Simply Personal Health

Transcription

1 Simply Personal Health Your policy document guide Connections netwk Diagnosis Treatment Heart cancer Effective from 1 April 2015

2 Contents 3 Befe joining Simplyhealth 3 Switching from another insurer 4 Your Simply Personal Health policy document 5 Section 1: Benefits 16 Section 2: General exclusions 19 Section 3: Making a claim 20 Section 4: Who can join the policy? 20 Section 5: Cancelling the policy, cancelling membership 22 Section 6: No claims discount 23 Section 7: Legal points 24 Section 8: Definitions 26 Section 9: Data protection 26 Section 10: Customer care 28 Appendix 1 - What is a chronic condition? 30 Appendix 2 - Understing the underwriting options 31 Appendix 3 - Explaining cover f cancer 2

3 What is Simply Personal Health? Simply Personal Health gives the flexibility to choose cover options that pay f diagnosis, treatment f acute heart conditions cancer, treatment f other acute conditions. Acute conditions are illnesses injuries that are likely to respond quickly to treatment, leading to your full recovery returning you to the state of health you were in befe suffering that episode of ill health. In common with many other private medical insurance products, Simply Personal Health does not cover treatment moniting of chronic conditions. These are conditions that tend not to be cured but are often managed, meaning that treatment continues indefinitely (you can find the full definition f a chronic condition in section 8: Definitions). Befe joining Simplyhealth Insurance policies provide cover against an unexpected event happening after the start of the policy. F Simply Personal Health this usually means cover f the cost of private medical treatment f unfeseen medical conditions arising after the policy starts. F the purposes of deciding whether a condition is pre-existing not, if you are transferring from another policy with no break in cover, we will consider that the date your previous policy was effective from is the start date f your Simply Personal Health policy. The policy does not cover conditions that you already have befe the policy starts these are called pre-existing conditions. Conditions that are related to pre-existing conditions are also not covered. A related condition is one that is caused by, could be the cause of, another condition. F example, if you suffer from diabetes, we would not pay f treatment of eye disders which occur as a result of having diabetes, f example diabetic retinopathy. The policy will not cover all medical treatment. Please read the policy your membership certificate carefully to see which benefit choices the policyholder has made, the exclusions section to see what the policy does not cover. If you have any questions, please call us on Switching from another insurer If you have a private medical insurance policy with another insurer you wish to switch to Simply Personal Health, we may accept your application apply the personal medical exclusions that your current insurer applies to the policy you have now. If you have a matium policy, we will use the date your current policy was effective from as the start date of your Simply Personal Health policy. We will ask you some medical questions about your health since you bought your current policy. We ll also need to see a membership certificate from your current insurer. When we have received the infmation that we ask f, we will assess your application. In der f us to consider your switch to Simply Personal Health, there must be no break in cover between your current policy ending the Simply Personal Health policy starting. Imptant: the cover offered by different policies is unlikely to be the same. You should compare the Simply Personal Health policy document with policy infmation from your current insurer. If you have any questions about the cover that we offer on Simply Personal Health, please call us on

4 Your Simply Personal Health policy document This is your Simply Personal Health policy document. It tells you exactly what is isn t covered so that you can get the most from the policy. This document sets out what you need to know about the benefits as well as the terms conditions of the policy. It also gives you infmation about making changes to your membership how to make a claim. You should read it together with your individual membership certificates, which shows any personal underwriting terms that apply to your cover. The policy document, membership certificate, summary of cover, hospital netwk the infmation the policyholder gave us whilst applying f the policy, fm the contract with us. Making infmation about us accessible We aim to make infmation about us accessible to you, whatever your needs, infmation is available in large print audio. How to contact us If you need to discuss any aspect of your membership, call our freephone number our friendly dedicated team will be pleased to help you. Membership helpline: The helpline operates Monday - Friday from 8am 6pm, except Bank Holidays. Your calls may be recded monited f training quality assurance purposes. pmimembershipservices@simplyhealth.co.uk Your benefits explained The tables show you the wide range of benefits available under the Simply Personal Health Connections policy your membership certificate will show you which benefit choices the policyholder has made f you. A key feature of this policy is that we will put you in contact with a hospital in der to arrange most of the consultations, tests treatment that the policy covers (there are some complementary therapies f example acupuncture, podiatry / chiropody which are exceptions to this rule. We will tell you about this if you need to call us to make a claim). If your GP feels that you need to see a specialist, we will select a suitable local hospital f that referral. The hospital will make an appointment with a specialist with the relevant expertise to investigate your symptoms, at a time convenient f you (subject to availability). We will pay the treatment provider directly, but we only cover consultations, tests treatment arranged through the helpline. Certain wds are shown in bold type throughout this policy wding. These are defined terms have specific meanings. The explanations f these wds are in section 8: Definitions. How to claim Call our claims helpline on befe arranging any private treatment so that we can advise you what the policy covers. If you do not call us then incur costs not covered by the policy, we will not be responsible f paying those costs. pmicustomerservice@simplyhealth.co.uk If the tests treatment that you need are covered by the policy, our helpful staff will give you authisation over the phone. In most cases it s as simple as that (although there are some circumstances when we might need me infmation we ll send you a fm with instructions f who needs to complete it if that is the case). We will ask you to pay the excess when you call us to claim. We also recommend that you call us if you need any further treatment, so you can ensure that you are still covered. 4

