2 CONTENTS Core Cover What s Included in Your Plan 04 Cover Options See What You Can Add or Remove 07 Hospital Lists 11 Excess Amounts 13 We Give You a No-Claims Discount 14 Underwriting 16 Important Information 20
3 Why PruHealth? FULL COVER Even when they say Full Cover, some other health insurers only pay consultants fees up to a certain amount so, if your consultant charges more than that, you ll have to cover the rest. You could end up paying hundred of pounds. When we say Full Cover, we mean it. You don t have to worry about what your consultant charges, because we take care of the fees as long as the condition is eligible on your plan which means you won t have to make up any shortfall. FULL CANCER COVER Our Full Cancer Cover is included within our Core Cover and covers all costs associated with cancer. It doesn t apply limits on the use of biological therapies, hormone or bisphosphonate therapy and provides cover for pain relief at the end stage of cancer. WE WON T HIDE BEHIND SMALL PRINT You can be confident that we won t use small print to try to get out of paying claims. We are transparent about what is covered and make it clear when limits or exclusions apply or where choices need to be made. Look out for the Cover Check logo. This guide provides a summary of our Personal Healthcare plan that you need to read before you make decisions on what is the right cover for you. For full details, please refer to our terms and conditions which you receive when you join. If you want to see these sooner, please let us know.
4 1 Start with Core Cover ALL PLANS START WITH CORE COVER, WHICH HAS A VARIETY OF BENEFITS. THEY ALSO INCLUDE VITALITY, WHICH IS OUR WELLNESS PROGRAMME DESIGNED TO HELP YOU LOOK AFTER YOUR HEALTH. You can then tailor your plan by picking any number of optional benefits, and premiums can be reduced with a range of excess levels and a choice of hospital lists. This table provides a summary of the benefits included within our Core Cover. The full benefits, terms and conditions are available on request. All benefits are per insured member, per plan year, unless stated otherwise. Treatment must take place at a hospital included on your chosen hospital list.
5 A guide to Personal Healthcare 05 CORE COVER IN-PATIENT AND DAY-PATIENT TREATMENT Hospital fees Specialists fees Diagnostic tests OUT-PATIENT TREATMENT MRI/CT/PET scans ADDITIONAL BENEFITS NHS Hospital Cash Benefit Childbirth Cash Benefit Home Nursing Private Ambulance Includes overnight stays, nursing, and any drugs you might need while in hospital. We also cover the costs of intensive care treatment and operating theatre charges. As long as your specialist is registered with an accredited body and recognised by us, we pay your in-patient and day-patient fees in full, including your surgeons and anaesthetists fees, physicians fees and other specialist consultations. If you are admitted to hospital as an inpatient or a day-patient, we pay for the diagnostic tests you need things like blood tests and x-rays. We also pay for any MRI, CT and PET scans if required. We pay for these scans if you are an outpatient, as long as you ve been referred by a specialist. If you choose to get treatment on the NHS, rather than being treated privately through your plan, we give you a cash amount. Once your plan has been in place for 10 months, we ll give you a cash payment following the birth or adoption of a child. We pay once per child, even if both parents are covered on the plan. The 10 month waiting period isn t applicable to adoption. If your specialist recommends home nursing instead or more in-patient treatment, we pay for it. It can get you back on your feet after a stay in hospital. The use of a private ambulance for transfer between hospitals, whether NHS or private, if a specialist recommends it as medically necessary. In-patient treatment: 250 per night up to a maximum of 2,000 Day-patient treatment: 125 per day up to a maximum of per child
6 06 A guide to Personal Healthcare CORE COVER Parent Accommodation Oral Surgery Pregnancy Complications Assistance at Home You might have a child under 14 on your plan. If the child needs to stay overnight in hospital, we pay for hospital accommodation so that a parent can stay with them. We cover surgical removal of impacted teeth, buried teeth and complicated roots, surgical drainage of a facial swelling, removal of cysts of the jaw, and apicectomy. If you have an accident we can also cover some kinds of dental surgery. We cover in-patient and day-patient treatment if you suffer from ectopic pregnancy, miscarriage, missed abortion, still birth, post partum haemorrhage, retained placental membrane and hydatidiform mole. We ll give you the help needed so you can recover in the comfort of your own home. If you ve been in hospital for more than 3 days, for any condition eligible on the plan, you ll be entitled to Assistance at Home. Help at home can include personal care such as help with getting washed and dressed, and domestic duties such as general tidying and changing bed linen. in specified circumstances for specified procedures The maximum benefit entitlement, subject to a needs assessment, is two weeks per hospitalisation, with up to two hours care per day. Six weeks benefit in total is available per plan year. FULL CANCER COVER If you are diagnosed with cancer, we cover your in-patient and out-patient costs in full. This includes: Radiotherapy, chemotherapy and follow-up consultations Biological therapies Hormone and bisphosphonate therapies Cancer surgery and reconstructive surgery Stem cell transplantation If your cancer is no longer treatable, we pay for you to have care that can relieve your symptoms. This includes pain relief at the end stage of cancer.
