Company Paid Health Insurance Enterprise Flexible Benefits

Transcription

1 wpa.org.uk Company Paid Health Insurance Enterprise Flexible Benefits Group Scheme Summary Effective from 1 June 2015 FS BCMS EMS IS

2 Why Enterprise Flexible Benefits? Freedom of choice Supported by service excellence Managed care ensures best clinical outcome Driving better healthcare value with Shared Responsibility Our standards are high FS BCMS EMS IS WPA has the feel of a family business, but one which is not motivated by profit, rather the pursuit of excellence in all that we do. Julian Stainton, Chief Executive, WPA Group

3 Build your Group Scheme 1 Choose a Core Benefit Essential or Essential Plus Company paid health insurance Wellness A range of cash benefits to help top-up your NHS care Dental Enhanced dental benefits 2 Add your Extras Enhanced Out-patient A&E Abroad * Enhanced Therapy mycancerdrugs * Worldwide Emergency Benefit Cosmetic Surgery Wellness Face to Face Counselling Enhanced Dental 3 Shared Responsibility premium savings of up to 50% Available on Essential and Essential Plus * These Extras are not available with Essential/Essential Plus As with all insurance Policies, there are some Key Facts we need to draw to your attention so that you can make an informed decision that best matches your needs. This document contains a summary of the Group Scheme terms and conditions. The full terms can be found in A Guide to Your Group Policy which you can view online at wpa.org.uk/efb or is available on request.

4 Core Benefit : Essential or Essential Plus Essential (Ess) and Essential Plus (EP) benefits are shown below. Enhance your benefits by adding Extras (see page 5). In-patient & day-patient treatment Ess EP Hospital treatment Specialists fees Diagnostic tests Complex diagnostic scans (MRI, CT & PET scans only) NHS cash benefit (overall combined benefit up to 4,500) 9 in- or day-patient 150 per day/night 9 in-patient stays for 3 nights or more 200 per night 9 out-patient diagnostic scans & procedures 150 per day Psychiatric treatment (28 days/nights in 5 years) Out-patient treatment enhance with Out-patient Extra Ess EP Consultations with a specialist up to 200 Single post-hospital consultation & tests Complex diagnostic scans (MRI, CT & PET scans at the request of a specialist and 1 MRI or CT scan arranged by your GP) Out-patient procedures Pre-admission tests Cancer care Ess EP Consultations with a specialist (including tests & ultrasounds) Radiotherapy/chemotherapy Targeted/biological therapies (advanced anti-cancer treatment) when not readily available on the NHS NHS cash benefit, cancer (overall combined benefit up to 6,000) 9 in- or day-patient 200 per day/night 9 out-patient diagnostic scans, procedures, blood tests and radiotherapy/chemotherapy 150 per day Other benefits Ess EP Nursing at home (up to 4 weeks) Parent & child Prostheses Private ambulance transport (when medically necessary) Hospice donation ( 70 per day/night, up to 700) Out of pocket expenses 10 per day General dental treatment up to 75 Optical treatment up to 75 Physiotherapy and other therapies up to 150 Scans and screens up to 200 New baby 100 * * A 10 month qualifying period applies. Employee Assistance Programme (EAP) 24/7 telephone support Health & medical information Telephone counselling Financial & debt advice Emergency domestic repair assistance Benefits are per person per Group Scheme year and claims will be paid in line with customary & reasonable fees. Refer to A Guide to Your Group Policy for full details of the benefits & rules. Enterprise Flexible Benefits Group Scheme Summary Page 4

