A bother free guide to Preferential Private Health Cover. Your Personal Policy Document

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1 A bother free guide to Preferential Private Health Cover Your Personal Policy Document Effective from 1 November 2010

2 We believe that your health is the most important thing of all and we want to help you feel better every day. So we d like you to know that we are always available to listen, to chat about your policy and to offer you all the practical help and support you need whenever you need it. Why? Because we can be bothered. Simplyhealth spoke and wrote in plain English and I knew exactly what was going on and what was covered financially. Simplyhealth customer All quotations are real but the names of the individuals have been withheld to safeguard their identities. 2

3 Welcome to your Preferential Policy Document. It tells you exactly what is and isn t covered so you can get the most from your policy. It sets out what you need to know about the benefits as well as the terms and conditions of your health cover policy. It also gives you information about making changes to your membership and how to make a claim. It should be read together with your Membership Certificate which details any personal underwriting exclusions and excess that applies to your cover. These documents form your policy with us. Certain words used in the policy have a special meaning. These words are highlighted in red and are defined on page 22. How to contact us If you need to discuss any aspect of your membership call our freephone numbers, where one of our friendly and dedicated team will be pleased to help you. Claims Helpline: Membership Helpline (changes to policy details): Call us from overseas: 44 (0) Your calls may be recorded and monitored for training and quality assurance purposes. Preferential Private Health Cover Preferential cover includes a comprehensive range of benefits to provide peace of mind throughout a period of ill health. Your Preferential policy gives you access to some of the finest medical facilities. If your GP refers you for further investigation you can have the reassurance that you will be able to see a consultant quickly, have treatment at a private hospital and if necessary, be covered for physiotherapy to help you recover. Our dedicated team of advisers are here to arrange treatment and guide you through every step. How to claim You must call our Helpline on before arranging any private treatment. If you do not call us, there is a risk that some or all of your treatment will not be covered. You will be responsible for paying for treatment that is not covered. Our helpful staff will authorise eligible treatment over the phone. In most cases it s as simple as that no claim forms and no paperwork to complete. If you have an excess you will be required to pay it at this time. You also need to call us if you require any further treatment, so we can ensure that you are still covered. Please see page 12 for more information on making a claim. More from Simplyhealth We understand that health choices are personal. The last thing you want is for your finances to get in the way of the quality everyday healthcare you and your family deserve. That s why we have developed our Simply Cash Plan which can complement your Preferential Private Health Cover. We want to help you plan for the cost of visits to the dentist or optician whether it s for a check-up, treatment or emergency. The Simply Cash Plan is for anyone aged 18 to 69 and a simple monthly payment means you get money back on your everyday health costs, up to your annual limit. We offer four levels of cover with a range of benefits. This makes everyday healthcare accessible, affordable and as stress-free as possible, so you can focus on more important things, like taking care of yourself and your family. For more information or to join the Simply Cash Plan, please visit our website 3

4 Contents 6 Benefits 8 What is not covered by your policy? 8 Cancer treatment - what is covered? 9 What is a chronic condition? 12 How to make a claim 12 What do I do in an emergency? 13 Second opinions 13 Claiming for further treatment 13 How any excess on your policy is applied 14 Scales of cover 14 Emergency inpatient treatment overseas 18 Fraud 18 Cancellation rights 19 If you have an accident 19 If you have other insurance policies 20 How we use information about you 21 If you have a complaint 21 Financial Services Compensation Scheme 21 Important notes 22 Definitions 23 About Simplyhealth 16 Your obligations 17 Membership 17 Joining Simplyhealth 17 Changes to your membership 17 Including family members within your policy 17 When a child is born 17 When children reach Underwriting options 4

5 My one occasion of going into hospital and the bill being settled quickly and easily was great. The peace of mind that this brings allows me to concentrate on work and family, rather than fret about health issues. Simplyhealth customer 5

6 Benefits What is Preferential Private Health Cover? Your policy is designed to provide cover to diagnose and treat acute conditions. These are medical conditions that are likely to respond quickly to treatment, leading to your full recovery and returning you to your previous state of health. Your health cover benefits explained The following table shows you the wide range of benefits included under your Preferential policy. For details of how to make a claim under your policy please refer to page 12. Where we have stated full cover this is subject to the terms of the policy. Treatment expenses must, in our opinion, be reasonable and exclusively for the treatment of an eligible acute condition. We will not pay for treatment of a chronic condition. We may require full itemisation of any charges giving rise to a claim. We will not pay more than the actual expenses incurred (except for payment of NHS cash benefit, Hospice benefit and New child payment). We may refuse to pay any expenses in excess of those normally charged for similar treatment in the UK. We pay benefit based on a fixed fee schedule for the treatment that is being provided. The Simplyhealth fee schedule can be seen on or call us on We will not pay for fees that are greater than those detailed within our fee schedule. Except in an emergency, all treatment for which benefit is claimed must be arranged with the knowledge and approval of your GP or of a specialist that you have been referred to by your GP. For details of the limited cover available for emergency inpatient treatment overseas and the claiming process that needs to be followed please refer to page 14. For the assessment of all inpatient claims the days of admission and discharge shall count as one day. For all benefits we will only pay for treatment that is normally provided under the NHS or approved by the National Institute of Health and Clinical Excellence (NICE). 6 Benefit 1 Outpatient specialist consultations 2 High cost scans including CT, MRI and PET scans 3 Outpatient services Acupuncture Podiatry/chiropody Radiology, including ultrasounds Chiropractic Pathology Osteopathy Physiotherapy 4 Hospital charges for inpatient and daypatient treatment Accommodation and nursing (including intensive care) Operating theatre charges Drugs and dressings prescribed for use while an inpatient or daypatient Pathology, physiotherapy and diagnostic tests Prostheses, when implanted as an integral part of a surgical procedure 5 Surgeons and anaesthetists fees Level of cover per person Full cover Full cover Full cover for specialist referrals Full cover Full cover Notes Outpatient consultations with a specialist/surgeon to diagnose a condition or to assess progress of treatment of an eligible acute condition. Routine monitoring of a chronic condition is not covered. There is a combined limit of 500 per claiming year for acupuncture, podiatry/chiropody, osteopathy and chiropractic where referral is made by a GP. This financial limit does not apply when referral is made by a specialist. Benefit 4 is payable for treatment received in a hospital which is listed in our Hospital Directory, either within your scale (as detailed on your Membership Certificate) or a lower scale of cover. If you receive treatment in a higher scale hospital Out of scale limits will apply which will fall short of the actual expenses incurred, leaving you responsible for paying the balance. Please refer to page 14 for further details on the Out of scale limits. Outpatient drugs and dressings related to inpatient or daypatient treatment are not included under this benefit. Benefit for surgeons and anaesthetists fees is paid in accordance with the maximum amounts set out in our fee schedule. The Simplyhealth fee schedule can be seen on or call us on

