Terms and conditions for. personal healthcare

Transcription

1 Terms and conditions for personal healthcare

2 Contents Introduction 3 Your benefits explained 4 Personal healthcare cover options explained 9 What s not covered 16 Dental Cover 20 Claims conditions 24 Membership 25 Paying premiums and renewing the plan 26 Cancelling the plan 27 General conditions 27 No-claims discount scale 28 How the excess works 29 Definitions 30 Complaints procedure 35 Your rights under the Financial Services Compensation Scheme 36 Data protection notice 36 2 PruHealth

3 Hello. This document contains the terms and conditions that apply for the personal healthcare plan from PruHealth. It does not include the benefits and exclusions for the Travel Cover option available with the plan. Please refer to the document Benefits and exclusions for personal healthcare Travel Cover from PruHealth for this information. When you take out a personal healthcare plan with us we will send you a membership pack, which will include the specific terms and conditions that will apply for your plan. We have tried to make sure that the plan is as clear and straightforward as possible by writing this document in plain English. Certain words used within these terms and conditions have special meaning that we d like to draw to your attention: We/us/our means PruHealth You/your means the planholder and insured dependants. Where the words you or your refer specifically to the planholder, we ll say you (the planholder) We have printed the remaining defined words in bold to help you identify them as you read through this document. You ll find a full explanation of each word in the Definitions section. If you have any queries about the plan, please contact us or speak to your adviser who will be happy to help you. PruHealth 3

4 Your benefits explained Important notes In this section we have set out the rules on paying benefits and the specific exclusions that apply to each benefit. Other exclusions applying to this section of the plan are contained within the What s not covered section on page 16. All benefits are per insured person, unless stated otherwise. The plan does not cover you for out-patient treatment except for the scans and cancer treatment shown in the benefit table. In order to be covered for out-patient treatment, you will need to add the Out-patient Treatment cover option to your plan. Alternatively, you could pay for any other outpatient tests or treatment yourself, if undertaken privately, or have these under the NHS. All treatment must take place in a hospital on your chosen hospital list. In the rare circumstances where eligible treatment is unavailable in a hospital on your chosen hospital list, we will make arrangements for it to take place at another convenient and appropriate hospital. All treatment must be under the care of a specialist following referral by your GP or dental practitioner. Also, all treatment must be: for a specific medical condition given by a specialist, physiotherapist, qualified nurse or other practitioner recognised by us, and given just to cure an acute condition or the acute flare-up of a chronic condition. We do not pay for treatment that takes place after your cover has ended, even if this is a continuation of treatment that started while you were still covered by this plan. We will pay benefit after taking off any excess that may apply under the plan. Guided Option If you choose the Guided Option hospital list the claims process is different and the following will apply: Before having any consultations, tests or treatment for which you intend to claim under the plan, you must first see your GP or dental practitioner to receive an open referral letter* from them. As soon as you have your open referral letter, you will need to contact us straightaway. Once we ve approved your claim, we will then contact the nearest appropriate hospital on the Guided Option hospital list for you. The hospital will then arrange for you to see an appropriate specialist. You must not contact the hospital yourself as they will be unable to make any arrangements without our prior approval. You must not send your open referral letter direct to a hospital or arrange your own appointment. Treatment, investigations and consultations are only covered if they are arranged by us contacting the hospital that you need to attend. If you do not follow the open referral procedure but have treatment in a hospital on the Guided Option hospital list, then we will only pay a contribution towards the cost of your treatment as detailed within the section Treatment at a hospital not included on your list. * An open referral letter is a letter provided by your GP or dental practitioner referring you on for specialist care but without specifying who that specialist is. This letter will be used by the hospital on your Guided Option list that we direct you to, for the purposes of choosing an appropriate specialist to look after you. Your membership pack will include some open referral forms that your GP can use if they want. We would suggest you take one of these with you when you see your GP. 4 PruHealth

5 NHS wait option This section only applies if you choose the NHS wait option. What we mean by the NHS wait option This simply means that if treatment is available on the NHS within six weeks of the day your specialist tells you that you need in-patient or day-patient treatment, you agree to have your treatment as an NHS patient and cannot claim under your plan with us. However, if in-patient or day-patient treatment is not available on the NHS within six weeks, then you can immediately choose to be treated in a private hospital on your chosen list and can claim under your plan with us, subject to our normal benefits, terms and conditions. How we check if treatment is available on the NHS within six weeks The NHS has details of waiting times for both specialists and hospitals. If you know which specialist is treating you, then we ll check with the hospital to see if your specialist is able to treat you on the NHS within six weeks of telling you that you needed in-patient or day-patient treatment. If you don t know which specialist is going to treat you, then we ll check the hospital waiting times to see if you can be admitted to a public ward of an NHS hospital in your Regional Health Authority within six weeks of being told you needed in-patient or day-patient treatment. The NHS wait option is not available if you choose the Guided Option hospital list. Core Healthcare Hospital charges Charges for in-patient treatment at a hospital on your chosen hospital list accommodation, nursing, drugs prescribed in a ward, intensive care operating theatre charges, surgical dressings and drugs surgical appliances needed as a vital part of an operation diagnostic tests, including pathology, radiology, CT, MRI and PET scans physiotherapy Charges for day-patient treatment at a hospital on your chosen hospital list accommodation, nursing, drugs prescribed in a ward, intensive care operating theatre charges, surgical dressings and drugs surgical appliances needed as a vital part of an operation diagnostic tests, including pathology, radiology, CT, MRI and PET scans full cover full cover for medical aids or appliances (e.g. neck collars, splints and foot supports) for mobility aids (e.g. deposit on use of a wheelchair and crutches) for any prosthesis when the prosthesis is not an integral part of the treatment for personal expenses PruHealth 5