7 2 Choose your cover options YOU CAN CHOOSE OTHER COVER OPTIONS FOR YOUR PLAN. THIS MEANS YOU CAN CREATE A PLAN TO SUIT YOUR NEEDS AND YOUR BUDGET. All benefits are per insured member, per plan year, unless stated otherwise. Treatment must take place at a hospital included on your chosen hospital list.
8 08 A guide to Personal Healthcare COVER OPTIONS OUT-PATIENT COVER PHYSIOTHERAPY COVER OUT-PATIENT DIAGNOSTICS PSYCHIATRIC COVER THERAPIES COVER PRIVATE GP HELPLINE CORE CANCER COVER We already cover you for MRI, CT and PET scans through our Core Cover. Out-patient Cover pays for other out-patient costs, such as specialist consultations, physiotherapy, and diagnostic tests things like blood tests and x-rays. With Out-patient Cover you can also use the physiotherapy network. The PruHealth physiotherapy network includes over 1,400 accredited physiotherapy clinics across the UK. This means that, more often than not, you ll be able to have treatment at a convenient location, less than 10 minutes drive away from your home or place of work You can choose to add on full cover for diagnostics you can upgrade your Outpatient Cover so that out-patient diagnostic tests would be covered in full, and only specialist consultations and physiotherapy would be covered by your chosen Outpatient Cover limit. We pay for consultations and treatment with a psychiatrist or psychologist. If you need it, we can pay for hospital stays. All psychiatric claims are managed on a case-by-case basis. Chiropractic treatment, osteopathy, chiropody/podiatry, acupuncture, homeopathy, and two consultations with a dietician following GP or specialist referral If you want to speak to a doctor at any time, you can call our Private GP Helpline. Because the Helpline is open 24 hours a day, 7 days a week, you won t have to worry about waiting for an appointment with your own GP. Core Cancer Cover applies a 12 month limit on the use of biological therapies. It will also apply a 3 month limit on hormone or bisphosphonate therapy when prescribed on their own. This will result in a discount on your premium. These limits apply for the whole of the time a member is covered by PruHealth, whether under this plan or any other plan with us. The costs we cover depend on what you add to your plan: Out-patient Cover with a limit. We can pay for out-patient diagnostic tests, specialist consultations and physiotherapy up to a set limit. A limit of 500, 750, 1,000, 1,250 or 1,500 can be chosen. Full Out-patient Cover. We pay for all the out-patient treatment, specialist fees and diagnostic tests needed. Cover for a physiotherapist within our network We pay for the treatment in full (up to the Out-patient Cover limit on your plan) Cover for a physiotherapist outside of our network You pay the invoice and we reimburse you for 35 per session. We pay for up to five sessions. 15,000 or 20,000 for each plan year. Up to 1,500 of this total can be used for out-patient psychiatric treatment 350 or (subject to the limits specified)