7 Benefit Level of cover per person Notes 6 Oncology including radiotherapy and chemotherapy Full cover Please refer to Cancer treatment what is covered? on page 8. 7 Specialist physicians fees For inpatient and daypatient treatment Full cover You must be under the regular care of a specialist and, in respect of inpatient treatment, benefit would not normally be payable unless the specialist attends you at least five days each week. Paid for up to 91 days in any one claiming year. Physician fees are paid in accordance with the maximum amounts set in our fee schedule. 8 Oral surgery Full cover for specific conditions in accordance with benefits 4 and 5 Oral surgery carried out at a hospital by an oral maxillofacial surgeon restricted to the following conditions: Surgical removal of impacted/buried or unerupted tooth/teeth. Surgical removal of complicated buried roots. Apicectomy of tooth/teeth (removal of the tip of the root). Enucleation of cyst of jaw (surgical removal of cyst from the jaw bone) 9 Psychiatric benefits Outpatient consultations and treatment Inpatient and daypatient treatment Full cover Paid provided the treatment is carried out under the care of a recognised specialist and treatment has been agreed in advance by us. Inpatient and daypatient treatment must be in a hospital which is listed in the Hospital Directory, either within your scale or a lower scale of cover. Maximum of 28 days cover per claiming year for inpatient and daypatient treatment. 10 NHS cash benefit 100/day or night Paid for each day or night when you receive inpatient or daypatient treatment free of charge under the NHS for an eligible acute condition, up to 91 days or nights (28 days or nights for psychiatric treatment) in any one claiming year. 11 New child payment 150/birth Paid once per birth, provided the parent has been a member for more than one claiming year. 12 Parent accommodation charges Full cover For one parent staying overnight in hospital while their child receives inpatient treatment. The child must be under the age of 12 and enrolled in their parents membership. 13 Private ambulance Full cover Paid when an ambulance is required out of medical necessity and in connection with eligible inpatient or daypatient treatment. 14 Home nursing Full cover Paid for the full-time services of registered nurses, on a resident or daily basis, following an inpatient stay, when prescribed by a specialist solely for medical reasons. 15 Hospice benefit 100/night A payment to the hospice, up to 91 nights in any one claiming year. 16 Emergency inpatient treatment overseas 17 Advice Lines and Counselling Services 100,000 policy lifetime limit/person Full cover for telephone services Limited overseas medical cover for emergency inpatient treatment available to members resident in the UK while travelling outside the UK. All treatment must be authorised in advance by our Overseas Assistance Helpline and we will only pay up to 100,000 policy lifetime limits for any eligible treatment. This limited cover does not replace the medical section of a travel insurance policy. Please refer to page 14 for more information. Available 24 hours a day, 365 days a year by calling Our experts provide help on matters such as: health and lifestyle issues, childcare, care of the elderly and hospital procedures. The service also gives you access to highly experienced and professionallytrained counsellors who are able to help resolve issues such as: relationship or family difficulties, emotional problems, work related issues, bereavement and debt. At times, further assistance might be appropriate. Any costs incurred resulting from onward referral would be at the caller s own expense. All counsellors uphold the British Association of Counselling and Psychotherapy (BACP) Code of Ethics and Practice for Counsellors. Calls may be recorded. 7