6 Core Healthcare Consultants / specialists fees Specialist fees for in-patient and day-patient treatment that takes place at a hospital on your chosen hospital list surgeons and anaesthetists fees for operations and surgical procedures given as in-patient or day-patient treatment physicians fees and other specialist consultations full cover Core Healthcare Out-patient scans CT, MRI and PET scans undertaken as an out-patient at a hospital on your chosen hospital list. full cover Core Healthcare Private ambulance The use of a private ambulance to and from hospital if a specialist recommended it as medically necessary. full cover 6 PruHealth

7 Core Healthcare NHS cash benefits NHS hospital cash benefits for in-patient treatment received for a medical condition covered by the plan, as a non-paying NHS patient day-patient treatment received for a medical condition covered by the plan, as a non-paying NHS patient 250 a night, up to a total of 2,000 per 125 per day, up to a total of 500 per if treatment is not eligible under this plan Core Healthcare Treatment at a hospital not included on your list If you have in-patient treatment in a hospital that s not on your chosen hospital list then we ll only pay a contribution towards all of the costs of your in-patient treatment, including your specialists fees. If you have day-patient treatment or out-patient scans in a hospital that s not on your chosen hospital list then we ll only pay a contribution towards all of the costs of your day-patient treatment or out-patient scans, including your specialists fees. Important notice: the amounts we pay in the above circumstances may be much lower than the total cost of your treatment, so we strongly recommend that you always go to a hospital that s on your chosen hospital list. 300 per night 150 per PruHealth 7

8 Core Healthcare Cancer treatment The cover described within Core Healthcare also applies to the treatment of cancer. This section provides details of the other treatments covered that are specifically relevant to cancer. Specific treatment Reconstructive surgery Radiotherapy including internal and external radiotherapy full cover full cover Chemotherapy (the use of drugs to destroy cancer cells) cytotoxic drugs, antiemetics (anti-sickness drugs) and steroids as appropriate hormone therapy or bisphosphonates therapy combined with chemotherapy oral chemotherapy prescribed by an oncologist Biological therapy (the use of substances that occur naturally in the body to destroy cancer cells or prevent them from developing or spreading), including monoclonal antibodies (MABs) cancer growth blockers anti angiogenics Stem cell therapy Hormone therapy or bisphosphonates therapy (if prescribed on their own) Treatment at home Those treatments outlined under Specific treatment that can be safely delivered in your home setting or another clinically appropriate setting that otherwise would require hospital admission as an in-patient or day-patient. Specialists fees for supervising the treatment Out-patient treatment Treatment, including those outlined under Specific treatment, diagnostic tests and monitoring or follow-up consultations that are considered medically necessary. *Important note: Once the maximum limit has been reached, no further cover will be available for this type of treatment under this plan for the same or any related condition. full cover full cover up to 12 months* full cover full cover up to 3 months* full cover subject to the relevant limits shown under Specific treatment full cover full cover subject to the relevant limits shown under Specific treatment for reconstructive surgery that takes place after three years have elapsed from the last date of any in-patient or day-patient treatment for personal expenses for any diagnostic tests or treatment not considered clinically appropriate within the UK for any drugs that would normally be prescribed by your GP for personal expenses for any monitoring or follow-up consultations that take place after five years have passed since your last cancer treatment 8 PruHealth

9 Personal healthcare cover options explained Out-patient Treatment Level 1 Specialist fees for out-patient treatment at a hospital on your chosen hospital list specialist consultations and diagnostic tests, including pathology and radiology physiotherapy but if you have out-patient treatment in a hospital that s not on your hospital list then we ll only pay up to 500 per up to 150 per please note this amount would then be deducted from your monetary limit for routine medical or dental checks for routine sight and hearing tests for medical aids or appliances (e.g. neck collars, splints and foot supports) for mobility aids (e.g. deposit on use of a wheelchair and crutches) for spectacles, contact lenses, hearing aids, cochlear implants or dentures for drugs or dressings that you take home Other levels of cover are available under the Out-patient Treatment option and these are shown below: Level 2 Level 3 Out-patient Treatment We will pay up to 1,000 per but if you have out-patient treatment in a hospital that s not on your hospital list then we ll only pay up to 150 per please note this amount would then be deducted from your monetary limit full cover but if you have out-patient treatment in a hospital that s not on your hospital list then we ll only pay up to 150 per PruHealth 9