9 A guide to Personal Healthcare 09 DENTAL COVER You can choose between two levels of dental cover, depending on how much you want to spend, and how much cover you want. All benefits are per insured member, per plan year unless otherwise stated. MAJOR DENTAL TREATMENT MAJOR AND ROUTINE DENTAL TREATMENT Routine examinations Maximum of two claims per plan year Routine scaling and polishing Maximum of two claims per plan year Dental x-ray (radiography of the teeth or jaw) Charges for radiography of teeth or jaw Maximum of two claims per plan year Fillings Maximum of two claims per plan year Up to 30 per claim Up to 40 per claim Up to 40 per claim Up to 40 per claim New or replacement crowns Up to 300 Up to 400 New or replacement inlays, onlays and overlays New or replacement bridges or implants Up to 100 Up to 200 Up to 300 Root canal treatment Up to 150 Up to 250 Apicectomy Up to 100 Up to 150 Extractions Up to 150 Up to 250 New or replacement dentures Up to 250 Up to 350 Emergency treatment from a specialist if you have a dental accident We can cover up to four claims for each year of your plan Emergency dental treatment for severe pain, a haemorrhage or an infection We can cover up to two claims for each year of your plan Emergency call-out fees We can cover up to two claims for each year of your plan Up to 2,500 per claim Up to 50 per claim Up to 2,500 per claim Up to 300 per claim Up to 50 per claim To get this cover, you need to have had a check-up with your regular dentist and finished any recommended treatment within twelve months before your cover starts. If you haven t done this, then you ll only be covered once you have had a check-up and finished any recommended treatment. Separate terms, conditions and exclusions apply to our Dental Cover please speak to your adviser or visit pruhealth.co.uk for more information.
10 10 A guide to Personal Healthcare WORLDWIDE TRAVEL COVER This covers trips of up to 120 days and includes things like emergency medical expenses to a lost passport. We can cover you as long as you are aged 79 or under. OVERSEAS MEDICAL EXPENSES Medical cover if taken ill overseas, including accommodation costs and travel expenses for one person to remain behind with the sick or injured member* Repatriation expenses* Up to 10 million Transfer of body or ashes back to the UK Cost of burial or cremation outside the UK Up to 1,000 OTHER TRAVEL EXPENSES Loss of or damage to personal belongings* Up to 2,000 Loss of personal money* Up to 1,000 Delayed departure Up to 100 Missed departure* Up to 500 Cancelling the trip or cutting it short* Up to 4,000 Personal accident Up to 25,000 Personal liability Up to 2 million Loss of passport* Up to 250 Delayed baggage* Up to 200 Legal expenses Up to 25,000 WINTER SPORTS COVER (COVER IS LIMITED TO 21 DAYS IN TOTAL EACH PLAN YEAR) Loss of or damage to ski or snowboarding equipment* Loss of ski pass* Piste closure ( 30 a day)* Loss of use of hired skis and ski pass due to illness or injury* Up to 500 per plan year Up to 500 per plan year Up to 500 per plan year Up to 500 per plan year *You will need to pay a 50 excess on these benefits. Unless we agree otherwise, the benefits are for one person covered on your plan, per trip. Separate terms, conditions and exclusions apply to our Worldwide Travel Cover please speak to your adviser to find out more.