8 What is not covered by your Preferential policy? Any exclusions specific to your cover as shown on your Membership Certificate. Treatment not normally provided under the NHS or not approved by the National Institute of Health and Clinical Excellence (NICE). Pre-existing conditions which have not been disclosed to us and accepted by us for benefit. Charges which exceed those listed within the Simplyhealth fee schedule. Treatment received outside the UK where the purpose of being abroad is wholly or in part to obtain such treatment see page 14 for details of emergency inpatient treatment overseas. Repatriation or transfer from a ship, oil rig, or similar off-shore location. Repatriation to the UK, from a hospital abroad unless covered under inpatient treatment overseas benefit. Dental treatment which has not been carried out in a hospital by an oral and maxillofacial surgeon and is not specifically listed under benefit 8 of the benefit table. Chronic conditions see page 9 for further details. Consumables and appliances including medical, dental and surgical appliances, prostheses (except as included in the benefit table), drugs and dressings for use whilst an outpatient, spectacles, contact lenses and hearing aids. Cosmetic treatment or surgery. Treatment required as a result of alcoholism, alcohol abuse, solvent abuse or addictive conditions or any associated psychiatric condition. Treatment related to developmental problems, learning difficulties or delayed speech disorders, for example, dyslexia or attention deficit hyperactivity disorder. HIV infection, AIDS or any associated condition. Preventative treatment or investigations - including sight testing, vaccination, inoculation, routine medical or dental examinations or other investigations or treatment taken as a preventative measure. Genetic testing. Treatment of low fertility or infertility, or pregnancy, or childbirth resulting from such treatment. Pregnancy or childbirth including any medical conditions relating to childbirth. Termination of pregnancy. Dialysis regular or long-term renal dialysis. Transplantation operations or procedures for example autologous plasmapharesis, transplant of bone marrow or stem cells, organ transplant, autologous blood transfusion or similar procedures. Removal of non-diseased tissue, e.g. breast reduction. Self-inflicted non-accidental conditions. Treatment required as a result of dangerous sports. Accommodation without treatment including a stay in hospital wholly or partly for domestic reasons; when the patient is not undergoing regular treatment by a specialist or where treatment could be reasonably provided elsewhere; or where the hospital has effectively become the patient s permanent abode. We also exclude stays in a convalescent home, convalescent hospital, health hydro or nature cure clinic or similar establishments. GP or dentists fees. Unlicensed drugs or the use of drugs outside the scope of the licence issued by the European Medicines Agency (EMEA) or the National Institute of Health and Clinical Excellence (NICE). Treatment for injuries or illness arising out of war, invasion, act of foreign enemy, nuclear or chemical contamination, hostilities (whether war be declared or not), civil war, riot, civil commotion, rebellion, revolution, insurrection or military or usurped power. Cancer treatment what is covered? Cancer as a condition does not fit easily into the acute and chronic definitions used to categorise other illnesses. We want you to have a clear understanding of what is covered (eligible treatment) and what is not covered (non-eligible treatment) for cancer treatment under your policy. If treatment for cancer is ever necessary, then you will have the personal support of your own Simplyhealth nurse adviser. We will authorise your claims, guide you through your treatment programme and explain what treatment is covered under your policy. Your nurse adviser will be there to support your care whether this is given privately or through the NHS. Remember, we are always here to help. 8

9 We will pay for: Surgery, chemotherapy, radiotherapy and support services that are administered to achieve cure or to reach remission. Treatment plans and surgery must be proven to be safe and effective treatments, and we must have decided that there is credible scientific evidence to support its use. Chemotherapy drugs, hormonal and biological therapies licensed by the European Medicines Agency (EMEA). They must be used for the purpose for which they are currently licensed and widely available within the NHS. Combination drug therapies will only be considered if widely recognised for use within the NHS. Hormonal and biological therapies in combination with other drugs will only be considered if these combinations are widely recognised for use within the NHS. Benefit for follow-up consultations and monitoring for a period of five years once treatment to achieve cure or to reach remission has ceased. Breast reconstruction and surgery to improve symmetry, following a mastectomy or lumpectomy. We will pay for such operations for a period of up to five years following initial surgery. NHS cash benefit for daypatient or inpatient cancer treatment received under the NHS. A payment to a hospice when a patient receives hospice care. We will not pay for: Drugs that are still under trial or trials of combination drug therapies. Maintenance or long-term therapies where the condition is stable, remains in remission, or remission cannot be achieved. At this time your nurse adviser can help with the smooth transition of care into the NHS. We will continue to support you during this transition period. What is a chronic condition? A chronic condition is a disease, illness, or injury that has one or more of the following characteristics: It needs ongoing or long-term monitoring through consultations, examinations, check-ups, and/or tests. It needs ongoing or long-term control or relief of symptoms. It requires your rehabilitation or for you to be specially trained to cope with it. It continues indefinitely. It has no known cure. It comes back or is likely to come back. It is not always clear that you have a chronic condition when you visit your GP. This is why we will pay for referral to a specialist and any eligible tests, investigations and consultations to make a diagnosis. The aim of any treatment must be to return you to the state of health you were in immediately before suffering the disease, illness or injury, or lead to your full recovery. What does this mean in practice? If your condition has or acquires one or more of the characteristics detailed above in our description of a chronic condition, we will not pay any benefit for this condition, unless agreed by us in advance of the treatment. Even if we have paid for previous treatment, it does not mean that we will continue to cover that condition, if we think it has become chronic. If your diagnosis is for a chronic condition, we will confirm to you that we will not pay for further investigations or treatments. What if your condition gets worse? We do not pay for on-going treatment or investigations to maintain a chronic condition in a stable state. Depending on individual circumstances, and any other guidance we have given you on your claim, we may pay benefit for an acute flare-up of symptoms related to a chronic condition. The aim of the treatment should be to return you to a stable condition. We would not pay benefit for frequent reoccurrences of an acute flare-up of a chronic condition. To establish whether we could consider an acute flareup of symptoms related to your chronic condition to be eligible for benefit you must call us on for pre-authorisation of treatment. We would not pay benefit for an acute flare-up of a chronic condition unless the cost of treatment has been pre-authorised by us. 9