10 Psychiatric Treatment In-patient and day-patient treatment in any psychiatric hospital on your chosen hospital list accommodation, nursing, drugs prescribed on a ward, diagnostic tests, physicians fees and specialist consultations full cover, for up to 28 days per note: each session of day-patient treatment whether or not it is a half-day session will count as one full day towards the 28 day limit for any treatment not under the control of a psychiatric specialist Out-patient treatment in any psychiatric hospital on your chosen hospital list specialist consultations, ECT and diagnostic tests up to 1,500 per Additional Therapies The following therapies or consultations after referral by your GP or specialist chiropractic osteopathy chiropody / podiatry acupuncture homeopathy consultations with a dietician (maximum of two per ) up to 350 per for drugs or dressings that you take home for medical aids or appliances (e.g. neck collars, splints and foot supports) for mobility aids (e.g. deposit on use of a wheelchair and crutches) for treatment following self-referral where you ve not visited your GP, unless this has been agreed by us in writing in advance of the treatment Level 2 Additional Therapies We will pay full cover 10 PruHealth

11 Private GP Private GP services including consultations, prescriptions, minor surgery and fees for the completion of claim forms at any private GP surgery. up to 300 per Maternity Cover Private ante-natal and post-natal care, including specialist consultations, diagnostic tests and investigations, and delivery for a normal pregnancy in any hospital on your chosen hospital list. up to 3,000 per pregnancy for any charges incurred before the mother-to-be has been covered under this plan for at least two continuous years for any treatment as a result of pregnancy complications Core Enhancement Parent accommodation Accommodation for you or your insured husband, wife or partner to stay with your insured child under age 14 while they are receiving in-patient treatment in a hospital on your chosen hospital list. full cover for personal expenses PruHealth 11

12 Core Enhancement Pregnancy complications Charges for in-patient and day-patient full cover for ante-natal care treatment at a hospital on your chosen for any complication hospital list for the following conditions and of pregnancy or directly associated complications directly related ectopic pregnancy miscarriage condition that the mother is aware of at her cover start date missed abortion for any complication still birth of pregnancy and post partum haemorrhage retained placental membrane childbirth not listed under the What s covered section hydatidiform mole We will cover caesarean sections that are medically necessary but only in the following circumstances where the baby is breech at the end of the pregnancy (at 36 weeks) and where it has not been possible to move the baby round to head first if having twins and the first is in a breech position in an emergency (where there is an immediate threat to the life of the mother or baby) but we will not cover hospital charges and specialist fees where you choose to have your baby in a private facility except where these are directly related to the above complications for any complications following infertility treatment, IVF or other assisted reproduction for investigations and treatment of recurrent miscarriages Core Enhancement Investigations into infertility The costs of investigations into the cause of infertility. The investigations must take place in a hospital on your chosen hospital list. full cover for any form of infertility treatment, IVF or other assisted reproduction for any investigations unless you or your insured dependant have been on the plan for two years 12 PruHealth

13 Core Enhancement Oral surgery Charges for in-patient and day-patient treatment at a hospital on your chosen hospital list for the following oro-surgical procedures only removal of buried, impacted or unerupted teeth removal of roots from antrum removal of complicated buried roots covered by bone full cover for any other dental treatment or oro-surgical procedure Core Enhancement Home nursing The services of a qualified nurse for skilled nursing care at home. For you to qualify for this benefit, all home nursing must immediately follow a period of in-patient treatment for a medical condition covered by the plan be certified by your specialist as necessary for medical (not domestic) reasons be skilled nursing care provided at your home, which would otherwise be provided in hospital as an in-patient be given by a qualified nurse and carried out under the direction of your specialist full cover for up to 13 weeks per for home nursing following in-patient treatment for psychiatric and mental conditions for any charges for domestic or social reasons PruHealth 13

14 Core Enhancement Help at home The services of a qualified nurse for secondary nursing care, or up to 3 hours per day for a maximum of 7 days per a care assistant to provide personal care services (or both) For you to qualify for this benefit, all secondary nursing care and personal care services must immediately follow a period of in-patient treatment for a medical condition covered by the plan and be certified by your specialist or GP as being medically necessary because of your domestic and medical circumstances be for those domestic duties which would normally be carried out by you or your insured dependant claiming this benefit, and not provided by your husband, wife or partner or a housekeeper regularly employed to do those duties be authorised in advance by our claims department. If you don t get our written approval before taking on costs for secondary nursing care and personal care services, we ll only pay 50% of any of those costs that you are covered for for services provided by anyone other than a qualified nurse or care assistant under the direction of your specialist or GP 14 PruHealth