5 Section 1: Benefits We will pay f diagnostic tests treatment (we pay f treatment provided that you have cover under the Treatment cover option) f an acute condition when: your GP has referred you to a specialist the specialist arranges the diagnostic tests treatment. We clearly state any circumstances where we will pay f diagnostic tests treatment that a GP arranges without making a referral to a specialist. After deducting your excess we pay all benefits in full unless we have stated a specific limit. 1.1 What you re covered f Diagnosis cover Diagnosis cover pays f diagnostic tests consultations with a specialist in der f the specialist to diagnose your condition, some tests on GP referral. Diagnosis cover does not pay f treatment of your symptoms condition. We will only pay f treatment that you receive if you have cover under the Treatment cover option. Imptant: You must arrange all consultations diagnostic tests through our helpline. We will choose the provider (f example the hospital it is the hospital which will allocate a specialist with the relevant expertise to see you). If you have consultations diagnostic tests which you have not arranged through the helpline, we will not pay any of the costs. This could leave you with a large bill that you will have to pay to the provider. Diagnosis cover Full cover Benefit 1 Specialists fees f consultations diagnostic tests Details of cover We pay f consultations with a specialist specialists fees f diagnostic tests that you need in der to diagnose your condition. 2 Diagnostic tests If a specialist refers you f tests, we will pay f all diagnostic tests that you need in der to diagnose your condition (this includes tests where you need to be admitted to hospital, f example endoscopy, laparoscopy). We will pay f blood tests, X-rays scans (including CT, MRI PET scans) on GP referral in der to diagnose your condition. 3 NHS cash benefit We will give you 250 f each admission that you have as a daypatient each night when you are an in-patient if you choose to be admitted f diagnostic tests: -- free of charge as an NHS patient rather than as a private patient -- we would have paid f the tests as a private patient. We will not pay NHS cash benefit f out-patient diagnostic tests (f example a CT scan), f diagnostic tests that we would not pay f as a private patient (f example further tests after you have been diagnosed). 5

6 4 Pain in your joints muscles If you have pain stiffness in your joints muscles, you do not have to see your GP in der to find out what is causing the pain - call our Rapid Access Physiotherapy service on The service will arrange f a physiotherapist to call you assess your condition, giving you advice appropriate exercises to help you recover me quickly. If you need to see a physiotherapist f face to face consultation in der to find out what is wrong, the service will refer you to a physiotherapist near where you live wk we will pay the cost of one session in der to make a diagnosis. 5 Private ambulance We will pay f a private road ambulance if you have been admitted to a hospital as an in-patient day-patient f diagnostic tests covered by the policy : it is medically necessary f you to travel to another hospital f those diagnostic tests your specialist says that you are not fit to travel by any other fm of transpt. 6 Parent accompanying child We will pay hospital charges f one parent to stay overnight in the hospital while their child receives diagnostic tests as an in-patient that are covered by this policy. Exclusions that apply to diagnosis cover Treatment we will pay f treatment only if you have cover under the Treatment cover option. We will pay f treatment of a heart condition cancer only if you have cover under Treatment f heart cancer. Routine ongoing consultations moniting. General exclusions (section 2). Angiogram we will pay f an angiogram only if you have cover under the Heart cancer cover option. Consultations diagnostic tests after your GP specialist has given you a diagnosis. 6

7 Choice: Treatment cover Imptant: You must arrange all treatment through our helpline. We will choose the treatment provider (f example the hospital it is the hospital which will allocate a specialist with the relevant expertise to see you). If you receive treatment which you have not arranged through the helpline, we will not pay any of the costs. This could leave you with a large bill that you will have to pay to the provider. Treatment cover Your membership certificate will show if the policyholder has chosen Treatment cover f you. Benefit Details of cover 7 Hospital charges f treatment tests This benefit includes: surgery treatment with drugs (f example intravenous antibiotics, injections) treatment as an in-patient, day-patient out-patient tests that you need to ensure that you are well enough to receive any planned treatment follow-up tests that you need f up to three months after your treatment has finished to check whether any treatment you have received has been successful prostheses: -- we pay in full f prostheses implanted during an operation, f example hip knee replacements -- we will pay up to 5,000 f an external prosthesis, f example a false leg eye (we will pay towards one prosthesis only f each body part that is replaced). We will not pay hospital charges f drugs dressings that you take home from hospital as a result of treatment as an in-patient day-patient. 8 Specialists fees f tests treatment We pay specialists fees f tests treatment in full. 9 Specialists fees f consultations We pay f one consultation to plan your treatment We pay f consultations with your specialist whilst you are having ongoing treatment We pay f one follow-up consultation after your treatment has finished. 10 Physiotherapy If you have pain stiffness in your joints muscles, you do not have to see your GP in der to get a referral - call our Rapid Access Physiotherapy service on The service will arrange f a physiotherapist to call you assess your condition, giving you advice appropriate exercises to help you recover me quickly. If you need to see a physiotherapist f a face to face consultation the service will refer you to a physiotherapist near where you live wk. If physiotherapy is not suitable, not wking, the service will ensure that you are referred towards the best clinical pathway, f example seeing a specialist. If you have been referred to a specialist who then recommends physiotherapy (f example following surgery), we will pay in full. F GP referred physiotherapy you must use the Rapid Access Physiotherapy service. 7