10 Examples of chronic conditions While these case studies are fictitious they are intended to illustrate how this policy works in practice to support the health and wellbeing of individual members. Alan Alan has been with Simplyhealth 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 will pay for the consultations and investigations to stabilise Alan s angina provided Alan calls us to discuss his consultations and treatment. We do not pay for outpatient medication. Two years later, Alan s chest pain recurs more severely and his specialist recommends that he has a heart by pass operation. We will pay for Alan s consultation with the specialist and for his heart by-pass operation. Following his operation Alan will need to have further consultations to check that the operation was a success and to adjust his medication so his condition remains stable for the future. Assuming that Alan s condition remains stable, we will pay for these consultations and related tests for a maximum of one year. Bob Bob has been with Simplyhealth 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 returns once a month for additional treatment to prevent a recurrence of the original symptoms. We will pay benefit for Bob s initial two week course of treatment. We will however apply a maximum benefit limit under outpatient services of 500 in any one claiming year for treatment given by an osteopath where the referral has been made by a GP. If a specialist had made the referral this limit would not apply. We will not pay for Bob s additional treatment as this is purely being recommended as a preventative measure, not to cure his hip pain. We will write to Bob to advise him of our decision and to explain the future circumstances when we will pay benefit for his hip pain. 10 Deirdre Deirdre has been with Simplyhealth for two years when she develops symptoms that indicate she may have diabetes. Her GP refers her to an endocrinology specialist who organises a series of investigations to confirm the diagnosis, and she then starts on oral medication to control the diabetes. After several months of regular consultations and some adjustments to the medication regime, the specialist confirms the condition is now well controlled and explains he would like to see her every four months to review the condition. We will pay for Deirdre s investigations and treatment up to the point that her specialist considers her condition has been brought under control and stabilised. Once this has been achieved we will not pay for any further consultations undertaken as part of long-term monitoring of her condition. We will write to Deirdre to explain this decision and to inform her of the future circumstances when we will pay benefit for her condition. One year later, Deirdre s diabetes becomes unstable and her GP arranges for her to go into hospital for treatment. Deirdre correctly follows the claims procedure and contacts us before arranging treatment. We authorise the admission for treatment in this instance. This does not mean that we would continue to cover future treatment for the condition and Deirdre must contact us for authorisation of future treatment for diabetes. Eve Eve has been with Simplyhealth for five years when she develops breathing difficulties. Her GP refers her to a specialist who arranges a number of tests. These reveal that Eve has asthma. Her specialist puts her on medication and recommends a follow-up consultation in three months to see if her condition has improved. At that consultation Eve states that her breathing has been much better. So the specialist suggests she has check-ups every four months. We will pay for the investigations into the cause of Eve s breathing difficulties and the initial follow-up consultation undertaken to ensure her condition has been stabilised. We will not pay for any further consultations undertaken as part of long-term monitoring of her condition. We will write to Eve to explain this decision. Eighteen months later, Eve has a bad asthma attack. As Eve has not had a bad asthma attack before, we will pay for further treatment on this occasion. However, we would not continue to pay benefit for Eve s asthma indefinitely.

11 Cara Cara has had breast cancer, which was previously treated by lumpectomy, radiotherapy and chemotherapy under her existing policy. She now has a recurrence in her other breast and has decided to have a mastectomy, radiotherapy and chemotherapy. Will her insurance cover this and are there any limits to the cover? The mastectomy performed on Cara s affected breast will be covered under the terms and conditions of the policy. Reconstruction of the affected breast would also be covered under the policy. The reconstruction needs to be done within five years of the date of the mastectomy. Radiotherapy and chemotherapy will be covered under the terms of Cara s policy. The chemotherapy drugs must be licensed by the European Medicines Agency (EMEA) and used for the purpose for which they are currently licensed and commonly available on the NHS. Combination drug therapies will be considered if commonly recognised for use within the NHS. Sharon Sharon would like to be admitted to a hospice for care aimed solely at relieving symptoms. Will her insurance cover this and are there any limits to her cover? No. We will not cover her admission to a hospice as her care is aimed solely at relieving her symptoms and not for cure or remission. However, we will make a payment to the hospice on Sharon s behalf. Beverley Beverley has been with Simplyhealth for five years when she is diagnosed with breast cancer. Following discussion with her specialist she decides to have her breast removed followed by breast reconstruction. Her specialist recommends a course of radiotherapy and chemotherapy. In addition she is to have hormone therapy tablets for several years. Will her insurance cover this treatment plan and are there any limits to the cover? We will cover the removal of Beverley s affected breast and will also pay benefit for breast reconstruction. To be eligible for cover the reconstruction must be done within five years of the mastectomy. Radiotherapy and chemotherapy will be covered under the terms of Beverley s policy. The chemotherapy drugs must be licensed by the European Medicines Agency (EMEA) and used for the purpose for which they are currently licensed and commonly available on the NHS. Combination drug therapies will be considered if commonly recognised for use within the NHS. The hormone therapy tablets will not be covered by her policy as these are considered preventative therapy and are readily available through Beverley s GP. We will pay for Beverley to receive follow-up consultations and monitoring for a period of five years once treatment has ceased. Monica Monica, who was previously treated for breast cancer under her existing policy, has a recurrence, which has unfortunately spread to other parts of the body. Her specialist has recommended the following treatment plan: A course of six cycles of chemotherapy aimed at destroying cancer cells, to be given over the next six months. Monthly infusions of a drug to help protect the bones against pain and fracture. The infusion is to be given for as long as it is working (hopefully years). Weekly infusions of a drug to suppress the growth of the cancer. These infusions are to be given for as long as they are working (hopefully years). Will her insurance cover this treatment plan and are there any limits to the cover? The six-cycle course of chemotherapy, aimed at destroying cancer cells, would be authorised for Monica as long as the European Medicines Agency (EMEA) licenses the chemotherapy drugs, and the drugs are used for the purpose for which they are currently licensed and commonly available on the NHS. The monthly infusions of a drug to help protect Monica s bones against pain and fracture will be covered by the policy during the six months whilst the cancer is being actively treated with chemotherapy. We will stop paying for these monthly infusions once either remission from the disease has been established or the cancer fails to respond to treatment. In these circumstances we will provide a nurse adviser to help with the smooth transition of care to the NHS. The weekly infusions of a drug to suppress the growth of cancer will be covered by the policy during the six months whilst the cancer is being treated. We will stop paying for these weekly infusions once either remission from the disease has been established or the cancer fails to respond to treatment. In these circumstances we will provide a Simplyhealth nurse adviser to help with the smooth transition of care to the NHS. 11