15 Home Care Home nursing The services of a qualified nurse for skilled nursing care at home. For you to qualify for this benefit, all home nursing must immediately follow a period of in-patient treatment for a medical condition covered by the plan be certified by your specialist as necessary for medical (not domestic) reasons be skilled nursing care provided at your home, which would otherwise be provided in hospital as an in-patient be given by a qualified nurse and carried out under the direction of your specialist full cover for up to 13 weeks per for home nursing following in-patient treatment for psychiatric and mental conditions for any charges for domestic or social reasons Home Care Help at home The services of a qualified nurse for secondary nursing care, or up to 3 hours per day for a maximum of 7 days per a care assistant to provide personal care services (or both) For you to qualify for this benefit, all secondary nursing care and personal care services must immediately follow a period of in-patient treatment for a medical condition covered by the plan and be certified by your specialist or GP as being medically necessary because of your domestic and medical circumstances be for those domestic duties which would normally be carried out by you or your insured dependant claiming this benefit, and not provided by your husband, wife or partner or a housekeeper regularly employed to do those duties be authorised in advance by our claims department. If you don t get our written approval before taking on costs for secondary nursing care and personal care services, we ll only pay 50% of any of those costs that you are covered for for services provided by anyone other than a qualified nurse or care assistant under the direction of your specialist or GP PruHealth 15

16 What s not covered Below we ve set out the exclusions that apply to this section of the plan. For ease of reference, we have divided the exclusions into the following categories Medical conditions Treatments General exclusions Medical conditions We will not pay for the following If you or your insured dependants are covered on a moratorium underwriting basis: We will not pay for treatment of any medical condition or related condition which you have received medical treatment for had symptoms of asked advice on, or to the best of your knowledge were aware existed in the five years before the cover start date. This is called a pre-existing medical condition. After two years of continuous insurance cover from the cover start date, pre-existing medical conditions will become eligible for benefit subject to the plan terms and conditions. However, this only applies if, when you first receive treatment, you have not consulted anyone (e.g. a GP, dental practitioner, optician or therapist, or anyone acting in such a capacity) for medical treatment or advice (including check-ups), or taken medication (including drugs, medicines, special diets or injections), for that medical condition or any related condition for a continuous period of two years. If you or your insured dependants are medically underwritten on a full medical underwriting basis: we will not pay for treatment of any medical condition we specifically exclude you or your insured dependants for. Any exclusions will be shown on your certificate of insurance. Also, treatment for any medical condition you did not disclose on your application form. If you or your insured dependants transfer from another insurance plan with continued personal exclusions on a switch basis: we will not pay for treatment of any condition specifically excluded by your previous insurance plan. If you or your insured dependants transfer from another insurer with a continued moratorium: we will not pay for the treatment of any pre-existing medical condition or related condition unless two years have elapsed since the insured person s cover start date during which the insured person has not had any treatment for that pre-existing medical condition or related condition, or any medication, medical advice or symptoms for that pre-existing medical condition or related condition 16 PruHealth

17 Additional exclusions that apply under this medical conditions section are treatment of alcoholism, drug abuse or any addiction and treatment of any related medical conditions resulting from these treatment of any self-inflicted illness or injury, or any treatment related to them, or treatment arising from attempted suicide treatment of any illness or injury which is medically considered to be linked directly or indirectly with Human Immunodeficiency Virus (HIV) and/or Acquired Immune Deficiency Syndrome (AIDS) and/or any form or variation of HIV or AIDS, however caused treatment of chronic conditions except treatment of an acute flare-up of a chronic condition treatment to maintain your state of health or to monitor your health on a regular basis treatment, including investigations and assessments, related to developmental problems and learning difficulties including but not limited to dyslexia, dyspraxia and behavioural problems such as attention deficit hyperactivity disorder (ADHD) treatment for myopia (short sightedness), hypermetropia (long sightedness), astigmatism or any other refractive error or treatment which results from, or is in any way related to, these conditions treatment of sleep apnoea, snoring, insomnia or other sleep disorders treatment for obesity, including surgery treatment of any psychiatric, mental or nervous conditions (would not apply if the Psychiatric Treatment option is selected) Treatments We will not pay for the following the services of a GP or dental practitioner or any person acting as one treatment, including surgery, to remove healthy or non-diseased tissue whether or not for psychological or medical reasons, including but not limited to breast reduction and blepharoplasty (eyelid lift) cosmetic treatment, whether or not for psychological reasons, or any treatment that results from or relates to previous cosmetic treatment or reconstructive surgery. However, we will cover cosmetic treatment necessary as a direct result of an accidental injury that occurs after your cover start date sex change/gender reassignment or treatment which results from, or is in any way related to, sex change/gender reassignment hormone replacement therapy dental treatment regular or long-term dialysis in chronic or final kidney failure treatment or drug therapy which, based on established medical practice in the UK, is considered to be experimental or unproven any treatment using unlicensed drugs or the use of drugs outside the terms of their licence in the UK rehabilitation following treatment out-patient drugs, medicines and dressings, surgical appliances (such as neck supports, shoe inserts and braces), dental appliances, hearing aids (such as cochlear implants), contact lenses, spectacles, and mobility aids such as wheelchairs and crutches treatment that s given solely to provide relief of symptoms including psychological support, terminal care or hospice care oral surgery (except those procedures shown in the benefit table if Core Enhancement is selected) out-patient treatment except for the scans and cancer treatments shown in the benefit table (would not apply if the Out-patient Treatment option is selected) any kind of alternative or complementary therapy (would not apply if the Additional Therapies option is selected PruHealth 17

