symptoms of receive medication for, or receive advice about the condition for a continuous period of two years. When you joined the scheme you agreed you would not be covered for any moratorium conditions. Each time you make a claim you must provide us with information so we can confirm whether your proposed treatment is covered under your benefits. When you call us we will send you a pre-treatment form to complete giving details of the history of the medical condition you are claiming for, including information that you will need to ask your GP or consultant for. Your GP or consultant may charge you a fee for providing a report which we do not pay. Each claim you make during your membership will be assessed on this information and any further information we ask you to provide to us at the time you claim. Once we receive all the information we ask you for we will: o o confirm whether your proposed treatment, medical provider or treatment facility will be eligible under your benefits confirm the level of benefits available to you, and o o if you wish to make a claim, tell you whether you will need to complete a claim form. If you do not need to complete a claim form, we will treat your submission of your pre-treatment form to us as your claim once we are notified that you have received your 14

17 treatment. In most cases we will be notified that you have received treatment by your consultant or recognised facility. If you do need to complete a claim form you will need to return the fully completed claim form to us as sn as possible and in any event within six months of receiving the treatment for which you are claiming unless this was not reasonably possible. Remember: The value of the claims you make can affect the level of your subscriptions for the following year. See also the No claims discount and Low claims bonus section in How your membership works or call us for more information Claims for cash benefits Call the helpline to check your benefits. We will confirm your benefits and tell you whether you need to complete a claim form. You must send us either: o o your completed claim form if you need to complete one please note that for NHS cash benefits you will need to take your claim form with you to the hospital and ask them to complete the hospital sections, or o o if you do not need a claim form, a covering letter giving your name, address and membership number - please note that for NHS cash benefit for home treatment for cancer we will accept a letter, on the headed paper of your hospital, providing details of your NHS home treatment together with your original documents for example discharge notes, invoices and receipts Treatment needed because of someone else s fault When you claim for treatment you need because of an injury or medical condition that was caused by or was the fault of someone else (a third party ), for example, an injury suffered in a road accident in which you are a victim, all of the following conditions apply when you make such a claim: o o you agree you are responsible for the payment of any costs which may ultimately be recovered from the third party o o you must notify us as sn as possible that your treatment was needed as a result of a third party. You can notify us either by writing to us or completing the appropriate section on your claim form. You must provide us with any further details that we reasonably ask you for o o you must take any reasonable steps we ask of you to recover from the third party the cost of the treatment paid for by us and claim interest if you are entitled to do so o o you (or your solicitor) must keep us fully informed in writing of the progress and outcome of your claim o o if you recover the cost of any treatment paid for by us, you must repay the amount and any interest to us Other insurance cover If you have other insurance cover for the cost of the treatment or services that you are claiming from us you must provide us with full details of that other insurance policy as sn as possible. You must do this either by writing to us or by completing the appropriate section on your claim form. In which case we will only pay our share of the cost of the eligible treatment for which you are claiming. 2.2 HOW WE WILL DEAL WITH YOUR CLAIM General information We only pay for eligible treatment that you receive, or the benefits that you are entitled to, while you are covered under the agreement and we only pay in accordance with the agreement. We also only pay the benefits that applied to you on the date you received your treatment or the date that you became entitled to those benefits. Except for NHS cash benefit and the Cancer Assist Add on (if applicable), we only pay eligible costs and expenses actually incurred by you for treatment you receive. We do not have to pay a claim if you break any terms and conditions of your membership. Unless we tell you otherwise, your claim form and prf to support your claim must be sent to us. 15