12 Making a claim is simple. Here s how... Simplyhealth is here to help. We know that, at times of ill-health, a friendly and efficient claims service is very important to you. We want to simplify the paperwork and make claiming as easy as possible. If you want to make a claim please call us on before arranging any private treatment. We can give you guidance on exactly what you are covered for, checking whether the costs of your treatment are within our fee schedule and that the hospital you plan to use is within your scale of cover offering you peace of mind at a worrying time. We can also highlight any costs you may liable for, helping you make an informed decision about your treatment. If you prefer, for no extra charge, we can also arrange diagnostic tests, medical treatment and hospital accommodation on your behalf. We look after the small details that can make such a big difference, authorising and arranging your treatment at a time to suit you (subject to availability) and then settling accounts directly with your specialist and hospital. Making a claim Where your GP has informed you that you need to be referred to a specialist, claiming under the Preferential policy is straightforward. In order to claim you need to follow the following claims procedure: You must call our Helpline on Our helpful staff will discuss your requirements and authorise eligible treatment. They can even arrange your treatment over the phone if you want them to. In most cases it s as simple as that no claim forms and no paperwork to complete. Although on some occasions we may need more medical information. We will confirm the extent of the treatment we have authorised by phone or letter. If this is your first claim in your claiming year and you have an excess on your policy, you will now be asked to pay it over the phone. Your Membership Certificate will show the amount of excess you have to pay (where applicable). Once you have had your consultation, please call the Helpline to either discuss further treatment or to let us know if your treatment has been completed. We pay invoices directly and promptly to the treatment providers and we ll send you details of any payments we make. If you are given an invoice but are not asked for immediate payment, just send it to us, along with your membership details, and we ll settle the account. If you are asked to pay for your treatment immediately, please send us the receipted invoice, along with your membership details, and we ll refund you directly. We will confirm to you in writing the payments that we have made and that the excess has been paid. What do I do in an emergency? If you need emergency treatment, please go to your nearest NHS Emergency department. If you have received emergency treatment in an NHS hospital and then require further non urgent treatment, you may be eligible to be transferred to a private hospital. Please call us on to check whether your transfer and treatment is covered. 12 For details of what is and is not covered for emergency inpatient treatment while travelling overseas and the claims process that needs to be followed before treatment commences please refer to page 14.

13 Second opinions If you have had a consultation and you and your GP are unhappy with the outcome, you can request a second opinion where there are medical grounds to supports this. Just call us and follow the steps for making a claim. Claiming for further treatment You must call us if you require further treatment. We will confirm whether this treatment is eligible for cover, ensuring that you know exactly what is covered under your policy. If you need to undertake a prolonged series of medical treatments, we ll provide you with a personal contact who can help you every step of the way. Claims important notes 1 We do not cover fees charged for providing supporting information to assess your claim, such as fees charged for completing a claim form or producing a medical report. These fees are your responsibility. 2 Only Simplyhealth can confirm the acceptance of any claim. No one else has any power or authority to confirm acceptance or change any of the policy rules, on our behalf. Please call our Helpline on to confirm cover is available. 3 Authorisation is valid for three months from the date given to you for your first appointment. If your original appointment is cancelled for any reason and is not rearranged within three months of your original authorisation date, the authorisation will lapse. You must call us for new authorisation to proceed further. 4 We will not be responsible for any charges made for an appointment that you fail to attend. You must provide us, the hospital or specialist at least 48 hours advanced notice if you are unable to attend an appointment. Any charges, including the costs that would have been incurred for diagnostic procedures, must be met by you where you fail to provide the appropriate notice. 5 We will only pay for treatment received during a period for which premiums have been paid. If a staged treatment plan has been authorised it is your responsibility to ensure that you are still eligible for the treatment. How any excess on your policy is applied If an excess applies to your policy then this is shown on your Membership Certificate. The excess options are: Excess level Excess amount Saving Scale D Scale C Scale B Scale A 1 8% % % % Excesses are only applied once each claiming year for each person included on the policy. The full excess is not applied for every claim made. You will need to pay the excess when you call us to authorise the first claim or claims for treatment in your claiming year. We apply the excess to the first claim. If the excess is not fully paid, the remainder will be carried over to subsequent claims, until it is paid in full. The excess starts again on your renewal date each year. If you are continuing treatment when you renew the policy, the excess will apply twice. The same outpatient limits apply whether you have an excess or not. Excesses do not apply to any NHS cash benefit, Hospice benefit or New child payment. Year 1 March Member joins Simplyhealth with 200 excess December Member receives physiotherapy, cost 90 February Year 2 March Full excess 200 Member pays 90 We pay 0 Member has consultation with specialist, cost 150 Remaining excess 110 Member pays 110 We pay 40 Member has diagnostic tests, cost 500 Remaining excess 0 Member pays 0 We pay 500 Member renews with 200 excess Member receives surgery, cost 8,000 Full excess 200 Member pays 200 We pay 7,800 Remaining excess 110 Remaining excess 0 Remaining excess 0 Please note the claiming year runs from your renewal date. Excesses are charged in line with your claiming year. 13