18 any treatment provided by a specialist, therapist or complementary medicine practitioner who is not recognised by us as having specialised knowledge of, or expertise in, the treatment of the disease, illness or injury or who is not a member of their recognised professional body or Health Professions Council (HPC) If the Core Enhancement AND Maternity Cover options are not selected: any treatment for, related to or arising from or as a consequence of male or female birth control including sterilisation and its reversal any type of contraception pregnancy or childbirth investigations into or treatment of infertility investigations into or treatment of impotence or other sexual dysfunction any form of human-assisted reproduction any treatment received within 91 days of birth by a dependant born as a consequence of any form of human-assisted reproduction If the Core Enhancement option is not selected but the Maternity Cover option is selected: any treatment for, related to or arising from or as a consequence of male or female birth control including sterilisation and its reversal any type of contraception pregnancy complications termination of pregnancy investigations into or treatment of infertility investigations into or treatment of impotence or other sexual dysfunction any form of human-assisted reproduction any treatment received within 91 days of birth by a dependant born as a consequence of any form of human-assisted reproduction If the Core Enhancement option is selected but the Maternity Cover option is not selected: any treatment for, related to or arising from or as a consequence of male or female birth control including sterilisation and its reversal any type of contraception termination of pregnancy pregnancy, except the obstetric conditions listed in your benefit table childbirth, except the obstetric conditions listed in your benefit table treatment of infertility, but we will cover the cost of investigations into the cause of infertility providing you and, if applicable, your insured dependant have been covered under this plan for at least two continuous years before any investigations begin investigations into or treatment of impotence or other sexual dysfunction any form of human-assisted reproduction any treatment received within 91 days of birth by a dependant born as a consequence of any form of human-assisted reproduction 18 PruHealth

19 If both the Core Enhancement and Maternity Cover options are selected: any treatment for, related to or arising from or as a consequence of male or female birth control including sterilisation and its reversal any type of contraception termination of pregnancy treatment of infertility, but we will cover the cost of investigations into the cause of infertility providing you and, if applicable, your insured dependant have been covered under this plan for at least two continuous years before any investigations begin investigations into or treatment of impotence or other sexual dysfunction any form of human-assisted reproduction any treatment received within 91 days of birth by a dependant born as a consequence of any form of human-assisted reproduction If Health Screening option is not selected: anything to do with routine, precautionary or preventive examinations, dental check-ups, routine hearing and sight tests, vaccinations, screenings (including screenings of familial conditions) or preventive treatment If Health Screening option is selected: anything to do with routine, precautionary or preventive examinations, dental check-ups, routine hearing and sight tests, vaccinations, screenings of familial conditions or preventive treatment General exclusions In addition to the specific exclusions detailed, the following general exclusions apply treatment arising from nuclear or chemical contamination, war, invasion, act of foreign enemy, hostilities (whether war is declared or not), civil war, riot, civil disturbance, rebellion, revolution, military force or coup, act of terrorism treatment received after the period covered by any premium or after the plan has been cancelled treatment in a hospital that s not on your chosen hospital list, unless we ve made alternative arrangements for you extra accommodation costs for going into hospital early or leaving late because of your or your insured dependant s domestic circumstances or where there is no required treatment treatment received outside the UK (except as described under the Travel Cover option, if selected) PruHealth 19

20 Dental Cover In this section we ve set out the rules on paying benefits under the dental cover and the specific exclusions that apply to each benefit. Other exclusions applying to the dental cover are contained within the What s not covered section on page 22. All benefits are per insured person unless stated otherwise. Important notes To be eligible for this benefit, you must have undergone a check-up with your regular dental practitioner and have completed all dental treatment recommended in the 12 months before your cover start date. If you have not seen your dental practitioner in the 12 months before your cover start date, then eligibility for this benefit will only begin after you have undergone a check-up by a dental practitioner and completed all dental treatment recommended. This requirement does not apply for routine examinations and routine scaling and polishing. Maintenance Level 1 Level 2 Level 3 The charges made for for dental treatment routine examinations not covered up to 15 per claim up to 30 per claim which is classed with a maximum with a maximum as accidental or of 2 claims per of 2 claims per for emergency dental treatment routine scaling and polishing provided by a registered dental practitioner or hygienist radiograph of teeth or jaws which must be medically necessary not covered not covered up to 25 per claim with a maximum of 2 claims per up to 15 per claim with a maximum of 2 claims per up to 40 per claim with a maximum of 2 claims per up to 40 per claim with a maximum of 2 claims per Emergency dental Level 1 Level 2 Level 3 The charges made for immediate relief of severe not covered pain, haemorrhage and/or infection You must have been treated in an emergency dental appointment with a dental practitioner. up to 200 per claim with a maximum of 2 claims per up to 300 per claim with a maximum of 2 claims per any subsequent dental treatment following the initial emergency appointment, except where this is included under another part of your dental cover 20 PruHealth