5 Extras : enhance your core benefit The following Extras are available with Essential/Essential Plus. Enhanced Out-patient (choose the Full Refund or 1,000 option) Specialist consultations Diagnostic tests referred by a specialist referred by a GP 500 Physiotherapy and other therapies 200 Psychiatric treatment Enhanced Therapy up to a combined total of 1,000 Acupuncture Chiropody/Podiatry Chiropractic Dietary Services Homeopathy Osteopathy Physiotherapy Psychology / Psychotherapy Speech & Language Therapy Diagnostic tests (at the request of your GP) Worldwide Emergency Benefit (choose either W35 or W70) W35 up to 35 days per trip and a maximum of 250,000 or W70 up to 70 days per trip (35 days if in the USA) and a maximum of 500,000 Emergency/overseas treatment Evacuation/Repatriation to the nearest country for treatment where it is medically necessary and the treatment cannot be obtained locally Family assistance Up to 6 months Benefit for trips outside the EU for business purposes only. The Worldwide Emergency Benefit extra is not a substitute for a comprehensive travel insurance policy. It does not include destinations that are considered at risk by the Foreign & Commonwealth Office (FCO) website. See gov.uk/foreign-travel-advice for details. Shared Responsibility A cost saving option available on Essential/Essential Plus. An added feature and an innovative cost-saving option which reduces your company s premium without reducing your Group Scheme members benefits. Step 1 Choose a personal annual limit for each Group Scheme member. Step 2 WPA pay 75% of all eligible claims up to the personal annual limit. Step 3 Your Group Scheme member pays the remaining 25%. Step 4 Once your Group Scheme member s 25% contributions reach their personal annual limit, WPA will pay 100% of all eligible claims until the next annual renewal date. Note At renewal you can increase the Shared Responsibility limit, however you can only reduce it by one level at a time (e.g. from 3,000 to 1,000 or 1,000 to 500). Further information is available at wpa.org.uk/shared or on request. Shared Responsibility level ,000 3,000 5,000 Increasing the level of Shared Responsibility will reduce your premiums by up to 50%. Wellness see page 6 Enhanced Dental see page 7 Benefits are per person per Group Scheme year and claims will be paid in line with customary & reasonable fees. Refer to A Guide to Your Group Policy for full details of the benefits & rules. Enterprise Flexible Benefits Group Scheme Summary Page 5

6 Wellness : Top-Up your NHS care A range of everyday cash benefits to enhance Essential/Essential Plus (except where shown) or as a standalone plan. 100% cashback payable up to the amounts shown General dental treatment 150 Optical treatment 150 Eye tests 40 Physiotherapy (and other therapies) 400 Specialist/second opinion 250 New baby (10 month qualifying period applies) 200 GP services 150 Prescription charges 40 Scans & screens 200 Cash benefits up to the amounts shown NHS hospital in/day-patient admission ( 65 per day/night, max. 20 days) 1,300 A&E attendance ( 40 per emergency attendance) 80 Post-hospital recovery bonus (after 7 consecutive nights) 400 NHS car parking (up to 300 for cancer treatment, 50 for other hospital stays) Employee Assistance Programme (EAP) 24/7 telephone support Health & medical information Telephone counselling Financial & debt advice Emergency domestic repair assistance Legal helpline Extras : enhance your Wellness cover The following Extras are available with Wellness. Cosmetic surgery 20,000 Reconstructive plastic surgery following an accident or injury. Choose from 3 levels of cover: Upper body, Lower body, Total body A 1 month qualifying period applies Face to face counselling A&E abroad * 100,000 Supplementary EHIC cover in and outside the EU, for business purposes only Benefits apply to trips abroad of no more than 21 days and a maximum total of 90 days in each Group Scheme year. Excludes any trips where the FCO advises against travel (see gov.uk/foreign-travel-advice) mycancerdrugs * Access to advanced cancer drugs not available on the NHS Children covered free of charge Children under 18 are free under Wellness and will enjoy the benefit limits stated, if the adult under whom they are enrolled also holds the benefits. A maximum of 5 children per Group Scheme member on the Group Scheme. 50,000 (lifetime benefit) A 90 day deferment period applies and benefit is available up to your 66th birthday * The above Extras are not available in conjunction with Essential/Essential Plus 6 sessions A diverse network of over 2,500 face to face affiliated clinicians across the UK. Feedback from the counsellor after every session (maximum 6 sessions) If this Extra is chosen it must be selected for all Group Scheme members Benefits are per person per Group Scheme year and claims will be paid in line with customary & reasonable fees. Refer to A Guide to Your Group Policy for full details of the benefits & rules. Enterprise Flexible Benefits Group Scheme Summary Page 6

7 Enhanced Dental In addition to Essential/Essential Plus or as a standalone Group Scheme. Reimbursement up to the benefits shown General dental treatment (75% of costs) 250 Dental emergencies (75% of costs up to 250 per episode, maximum 4 per year) 1,000 Dental injuries 20,000 Oral cancer (restorative dental treatment only) 10,000 A 14 day qualifying period applies to these benefits. Employee Assistance Programme (EAP) 24/7 telephone support Health & medical information Telephone counselling Financial & debt helpline Emergency domestic repair assistance Note Group Scheme members can choose their own dentist. There s no need for a dental examination before applying as long as you have visited a UK dentist in the last 18 months. Children Children under the age of 18 are entitled to 50% of the benefit available for Dental injuries and Oral cancer. No cover is available for General Dental Treatment or Dental Emergencies as they are entitled to free treatment under the terms and conditions of the NHS. Benefits are per person per Group Scheme year and claims will be paid in line with customary & reasonable fees. Refer to A Guide to Your Group Policy for full details of the benefits & rules. Enterprise Flexible Benefits Group Scheme Summary Page 7