14 Scales of cover Private hospitals are classified according to how much they charge for treatment. The hospital scales are from A to D, where scale A covers the most expensive hospitals (such as those in central London), and scale D covers the least expensive. The scale does not reflect the quality of the treatment received in these hospitals, merely the associated expenses like the cost of a room. The scale of cover that you have selected will be shown on your Membership Certificate. Our Hospital Directory confirms the scale that applies to each hospital. Out of scale limits what is and isn t covered? If you choose to go to a hospital that is in a higher scale than you are covered for you will not be entitled to benefit under the items listed in benefit 4. Instead, you will be provided with the following amount for each night of an inpatient stay: Scale A: Up to 380 Scale B: Up to 340 Scale C: Up to 275 Scale D: Up to 210 The out of scale limit shown above is the total amount paid for all of the following; Accommodation and nursing (including intensive care). Operating theatre charges. Drugs and dressings prescribed for use while an inpatient or daypatient. Pathology, physiotherapy and diagnostic tests. Prostheses, when implanted as an integral part of a surgical procedure. There will be a significant shortfall if you choose to go to a hospital that is on a higher scale than you are covered for. You will be required to pay the treatment provider the difference between the amount we agree to pay and the actual expenses incurred. We strongly recommend that you obtain treatment in a hospital which falls within your scale of cover so you avoid additional costs. If you are in any doubt, or would like to discuss your options, call our Helpline on Emergency inpatient treatment overseas Your Preferential policy is designed to provide you with health cover here in the UK. Its range of health benefits are designed to work within the UK healthcare system and the costs of cover reflect claims for treatment within the UK system. Should you unexpectedly find yourself in a medical emergency whilst overseas, it will provide cover for emergency inpatient treatment, emergency evacuation and emergency repatriation up to a combined lifetime policy limit of 100,000 per person for eligible acute conditions. Please read the sections What we will pay for and What we will not pay for below for full details. This overseas assistance does not replace the need for travel insurance to ensure you are fully covered for medical emergencies. The costs of treatment overseas can significantly exceed the costs of treatment within the UK, we would therefore encourage you to make other provisions prior to travelling abroad, as you will be liable for any costs where you have exceeded the lifetime 100,000 policy limit. What we will pay for: Emergency overseas inpatient treatment for unexpected acute conditions when travelling overseas, where you require immediate hospitalisation out of medical necessity in order to treat an eligible acute condition and where treatment could not, in our opinion, have been reasonably anticipated or delayed. All admissions for inpatient treatment must be authorised in advance by our Overseas Assistance Helpline. Medical evacuation of the patient (but not accompanying parties) to an alternative hospital abroad if, in our opinion, the facilities at the original hospital are not able to provide suitable treatment of your acute condition. The evacuation must be approved and organised in advance by our Overseas Assistance Helpline. Repatriation of the patient (but not any accompanying party) to the UK if, in our opinion, the original travel arrangements are unsuitable, when authorised in advance by our Overseas Assistance Helpline. 14

15 We will not pay for: Costs associated with a medical condition that, in our opinion, does not require emergency inpatient treatment and immediate hospitalisation out of medical necessity, as set out above. Claims not normally covered by your Preferential policy as set out on page 8, for example, any treatment of a medical condition related to a personal exclusion as detailed on your Membership Certificate and repatriation/transfer from an oil rig or cruise ship. Any claim for repatriation to a country other than the UK. Any treatment or repatriation that is not authorised in advance by our Overseas Assistance Helpline, Treatment, evacuation, or repatriation where the total costs claimed for Overseas Assistance for the lifetime of your policy have reached 100,000. Any treatment which is not provided as an inpatient in the UK, including daypatient admissions, consultations with the overseas equivalent of a GP and outpatient treatment including drugs, medicines and dressings prescribed as an outpatient or on discharge from hospital following an inpatient stay. Treatment received abroad where the purpose of the overseas trip is wholly or in part to obtain such treatment. Treatment of any condition overseas where you are fit enough to travel to the UK for treatment. In these circumstances you must return to the UK. Making a claim whilst overseas In the event that you need to use your Preferential Private Health Cover for emergency inpatient treatment while travelling overseas, you must call the Overseas Assistance Helpline immediately for authorisation before any treatment or repatriation commences. This service is available 24 hours a day, 7 days a week. Overseas Assistance will confirm whether or not you have any cover for your emergency inpatient treatment, evacuation or for your repatriation to the UK. It also provides a range of practical services to help deliver emergency healthcare when you are travelling abroad. One call puts you in touch with an experienced multilingual medical co-ordinator. Payment of authorised claims for treatment received outside the UK is made in Sterling. Eligible claims for treatment submitted in other currencies will be converted to Sterling at the exchange rate prevailing as at the date of treatment. Emergency Telephone and Fax Number for Overseas Assistance From the UK T F From the USA T F From the rest of the world T F The costs of hotel accommodation or travel (for you or other people who are travelling with you) and other related costs. Treatment in or repatriation from a country where the Foreign & Commonwealth Office have advised against all travel or essential travel only at the time of your departure from the UK. Repatriation of your body should you die outside the UK. 15