11 A guide to Personal Healthcare 11 3 Choose where you can get treatment YOU CAN CHOOSE A LIST OF HOSPITALS WHERE YOU CAN GET TREATED, DEPENDING ON WHERE YOU LIVE AND HOW MUCH YOU WANT TO PAY. We ve got three different hospital lists for you to choose from. To make sure you get the best possible care, we use the leading private hospitals in the UK. When you need treatment, you will go to a hospital on your chosen hospital list. All the hospitals on our lists offer first-class facilities and clean, comfortable surroundings. You can choose which list will suit you best. LOCAL HOSPITAL LIST This hospital list includes: All of the hospitals in the UK s largest hospital groups, BMI Healthcare, Nuffield Health, Spire Healthcare, Aspen and Ramsay Health Care Independent providers, New Victoria and St Anthony s No Central London hospitals COUNTRYWIDE HOSPITAL LIST This hospital list includes: All hospitals from the UK s largest private hospital groups, Aspen, Spire Healthcare, BMI Healthcare, Ramsay Health Care and Nuffield Health The London Clinic and King Edward VII s Hospital Sister Agnes Most other private hospitals outside of London All NHS Private Patient Units outside of London Some Central London NHS Private Patient Units PREMIER HOSPITAL LIST This hospital list includes: All private hospitals in the UK All NHS hospitals with private facilities in the UK TREATMENT AT A HOSPITAL NOT ON YOUR CHOSEN LIST If you use a hospital that isn t on your chosen hospital list, then you ll need to pay 40% of your treatment costs, excluding the specialists fees. If you want to avoid paying this, you ll need to travel to a different hospital on your list. But if you need treatment that the hospitals on your list can t give you, you can contact us. We will find a hospital and a consultant to give you the treatment you need.
13 A guide to Personal Healthcare 13 4 Choose how much you pay towards you treatment YOU CAN CHOOSE TO PAY A FIXED AMOUNT OF MONEY TOWARDS YOUR TREATMENT. THIS IS CALLED AN EXCESS. We then pay for the rest of your treatment, up to any limits on your plan. The higher excess you pay, the smaller we can make your premiums. You can choose to pay nothing, or to pay an excess of 100, 250, 500 or 1,000. Once you ve chosen an excess, you choose whether you pay: ONCE A PLAN YEAR You pay an excess once a plan year, even if you make two or more claims in the same plan year. If your claim carries on into the next plan year, you ll need to pay the excess again. This also applies to each person included under your cover. EACH TIME YOU MAKE A CLAIM You pay an excess every time you make a claim. If you make two or more claims in the same plan year, you ll have to pay an excess for each claim you make. When you claim for treatment of a particular condition, we consider it a new claim after 12 months so, you will need to pay the excess again for any treatment after this point. This also applies to each person included under your cover. THE EXCESS DOESN T APPLY TO SOME BENEFITS The excess levels described above do not apply when making claims for NHS Hospital Cash Benefit, Childbirth Cash Benefit and Assistance at Home. This excess would also not be applied to claims made under the Dental Cover option and also the Worldwide Travel Cover option where a different excess may apply.
14 14 A guide to Personal Healthcare 5 We give you a no-claims discount AT THE END OF EVERY PLAN YEAR, WE GIVE YOU A NO-CLAIMS DISCOUNT ON YOUR NEXT YEAR S PREMIUMS. THE NO-CLAIMS DISCOUNT YOU START WITH CAN BE UP TO 65%. If someone on your plan makes a claim, your no-claims discount in your next year will be lower. It moves down two levels on the scale below for each person who claims, however many claims they make. 0% 10% 20% 30% 40% 50% 55% 60% 65% For every claim-free year you have, you ll move up one level on the scale. The no-claims discount you start with depends on your circumstances If you don t already have private health insurance, you start on a no-claims discount of 65%. If you already have private health insurance with another provider and want to switch to us, we need to work out how much no-claims discount you can start on. To do this we look at how many relevant claims you ve made, and how long you ve been insured. You may still get a no-claims discount of 65%. VITALITY LINKED NO-CLAIMS DISCOUNT By engaging with Vitality you could qualify for an enhanced no-claims discount of up to 80%. There would be three additional no-claims discount levels of 70%, 75% and 80%. Your maximum no-claims discount level will depend on your Vitality status, and whether or not you make a claim. By engaging with Vitality you could also protect your no-claims discount. The level of protection will depend on your Vitality status, and whether or not you make a claim. Some claims don t affect your no-claims discount: The no-claims discount doesn t apply to Worldwide Travel Cover and Dental Cover. So it doesn t affect your discount if you claim on either of these. Claims for the NHS Hospital Cash Benefit, Assistance at Home and the Childbirth Cash Benefit don t affect your no-claims discount either. For more information, please refer to our terms and conditions document which you ll receive when you join. If you want to see these sooner please let us know.