21 Treatment Level 1 Level 2 Level 3 The charges made for for routine, fillings not covered up to 20 per claim up to 40 per claim precautionary with a maximum with a maximum or preventive of 2 claims per of 2 claims per examinations (if Level 1 is selected) new and replacement crowns up to 300 per up to 300 per up to 400 per for dental check-ups (if Level 1 is selected) new and replacement inlays, onlays and overlays not covered up to 50 per up to 100 per new and replacement bridges or implants up to 200 per up to 200 per up to 300 per root canal treatment up to 150 per up to 150 per up to 250 per apicectomy / excision of the root of a tooth up to 100 per up to 100 per up to 150 per extractions up to 150 per up to 150 per up to 250 per new, partial or repairs to dentures up to 250 per up to 250 per up to 350 per If the dental treatment required is as a result of an accident or injury this is covered under the Accidental dental section. Accidental dental Level 1 Level 2 Level 3 The charges made by a dental practitioner or specialist for a dental accident damage to dentures whilst being worn prescription charges The dental accident sustained must be immediately followed by an emergency dental appointment or the insured person must seek treatment via an A & E department. up to 2,500 per claim with a maximum of 4 claims per up to 2,500 per claim with a maximum of 4 claims per up to 2,500 per claim with a maximum of 4 claims per For dental treatment required for any injury caused while engaging in professional sports any injury, caused other than as a direct result of an accident repair or replacement of crowns, bridges or dentures unless damaged as a direct result of a dental accident Additional exclusions apply to Accidental dental please see the section What s not covered. PruHealth 21

22 Emergency call-out fees Level 1 Level 2 Level 3 The charges made for the cost of an emergency call-out Dental treatment must be deemed necessary for the dental practitioner to re-open the practice between the hours of 2100 and 0800 on weekdays, weekends and bank holidays when the practice would otherwise be closed. up to 50 per call-out with a maximum of 2 claims per What s not covered up to 50 per call-out with a maximum of 2 claims per up to 50 per call-out with a maximum of 2 claims per These are the exclusions that apply to this section of the plan. We will not pay claims arising from any dental treatment that s planned or already taking place at your cover start date or which has been recommended in the 12 months immediately before your cover start date. This does not include routine examinations or routine scaling and polishing cosmetic dental treatment such as bleaching, teeth whitening, orthodontic or periodontal treatment and procedures related to such treatment mouth guards, gum shields or dental appliances of any kind any injury caused while engaging in contact sports unless the appropriate mouth guard was worn wisdom teeth extraction other than those extracted by your dental surgery loss of, or damage to, dentures other than whilst being worn any treatment or care in relation to tooth jewellery any treatment charges related to non-invasive tumours any treatment charges related to oral cancer any prescription charges unless related to an accident and emergency any treatment under the care of a specialist unless the treatment is the result of a dental accident Accidental dental These are the additional exclusions that apply to Accidental dental. We will not pay claims arising from any damage to dentures when not being worn any injury caused by eating and drinking normal wear and tear any treatment relating to injury which is received more than 12 months after the incident giving rise to a claim 22 PruHealth

23 General exclusions In addition to the specific exclusions applying to the Dental Cover option, the following general exclusions apply treatment of alcoholism, drug abuse or any addiction including the treatment of any related condition resulting from these treatment of any self-inflicted illness or injury, or any treatment related to them, or treatment arising from attempted suicide treatment of any illness or injury which is medically considered to be linked directly or indirectly with Human Immunodeficiency Virus (HIV) and/or Acquired Immune Deficiency Syndrome (AIDS) and/or any form or variation of HIV or AIDS, however caused treatment arising from nuclear or chemical contamination, war, invasion, act of foreign enemy, hostilities (whether war is declared or not), civil war, riot, civil disturbance, rebellion, revolution, military force or coup, act of terrorism treatment received after the period covered by any premium or after the plan has been cancelled treatment received outside the UK (except as described under the Travel Cover option, if selected) PruHealth 23