8 11 Complementary therapies - osteopathy, chiropody / podiatry, chiropractic, acupuncture, homeopathy If you have been referred to a specialist who then recommends complementary therapy (f example following surgery), we will pay in full. If you have been referred f complementary therapy by a GP, we will pay up to 500 each policy year. F GP referred therapy you may have to pay the bill yourself then claim the costs back from us. If you need physiotherapy you must use the Rapid Access Physiotherapy service (benefit 10), we will pay the physiotherapist directly. 12 Dental surgery f specific conditions only We pay f treatment of these conditions in line with the rules f other benefits on this policy - f example hospital charges are paid accding to the hospital charges benefit. We pay f dental surgery f treatment of specific conditions carried out by: a dentist in the Simplyhealth Denplan Netwk in a hospital by an al maxillofacial specialist. These conditions are: surgical removal of unerupted teeth that are impacted buried surgical removal of complicated buried roots removal of the tip of a tooth s root (apicectomy) which are causing you pain causing repeated infections, surgical removal of cyst from the jaw bone (enucleation of cyst) replanting of existing teeth after an accidental dental injury. 13 Psychiatric treatment We will refer you to the Simplyhealth Mental Health Management service this service will offer you a face to face consultation to assess your condition refer you to the treatment pathway that you need. This may include counselling, psychological therapy services (f example cognitive behavioural therapy - CBT) a referral to a psychiatric specialist. We will only pay f treatment that you have arranged through this service. If you need to be admitted to hospital as an in-patient day-patient we will pay f treatment, NHS cash benefit, f up to 28 days nights in total each policy year. 8

9 14 Complications of pregnancy childbirth specific conditions only We pay f treatment of these conditions in line with the rules f other benefits in Treatment cover - f example hospital charges are paid accding to the hospital charges benefit. We will pay f hospital treatment in specific circumstances only. These are: ectopic pregnancy stillbirth hydatidifm mole post partum haemrhage miscarriage retained placental membrane caesarean sections we will pay f an emergency caesarean section if: there is an immediate risk to the life health of the mother baby, the baby needs to be delivered early. If you choose to give birth as a self funded private patient then need an emergency caesarean section, we will only pay the extra cost that is above the cost of a nmal delivery as a private patient. We will pay f treatment, care moniting of a premature baby, but this will be limited to 28 days from the baby s date of birth. We do not pay f surgery to a foetus. We will not pay f complications of pregnancy childbirth until you have been covered by the policy f 10 months. 15 NHS cash benefit We will give you 250 f each admission that you have as a day-patient each night when you are an in-patient if you choose to be admitted f tests treatment: free of charge as an NHS patient rather than as a private patient we would have paid f the tests treatment as a private patient. We will not pay NHS cash benefit f tests treatment as an out-patient (f example a CT scan), f tests treatment that we would not pay f as a private patient (f example rehabilitation / convalescence, an admission f a pre-existing condition a chronic condition). 16 Private ambulance We will pay f a private road ambulance if you have been admitted to a hospital as an in-patient day-patient f tests treatment covered by the policy : it is medically necessary f you to travel to another hospital f those diagnostic tests treatment your specialist says that you are not fit to travel by any other fm of transpt. 9

10 17 Home nursing We will pay f a nurse to administer treatment to you at home if: you were admitted to hospital as a day-patient an in-patient f treatment covered by the policy you could be discharged but need to finish treatment that you would nmally receive in a hospital - f example, a course of intravenous antibiotics your specialist remains in charge of your treatment. We will not pay f a nurse to provide personal care, f example help with washing dressing, childcare. 18 Parent accompanying child We will pay hospital charges f one parent to stay overnight in the hospital while their child receives tests treatment as an in-patient that are covered by this policy. 19 New child payment 150 each child We will give the policyholder 150 when a child is bn to adopted by them. The policyholder must have been a member on the policy f at least 10 months when the child is bn adopted. We will not pay new child payment f adoption if the child is already a member of: the policyholder s family (f example a niece a grchild) the policyholder s partner s family. Exclusions that apply to Treatment cover Treatment f cancer we will pay f cancer treatment only if you have cover under Treatment f heart cancer. General exclusions (section 2). Treatment f a heart condition we will pay f heart treatment only if you have cover under Treatment f heart cancer. 10