16 6 Choose how you want to be underwritten WHEN WE RE WORKING OUT WHETHER WE CAN COVER YOU, WHAT WE CAN COVER YOU FOR AND HOW MUCH YOUR COVER WILL COST, WE GO THROUGH A PROCESS CALLED UNDERWRITING. This just means looking at your age, your medical history and, if applicable, whether you ve made any claims before. Any conditions we can t cover are called personal medical exclusions. A personal medical exclusion is usually a pre-existing condition or symptom, or a previous illness. If we apply a personal medical exclusion to your cover, we also exclude any related conditions. A related condition is any symptom, disease, illness or injury which reasonable medical opinion considers to be associated with another symptom, disease, illness or injury. There are three different kinds of underwriting that you can choose from. All applicants to be covered must be underwritten on the same basis. Which one s right for you depends on whether you ve already got a private health insurance plan with someone else and how much information you want to give us. For more information about the underwriting options, please refer to our terms and conditions document which you will receive when you join. Please let us know if you d like to see this sooner.
17 A guide to Personal Healthcare 17 I. FULL MEDICAL UNDERWRITING If you re happy for us to ask you about your medical history, you can choose Full Medical Underwriting. We might need to exclude some pre-existing conditions from your cover. But we always tell you upfront exactly what you re covered for. How it works When you apply to join, we ask you some questions about your health. If we need to know more about your medical history, we might need to get in touch with you or, on some occasions, your GP. You will be informed if this is the case. We use this information to decide whether we need to put any personal medical exclusions on your cover. If we need to apply any personal medical exclusions, they will be detailed on your certificate of insurance. That way you can be clear from the start what we can and can t cover. Your cover starts after we have gone through this process. In some circumstances we may be unable to offer cover. II. MORATORIUM UNDERWRITING If you don t want to tell us about your medical history, you can choose Moratorium Underwriting. Because we don t look at your medical history, we tell you whether you re covered at the time you make a claim. How it works When you apply to join, you don t need to fill in a health history questionnaire. This means it s quick to apply and we can cover you straight away. Because we don t ask about your medical history when you apply, we can t tell you upfront what personal medical exclusions you may have. Instead, if you need to make a claim, we tell you whether you re covered or not at that time. If, after your cover starts, you need treatment for a medical condition or symptom that you ve never had before, we will cover it subject to the terms and conditions of the plan. The same goes for any medical conditions that you ve had more than five years before your cover start date with us. But if you ve had any conditions in the five years before your cover start date with us, we usually won t cover them. We can only cover conditions like these if, after your cover has started, you go for two continuous years without having any treatment, medication or advice for these pre-existing conditions or any directly related conditions. That does mean we probably won t ever be able to cover long term conditions like heart problems or psychiatric conditions that s because you probably won t go for two continuous years without having treatment, medication or advice. III. CONTINUED PERSONAL MEDICAL EXCLUSIONS UNDERWRITING (CPME/SWITCH) If you have already got a private health insurance plan with someone else, you could choose Continued Personal Medical Exclusions (Switch) Underwriting. How it works When you apply, you don t need to fill in a medical questionnaire. Instead, we ask you some questions about your health and any recent claims made, and we ask to see a copy of your current insurance certificate. If we need to know more about the medical history provided, we might need to contact you further, and on some occasions we may need to get in touch with your GP. You will be informed if this is the case.