8 Choose your joining method If you have chosen Moratorium Underwriting: Benefit will not be provided for at least two years for any pre-existing condition(s) which a Group Scheme member (including any family members) have had during the five years before the Group Scheme membership starts. For Group Schemes with less than 5 Group Scheme members, benefit will not be provided for any new symptoms/conditions that start in the first 14 days of the Group Scheme membership. Pre-existing conditions are medical condition(s) and other directly related conditions, for which treatment was received and/or medication was prescribed or professional advice was sought or where symptoms existed (whether the underlying condition has been diagnosed or not). If a Group Scheme member (including any family members) do not have symptoms, treatment, medication or advice for pre-existing conditions for two continuous years after the Group Scheme membership starts, then benefit may be provided within the terms of the Group Scheme membership. Group Scheme membership will not provide benefit for pre-existing long-term medical conditions (and associated conditions) which are likely to require regular or periodic treatment, medication or advice. This is because the moratorium period starts each time treatment is received, so it s unlikely to ever have two consecutive years free of treatment. Conditions include (but are not limited to): Moratorium Criteria Have never been diagnosed with any disease/abnormality of the heart or cardiac function, stroke, cancers or undergoing regular screening for cancer owing to family history. For joint and back conditions: have never had a surgical procedure/arthroscopy (keyhole surgery). Have a Body Mass Index (BMI) below 35. If you have chosen Full Medical Underwriting: With Full Medical Underwriting a Group Scheme member provides us with details of their and their family member(s) full medical history for greater certainty of what benefits may or may not be provided under the Group Scheme. No benefit is available for treatment of any illness or injury which started on or before joining the Group Scheme, even if the reason for any symptom has not yet been diagnosed (unless disclosed to and accepted in writing by WPA). Diabetes Uncontrolled hypertension Multiple Sclerosis (MS) Chronic Fatigue Syndrome/ME Crohn s disease Rheumatoid Arthritis Ulcerative Colitis Lupus (SLE) Ankylosing Spondylitis Fibromyalgia Polymyalgia Rheumatica No underwriting required This is when we do not require or ask for any medical information and would be used when either adding a baby within 6 months of his/her birth or when adding a member to one of our cash plan products such as NHS Top-Up, Wellness or Dental. It is important that Group Scheme members (including any family members) do not delay seeking medical advice or treatment for any condition during the moratorium period. Group Scheme members (including any family members) must satisfy the following criteria to join on a Moratorium basis. Enterprise Flexible Benefits Group Scheme Summary Page 8

9 What is not covered Administration As with all health insurance policies, there are certain things that are not included within the Group Scheme benefits. Enterprise Flexible Benefits specifically excludes the following list which is a summary only. For a full list of exclusions please see A Guide to Your Company Policy. A copy is available from wpa.org.uk/efb or upon request. General exclusions: For Group Schemes with 5 or less Group Scheme members, benefit will not be provided for any new symptoms/conditions that arise in the first 14 days of joining the Group Scheme. Any claims submitted more than 6 months after the treatment took place. Chronic conditions (which are long term illnesses that lead to long-term monitoring or management). Treatment for allergic conditions. Childbirth, fertility or neonatal treatment (except new baby benefit). HIV/AIDS. Cosmetic surgery (unless you buy Wellness with the Cosmetic Surgery Extra). Varicose veins for the first 2 years of each Group Scheme member joining, if joining on a full medical underwriting basis. Any claim that has not been pre-authorised. Care and/or treatment arising from or related to taking part in winter sports (e.g. skiing, snowboarding), or any accident or injury that occurs whilst on a winter sports holiday and whilst staying in a winter sports resort. Care and/or treatment arising from or related to scuba diving and motor sports or engaging in professional sport. If the mycancerdrugs option is chosen as an extra your Group Scheme members will not be eligible for benefit if: They have had, or at the time of application have, cancer or symptoms of cancer or they are on (or have been advised by a healthcare professional to take part in) a medically supervised health screening or review programme because they are considered to be at higher risk of developing cancer. Either their parents, brothers or sisters have developed or died of cancer under the age of 60. Cancer is diagnosed, or symptoms develop, before or within the first 90 days of the Group Scheme member joining or 90 days from the date they add the mycancerdrugs extra (referred to as a 90 day deferment period). Note: NHS cash benefit can only be claimed under either Essential/Essential Plus or Wellness in respect of one hospital stay. Group Scheme requirement Where Essential or Essential Plus Core Benefits have been chosen: There must be a minimum of two Group Scheme members with Essential or Essential Plus Core Benefits who reside at different UK addresses. For Groups Schemes with only Standalone Wellness or Dental Extra Benefits: There must be a minimum of three Group Scheme members who reside at different UK addresses. All Group Scheme members must be actively involved in the business. Family members of the Group Scheme member must reside at the same address, unless they are a child dependant in full-time education. A family member may be a partner/spouse and/or any children who are under 21 years of age (or 25 if in full-time education). Pricing The premiums for the Group Scheme will be priced on the location of the company s principal place of business at which the majority of the company s insured Group Scheme members have as their normal place of work, as defined by HMRC. In cases where there are significant numbers of Group Scheme members distributed across multiple centres where Group Scheme members work, it is possible to set up sub-groups priced on each centre. Benefits payment Where you have a cash plan with WPA (either Wellness or NHS Top-Up) as well as the private medical insurance (PMI) benefit (i.e. Essential or Essential Plus) all eligible claims received will be processed from the PMI benefit first. If the PMI benefit limit is reached we will then process the claim from your cash plan if benefit is available. Enterprise Flexible Benefits Group Scheme Summary Page 9