11 Choice: Treatment f heart cancer Simply Personal Health gives the option to: cover heart conditions cancer in full limit cover to 50,000 f heart conditions 50,000 f cancer during the time that you are covered by the policy not cover any treatment f heart conditions f cancer. Imptant: You must arrange all treatment through our helpline. We will choose the treatment provider (f example the hospital it is the hospital which will allocate a specialist with the relevant expertise to see you). If you receive treatment which you have not arranged through the helpline, we will not pay any of the costs. This could leave you with a large bill that you will have to pay to the provider. Treatment f heart conditions Your membership certificate will show if the policyholder has chosen Treatment f heart cancer f you, if so, whether not the cover is in full limited to 50,000 f heart conditions Benefit Details of cover 20 Treatment f heart conditions Treatment f heart conditions, f example open heart surgery angiogram (sometimes called a cardiac catheter), stabilisation following a heart attack, prostheses implanted during an operation, f example a pacemaker. We pay specialists fees f treatment in full. If we pay f an electronic device, we will not pay f the replacement of consumables, f example batteries leads, replacement of the device itself. We will not pay hospital charges f drugs dressings that you take home from the hospital. 21 Moniting We will pay f post-surgery consultations tests to monit you f a period of two years following treatment that we have paid f. 22 End of life care If your specialist confirms that you need end of life care, we will make a payment of 500 to you to spend as you wish. 23 NHS cash benefit We will give you 250 f each admission that you have as a day-patient each night when you are an in-patient if you choose to be admitted f tests treatment: free of charge as an NHS patient rather than as a private patient we would have paid f the tests treatment as a private patient. We will not pay NHS cash benefit f tests treatment as an out-patient (f example a CT scan), f tests treatment that we would not pay f as a private patient (f example rehabilitation / convalescence, an admission f a pre-existing condition a chronic condition). 24 Private ambulance We will pay f a private road ambulance if you have been admitted to a hospital as an in-patient day-patient f tests treatment covered by the policy : it is medically necessary f you to travel to another hospital f those tests treatment your specialist says that you are not fit to travel by any other fm of transpt. 11

12 25 Home nursing We will pay f a nurse to administer treatment to you at home if: you were admitted to hospital as a day-patient an in-patient f treatment covered by the policy you could be discharged but need to finish treatment that you would nmally receive in a hospital - f example, a course of intravenous antibiotics your specialist remains in charge of your treatment. We will not pay f a nurse to provide personal care, f example help with washing dressing, childcare. 26 Parent accompanying child We will pay hospital charges f one parent to stay overnight in the hospital while their child receives tests treatment as an in-patient that are covered by this policy. Treatment f cancer Your membership certificate will show if the policyholder has chosen Treatment f heart cancer f you, if so, whether not the cover is in full limited to 50,000 f cancer. We want you to have a clear understing of what the policy does does not cover f cancer treatment. If you ever need treatment f cancer, we will offer you personal telephone suppt from a nurse case manager. We will guide you through your treatment programme explain what treatment is covered under the policy. Your nurse case manager will be there to authise treatment suppt your care whether this is given privately through the NHS. Remember, we are always here to help. You can find examples of how cancer cover wks in practice in Appendix 3: Explaining cover f cancer. Benefit Details of cover 27 Surgery f cancer We will pay f surgery f cancer. We pay specialists fees f surgery in full. We will pay up to 5,000 f an external prosthesis, f example a false leg eye (we will pay towards one prosthesis only f each body part that is replaced). We will not pay hospital charges f drugs dressings that you take home from the hospital as a result of surgery f cancer. 28 Reconstruction We will pay f one reconstruction operation within five years of surgery f cancer, in the case of breast cancer: one operation to reconstruct that breast one further operation to improve the symmetry of your breasts. We will not pay f further cosmetic operations to a reconstructed breast. We will not pay hospital charges f drugs dressings that you take home from the hospital as a result of reconstructive surgery f cancer. 29 Radiotherapy We will pay f radiotherapy at a hospital in your chosen netwk. 12

13 30 Chemotherapy We will pay f chemotherapy: which aims to cure your cancer induce a remission if the drug is licensed by the European Medicines Agency (EMEA) used f the purpose f which it is currently licensed. In addition, during the time that you are covered by the policy we will pay up to a maximum of 12 months f chemotherapy: whilst you are in remission to keep your cancer stable prevent disease progression (this is sometimes called maintenance therapy) as palliative treatment. 31 Side effects of treatment Whilst you are receiving chemotherapy radiotherapy that we pay f, we will also pay f treatment prescribed by your specialist that you need to deal with any side effects, f example: antibiotics anti-sickness drugs steroids pain killers drugs to boost your immune system blood transfusions. 32 Cancer services Treatment f cancer can mean that you need a variety of services. If your specialist recommends it, we will pay f treatment advice from: a dietician, to stabilise your diet following surgery, chemotherapy radiotherapy a stoma nurse, to show you how to care f your stoma a specialist nurse to show you how to manage lymphoedema. 33 Moniting We will pay f consultations with a specialist tests to monit your condition f five years after the last treatment f cancer that we paid f on this policy. 34 Wigs If you suffer hair loss as a result of treatment f cancer that we have paid f ( paid NHS cash benefit f), we will pay up to 250 towards the cost of a wig. We will only pay f one wig whilst you are covered by this policy. 35 Preventative treatment We will pay f surgery to prevent further cancer only if we have already paid f treatment f cancer f example, we will pay f a mastectomy to a healthy breast in the event that you have been diagnosed with cancer in the other breast. We will not pay f treatment where you have no symptoms of cancer, f example if you have surgery f preventative reasons because you have a strong family histy of cancer such as breast cancer, bowel cancer. 36 End of life care If your specialist confirms that you need end of life care, we will make a payment of 500 to you to spend as you wish. 13

