MAYFAIR DENTAL PLAN. The Mayfair UK Dental Insurance Policy. As arranged by: Mayfair Consultancy Services UK Limited FSA no.

Transcription

1 MAYFAIR DENTAL PLAN The Mayfair UK Dental Insurance Policy As arranged by: Mayfair Consultancy Services UK Limited FSA no

2 TCS UK DENTAL PLAN Contents Section 1 - Important information about your policy Introduction Page 3 Table of Benefits Page 4 Section 2 Your Mayfair Policy cover in detail Claims Guidance & Procedure Page 5-6 Definitions & Eligibility Page 7-8 Exclusions Page 8-9 Claims General Page 10 Contact details of Mayfair Region Page 10 General Conditions Page 11 Your Questions answered Page 12 Page 2

3 Introduction This handbook tells you all you need to know about the benefits of your policy, and much more besides. If you have any further questions upon reading this handbook, please do not hesitate to contact our advisers, by calling on or and they will be delighted to help you. Welcome to the Mayfair Dental Plan For help and advice If you have any queries at all, please call Mayfair on and talk to one of our advisers. Lines are open during normal business hours (8 A.M to 6.P.M GMT). Calls may be recorded. Always quote your Mayfair ID/Emp ID and Company name Page 3

4 SUMMARY OF BENEFITS The Mayfair Dental Plan provides the following dental cover for accidents, emergencies and reimbursement towards the costs of the below dental treatments: Regular and preventive dental care Routine examinations up to 55 per year. Routine hygiene treatment up to 65 per year. Dental x-rays up to 50 per year. Remedial or restorative treatment - 75% of the cost up to 1,000 per year (i.e., fillings, crowns and bridges etc). Emergency cover Accidental Dental Cover-Up to 10,000 per year Emergency dental treatment- Up to 1,000 per year. Emergency dental treatment in UK - Up to 250 per incident Emergency dental treatment outside UK - Up to 400 per incident Dentist callout fees - Up to 200 dentist per year (up to 100 per incident). Hospital cash payments - 50 for each night spent in hospital under the care of a consultant maxillofacial surgeon. Max Up to 1,000 per year Oral cancer cover Oral cancer - Up to 12,000 for treatment costs on diagnosis and for up to twelve months following diagnosis. Smokers are included in this plan. Additional benefit Choice of visiting any dentist whether NHS or Private. Page 4

5 Your guide to making a claim Making your claim couldn t be simpler. You can access your Mayfair Dental Plan claim form from your member s login in the Mayfair website. If you would like confirmation that any treatment you have been prescribed will be covered under the terms of this policy or you would like confirmation of the benefits available to you, please give us a call at or us at mayfair.claims@simplyhealth.co.uk When speaking to our advisers, we ask that you have your Mayfair ID/ Emp ID to hand: How to complete your claim form You should complete your claim form after your dental appointment. You should complete all sections of your claim form in full to avoid delay in the processing of your claim. Section A needs to be completed with details of the policyholder. Sections B, C and D need to be completed with full details of treatment received and being claimed for. The declaration should be signed by the policyholder. When you are satisfied that your form is complete you should attach your original itemised receipt and return it to us at Mayfair. (Unfortunately we cannot accept any form of receipts that do not itemise your treatment.) The claim form must be submitted within 30 days of receiving treatment, however, if the treatment plan is going to exceed 30 days you MUST call MA Reg 2 to notify us that you are having Dental treatment that will exceed the 30 day notification limit. Please remember that we cannot settle claims directly with your dentist. Page 5

6 The procedure you should follow when making a claim To ensure your claim proceeds smoothly, please follow these simple steps: Obtain your claim form and receive your dental treatment. Complete the claim form after your appointment. Use this guide for extra help. Attach your itemised original receipt to the fully completed claim form and return both to us at Mayfair within 30 days of receiving your treatment. Once we have received your fully completed claim form and itemised receipt, we will be able to assess your claim and, subject to no outstanding queries, dispatch a settlement to you within 10 working days. Page 6