10 Your rights Duration of the Group Scheme The Group Scheme is an annual contract of insurance and we will offer to renew it, and will send the relevant information including any changes to the Group Scheme for the forthcoming year, at least 21 days before the contract expires. Changing your mind If you are not satisfied with the Group Scheme and the benefit it provides you have the right to cancel the Group Scheme provided you notify us within 14 days (28 days if you purchased online) of receiving the Group Scheme documents as long as no claims have been submitted. In the case of a premium refund we reserve the right to withhold 25 as an administration fee. Cancellation of the Group Scheme cannot be backdated. If a Group Scheme member cancels their Group Scheme membership and wishes to rejoin, they will be required to rejoin as a new customer. Easy to claim All claims must be pre-authorised and any claims your Group Scheme members make will be handled by our Enterprise Division who can be contacted directly on or ebd@wpa.org.uk Consultant and Anaesthetist fees When a Group Scheme member receives treatment, a contract exists between them and the provider, be that a hospital or a consultant. We have cost agreements with almost every hospital, and we publish our schedule of fees for consultants these may be viewed at any time at wpa.org.uk/guideline Fee reimbursement levels are set at customary and reasonable levels by means of our continuing dialogue with the medical profession. A consultant or anaesthetist may charge more than we consider to be customary and reasonable and, where they have advised the patient in advance, if the patient decides to proceed with the treatment, then it is their responsibility to settle the difference (the shortfall). Making yourself heard If you have a complaint at any time, you should write to: The Director of Best Practice WPA Rivergate House Blackbrook Park Taunton Somerset TA1 2PE Alternatively, you can directorofbestpractice@wpa.org.uk If you are still not totally satisfied, we encourage you to appeal to: The Financial Ombudsman Service Exchange Tower London E14 9SR Telephone free from a landline/mobile phone; or free for mobile phone users who pay a monthly charge for calls to numbers starting 01 or 02). Compensation scheme WPA customers are covered by the FSCS which can provide entitlement to compensation to customers where an insurer cannot meet its obligations. The maximum level of compensation is 90% of the claim with no upper limit. Further information about compensation scheme arrangements is available from the FSCS ( Enterprise Flexible Benefits Group Scheme Summary Page 10

11 Making the most of your membership In addition to the Employee Assistance Programme (EAP) your Group Scheme members will also benefit from the following value added discounts. Gym membership discounts Golf discounts Health screening and assessment discounts Spa discounts Optical discount Full details of the discounts available will be provided upon joining WPA. Enterprise Flexible Benefits Group Scheme Summary Page 11

12 Join our community To join, simply phone WPA free, Monday-Friday 8am-6pm or contact your Adviser/Broker directly. wpa.org.uk/efb WPA: call free Mon-Fri 8am-6pm wpa.org.uk Western Provident Association Limited Rivergate House Blackbrook Park Taunton Somerset TA1 2PE Registered in England No Cover photo by kind permission of Liverpool Science Park. FS EMS IS The member state of the insurer is the United Kingdom. WPA is a registered service mark of Western Provident Association Limited. WPA is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and Prudential Regulation Authority (Reg No ). To help protect your interests, and those of the Association, telephone conversations may be recorded for the purpose of ensuring an accurate record of discussions. Western Provident Association Limited All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of Western Provident Association Limited. 07/15427