18 18 A guide to Personal Healthcare We use this information to work out if we need to apply any additional personal medical exclusions to your cover with us. Any existing personal medical exclusions are carried over from your previous plan. If your previous plan had a moratorium clause applied for pre-existing conditions, we will apply our own moratorium clause to your new plan but it is backdated to when your previous plan started. We are unable to offer you this type of underwriting if you haven t been covered under private health insurance for a minimum of nine months continuously. The number of years that you have been insured and the number of relevant claims you ve made are also considered when determining if this type of underwriting is available. Sometimes, we may be unable to offer cover, so please don t cancel your current plan until we tell you we can accept you. NO-CLAIMS DISCOUNT FOR SWITCH UNDERWRITING Once we have confirmed you are eligible to apply for switch underwriting, we use your claims history to determine the appropriate no-claims discount you will receive. The no claims discount will be based on how long you have been insured and how many relevant claims you have made, as per the table below. NUMBER OF CLAIMS % 30% not available not available YEARS INSURED 2 60% 40% not available not available 3 60% 50% 30% not available 4 65% 55% 30% not available 5 65% 60% 40% not available Relevant claims are those which have been made by all applicants in the past five years on health insurance, not on dental or travel insurance. However, you may ignore claims that meet the following criteria: 1. The total cost of the treatment was less than 350; or 2. It is one of the medical conditions or procedures listed below; and 3. In both instances treatment must have been completed more than 12 months prior to the requested cover start date and a full recovery made, with no further investigations, consultations or treatment planned or recommended. Gall bladder removal (if due to gallstones) Hysterectomy (provided not related to cancer) Adenoidectomy Appendectomy Wisdom teeth removal Fractures (with no pins or plates in place) Tonsillectomy Normal pregnancy If you have been insured for less than one year but more than nine months, the no-claims discount will be based on one year. Continued Personal Medical Exclusions (Switch) Underwriting is not available for those with a claims history marked as not available above. However, you can still apply for a new plan under Full Medical Underwriting or Moratorium Underwriting terms with a no-claims discount of 65%. For more information go to page 17.
20 7 Important information THIS GUIDE PROVIDES A SUMMARY OF OUR PERSONAL HEALTHCARE PLAN THAT YOU NEED TO READ BEFORE YOU MAKE DECISIONS ON WHAT IS THE RIGHT COVER FOR YOU. For full details, please refer to our terms and conditions which you receive when you join. If you want to see these sooner, please let us know. Your Personal Healthcare plan is an annual contract. That means we review your premiums and the terms and conditions each year. But we ll always give you reasonable notice if we re going to change anything. No private health insurance plan covers every single person or every single medical condition. If it did, it would be too expensive. As long as you re eligible to take out a plan with us, you can apply for cover. But there are some conditions and treatments that we can t cover. These are called exclusions. We list any personal medical exclusions on the certificate of insurance we give you when your cover commences. General plan exclusions are listed in the terms and conditions document which we give you when you join.
21 A guide to Personal Healthcare 21 WHO CAN APPLY FOR COVER? You, the main applicant, can apply for cover providing you are aged between 18 and 79 at the start date of the plan. Your husband, wife or partner can also apply for cover if they live at the same address as you and are aged between 16 and 79 at their cover start date. Your children, including adopted children, can apply to be covered as long as they are aged 20 or under when their cover starts. If all applicants are joining us on a switch basis and your dependent children are aged 25 or under and are currently covered with you, as evidenced by your certificate of insurance, they can apply to continue to be covered by us as dependent children. Once they are accepted for cover, eligible dependent children can remain covered on that basis. They will be charged at an adult rate at the commencement or the renewal date on or after their 21st birthday, whichever is the earliest date. All applicants must live in the UK for at least 180 days in each plan year. By this we mean Great Britain and Northern Ireland, including the Channel Islands and the Isle of Man. All applicants to be covered must have the same benefits, excess level and hospital list. They must also be underwritten on the same basis. If you choose Worldwide Travel Cover, we can cover you and your dependants as long as you are all aged 79 or under. Whilst we won t decline cover due to the occupation or pastimes of any applicant, we will not pay claims relating to the following: treatment for any condition or injury arising from working offshore in the extraction / refinery of natural / fossil fuels treatment for any condition or injury arising from working in the armed forces (including the Territorial Army) treatment for injuries arising from participation in hazardous or dangerous sports, such as mountaineering or rock climbing, hang gliding, parachuting, bungee jumping, pot-holing, racing of any kind, winter sports, underwater activities and flying (except as a fare-paying passenger on a commercial aircraft). This list is not exhaustive, so please contact us if you need more information. Any treatment for eligible sports injuries must follow our normal authorisation process, unless we ve agreed otherwise in writing. WE CAN T COVER CHRONIC CONDITIONS We cover eligible acute conditions in other words, diseases, illnesses or injuries that happen after your plan has started, and that are likely to respond