18 2.2.2 Providing us with information You will need to provide us with information to help us assess your claim if we make a reasonable request for you to do so. For example, we may ask you for one or more of the following: o o medical reports and other information about the treatment for which you are claiming o o the results of any independent medical examination which we may ask you to undergo at our expense o o original accounts and invoices in connection with your claim (including any related to treatment costs covered by your excess if any). We cannot accept photocopies of accounts or invoices or originals that have had alterations made to them. If you do not provide us with any information we reasonably ask you for we will be unable to assess your claim. Obtaining medical reports from your GP: When you need to request a medical report from your GP, we can do this on your behalf with your consent. We will always ask for your consent before requesting a report from your GP on your behalf and we will ask for your consent on the telephone when we explain to you the need for the report. You can chse from three courses of action: o o You can give your consent without asking to see the doctor s report before it is sent to us. The doctor will send the report directly to us. If you give your consent to us obtaining a report without indicating that you wish to see it, you can change your mind by contacting your doctor before the report is sent to us. In which case you will have the opportunity to see the report and ask the doctor to change the report or add your comments before it is sent to us, or withhold your consent for its release. o o You can give your consent, but ask to see any report before it is sent to us, in which case you will have 21 days, after we notify you that we have requested a report from the doctor, to contact your doctor to make arrangements to see the report. If you fail to contact the doctor within 21 days, we will request they send the report direct to us. If however you contact your doctor with a view to seeing the report, you must give the doctor written consent before they can release it to us. You may ask your doctor to change the report if you think it is misleading. If your doctor refuses, you can insist on adding your own comment to the report before it is sent to us. o o You can withhold your consent, but if you do, please bear in mind that we may be unable to progress with your claim. Whether or not you indicate that you wish to see the report before it is sent, you have the right to ask your doctor to let you see a copy, provided that you ask them within six months of the report having been supplied to us. Your doctor is entitled to withhold some or all of the information contained in the report if (a) they feel that it may be harmful to you (b) it would indicate their intentions in respect of you or (c) would reveal the identity of another person without their consent (other than that of a health professional in relation to your care). We may make a contribution to the costs of any report that we have requested on your behalf, this will be confirmed at point of telephone consent. If we do make a contribution, you will be liable for any amount above this How we pay your claim Claims other than cash benefits: for treatment costs covered under your benefits we will, in most cases, pay the provider of your treatment direct such as the recognised facility or consultant or whichever other person or facility is entitled to receive the payment. Otherwise we will pay the main member. We will write to tell the main member how we have dealt with any claim. Claims for cash benefits: we pay eligible claims by cheque to, or by direct payment to the bank account of, the main member. 16

19 2.3 IF YOU WANT TO WITHDRAW A CLAIM If, for any reason, you wish to withdraw your claim for the costs of treatment you have received, you should call the helpline to tell us as sn as possible. You will be unable to withdraw your claim if we have already paid your claim. If you do withdraw your claim you will be responsible for paying the costs of that treatment. 2.4 EX-GRATIA PAYMENTS If we agree to pay for the costs of treatment to which you are not entitled under your benefits, ie an ex-gratia payment, this payment will still count towards any maximum amount we will pay under your benefits. Making these payments does not oblige us to make them in the future. 2.5 IF YOU HAVE AN EXCESS You may have agreed with us that an excess shall apply to your benefits. The membership certificate shows if one does apply and if so: the amount who it applies to what type of treatment it is applied to; and the period for which the excess will apply. Some further details of how an excess works are set out below and should be read together with your membership certificate. If you are unsure whether an excess does apply to you please refer to your membership certificate or contact the helpline How an excess works Having an excess means that you have to pay part of any eligible treatment costs that would otherwise be paid by us up to the amount of your excess. By eligible treatment costs we mean costs that would have been payable under your benefits if you had not had an excess. If your excess applies each year it starts at the beginning of each year even if your treatment is ongoing. So, your excess could apply twice to a single course of treatment if your treatment begins in one year and continues into the next year. We will write to the main member to tell them who you should pay the excess to, for example, your consultant, therapist or recognised facility. The excess must be paid direct to them not to Bupa. We will also write to tell the main member the amount of the excess that remains (if any). You should always make a claim for eligible treatment costs even if we will not pay the claim because of your excess. Otherwise the amount will not be counted towards your excess and you may lose out should you need to claim again How the excess applies to your benefits Unless we say otherwise in your membership certificate: o o we apply the excess to your claims in the order in which we process those claims o o when you claim for eligible treatment costs under a benefit that has a benefit limit your excess amount will not count towards your total benefit limit for that benefit o o the excess does not apply to NHS cash benefits or to the Health Expenses Cover, Dental Cover, Complementary Therapies Cover and Cancer Assist Add ons or to the Fitness check within Fit and Active Cover. 17