14 37 NHS cash benefit We will give you 250 f each admission that you have as a day-patient each night when you are an in-patient if you choose to be admitted f tests treatment: free of charge as an NHS patient rather than as a private patient we would have paid f the tests treatment as a private patient. If you choose to have chemotherapy radiotherapy as an NHS patient that we would pay f as a private patient, we can offer an alternative NHS cash benefit payment. Your nurse case manager will be able to discuss this with you. We will not pay NHS cash benefit f tests treatment as an out-patient (f example a CT scan), f tests treatment that we would not pay f as a private patient (f example rehabilitation / convalescence, an admission f a pre-existing condition). 38 Private ambulance We will pay f a private road ambulance if you have been admitted to a hospital as an in-patient day-patient f tests treatment covered by the policy : it is medically necessary f you to travel to another hospital f those tests treatment your specialist says that you are not fit to travel by any other fm of transpt. 39 Home nursing We will pay f a nurse to administer treatment to you at home if: you were admitted to hospital as a day-patient an in-patient f treatment covered by the policy you could be discharged but need to finish treatment that you would nmally receive in a hospital - f example, a course of intravenous antibiotics your specialist remains in charge of your treatment. We will not pay f a nurse to provide personal care, f example help with washing dressing, childcare. 40 Parent accompanying child We will pay hospital charges f one parent to stay overnight in the hospital while their child receives tests treatment as an in-patient that is covered by this policy. Exclusions that apply to Treatment f heart cancer Any costs over 50,000 f treatment of heart conditions during the time that you are covered by the policy if the policyholder has chosen limited cover f Treatment f heart cancer. Any costs over 50,000 f treatment of cancer during the time that you are covered by the policy if the policyholder has chosen limited cover f Treatment f heart cancer. General exclusions (section 2). 14

15 1.2 Excess Your policy has an excess. This means that we will pay f costs covered by the policy, minus the amount of the excess. We apply the excess to each member, every policy year (not necessarily f each claim that you make). This means, f example, that if a claim continues from one policy year to the next, the excess will apply again. F example, if you have a 300 excess you incur costs of 1,000 in a policy year, you will pay the first 300 we will pay the rest. If the tests treatment carry on into the next policy year, another excess will apply so you will again pay the first 300 of costs that you incur in that policy year. When you make your first claim in a policy year, you can pay the excess to: us over the phone by debit credit card the provider of treatment services, f example the specialist hospital. We do not apply the excess to NHS cash benefits, telephone consultations through the Rapid Access Physiotherapy service, new child payment end of life care benefit. We prefer you to pay the excess to us directly as this makes claims payment simpler f you as you will not need to pay the provider at a later date. Your membership certificate will show the excess amount that applies to your cover. 1.3 Imptant note on payment of hospital charges Simply Personal Health offers three hospital netwks: Metropolitan, National Connections. The policyholder has chosen Connections (your membership certificate shows this). F details of the hospitals covered by each netwk you can call us visit: A key feature of this policy is that we will put you in contact with a hospital in der to arrange most of the consultations, tests treatment that the policy covers (there are some complementary therapies f example acupuncture, podiatry / chiropody which are exceptions to this rule. We will tell you about this if you need to call us to make a claim). If your GP feels that you need to see a specialist, we will select a suitable local hospital f that referral. The hospital will make an appointment with a specialist with the relevant expertise to investigate your symptoms, at a time convenient f you (subject to availability). We will pay the treatment provider directly, but we only cover consultations, tests treatment arranged through the helpline. 1.4 Being treated in the appropriate clinical setting We will only pay f tests treatment that take place in the appropriate clinical setting. F example, we would pay f a CT scan as an out-patient, but not f you to be admitted as a day-patient in-patient in der to have a CT scan unless there was a medical reason f this we agreed with your specialist that it was medically necessary. 15