16 Your obligations 1 You are required to follow the steps set out under Making a claim on page 12 and seek authorisation of your claim from Simplyhealth prior to arranging any private treatment. Failure to obtain authorisation may mean that your claim may not be paid. You will then be responsible for paying any expenses for treatment that you receive. 2 Authorisation is only valid for three months. If you fail to commence treatment within three months of authorisation you must call us for new authorisation before proceeding with treatment, otherwise you may be responsible for the cost of treatment. 3 You will be responsible for any charges made for an appointment that you fail to attend. This will include the costs that would have been incurred for diagnostic procedures where you fail to provide us, the hospital or specialist with at least 48 hours advance notice of cancellation if you are unable to attend an appointment. 6 You will be responsible for any treatment costs that would normally be payable under the policy in the event that premiums have not been received for the period when treatment was received. 7 You are required to pay any excess on your policy prior to receiving any treatment. Your excess will be collected when you call us to authorise your claim. 8 If you receive any invoices for treatment that you wish to claim for you should ensure that these are forwarded to us as soon as you receive them from the treatment provider. Failure to make a timely claim may result in your claim not being paid by us. 9 You are required to notify Simplyhealth if you have a personal injury claim against another party as a result of an accident, or if you have insurance with another insurance company or provident association that covers you for any of the same benefits under your policy. 4 You are required to use a hospital which is classified in our Hospital Directory within your scale or a lower scale of cover. Your scale of cover is detailed on your Membership Certificate. If you receive treatment in a higher scale hospital the maximum amount we will pay for eligible treatment is the Out of scale limit for your scale, as set out on page 14. You will be responsible for paying the difference between the amount we agree to pay and the treatment expenses incurred. 5 You are required to contact our Overseas Assistance Helpline to check that your emergency inpatient treatment is covered by your policy and the eligible treatment is within your policy limits before any treatment commences. You will be responsible for paying any additional amount above the lifetime 100,000 policy limit (refer to page 14 for further details). 16

17 Membership Joining Simplyhealth You apply for membership of the policy by completing an Application Form. You will also receive from Simplyhealth a copy of the Association of British Insurers guide to buying private medical insurance and our Underwriting Explained guide, which you should read carefully before making your choice of cover. The Application Form includes choices of: scale, payment method and frequency, excess selected, if any, underwriting options, and a few questions about your medical history. You don t need a medical examination of any kind. Membership is based on the information provided on the Application Form and is part of your contract. Please take care to provide us with a full and accurate disclosure to all questions asked. We will write and confirm your policy details and any personal conditions that apply on your Membership Certificate. This will also tell you the date on which your cover commences. We will also provide you with information about payments when they become due. The policy is designed to cover treatment within the UK for residents of the UK, Channel Islands or Isle of Man. If you are resident abroad we will consider covering you provided that you have notified us in writing before you take up residence abroad. If we agree to cover you abroad, we will write to you giving our consent. We will only pay up to the amount we would normally pay for treatment in the UK as detailed within our fee schedule which can be found at or by calling us on Your cover is renewable each year. We will write to you in advance of your renewal date with details of your premium and to explain the renewal process. In order that your cover remains appropriate for your needs, you should review it at each annual renewal and inform us of any changes to your requirements. Benefits may be adjusted from time to time. However any changes will only apply to your policy from your next annual renewal date. Changes to your membership If you need to make changes to your membership simply call our Helpline on You can make changes to your excess, scale of cover and payment frequency only at renewal. You can add or remove dependants from your cover at anytime. Including family members within your policy You may include a spouse or partner and unmarried dependent children under the age of 21, or 24 if they are in full-time education. Your family members must be resident in the UK, Channel Islands or Isle of Man. You may add new dependants to your membership at any time simply by completing an Application Form and returning it to us. Once we receive your application we will confirm individual terms of acceptance and inclusion within the policy. You will need to decide which underwriting option you wish to be applied to your dependants. The options are explained on the Application Form. When a child is born To include newborn children, all you have to do is complete and return an Application Form for the child to us. Provided your child is enrolled on an existing policy within three months of birth, they will be accepted without medical underwriting and no additional premiums will be payable until your next renewal date, following the date of birth. Once we receive your application we will confirm individual terms of acceptance and inclusion within the policy. New child payment is payable if the parent has been a member for more than one claiming year. Please call our Helpline on When children reach 21 Unmarried children, who are already on your policy, remain covered by family membership until the annual renewal date following their 21st birthday, or their 24th birthday if they are in full-time education. They may then apply for a Simplyhealth policy in their own right, on specially low rates for young people. For full details of the options available, please call our Sales Helpline on Underwriting options The underwriting option you have selected will be shown on your Membership Certificate. Don t forget to tell us about any change of address it s important that we have your up to date contact details. 17