quickly to treatment. While we can t cover long-term chronic conditions, whether they start before or after you take out cover, we can cover you when you first become ill. We will pay for any specialist consultations and diagnostic tests covered by the plan that are needed to find out the cause of the symptoms. We will also pay for any initial hospital treatment you require in order to stabilise your condition. However, there may come a point when the kind of treatment you are receiving appears only to be monitoring your state of health or keeping symptoms of your condition in check rather than actively curing it. When such circumstances arise, we will contact your GP or specialist to obtain further information about your condition and treatment and will advise you of the outcome. We will always take into account your own specific circumstances and we will never withdraw cover for that condition without giving you plenty of time to make alternative arrangements. YOU MAY HAVE A CHRONIC CONDITION IF AT LEAST ONE OF THE FOLLOWING IS TRUE: You need ongoing or long-term monitoring for your condition, through consultations, checkups and/or tests You need ongoing or long-term control or relief of your symptoms You need rehabilitation, or special training to cope with the condition The condition continues indefinitely The condition has no known cure The condition comes back, or is likely to come back Often, medicines and preventative treatments can help with chronic conditions. These are usually available from the NHS. BUT WE CAN COVER SOME OTHER CONDITIONS THAT ARE CAUSED BY CHRONIC CONDITIONS You could develop an acute condition because of a chronic condition. Whether we can cover the acute condition depends on how long you ve had the chronic condition: If your chronic condition developed after your cover started, we cover the acute condition, subject to the terms and conditions of the plan. But if you already had the chronic condition when your cover started, we can t cover the acute condition.
22 22 A guide to Personal Healthcare WE CAN T COVER SOME OTHER TREATMENTS AND CONDITIONS Unfortunately we can t ever cover: Any treatment received outside the UK, unless you ve selected the Worldwide Travel Cover option Any emergency treatment or visits made to a GP Normal pregnancy and childbirth, and most related conditions Organ transplants Any treatments or practices that are experimental, unproven or unregistered Any treatment for learning difficulties, delayed speech disorders and other developmental problems Full details of these and our other exclusions are in the terms and conditions we give you when you join. Please let us know if you d like to see these details sooner. WE CAN STILL HELP WITH CHRONIC CONDITIONS While we can t pay for all the treatment, we can still help with some of the costs. Here are some examples of how we can do this: Example 1 Alan Alan has been with PruHealth for many years. He develops chest pain and is referred by his GP to a specialist. He has a number of investigations and is diagnosed as suffering from angina. Alan is placed on medication to control his symptoms. We cover Alan s initial consultations and tests and advise him that we will cover further consultations with his specialist until his symptoms are well controlled. Two years later, Alan s chest pain recurs more severely and his specialist recommends that he has a heart bypass operation. We confirm to Alan that we will cover this operation as it will substantially relieve his symptoms and stabilise the condition. We also advise him that we will cover his post-operative check-ups for one year to ensure that his condition has been stabilised. Example 2 Bob Bob has been with PruHealth for three years when he develops hip pain. His GP refers him to an osteopath who treats him every other day for two weeks and then recommends that he return once a month for additional treatment to prevent a recurrence of his original symptoms. As Bob s plan includes cover for alternative therapies, we pay for two weeks of treatment as this helps stabilise his symptoms. We also tell him that we cannot cover his regular monthly treatments, as these are designed just to keep the symptoms in check but that if his symptoms worsen he should contact us again. If Bob s condition did deteriorate significantly and his consultant recommended a hip replacement, PruHealth would cover the cost of this. As the operation would replace the damaged hip and thereby cure Bob s problem, we would pay for all the costs relating to this operation. PAYMENT OF PREMIUM You must pay us premiums for you and any insured dependants who are covered under the plan. YOUR PREMIUM CAN CHANGE Lots of things can affect your premium each year. For instance, the older we get, the more likely we are to claim so, your premiums rise each year in line with how old you are. We also review your premiums to reflect increases in the charges made by hospitals and other providers, as well as medical advances in drugs and technology. A change in the level of your no-claims discount will also affect your premium. WE SEND YOU ALL THE DETAILS ABOUT YOUR PLAN As soon as your Personal Healthcare plan starts, we send you a welcome pack. This pack contains all the terms and conditions of your plan, your certificate of insurance, a membership card, and all the details you need to get started with Vitality, our healthy living programme. WE MAKE IT QUICK AND EASY TO CLAIM If you need to make a claim, you can contact our customer services team or make a claim online at pruhealth.co.uk. More details about how to claim are in your welcome pack, and in the Member Zone. WE WANT TO KNOW IF YOU RE NOT HAPPY We hope you will be happy with your plan. But if you re not, please let us know we ll do everything we can to put things right. You can write to us at PruHealth Customer Services, Stirling FK9 4UE or give us a call on Calls may be recorded/monitored to help improve customer service. Call charges may vary. A copy of our complaint handling procedures is included in the plan terms and conditions document and is also available on our website.