16 Section 2: General exclusions If we have applied exclusions specifically to you as a result of any pre-existing conditions that you have have had, you can see these on your membership certificate. We will not pay costs f tests treatment that you have not arranged through our helpline. AIDS HIV We do not pay f treatment of: AIDS (Acquired Immune Deficiency Syndrome) HIV (Human Immunodeficiency Virus) any related condition of AIDS HIV. Addictions substance abuse We do not pay f treatment - f example surgery, drugs psychiatric treatment f: addictions - f example alcohol addiction drug addiction substance abuse - f example alcohol abuse solvent abuse any illness injury you develop directly indirectly as a result of any substance abuse addiction, f example: -- hepatitis -- cirrhosis -- oesophageal varices -- psychiatric conditions. Chronic conditions We do not pay f routine treatment of a chronic condition, f example drugs to keep the condition stable consultations to monit the condition. We will pay f treatment f an acute flare-up of a chronic condition if: you need to be admitted to hospital as an in-patient f that treatment the treatment aims to quickly stabilise your chronic condition the flare-up was unexpected (f example we will not pay f recurring in-patient admissions which may be a natural consequence of your chronic condition, which happen on a regular predictable basis). We will not pay f an acute flare up of a chronic condition which is a pre-existing condition. Appendix 1 at the back of this document shows examples of how we manage claims f chronic conditions. Cosmetic treatment We do not pay f treatment to: change your appearance - f example a facelift, tummy tuck breast enlargement remove tissue that is not diseased f example fat, surplus skin put right any past treatment to change your appearance remove tissue that is not diseased whether not you have the treatment f medical psychological reasons. We will pay f one reconstructive operation to reste your appearance if that treatment is needed as a result of either: an accident that happened whilst you were covered by this policy surgery f cancer that we paid f, that we paid NHS cash benefit f. We will only pay f a reconstructive operation if it takes place within five years of the accident cancer treatment, there has been no break in cover since then. Dental treatment We do not pay f any dental treatment except f the operations listed in the dental surgery benefit. Developmental behavioural problems We do not pay f treatment f developmental behavioural problems, learning difficulties delayed speech disders, f example: dyslexia including investigations assessments attention deficit hyperactivity disder (ADHD) autism. Dialysis We do not pay f regular planned kidney dialysis f treatment of a chronic condition. We will pay f sht-term kidney dialysis: if you are an in-patient receiving treatment f another condition which we are paying f you need your regular kidney dialysis during this admission if you need it as a result of secondary kidney failure during treatment as an in-patient f another condition which we are paying f. Drugs, dressings medical appliances We do not pay f: drugs, medicines dressings that you take home as a result of having tests treatment - f example, painkillers bages surgical, medical dental equipment - f example, neck suppts, shoe implants (thotics), braces dentures hearing aids cochlear implants, contact lenses glasses mobility aids - f example wheelchairs crutches. 16

17 This exclusion does not apply to a prosthesis an electronic device such as a pacemaker. However, even if we pay f an electronic device, we will not pay f the replacement of consumables, f example batteries leads, replacement of the device itself. Whilst you are receiving chemotherapy radiotherapy that we pay f, we will also pay f treatment prescribed by your specialist that you need to deal with any side effects. Experimental unproven treatment We do not pay f treatment that we consider to be experimental. There are a number of facts which will help us decide whether not your proposed treatment is experimental unproven. F example, we will not exclude treatment f your condition as experimental if it: is widely used in the NHS the National Institute f Health Care Excellence (NICE) has reviewed the treatment agrees that, on both its safety efficacy, there is adequate evidence to suppt its general use is a drug that has been licensed f use in the UK that is being used within the terms of its licence. We will also consider infmation such as published clinical evidence, discuss the matter with your specialist to help us make a reasonable decision. Eyesight We do not pay f treatment f sht sight long sight, f example glasses, contact lenses laser eyesight surgery. We will pay f treatment of an eyesight problem which is an acute condition - f example a cataract detached retina. GP treatment charges We do not pay f tests treatment provided by a GP. Medical infmation, claim fms We do not pay f charges fees f medical infmation in suppt of your claim, f example a GP s charge f completing a fm a specialists charge f sending us a medical rept a treatment plan. These fees are your responsibility. We will pay f you to see an independent medical examiner if we have asked f a second opinion on your condition proposed treatment. Overseas treatment We do not pay f any costs that you incur outside the UK. Pre-existing conditions The policyholder has chosen the underwriting which applies to your cover - whether, how, we will consider preexisting conditions when we assess a claim. There are five possible methods of underwriting your membership certificate will show which type applies to you. Appendix 2 at the back of this document gives examples of how matium full medical underwriting wk in practice. 1. Matium We do not cover costs f any pre-existing condition, any related condition, if you had: symptoms of medication f diagnostic tests f treatment f advice about that condition in the five years befe you joined the policy. However, this exclusion will not apply if you do not have: symptoms of medication f diagnostic tests f treatment f advice about that condition during a continuous two year period after you join the policy. 2. Full medical underwriting (FMU) We do not cover costs f any pre-existing condition, any related condition, unless you told us about that condition on the application fm we did not apply an exclusion f it. Your membership certificate will show any personal medical exclusions that we have applied to your cover. We will review your personal medical exclusion(s) at the renewal date if you ask us to. We will not alter remove a personal medical exclusion if the excluded medical condition ( any related condition) is likely to need treatment in the future. There are some medical exclusions that we will not review - f example, exclusions f chronic conditions. 3. Continued personal medical exclusions (CPME CME) This can only apply to members who were fully medically underwritten on another policy then transferred to this policy. We apply the personal medical exclusions f pre-existing conditions that were applied by your previous insurer. Your membership certificate will show any personal medical exclusions that we have applied to your cover. 4. Continued matium This can only apply to members who were insured on a matium basis on another policy then transferred to this policy. We do not cover costs f any pre-existing condition, any related condition, if you had: symptoms of medication f diagnostic tests f treatment f 17