7 Terms and conditions This document constitutes the full terms and conditions of your dental policy, which carries a 12 month term. 1. Definitions The words, which appear in this policy in bold, have specific meanings, which are explained below: Accidental dental injury a sudden unforeseen external blow to the face, teeth or jaws which occurs at an identifiable place and time resulting in an injury to the teeth or gums. Call-out means the necessity for a dentist in the UK to re-open the practice to provide: emergency dental treatment between the hours of 6.00pm and 8.00am on weekdays or at any time on weekends and bank holidays. Commencement date means the cover start date of the company scheme. Cosmetic treatment means dental treatment not necessary for the establishment or maintenance of oral health. Dental x-rays means a clinically necessary radiograph of the teeth and jaws. Emergency dental treatment means dental treatment provided at the initial emergency appointment urgently required for the relief of severe pain, arrest of haemorrhage, the control of acute infection or a condition which causes a severe threat to your general health. For the avoidance of doubt any subsequent treatment required after the initial emergency appointment is specifically excluded. Examination means a consultation and report provided by a dentist. Hospital means a lawfully operated establishment, which has residential patients and has facilities for diagnosis, major surgery and provides 24-hour nursing care by registered nurses and hospitalisation shall be construed accordingly. Hygiene means routine scaling and polishing provided by the dentist or hygienist. Oral cancer means a malignant tumour, with its primary site being in the oral cavity which is characterised by the uncontrolled growth and spread of malignant cells and the invasion of tissue. This excludes non-invasive cancer in situ and HIV related tumours. Oral cavity means the hard and soft palate; accessory, salivary, lymph and other gland tissue in the mucosal lining of the oral cavity as defined but excluding the tonsils. Premium means the premium you pay us or the premium, which is paid by your employer on your behalf in relation to this policy. Remedial & restorative means clinically necessary, routine dental treatment provided in the UK by a general dental practitioner including but not limited to fillings, crowns and dentures. Page 7

8 Specialist dentist means a dentist who is included in the Specialist lists on Distinctive Branches of Dentistry within the Dentists Register, as defined by the General Dental Council (Distinctive Branches of Dentistry) Regulations 1998; a dentist who has additional specialist or further qualifications in a particular speciality, or whose practice is limited to such a speciality. Specialist treatment is any form of dental care or treatment beyond the scope of the average competent dental practitioner. Term means the twelve months immediately following the commencement date or, in the case of a renewed policy the twelve month period immediately following the renewal date. Year means the twelve month period immediately following the commencement date or, in the case of a renewed policy the twelve month period immediately following the renewal date. Termination date means the date your insurance cover under this policy ends, which will be the earliest of the following: (1) the expiry of the term; or (2) the date of your death; (3) in the case of a company funded scheme, cessation of employment. United Kingdom (UK) means England, Wales, Scotland, Northern Ireland, Isle of Man and the Channel Islands. You or your means a person who has been accepted for insurance hereunder. The masculine gender shall include the feminine and the singular shall include the plural and vice versa. 2. Eligibility You will be eligible to become insured under this policy if you meet the following conditions: (1) you are entitled to enter the scheme in accordance with the eligibility rules defined by your employer; (2) you are related to an eligible employee and are a permanent resident of the employee s household; 3. Exclusions You are not covered for any dental treatment which was prescribed, planned (by you or a dentist) advised or is currently taking place at the commencement date and in addition no benefit will be payable under the Schedule of benefits as a result or consequence of any of the following: (1) Any payment in excess of the maximum benefits for each year as stated above. (2) Routine dental treatment when carried out outside of the United Kingdom is specifically excluded under this policy. (3) Any fees recoverable or otherwise covered by other dental schemes or insurance policies including The Mayfair PMI plan. (4) Any treatment relating to damage or injury caused whilst participating in contact sports (including training) unless recommended mouth protection is worn. (5) Laboratory fees associated with excluded treatment. Page 8