24 Claims conditions The cover The overall intention of the plan is to provide you with cover for access to prompt private medical care for acute conditions and to meet the eligible costs of treatment provided by a specialist for these acute conditions. Acute conditions often have a rapid onset and respond quickly to treatment. There should not be a need for prolonged care once recovery is complete. You will see from the section headed What s not covered that we do not pay for treatment of chronic conditions. Therefore, once it is clear that a medical condition is of a chronic nature, we will stop paying treatment costs. For example, we will not pay for routine follow-up consultations or for the monitoring of medical conditions such as diabetes, multiple sclerosis and other long-term conditions. However, if you suffer an acute flare-up of a chronic condition, we will pay the eligible costs of the treatment required to bring the symptoms back under control. Your responsibilities These are conditions of the insurance you ll need to follow in order to make a claim. You and your insured dependants must obtain authorisation from us for any claim before starting treatment. We will confirm whether or not the claim is eligible for benefit in writing. If requested, you must send us a fully completed claim form, ideally before treatment starts, but at the very least as soon as possible after treatment. We will not pay fees charged by a medical practitioner for completing a claim form. If treatment continues for a long time, we may need further medical evidence. We may need your consent to obtain a medical report or a copy of your NHS medical records from your GP, specialist or another practitioner involved in your treatment, in accordance with your rights under the Access to Medical Reports Act If you do not give your consent, we may not be able to assess and pay your claim. If we need a medical report to support a claim, we will pay for that report. Unless specifically confirmed by us, you and your insured dependants may only use the hospitals shown on the hospital list that you have chosen. We reserve the right to amend the list at any time, at our discretion. We may need to do this if, for example, we are unable to reach agreement with an individual hospital, or group of hospitals, on its proposed charges. We will notify you of any such changes, which will then take immediate effect. If you re covered by another plan If you have any other current plan that may also cover the same costs, you must provide us with full details of the other plan, including insurer name and address, plan and claim number and any other relevant information. We will then contact the other insurance company to ensure that we only pay our proportion of the claim. If somebody else has caused you to claim If you or an insured dependant make a claim due to the fault or negligence of a third party, you must tell us as soon as possible and supply us with all the relevant details of that third party. If you are then pursuing a personal claim against the negligent third party, you must provide us with the full name and address of the solicitor handling the action. We will then contact the solicitor to register our interest and seek to recover our own outlay, plus interest, in addition to any damages that may be recovered. We also have the right, if we choose, in your name but at our expense to 24 PruHealth take over the defence or settlement of any claim start legal action to claim compensation from a negligent third party start legal action to recover from any third party payments that have already been made If you or an insured dependant are able to recover the cost of any treatment for which we have paid, whether or not through a legal action, you must repay that amount, together with any interest, to us.

25 General claims conditions Any money paid to or by us will be in pounds sterling. We will not add interest to any money paid under the plan. We prefer to pay money direct to the hospital or person who provided your treatment. If you have already paid for your treatment, then you will need to provide us with a receipted invoice and we will then reimburse you for any eligible costs. If you have died, we will reimburse the executors of your estate. If an excess applies under your plan, we will deduct this amount from any payments that we make. Membership Who can be covered under the plan? The following people can be included under the plan: you (the planholder). You must be over the age of 18 at the plan start date your husband, wife or partner, who live at the same address as you your children (including adopted children) providing they are under the age of 25, regardless of their marital status and whether they are in full-time education You and your husband, wife or partner (if joining as an insured dependant on your plan) must also be under age 80 at the cover start date. An insured person must live in the UK for at least 180 days in each and must be registered with a UK GP/dental practitioner who holds their full medical records. If any person applying to join the plan already has cover with another insurer, we recommend they do not cancel that cover until we have confirmed in writing that we have accepted their application. Adding more dependants to the plan Your (the planholder s) husband, wife or partner and dependent children may apply to join at any time during a by completing the relevant form. If we accept them, we will write to confirm the cover start date and any special terms that may apply. Adding newborn babies If you add a child to the plan as an insured dependant within 30 days of their birth, by completing the relevant form, we will cover them up to the next annual renewal date after their date of birth for no extra premium. In addition, as long as the parent has been an insured person for at least 10 months before the birth, and the child is added within the first 30 days of their birth, then we will not apply the exclusion for pre-existing medical conditions or require them to be medically underwritten. When insured children reach 25 Cover for your insured children will stop on the first annual renewal date on or after their 25 th birthday. At the appropriate annual renewal date, they will be allowed 30 days to apply to continue their cover with us on an individual basis. If they join within that period, then they can continue with the same medical underwriting terms that applied under this plan. Cover must be continuous and any existing special terms will continue to apply. PruHealth 25

26 If you die If you (the planholder) should die, your plan will be cancelled from midnight on the date of death. If you have paid any premiums that relate to the period after the cancellation date, then these will be refunded to the executors of your estate. We will allow your husband, wife or partner to continue their cover with us under their own individual plan. We will advise them of the new premium and they must then inform us within 30 days whether they wish to take out a new plan. If they join within that period, then they can continue with the same medical underwriting terms that applied under this plan. Cover must be continuous and any existing special terms will continue to apply. If you become divorced or legally separated If you (the planholder) have married or family cover and you become legally separated or divorced, then your husband, wife or partner will no longer be eligible to be included as an insured dependant on this plan. You must inform us in writing that you have become separated or divorced. Your husband, wife or partner may apply, within 30 days of the date of divorce or legal separation, to continue their cover with us under their own individual plan. If they join within that period, then they can continue with the same medical underwriting terms that applied under this plan. Cover must be continuous and any existing special terms will continue to apply. Paying premiums and renewing the plan In this section we have set out the rules on paying premiums and also what happens at the plan renewal date. You should pay the first premium on or before the plan start date in accordance with the invoice we will send you. You (the planholder) are responsible for paying premiums to us. This plan lasts for one year at a time. Before each annual renewal date we will tell you the premium rates and plan terms that will apply for the next. We will also tell you of any changes to your benefits and the plan rules for the next. We will automatically renew your plan at each annual renewal date on the basis notified to you, unless you tell us not to. You can choose to pay your premium annually, half-yearly, quarterly or monthly. If you pay annually, then your premium will correspond to one year s cover. If you pay half-yearly, quarterly or monthly, then each premium will correspond to six months, three months or one month s cover, respectively. You must pay premiums in advance. Your entitlement to benefit will end after the last day of the period covered by your final premium payment. In such circumstances, we will only be liable for the cost of eligible treatment that takes place before that date. Once your cover under the plan ends, no further benefit will be payable for any treatment received after that date. This will be the case even if: your claim started before your cover ended, or you are in the middle of treatment, or you have previously notified us of further treatment that is due to take place after your cover has ended. 26 PruHealth