23 A guide to Personal Healthcare 23 We re covered by the Financial Ombudsman Service. If you re not satisfied with our response to your complaint, you can contact them at: The Financial Ombudsman Service South Quay Plaza 183 Marsh Wall London E14 9SR T: E: The Financial Ombudsman Service is an independent body that will investigate complaints if you need them to, at no extra cost to you. You still have a right to legal action if they investigate and you re not happy with the outcome. Your plan is bound by English Law and comes under the jurisdiction of the UK courts. YOUR RIGHTS UNDER THE FINANCIAL SERVICES COMPENSATION SCHEME As a member of a PruHealth plan, you will be protected by the Financial Services Compensation Scheme. This will pay you compensation should PruHealth, as your insurer, be unable to pay your claim because we have become insolvent or gone out of business. For more information call or go to CANCELLING YOUR PLAN In the first 14 days If you change your mind about your Personal Healthcare plan, you can cancel it: Within 14 days of the start date, or Within 14 days of the date you received your terms and conditions whichever is the later. You don t have to give us a reason for cancelling. And we ll give you a full refund of the premiums you ve paid, as long as no claims have been made on your plan during this time. These cancellation rights also apply every time you renew your plan. After the first 14 days If you decide to cancel your plan after the first 14 days, please let our customer services team know. We ll then confirm that we ve cancelled your plan. We ll refund any premiums you ve paid that cover any time after your cancellation date. We can t pay for any treatment that you have after your last day of cover and we cannot backdate your cancellation date. This brochure is intended to provide you with a summary of the benefits of our Personal Healthcare plan. However it does not describe in full the plan terms and conditions which you receive when you join us. If you would like to see these sooner, please ask us for a copy or speak to your adviser. For an independent guide on what to look for when choosing a plan, we recommend you download the Guide to Buying Private Medical Insurance by the Association of British Insurers. You can find it at pruhealth.co.uk. IMPORTANT REGULATORY INFORMATION PruHealth is a trading name of Prudential Health Limited and Prudential Health Services Limited. Prudential Health Limited, registration number is the insurer that underwrites this insurance plan. Prudential Health Services Limited, registration number acts as an agent of Prudential Health Limited and arranges and provides administration on insurance plans underwritten by Prudential Health Limited. Registered office at Laurence Pountney Hill, London EC4R 0HH. Registered in England and Wales. Prudential Health Services Limited is authorised and regulated by the Financial Conduct Authority. Prudential Health Limited is authorised by the Prudential Regulation Authority and is regulated by the Financial Conduct Authority and the Prudential Regulation Authority.
24 PruHealth is a trading name of Prudential Health Services Limited. Registered number Registered in England and Wales. Registered office at Laurence Pountney Hill, London EC4R 0HH. Prudential Health Services Limited is authorised and regulated by the Financial Conduct Authority. PRUHB21106_12_13_J505
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