9 (6) Any prescription charges unless related to a dental accident or emergency dental treatment. (7) Mouth guards, gum shields or any dental appliances. (8) Self-inflicted injuries. (9) Costs which we consider are not reasonable and or necessarily incurred. All benefits will be paid in accordance with customary and accepted levels of charges for the treatment received. The charges must be in line with our dental adviser s opinion. (10) Implants, cosmetic treatment, bleaching or other tooth whitening and orthodontics. (11) Loss of, or damage to dentures, other than whilst being worn. (12) Reimbursement for traveling expenses or telephone calls (13) Referrals to a specialist dentist or specialist treatment unless the treatment is as a result of a dental accident. (14) Wisdom teeth extraction, other than those extracted at the dentist s surgery (15) Any treatment, care, repairs to, or in connection with "tooth jewellery". (16) Any treatment received for injuries not apparent within 30 days from the date of the original cause of the claim. (17) Oral cancer diagnosed before you joined The Mayfair Dental Plan. (18) Oral cancer diagnosed within 90 days after you joined The Mayfair Dental Plan or for which tests or consultation began within those 90 days, even if the diagnosis is not made until later. (19) Oral cancer which is related in any way to HIV infection or AIDS. (20) Any charges for consultations or tests for non-invasive tumours. (21) Oral cancer resulting from the chewing of tobacco or other products (including betel nut juice), or from prolonged alcohol abuse. (22) Any charges made by your dentist for completing the claim form. Page 9

10 4. Claims general The Claims administrator for the Mayfair Dental Plan is SIMPYHEALTH. Contact Details Address: James Tudor House, 90 Victoria Street, Bristol BS1 6GH Tel Number: (Available 8am 6pm) ID: (1)(a) Your claim must be notified to us by you completing our official claim form, and returning it to us at: MA REG 2, James Tudor House, 90 Victoria Street, Bristol BS1 6GH All claim forms must be fully completed and signed by the policyholder. Incomplete claim forms will be returned. (b) In any event claim forms must be completed at your own expense and must be received by us within 30 days of each dental appointment. (c) Your claim must be supported by an invoice detailing the dates and costs of each individual treatment. The invoice must be an official document issued by the treating practice. (d) No benefit will be payable if, within that 30 day period or any extension agreed by us, we do not receive your completed claim form. (2) No benefit will be payable if we have not received proof to our reasonable satisfaction of all facts relevant to your claim. This shall include but not be limited to: (a) Proof of the dental treatment, this may be by way of a medical report (at your own expense); (b) For claims under the accident dental benefit, details pertaining to the circumstances of the trauma you have experienced. (3) Claims settlement will only be made payable to the policyholder or another named life covered under this policy. Claims will not be settled directly with any dentist or any other third party. (4) We may require you to be examined by a dentist or other medical specialist (at our expense). If you refuse or fail to keep your appointments we may refuse to consider your claim. Page 10

11 5. General (1) You cannot assign or change the policy in any manner whatsoever. (2) This policy shall not acquire a surrender value. (3) The policy shall be governed by the law of England and Wales. The policy is written in English and all other information and communications to you relating to the policy will also be in English. (4) All policyholders must provide a UK mailing address. (5) All correspondence including claims settlement will be directed to the policy holder using the address currently held by us. (6) We reserve the right to refuse renewal of the policy. (7) Telephone calls may be recorded. We may also monitor telephone calls to help us improve our customer service. (8) In the event that you obtain cover via fraudulent means, or any claims are made which are found to have been made as a result of person insured fraud, we reserve the right to cancel your policy, demand that any such claim settlements are repaid by you, and/or take the appropriate legal action against you. (9) Insurers share information with each other to prevent fraudulent claims. In the event of a claim, any information the person insured has supplied relevant to this insurance and on the claim form, together with other information relating to the claim, may be shared. (10) The information you provide will be held in Accordance with the Data Protection Act It will be used to administer the insurance cover to you. All information that we request is necessary to arrange cover and assess and pay claims. The information will be disclosed to Mayfair Worldwide Limited, their insurers and representatives for this purpose only. If you want to make a complaint: It is always our intention to provide a first class standard of service. However, should you have reason to complain you can do so in the following way: (i) In the first instance, you should document your complaint and send it to us at: Mayfair Claims, James Tudor House, 90 Victoria Street, Bristol BS1 6GH Please quote your Mayfair ID no. so that your enquiry can be dealt with quickly. (ii) Should the matter still not be resolved to your satisfaction, you have the right to refer your complaint to: info@mayfairworldwide.com Page 11

12 Your questions answered Why can t you pay direct to my dentist? MA deals direct with the policyholder in order to keep administration to the minimum, which in turn controls costs, which helps us keep premiums as low as possible. Dentists would need to recover from the patient any fees not met by MA, this would mean that your dental practice costs could increase and in turn affect your treatment charges. Do I have to complete a new claim form each time I submit a claim? Yes, we need a new claim form for every separate claim that you submit to us for payment. For further information: info@mayfairworldwide.com Page 12