27 Cancelling the plan Cancelling the plan in the first 14 days You may cancel the plan from the plan start date providing you tell us within the first 14 days, or within 14 days from when you receive your personalised terms and conditions, whichever is the later. You do not have to give a reason for cancelling it and we will refund all premiums you have paid, providing you ve not already made a claim. The same cancellation rights also apply at each annual renewal date of your plan. Cancelling the plan after the 14 day period If for any reason you decide to cancel the plan, please let us know either by telephoning or writing to the customer care team that administers your plan. We will then write to you to confirm that your plan has been cancelled. We will also refund any premiums you have paid that relate to a period after your cancellation date. Our right to cancel the plan We can cancel, refuse to renew, or vary the plan at any time if any of the following happen: you have given us incomplete or untruthful answers in any information we ve asked you for you break the terms and conditions of the plan you have not paid your premiums when they were due. We may, at our discretion, reinstate cover if any outstanding premiums are paid within seven days of our telling you that we have cancelled your plan you attempt to claim benefits that you know you are not entitled to you stop living in the UK we end the plan type listed on your certificate of insurance or any part of the plan. If this happens, we will offer to transfer you to another plan with similar benefits if one is available General conditions These are the conditions that you must meet as part of the insurance contract. There are other conditions that specifically relate to the claims process that you must follow and these are shown within the Claims conditions section. What we expect from you It is your responsibility to: ensure that all premiums are paid when due, and inform us if your or any insured dependants personal details change, and inform us if you or any insured dependant, are no longer resident in the UK, and inform us of your new address if you move house within the UK. Plan conditions We have the right to review and alter the terms of your plan at each annual renewal date, including premium rates and benefits. Your plan will only be changed at an annual renewal date unless there is a change in the tax rules or the law. This is with the exception of your hospital list, which we may amend at any time. We may increase your premium if: due to our overall claims experience and medical inflation we increase the premiums of all planholders you move into the next age band PruHealth 27

28 We will tell you about any changes to the cover or general procedures by writing to your last known address. Even if you do not receive this, the change will still stand. We do not accept proof of posting an application form, claim form or premium payment as proof that we have received it. Any endorsements to your cover we have issued will remain in force at each annual renewal date unless stated otherwise. You may usually only apply to change the level of cover at the annual renewal date. Any increase in cover may be subject to new medical underwriting terms. Dishonesty / fraud We believe our customers are honest, and the contract between us is based on mutual trust. However, dishonest or fraudulent insurance claims are occasionally made. Where dishonesty or fraud (which includes exaggeration) is detected, claims will not be paid and we may refer the matter to the Police for criminal prosecution. This plan may be rendered invalid and we may take other action consistent with our legal rights. If any claim is in any respect dishonest or fraudulent or if any dishonest or fraudulent means or devices are used by you, any member of your household or anyone acting on your or their behalf to obtain benefit under your plan, then all benefits under your plan will be lost and you must return to us any payments already made as a result of any dishonest or fraudulent actions. PruHealth is involved in a number of initiatives to detect and prevent insurance fraud. If a fraud is suspected, we may exchange information about you with other insurance companies, fraud prevention agencies and the Police. Non-disclosure If you (the planholder) or any insured dependants have given us any incomplete or untruthful answers to any information we have asked for in respect of your membership or a claim, then we reserve the right to cancel or amend your plan with effect from the date of non-disclosure and you may be required to return to us any claim payments we have already made. The law and language applicable to this plan Your plan is bound by English law and comes under the jurisdiction of the UK courts. The language used in these terms and conditions and any communication relating to them will be in English. No-claims discount scale The no-claims discount scale which applies to the plan has eight levels. This scale is as follows: Level Base % discount off basic premium rate The no-claims discount level is dependent on whether or not you make a claim during a. We define a claim as: The amount of benefit we agree is paid, after taking off any excess, for providing treatment for one medical condition for you or your insured dependants. If treatment for the same condition has gone on for more than a year, we will treat it as a new claim for any further treatment after the anniversary of the claim. In this instance, we will require an updated claim form or a specialist s report and we will reapply any excess due on your plan. As a new claim, it will also affect your no-claims discount. We will review the no-claims discount level applying to your plan at each annual renewal date. 28 PruHealth