20 3. BENEFITS: WHAT YOU ARE COVERED FOR Please take a lk at your membership certificate for a list of the specific benefits of your chosen Bupa By You policy. Any elements of cover that you see described in this guide that are not listed on your certificate or are shown as not covered, are not included in your insurance. You ll see that cover is divided into three core options: Prompt Diagnosis, Treatment and Care, and Comprehensive. There are also sections dedicated to the wide variety of add ons that are available with Bupa By You. If you have purchased any add ons on top of your core health insurance, you will find important information about these within this section. 18

21 This section explains charges we pay for eligible treatment and the impact of both the type of treatment you need and your chosen medical practitioners and/or treatment facility to be eligible under your benefits. NOTES ON BENEFITS The following notes apply equally to all the benefits and should be read together with those benefits. Restrictions and/or limitations to benefits Your cover may be limited or restricted through one or more of the following: benefit limits these may be limits on: -- the amounts we will pay and/or restrictions on the cover you have under your benefits. Your membership certificate shows the benefit limits and/or restrictions that apply to your benefits, or -- the maximum amounts we will pay towards the costs of your treatment, which apply particularly when you use a recognised facility that is not within your facility access or a consultant who is not a fee assured partner o o an excess this is explained in section 2.5 in the section Claiming. Your membership certificate shows if an excess applies to your benefits. o o waiting periods if you are an underwritten member, waiting periods apply to certain benefits and certain exceptions as set out in this membership guide. Your membership certificate shows if waiting periods apply to your benefits and if so how long your waiting periods are o o exclusions apply to your cover: the general exclusions are set out in the section What you are not covered for. Some exclusions also apply in this section and there may also be exclusions in your membership certificate. Being referred for treatment and Bupa recognised medical practitioners and recognised facilities Your treatment must, in most cases, follow an initial referral by a GP after you have seen the GP in person. However, for day-patient treatment or in-patient treatment provided by a consultant such referral is not required in the case of a medical emergency. There are some conditions where a GP referral is not required and details of these are available from us on request. For information on these conditions please call your member helpline or go to bupa.co.uk/policyinformation. The list of conditions for which a GP referral is not required may be updated from time to time. You are only covered for eligible treatment. Please see the glossary section for what we mean by eligible treatment. Your cover for eligible treatment costs depends on you using certain Bupa recognised medical and other health practitioners and recognised facilities. Please note: o o the medical practitioners, other healthcare professionals and recognised facilities you use can affect the level of benefits we pay you o o the level of benefits we pay you depends upon whether the recognised facility you use is within your facility access o o certain medical practitioners, other healthcare professionals and recognised facilities that we recognise may only be recognised by us for certain types of treatment or treating certain medical conditions or certain levels of benefits o o the medical practitioners, other healthcare professionals and recognised facilities that we recognise and the type of medical condition and/or type of treatment and/or level of benefit that we recognise them for can change from time to time. 19

22 Your treatment costs are only covered when: o o the person who has overall responsibility for your treatment is a consultant. If the person who has overall responsibility for your treatment is not a consultant then none of your treatment costs are covered the only exception to this is where a GP refers you (or where we refer you when we have told you that a GP referral is not required for your condition) for out-patient treatment by a mental health and wellbeing therapist (if applicable), therapist or complementary therapy practitioner (if applicable) o o the medical practitioner or other healthcare professional and the recognised facility are recognised by us for treating the medical condition you have and for providing the type of treatment you need. In addition, the level of benefits we pay depends upon whether the recognised facility you use is within your facility access. Important: Always call us before arranging any treatment to check your benefits and whether your chosen medical practitioner or other healthcare professional or recognised facility is recognised by us for both treating the medical condition you have and for providing the type of treatment you need and the recognised facility is within your facility access. Any treatment costs you incur that are not covered under your benefits are your responsibility. Using a non-recognised facility When you contact us we will check your cover and help you to find a suitable alternative Bupa recognised treatment facility. However, if, for medical reasons, your proposed day-patient treatment or in-patient treatment cannot take place in a recognised facility we may agree to your treatment being carried out in a treatment facility that is not a recognised facility. We need full clinical details from your consultant before we can give our decision. If we do agree, we pay benefits for the treatment as if the treatment facility had been a recognised facility. Reasonable and customary charges We only pay eligible treatment charges that are reasonable and customary. This means that the amount you are charged by medical practitioners, other healthcare professionals and/or treatment facilities and what you are charged for have to be in line with what the majority of our other members are charged for similar treatment or services. 20

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