18 advice about that condition in the five years befe your initial date of cover. Your initial date of cover is the date you started cover with your first insurer (provided there has been no break in cover since then). However, this exclusion will not apply if you do not have: symptoms of medication f diagnostic tests f treatment f advice about that condition during a continuous two year period after your initial date of cover. 5. Medical histy disregarded (MHD) We do not apply any personal medical exclusions to your cover as a result of pre-existing conditions. Pregnancy, childbirth fertility treatment We do not pay f: childbirth termination of pregnancy fertility treatment diagnostic tests f fertility surgery on a baby that hasn t been bn (a foetus) any fm of contraception f example drugs, devices surgery. We will pay f: the conditions listed in the complications of pregnancy childbirth benefit the treatment, care moniting a premature baby needs - this is limited to the first 28 days from the date of birth. Preventative treatment We do not pay f treatment to prevent a disease illness f example: a vaccination surgery to remove a healthy breast to avoid cancer where you have no symptoms of breast cancer whatsoever. Rehabilitation, convalescence general nursing care We do not pay f: rehabilitation convalescence nursing home care hospital charges if the reason you are in hospital is that you need help with mobility, personal care preparation of meals, even if the policy covered your admission when you were first admitted. Screening moniting We do not pay f: routine medical examinations f example sight hearing tests tests check ups to look f a disease illness if you do not have symptoms f example health screens genetic tests routine tests, check ups consultations f a chronic condition. If we have paid f, paid NHS cash benefit f, your cancer treatment, we will pay f tests consultations with a specialist to monit you f five years after you finish treatment f the cancer. We will pay f post-surgery tests consultations to monit you f a period of two years following heart treatment that we have paid f. Self-inflicted injury We do not pay any costs that you incur as a result of an injury that you deliberately inflicted upon yourself f example following an attempted suicide. Spt professional sptsmen women dangerous spts We do not cover any costs that you incur as a result of an injury sustained whilst you are: training f taking part in spt f which you are paid, funded by sponsship grant (unless you receive travel costs only) taking part in a dangerous spt. Transplants We do not pay f any element of treatment involving any fm of transplant, f example: gan transplant f example a heart, a kidney stem cell bone-marrow transplant body part transplant f example a h plasmapheresis. We will pay f skin grafts cneal grafts if you need them f treatment of an acute condition. War dangerous substance contamination We do not pay f treatment of any illness injury caused directly indirectly by: war (whether war has been declared not) military paramilitary activity acts of terrism contamination from radioactivity, chemical biological agents. Weight loss treatment We do not pay f: bariatric surgery (weight loss surgery) - f example gastric bing a gastric bypass the removal of fat surplus tissue treatment of complications from bariatric surgery the removal of fat surplus tissue. 18

19 Section 3: Making a claim We are here to help. We know that, when you are ill, a friendly efficient claims service is very imptant. We want to make claiming as easy as possible. If your GP refers you to a specialist, please call our claims helpline on Our helpful staff will discuss your claim with you put you in contact with a hospital from our netwk in der to arrange tests treatment that the policy covers. We will only pay costs f services that you have arranged through the helpline - we will not accept any liability f any claims f services which you have not arranged through this helpline. If you incur costs f services that you have not arranged through the helpline, this could leave you with a bill that you will have to pay to the provider. If you need hospital tests treatment, we will pay f a private room if you need one, wherever possible in a hospital within 25 miles of your home. In most cases it s as simple as that, although there are some circumstances when we might ask you to complete a fm. When you call it makes the process easier if you can tell us: your name policy number (we will carry out a brief identity check by asking you to confirm personal infmation that we hold about you). If the claim is f someone else, f example a child, we will need their details too the medical condition symptoms that you are suffering from your GP s name, address phone number the date that you first visited a GP about this medical condition symptoms the plan that the GP is recommending, f example the name of the medical specialty that you are being referred to (f example thopaedics). We can give you guidance on exactly what the policy will pay f, offering you peace of mind at a wrying time. We can also highlight any costs that we will not pay, helping you make an infmed decision about your care.. We look after the small details that can make such a big difference, authising helping make arrangements at a time to suit you (subject to availability) then settling accounts directly with your specialist hospital. 3.1 Assessing your claim If we need me medical infmation (f example we may give the doct a fm to complete, ask f a medical rept), we will ask f your consent to approach the relevant doct medical professional f this. You do not have to give your consent, but if we cannot obtain the infmation that we need to assess your claim, we will not be able to pay the costs. We will not be liable f any charges f me medical infmation (although if we arrange f you to see an independent medical examiner we will pay f this). 3.2 Confirming cover f your claim Once we have the infmation that we need to assess your claim, we will be able to make a decision about whether not the policy will pay f your consultation, diagnostic tests treatment (based on the choices that the policyholder has made f your cover). We will nmally tell you over the phone, although we will write to you with the details if you ask us to. We will ask you to pay your excess over the phone. This means that we can settle bills with providers like hospitals specialists me quickly, you will not need to pay the provider at a later date, although you can choose to pay the excess directly to the provider if you wish. Your membership certificate will show the excess amount that the policyholder has chosen f your cover. Please call us if you need further treatment tests. We can then assess whether not this is treatment tests that the policy will pay f. If you need treatment a series of treatments that will last f some time, we can offer you a personal contact in our claims team who can help you every step of the way. 3.3 Paying claims We pay invoices directly promptly to the providers (f example the hospital specialist). If a provider gives you an invoice but does not ask f immediate payment, just send it to us along with your membership details. If it is f services that the policy covers, we will pay the provider directly. If the provider asks you to pay immediately, please send us the receipted invoice along with your membership details. If it is f services that the policy covers, we will reimburse you. We will write to you with details of any payments we make, to tell you how much excess you have paid. 3.4 Second opinions Your rights If you have a consultation with a specialist you your GP are unhappy with the outcome, we will pay f a second opinion where there are medical grounds to suppt this. Just call us follow the steps f making a claim. Our rights In der to assess any claim that you make, we have the right to obtain a second opinion from an independent medical examiner if it is reasonable f us to do so. If the independent medical examiner needs to examine you personally (rather than making an assessment from a rept), we will make the arrangements at a time place that is suitable f you. 3.5 Claims imptant notes We will only pay f costs if the policy is in fce at the time you incur those costs. This means that the policyholder has paid the premium f the period of time during which you incurred the costs. F example, if we have received the premium covering the period until the end of January you have treatment in February, we will not pay the claim if we have not received the premium f February. If your specialist has planned a course of treatment, a series of treatments over a period of time, it is your responsibility to check with us if we will pay f that continued treatment. 19