18 Fraud The contract between you and us is based on mutual trust. To protect the vast majority of members who are honest, we have rigorous anti-fraud measures. These include: Investigating claims through the use of private investigators. Passing details of suspected fraudulent claims to the police or the Crown Prosecution Service for them to investigate and prosecute through the criminal courts. Working with the NHS Counter-Fraud team, Health Professionals Trade Associations, other insurance companies and other agencies with an interest in controlling fraud of this nature. Fraud is a criminal offence that can result in a large fine or even a prison sentence. When we find examples of fraud, we will always seek to prosecute offenders. If a member acts fraudulently, we will always seek to recover the costs of all fraudulent claims plus interest and our own legal costs. If we reasonably suspect that you have submitted a fraudulent claim, we are unlikely to pay any claims and we may suspend your membership. We may cancel all your insurance policies with us and with any other company within the Simplyhealth Group. To avoid doubt, the following list contains examples of practices we would class as fraudulent: Deliberately giving us false information about you, a person on your policy or a claim on your policy. Making any claim under your policy where you know the claim is false, or is exaggerated in any respect. Making a statement in support of a claim where you know the statement is false in any respect. Sending us a document in support of a claim where you know the document is forged, false or otherwise misleading in any respect. Making claims under more than one insurance policy in order to receive a sum greater than the cost of treatment (also known as betterment). 18 Cancellation rights Can I cancel my policy? You are free to cancel your policy for any reason up to 14 days from either the day you receive your new Policy Documents, including Membership Certificate, or the day on which payment of premiums is received for the new policy, whichever is the later. If you choose to cancel your policy within the 14 day period, you will be required to reimburse us in full for any claims we have paid for treatment received since the cover commencement date, which is stated on your Membership Certificate. This is payable within 30 days of the date you tell us you wish to cancel. We will refund any premiums received for your new policy within 30 days of receipt of your notification of cancellation. We will deduct from this the total of any relevant claims we have paid that have not already been repaid to us in full. If you do not inform us that you wish to cancel the policy within 14 days, the policy will start on the cover commencement date specified in the Membership Certificate, subject to the terms and conditions of the policy. How do I cancel my policy? If you wish to cancel your policy you must notify us in writing. You may us at: fax us on: , or write to us at: Membership Services, Simplyhealth James Tudor House, 90 Victoria Street, Bristol BS1 6DF Our right to cancel the policy We may cancel the policy or amend the terms for the following reasons: The premium (or any part of it) due is more than 30 days in arrears. You cancel the policy. We discontinue the Preferential product or any part of it, in which case we will offer alternative arrangements for cover. A resolution is passed or an order made for the winding up of Simplyhealth. You knowingly claimed benefits which are not covered. You misled us by misstatement or concealment. You attempted to obtain an unreasonable financial advantage to our detriment. You failed to act in good faith.

19 If you have an accident In many accidents, someone or something is at fault and the accident victims have a right to claim compensation. Simplyhealth has a legal right to recover any medical expenses if you make a claim for treatment resulting from an accident or illness which was someone else s fault. When claiming for treatment you must notify us that you have a personal injury claim against another party as a result of an accident. We will ask for your solicitor s details. You, or your solicitor, then need to keep us informed of the claim s progress. You need to: If you have other insurance policies If you are making a claim and you have insurance with another insurance company or provident association that covers you for any of the same benefits under your policy, you must tell us and provide us with this other company s details. This additional cover might be in the form of travel insurance, home insurance or other types of insurance cover. We may well need to contact these other companies, since we will not be liable to pay more than our proportionate share when split between the various insurance companies. Pursue your personal injury claim at your own personal expense. Tell your solicitor immediately that you are insured by Simplyhealth for medical expenses. Include all the medical expenses which you have claimed, or will claim from us, under your policy cover in your personal injury claim. Ask your solicitor to help us, in particular, ensure we can contact your solicitor and obtain copies of any pleadings, expert reports, witness statements, court documents or other legal documents concerning your personal injury. We will pay reasonable photocopying charges for any documents we ask to see. Ask your solicitor not to agree any final settlement of your claim or waive our right to recover expenses paid out for medical treatment without consulting us first. Ask your solicitor to repay your medical expenses direct to us from any settlement of your claim. 19

20 How we use information about you As the Data Controller, we will store and process your personal data in accordance with the Data Protection Act 1998 (DPA). We will use your information to provide our services, for assessment and analysis, for underwriting and claims handling, to improve our services, and to protect our interests. We and other Simplyhealth Group companies may use your information to keep you informed by post, telephone, or other means about products and services, which may be of interest to you. If you do not wish your information to be used for these purposes please write to: The Data Protection Co-ordinator, Simplyhealth, James Tudor House, 90 Victoria Street, Bristol BS1 6DF. We will keep information about you confidential. However we may give information about you and how you use our products to the following: Fraud prevention agencies and other organisations who may record, use and give out information to other insurers. People who provide a service to us, or act as agents on the understanding that they will keep the information confidential. Anyone to whom we may transfer our rights and duties under this agreement. Sensitive data In order to assess the terms of the insurance contract, including any specific medical exclusions or administer claims, we may collect data, including medical information, which the DPA defines as sensitive. Medical information will be kept confidential and only disclosed to those involved in providing the patient s treatment or care, including their GP or dentist, or their agents. Only in exceptional circumstances will we disclose medical information to other third parties or family members, without the patient s explicit consent. If you have appointed an intermediary, we may disclose to them the personal information that they need to deal with your cover. Details of medical information will not be disclosed to the intermediary unless we have the specific consent of the patient. Accuracy of personal information To help us ensure that your personal information remains accurate and up to date please inform us of any changes. You have the right to see personal information, which is held by us. There may be a charge if you want to do this. For more details please write to: The Data Protection Co-ordinator, Simplyhealth, James Tudor House, 90 Victoria Street, Bristol BS1 6DF. Your calls may be recorded and monitored for training and quality assurance purposes We may also give out information about you if we have a duty to do so (such as regulatory bodies), or if the law allows us to do so, or if the person requesting the information has in our opinion, a legitimate interest in the disclosure. 20

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