20 We will not pay f any costs that you incur if the policyholder has not paid the premium f the period of time when you incur those costs even if we have given authisation. When we authise your claim, that authisation is valid f three months from the date given f your first appointment (provided that the premiums are paid). If the iginal appointment is cancelled f any reason is not rearranged within three months of your iginal authisation date, the authisation will lapse. We strongly recommend that you call us f new authisation befe going on to have any consultation, test treatment. We will not be responsible f any charges made f an appointment that you do not attend. Only we can confirm whether not we will pay a claim. You should not rely on the advice of a provider, f example a specialist a hospital, about what the policy covers. If you are unsure whether not the policy covers any proposed tests treatment please call our helpline on What to do in an emergency If you need emergency tests treatment, please go to your nearest NHS emergency department. If you have received emergency tests treatment in an NHS hospital then need further non-urgent treatment that the policy covers, you may be able to transfer to a private hospital. You can call us on to check whether the policy covers your transfer tests treatment. Section 4: Who can join the policy? The people who can be included are: the policyholder the policyholder s husb, wife, civil partner someone who lives with the policyholder as if they were their husb, wife civil partner (the policyholder s partner) the policyholder s children (this includes children of the policyholder s partner). All members on this policy must have the same hospital list the same excess, but members can have different benefit choices. This policy is f people who live in the UK. If you move outside the UK, you must tell us because the policy may not be suitable f your needs. 4.1 Adding members to the policy The policyholder can ask us to add a new partner a child to the policy at any time. If we need the policyholder the potential member to complete an application fm, we will tell them. We do not have to accept an application to join the policy. 4.2 Adding newbn babies to the policy F babies bn after the policy started who are added to the policy within three months of being bn, we will: not apply any personal medical exclusions to the baby s cover, regardless of the baby s health not charge a premium f that baby until the next policy year. Section 5: Cancelling the policy, cancelling membership 5.1 When we can cancel the policy We can cancel the policy if: the policyholder has -- not fully paid the premium within 30 days of the date it was due to be paid -- deliberately misled us in any way, f example given us false infmation, not given us infmation that we have asked f about a person on the policy a claim on the policy -- not acted honestly in any of their dealings with us. we decide to no longer offer this product at the renewal date. If this happens, we will offer an alternative product, if we have one, in der f cover to continue. We will not cancel your cover as a result of the number, the cost, of claims that you make, although we may adjust premiums to reflect the risk of further claims. 5.2 When the policyholder can cancel the policy This is an annual policy. The policyholder can cancel the policy f any reason up to 14 days from either: the day they receive the policy documents the day on which we receive payment of the first premium each policy year whichever happens later - this applies f a new policy following a renewal date. Provided that we have not paid any claims during this 14 day period, we will refund in full any premium that the policyholder has paid. If we have paid claims, we will deduct the cost of those claims from any refund we give. If the cost of the claims is greater than the premium, we do not have to refund the premium. After this 14 day cooling off period, the policyholder can cancel the policy by giving us one month s notice. If the policyholder pays a monthly premium, we will not refund that premium. If the policyholder pays a three, six twelve monthly premium, we will refund any remaining premium. 20